CHAPTER VI.
SURGICAL NURSING.
Before I dwell particularly upon surgical cases and wounds of all kinds, I will refer to some general duties of the nurse who attends during a surgical operation.
Generally the patient to be operated on should have a bath the previous night, and perhaps an enema on the morning of the operation; if the operation is on the female genital organs a warm douche should be given.
Prepare the room by having it well cleaned and aired and of a temperature of about 85°. Such things as are likely to be needed; for example, vaseline, carbolic acid, basins, sponges, towels, scissors, needles, pins, ice, hot and cold water, should be provided. If you have to make bandages, an old cotton sheet is good material from which to tear the strips. To join the strips lay two ends flat on each other overlapping for an inch, and baste together all four sides. A roller bandage may be from two to twelve yards long; it must be rolled as tightly as possible; the selvage and all loose threads must be trimmed off.
The proper cleaning and preparing of sponges is important. If one has been used it should be well washed and left in a solution of sal soda, and then kept for several days in a five per cent. solution of carbolic acid. New sponges should be prepared with twice as much care.
In a case where there is to be an operation upon the female genitals, a T bandage may be required; this should be put on before the ether is given, at least the part above the hips, the other part may be left free till after the operation, to be then brought between the thighs and attached to the other in front.
Only a little light food should be taken for three or four hours before etherization. Prepare the patient for going to the room by having her hair combed and braided, artificial teeth must be taken out, and all tight bands loosened. Arrange the clothing so that it will be protected, and so that it can be changed afterwards easily. See that she passes the urine the last thing before taking her place for the operation.
Have a bed ready that is properly made and protected, to which she can be moved when the doctors allow it, and where she can be kept quiet. If there is nausea and vomiting, the effects of the ether, you may quiet it by letting her sip a little hot water or by putting a hot, dry cloth on her neck and chest. During the operation you had simply to wait on the surgeon, now the patient will be principally in your care.
You will receive instruction from the surgeon in regard to things needing peculiar watchfulness and every point must be carefully noted.
As the wound may need to be watched during the first twenty-four hours for hemorrhage, it must be so arranged that it can be looked at without waking the patient.
The danger to which surgical cases are liable are, 1. Shock; 2. Hemorrhage; 3. Erysipelas; 4. Pyemia; 5. Tetanus. If there is TRAUMATIC ERYSIPELAS the edges of the wound are red and swollen, the secretion of pus ceases, and by the next day the skin around the wound becomes of a peculiar red color. There will be fever, headache, nausea, and a coated tongue.
ERYSIPELAS can be generated by inattention to sanitary laws. It is infectious and spread by fomites, and the virus of erysipelas may give rise to puerperal fever. It is not proper for a nurse that has had the care of a case of erysipelas, to soon be the nurse of a lying-in woman, even if she is careful about using disinfectants on her hands and changing her clothes.
Certain influences augment the susceptibility of the body to the agency of the poison. Among the influences are intemperance, low spirits, anxiety, insufficient nourishment, and foul air. There should be great care in regard to ventilation, and clearing and cleaning the room where it has been present.
The disease cannot be cut short by active remedies, but may be made to terminate favorably by the use of the perchloride of iron, &c. (F. 177.)
TETANUS (lockjaw) may follow slight wounds. At first the muscles of the jaw are rigid, but the rigidity or spasms may extend all over the body. It may result from exposure of the wound to cold, and some cases of tetanus in infants have been attributed to the funis, in instances where as much as three or four inches were left attached to the umbilicus. In a case of tetanus the patient should lie in a darkened room, and noise should also be excluded.
INCISED WOUNDS, made in the flesh by sharp cutting instruments, of course may be trivial cuts, or deep incisions, and may sometimes be treated by the nurse, either because they are slight injuries or because a surgeon cannot immediately be obtained.
If there is not much bleeding there will not be very much to do. It is well to have a little carbolic acid in the water with which it is washed. The bleeding will soon cease if only small vessels are divided. If there is any extraneous matter on the surface of the wound it must be removed. Then put the surface of the lips of the cuts together, and take measures to keep them in this state till they have become firmly healed. If sutures are necessary take one or more stitches. The most common method of keeping the surface of divided parts in contact is by strips of adhesive plaster. Apply them after having put the wounded parts in a position favorable for bringing the edges of the wound together, then while one holds the lips of the wound evenly together secure them in this position by strips of adhesive plaster applied across the line of the wound. Leave a little interspace between each two strips of plaster. It is not best to bind it up so that there is no passage or exit for blood. But slight wounds may become serious if some poison or virus gets into it; you may need to put on lint or a compress over the strips of plaster and then a roller or bandage.
But some incised wounds instead of being immediately dressed and bound up, demand that immediate attention should be paid to the hemorrhage. We may usually know whether the bleeding is arterial, venous or capillary. If the wound is open, blood from an _artery_ will _spurt out in jets_ and is of a bright red color. Unless the artery is very small a surgeon will be needed, but you may be required to act very promptly to suppress for a time a dangerous flow of blood. If a large artery is cut or punctured the hemorrhage may be fatal in a short time. The application of heat or cold, and the elevation of the part injured, may suffice in slight cases, but in these severe cases other means are necessary.
First endeavor to arrest the rapid flow of blood by pressure upon the wounded artery with your thumb. Then if the wound is in a limb let some one tie a handkerchief loosely around the limb, and if you know the course of the artery have the knot directly over it and between the heart and the wound. Then put a stick in under and twist the handkerchief so that it is tight enough to compress the artery. The hemorrhage can thus be checked until the surgeon arrives. If the wound is over a bone in the head or body, the bleeding may probably be checked by binding on a hard compress where the artery is cut, thus making direct pressure upon it. A ligature upon a limb ought not to remain very tight more than an hour.
If the hemorrhage is from a leg below the knee it may be checked by putting a firm roll of cotton in the flexed joint, and pressing the lower part of the leg against the thigh; this will compress the artery.
CONTUSED WOUNDS are not often attended with serious hemorrhage. If there is in the bruised part only slight subcutaneous laceration, nature may soon repair the injury. But if there is considerable contusion indicated by the ecchymosis where small blood vessels have been lacerated and the blood extravasated into celular tissue, causing the dark discolored spots and other evidences of severe injury, there will be subsequent inflammation, perhaps suppuration, demanding treatment. A proper mode of dressing at first is to bind on a compress saturated with a four per cent. solution of carbolic acid, and for the fever and inflammation one drop doses of ext. veratrum may be given.
But in all cases where wounds are severe the services of a physician will be required.
A PUNCTURED WOUND signifies one made with a sharp pointed instrument, the external opening being small compared to its depth. It is a good rule in these cases to leave a free vent for any discharge that may be set up. The danger in these cases is from serious injury to the deep seated parts, and from suppuration which may burrow and extend still deeper if there is not free exit for the pus.
One mode of treating POISONED punctural wounds (serpent bites, &c.), which of course are peculiarly dangerous, is by applying cups over the wound.
Any wound that suppurates much or sloughs causes a cavity to be filled up, and the process by which the wounds and sores heal is called granulation, and cicitrization. The wound is gradually filled up to the surrounding level by new tissue appearing in the form of small red granules bathed in pus. Healthy granulations on an exposed or flat surface rise nearly even with the surrounding skin, and often a little higher, but when they are much higher, and take on a growing action, they are what is called proud flesh. Their growth may be checked by the application of active astringents; nitrate of silver or burnt alum may be used, or adhesive straps may be applied. The skin with which it is covered when healed is formed from the surrounding skin, and the process which is called CICITRIZATION does not go on well except when the granulations are nearly level with the adjacent skin. The centre of a sore has power to form new skin when there is a particle of live skin there, and for this reason skin is sometimes grafted in.
A patient suffering from a suppurating wound becomes enfeebled from the discharge of pus, and should have his strength kept up by nourishing food. A surgeon will always endeavor to prevent the retention and decomposition of discharges, and to protect from external contamination. He will direct the time and means of dressing the wounds, but the nurse must remember that decomposed animal matter acts as a virulent poison introduced into the system as it may be through any abrasion of the skin. All instruments used about a wound must be thoroughly cleansed before being put away. Dressings which have been next the wound should be burned; those which are to be washed should be disinfected. Avoid soiling your own hands with discharges; protect with a bit of plaster every place where there is any cut, or scratch, or sore. If you fear that any virus has got in where there is any sore, or where the skin is broken, touch it with carbolic acid.
FRACTURES AND DISLOCATIONS.
One of the signs of a FRACTURE is crepitus, the sound made by the rubbing of the ends of broken bones together. This sound cannot always be obtained, even when the bone can be moved so that the ends rub each other, and as such motion causes considerable pain the nurse should not seek for it, except as she harkens when the limb is accidentally or necessarily moved. The separation and inequalities of the ends of the fracture (when the bones are superficial), the change in the form of the limb, and the shortening of it, are circumstances communicating information in very many cases, and the diagnosis is made pretty certain if there is unnatural mobility of the limb. In other cases there is loss of motion or immobility, swelling and pain in the injured part, &c., but it will possibly require the services of the skillful surgeon to detect the existence and character of a fracture; and generally the coaptation or setting of the bone, can be deferred until he arrives. The nurse can do something in the meantime—can have the patient and fractured limb put in as easy a position as possible; perhaps have something ready for bandages and splints. A splint may be made of anything that will hold the bone securely in place; it should be longer than the bone that is broken. Sole leather is sometimes used; cut the required size, softened in hot water, moulded to fit the part and left on until dry, when it will be of the desired shape. Plaster of Paris bandages are sometimes used. These are prepared by rubbing into the ordinary muslin rollers dry plaster. They are then rolled. When they are applied, soft flannel bandages are first put on the broken limb, then the one containing plaster is (after being dipped in water, and some of the water squeezed out), applied over the flannel. It takes ten or twelve hours for this to set and become hard, and the broken limb must be kept still during the time. Dust the part over with toilet powder before the bandage is applied. The success of the surgeon depends very much on the good constant care of the nurse. If it is necessary to move the limb keep up some extension on it and do not twist it. Be very careful that the directions of the surgeon are carried out, and it will probably be necessary to keep up extension all the time, otherwise the deformity may return and the limb be shortened.
DISLOCATIONS are not so easily reduced as fractures, but after the setting and reduction of a dislocated joint the action of the muscles tends to keep it in place. There is always some laceration of the ligaments and sufficient injury to the soft parts to excite a little inflammation, but the pain is relieved as soon as the bones are replaced.
In general recent dislocations are easily reduced, but when the head of a bone has been out of its place for several days the reduction becomes exceedingly difficult, and as a rule the difficulty of reduction arising from the muscles is proportioned to the length of time that has elapsed from the period of the accident. For this reason a person who has a little general knowledge on the subject of dislocations, should sometimes make an attempt at reduction immediately after the accident.
The signs of dislocations are pain, incapacity of motion in the limb, change in the length of the limb and in the direction of its axis. Sometimes the dislocated limb is nearly incapable of any motion, and sometimes the destruction of the means of union, allows the limb to obey any extraneous influence.
The replacing of the dislocation would require very little effort or force were it not for the resistance of the muscles and tendons attached to them. In reducing a luxated bone the main point is to apply force until the head of the bone dislocated can be slipped into its place, which is generally when it is nearly to a level with its socket. This is easily effected immediately after the accident, because at that time the resistance of the muscles is not great; it may be best to attempt it, but there should be no delay in sending for a surgeon.
I recommend that an attempt be made to set a DISLOCATED THUMB or FINGER by making extension on the lower member and at the same time pressing the head of the bone towards its natural situation. If the reduction is effected, the thumb or finger should be rolled with tape and surrounded and supported with pasteboard; and the hand and forearm put in a sling. A surgeon may be necessary even in a case of dislocated thumb or finger, but bones out of joint are so much more easily set at first, that it is best to attempt to set them then, and the same may be said of some larger bones.
For instance, if there is a DISLOCATION OF THE ELBOW, the patient being settled, let one man take hold of his arm near the shoulder, to make counter extension while another makes extension at the wrist. You yourself being seated grasp the elbow with your two hands by applying your fingers to the anterior part and your thumbs to the posterior, press on the projecting point of bone downwards and forwards. You will generally be successful, but I do not advise five minutes’ delay in sending for a surgeon. I only advise that an effort be made immediately.
After thus reducing a dislocation of the forearm backwards at the elbow, apply a bandage in the form of a figure of eight; apply some lotion or liniment, and keep the arm in a sling. At the end of seven or eight days when the inflammation has subsided, the articulation can be gently moved, and the motion may be increased every day.
The figure of eight bandage is a roller applied alternately above and below a joint, the roll being carried obliquely over a central point.
The art of putting on a roller bandage is an important one for a nurse to acquire, and I may here give a few general principles though no exact directions can be given. In applying a bandage care must be taken that it is put on tight enough to fulfil the object in view, without running any risk of stopping the circulation. A bandage must lie smoothly, without wrinkles, and making an even pressure. For bandaging an arm or leg a roller from two to three inches wide may be used; a few turns may first be given on the hand or foot, and after this every circle is to be applied so as to ascend up the limb in a gradual spiral form and cover about one-third of the turn of the roller immediately below it. To accommodate it to the shape of the limb reverses are made. The bandage is doubled back by placing a finger on the lower edge to hold it firmly, and turning the bandage downward over itself, at such an angle as properly shapes its direction, and these turns can be made as often as is necessary.