SOME POINTS IN THE NURSING CARE OF THE ADVANCED CONSUMPTIVE
By ELSA LUND, R. N.
Head Nurse, Iroquois Memorial Dispensary of the Chicago Municipal Tuberculosis Sanitarium.
The problem of caring for the advanced consumptive is a very complicated one; it involves not only the patient, but the whole family as well. A complete rehabilitation of the entire family is necessary in most of the dispensary cases.
The first thing the nurse must do is to gain the confidence of both the patient and the family. The chief requisite in the nursing of the advanced consumptive is a clean, careful, patient and sympathetic nurse. Frequently she finds her patient extremely irritable, and often this mental condition has affected his whole family, or whoever has been associating with him. A painstaking, sympathetic nurse will readily understand that the causes for this state of affairs are most natural. The consumptive may have spent wakeful nights, due to coughs and pains and distressing expectoration; the enforced cessation of work may have caused pecuniary worries; all his customary pleasures are now denied him, and he has strength for neither physical nor mental diversion. Realizing this, the nurse must kindly but firmly impress upon the patient the necessity of co-operation and the danger of infecting others and of reinfecting himself. She should at once create a more cheerful atmosphere by repeated suggestions that if he will only do his duty as a hopeful patient, he will not be considered a menace by those who come in contact with him, and his family will gladly associate with him.
Next comes the concrete problems which the nurse must solve. That of proper housing of the patient is one of the most important, and especially so in the case of the advanced consumptive, because of the greater danger of spreading the infection if the conditions are unfavorable. Where it is necessary that the family should move, the nurse should assist in the selection of a new home. If possible, a detached house should be chosen, affording plenty
of light and sunshine, away from dusty streets and roads. Offensive drains and other insanitary conditions should be avoided. The water supply should be abundant and the plumbing in good repair.
The room of the patient should be well lighted and well ventilated, and preferably have a southern exposure. Cross ventilation is very desirable. When all unnecessary furniture and all hangings and bric-a-brac have been removed, and the old paper stripped from the walls, the walls should be whitewashed, or covered with washable paper, or painted. Painted walls are inexpensive, and they have the further advantage that they can be washed frequently. The floor should be bare and likewise frequently washed. Simple furniture is commendable, and old pieces can be made very attractive by having them enameled. Proper furnishings include a comfortable bed (one made of iron and raised on wooden blocks makes nursing care easier), a bedside table, chairs, a rocking chair, a washstand, and even a couch on which the patient could be placed occasionally to relieve the monotony. Two or three pictures which can be readily dusted and cleaned will brighten the bare walls one finds in what are generally recommended as sanitary rooms. Flowers always add to the attractiveness of a room, and when the bed is placed near the window the patient is given the opportunity of enjoying, to some extent, at least, the pleasures of out-of-doors. The mattress should be provided with a washable cover. Strips of muslin sewed across the tops of the blankets will protect them from sputum, in case the sheets happen to slip. Soiled bed linen must be handled as little as possible, soaked in water, washed separately and boiled. If sputum-covered, it should be soaked in a five per cent solution of carbolic acid or a solution of chloride of lime. Instead of dry sweeping and dusting, the floors should be washed with soap and water and dusted with wet cloths. Great care should be taken in instructing and demonstrating to the family how to properly care for the room. Special attention must be given to the bed, its comforts and its cleanliness. Every nurse is familiar with what is known as the "Klondike" bed, and it is unnecessary to discuss it here in detail. Since both patient and family derive such direct benefit from a constant supply of fresh air, too much attention can not be given to proper ways of securing it, and at the same time keeping the patient warm. Where bed coverings are limited, warmth can be secured by sewing layers of newspapers between two cotton blankets; again, sheets of newspapers or tar paper keep out the cold to a great extent. Proper ventilation prevents night sweats. Means of heating the room must be provided,
because of the low vitality of the patient and the need of frequent care.
The patient's clothing needs to be light but warm; where wool proves irritating to the skin, a heavy linen mesh has been found a good substitute, due to the fact that it dries quickly when the patient perspires. The patient should have two good soap and water baths a week. The nurse should let the family know when she is coming to give these baths and explain to them that she expects them to have ready for her towels, soap, clean bed linen, wash basin, wash cloths, newspapers and hot water. Night sweats demand careful rubbing, first with a dry towel; vinegar sponging is found to be very effective; alcohol rubs prevent bed sores.
The hair, nails and teeth require special attention; beards and mustaches should be shaved. Every patient must learn to use the tooth brush after meals, that the mouth may be kept scrupulously clean. Gargling should also be insisted upon. Tooth brushes can be kept in a 50 per cent Dobell's solution, Liquor Antiseptic (U. S. P.), or a 2 per cent solution of carbolic acid colored with vegetable green coloring matter as a warning against swallowing. As an aid in hardening the gums, all foreign deposits should be removed, the gums massaged by the patient and normal salt solution used as a gargle. Where the patient is suffering from pyorrhea, the gums may be painted, on the order of the physician, with tincture of iodine (U. S. P.) or a 2 per cent solution of copper sulphate. While the patient is learning to cleanse his mouth carefully after every meal, he may also be instructed to avoid placing anything in his mouth, except food, drink, gargling solution or tooth brush. The reason for using some kind of mouth wash, instead of merely water, is because in that way the need of cleanliness is more forcibly impressed upon the patient.
Such matters as the use of separate dishes, etc., are so well known to every tuberculosis nurse that it is unnecessary to dwell on them at length in this paper.
Difficulties always arise regarding proper method for the care and disposal of sputum. The following are some of the plans adopted by tuberculosis hospitals for advanced cases:
1. Infirmary of Eudowood Sanatorium, Towson, Maryland.
Pasteboard fillers in such quantities as will be required during the current day are issued to the patients. When the filler becomes not more than two-thirds full, it is carefully filled with sawdust, wrapped in a newspaper, tied with a cotton cord and deposited in a large galvanized
iron bucket, in which it is carried, with the others, to the incinerator.
2. North Reading (Mass.) State Sanatorium.
A room specially equipped for the disposal of sputum is recommended. Paper sputum boxes are changed twice daily, inspected as to character, quantity and presence of blood. Then the box is filled with sawdust, wrapped in newspaper and carried to the incinerator for burning.
3. Montefiore Home Country Sanitarium, Bedford Hills, N. Y.
In cases where bed patients have a very large amount of sputum, large cups of white enamel are used, with a hinged lid that lifts readily. The sputum is from there thrown into receptacles containing sawdust, taken to the incinerator and burned twice daily. Both sputum cups and the large container holding sawdust are sterilized by live steam.
4. House of the Good Samaritan, Boston, Mass.
Paper handkerchiefs and bags are recommended when the quantity of sputum is small. Burnitol sputum cups without holders are used; the bottom of each cup holds a small amount of sawdust, which serves the purpose of hindering the sputum from penetrating through the cup. All the cups are carefully tied up in newspaper by the nurse or the patient before they are sent to the incinerator.
5. Chicago Fresh Air Hospital.
Paper fillers and metal holders are used. The fillers are placed in a large can, covered with sawdust, and then burned in the incinerator. The holders are sterilized daily. The Hospital recommends paper napkins where the quantity of sputum is small; if there is no possible means of burning the sputum, it should be treated with a strong solution of concentrated lye and then poured into the water closet.
The chief source of infection is undoubtedly the expectoration of the consumptive, spread by careless coughing and spitting. Be very emphatic in instructing the patient to cover his mouth with a paper napkin when he coughs and then to dispose of it carefully in such a way that no particle of the sputum touches either his hands or his face. Insist on frequent washing of the hands.
The following methods and solutions are employed in the treatment of laryngeal tuberculosis in various institutions:
North Reading (Mass.) State Sanatorium.
The following are used as gargles:
Dobell's solution; Dobell's solution and formalin (one drop of formalin to an ounce of solution); alkaline antiseptic N. F. (one to four water); salt and sodium bicarbonate (one dram of salt and two drams sodium bicarbonate to a pint of water).
Sprays used at this institution are as follows:
Spray No. 1. Menthol spray in proportion of fifteen grains of menthol to one ounce of alboline.
Spray No. 2. Menthol (4 drams plus 10 grains); thymol (7 drams plus 25 grains); camphor (7 drams plus 25 grains); liquid petrolatum (64 ounces).
Heroin spray. From one to three grains of heroin to one ounce of water.
Cocaine spray. From one-half to two per cent, usually before meals, for dysphagia.
For local applications: Argentide, 1 to 200; argyrol, 10%; iodine, potassium iodide and glycerine; heroin powder applied dry to ulcerations; orthoform powder applied dry.
Montefiore Home Country Sanitarium, Bedford Hills, N. Y.
In the routine treatment of laryngeal tuberculosis at the Montefiore Home Country Sanitarium orthoform emulsion is used, made up as follows: Menthol, 2-5 grams; oil of sweet almonds, 30 grams; yolk of one egg; orthoform, 12.5 grams; water added to make 100 grams.
In addition, silver salts are used in various strengths; also lactic acid in various strengths. These two agents are applied by means of applicators, whereas the emulsion is injected by a laryngeal syringe. The laryngeal medicator of Dr. Yankauer, made by Tiemann, is also employed. By means of this little apparatus a patient may medicate his own larynx, using the emulsion mentioned or any other agent (such as formalin) which may be desired.
Eudowood Sanatorium, Towson, Md.
At the Eudowood Sanatorium, Towson, Maryland, the following procedure is used in the treatment of tuberculous ulcers of the larynx:
Topical applications of lactic acid, 15 to 50%, followed by a spray composed of 20 grains of menthol to 1 ounce of liquid alboline.
A spray of 2% cocaine is used as often as is necessary to relieve the pain.
Insufflation of orthoform powder, or the patient is directed to slowly dissolve an orthoform lozenge in his mouth.
These treatments are enhanced by the application of an ice bag to the throat, enforced rest of the vocal cords and rectal feeding, if necessary.
In laryngeal complications, semi-solid diet is generally more easily swallowed. This is facilitated by a reclining position. Cold compresses give some relief.
Chicago Fresh Air Hospital
For the relief of pains and difficulty in swallowing, the nurse is instructed to spray the larynx with a 3 per cent solution of cocaine before each meal.
As a more efficient treatment, but slower in action, the administration of anaesthesine to the ulcerated epiglottis with a powder blower is recommended. This is usually done by the physician, as is, also, the insufflation of iodoform.
Cold packs are also used to give temporary relief, but they are not recommended as being very reliable.
Authorities differ regarding the proper diet for the advanced consumptive. It is generally conceded, however, that it should not vary to any great extent from the ordinary liberal diet, unless intestinal or other complications arise. The physical idiosyncrasy of each patient must first of all be taken into consideration, and this is primarily a matter to be decided upon by the physician in charge. The nurse should, however, be resourceful in her suggestions as to preparing a variety of palatable dishes. According to Walters ("The Open Air Treatment"), in intestinal tuberculosis, such foods as oatmeal, green vegetables, fruit and various casein preparations are better dispensed with, as they are likely to cause irritation and diarrhoea. Meat and meat juices should also be given with caution, as they, too, cause diarrhoea.
In hemorrhage, a cold diet should be given, such as milk, eggs, gelatin and custard. The nurse must insist in absolute rest and the patient should not be permitted to move until the danger of bleeding is over. Nervousness always accompanies hemorrhage, and the nurse can do much to allay this by assuring the patient that few people die from hemorrhage.
In closing, it might be well to mention some points relative to the nurse's equipment, her mode of dressing, etc. Her dress should be simply made and washable. Aprons made of soft cotton crepe are recommended because of the small space they occupy in the bag.
The contents of the bag, which should be lined with washable, removable lining, should include: Alcohol, tr. iodine, green soap,
olive oil, boric acid powder, boric acid crystals, vaseline, cold cream, mouth wash, tongue depressors, adhesive plaster (3" wide), bandages, safety pins (small and large), applicators, scrub brush, face shields, probe, scissors (2 pair), forceps, thermometers (3), medicine dropper, bags of dressings, dressing towels, hand towels (2), apron.
Because tuberculosis is so lasting and makes a family, ordinarily self-supporting, frequently dependent, it will be absolutely necessary for the nurses to have access to a loan closet. This closet should contain the following articles: Sheets and pillow slips, bed pan, blankets, rubber rings, gowns or pajamas, rubber sheets, tooth brushes, cold cream, rubber gloves, glass syringes, pus basins, enema bags, connecting tubes, rectal tubes, nurses' hand towels, surgical towels, instrument cases, aprons and gown, loan book.
Up to the present time the field nurses of the Dispensary Department of the Chicago Municipal Tuberculosis Sanitarium have taken care chiefly of ambulant cases, the total number of cases under observation in 1913 being 12,397, with 39,737 visits by nurses to positive and suspected cases in their homes. Lately (September 1914) the nursing force of the Dispensary Department has been increased to fifty nurses to take care of all tuberculosis cases in their homes, including advanced cases and those of surgical tuberculosis.
