CHAPTER XI
Inspection of the House—The Patient’s Bedroom—Porches—Gardens and Tents—Flat Roofs—Clothing and Bedclothing—Artificial Heat—Rest—Fresh Air—Food—Cooking—The Bedridden Patient.
Inspection of the House. On her first visit the nurse must inspect every room in the patient’s home, with a view to knowing what possibilities it affords for treatment and isolation. Some contain no facilities whatsoever; some but meagre ones, while in others may be found excellent opportunities which the patient must be taught to use. Before advising any change or rearrangement, several factors must be considered: the stage of the disease, number in family, financial condition, home surroundings and the institutional facilities of the community. The course to be taken depends whether or not there is a hospital, or whether or not the patient must wait some time before admission. The first object is the protection of the family, but all those measures which bring this about, offer at the same time the maximum advantage to the patient himself. To remove him to an institution is the best way to accomplish both ends. If this cannot be done, the nurse must endeavour to secure conditions in the home which as nearly as possible approach those of an institution. The closer this approximation, the greater the gain to both patient and those who surround him.
The Patient’s Bedroom. The first thing to be considered is the patient’s bedroom, or sleeping quarters. He should have this room to himself, sharing it with no one. If this cannot be arranged, he should at least have a bed to himself. This bed, and that of the other person, or persons, should be placed at opposite ends of the room, and as far apart as possible.
The more windows in the room the better; these should be kept open to their fullest extent. In some houses, where the windows are small, it is often possible to lift out the entire sash, thereby admitting more air. The bed should be placed directly at the window, so that the patient may lay his pillow on the window sill if he chooses. He should be instructed to sleep facing the opening, in order to get all the air he can. The nurse should rearrange the furniture as she wishes it, otherwise misunderstandings may occur. If the family object to her moving it but promise to do this themselves, she must be careful to inspect the room again on her next visit, to see that this has been properly done. Even with families that have been under supervision a long time, it is well to inspect the bedrooms occasionally, for the patient’s bed always has a tendency to retreat into a remote corner of the room, especially in winter.
The floor should be bare, and this, together with all other plane surfaces should be washed several times a week with hot water and soda. Great caution must be exercised in making a sanitary sick-room, but, in her enthusiasm to produce ideal conditions, the nurse must remember that articles used for months by the patient, and suddenly banished from his proximity, may be very deadly elsewhere. In advising that carpets and curtains be removed, she must be careful what becomes of them. If germ-laden carpets are sold, or given to the neighbour next door, they would better remain where they are. Poor people find it hard to withstand the temptation to sell or give away serviceable articles, which is of course but natural, but the nurse must be on guard against such occurrences.
To have an ideal sick-room, there is no necessity for its being depressing by its bleak ugliness, or bare and dismal as a cell. Washable muslin curtains may be permitted, and there is no objection to pictures and ornaments in moderation. It is bad enough to have tuberculosis, without penalizing the patient by removing from him all those little treasures which give him pleasure and harm no one.
In selecting a good room for the patient, the nurse may find it necessary to have him exchange with some other member of the household. In this event, great care must be taken that the room vacated by the patient is thoroughly cleaned and disinfected before being occupied by anyone else. There are also circumstances which render it unwise to make this exchange: for example, say that we have a moderately advanced case, whose improvement is doubtful. He is occupying a room with one window—not ideal, but fair enough. There is also another room in the house, containing several windows, altogether brighter and larger, but occupied by three or four people, so far healthy and sound. To exchange rooms under such conditions would be bad policy—it would be of little advantage to the patient himself, while the other people would be subjected to overcrowding and bad ventilation, which would decidedly lower their resistance. Those in prolonged, intimate contact with a consumptive must not be allowed to reduce their vitality in any way.
To arrange a good sanitary room for a patient does not in the least mean that he will use it. Such a room would doubtless appear well in a photograph, illustrating the “before and after” phases of the nurse’s activity, but this does not necessarily mean that the patient is isolated and harmless. He will probably use his nice room for sleeping purposes only, and it is what he does with the remainder of his time that counts. He comes into contact with the household at meals, in the evenings, and on innumerable other occasions, and the consciousness of an immaculate bedroom should not lessen the nurse’s anxiety about the kitchen, the living-room, and the family sofa. There is where the danger lies.
Porches. In some houses we find a porch readily available for the patient’s use, where he can sleep and spend most of his daylight hours. It is sometimes difficult to induce him to make use of it, however. We must also remember that there is a great difference in porches. Some are narrow, unroofed, exposed to sun and wind, have disagreeable outlooks, for instance, as on unsavoury alleys, and in other ways are unfit to be used as living-rooms. They should be used, of course, whenever practicable, since undoubtedly the patient will get more air, and more constantly changing air, than if he sleeps indoors. Yet it is well to realize that a place where the patient is unsheltered, uncomfortable, and where he cannot sleep or have a quiet mind, is often far less valuable than a good bedroom which may give him all of these necessities.
Patients in well-to-do circumstances can equip their porches admirably, both with awnings and with canvas screens. These latter should roll up from the floor, rather than down from the roof. Screens and awnings can be made to order by any awning or sail maker; the price varies with their construction, from about five dollars upward. To teach a patient to use a porch for sleeping and also to use it as a living-room should be the nurse’s constant endeavour. Even an ideal porch is like an ideal bedroom—only valuable if it is used.
Gardens and Tents. Many houses have little yards or gardens, easily adaptable for open-air living. A tent may be erected for sleeping purposes, if the space is large enough and the family can afford it. Women and children are usually afraid to sleep under such exposed conditions, and in consequence refuse to make use of what would otherwise be an excellent opportunity. These gardens may be used during the day, however, and the patient made comfortable in a reclining chair or lounge. But excellent as they appear theoretically, the extremes of our climate, excessive heat and cold, often make them unpractical for the consumptive’s use. Under such circumstances, these little back yards often become anything but ideal places in which to “take the cure.”
Flat Roofs. We also find flat roofs or sheds attached to certain houses in the tenement districts. These sometimes offer excellent conditions for long hours out-of-doors, and may also be used as sleeping-porches. The nurse must be alert to seize all opportunities which present themselves, and to teach her patients to utilize them.
Clothing and Bedclothing. In her effort to teach her patient to sleep out-of-doors, and to spend most of his waking time there, the nurse must remember that in winter this is impossible, if he is insufficiently clad. The vitality of the consumptive is always below par, consequently he needs much more clothing than would a healthy person under the same conditions. It is impossible to expect patients to remain out-of-doors if they are cold and uncomfortable, and before insisting upon open-air treatment the nurse must see that it is possible for them to take it. If they lack the necessary clothing—underwear, blankets, sweaters, overcoats—these may be procured through some charitable association. It is a part of the nurse’s duties to arrange for this assistance, the question of which will be dealt with in a later chapter.
Artificial Heat. In addition to extra clothing, artificial heat is nearly always necessary, and this may be procured by means of hot-water bottles, hot bricks, stove lids, and so forth. The clothing itself may be sufficiently warm, and a hot brick may be all that is necessary to keep the patient in the yard, rather than in the kitchen. The patient must learn to live in the open-air—and the family must also learn that their safety lies in keeping him there, and is well worth the trouble of filling a hot-water bottle now and then. A hot kitchen is the worst place in the world for a coughing consumptive—and a coughing consumptive is the worst thing in the world for a hot kitchen—and the inhabitants thereof. It is fortunate that the rule works both ways, so that both sides may be appealed to.
Rest. The three things necessary to improvement are rest, fresh air, and food. Not one alone, nor two alone, but all three together, if results are to be obtained. It is very difficult to impress upon the patient that rest is not exercise, and that nothing is as bad for him as exertion. He instinctively associates fresh air with exercise, and does not realize that fresh air and rest is the combination required. If a physician is in charge of the case, he of course would direct the amount of exercise to be taken, but if, as often happens, there is no doctor in attendance, the nurse must use her own knowledge of what is best. In a sanatorium the usual rule is that all patients with more than 99 degrees of fever shall stay in bed. After a hemorrhage, absolute rest is of course indicated.
Therefore the nurse should try to induce her patients to rest as much as possible—not to walk about, or to drag themselves to a park, and so tire themselves out. Exertion increases fever, and this will counteract what benefit might have been gained through the fresh air. They should be taught to sit comfortably in their gardens, on their front sidewalks, on their porches, at their open windows. Best of all, they should go upstairs to their bedrooms, and lie at full length on the bed placed next to the open window. By thus emphasizing the importance of rest—synonymous in this case with outdoor rest—the nurse is not only giving sound advice to her patient, but she is protecting the community from the ambulatory consumptive.
Whenever possible, the patient should be induced to remain in bed permanently. The sooner the weary, advanced case gives up his painful wanderings, stops dragging himself from his own to his neighbour’s kitchen, or to the hospitable bar, the better for him and for the community. If he were to go to bed in a hospital, instead of at home, greater still would be the gain. The part of the community constituted by his family would be freed from danger, while he himself would be adequately cared for. Again we are struck by the coincidence of what is best for the patient being also best for those who surround him.
Fresh Air. Fresh air is the second great essential in the treatment of tuberculosis, and every patient should be taught to spend as many hours as possible out-of-doors. The nurse must explain in words of one syllable why this is necessary—that clean, pure air contains life-giving oxygen, and that to breathe it entails little exertion on the part of the sick lungs. On the other hand, impure air contains no upbuilding principle, but greatly taxes the lungs and makes breathing difficult. Outdoors, every breath of air is clean and pure; indoors, especially in a closed room, one is soon reduced to rebreathing expired air, with all its impurities. Just as tainted meat or spoiled fruit or vegetables are unwholesome, and bad for the stomach and general system, so is impure air harmful to the lungs and general health. One organ surely deserves as much consideration as another. And when the lungs become impaired through disease, it is still more necessary to take care of them. They need to be strengthened in every way, in order to defy the inroads of tuberculosis. The nurse must make her points clear and emphatic; if the patient takes an intelligent interest in his treatment, it will become less irksome.
But it is not enough to tell the patient why he needs fresh air—the nurse must show him how to get it. He is singularly helpless and unable to recognize such ways for himself. Also she must overcome his objections and bring him to her way of thinking. Thus, he objects to his porch because it is shaky, or because it may only be reached by passing through another person’s room. Investigation may prove the shakiness imaginary, or at least not dangerous, while the other person may be only too willing to let his room be used as passageway to this desirable goal. Again, he objects to sitting in the yard, or on the sidewalk, or even at his window, for fear of what the neighbours may say. It should be pointed out that his health is more important than their comments—whatever they may or may not be—and that his interest, not theirs, should come first. The nurse must plan every little detail; she must select his chair or sofa; must show how he can be warmly tucked up, and sit out of the wind or sun, as the case may be. She must teach the family about the hot brick and how to place it at the patient’s feet—or two hot bricks, if need be. It is not enough to say: Do thus and so—she must herself demonstrate how the thing is done. The consumptive is sick and helpless and needs constant reassuring. If he belongs to the very poor, he has little to do with, and is so ignorant that he cannot make the most of what he has. This teaching is one of the chief duties of the nurse.
Food. The third great essential in the trilogy is food. The patient’s diet is of the utmost importance, since his ability to take and assimilate nourishing food determines his ability to build up enough resistance to cope with tuberculosis. Generally speaking, he should be encouraged to eat every kind of nourishing food that he can digest—for tuberculosis does not call for a special diet as does typhoid or diabetes. Anything which specifically disagrees with him should, of course, be excluded. The question of food values must be considered; with the poor, this requires careful teaching and explanation. The nurse should point out the difference between food which merely fills the stomach, and food which nourishes and upbuilds. In the first class may be instanced cabbage, turnips, doughnuts, pies—all highly esteemed by the poor, and cheap and indigestible. In the second class are meat, eggs, milk, fish, rice, beans, hominy, oatmeal, and so forth. Some of these nourishing foods—rice, beans, hominy, oatmeal—are no more expensive than cabbage and pie. The family should be taught the difference. Very harmful and indigestible are the products of the corner bakery, the penny candies, the enormous pickles, and the copious strong brews of tea and coffee which form so large a part of the dietary of those near the poverty line. Considerable money is spent on these things—often money enough to provide a wholesome meal, if the family but knew how to discriminate. In planning a patient’s diet, the nurse will have to do as much exclusive as inclusive propaganda.
It is not necessary to insist on milk and eggs, certainly not in the abnormal quantities which a few years ago were considered indispensable in the treatment of tuberculosis. If a patient likes these and can afford them, well and good, but they need by no means be made the staple article of diet. This rich and highly concentrated food has a tendency to cause indigestion, and since this is one of the gravest and most distressing complications of tuberculosis, it must be prevented at all costs. A patient unable to digest his food has but slim chance of increasing his vitality, and little hope of improvement. Therefore, in advising raw eggs, the nurse must be very careful; one or two a day will be sufficient, over and above the regular meals.
Milk should be substituted for tea and coffee. Three or four glasses a day will be enough, and even that may be too much if the patient eats well of other things. In place of raw milk, it may be peptonized, malted, given hot, made into junket, taken in cocoa, or as one of the flavoured milkshakes, or turned into clabber or buttermilk. These varieties of milk are good for advanced patients, who may also be given egg albumen, flavoured with lemon, orange, ginger ale, grape juice, and so forth. The family must be taught to make these little innovations, in the ordinary diet, and instruction in these is part of the nurse’s work.
By careful supervision and attention, the nurse can procure a very satisfactory dietary, one both nourishing and digestible. Three good meals a day, with a little nourishment between meals and at bedtime (a glass of milk or its equivalent), will be found quite satisfactory. If a doctor is in attendance, he will of course arrange such diet as he thinks best, but if the nurse is left to herself, she will not overstep the boundaries if she advises some such plan as we have outlined.
As we have said, indigestion is one of the most frequent complications of tuberculosis. In some cases this can be overcome or relieved by advising rest in the reclining position for an hour before, and immediately following meals. If the patient lies flat on the bed or lounge, this will be more effective that if he sits in a rocking-chair.
Cooking. Cooking and the preparation of food also require supervision, for, especially among the poor, dense ignorance of these important matters prevails. Through improper cooking, wholesome, excellent food is often turned into something quite the reverse, indigestible and injurious to a high degree; or, if not ruined, it may lose so much of its food value as to be practically worthless. Thus, a hard-boiled egg or a fried egg (especially if fried on both sides) is less easy to digest than a soft-boiled one. A good piece of meat may have its entire value removed by overcooking. All nurses have had training in dietetics, and this special knowledge is of immense value in public health work, where for the most part they come in contact with a class of people whose ignorance of culinary matters is profound.
Alcohol. The question of giving alcohol frequently arises in this work. If a doctor is in attendance, he will prescribe it or not as he chooses. But if the nurse alone is in charge of the case, and the matter is left to her decision, we feel that the ruling of the Phipps Dispensary of the Johns Hopkins Hospital is a wise one to follow—no alcohol for the consumptive under any circumstances. This means that there shall be no eggnogs, made with brandy, sherry, rum, etc.; no sherry with raw eggs—no indulgence in wine, beer, or alcoholic stimulants of any sort.
The Bedridden Patient. When the patient is confined to bed, the nurse’s task becomes easier. Isolation, therefore better protection to the family, is more readily secured than when he wanders from room to room, leaving a trail of germs behind him. It is well to exclude from the sick-room every one except those in actual attendance upon the patient; this is especially necessary in the case of children, to whom the danger is greatest. Neighbours and friends should also be excluded, and if they refuse to consider the risk, the plea for exclusion should be made on the ground that visitors are disturbing and harmful to the patient.
In the sick-room we sometimes find the young children of neighbours, whose mothers are all unconscious of the danger to which they are exposed. If through sheer indifference, the patient’s family does not exclude these children, it would then become the nurse’s duty to seek out their parents and warn them. When a patient’s household becomes indifferent to community welfare, the nurse should then extend her teachings farther afield—into the next house or block if need be—and try to protect others who are unknowingly exposed to infection.
In brief, these are the duties of the nurse in the home of the patient. At her first visit, she cannot say everything she wishes, but later it will be possible to do so. In many cases, the household will be suspicious, antagonistic, or not inclined to want her, so that she must feel her way cautiously, step by step. It may take two, three, four, or even a dozen visits to accomplish her object, and before she can drive her points home with the requisite vigour. When the situation is acute, and the danger great, it is difficult and discouraging to make haste slowly, yet this policy will pay in the end. It is better to proceed cautiously with an uneasy family, winning them gradually from point to point, than to arouse their resentment by an impatient enthusiasm which sees no wisdom in delay.
In dealing with patients, the nurse must speak plainly; it will not do to insinuate or imply. What she has to say must be said straightforwardly, in simple words adapted to the intelligence of her hearers. The situations one encounters in this work are often sad and trying to a degree, and it would be far easier to insinuate a disagreeable or painful thing than to speak out plainly. The nurse who cannot express herself clearly, forcibly, and convincingly will get poor results. She must be able to meet prejudice with reason, to impose her view upon another, and to convince the ignorant that what she says is right.
There is an old fable which all public health nurses should remember—the old story of the Wind and the Sun, who both tried to remove the Traveller’s cloak. The Wind tried first, and he blew and blustered, but his frantic efforts only made the Traveller clutch it tighter. And then the Sun tried. He shone, blandly, warmly, gently, and in a few moments off came the cloak. It is the method of the Sun, rather than of the Wind, which usually wins out.