FOURTH ARTICLE.

Having fully considered the choice and management of a sick-room, we now turn to those personal cares essential alike to the patient’s comfort and well-being.

We have already spoken of the need of absolute cleanliness in the sick-room; and as regards the patient himself, it is hardly possible to overestimate the importance of scrupulous attention to every detail affecting the purity of his immediate surroundings. Not only should bed and body linen be kept fresh and clean, but everything that has become soiled in using must at once be removed from the room. It is a very common practice in home-nursing to make a collection of dirty things, to be carried downstairs when any one is going; in this way, I have known a room to be fouled for hours, the patient being considered whimsical for complaining of odours not perceptible to his nurse. Now, any such complaint should receive immediate attention, and a nurse should never rest satisfied till she has discovered and remedied the evil. It not seldom happens that the patient’s sensitive condition makes him extra quick to discern such warning of danger; and the nurse who really desires to do her duty, instead of taking offence, will gladly avail herself of the help thus given; for it must be borne in mind that as surely as smoke indicates fire, so surely does a bad smell indicate a foulness of air, which will never be remedied till the cause has been removed. Remembering this, it will be seen how foolish is the practice of drowning unpleasant odours by the indiscriminate use of disinfectants; these have their special value—their proper sphere we shall consider in dealing with infectious diseases; but in ordinary illness, they are apt to be used simply as a covering-up of evils which demand entire and immediate removal.

As regards personal cleanliness, many people still retain the old-fashioned fear of washing, which used to condemn the patient to a state of dirt, equally uncomfortable and injurious. Of course, care and discrimination are needful, and if there is any doubt on the matter, it is better to ask the doctor’s opinion; but as a rule, daily washing of face, neck, and arms is possible in all cases fit for home-nursing; in addition, the legs and feet should be washed about every other day; and whenever practicable, a weekly bath should be given. For the daily wash, tepid water and a piece of flannel suit most patients best; but where cold sponging is a refreshment, it may be used, provided due care is taken to avoid a chill.

In cases where there is great feebleness, much care must be exercised in washing the patient and changing his body-linen. Before beginning, the nurse should see that the room is properly warmed, and that all she is likely to need is ready to hand; she must be careful that no draught shall reach her patient, and that he does not get a chill through unnecessary dawdling; at the same time, she must not hurry him, so as to increase the fatigue.

Any amount of washing is tiring to the very weak, and therefore toilet operations had better begin soon after breakfast. If possible, the body-linen should be changed at the same time. It is a good plan to keep two sets of under-linen going, so that the same may not be worn day and night. If the patient perspires much, the linen must be dried and warmed each time of changing; it is not enough that it has been once aired; every time it becomes damp the same process must be repeated. The same thing applies to towels, which are so often put away damp and used again without airing; no wonder that illness, resulting from cold, shivering or a fit of coughing, not seldom follows the washing process, whilst the simple precaution of using a towel well aired and warmed would do away with the discomfort.

Sometimes lying in bed produces great irritability of the whole skin, and the patient shrinks from any attempts at washing. In such cases, a soft sponge should be used, in one direction only, and that downwards; and a nice way of drying a sensitive part is to lay the towel smoothly over the place and pass the hand over the towel three or four times, very much as though drying a wet page with blotting-paper.

During the process of bit-by-bit washing, the bedclothes must be protected by a piece of mackintosh or thick towel; but should they become wetted, they must be changed at once, for even if not damp enough to do serious injury, there is sure to be some amount of discomfort; and everything, however small, that causes annoyance must be looked upon as a drawback to recovery, and treated accordingly.

In addition to the regular washing, any portion of the patient’s body that becomes accidentally soiled must be at once cleansed; and whenever the confinement to bed becomes lengthy, the back and shoulders should be washed every day with warm water and soap, thoroughly dried, and lightly dusted over with finely powdered starch. The patient must also be prevented from remaining too long in one position; and if too weak to move himself, it will be part of the nurse’s care to turn him from side to side every three or four hours. Where this is impracticable, pressure must be relieved by the use of cushions, those with a hole in the middle being most useful for the purpose. If these precautions are not taken, the most prominent bones, exercising undue pressure on soft parts, will cause them to give way, the skin will become tender and inflamed, and if not stopped in time, a painful wound, difficult to relieve or cure, will be the result. I have known cases where these wounds have caused infinitely more distress and pain than the patient’s actual disease; and yet, with few exceptions, it is only a question of care and attention. So true is this, that a trained nurse looks upon such wounds as a disgrace, and is constantly on her guard against them; but the inexperienced nurse neglects this necessary watchfulness, simply through ignorance of the danger to be avoided. But forewarned should be forearmed; and by taking care to avoid dirt, pressure, and creases in the bedding, even the most inexperienced stand a good chance of success in this most troublesome part of nursing. At the same time, if, in spite of care, any portion of the skin reddens or becomes sensitive, the doctor should at once be informed of the fact, for this is one of the best examples of the old saying, ‘Prevention is better than cure,’ and it is too late to cry out when the mischief is done.

If the patient is too weak to sit up and use a toothbrush, a piece of lint should be tied to the end of a small stick such as a penholder, and wetted with water to which a little Condy’s fluid has been added; with this, the nurse can easily clean the teeth and gums. Brushing the hair requires a certain amount of tact and gentleness; with female patients the hair is apt to get into a troublesome tangle, unless plaited up loosely and tied at the ends. Sometimes moistening the brush with toilet vinegar will be liked, and in not a few cases gentle brushing has a soothing effect. I remember one instance where, under this influence, and this alone, restlessness would subside into quiet, leading to refreshing sleep. The same effect may sometimes be produced by sponging the face and hands with tepid water, with or without the addition of a little vinegar or Eau de Cologne; and again, in other cases, letting the hands lie in a basin and gently pouring cold water on them will be found grateful. It is well worth a nurse’s while to study her particular patient’s taste, and to find out some such simple method of relieving the weariness and monotony of illness.

To lift a helpless patient is by no means an easy task to inexperience, and should never be attempted without help. When the patient is utterly helpless, two long poles or broom-handles will be needed; these must be tightly rolled round in the under sheet and blanket, and the patient can then be moved, as in a stretcher, by four bearers.

To move a patient from side to side, the draw-sheet alone is needed. Rolling one end close to the body, the nurse goes round to the other side of the bed, and by taking hold of the rolled-up part, will be able to turn the patient gently over with perfect ease. Where the draw-sheet is not being used, it is a good plan to let a heavy patient lie on a strong roller-towel, which can be used as above; and if two people grasp it firmly on each side, they will be able to move the patient up and down in bed without fatigue or injury. This plan is especially useful in dropsy, when the patient becomes a dead, heavy weight, and is often restless to a painful extent.

In many cases, a patient, otherwise helpless, will be able to move at least his position by the use of a strong towel or cord tied to the foot of the bed. Hospital-beds are almost invariably provided with a cord and handle for the patient to grasp; but a better thing still is a netted hammock, a simple contrivance consisting of a piece of netting—of twine or coarsest knitting-cotton—four yards long by one and a half wide, the loops at each end being drawn up with tape; these tapes are tied to the foot of the bed; and the netting not only serves as a cord, but, thrown over the patient’s head and drawn out across his shoulders and back, forms a most easy, comfortable support. I have seen patients sitting up thus, who had mournfully declared it an impossibility, and whose delight at the change of position was a thing to be remembered.

In grasping any part of a patient’s body, be very careful not to take hold with the finger-ends; the whole hand should be used, and the fingers slightly spread out; anything like a hesitating touch is exasperating, and indeed hesitation in any way must be carefully avoided in dealing with the sick. It is well to remember that a certain amount of work has to be done, and a certain amount of noise must follow; make up your mind how much, and go to work thoroughly, quickly, and quietly; quiet, though, must be natural, not laboured; the tiptoe, whispering style is torture to sensitive nerves; a firm, even tread and a distinct way of speaking should be cultivated; the latter, especially, will make all the difference to a patient’s comfort. To be constantly on the strain to hear is by no means soothing; and whispered conversation as to the patient’s condition must never be indulged in. Some people, realising this, will go out of the sick-room, to carry on low-toned consultations just outside the door and within hearing of the patient, who involuntarily strains every nerve in the endeavour to catch what is being said. Such treatment is even worse than unnecessary noise, and all discussion relating to the patient must be carried on where there is no possibility of his hearing it. It is a safe rule to avoid detailing the patient’s symptoms to relatives or friends; sensitive, delicate minds are often made to suffer unnecessarily, from the consciousness that sick-room details are being made the subject of curious inquiry and remark.

It not seldom happens that in delirium, or extreme weakness, the patient will let out some cherished secret, and this should be as jealously sacred to the nurse as though the confidence had been voluntary, the only allowable violation being when the revelation made throws any light upon the patient’s illness; in such a case, the doctor must be told; and this brings us to a most important point—the relations between doctor and nurse, a point which is seldom understood by the inexperienced.

The nurse’s responsibility is great; she has many duties to perform, some of them apparently slight, yet really of vital importance; but at the same time, she is only acting under orders, and when those orders have been faithfully carried out, her responsibility ends; it therefore follows, that whatever her private opinion, she must never alter the treatment without the doctor’s express permission, and whatever she may think, she should never, by word or deed, seek to lessen the patient’s confidence in the patient’s doctor. It sometimes happens that injudicious friends suggest remedies of their own, and insist upon their being used; any such interference should be at once reported to the doctor, for how else can he form a right opinion as to the patient’s condition? Yet so often is this overlooked, that, I believe, in many home-nursed cases the doctor’s treatment is never allowed fair-play; and I have even known a prescription, that had been torn up by the doctor as unsuitable, carefully pieced together after his departure, and used. Perhaps in no other point is there such a marked difference between the trained and untrained nurse. The former has been taught that her power lies in obedience; the latter, ignorant of her very ignorance, ventures to meddle in matters which, had she but a little more knowledge, she would understand to be beyond her.

Not a little of the nurse’s value depends on her ability to give the doctor a proper report of how matters have been going during his absence. A patient will often pull himself together and even feign convalescence for the doctor’s visit, which is necessarily brief; whilst the nurse, spending hours with him, sees every varying mood and symptom; at the same time, she must remember that the doctor does not want her opinion, but asks only facts, which will enable him to draw his own conclusions. From this it will be seen that the nurse needs to understand what to notice and how to report her observations.

As to what to notice—each illness has its specific symptoms, about which the doctor will make special inquiries, and he will also expect to hear what effect has followed the use of remedies; but in addition to these, there are general symptoms to be taken account of in all illness. Amongst those most frequently overlooked by the inexperienced nurse, are: The appetite, whether good, failing, fanciful, or voracious. The skin, whether moist or dry, hot or cold; and whether sensitive to touch. Sleep, its character and duration; whether quiet, disturbed, broken, or uninterrupted, and whether the same by day and night. Posture, whether the patient lies very flat, or likes to be raised, or prefers to keep on one side; in going to sleep, the easiest attitude will be chosen, and any marked change in this respect should be noticed. Temper and spirits, whether equable or variable, moody, cheerful, excitable, calm, depressed, or inclined to tears. Countenance, whether liable to changes of complexion or expression.

When visitors are allowed, the effect upon the patient should be noted; and at any cost, in serious cases, those whose influence is depressing or exciting must not be admitted.

A nurse should also, without being fussy, keep an eye to any fresh symptoms that may appear, and duly report them; but nothing is more worrying than to be constantly teased with such questions as: ‘Are you in pain?’ ‘Do you feel better now?’ ‘Will you let me look at your tongue?’ Those who have endured the martyrdom, know what it means, and know, too, how little information can be gleaned by such methods. Let a nurse be sympathising by all means, but let her sympathy show itself in caring for her patient’s wants, and in efforts to save him from worry as well as from pain.

I remember a trained nurse who was deeply hurt at being told that a bell would be placed within her patient’s reach, in case he wanted anything at night. ‘Thank you, ma’am,’ was her reply; ‘my patient will not need to ring.’ Nor did he, thanks to his nurse’s constant care to anticipate his wants. A nurse thus watchful, will be quick to notice any change in her patient; but it is quite one thing to notice, and another to give a faithful report of what has been observed; and I would urge every inexperienced nurse to be very particular in jotting down at once all that strikes her attention. The simplest way of doing this is to keep a sort of diary of all that happens. Take a piece of writing-paper, keep one side for day and one for night, write the date at the top, crease it down the middle, and note on one half, all the patient takes and does, and on the other, anything you think demands notice. The following is a specimen of the sort of chart I mean.

October 4.
A.M.		A.M.
8.	Cup of tea and toast.
10.	Four ounces milk.	10.	Milk taken with difficultyand dislike.
11.	Medicine.
11.15.	Poultice to chest andback.
11.30.	Slept twenty minutes.	11.30.	Turned on right sidebefore going to sleep.
12.	Four ounces beef-tea.
12.30.	Mrs A. called, stayedquarter of an hour.
		12.45-1.30.	Excited anddepressed by Mrs A.’s call.
Are visitors to be allowed?

The reverse side might read thus:

October 4.
P.M.		P.M.
8.	Four ounces milk.
9.	Jacket poultice.
9.30.	Dozed half-hour.	9.30.	Skin hot and dry,face flushed; woke excited and restless.
10.	Opiate as directed.
10.45.	Slept two hours.
		11.30.	Began to perspire,expression tranquil; woke refreshed.
12.45.	Four ounces milk.

To keep such a chart properly requires some practice, but it is the only way of insuring accuracy, and it will also save a good deal of questioning on the doctor’s part, a glance being enough to show him how matters stand.

At the bottom of the first page, it will be noticed there is a question, which, unless so marked, would very likely be forgotten; and whenever the nurse is in any difficulty or uncertainty, she must never hesitate to ask for guidance. The doctor will not expect perfection from inexperience, and even if he does not volunteer information, will certainly not object to answering reasonable questions. Of course, there is a great deal of difference in this as in all things, and there are doctors who take for granted that everybody knows certain things, of which even the intelligent, who have not had their attention called to nursing, may be quite ignorant. But even when this is the case, the nurse’s object being her patient’s good and not the support of her own dignity, if she is not sure of her ground, it is her duty to ask for instruction.