After the bath rub the patient with alcohol. If a complete alcohol rub is impossible, at least rub the points where pressure comes, especially the back. After the rub apply a little toilet powder if the patient desires it. When the toilet is complete remove the bath blanket, remake the bed and put the room in order.

CARE OF THE MOUTH AND TEETH.--In sickness the mouth and teeth require more than ordinary attention; indeed, the condition of a patient's mouth is a fair index to the quality of the care she is receiving. If the patient can brush her own teeth she should do so in the morning, at night, and after meals. At those times the attendant, without waiting to be asked, should bring her a towel, tooth-brush, cup of tepid water, tooth paste or powder, and a small basin or dish to receive the used water. The process is generally more thorough when the patient does it herself, and even a patient unable to sit up can brush her teeth successfully if the nurse holds the powder and cup of water, and provides a basin shallow enough for the patient to use by turning her head to one side.

[Ill.u.s.tration: FIG. 17.--THE NURSE a.s.sISTING THE PATIENT IN BRUSHING THE TEETH. (_From "Elementary Nursing Procedures," California State Board of Health._)]

The attendant must cleanse the mouth of a patient who is unable to do it herself. If this cleansing is neglected, a dark tenacious substance collects upon the teeth and gums, composed chiefly of food particles, bacteria, mouth secretions, and worn out cells of the mucous membrane.

Once formed it is difficult to remove, hence the mouths of all patients and especially those who have fever, must receive proper care from the very beginning of illness. Cotton swabs are convenient for cleansing the mouth; they are made by winding a small piece of absorbent cotton upon a match or wooden tooth-pick.

To cleanse the mouth of a helpless patient, take to the bedside the mouth wash prescribed by the doctor, a towel to protect the bedclothes, several swabs, and a receptacle for used swabs; the latter should be a strong paper bag or several thicknesses of newspaper. Clean the tongue, gums, teeth, and s.p.a.ces between the teeth gently but thoroughly, using especial care if the gums are tender. Dip only clean swabs in the solution, discard each one after using it once, and burn it afterward.

Let the patient rinse her mouth after cleansing it if she is strong enough. If the mouth is very dry, encourage her to drink more water.

Notify the doctor if the gums and tongue crack or bleed since he may wish to order a special mouth wash. Cold cream or boracic ointment may be used if the lips are dry and cracked.

False teeth should be thoroughly brushed and cleansed, and kept in cold water if taken out during the night.

CARE OF THE HAIR.--Long hair, if neglected, becomes tangled and matted in a surprisingly short time. Unless the patient is actually in a dying condition she is not too sick to have it properly attended to at least once a day. Before combing the hair protect the pillow with a towel; then part the hair in the middle from the forehead to the nape of the neck, and draw it to either side. Begin to comb at the ends, holding the strand of hair firmly in one hand placed between the head and the comb; in this way tangles can be removed without hurting. After combing and brushing the hair, braid it in two braids, beginning near the ears; draw it as tightly or loosely near the head as the patient prefers, but remember that tight braids mean fewer tangles. If the hair is heavy or badly tangled the patient may be too much fatigued to have it all combed at one time; in this case braid the part that has been finished and complete the work later.

TO WASH THE HAIR OF A BED PATIENT.--The hair of a patient can be successfully washed in bed if sufficient care is taken not to chill or tire the patient, or to wet the bed. The following articles are needed: one small jug of strong soap suds made by dissolving a pure soap in hot water, one large jug of hot water at about 112 F., one jug of cold water, a slop jar or foot tub, one long rubber sheet or piece of enamel cloth, and several towels including at least one bath towel. Let the patient lie as near the edge of the bed as possible. Roll one small towel lengthwise, place it below the hair at the back of the neck, bring it up above the ears to the forehead and pin tightly, in order to catch water that might wet the face and neck. Next make a kind of trough of the large rubber by rolling its long edges inward for a few inches.

Place this across the bed under the patient's head so that her neck rests on the lower roll. Raise by means of pillows the end of the rubber trough that lies toward the middle of the bed, in order to prevent water from running into the bed or collecting under the patient's head. Let the other end of the rubber extend over the edge of the bed down into the slop jar or foot tub, which may be placed on a chair or stool. Then wash the hair and scalp with the soap solution, and rinse them thoroughly with water from the large jug. Squeeze as much water as possible from the hair, remove the rubber and subst.i.tute a heavy bath towel, and rub and fan the hair until dry. A shampoo in bed is tiring.

Do not attempt it unless the patient is strong enough to stand not only the shampoo itself, but also a complete change of bed clothing, which will almost certainly be necessary if the attendant has been careless or clumsy in the slightest degree.

HOT FOOT BATHS properly speaking are medical treatment, but they are taken by many persons to relieve colds, headache, or insomnia. Let the patient sit, well wrapped, with her feet in water at about 105, and then increase the temperature gradually by adding hotter water. Take care to add hot water slowly and not to pour it directly upon the patient's feet or ankles; otherwise she may be scalded. Mustard may be added to the bath water in the proportion of one tablespoonful of mustard to each gallon of water. If mustard is to be used make it into a smooth paste with cold water, thin the paste with warm water, and when thin enough to pour easily add it to the bath water and stir well. The bath may continue for 10 to 20 minutes, and the feet should be dried afterward without friction. The patient should go to bed at once; she should not wander about, clearing away her foot bath, doing forgotten things, getting herself chilled, and losing all the good effects.

A foot bath may be given easily to a patient in bed. Bring to the bedside a blanket, a towel, the tub filled with water, and something with which to protect the bed; this may be a rubber sheet, bath towel, old blanket folded, or several thick clean newspapers. Loosen the upper covers at the foot of the bed, fold them back above the patient's knees, and cover her legs and feet with the extra blanket making it overlap the bed clothing so that it will not slip. Flex the patient's knees, put the bed protector under her feet, place the tub on the side of the bed, raise the legs and feet with one hand and arm, and slide the tub into place with the other, raising the elbow in such a way that it keeps the blanket out of the water. Lower the feet slowly into the water, fold the towel, and place it over the edge of the tub in order to protect the patient's knees from the cold rim; then tuck the blanket closely about the tub and legs and proceed as before. After the bath use the towel, unless it is wet, to receive the feet when they are withdrawn from the tub. Remove the tub, dry the feet thoroughly, cover them warmly, and remake the bed.

COOL SPONGE BATH.--For feverish patients doctors often order cool sponge baths. In order to give a cool sponge bath, first protect the bed thoroughly, but leave the patient uncovered except for a towel laid over the hips. Use cool water, or cool water and alcohol, and have the wash cloth as wet as it can be without dripping. Bathe the body without friction, using long, light strokes, and leave each part wet until the bath has been completed. Do not use soap. Sponge in this way the arms, legs, chest, and back, but not the abdomen, for ten to twenty minutes, giving special attention to the neck and inner side of the arms and legs, because in those places large blood vessels lie nearer the surface of the body. After finishing the bath dry the body by patting it gently with towels.

Take the patient's pulse occasionally during the bath, and stop the bath at once if the patient's pulse grows weaker, if she shivers violently, or if her face, fingers, or toes turn a bluish color. Babies react rapidly to cool sponging; for a baby use tepid water, sponge for five minutes only, and watch the child closely during the bath.

EXERCISES

1. What may a bath be expected to accomplish in addition to cleansing?

2. In giving a tub bath, what precautions should be taken to avoid chilling the patient? to avoid tiring the patient?

3. What symptoms would lead you to think that a tub bath was not agreeing with a patient? What should you do in such a case?

4. Name six essentials of a skillfully given bed bath.

5. What preparations should be made and what articles a.s.sembled before beginning a bed bath?

6. Describe the method of bathing a patient in bed.

7. What care should the mouth and teeth of every sick person receive?

How should such care be given to a patient who is helpless?

8. Describe the daily care of a patient's hair, and tell how a shampoo may be given to a patient in bed.

9. How should you give a mustard foot bath to a patient in bed?

10. When and how should you give a cool sponge bath?

FOR FURTHER READING

The Human Mechanism--Hough and Sedgwick, Chapter XI.

CHAPTER VIII

APPLIANCES AND METHODS FOR THE SICK-ROOM

Patients who are confined to bed even for a few days often suffer acutely from muscular tension, from pressure, and from fatigue due to lack of exercise. Indeed, many a sick person is surprised to find that the bed which had seemed so infinitely desirable can change into a place of torment after a few short days of illness. "Bed-weariness" is hard to bear in any case of illness, but it is doubly hard for persons who are really helpless.

Unless the patient is an experienced sufferer he often has no idea what should be done to make him comfortable; while an equally inexperienced helper, though full of good will, is often discouraged to find that the arrangement she had thought perfect soon fails to satisfy her restless patient. But if she is willing to devote thought and ingenuity to removing small annoyances, she can do many things to alleviate his misery.

BED SORES, or pressure sores, are caused by continued pressure upon the skin. The weight of the body, or of a part of the body, if it comes for a long time upon one place finally interferes with the circulation in the tissues on which the part rests, and consequently interferes with the nutrition of the affected part. Any tissue to which the blood is not bringing all its necessary food supply tends to lose its tone, to become weak, and if the condition persists, to break down altogether.

The direct cause of bed sores then is pressure, and pressure is aggravated by moisture, wrinkles in the bed clothes, crumbs or other hard particles, lack of cleanliness, friction of any kind, or by rough, careless handling. Bed sores occur most often over bony prominences, such as the end of the spine, elbows, heels, shoulders, hips, ankles, and knees, but they may form anywhere, even on the ears or back of the head. They are more likely to appear on thin, aged, or depleted patients. These painful and serious sores can be prevented almost always by faithful care. When they occur, they result in the great majority of cases purely from negligence, and a person who knows the danger and yet through carelessness allows one to develop upon a patient may justly feel herself disgraced.

Prevention of bed sores depends upon keeping the skin dry and clean and upon relieving pressure by special devices and by turning the patient frequently. The parts where pressure comes should be washed at least twice daily with warm water and soap, rubbed frequently with alcohol to improve the circulation and to keep up the tone of the skin, and powdered with a little good toilet powder. Much powder is likely to do harm by collecting in hard, irritating particles. The bed should be kept constantly dry and smooth, and free from crumbs, lumps, wrinkles, or other inequalities. Prolonged pressure should be relieved by turning the patient often,--once every waking hour is not too often if the body is emaciated,--and by pillows, pads, and rings.

Small pillows or thick pads of cotton should be placed under the patient's back and shoulders, between the knees and ankles when he lies on his side, and in other places where sores are likely to develop.

Rubber rings are useful, but few patients like them for a long time.

They should not be inflated more than necessary to raise the affected part from the bed; if much inflated, they are uncomfortable and may do harm. The ring may be covered with a muslin pillow case, or it may be wound smoothly with long strips of bandage or old muslin. Ordinary cotton batting wound with strips of muslin may be made into rings and used to remove pressure from heels, elbows, or other parts. These cotton rings are less heating than pads, and give better support.

The first sign of a bed sore is either redness of the skin or a dark discoloration like a bruise. Every point where a bed sore may form should be inspected daily. If the slightest symptom of a sore appears, the patient must not lie on the affected part, and every effort should be made to keep the skin from breaking; vigorous rubbing at this stage is dangerous, and will by no means make up for previous neglect. The condition should be reported to the doctor at once. If in spite of all efforts the skin does break, a peculiarly difficult kind of open wound results which must be treated and dressed according to the doctor's directions.

DEVICES TO GIVE SUPPORT.--The variety and number of pillows one patient can use is almost unlimited. A weak patient when lying on his side should have his back supported by a pillow. When he lies on his back a pillow should be placed under his knees to lessen muscular tension, and if he may be raised in bed, several pillows are needed to support him comfortably. A back rest is useful for a patient who can sit up in bed.

Satisfactory back rests of several types can be purchased, or one may be improvised from a straight chair placed on the bed bottom side up, so that its legs lie against the head of the bed and its back forms an inclined plane. Back rest and chair alike should be covered by several pillows to make them comfortable, and other pillows should be used to support the patient's arms.

A person who is sitting up in bed always tends to slip down toward the foot. This tendency may be corrected by using a foot rest, knee pad, or pillow. A hard pillow may be placed in the bed at the foot for the patient to brace his feet against; or a short board, well padded, may be arranged as follows for the feet to rest against: Fasten ropes to the board, as the ropes of a swing are fastened to the seat; set the padded board on edge at a convenient point below the patient's feet, and hold it in place by tying the ropes of the "swing" to the head of the bed. A pillow may be used in the same way, either at the feet or under the knees, by folding it over a long strip of muslin, the ends of which are then tied to the sides of the bed, brought up to the head, and there tied to prevent slipping. A cylindrical cushion six or eight inches in diameter and as long as an ordinary pillow, stuffed with firm material, may also be used for this purpose. It should be held in place by strips of strong muslin or ticking sewed to the ends of the cushion and tied to the head of the bed. The cushion should have a washable cover.

[Ill.u.s.tration: FIG. 18.--SHOWING FOOT-SLING FOR SUPPORTING PATIENT IN THE UPRIGHT POSITION. (_Sanders "Modern Methods in Nursing."_)]

Supports called _bed cradles_ are used to keep the weight of the bed covers from sensitive parts of the body, generally the feet or abdomen.

They are semi-circular pieces of wood or iron fastened together so that they will stand up. A satisfactory cradle may be improvised as follows: Cut a barrel hoop in two, cross the halves at right angles and tie them together firmly; place the cradle over the affected part under the bed clothes. A smaller cradle may be made by taking sections that are less than half of the barrel hoop. If used for one foot only, the cradle should be small enough not to interfere with the motion of the other foot; if used for both feet, it should be large enough to allow some freedom of motion. Since the cradle leaves an air s.p.a.ce, the feet should be wrapped in a piece of soft flannel. A cradle used for the protection of the abdomen should extend a little beyond the body on each side.

[Ill.u.s.tration: FIG. 19.--ADJUSTABLE BED REST.]

Adjustable tables are convenient for patients who are able to sit up in bed. These tables are supported on one side only so that they may extend over the bed. Another kind of bedside table has short legs and stands directly on the bed. Such a table can easily be made at home from a wide board with supports six or eight inches high nailed to each end. A lap board supported by heavy books may serve for temporary use. Indeed, home-made subst.i.tutes are often as good as expensive apparatus or even better. If sick-room appliances must be bought, it is well to remember that simple standard designs are best. Complicated apparatus is soon out of order, and is generally a trial both to the patient and to those who must adjust it. Persons taking care of chronic patients may often obtain valuable suggestions in regard to appliances by consulting a visiting nurse or the superintendent of the local hospital.

[Ill.u.s.tration: FIG. 20.--ADJUSTABLE TABLE.]

BEDPANS are utensils to receive bowel and bladder discharges of patients lying in bed. Enamel bedpans are better than porcelain, although more expensive. The shape known as the "Perfection" is best for general use.

A "slipper" bedpan, although harder to clean and ordinarily less comfortable, may be preferable if it is especially difficult or undesirable to raise the patient. The square or douche pan is preferred by some people, and is especially useful when the quant.i.ty of discharge is large, as after an injection.