When a patient asks for the bedpan it should be brought if possible without a moment's delay, not only because no other form of neglect makes a patient realize her helplessness more acutely, but also because the desire to use it often pa.s.ses quickly and delay may encourage the habit of constipation. If the patient does not ask for the bedpan, the attendant should offer it at suitable times. Bedpans should be warmed before use. An easy way to warm one is to let hot water run over it; the outside should afterward be dried.

To place the bedpan, first flex the patient's knees and push the night gown up; place one hand under the patient's hips, raise them slightly, and with the other hand slip the pan into place. If the patient is entirely helpless two persons are needed to lift her. Place a pad or folded cloth between the patient's back and the pan; then lower the patient gently. Before removing the pan, bring toilet paper, water and two pieces of soft old muslin or gauze. A patient, if able, prefers to use the toilet paper without a.s.sistance; her hands should afterward be thoroughly washed. If she is unable, the attendant must do everything needed. After the patient has been cleaned as thoroughly as possible with paper raise her hips with one hand and then remove the pan; it is important to raise her first because the skin often adheres and may be injured if the pan is suddenly pulled away; carelessness in managing the bedpan has caused more than one bed sore. Then remove the pan with one hand and cover at once. Turn the patient, if helpless, on her side, wash the parts with one piece of old muslin, thoroughly dry them with the other, and either burn or thoroughly wash both pieces afterward.

Empty the bedpan and clean it at once; ordinarily one can clean it without wetting or soiling the hands. Use cold water first, removing all adhering solid particles with a tightly rolled piece of toilet paper. Do not use a brush for this purpose. After using cold water, rinse the pan thoroughly in hot water, and at least once a day wash it well in hot soapsuds. Directions for disinfecting the pan will be given later, but remember that a properly kept pan needs no deodorant solution. Gla.s.s urinals should be provided for men, and kept clean in the same way.

Contents of both bedpan and urinal should always be carefully inspected; neither should be emptied in the dark.

DAILY ROUTINE IN THE SICK-ROOM

Obviously the routine of a patient's day must vary according to her condition, her preferences, and the amount of time the attendant has to give her. The temperature, pulse, and respiration must be taken and all medicine, nourishment, and treatment given at the exact times ordered, but the attendant should learn whether or not the doctor wishes her to wake the patient for food or treatment. Good management in the sick-room depends upon foresight and planning, and therefore it is well to keep in mind the following suggestions:

Vitality is lowest in the early morning, hence baths and treatments, especially if they are fatiguing or painful, should if possible be left until after breakfast. Patients often wake early and wait, weak and miserable, for the day to begin. A hot drink at this time may give relief and enable the patient to sleep again. Even though breakfast time is near, nourishment should be given as soon as the patient wakes. She may not admit that she is hungry, but her nourishment should not be delayed until the family breakfast is ready, or still worse, finished.

Before breakfast the bedpan should be offered, the patient's face and hands should be washed, her teeth brushed, her hair tidied, the bed straightened, and the room put in order. These services should require a few minutes only. The room if properly arranged at bed time needs only a little attention now unless untidy work has gone on during the night; disorder in a sick-room is as unnecessary in the early morning as at any other time.

After the patient has finished her breakfast she may rest, or if allowed, read her mail or the newspaper while the attendant prepares for her day's work; about an hour after breakfast the patient should be bathed, unless she prefers her bath in the evening. After the bath some form of light nourishment should be given, even to a patient who has regular meals. If a patient is able to sit up in a chair, the best time for her to do so is generally just after the bath and toilet have been completed; but if she feels tired she had better wait until afternoon.

The bed room can be better aired and cleaned if it is possible to take her into another room; and she herself generally profits by a change of scene.

The doctor should definitely state when and for how long a patient may sit up for the first time after an illness, and an amateur who may be ignorant of the dangers involved should not a.s.sume the responsibility of deciding. When a patient is to sit up for the first time, put on her stockings, slippers, and wrapper before she leaves the bed. Arrange an arm chair with pillows in the seat and at the back, bring it close to the bedside and cover it with a large blanket unfolded. The chair may face either the head or the foot of the bed. Help the patient to a sitting position on the extreme edge of the bed, with her feet hanging down. Next, standing in front of her and supporting her well, let her slip down until she stands upon her feet, then let her turn, and gently lower her into the chair. See that the patient while sitting up is warmly covered, and that her foot-stool, pillows, etc., are adjusted comfortably. Move her chair so that the outlook may be as interesting as possible, and at least a little different from the view from the bed.

Most patients like to look out of the window; children and old people enjoy it particularly.

If the patient shows signs of fatigue, she should go back to bed even before the appointed time. To help her back to bed, reverse the process of helping her out. A footstool may be needed if the bed is high, or two people to lift her if she is weak or heavy. When a patient is in bed no one should ever sit on the bed, lean against it, use it as a table for folding linen, making pads, etc., take hold of the bed posts in pa.s.sing, or touch the bed unnecessarily in any way.

The best time for visitors is the last of the morning or the early afternoon. A judicious visitor may do an immense amount of good, especially to a chronic patient; indeed, she may be the only ray of light in a dark day. Subjects of conversation should be pleasant, but not too stimulating or exciting. The visitor should be prepared to carry the burden of the conversation, to drop topics skillfully that seem to involve fatigue or excitement, and either to go or to stop talking if the patient seems tired. Visitors should remember to talk naturally and cheerfully on ordinary topics, and to avoid excessive sympathy and labored attempts to cheer the patient. They should also remember that few patients bear well even the mildest forms of teasing. The patient's room is not the place to discuss personal or family troubles; yet it is only too often chosen for such purposes, probably because the complainer knows that in it an audience is always to be found.

Visitors not belonging to the family should not be present in the sick-room during treatment of any kind, unless their help is required; neither, as a rule, should they stay during the patient's meals. A member of the family may stay with advantage if the patient tires of eating alone, but casual visitors almost invariably offend by undue urging if the patient's appet.i.te is poor, or by facetious remarks if it is good.

Ordinarily only one visitor should be admitted at a time, since a weak patient may be tired merely by looking from one to another. If it is desirable to limit the call, the attendant should tell the visitor beforehand how long to stay, or arrange a signal for the visit to end.

To announce baldly in the sick-room that the patient is tired and the visitor must go, will only elicit aggrieved protests from both. In illness lasting only a day or two all visitors should be discouraged; during colds, because they are communicable; during general fatigue, headaches, digestive upsets, and painful menstruation, because rest and quiet are highly desirable. Visitors at such times too frequently give injudicious sympathy, and may actually delay the recovery of patients who enjoy playing the role of interesting invalid.

The time when a trustworthy visitor is present may be the best time for the attendant to rest. The patient should be told when the attendant is going, and approximately when she will return. It is a mistake to slip away while the patient sleeps; she seldom fails to wake before the time scheduled and to resent the desertion. Surprises of any kind, pleasant or unpleasant, are seldom good for patients.

Toward the end of the afternoon the patient is probably tired, especially if she has not slept during the day. When fever is present her headache and restlessness increase as the day goes on, but it should be remembered that uncomfortable beds and too heavy covers cause much of the restlessness attributed to fever. Rubbing the back and legs with alcohol, giving a tepid sponge bath, remaking the bed or changing her position may help to soothe her.

The evening should be kept free from excitement, and every possible effort should be made to encourage sleep. It is a mistake to think that a better night results from keeping a sleepy patient awake all the evening; sick people should sleep when they can. Just before bedtime the attendant should prepare her own cot, and then make the following preparations for the patient to sleep: wash the patient's face and hands or give a sponge bath if it is desired, brush the hair, change the night gown, brush crumbs from the bed, tighten the sheets or remake the bed if necessary, rub the back and other pressure points with alcohol, shake the pillows, give liquid nourishment, preferably hot, cleanse the mouth, and give the bedpan. See that the patient's feet are warm, the bed covers right, the room ventilated properly and in good order, and the light extinguished or arranged for the night. If the patient is inclined to be wakeful a hot foot bath may help her, or sponging the entire length of the spine for fifteen minutes, using very hot water and long downward quiet strokes. No conversation should be encouraged during preparations for the night. Patients in bed all day often lose the habit of sleeping at the regular time, and lie awake far into the night from a vague feeling that someone else is coming or something further is to be done for them. Consequently last of all ask the patient if she wants anything more; if not, say good-night, go out and stay out, at least until she has had a chance to go to sleep. She is thus helped to realize that nothing further is likely to happen, and that it is time to go to sleep.

Toward morning the patient grows weaker. More bed covers will probably be needed, and they may often be added without waking her. Night at the best is a dreary time for the sick. Pain and weariness and discouragement are less bearable in the darkness; nervous fears and morbid fancies defy control. Never is kindness more needed or more appreciated than it is by those who lie awake and watch for the morning.

EXERCISES

1. Name all the causes, direct and indirect, of pressure sores.

2. Why are pressure sores generally more serious than injuries of equal extent to the skin of a well person?

3. Where are pressure sores most likely to occur and what are their symptoms?

4. What measures should be employed to prevent pressure sores?

5. Describe ways to support a person lying down in bed.

6. Describe ways to support a person sitting up in bed.

7. How may the weight of the bedclothes be removed from any particular part of the body?

8. How should a bedpan be cared for?

9. Describe in detail a day's routine either of yourself the last time you were ill in bed, or of another patient personally known to you.

Could the plan of the day have been improved, and if so, in what ways?

CHAPTER IX

FEEDING THE SICK

Substances used for food are generally grouped into three cla.s.ses, called the three nutrients. The nutrients are: first, the proteids or nitrogenous substances, which are found in meat, fish, eggs, milk, cheese, peas, beans, etc.; second, the carbohydrates, which include sugars and starch; and third, the fats, which are found in b.u.t.ter, oil, the fat of meat, etc. In addition to the nutrients, water and certain mineral salts are essential to life, while some indigestible material like the fibre of vegetables is needed to give bulk and to stimulate the action of the intestines.

The nutrients furnish the body with materials for growth, and for repair of tissues worn out by use; they also furnish fuel substances from which the body obtains its heat and its energy. All three nutrients can serve as fuel, but the proteids alone can furnish materials for growth and repair of tissues. In order to be used by the body for any purpose, nutrients must first go through a series of complicated changes known as digestion, which renders them soluble so that they can soak through the walls of the intestine.

THE DIGESTIVE PROCESS

Digestion begins in the mouth. There the food is crushed and its fibres separated by the teeth, it is moistened by the saliva, and substances in the saliva begin a chemical action upon the starch. Chewing should be sufficient to reduce the food to a soft ma.s.s well moistened with saliva.

Slow eating is desirable, but the emphasis should be placed on thorough chewing. For instance, long intervals between bites are of no special benefit if mouthfuls of food are washed down by swallows of water.

After it has been swallowed, the food pa.s.ses into the stomach and remains there for a variable length of time, while it undergoes further preparation for absorption. It is moved about by the contraction of the muscular walls of the stomach, so that it becomes mixed with the stomach juices and more thoroughly softened. Some digestion of proteids goes on in the stomach, and a little absorption through the walls.

Little by little the food is discharged from the stomach into the small intestine, and the most important part of digestion then begins. It is acted upon chemically by a fluid flowing into the intestine from an organ called the pancreas; this pancreatic juice acts upon all three nutrients and is of great importance in the digestive process. The bile and other juices that flow into the intestine perform important functions also.

The food ma.s.ses are moved along by rhythmic contractions of the intestine, and absorption goes on when the food has been so changed that it can soak through the intestinal walls into the blood and lymph vessels. The small intestine is about 20 feet long, and consequently affords a large surface for absorption, as does also the large intestine, into which the small intestine opens. The blood and lymph carry the digested food substances to all parts of the body, and thus the different tissues are provided with the materials they need for growth, repair, and energy. Excess of food substances may be stored as fat or expelled from the body.

As the blood and lymph go through the tissues they take from the tissues the refuse, or the part that remains after the fuel substances have been consumed. This refuse from the tissues may be likened to the ashes from a furnace; it is finally eliminated from the body through the kidneys and lungs, and to some extent through the skin and bowels. The part of the food that is not digested of course never soaks through the intestinal walls; it merely pa.s.ses through the small and large intestines and is finally expelled as feces or bowel movements. The characteristic odor of fecal matter results from the action of bacteria upon it while in the large intestine.

It must be remembered that the body is not nourished merely by swallowing food: in order to nourish the body food must also be digested, absorbed, and made use of by the tissues. Many factors may operate both in health and in sickness to render food indigestible. It may be originally unsuited to the human digestive apparatus, or spoiled, or poor in quality, or badly cooked. But even when wholesome in itself it may be ill-adapted to a particular person at a particular time; thus it may be too great in amount, or eaten at improper hours. Moreover a person's own idiosyncrasy or manner of living or fatigue or illness may render it especially indigestible for him.

Experiments have shown that pain, fear, worry, and other unpleasant emotions actually stop the action of the digestive juices and check muscular contractions of the small intestine. Furthermore, even the absence of pleasant antic.i.p.ation of food has been shown to delay digestion for hours. Thus scientific knowledge confirms our common experience that such mental states seriously interfere with digestion.

The converse is also true. Agreeable taste and odor of food, or even pleasurable thought of it, start the secretion of digestive fluids. It is a common saying that the mouth waters at the prospect of inviting food, but it is less well known that appetizing food does actually start the stomach juices also. A person who understands the physiological effect that the emotions have upon digestion is in a far better frame of mind to cope successfully with the difficulties of feeding the sick than one who considers sick persons' likes and dislikes entirely irrational.

FEEDING THE SICK

Nourishing the sick is not always an easy problem, but its importance can hardly be overestimated. Indeed, proper feeding in many illnesses makes the difference between life and death. The actual amount of nourishment needed in sickness is often less than in health, but it may be just as great, or even greater if the illness causes increased tissue waste. Yet the digestive process of a sick person must be rendered as little laborious as possible, all foods ordinarily difficult to digest must be eliminated, certain others must be withheld or restricted according to the nature of the sickness, and in addition one may have to deal with an appet.i.te that is capricious, diminished, or totally absent.

Diet for the sick is often a part of medical treatment; in such cases the doctor will prescribe special diets and his orders must be carefully carried out. Except for special diets, food for the sick is generally divided into four cla.s.ses: first, liquid or fluid diet; second, semi-solid diet; third, light or convalescent diet; and lastly, full diet. These diets are not very sharply distinguished.