Copyright
Charles Field Mason.

A complete handbook for the sanitary troops of the U. S. army and navy and national guard and naval militia online

. (page 14 of 38)
Online LibraryCharles Field MasonA complete handbook for the sanitary troops of the U. S. army and navy and national guard and naval militia → online text (page 14 of 38)
Font size
QR-code for this ebook


should be inclosed in a flannel cover or otherwise wrapped to prevent
danger of burning; when used about unconscious or paralyzed
patients especially, the greatest care and watchfulness should be
employed to prevent accidents. Hot-water bags should be filled a
little more than half full and all the air expelled before the top is
screwed on ; this makes them lighter and more easily adjusted.
They should be examined closely before use to see that they do not
leak. Hot bottles are not very safe, as they are apt to crack or burst.
The great advantage of bricks is that they retain the heat a longtime,
but they are very heavy and awkward.

Moist heat is more penetrating and more relaxing than dry heat.
It is applied in the form of poultices or fomentations or stupes.

Poultices are made of various materials ; anything which will hold
heat and moisture is adapted to the purpose; flaxseed meal is the
time-honored basis for poultices, and where the skin is unbroken
answers very well; but where a wound or abrasion exists such a
poultice is a veritable culture-bed for bacteria, and should be re-
placed by layers of gauze wrung out of a hot antiseptic solution
and covered by a layer of cotton batting and oil silk.

To make a flaxseed poultice stir the meal slowly into boiling
water until a thick paste is formed; boil for a few minutes, then

(169)



170



NURSING



beat briskly with a spoon until the admixture of air makes it light ;
spread with a spatula or knife to the thickness of one-fourth or one-
half inch upon strong muslin, leaving a free -border of an inch all
the way round. Then cover the face of the poultice with gauze,
or oil it with vaseline, and turn over the edges. Apply, and cover
with a layer of cotton and oil silk. Such a poultice should be changed
once every two or three hours. The fresh poultice should be ready
before the old one is removed, and they should never be used a
second time. Oatmeal or cornmeal will do very well in the absence
of flaxseed.

A fomentation or stupe consists of a couple of layers of flannel
wrung out of hot water and cover with cotton and oil silk. A few
drops of laudanum or turpentine are sometimes sprinkled upon the




FIG. 89. Application of Cold Compresses to the Eye.

flannel after it is wrung out, or added to the hot water. To prepare
a stupe dip the flannel in very hot water and wring it out quickly
with a stupe wringer composed of a strip of muslin about eighteen
inches square with a stick run through a hem at each end; any
stupe which can be wrung out with the hands is not hot enough to
be of much value. Stupes must be changed oftener than poultices
about once or twice an hour.

Cold is used locally to relieve pain and reduce inflammation. It
may be applied in the form of compresses, the ice bag, or cold coils.

Cold compresses consist of a couple of layers of gauze dipped in
ice water or laid upon ice and afterward applied to the part ; they
must be renewed constantly before they get warm'. A large piece



EXTERNAL APPLICATIONS 171

of ice is placed in a basin upon a towel or piece of flannel ; upon this
the compresses, first soaked in water, are placed; as a. fresh one is
taken the old one is put back upon the ice (Fig. 89).

The ice bag is filled about half full of finely crushed ice mixed
with a little salt, and care taken to expel the air before it is closed.
A layer of dry lint or cotton is placed between the bag and the skin
to prevent pain or even frost-bite. Care must be taken to refill the
bag before all the ice melts; nothing is more common than to see
neglect of this necessary rule. To crush the ice conveniently a stout
canvas bag and mallet should always be at hand.

Ice-water coils are made of rubber tubing sewed upon a piece of
rubber sheeting of such size and shape as to fit the part to be kept
cool; several feet of tubing are left free at each end to act as a
siphon ; one end is placed in a pail of ice water above the patient's
head and the other in a basin on the floor, and the siphon started.

Lotions are medicated solutions used externally. Evaporating
lotions are applied on a single layer or two layers of gauze and left
exposed to the- air. With other lotions several layers are used and
covered with a protective.

Counter-irritants are substances used to produce irritation of the
skin in order to relieve pain, congestion, or inflammation in a part
beneath or even at a distance; they accomplish this by dilating the
superficial blood-vessels, and at the same time by reflex action causing
a contraction of the deeper ones, thus drawing the blood away from
the affected part. Counter-irritants are classified as: rubefacients,
those causing only redness of the skin; vesicants, those producing
blisters; and the cautery.

Mustard, turpentine, iodine, liniments, and cups are rubefacients.
Mustard is used in the form of foot bath, poultice, plaster, and
leaves. The first two have already been described. A mustard
plaster is prepared by mixing one part of mustard with one to five
parts of flour according to the strength desired ; sufficient tepid water
is slowly added to make a smooth paste, which is then evenly spread
on paper or muslin and covered with a layer of gauze or tissue paper.
The plaster is applied to the part and held in place by a bandage or
adhesive-plaster strips. Hot water or vinegar should never be em-
ployed in making a mustard plaster, as either causes the evaporation
of the volatile oil of mustard. The plaster should be left on for
twenty minutes or a half-hour, the purpose being to produce redness



172 NURSING

of the skin. In old persons and children the effect should be closely
watched to prevent blistering. After removal, any adherent particles
of mustard should be wiped away and the surface dusted with
starch or oiled with vaseline.

Mustard leaves are ready prepared and require only to be dipped
in tepid water before use; the objection to them is that they have
usually lost their strength.

Turpentine is used in the form of stupes above described.

Iodine in the form of tincture is painted on the part, one or two
coats, with a camel's-hair brush. Where the skin is thin and moist,
as in the groin or in young children, it may blister. When the burn-
ing caused by it is excessive it may be stopped by washing off the
iodine with alcohol. The stain may be removed by washing with
ammonia or thiosulphate of soda.

The various stimulating liniments have some value as counter-
irritants, though they are chiefly useful by virtue of the massage by
which they are applied.

Dry cups act not only as a counter-irritant but they also leave
an actual extravasation of blood beneath the skin ; they cannot be
applied over bony or irregular surfaces. The number is usually
designated, from a dozen to a hundred; half a dozen or more may
be in place at a time and they may be left on about five minutes
unless they drop off sooner. To apply them we need a dozen cups
or small tumblers, an alcohol lamp, a cup of alcohol, a swab, matches,
and towels. The swab is prepared by wrapping tightly with cotton
the end of a small stick, probe, or wire.

Dip the swab in the alcohol, light it, hold it for a moment inside
the cup to exhaust the air, then quickly apply the cup to the part;
repeat the motion as rapidly as possible. Be careful to avoid burn-
ing the patient by dropping burning alcohol upon him or by undue
heating of the edges of the cup. To remove the cup hold it in one
hand and with the index finger of the other press the skin just under-
neath the edge of the cup so as to admit the air, when the cup will
fall off. Before reaplpying the same cups they must be wiped dry
inside with a towel. Wet cupping is done in the same way as dry
cupping only the skin is first scarified by means of a special instru-
ment known as a scarifier.

Biers cups, which have an attached rubber bulb as an exhaust



EXTERNAL APPLICATIONS 1/3

pump, are used not only as a counter-irritant, but to relieve inflamma-
tion and pain by increasing the amount of blood in a part.

Vesication or blistering is used when we wish a more decided effect
than can be obtained from rubefacients. The principal vesicant
is cantharides in the form of plaster or collodion. Before the appli-
cation of a blister the skin should be washed, and shaved if neces-
sary; a piece of plaster of the designated size is then moistened with
a little alcohol, applied to the part, and held in place by a bandage ;
strips of adhesive plaster are objectionable because they may exert
painful pressure on the blister as it rises.

The cantharides is left on until a blister forms, usually eight to
ten hours ; at the end of that time if there is still no blister the plaster
should be removed and a poultice applied; this will usually raise
the blister promptly. The cantharidal collodion is used by painting
on a couple of coats and covering with cotton or oil silk. When a
blister is required to be raised quickly it is done by soaking a
piece of lint with ammonia or chloroform, applying it to the part
and covering with a watch glass or cupping glass to prevent evapora-
tion. A still more prompt effect may be obtained from the actual
cautery.

After the blister is raised its management will depend upon the
directions of the physician. It may be protected by a layer of cotton
and left to be absorbed unbroken, or it may be punctured with a
sterile needle and the fluid allowed to escape, or the whole of the
raised cuticle may be cut away and the raw surface dressed.

The actual cautery is simply a hot metal instrument applied to
the skin usually at a cherry-red heat ; it is used to relieve pain, cause
the absorption of effusion, and to control bleeding. The form used
in the army is the Paquelin cautery, an instrument in which the
platinum tips, first heated in an alcohol flame, are maintained in-
candescent by pumping into them the vapor of benzine; it is a
valuable appliance, but requires care in handling, as it readily gets
out of order. The benzine is poured into the reservoir until the
lint or sponge which it contains is just saturated; any free liquid
might get into the tube and cause an explosion.

Care must be used not to let anything touch the tip while it is hot.

Among the caustics in common use are nitrate of silver (lunar
caustic), sulphate of copper (blue stone), and nitric acid.

Lunar caustic is kept in a caustic holder; it should be cleaned



174 NURSING

before use with a piece of moist cotton, and dried after use ; it should
not be allowed to touch the hands or linen, because it makes a black
stain. To give a point to a stick of lunar caustic rub it on wet lint ;
never attempt to scrape it.

Blue stone is used especially for touching granulated lids; the
crystal should be ground to a point on a fine stone.

Nitric acid is used for burning (disinfecting) chancroids. Dry
the ulcer and drop on it a few drops of four-per-cen f solution of
cocaine; after a minute or two dry again, dip the wood end of a
match in the nitric acid and touch thoroughly every point of the
sore ; then pour cold water over the part.



CHAPTER VII

TEMPERATURE, PULSE, AND RESPIRATION

THE normal temperature of the human body is about 98.6 F.
(37 C.), but the normal varies within certain limits according to
the part of the body in which the temperature is taken, and accord-
ing to the time of day. The temperature is ordinarily taken in the
mouth, in the axilla, or in the rectum; the axillary temperature is
about one-fourth of a degree lower than that taken in the mouth,
while the rectal temperature is a fourth to a half a degree higher.
The highest temperature is usually recorded about four o'clock in
the afternoon and the lowest about two o'clock in the morning; the
difference may be as much as a degree. A variation of temperature
below 97.5 F. or above 99 F. may be regarded as abnormal and
an indication of disease.

Abnormal temperature may be subnormal or elevated.

Subnormal temperatures are produced by anything which causes
a general depression of the vital powers. Shock, hemorrhage, heat
exhaustion, exhausting disease, may all cause subnormal tempera-
ture ; when the depression of temperature is below 96 F. the con-
dition is one of collapse.

Elevation of temperature, or fever, means either that more heat
is being produced than usual or that it is not being gotten rid of
promptly ; usually both conditions are present. You will remember
that the evaporation of perspiration is one of the most important
provisions of nature for regulating temperature, and as a matter
of fact in fever the skin will usually be found to be very dry. A
fever of 100-103 F. is regarded as moderate; 103-105 F. as high
fever, while temperatures above 105 F. are denominated hyper-
pyrexia.

A depression of temperature of several degrees is usually of much
.more importance than a corresponding elevation ; thus a depression
of three and a half degrees would give a temperature of 95 F., or
the temperature of collapse, a condition which means speedy death



176 NURSING

unless prompt reaction takes place. On the other hand, an elevation
of three and a half degrees would only give 102 F., a temperature
by no means alarming. Hyperpyrexia, however, temperatures 106
to 109 F., is very dangerous, although recovery has often followed
prompt remedial measures.

The instrument for measuring the temperature of the body is
called a clinical or self-registering thermometer. The self -register-
ing feature is secured by a break in the mercurial column correspond-
ing to a constriction Jn the glass. When the mercury column has
risen above the normal line, which is usually indicated by an arrow,
it must be shaken down by a sweeping motion of the arm before the
thermometer is used again.

The Fahrenheit scale is usually employed in this country, but the
thermometers issued to the army are generally graduated in the
Centigrade scale also. The normal in the Centigrade is 37, 40 C.
corresponding to 104 F. To convert Fahrenheit degrees into Centi-
grade subtract 32 and multiply by %. For example :
98.6 F. = [ (98.6 - 32) X %] = 37 C.

Conversely, to convert Centigrade to Fahrenheit multiply by %
and add 32 ; example :

37 C.= [(37 X %) +-32] =98-6 F.

When in doubt about a thermometer compare it with one of
known accuracy by simultaneous observations on the same patient.

Temperatures are ordinarily taken in the mouth, the bulb being
placed under the tongue and the patient directed to close his lips,
but not his teeth upon it. If the patient is very weak it may be
necessary for the nurse to hold the thermometer in his mouth. With
modern thermometers three minutes is ample for mouth tempera-
tures. When the patient is delirious or unconscious, or is a child,
it is not safe to take the temperature in the mouth.

In infants and children the temperature is usually taken in the
rectum ; the bulb well oiled is introduced for about an inch and a
half ; one or two minutes' time is sufficient.

To take a temperature in the axilla, the arm pit is first wiped dry,
the bulb put in place and the arm carried across the chest so as to
bring the opposing skin surfaces in close contact with the ther-
mometer ; a little longer time is required than in the mouth or rectum
about five minutes usually.

Thermometers when not in use should be kept in an antiseptic



TEMPERATURE, PULSE AND RESPIRATION 177

solution and resting on a bed of cotton ; bichloride of mercury is
objectionable for this purpose as it soon removes the markings on
the glass. Before using for another patient the thermometer should
be rinsed in clean water and wiped dry.

Fevers are classified as continued, remittent, or intermittent. A
continued fever is one in which the temperature is continually above
normal, and there is a difference of not more than about one degree
between morning and evening; typhoid fever in the second week
is usually a continued fever. In remittent fever there is a decided
drop some time in the twenty- four hours, but the temperature does
not reach normal. In the intermittent fevers the temperature at
certain intervals falls to or below the normal ; malarial fevers are
apt to be remittent or intermittent.

In keeping a record of fevers charts or thermographs are employed.
Temperatures are usually recorded morning and evening, but in
typhoid fever and other serious fevers this is generally done every
three hours or oftener. In marking charts a dot is placed on the
point at which the temperature stands, and these dots are connected
by straight lines drawn with the aid of a ruler.

The normal pulse rate in the adult is about seventy-two to the
minute; it varies, however, from about sixty-five to seventy-five.
In children it is much more rapid. In fevers it rises considerably.

The condition of the pulse is very important, as it usually accur-
ately indicates the condition of the heart and vital powers.

The pulse may be taken by laying the fingers gently on any super-
ficial artery, but usually the raidal artery is the most convenient;
the temporal is also frequently used for the purpose. The points
to be noted are frequency, regularity, intermittence, fullness, tension
and strength. Frequency of the pulse is increased by exercise, food,
excitement, and position ; the pulse is more frequent in the standing
position than when lying down or sitting.

An irritable pulse is one which is easily excited; an intermittent
pulse is one which drops a beat now and then ; a dicrotic pulse occurs
in extreme weakness, as in typhoid fever, and consists of two waves
to each beat so that the rate may appear twice as fast as the actual
pulsations of the heart.

The normal respirations occur at the rate of about eigtheen to the
minute. In disease there occur marked variations in the frequency
and character of the respirations ; in narcotic poisonings the respira-
12



178 NURSING

tions are very slow, while in pneumonia and peritonitis they are very
rapid.

In taking respirations one should notice their frequency and
regularity, whether difficult or easy, noisy or quiet, deep or shalloiv,
and whether symmetrical, that is to say, the same on the two sides
of the chest.

Cheyne-Stokes respiration is that peculiar type of breathing which
occurs in certain diseases of the heart and kidneys. The respira-
tions gradually increase in frequency and intensity up to a certain
point, then slowly decrease until they seem to entirely cease; after
a short pause the same course is gone through with again.

In stertorous breathing there is a loud snoring noise with inspira-
tion.

Dyspnea means difficult or painful breathing.

In taking respirations it must be remembered that they are in
a measure under the control of the will; therefore, they must be
taken without the patient's knowledge, and this is done by laying
the arm across the chest in taking the pulse, and then without remov-
ing the fingers from the wrist taking the respiration while appear-
ing to take the pulse. With a little practice a nurse should become
so expert that he can take the pulse and respiration of a sleeping
patient without arousing him.

In the normal condition, the pulse, temperature, and respiration
rates have a definite relation to each other, and the three factors
should always be considered together in disease, as disturbance in
the normal ratio may have the most important meaning.

In health the pulse rate is about four times the respiration rate ;
w r hen the respiration rate is increased to a third or a half of the
pulse rate it is usually an indication of disease of the lungs such as
pneumonia. In fevers, when the temperature rises the pulse becomes
proportionally more rapid ; if instead of rising with the temperature
the pulse slowly falls, an important sign of yellow fever is present ;
if, on the other hand, the pulse rate becomes more rapid than that
which is usual with a given temperature, it is an indication of weak-
ness and diminished vital powers.



CHAPTER VIII

SYMPTOMS AND CLINICAL RECORD

ONE of the most important duties of a nurse is to cultivate the
habit of observing symptoms accurately and reporting them clearly
and intelligently.

The physician can only be with the patient a short time, and he
must depend upon his nurse to inform him of everything that takes
place in his absence; the nurse may thus obtain information of
the greatest value in diagnosis and treatment. Symptoms may be
divided into two classes : subjective symptoms, those which are only
apparent to the patient himself, such as pain ; and objective symp-
toms, those which are apparent to others, such as redness and swell-
ing. Sometimes the symptoms are feigned, when the patient is said
to be malingering; it is always safer to assume, however, that the
symptoms are real until the contrary is proved.

Not only must the nurse cultivate the habit of observing symptoms,
but he must learn how to attach to them their relative importance.
Emergencies continually arise when he must determine what is to
be done ; are the symptoms of sufficient gravity to cause him to call
in the noncommissioned officer or send for the surgeon? Shall he
loosen a bandage or give a stimulant on hi.s own responsibility ?

The observations should commence with the giving of the first
bath or putting the patient to bed. Are there any scars, wounds,
or eruptions upon the body? Is the patient emaciated or dropsical?
Does he appear weak and ill? The attitude and expression are
sometimes characteristic. In inflammation of one lung the patient
usually lies on that side so as to give free play to the uninjured lung.
In appendicitis or peritonitis he is apt to lie on the back with one or
both legs drawn up.'

Slipping down toward the foot of the bed means weakness and
is therefore unfavorable.

With colic the patient often lies on the abdomen with a pillow
pressed against it; but when the pain is inflammatory he can not
stand the pressure.

(179)



180 NURSING

When the patient can not breathe while lying down there is usually
trouble with the heart or lungs.

Great restlessness is often a bad sign.

An anxious look is unfavorable, while a tranquil expression is of
the opposite import.

The pallor and pinched expression of seosis are characteristic,
but can not well be described.

Rattling in the chest, with shortness of breath and a bluish tint of
the lips, is a sign of edema of the lungs and often indicates approach-
ing death.

The mental condition gives important indications: whether the
patient is conscious or unconscious ; rational or irrational ; depressed
or excited or muttering. The speech may be thick or clear or hoarse.

The eyes are to be observed; whether the pupils are dilated or
contracted or unequal; whether there is any squinting; any yellow-
ness or congestion of the conjunctiva.

The hearing may be painfully acute or it may be defective ; there
may be a discharge from the ear.

Bad taste may be complained" of or offensive odors.

The skin, especially of the face, may give important indications ;
it may be pale, flushed, livid, or jaundiced; hot, cold, dry, or moist.
A moist skin with high temperature is usually a bad omen. A
peculiar red spot high up on either cheek is often indicative of pneu-
monia or consumption; pallor about the lips is a sign of nausea.
Then we have the waxy hue of Bright's disease and the rashes of
the eruptive fevers ; the sallow color of narcotic users, the pallor of
anaemia, the blue tint of cyanosis, the bronzing of Addison's disease.
Bluish spots about the size of a finger nail distributed about the
trunk are a sure sign of body vermin.

The tongue offers many valuable indications; note whether it is
dry or moist, clean or coated, large or small, bitten, or indented on
the edges by the teeth. In malarial fevers and digestive disorders
the tongue is apt to be heavily coated and indented by the teeth;
in typhoid fever it is at first moist and coated, but soon becomes
dry and cracked; when such a tongue becomes moist and begins
to clean up from the edges it is a very favorable sign. In scarlet
fever the bright-red papillae showing through the white fur produce
the characteristic strawberry tongue. In yellow fever the tongue is
small, red, and pointed.



SYMPTOMS AND CLINICAL RECORD 181

Note at the same time the condition of the mouth and teeth; white
slightly raised patches on the inside of the lips and cheeks, at the
corners of the mouth, and in the throat are frequently mucous
patches, a sign of syphilis. The dark accumulations which occur on
the teeth in fevers are known as sordes; their presence indicates that



Online LibraryCharles Field MasonA complete handbook for the sanitary troops of the U. S. army and navy and national guard and naval militia → online text (page 14 of 38)