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Charles Field Mason.

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

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a force pump for compressing- the air, tubing for connections, a
cut-o.ff for controlling the escape of the compressed air, and a set
of spray tubes (Fig. 206).

Apparatus, electric: This is issued in several forms. The essen-
tial parts are the cells, which generate the current, the electrodes by
which it is applied, the conducting cords, and the coil and inter-
rupter in the case of a faradic battery (Fig. 207).

Apparatus, restraint: This is contained in a locked wooden box,
and consists of a bed strap which is firmly fastened to the bed before
the patient is placed upon it ; a breast strap which fastens the patient
to the bed strap and bed, anklets, wristlets, a muff, and a set of keys,
by which the buckles of the apparatus can be locked (Fig. 208).



INSTRUMENTS AND APPLIANCES 235




FIG. 108.



236 NURSING



Explanation of Figs. 209 to 210.

Apparatus, steam sterilizing:^ or instruments and dressings (Fig.
209).

Apparatus, infusion: For saline injection (Fig. 210).



INSTRUMENTS AND APPLIANCES



237




FIG. 209.




FIG. 210.



238 NURSING



Explanation of Figs. 211 to 213.

Apparatus, blood pressure: For determining the diastolic and
systolic blood pressure in diagnosis of diseases of heart, arteries and
kidney (Fig. 211).

Bottle, drop: For chloroform and ether (Fig. 212).

Case, aspirating: This consists of a rubber stopper containing
a double current metal tube with stopcocks, a pump, aspirating
needles, trocar and cannula, and tubing attachments. To use it a
bottle in which the rubber stopper fits tightly must be supplied;
the double current metal tube is connected on one side with the pump
and on the other with an aspirating needle. The air is pumped
out of the bottle, creating a partial vacuum, after which the stop-
cock connecting with the aspirating needle is opened and the fluid
drawn off into the bottle (Fig. 213).



INSTRUMENTS AND APPLIANCES 239




FIG. 213.



240



NURSING



Case, emergency: This is a case for use of medical officers, con-
taining a hypodermic syringe, clinical thermometer, a few simple
instruments, and tablets of the most useful medicines.

In the field everything is made as light and portable as possble
in order to reduce transportation. Appliances and equipment are
packed in certain chests, cases, etc., which require some description.

Diagnosis Tags: A book of diagnosis tags with a pencil attached
is contained in each orderly pouch. The diagnosis tags are made
according to the following specifications :

Size 2.y 2 by $ l /2 inches, provided with a copper wire four (4)
inches long for fastening to the clothing.

Material to be linen, faced with paper.

All inks and colors used to be "fast."

Twenty-five (25) or fifty (50) to be bound in a book with paste-
board covers.

Form to be as follows :





Date and hour


(Blue.)


(White.)




Name and rank








Regiment or department
Diagnosis


J
rt
pS








o


jd

n




Treatment


1


in




Ambulance station


ts






Field hospital


^






Signature















FIG. 214.

The following directions should be printed on the inside of the
cover :

i. In any wound or disease not rendering the patient unable to
walk, detach the white body of the tag, leaving the colored border
attached to the stub. In a wound or disease rendering the patient
unable to walk, detach the entire tag, including colored border.

It will thus be always possible to ascertain by the number of
colored borders left with the stubs how many of the patients treated
were or were not able to walk.



INSTRUMENTS AND APPLIANCES 241

2. Under " Diagnosis " note all essential facts, character of in-
jury, parts involved, fracture, etc.

3. Under " Dressing Station " and " Field Hospital " note any
additional treatment applied. If at either place it is deemed best not
to evacuate a desperately sick or wounded patient any further, write
the words " not transportable," or the initials " N.T."

4. Under " Remarks " on the back may be noted any important
fact for which there is no room on the face, whether operation or
treatment is urgently needed, the amount of stimulant or anodynes
already administered, etc.

5. Fasten to button on clothing of patient over sturnum or as
near it as possible (Fig. 214).

Field desk: This is an iron-bound oak chest, with padlock, in a
hinged case. It contains writing materials, blank books, and blank
forms ; there are two sizes, Nos. i and 2.

Food box: Contains hospital stores or containers for the same.

Commode chest: A box containing a bed pan, chamber pot, urinal,
spit cup, and toilet paper.

Acetylene chest: A chest completely equipped \vith apparatus for
illumination with acetylene gas.

The regimental combat equipment includes a medical and surgical
chest, a water sterilizing bag, a box of surgical dressings and other
necessary articles enumerated in par. 866 M. M. D.

Mess chests: This contains equipment to serve 25 persons.

Belt, tueb ivith pouch: This takes the place of the old hospital
corps pouch. The pouch contains dressing forceps, scissors, pencil
and book of diagnosis tags, while the belt provides ten pockets for
field tourniquets, dressing packets, iodine swabs, bandages, sub-
limated gauze, adhesive plaster, pins and aromatic ammonia.

Chests, field laboratory, Nos. i and 2.

Chest, medical and surgical, supplementary.

Chest, tableware.

Saddle, pouch.

Venereal prophylaxis unit.
16



CHAPTER XII

THE OPERATING ROOM AND SURGICAL NURSING

IN the chapter on infection and disinfection we have already
spoken of bacteria in relation to disease; here we must consider
them with special reference to surgical infections.

\{,V- -vV l /i \ / '

'' / '' ' ct V ' ^



~

l.i S



'' s" d '\ e ^ \ 'f

FIG. 215. Various Types of Bacilli.

Bacteria may be divided into two general classes, bacilli or rods,
(Fig. 215), and micrococci or spherical bacteria (Fig. 216); it is
these latter that are specially concerned in wound infections. Mi-
crococci may also be divided into two classes; those which are



oocc_

"^CODOCQv

V




* O 00

o GO
FIG. 216. Staphylococc! and Streptococci.



grouped in clusters like grapes, called staphylococci, and those
arranged in chains, streptococci; the former are concerned in ordi-

(242)



OPERATING ROOM AND SURGICAL NURSING 243

nary suppurations such as boils and abscesses, while the latter are
the active agents in septicemia and erysipelas.

Some bacteria produce spores or seed which are much harder to
kill than the bacteria themselves.

We have already seen that sepsis means putrefaction; an aseptic
wound is one that is surgically clean, that is free from all germs;
antiseptics prevent putrefaction by destroying the germs or prevent-
ing their development. A wound offers just the conditions neces-
sary for the growth of bacteria heat, moisture, and abundance
of nutritive material, and the bacteria are everywhere present, on
the skin, on the clothes, instruments, and fingers, and in the air,
so that if we are to avoid infection minute care is necessary. All
disease germs in the process of their growth produce certain poisons,
the nature and action of which vary with the particular germ.
Yeast, which is really a mass of germs, in its growth in sugar solu-
tion produces alcohol, which when absorbed causes intoxication and,
if in excessive amounts, death. The nux-vomica plant in its growth
produces strychnine, one of the most powerful of all poisons. So
with disease germs. The staphylococci in a wound cause inflam-
mation and suppuration; if the poison is absorbed fever results,
toxemia or blood poisoning. Streptococci have the same effect, and
in addition frequently invade the blood themselves and grow there,
producing septicemia, pyemia, and death.

Pyemia differs from septicemia only in that abscesses form at a
distance from the original infection, especially in the joints, muscles,
and lungs ; the abscesses are caused by the pus cocci which reach
those points through the blood.

The most important point in surgical nursing is absolute cleanli-
ness on the part of the nurse ; a nurse with dirty hands and finger-
nails is an abomination and should not be tolerated for a moment.
It should be borne in mind that surgical infections are readily carried
from one patient to another, and thorough cleansing and disinfection
of the hands before dressing each case should be an invariable rule.

The preparation of a patient for a major operation usually begins
the night before, when a laxative is given followed by an enema
early in the morning of the operation.

About twelve hours before the operation the field of operation
and the surrounding skin are shaved and then washed with hot
water and soap; about six hours before the operation the skin is



244 NURSING

wiped dry with a sterile towel and then moistened with tincture of
iodine, and covered with dry sterile gauze.

If the operation is done in the, morning no food is given after the
light supper of the previous night, except perhaps an early cup of
coffee. The urine is passed or drawn the last thing before going to
the operating room ; at the same time any false teeth are removed.

Just before the operation a second application of iodine is usually
made, but many surgeons do not consider this necessary. The
iodine is applied with a sterile swab.

In emergency operations the washing is omitted and the shaving
done without soap because the iodine penetrates the skin better if
it is perfectly dry.

After-care: While the operation is being done the bed has been
prepared in the prescribed manner; when the patient is in bed a
nurse is detailed to remain by him until the effects of the anesthetic
have passed off. This is necessary as in his unconscious condition
he. may fall out of the bed, tear off his dressings, get up, or choke
while vomiting, and be unable to help himself. Sometimes the
patient may be in a condition of extreme shock, with cold, clammy
skin, shallow breathing, and weak rapid pulse; in such a case hot-
water bottles should be freely used, stimulants given, and the foot
of the bed raised. After shock the next dangers to be looked for
are hemorrhage and infection. Infection usually first manifests
itself by a rise of temperature and chilly sensations; even aseptic
cases, however, often have a temperature of about 100 F. for the
first day or two, constituting what is known as surgical fever. In
aseptic cases there is little for the nurse to do beyond the adminis-
tration of diets, as the first dressings are not changed for a week or
ten days. The urine usually has to be drawn every six hours for
the first twenty-four hours, or until the control of the bladder is
regained.

In surgical rounds the duty of the nurse is to have everything
ready for any necessary change of dressings. Dressings may be
done in the ward, or there may be a special dressing room to which
the patients are taken on a litter. In the former case a movable
dressing table or ward carriage is usually employed. Besides a
liberal supply of sterilized dressings in glass jars there will be
required bandages, safety pins, an irrigator, antiseptic and sterile
normal saline solutions, scissors, dressing forceps, dissecting forceps,



OPERATING ROOM AND SURGICAL NURSING 245

basins, and a covered pail or paper bags for the soiled dressings, hot
and cold water, soap, hand brushes, towels, and rubber sheeting.'

Dressings are of two general types, dry dressings and wet dress-
ings; the former are almost invariably used in aseptic wounds and
consist of a pad of sterile gauze about half an inch thick, covered
with a layer of absorbent cotton. Wet dressings are used in infected
wounds and consist of a pad of sterile gauze soaked in a i :2ooo
solution of corrosive sublimate or a two-per-cent solution of phenol ;
over this a layer of absorbent cotton, and then a piece of oil silk,
rubber tissue, or waxed paper. Antiseptics are used in wet dress-
ings because we wish to destroy the germs which we know are
already present, and the whole dressing is covered by a protective,
as we call the oil silk, because we wish to keep the dressing moist
and so allow a more uniform diffusion of the discharges which
always occur in infected wounds.

The operating room: The attendant in charge of the operating
room must have a clear understanding of the technique of aseptic
operating and must be a man of great carefulness and conscientious
in details. He must remember always that surgical infections
usually come from contact with something not surgically, clean, and
not from the air. The room itself must be clean and free from
dust; it must be disinfected at frequent intervals and no dusting
must ever be permitted there; instead the floors must be mopped
and the walls wiped with cloths moistened with an antiseptic solu-
tion. The temperature of the room should be about 72 F., 80 F.
in abdominal operations.

Sterilisers: There are two general types of sterilizers in use, the
essential difference being that in one steam is used under pressure,
and in the other the steam is flowing. Of the latter kind of
sterilizer, the Arnold is a type. In hospitals, steam under pressure
is always used.

The steam pressure sterilizer is known as an autoclave. It con-
sists essentially of a metal cylinder with a tight fitting door, and pro-
vided with a steam pressure gauge, safety valve, air vent, ther-
mometer, and apertures for the entrance of steam.

Outside the cylinder is a steam jacket, with a space between it and
the cylinder, in which the steam circulates.

In sterilizing dressings, a pressure of fifteen pounds of steam for
twenty minutes is usually employed.



246 NURSING

If glassware is used in the sterilizer, it is necessary to put a folded
towel, or something of that nature, between the glass and the metal,
to prevent breakage, and if liquids are contained in the glass, the
door of the chamber should not be opened until the pressure within
is reduced to the normal, otherwise the liquid may boil over or the
stopper may be blown out.

The operating table is prepared by covering it with a folded blan-
ket, over which is placed a rubber sheet and over that a sterilized
sheet or a Kelly pad or surgical cushion may be used. On a small
table by the head of the operating table are placed the appliances
used in anesthesia.

Instruments are usually sterilized by boiling from two to five
minutes in one-per-cent solution of soda, the soda being used to pre-
vent rusting. As boiling dulls sharp instruments, these may be
better sterilized by soaking in 95 per cent alcohol for half an hour.

Aluminum instruments are ruined by soda solution; they must
be boiled in plain water.

Instrument trays, basins and pitchers, and rubber irrigators are
boiled five minutes in plain water.

Dressings cut in proper sizes, bandages and gauze, sponges, tow-
els, sheets, and operating gowns are wrapped in towels or sheets,
pinned in small packages, and sterilized twenty minutes under fifteen
pounds steam pressure. Besides the dry sterilized towels a number
of damp towels sterilized by boiling should be ready to surround
the field of operation and for other purposes.

Gauze sponges are prepared of four or five thicknesses of gauze
about six inches square with the end sides folded in or stitched so
that there will be no loose threads to be left in the wound.

Laparotomy pads are usually of several thicknesses, with the edges
turned over and sewed, and with a tape fastened to one corner.

Gauze for packing is cut in long narrow strips, folded inward sev-
eral times from the edges, and the strips then packed in glass tubes
closed with cotton, before being sterilized.

In many hospitals gauze which has been used except in septic
cases is used over again after preparation as follows : Soak for
several hours in cold water, with frequent stirring. Wash clean,
under a running stream of tepid water. Boil for half an hour.
Wring out dry, and then proceed as with new gauze.

lodoform gauze is frequently used, especially for packing suppu-



OPERATING ROOM AND SURGICAL NURSING 247

rating wounds or abscess cavities ; it is prepared as follows : Sterilize
five yards of gauze ; mix ten ounces of glycerin with an equal amount
of water and boil fifteen minutes ; add a half-ounce of iodoform to
three ounces of alcohol and mix with the water and glycerin ; then
while stirring briskly, immerse the gauze in the mixture ; wring out
and keep moist in a closed glass jar.

The sutures and ligatures ordinarily used are catgut, silk, silkworm
gut, and silver wire ; the three last named are sterilized by simple




FIG. 217. Preparation of Gauze Sponges.

boiling in plain water. Catgut is not made from the gut of a cat,
but from that of the sheep; being animal in nature it requires
thorough sterilization, but will not stand boiling in water. Catgut
in the army medical service is usually issued already sterilized, but
most surgeons prefer not to rely on trade processes, and prepare
their own animal sutures. There are many different methods
employed ; nearly all include as the first step the removal of the fat
from the catgut by soaking forty-eight hours in ether which is
changed daily.

Among the methods are boiling in alcohol, the iodine method,
and the cumol method.

The iodine method is satisfactory and simple. The catgut without
previous preparation is wound on glass spools in one layer and
placed in a one-per-cent solution of iodine and iodide of potash in
distilled water for one week ; the spools are then withdrawn and kept
in alcohol.

Boiling in alcohol. Wind the catgut on clean glass spools, soak in
ether for twenty-four hours to remove grease, shaking several times
during the period; remove from the ether and soak twenty- four



248 NURSING

hours in alcoholic solution of corrosive sublimate 1:500; remove
from sublimate solution and boil in 95 per cent alcohol over a water
bath for ten minutes. Keep in same jar until required for use.

Metal and glass syringes with rubber or asbestos packing may
be boiled; if the packings are leather draw boiling water into the
syringe, immediately force it out, wash out several times with five
per cent phenol, and soak in the same solution while full ; the needles
are boiled with the wires in place.

Rubber goods: Vulcanized rubber may be boiled for one minute ;
fountain and bulb syringes, drainage tubing, rubber bandages, rub-
ber gloves and finger cots, soft-rubber catheters and bougies, may be
boiled five minutes in plain water.

Hard rubber is spoiled by boiling; soak in five per cent phenol.
Rubber tissue (gutta-percha) will not stand boiling; wash in cold
water with green soap, rinse, immerse twenty-four hours in solution
of corrosive sublimate I :iooo. .

Web catheters and bougies will not stand heat; disinfect in an
antiseptic solution.

Large quantities of boiled water, both hot and cold, will be neces-
sary, also sterile normal saline solution, and freshly prepared antisep-
tic solutions two per cent phenol and 1:2000 bichloride of
mercury.

Normal saline solution is a 0.9 per cent solution of sodium chloride
(common salt) in water. It is called " normal " because it has the
same specific gravity as blood serum, which fact renders it less irri-
tating than plain water. It is prepared by dissolving nine grammes
of salt in a liter of boiling water and sterilizing in a glass flask, which
is exposed to flowing steam in a steam sterilizer for a half-hour at a
time on three successive days. This method of fractional sterili-
zation is more successful than a single sterilization for an hour and
a half because, while a single exposure of half an hour will kill all
the adult bacteria, the spores or seeds are more resistant ; the inter-
vals of twenty-four hours allow the development of the spores
which are then killed by the next sterilization. The mouth of the
flask is closed with nonabsorbent cotton which is drawn over the
lip of the flask and held in place by a piece of gauze. In the absence
of normal saline tablets or exact means of measurement, the proper
amount of salt may be approximated by using a scant teaspoonful
to a pint of water. In emergency the water is simply boiled five



OPERATING ROOM AND SURGICAL NURSING 249

minutes instead of being subjected to fractional sterilization. When
used for intravenous or subcutaneous infusion the solution should
be filtered just before use.

Drainage may be tubular or capillary ; for the former, rubber or
glass drainage tubes are employed. Rubber drains are prepared
for use by washing with soap and water, rinsing, boiling five min-
utes, and keeping in a three-per-cent solution of phenol frequently
changed. Glass drains are boiled. For capillary drainage we use
a few strands of catgut or horsehair, or the so-called " cigarette
drain." The " cigarette drain " is prepared by rolling a strip of
gauze of the proper size in a piece of gutta-percha tissue, just as
tobacco is rolled in a paper to make a cigarette. For capillary
drainage we use strips of gauze about an inch wide and free from
any loose threads, or a few strands of silkworm gut may be
employed.

The most important part of the whole preparation is the disin-
fection of the hands and forearms of the operator and his assistants.
Many different methods have been recommended for this purpose,
and, while none are capable of making the hands germ free, most
of them give satisfactory results. In all the methods there are two
steps: first, mechanical cleaning; second, chemical sterilization ; the
first is by far the most important.

An excellent method of mechanical cleansing is as follows : After
trimming the nails close remove all dirt from beneath them with a
nail cleaner; anoint the hands with soft soap or a liniment of soft
soap, and rub thoroughly with a mixture of equal parts of corn-meal
and powdered mustard ; wash in running hot water and thoroughly
scrub for five minutes with a stiff brush recently boiled ; pay especial
attention to the edges of the nails ; again clean the nails with a sterile
cleaner, rinse the hands in boiled water, immerse in alcohol, and
scrub five minutes, using gauze sponges.

Most surgeons prefer to use freshly boiled rubber gloves, but even
with the gloves sterilization must be done just as thoroughly, as
gloves are often punctured or leaky.

3 The field of operation is prepared by painting it with tincture of
iodine ; only so much of the surface as is necessary is exposed, all the
rest of the body being protected by a blanket covered with sterile
sheets; immediately around the operating field wet antiseptic or
sterile towels are used.



25(> NURSING

The sterilization of the hands is usually done after the operating
gowns or suits are put on, and once done nothing should be touched
which is not sterile ; this is the rule which is most frequently broken
by the inexperienced nurse ; in his hurry or excitement he picks up
something which is not sterile and then he must disinfect nis hands
again.

Frequently during the operation the surgeon will wish to wash
his hands to remove blood, so that a basin of sterile water must be
kept ready at hand.

After the operation the room must be immediately cleaned. All
unused animal sutures which have been handled should be thrown
away; soiled or bloody towels, sheets, etc., placed to soak in cold
water and the instruments cleaned, counted, and put away.

To clean the instruments they are taken apart and washed in cold
water to remove the blood, paying special attention to serrated parts,
they are then washed in hot water and soft soap, rinsed, and thor-
oughly dried. Instruments which have been used in an infectious
case must be sterilized before being cleaned. Scalpels and other
cutting instruments must be cleaned separately, taking particular
care not to dull the cutting edge. Needles should be dipped in
alcohol, thoroughly dried, and placed in a box with lycopodium.

Artery forceps which take apart usually have the same number
stamped on the corresponding blades; if they do not, they should
be cleaned one by one, so as not to get them mixed. Locks, screws,
holes, and depressions must be carefully cleaned and dried with
wisps of absorbent cotton.

Rouge and putz-pomade may be used to remove rust and stain.

The leather packing and washers of syringes must be kept moist
by frequent use of water or glycerin, and such syringes should
always be tested before use to see that they are in working order.

Fountain syringes after washing should be hung bottom up to dry,
after which their mouths should be plugged with cotton to exclude



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 17 of 38)