: : PRIVATE Duy N URSIN BY KATHARINE DeWITT, R.N. n GRADUATE OF MOUNT HOLYOKE SEMINARY AND OF THE ILLINOIS TRAINING SCHOOL FOR NURSES; ASSISTANT EDITOR OF THE AMERICAN JOURNAL OF NURSING PHILADELPHIA & LONDON J. B. LIPPINCOTT COMPANY 1913 ~ mn - o 1 IOURNA1] No DEPT, COPYRIGHT, 1918, BY J. B. LIPPINCOTT COMPANY PRINTED BY J. B. LIPPINCOTT COMPANY AT THE WASHINGTON SQUARE PRESS PHILADELPHIA, U. 8. A. ~ Bl To My MOTHER MARY HASTINGS DEWITT Waost Course AND Goop Humor AND INTEREST IN LiFe Have Been My Exampre Anp My INsPIRATION IN ALL Tae Work I Have UNDERTAKEN. 743531 Cs . = nnn Selah dermmin PREFACE Private duty nursing is one of the most important and interesting branches of nursing work. It is certainly as needed as any, and combines the obligations of all. The nurse in hospital work is an edu- cator and administrator; so is the private duty nurse, for she is constantly teaching members of the families in which she finds herself how to care for the sick, and upon her often falls the entire guidance of a household. The visiting nurse is a health missionary; so is the private duty nurse, if she is a good one, for teaching about right living, hygiene, and sanitation is as much needed by the unenlightened of the wealthy and middle classes as by the ig- norant poor. Poverty and ignorance do not always go hand in hand, nor riches and knowledge. Preventive or health nursing must not be confined to the lower part of the social order, but must permeate the whole structure if the desired results are to be obtained. The private duty nurse, more than others, bears the praise or blame given 7 PREFACE our systems of training, for by her more than by others are they judged. The private duty nurse does her work under conditions that make it particularly effective and particularly wearing, for she lives in the home of her patient. The hos- pital nurse and the visiting nurse have fairly regular meal hours and are sure of a good bed and undisturbed sleep at night, no matter how tiring the day has been. The private duty nurse may be in homes where the food is not only unfit but un- clean, her bed may be any sort of hastily- contrived structure, and her sleep is dis- turbed for days and weeks and months at a time. She may do her most heroic work in homes of poverty at the risk of her health. My hope in sending forth this book is that the young nurse may find here some suggestions which may be of use to her. The older women will have reached the same conclusions long ago through their own experience, or might be able to give better hints than I have offered. Any suggestions as to what might be added or changed in another edition, should another be needed, will be most welcome, 8 PREFACE I wish to thank most heartily three friends who have helped me with sugges- tions and advice: Sophia F. Palmer, . R.N., editor-in-chief of the American Journal of Nursing, Mary Day Barnes, R.N., and Cornelia A. Conklin. To the last one I am indebted also for help in the copying of manuscript and in proof read- ing, and to Miss Palmer for permission to use such material as has appeared in the Journal. CONTENTS CHAPTER PAGE 1. QUALIFICATIONS 4» cuss + + sunsiviin sis svnmamsnns 15 YL. THR NORSE..ic0us 1 3 simmons vi x vonmmnmos sss 21 III. DIRECTORIES. ...o\viire ir eneennnnnnnnnnss 85 IV. ENGAGEMENTS AND CHARGES .......c0v..... 43 V. CLOTHIRG vr 0 ris umnions « ponmaitvies 3 3 pension 50 VI. EQUIPMENT ov0iiiini i is ssmmvnis » ss snamaivns 58 VII. THE NURSE AND THE FammLy.............. 65 VIII. THE NURSE AND HER PATIENT............. 76 IX. SErvANTS. GUESTS. uuucrssvninnves srnmmens 91 X. THE DOCTOR vu iss oinisiiefin 2 wisinis + yo wioiresiuins 99 XY. TUE RECORD: 1s innisnn + sanitnns i +s onmmnitn 108 RIL DIRE. vvi 0 asanimes sob atemmnns » 3 amie 114 XIII. STERILIZATION AND CLEANLINESS. ........... 124 XIV. PREPARATION FOR SURGICAL CASES.......... 133 XV. PREPARATION FOR OBSTETRICAL CASES....... 143 XVI. BEFORE AND AFTER THE CONFINEMENT...... 158 XVII. THE TRAINING OF BABIES. ................. 169 XVIII. THE CARE oF THE BREASTS IN OBSTETRICAL ee 182 XIX. Conracious DISEASES. . .cucemvnes ss snnnins 196 XX. HoreL LiFe AND TRAVELLING .............. 207 XXI. Special Nursing IN HosPITALS............ 217 XXL. Tae OD NUBSE « vovvine 05+ emvinimnse os sinn nin 232 11 INTRODUCTION THE time has come in the development of nursing education when we need books on special branches of nursing rather than more general text-books. This little book, written by my associate on the American Journal of Nursing, Katharine DeWitt, has been growing slowly into form during a period covering a number of years, in an endeavor to show the new graduate how to apply in the home, the knowledge she has gained in the hospital. Some of the ma- terial has been published in the Journal, but the bulk of it is new and is written from her experience of sixteen years in private duty nursing. She has not at- tempted to go into the detail of nursing procedure except to some extent in the subject of obstetrics, which was her specialty for some years before she be- came identified with the Journal. SorHI1A F. PALMER. Rochester, N. Y., January, 19138. 13 PRIVATE DUTY NURSING CHAPTER: r- QUALIFICATIONS TrE desirable attributes for a private duty nurse are somewhat different from those of the hospital nurse. ach needs the best of general and professional edu- cation, but it is not always the woman who has shown great executive ability during training, who has been a superior head nurse, or who has won the prizes, who proves most acceptable in the home. One is often surprised to find in great de- mand outside the hospital some quiet lit- tle creature who seemed rather slow dur- ing training, who puttered over her work, who needed to be helped with her side of the ward. Such a one goes along with no blare of trumpets, but if she makes her way as a private duty nurse we may be sure that she is willing, kind, sympathetic, 15 PRIVATE DUTY NURSING self-forgetful, and loyal, so that doctors and patients send for her again and again. Occupations that have to do with hu- i {man “heings; #ather than with things, re- .quire : ‘a Keérr- interest in human nature as iin essthtink: equipment for the worker, [and if a woman does not like her fellow ./ men and women, she had better not try “/_ to take care of them. A nurse’s work iso- lates her for such long periods of time from the world in general that she must find her interest in her work and in the people she serves if she is to be happy or to carry happiness with her. Let the nurse who undertakes private duty consider each new case as present- ing a problem to be solved—the problem of adapting herself to new personalities and fresh environment, and of making herself the most useful and helpful nurse who could be found in that situation. The problem will have to be solved in a differ- ent way each time. It is like a game of chess—one can learn the rules of the game from another and can be taught how to make certain moves, or how to avoid cer- tain complications that may arise, but, after all, the player must manage the 16 QUALIFICATIONS game in his own way and win or lose by Wis his own ability. No two games are alike. / For instance, here is a patient who is childish and wilful; it is hard for the nurse to keep her temper at times, the woman seems so foolish. She does not want to obey the doctor and demands sympathy from every one till all are worn out with her petulance. This is an intensely inter- esting puzzle, and there are several pos- sible solutions. Perhaps the nurse will have to treat her as the child she seems, all the way through, and first win her af- fection, then through that control her will. Or she may need the firm, wise guidance of a steady will to rouse the womanliness of her nature and to help her rise above her failings. Whatever path is chosen, the nurse must be genuine, honest, and kind or she will fail—but what a glow of joy is hers if she succeeds and sees the patient recovering better health and bet- ter behavior, the doctor less harassed, and the family machinery running smoothly. She returns to her room feeling that she has gained distinctly in her power to understand and control the perverse. In a short time another call comes. This 2 17 PRIVATE DUTY NURSING time she finds herself in a large and happy family, quite sufficient to itself and not desiring the presence of the necessary stranger. She is only wanted as a nurse, not as a friend or helper; her duties are purely professional, and her most accept- able attitude is that of self-effacement. | How natural to feel hurt and to wonder | how she is to use the knowledge she has | of late so painfully acquired. She must ' lay that aside for the present and devote herself to the situation at hand, making herself an adept in the art of appearing when needed and of disappearing when not needed. She should determine that she will fill this role to perfection, she may even have a bit of fun with herself over it. If she succeeds, she may find her thoughtfulness appreciated, though there will not be the same glow of success as in the preceding case; yet her victory is just as great, perhaps greater, for she has con- quered herself, and to learn to fit in any- where, without hurt feelings, is one of the most important lessons to be learned. To one who loves people and believes | in them, there is unfailing interest in the | human game with its constant changes and 18 QUALIFICATIONS adjustments. The nurse must cultivate this interest and not allow herself to grow indifferent, for even the dullest person may be a study in that line, while the sur- prises that lie beneath the surface keep up one’s hope of finding more good quali- ties than at first appear in some people. No nurse should think of her work as menial; if she does, it will be menial in her hands. In reading the history of nursing, note how high has been the qual- ity of work when ministry to the suffer- ing has been considered a Christian privi- lege, and how low it has sunk when piety and the work of the hands have taken separate paths, as if they could not walk together. ‘The opportunity of serving others is, at the last analysis, the highest aim of every true man or woman in pro- fessional life, public life, or in the home. , The personal service rendered by the nurse at the time of weakness and need | may become the sweetest of human oppor- tunities. No work is more appreciated when it is done in the highest spirit, and the worker often finds herself so over- whelmed with gratitude for her small ef- fort that she is touched and humbled and ET i 19 PRIVATE DUTY NURSING | resolves afresh that she will try to better ~ deserve the confidence that has been given her. Sister Dora said: “ Do not look upon nursing as an art or science, but as work done for Christ.” Let us start to each new case with a little prayer in our hearts that we may truly be a help in the un- known circumstances awaiting us, and then let us throw all our energies into the task of helping to answer the prayer. CHAPTER II THE NURSE A womAN with objectionable personal | habits should not take up nursing as an | occupation, but if she has been so blind as to choose that calling, she had better | stick to hospital work, where patients | come and go, and where she can fill some | executive position, rather than make one | helpless invalid for weeks at a time the | subject of annoyance.) Snuffing, clearing the throat, coughing, snoring, a rasping voice, and noisy ways are all annoying. She should be able to sit quietly when not actively at work, either reading or sewing or writing without rustling sounds, or, if the case requires, doing nothing, without rocking her chair or continually using her hands in nervous motions. Squeaking or very heavy shoes cause needless endur- ance to the listener, and rubber heels are most desirable. A nurse should be immaculate in her personal cleanliness. She should be free from the bad breath which comes from 21 PRIVATE DUTY NURSING neglected teeth, catarrh, or indigestion, and from all such odors as arise from in- frequent bathing and change of clothing, and from strong perspiration. The lat- ter affliction attends some persons through life, and is almost as bad as a deformity or an incurable disease. It may be partly controlled by daily bathing of the whole body, frequent changes of underwear, and by special bathing of the affected parts (the axille and feet) with a solution of soda and water. She should perform all the acts of mak- ing her toilet in a retired place, if such is to be found, if not, in a secluded part of the room, where the patient need not be aware that her nurse is cleaning her nails, using dental floss, arranging her hair, etc. Very few nurses need the suggestion that while caring for a patient they should avoid foods which impart an odor to the breath. I was convinced of this recently when I saw a whole tablefull of “specials” at a hospital refuse potato salad which was strong of onion, though it formed the chief feature of their sup- per. All external and unnecessary odors in the form of powder or perfume will, 22 THE NURSE of course, be avoided. They may be pleasant to the nurse personally, but if so they should be reserved for the days off duty. Perfume is often nauseating to a sick person. A woman who is physically well and strong, who is sweet and fresh from proper exercise, food, and baths, whose hair and teeth and hands show proper / care, and who is clad in a spotless uniform, | is a restful sight to the eye of the invalid. / As to her mind, the better equipped it is, the better for her and for her patient. If she has a good education, a well-in- formed mind, and a spirit alive to new in- terests as they present themselves, she will be a good companion as well as a skil- ful nurse, and this counts for a great deal in private duty. “a Morally, she must ring true. The homes of our patients with their numer- ous delicate family adjustments are not the proper spheres for the self-seeking adventurous woman, for the mercenary one, or for the one with her mind tuned to low things. All such will be sifted out / after a few years’ trial and will be found turning to other occupations. 23 PRIVATE DUTY NURSING How is a nurse to keep herself fresh and attractive and rested when on a long case’? This is often a difficult problem. She may find herself in a country house with no closet to the sick room, no bathroom, no unoccupied corner to flee to for bath- ing or dressing—the kitchen sink and a roller towel forming the accommodation for the family toilet. Or she may be sent to a tiny city flat where the giving up of one room for the patient has compelled the other members of the family to “double up” and sleep three or four in a bed. The ingenious nurse, if she can leave her patient unwatched for fifteen minutes, will by means of clothes-bars and comforters or by pulling a wooden bed away from the wall to make a retreat behind its head, with a hand basin, a little water, and her own towel and wash cloth, which she has learned to carry to meet such emergencies, make a comfortable and refreshing toilet, all the more grateful be- cause procured with difficulty. If her only chance for sleep is to use for a few hours by day, while her patient is at her best, the bed in which others sleep 24 THE NURSE by night, she can have two sheets and a pillow-case kept sacredly for her own use under her own eye, and get on very well. It is never wise to subject oneself to too long a strain without rest, even in un- selfish service, for without warning the tired brain may grow irresponsible, and either the nurse will finally fall asleep at a critical time, or she will get up in her sleep and perform services mechanically without knowing what she is about—not a safe condition. Most doctors are kind and watchful and will provide relief with- out being asked to do so, when they see that the nurse is growing too tired. If, however, the family cannot afford to pay for relief, and no member can be trusted to help, the nurse had better be replaced by a fresh one. Better a series of nurses, each staying as long as she is able, than that a catastrophe should occur to the pa- tient or that a nurse should serve until she breaks down. In many little ways strength can be con- served by using common-sense and inge- nuity. If a bed is low and broad, the in- valid helpless, and the case likely to be a long one, some change must be made. 25 PRIVATE DUTY NURSING Either the patient must be removed to a cot or to a new bed, or the bed she is in can be raised by placing under each cor- ner a block hollowed out to hold the caster securely. We are sometimes obliged to do our work in inconvenient surroundings. A bathroom may not be easy of access, the stairs may be steep and dark, the patient may be in a room too small for conve- nience. If these things can be remedied, for the patient’s good or for one’s own greater usefulness, they should be, but if they must be endured, no complaint should be made. The furnishings of a sick room should be so arranged as to save steps. If nourishment is given frequently, in small quantities, a nursery ice box may be se- cured and kept near at hand, or an ex- cellent one may be improvised from a tin box, a pail, or a stationary wash-stand. In the latter case the food must be kept in sealed jars. Some arrangement for heating water or food without going to the kitchen is needed in almost every sort of illness. Alcohol and gas stoves of many devices are familiar to us all. If the choice is 26 THE NURSE left to the nurse, she should take into con- sideration the risk of fire, the care needed in keeping the apparatus clean, and the cost of the fuel used. If a small electric heater can be afforded, it is ideal in its cleanliness, lightness, and simplicity. A one-burner oil stove can be made to serve many purposes, such as heating bath water, warming solutions, providing the supply of sterile water needed, and cooking. Of course, none of these heating ar- rangements will be kept or used in the sick-room, but in one adjacent, or even in a back hall. It is sometimes unavoid- able to use a bathroom as the place for such extra heating apparatus, but it is the room least to be desired, not only be- cause of its proper uses, but because it is inconvenient for the family to have the bathroom monopolized by the nurse and her affairs. If stairs are steep, and the working part of the house within easy call, a basket or stout clamp, tied to a cord hung from the upper railing, may be made to serve as | a freight elevator, and one not to be despised. 7 PRIVATE DUTY NURSING Daily outdoor exercise is needed and must be obtained unless the patient will be actually worse for the nurse’s absence. If the case is a serious one, she need not go far away. A brisk run about the gar- den, or a walk up and down a city block within reach of a call or signal from the house are far better than nothing. If the mother of the family is the only person to relieve the nurse, and if there are young | children to be looked after, they can be 'taken along, rather than left to get into trouble alone or to disturb the patient. | The presence of children may be a diver- sion rather than a care. A nurse should never impose on the family of her patient by taking her walk at an inconvenient time or by staying so long that she is missed and needed. A nurse who is willing to leave her patient in the care of an ignorant, irresponsible person is unfit for her calling, unfit to be entrusted with human life. When a nurse is on night duty and is relieved in the morning by another, she had better not go straight to her room and tumble into bed, great as the temptation may be, but first take a walk or a ride, 28 THE NURSE then a bath, and after that her sleep. Even though her sleeping time is shortened, she will be better rested in the end. During long nights on duty, when one must keep awake to watch, it is refresh- ing to put one’s head and shoulders out of a window at intervals and take long deep breaths of cool air. If continuous watching is not needed, and a nurse wakes easily when called, or can depend on her brain to summon her at intervals, to make sure that her patient is all right, it is sometimes possible for a nurse to get all the sleep she needs by snatches. Usually the sound of her own name will waken a nurse when other sounds do not disturb her, or if she has her mind attuned to the cry of a baby, she can sleep through a thunderstorm, yet hear the baby’s first call. Sometimes a nurse sleeps in a room near a patient, but not near enough to be sure of hearing a faint call. In such a case she may tie a long piece of tape to a small hand bell, fasten the end of the tape to the side of the patient’s bed with a safety pin, and place the bell on the edge of a chair beside her own bed. When 29 PRIVATE DUTY NURSING the patient wakes and wants the nurse, she pulls the tape, the bell tumbles down, and in so doing makes sufficient clatter to thor- oughly rouse the nurse. Sleep at night, though broken, is more refreshing than sleep by day, and, where the expense of a second nurse is out of the question, one nurse can often manage to work a long time without too great strain if she has the good habit of falling asleep easily whenever occasion offers. When a nurse knows that she is to be up and down all night she should dress more warmly than if she were going to bed to stay there—yet in order to feel rested in the morning she must get her clothes off. A good way to manage is this: to take off all the day clothing and put on a fresh combination suit, stock- ings and nightdress, having wrapper and slippers near enough to be donned in a second. In this way there are no con- stricting bands to interfere with relaxa- tion while sleeping, yet when called dur- ing the chill night hours, she is protected. By this method the day clothing is fresh to put on, after the morning sponge bath, 30 THE NURSE and the night clothing can be aired be- fore it is put away. A nurse’s health will be greatly af- fected, in the long run, by the food she eats, and by her use of stimulants. By _athe latter I mean tea and coffee; anything stronger is not to be thought of nor need it be mentioned. Many nurses allow themselves to become slaves to tea and coffee, and cannot stay awake for night work or endure a long strain without their aid. It is wise to take coffee but once a day, with one’s breakfast. Tea should be used in like moderation. Neither should be resorted to as a stimulus for hard work ahead. Nerves that are not™ overdriven will serve their owners faith- fully through long years of active work, and it is mad folly to depend on a vigor” not one’s own. During times of great stress and anxiety a nurse should eat light and easily-digested food. Sometimes nothing solid can be digested, and in such a case it is better not to try to take it. Nothing is better to tide one along than hot salted milk, or crackers and milk, or hot clear soup. Milk is the best reliance we have, 81 PRIVATE DUTY NURSIN G and the strength it gives comes not from any false stimulus or bracing qualities, but from the nourishment it supplies. One can get on for a day or two with no other food, and though the patient’s fam- ily will probably be in distress for the nurse and will press all sorts of tempting dishes upon her, she is wise if she sticks to the simplest things that she knows agree with her, and at the end of the hard time she can go back to good meals without an upset stomach to deal with. One thing for which a nurse is often criticised is the habit of talking shop in public places. No woman of refinement will do this, for she has an instinctive dis- taste for professional gossip or for at- tracting attention to herself. An inter- change of professional knowledge at the proper time and place is necessary and valuable, but it is the less-cultured nurse, to whom details of the sick room have be- come a delight, who is apt to offend by relating her patient’s symptoms to a friend on the street or in a car, to the horror of those about her. A nurse must constantly guard herself against the callousness and indelicacy 32 — THE NURSE which come so easily when one grows ac- customed to that which was at first shock- ing, for if her mind is kept free from ill, her speech will not offend. I should like here to protest most earnestly against the idea that years of nursing usually re- sult in a loss of sympathy. The true nurse, like the true doctor, becomes more tender and gentle as the years go by. The con- tinual demands upon her bring out the best of her womanly qualities. Her face, her voice, her touch, all invite confidence and trust. It is possible for this famil- iarity with weakness and suffering to transform her into one of the most beauti- ful of characters, and that is an ideal for which we should all strive. When off duty the nurse should have some corner which she has made home- like with her own little treasures, and she should spend her time between cases in occupations which are restful and helpful,—in out-of-door excursions, in a little wholesome recreation,—not giv- ing herself up wholly to laziness or mere amusement, but cultivating with enthu- siasm some other interests than nursing ones, so that her time may be happily 3 33 PRIVATE DUTY NURSING spent and both mind and body refreshed when the next call comes. If a nurse’s feet grow: very tired and sensitive from being on them constantly, the best treatment, if she has time to give them any, is a foot bath in cool salt and water each night, with a fresh pair of stockings each morning. 34 CHAPTER III DIRECTORIES How shall a nurse find employment after graduation? If she remains in the town or city where she has been trained, where she is known to various doctors, and where she knows about the direc- tories, the problem is simple. She will naturally register at the directory main- tained by her own hospital or alumna as- sociation, or, if there is such a thing, at the central directory in which all the nursing organizations of the city have united. If she goes to a distant city to estab- lish herself, she should investigate very carefully the available directories, and choose one maintained by nurses or by a nurses’ association, for these, as a rule, represent a higher professional plane than those established by business women or doctors. There are a few good directories under medical supervision, but usually doctors are too busy with their own af- fairs to trouble with ours, and the men 35 PRIVATE DUTY NURSING who take up directories do it for financial profit, and not from motives of profes- sional good. A nurse’s prestige is established, to some extent, by the directory with which she is associated, and she should not allow a dull season to throw her into a panic, and fly to several directories, indiscrimi- nately; it is doubtful whether she will se- cure a case more quickly by these means, and if one does come, it may be with a questionable backing which does not pay. In a state where nurses have a legal standing, obtainable by state registration, each nurse who has self-respect and pride in her profession should be registered, no matter how much trouble it may give her to go through the necessary formalities, whether of examination, or the filling out of certificates and obtaining proper cre- dentials. She should then make sure that the registry she has chosen represents the better class of nurses,—those who are eli- gible for registration,—for that means proper intellectual and moral preparation in the candidates accepted. She should not be content, through indolence, to class herself with nurses who cannot be regis- 36 DIRECTORIES tered because they have not been fortu- nate enough to have good training. In many cities the best directories accept only registered nurses, but this provision cannot be made in states where no law is in force. The nurse who establishes herself in the country or in a very small town will have to depend wholly on the doctors. The usual means of making herself known is to call on each of them in turn, during his office hours, to talk with him a few minutes about the work she wishes to do, and to leave her card. This should be neatly engraved or printed with her name, the initials, R. N., if she is a regis- tered nurse, the name of the school from which she has graduated, her address and telephone number. If she wishes to spe- cialize, she may indicate that, as, “ Medi- cal nursing preferred.” If the town is full of nurses, there may be a long and discouraging wait before a call comes, but when once a nurse is started, if she does good work she will be almost sure to be called again. Indeed, one disadvantage of small town nursing is that a good nurse has almost no time for rest. As soon as 37 PRIVATE DUTY NURSING she returns from one case, she is wanted for another. In city work, the directory, when once chosen, should be given a nurse’s loyal interest. The directory rules should be carefully obeyed. They are made for the purpose of giving efficient service to the public, and the nurse who complies with them is helping to maintain a desirable standard. She may register for a certain class of cases if she wishes, or against those for which she feels herself un- adapted, but she should answer promptly and willingly any call which comes to her in the line she has chosen, after she has reported herself ready for duty. When registering, she should reserve some defi- nite portion of the day for herself for ex- ercise, so that she need not be confined to the house for days or weeks, afraid to stir for fear of missing a call. Some nurses take risks and go off on short ex- peditions when they are supposed to be on call, but they are treating the registrar very unfairly by so doing, for they may delay the prompt filling of some need. Usually there is a penalty attached to such laxness, such as losing one’s place on 38 DIRECTORIES the list, but whether there is a penalty or not, the nurse who is not ready when needed is making an undesirable reputa- tion for herself. A nurse who is registered is usually al- lowed the privilege of special calls, either from doctors or patients, being sent out of turn if specially asked for. When a nurse is so well established that she is constantly in demand, she can do without the directory and leave it for the use of those who have not had so long a time to make themselves known,—but if the directory is having a struggle for ex- istence, the generous nurse, for old time’s sake, will continue to pay her yearly fee and to keep her nominal connection with it. Indeed, in some communities where nurses have been eager to establish a cen- tral directory, and where it has been hard to educate the public to use it, they have asked their patients to call them only through the registry,—in that way help- ing to make it known. A directory usually charges each nurse who registers a fixed sum yearly, payable in advance, either all at once, or semi- annually, while the people to whom nurses are supplied are not taxed in any way for 39 PRIVATE DUTY NURSING the service. Commercial directories, on the other hand, make a charge to the pa- tient, and the nurse has to pay a percent- age on each case obtained through it. It is absolutely necessary for a nurse to have good telephone service,—prefer- ably in her own home or boarding house. The days when a corner drug store re- ceived and forwarded messages to nurses for blocks around are rapidly passing, for telephone tolls have been greatly reduced. If a call comes to a nurse at her resi- dence, not from the directory, but from some former patient or some doctor who knows her, she must, no matter how ur- gent the call, take time to notify the di- rectory and remove her name from the waiting list. In all such matters a nurse proclaims herself as either business-like and dependable, or careless and indiffer- ent to obligation. When the registrar of a directory, or the doctors who send to it for nurses, find one who is ready and will- ing, they are much more inclined to send for her than for one who has disappointed them or kept them waiting, wasting valu- able time when summoned in asking many questions about the case to see whether it is to her liking. 40 DIRECTORIES If a nurse is thinking of what use she can be in the world, she will take the cases that come to her and do her best in each; if professional advancement is uppermost in her thoughts, she will take miscellane- ous cases at first, and will specialize later as she discovers to what work she is best fitted; if she is thinking of her own com- fort, she will take those that sound pleas- ant and lucrative, and will refuse those that are doubtful, and, in that case, she will probably defeat her own aim and sit at home idle much of the time, wonder- ing why other nurses are more “lucky ” than she. Those who have what is con- sidered good fortune have usually earned . it by working for it through hard and easy days, and among high and low. Some reasonable distinctions between calls must be made, of course. The nurse who takes surgical and obstetrical work should not take contagious cases. The nurse who does not get on happily with children should confine herself to adults, etc. Within these bounds, however, a nurse may still answer many calls and make herself a comfort by responding cheerfully and cordially to any call it is within her power to answer. 41 PRIVATE DUTY NURSING If a nurse knows of actual moral de- linquency in another member of her direc- tory,—what is her duty? It is natural to shirk doing anything, for it is hard to in- terfere with the work of another nurse and it is easier to let some one else find her lacking and report the fault. There is a larger view of the question to be taken, however,—loyalty to the standing of her own directory, and responsibility to the public. If she has any pride and loyalty she will not wish to let an un- worthy nurse keep her name on the roll of a reputable directory; and if she knows the nurse to be untrustworthy or immoral and a menace to a household, she is partly responsible for any ill which may happen if she keeps silent and allows the nurse to go on practising unquestioned. She should report all the facts that have come to her knowledge to the registrar or to the trustees of the directory, leaving in their hands the decision as to what course shall be pursued. She should not gossip or spread stories, for that is unnecessary and unkind, and she has fulfilled her un- pleasant duty when she has reported the truth as it has come to her. 42 CHAPTER IV ENGAGEMENTS AND CHARGES A NURsE cannot be too definite and business-like in regard to engagements. Many complications arise through vague- ness or misunderstandings on the part of employer or employed. Engagements are often made far in advance for obstet- rical, surgical, nervous or chronic cases, and while the interview is fresh in her mind, a nurse should write in her notebook the date for which she is engaged and the probable length of time she will be wanted, so that her calls may not con- flict. The only way to steer clear of trou- ble is to stand by her promise, no matter how inviting some other case may be. A nurse who has made an engagement for an obstetrical case some months ahead may, in the meantime, find herself in a household where she could be retained for a long time, and where she would like to stay. She will gain nothing on either side, by breaking her first engagement, however. Her word must be dependable, 43 PRIVATE DUTY NURSING and the woman who pleases herself, with- out regard to honor, will find herself in the end without the clientele she might have established. When a nurse is working among peo- ple who are acquaintances, one will some- times say to another, “ Won’t you please give up Miss Smith a little early, so that I may have her?” This puts the first pa- tient in an embarrassing position. Miss Smith can sometimes avert this by her firm stand in keeping to her original dates. A doctor sometimes wishes to transfer a nurse from one case to another. If both patients are his, he has a right to do so, but the position is a trying one for the nurse. Many nurses who refuse to take obstet- rical work say it is because they cannot lose time in waiting for such cases. It is rather difficult to arrange the waiting time in a satisfactory and fair way, but in the course of years the time lost in wait- ing is more than made up by the length of the obstetrical cases, by their recurrence, and by the fact that in even the dullest of healthy seasons, or in the midst of financial 44 ENGAGEMENTS AND CHARGES panics, babies continue to arrive and ob- stetrical nurses to be in demand. About charging for the time of wait- ing,—a nurse should talk this over frankly with her patient and come to a clear un- derstanding. If she explains that her time is, in a way, her capital, and that weeks lost can never be regained, the pa- tient will see that it is not fair to expect her to wait for an indefinite period of time without compensation, even though she is not at work. If the patient is un- able to pay for waiting time, she may agree that the nurse can take other cases until called to her. These other cases are taken with the understanding that the nurse may be called away. It is not a thoroughly comfortable arrangement for either patient, or for the nurse, but it is sometimes necessary, and is better and more honest than to present the obstetri- cal patient with a bill for waiting time which she did not expect. Sometimes a patient is able to pay a nurse one-half her usual rates while waiting, and this seems fair, if she is allowed to stay at home and rest. If she is with the patient, giving her constant attention, her time is worth 45 PRIVATE DUTY NURSING its full value,—but in all these things “ circumstances alter cases.” In communities where all nurses’ charges are about the same, and where the rate is generally understood, it does not seem always necessary for a nurse to state in her first interview with a patient what she is to be paid. It is often very awk- ward and difficult to introduce the sub- ject without seeming to have the question of remuneration uppermost in her mind, but she should do so if there is any pos- sibility of the patient’s not knowing the usual rate. If a nurse is going to make a lower rate for people who cannot pay her in full,— and we all should do our share in adjust- ing ourselves to the circumstances of those who need us,—it is better to make the dis- count from the whole bill than to lessen the rate charged per week. It amounts to the same thing in the end, but leads to less confusion in regard to the usual charges. We work very hard, our working lives are short, and we are justly entitled to all we earn,—we are even justified in insist- ing upon being paid what we have worked 46 ENGAGEMENTS AND CHARGES for and what people have agreed to pay us, but a nurse should never try to get the best of a bargain or to balance pecuniary gain against usefulness in deciding whether she will take a case,—it reflects upon her character, and harms her in the end. In travelling to out-of-town cases, when expenses are to be paid by the pa- tient, expenditures should be moderate, and an exact account should be kept. Bet- ter by far be laughed at for over-economy than to be treated coldly at the outset for extravagance. Imagine a nurse being called to a family of limited means, in an early evening, arriving in a cab and pre- senting a bill for three dollars before the family has had a chance to say, How do you do! The nurse would not have taken a cab had she been obliged to pay for it, and cabs are a luxury the people them- selves would not dream of indulging in. Such indifference to others’ interests is a poor introduction to a household. It has always seemed to me undignified, in the majority of cases, for a nurse to al- low the patient to pay for her washing. It is a personal expense with which the a PRIVATE DUTY NURSING patient has nothing to do and should be a part of her own budget. Her weekly charge is usually large enough to cover it, and very often a family is paying all it can without this added. In permanent cases, or in those families where a laun- dress is regularly employed and where the patient herself not only asks but in- sists that the nurse shall put her clothing in with the family washing, the case is different. Some nurses are much puzzled as to how they shall charge when caring for more than one patient. It is not possible to make any fixed rule, the circumstances vary so much. Usually, where there are two or three patients, an extra nurse must be employed, and this is as much of an extra expense as the family can afford, while the nurse who has help on such a case is not really working harder than if she had one patient alone, If, however, there are reasons why an additional nurse cannot be obtained, and if the nurse by good management can carry the case alone without undue strain, she is certainly en- titled to more than her ordinary rate, but to charge double seems to me out of pro- portion to the service rendered. 48 ENGAGEMENTS AND CHARGES If nurses would adopt charges, not fixed by an association, but adapted to the means of the patient and to their own ability, there would be a greater demand for their services and there would be fewer needing employment. So long as human beings vary in gifts and ability, so long will they vary in the value of the service they render, and their remuneration should vary accordingly. The nurse who is well-educated, well- trained, who is keenly interested in her work and successful in it, who has an agreeable personality so that her presence is a pleasure, and who has unusual skill, will always be more constantly in demand than her less fortunate sister who may have had poor training, or one who is too selfish to give other than grudging or im- perfect service, or one whose interests and opportunities have been so limited that she is not companionable. The nurse who has hardly a free day for herself is justified in raising her charges, while one who is only building up a practice, or who has not proven herself so well adapted to her work, cannot command more than the average rate, or less than the average, 4 49 CHAPTER V CLOTHING How shall a nurse dress when she is her own mistress? Perhaps after three years or more of one costume, she will long for something which seems to her prettier, and will try white dresses; or perhaps after three years of extreme tidi- ness, she will slip back with relief into looser costumes, or will leave her cap be- hind. We meet those who represent both extremes. There are nurses who are al- ways very fresh and immaculate, with ob- vious and rather tight corsets, with much dressed hair, with coquettish caps, with stiff’ skirts,—and I hear people complain that they take too much time to dress, that their rustling skirts are disturbing, and that their cuffs scratch. I once knew a nurse who wore no cap and no apron. She explained that she pinned a towel across the front of her dress while at work and so saved a great deal of washing. We can go a step further. I once met a nurse 50 CLOTHING who wore no collar. She must have saved washing, too! A large proportion of graduate nurses wear white uniforms. They are certainly pretty and attractive and they are de- sirable for a hotel case or for long chronic cases where the patient does not wish to be reminded of illness, but before deciding on wearing white altogether, a nurse should think of the expense of the material for her dresses, of the larger number needed, and of the larger laundry bills. One can- not keep neat in white without having two or three changes of dress in a week. The school uniform seems a fitting dress for ordinary nursing. Many people are interested in identifying the graduates of a school by their uniform and inquire with surprise why any one should alter it. The loyal nurse is fond of her old familiar dress for what it means to her. Every part of our dress has been objected to on the ground that maids copy it, but maids never put themselves into such severely simple dresses, or such plain aprons or such merely useful caps. We need not be afraid of comparison. The real beauty of a nurse’s uniform lies in its fitting well 51 PRIVATE DUTY NURSING and being perfectly clean. There are some fortunate women who can work and yet look spotless, like the English woman who thanked the Lord that she could black a grate without blacking herself, but if she is not so blest and can not work without growing warm and more or less dishevelled, she will have to resort to a larger supply of linen and to more fre- quent changes. It is better to put on one’s fresh collar, cuffs, and apron in the afternoon, when the busy morning work is over, and it is well to have a large ging- ham apron which covers one’s whole dress to slip on when going into the kitchen. One may take off her cuffs and turn back her sleeves for some kinds of work, but it does not look well to go about a whole morning with bare arms. A uniform is not suitable for street use. A nurse labels herself and invites atten- tion by appearing in it, and when on sur- gical and obstetrical cases there is real danger of bringing infection to her pa- tient by the street dust which she gathers on her skirts. When we see, as we some- times do, nurses in uniform in the midst of city crowds, on the cars, or even on 52 CLOTHING a railroad train, evidently enjoying the attention they arouse, we wish for a mo- ment we belonged to some profession which had no distinctive garb, that we need not feel the repugnance which we never want to have in our hearts for sis- ter nurses, known or unknown. The out- door uniform of many schools is suitable and attractive, and if it were always worn in the proper place and accompanied by the proper behavior it would be a welcome sight, but theatres, shops, or churches do not seem the right setting for it. When driving on a boulevard or in a park, one sometimes sees a nurse in full uniform, cap and all, riding proudly by the side of a patient. In such a case one’s inner criti- cism is directed not only toward the nurse, but toward the patient, for no one with good taste would be willing to appear in public accompanied by a nurse in uniform. A nurse sometimes apologizes for go- ing out in uniform by saying she has not time to dress and would get no walk un- less she went in her nursing dress. This is not necessarily true. With forethought, a street dress can be made so simply that it can be donned in five minutes, and 53 PRIVATE DUTY NURSING surely one feels greater self-respect when she appears on the street in street cos- tume, and there is a feeling of freshness and tidiness in getting back to her wash dress on her return. Also, she can go to her patient with a clear conscience if she is sure she is not carrying back street dust and germs to the sick-room. Her street dress requires consideration, too, for another reason. She usually meets her patient and the family for the first time in this, and the impression she makes is important. The impression she should wish to make is that of a capable, business-like, trustworthy person, and so her dress should be neither showy nor shabby. I have seen a nurse appear at a house in a silk dress, wearing a velvet hat loaded with feathers, and I have seen the amused smile which greeted her. I have also known nurses who had such heavy demands upon them and who were so care- less of self that they were poorly dressed and their patients could not take them with them to ride or walk. Whatever we wear, we should take a few minutes at meal-time to make ourselves fresh before appearing in the dining-room. It is al- 54 CLOTHING most always possible to find time to smooth the hair, wash face and hands, and take off the apron. It falls to the lot of some nurses to remain for long periods of time with wealthy patients where their duties are such that they do not wear uniforms, not even white dresses, and it is sometimes a perplexing problem to have clothes suited to their environment and yet keep within what they can afford to spend upon them- selves. If the patient is a woman, and one with good sense, it is best to talk the mat- ter over frankly with her, reaching a com- promise between what she demands and what the nurse can afford. To nurses in such positions, even temporary ones, there comes the temptation to copy the clothing worn by those they are with, and they are sometimes so foolish as to buy unneces- sary luxuries which are far beyond their means. They may do this innocently, thinking they must be dressed finely to be acceptable. Usually they are mis- taken, for such clothes are unsuitable for self-supporting women, and their pur- chase of them will arouse feelings of pity and perplexity rather than admiration. 55 PRIVATE DUTY NURSING It is quite right that a nurse should pur- chase good materials which will wear well, that her clothes should be well made and becoming, but lavishness in dress shows a lack of good judgment. The nurse who is busy with many short cases, and who is not off duty long be- tween calls, needs only a limited ward- robe. A heavy and a light suit, several shirt-waists and one silk waist will equip her for most needs. If she has many dresses, they will grow soiled from hang- ing and will get out of date before they are half worn out. Perhaps the advice most needed by those who have not nat- ural good taste is this: avoid anything conspicuous and never follow the ex- tremes of fashion. Underclothing should be possessed in abundance and enough should be taken to a case so that it may always be clean, even through the trials of hunting up washer-women in strange localities. Shoes should receive careful attention from the beginning of a nurse’s working days. She is on her feet so much, and her health and comfort depend so largely on the sort of shoes she wears, that she would 56 CLOTHING be quite justified in having them made to order if she can possibly afford to do so. Custom-made shoes cost from $9 to $15 a pair,—enough to take one’s breath away, yet many a woman pays that amount for a hat without many qualms, and the hat is less vital to her well-being than her shoes. The first pair usually costs more, because a last has to be made, after that the price may be a dollar or two less, and they certainly do long out- wear any other kind. If such shoes are out of the question, a nurse should search thoroughly the available shoe stores un- til she finds a shoe that exactly fits her,— not wearing a low heel if her instep is high, or crowding her toes into a narrow space—and then she should continue to buy that kind of shoe rather than try others. There is a temptation when the feet are tired to slip them into old easy shoes, but the foot needs proper support, and trouble may arise from the lack of it. 57 CHAPTER VI EQUIPMENT WHEN a nurse is called to a case out of town or to one in a city that promises a long engagement, a small steamer trunk is the most convenient thing in which to carry her belongings. If she lives in a small town from which she is sent off to cases in country districts, where she will have to drive over rough roads to reach her destination, she must abandon the idea of a trunk,—yet she must take something that will hold plenty of supplies, as she will be far from a drug store or physician. For this purpose the large-sized canvas telescope bag is as useful as it is ugly. It will give good service for a long time and will hold a marvellous amount. For ordinary cases, in ordinary work, two bags are best, a large one to be sent by express, and a smaller one to be car- ried by hand. The handbag will hold one set of uniform and all articles needed for immediate use. If a nurse attempts to carry her entire outfit with her in a suit- 58 EQUIPMENT case, she will be so tired by the time she reaches her patient that she will not be fresh for the demands made upon her, and also it is impossible to carry in one suit- case a sufficient quantity of clothing and supplies for a long case. The outfit will vary according to the personal taste of the nurse and the kind of work she does. One who works in the city, with all supplies at hand, need not try to carry a whole set of sick-room uten- sils. The country nurse, on the other hand, may need to carry some such arti- cles as a square douche pan, which can be used also for a bed-pan, a Kelly pad, a fountain syringe, and a hot-water bag. She should not begin her career, even in the country, with all these bulky articles, but should start her work with a moderate supply and add later such articles as experience shows her she needs. Some of the ordinary requisites for the nurse’s bag are: three or four dresses, a dozen aprons, an abundance of collars and cuff's, two caps, two washable petticoats, to be worn with the uniform only, under- clothing, nightdresses, wrapper, slippers, a convenient, compact toilet case holding 59 PRIVATE DUTY NURSING a clean brush and comb, dental floss, tooth-powder, tooth-brush, manicure scis- sors, nail cleaner, nail brush, hairpins, pins, and washcloth, a bath sponge, hand mir- ror, clothes brush, shoe paste, clothes bag, writing and sewing materials, and a case for one’s nursing utensils, filled. Let us consider some of these supplies more in detail. The wrapper should al- ways be of washable material, and should be sent to the laundry at the end of each case. For summer, it should be of light weight material, such as silk, pongee, cam- bric, or gingham, as one’s purse may af- ford. For winter, it may be of Shaker flannel, or any other of the washable va- rieties of wool and cotton goods combined. Eider-down flannel is too bulky to carry and too hard to clean, while that and flan- nelette are both inflammable and so not safe. The wrapper should be made in some trim style, not too much of a negli- gee to work in. A kimono is not good, as it is not securely fastened in front and the sleeves are too loose. It should cover every inch of the nightdress, so that when, as sometimes happens, a nurse is seen in it by members of the patient’s family, she 60 EQUIPMENT will be suitably clothed and protected. Her patient should never be waited upon by an untidy-looking person. One of the awful tales that linger in my memory is that of a nurse who slept until her pa- tient’s breakfast was brought to the room, and then, in her nightdress and with her hair streaming about her shoulders, sat down to feed her. It seems needless to suggest that a nurse’s hair should be neatly arranged at night. Slippers should have good soles and heels, because if one is up much at night her feet grow very tired from walking about in the ordinary bedroom slipper. The felt slippers made in the shape of storm rubbers have excellent soles and keep the foot and ankle warm. Turkish slippers may be used in very hot weather if one is not on her feet much. The nurse’s portfolio should contain all needed writing materials,—paper, envel- opes, stamps, fountain pen, pencils, knife, and record sheets. She should take pride in not having to borrow anything for her personal use, and should be prepared, rather, to lend, if need be. The workbag should be well stocked and should contain 61 PRIVATE DUTY NURSING a smaller bag or box to hold hooks and eyes, buttons, and bits of cloth for mend- ing. It is well to have in it a piece of work already started, not too complicated or absorbing, to pick up at odd minutes. A nurse who boasts that she has embroid- ered a shirtwaist for herself at each case she has had, raises a doubt in the mind of her hearer as to how much time she had left for her patient. I have always carried in my workbag a tape measure,—the kind that rolls up with a spring, and though I have seldom used it for its legitimate purpose it has afforded endless occupation and amuse- ment for little children. In the nursing case should be found a hypodermic syringe in perfect working order and with sharp needles, a clinical thermometer which is known to be accu- rate, dressing forceps, surgical scissors, rubber gloves, a glass catheter, and a rec- tal tube. These will carry one along with comfort through most emergencies, but each nurse will have her own pet acces- sories which she feels she cannot do with- out,—as a medicine dropper, small glass graduate, marked in ounces and drachms, 62 EQUIPMENT a funnel, and a gas heater or alcohol stove. It is well to keep the nursing satchels ready for a start at any moment, so that in an emergency one may catch a train at short notice or hasten to a desperately-ill patient without delay. “Dwell as if about to depart,” as the old motto says. If a nurse has ever been on a case where extra help was suddenly needed, and has had to wait three or four hours after the call was sent before the nurse appeared, she can appreciate the feelings of the anx- ious family awaiting her arrival and will eliminate all needless delay. When a young graduate has had sev- eral cases, she will work out a list of her own, containing just the supplies needed for her own work. Many a nurse likes to paste such a list on the inside of her suit- case, to be referred to as she does her final packing. It is well on coming home, to thor- oughly sun and air both cases and their contents. Wash everything that can be washed, and then repack carefully, leav- ing a list of articles to be added when the call comes,—such as one’s watch and pen. 63 PRIVATE DUTY NURSING Then one need not be distracted by the fear of forgetting some important thing in the haste of departure. Toilet, sew- ing, and writing materials can be kept in duplicate, so that the travelling set is not used at home. The surgical or ob- stetrical nurse may often wish to send her larger bag to her patient’s house ahead of her, carrying the smaller one when the call comes. By the use of duplicate sup- plies this can be done without great inconvenience, 64 CHAPTER VII THE NURSE AND THE FAMILY A NURsE’s first appearance in the house is often more or less trying,—to the pa- tient, to the family, and to herself. If the patient is acutely ill, and she can go vigorously to work, it is much easier. But sometimes it is a chronic illness, leaving much spare time; sometimes the patient is a child who will not let the nurse come near him at first; sometimes her arrival has been longed-for, and she will feel at once what a comfort she is; sometimes she is one of a long line of nurses and enters an atmosphere of criticism. She will soon learn to judge conditions quickly and to fall into her place. If she fixes her mind on the patient’s condition and needs, she will not be awkward or self-conscious, for she will not be thinking of herself. If the atmosphere is a critical one, no amount of self-glorification will mend matters; to go steadily ahead, doing one’s best, will win confidence if anything can. There are 5 65 PRIVATE DUTY NURSING some unfortunate people in the world who are habitually distrustful of others. The customs of the family often modify largely the care of the invalid. Work which can be done methodically and in or- der in a hospital must often be subject to interruptions in a home. The patient’s welfare comes first, to be sure, but it must not be put in such prominence as to up- set the entire household. There is a great difference in nurses in this respect; some enter the house with a flurry, are obliged to rearrange everything, have all the mem- bers of the house waiting on them and keep things generally stirred up during their stay. Possibly the family accepts all this confusion as a necessary part of illness and no complaint is made, but there is a feeling of relief when the nurse de- parts. The other type of nurse will enter a household full of distraction and anx- iety and from the first moment will evolve order from chaos. She will do her work deftly and unostentatiously, will find out for herself where things are kept, will make no show of authority, but every one realizes that she is in command of the situ- ation. Every one in the house feels 66 THE NURSE AND THE FAMILY strength and repose in her presence and regrets her departure. A nurse must often depend very much upon members of the family for help. She should receive suggestions graciously, though using her judgment as to the wis- dom of adopting them. It is often an ad- vantage to know a person’s preferences or dislikes, and many little “ ways” of an invalid may be catered to without inter- fering with the doctor’s orders or the pa- tient’s best good. At other times, the pa- tient has been humored to her disadvan- tage and needs discipline as well as care. The nurse will not, of course, cast any reflection on the amateur nursing which has preceded hers, nor on that of any other nurse who may have been on the case, though it is sometimes difficult to explain the difference between methods if they vary greatly. Sometimes it is sufficient to say that the same result may be ob- tained in different ways and that schools differ in instruction. By systematizing her work a nurse can reduce the confusion incident to illness to a minimum. For the first day or two she will be busy adjusting herself to the pa- 67 PRIVATE DUTY NURSING tient and to the ways of the household, but after that she should take some quiet mo- ment to sit down and think out clearly and definitely the various routine duties that fall to her through the day, and ar- range them in a schedule that shall con- form to the doctor’s orders, the patient’s needs and wishes, and the habits of the household. Such a plan saves time and steps for the nurse and confusion for the patient. It is also easier for the mem- bers of the family and the servants, as they know better what to expect. In whatever house a nurse finds herself she should try to help keep things in or- der. This does not mean that she is to leave the sick-room and dust the library, but does mean that books taken from their places should be returned to them, that the patient’s belongings should be kept orderly, and that the nurse’s own posses- sions should not be scattered all about the house or the sick-room, but should be kept tidily together in whatever place is al- lotted to her. It must be admitted that she sometimes has hardly a corner to call her own, sometimes because there is really not sufficient drawer or closet room for 68 THE NURSE AND THE FAMILY one extra person, sometimes because peo- ple are too distracted by illness to think of the nurse, or because they are thoughtless. A nurse should not monopolize the privileges of a house, taking the most com- fortable chair, reading the newspaper be- fore anyone else has a chance, taking her morning bath at an hour which keeps other busy people waiting for the use of the bathroom, ete. Does this seem need- less advice? Nurses have been known to do all of these things, and some of them did not leave the bathtub clean and ready for others’ use. A. nurse who gossips about her own affairs over the telephone is an irritating member of a household. When obliged to attend to a patient’s wants at night, a nurse should be as quiet as the proverbial mouse, both to keep her patient from getting too thoroughly awake, and also to preserve the peace for the rest of the family. It is best to use economy everywhere, with rich as well as poor. The everyday economies which we all practice at home should not be forgotten when other people are paying the bills. We should turn down all lights not needed, use water with- 69 PRIVATE DUTY NURSING out wasting it, should handle curtains without rumpling them, should keep blankets and counterpanes from the floor and from getting unnecessarily wrinkled, and should use towels in moderation. We should be very careful not to set hot or cold dishes or basins on unprotected tables or chairs and should not spatter or spill liquids on walls, carpets, or rugs. Every nurse knows these things, but not every one remembers them. It makes one more sure of not marring furniture by heat or cold or dampness to get some white table oilcloth and cover with it the tops of such articles as are to be most in use. Towels or table covers can be put over the oilcloth, or not, as seems preferable. It is an inexpensive and good protection. One nurse who thought she was distin- guishing herself by extreme neatness used to put thirty-five sheets in the wash in a week. She defeated her own end, for the laundress, naturally, thought this a folly, and smoothed out those that looked clean, without washing them. The parents of our patients are some- times treated slightingly, instead of with deference. They may waylay the nurse 70 THE NURSE AND THE FAMILY with advice when she cannot possibly lin- ger to talk, and may be always suggest- ing impossible remedies, but they should never meet with anything but courtesy. The nurse should think how she would like to have her own father or mother treated by a stranger. Very often they can sit quietly by the patient, and their pres- ence may be soothing. Old-fashioned ideas are not to be scoffed at, by any means. Some are based on sound sense. The children of a house are often made happy or miserable by the attitude of a nurse, especially if the mother is ill. The nurse may think it impossible to admit them to the sick-room, and it is true they should never be allowed free access to it at all times; admission should always be a privilege, conditioned on good be- havior, yet it usually harms a mother less to have a child listening to stories in her presence than to hear it crying in the distance. When a new baby has arrived, and the “old baby,” hardly on its feet yet, is for- lorn and unhappy, it can be tucked up be- side its mother for a nap,—on the outside of the bed, of course; it can be fed be- side its mother; it can be held on the 7 PRIVATE DUTY NURSING nurse’s lap with the new baby; it can be made to feel through all its little being that a new joy has come into its life, not that all its happiness is eclipsed. It is well to make a rule, in a house- ful of children, that they shall knock and ask to come into the sick-room. This pre- vents the rough tumbling in and out at all times, which really is fatiguing, and makes the children value the privilege a little more and behave a little better. To allow a child to assist a little, as one so often can, is to help develop the spirit of service which is so sweet in any human being. Sometimes they learn so much faster than the grown-ups that they be- come perfect little monitors and hover about the invalid continuously when the nurse leaves, demanding that things be done just as she did them. The roughest sort of a small boy may be trusted to lay the fire for the baby’s bath, to help rub its back, and to arrange its clothes in exactly the right order. A nurse who really loves children can manage four or five at once through the baby’s bath and have everything move smoothly. It is the happiest time of day for every one concerned and is both antici- 72 THE NURSE AND THE FAMILY pated and remembered with joy. Kach child is trusted with some special part of the programme, which he takes pride in carrying out well. The filling and empty- ing of the tub are such popular pursuits that they may have to be taken in turn. Even a tiny child of one and a half or two is fascinated by the performance and may be trusted to examine and test each article in the baby’s basket, putting each back in its place. One very restless little boy, who was left with me during the bath hour, used to harness my chair as a horse, sitting in his small chair back of me as I bathed the baby, and this kept him safely out of mis- chief during the time I was too occupied to look after him otherwise. Sometimes part of the physical care of the children will fall to the nurse, or they will be neglected. Indeed, there are hun- dreds of ways in which a nurse can make herself of use without neglecting her patient. It is impossible to define her duties—to tell where she should begin or end her labors. She does not wish to estab- lish a standard, which other nurses will be expected to follow, of doing household tasks,—but in times of stress she must 73 PRIVATE DUTY NURSING lend a hand where it is needed. Nurses who are afraid or unwilling to do anything beyond actual nursing lose much good- fellowship, many happy hours, besides, they are destined to a lonely and probably to a short career, for they will not be in great demand. There are occasionally people who de- liberately impose on a nurse, who be- grudge her any relaxation and think she needs no rest, who ask her to do tasks which there is no need of her doing and which are quite out of her rightful pro- vince. One must gently refuse to do more than care for her patient in such cases, but most people accept gratefully any ex- tra tasks performed and will not take ad- vantage of an accommodating spirit. We grow so used to the sight of sick- room appliances that we forget that their appearance is shocking or distasteful to most people. A bed-pan or fountain syringe should never be left exposed to view, either when in the bathroom, in the patient’s room, or while being carried from one place to the other. Specimens of any kind, soiled dressings, discharges of any sort should be decently covered and promptly disposed of. 74 THE NURSE AND THE FAMILY In her relation to the family as a whole, the nurse should remember that she is an outsider and should try not to be always in evidence. She should make sure that a husband and wife have some moments of privacy together each day without her presence. If she is with an invalid who is not acutely ill, it will need all her tact to determine when she is needed and when not. Nurses who are retained as com- panions or friends usually have a talent in this respect little short of genius. In some houses it is well for her to ask at the start whether the family would pre- fer to give her her meals alone. She will not often be asked to do this, but if the arrangement is to be made it is pleasanter that the suggestion come from her, and she should try to remember that it is not because the nurse is considered an inferior being, but because the family prefers its own circle without the presence of a stranger. On all formal occasions, such as a luncheon or dinner, or even when several guests are invited less formally, the thoughtful nurse will ask to be excused from the company. 75 CHAPTER VIII THE NURSE AND HER PATIENT WaEeN taking graduate work in a hos- pital some years ago, I was impressed with the fact that the patients’ desires were of secondary consideration. It is apt to be so in hospitals. The great wheels are moving and every one must fall into his or her place and move with them. Things are done for a patient’s good without much lingering by the way for his per- sonal opinion of the subject. It may be this is the best way to manage a large company of people,—results can be ob- tained more promptly,—but it is impos- sible to do work in that way in the home. There we must consider comfort, phys- ical and mental, as one of the necessities. A patient may have decided preferences in regard to the time of bathing, the kind of food, the amount of ventilation, ete. All these must be respected in so far as they do not interfere with the doctor’s or- ders and her own good. If a patient has a life-long habit of sleeping late, and 76 THE NURSE AND HER PATIENT there is no good reason against her doing so, the nurse must manage to do all the small tasks that can be accomplished out- side the sick-room early in the day, though it is a less convenient arrangement for herself. She must not only respect expressed preferences, but her imagination must be on the alert, ready to perceive, without the need of words, what is agreeable or disagreeable to her charge. She must carry out the doctor’s orders to the last detail, as she did in the hospital, but she must do it without the air of com- mand which is so irritating to the help- less. A patient once told me that when she was ill she always felt that her doctor and nurse were in league against her, and that she was powerless in their hands. She was not an unreasonable woman, either. Make your patient feel that you and she and the doctor are in league for her good, if there must be a league. If both nurse and patient have a sense of humor, half one’s problems are solved. A little fun goes a long way toward short- ening the weary hours of a long day,—but one should beware of ill-timed mirth. A ™ PRIVATE DUTY NURSING bright face is good to see, and we should cultivate the spirit that produces it, but there is an irritating sort of cheerfulness, a tiring exuberance, which is present in season and out of season, and which would make a well person weary. It is well to keep family worries out of the sick-room, but not to tell untruths in order to do so. Some persons have the pernicious habit of shielding a patient from worry by deceit, and the nurse may be asked to fall in with the scheme. It is a great mistake to do so. When a help- less person feels that she is being deceived, she suspects every one and worries more than she would have done over the original trifle. A nurse should notice what things cause her patient annoyance and shield her from them. Sick persons often have a quick- ened sense of hearing and are much dis- turbed by various sounds that might be avoided, such as conversation in the hall or nearby rooms, telephoning, the ringing of bells, flapping of window shades, rat- tling of sashes, the soft banging of a partly-closed door. Sounds of industry, if steadily carried on, and the natural 78 THE NURSE AND HER PATIENT music of birds, insects, and water, or the play and laughter of children, are rarely troublesome. If a sound is annoying and cannot be removed, the nurse should bend her energies not to sympathy but to awak- ening an interest in the cause of the sound or in establishing self-control. A patient who hates the continual call of a certain bird may be led to really like the bird and so not to mind its call. Sometimes sights are as disagreeable as sounds,—a half- opened drawer or door, a dusty spot on a table, a smudge on linen or china. The patient may not wish to speak of these to her tired nurse, but the nurse should have eyes to detect them. She should notice how and where her patient keeps her belongings and follow this arrangement as far as she can. It is a mistake to banish every object of beauty from a room. There should be something on which the patient may rest her eyes beside sick-room utensils. These should be kept in an adjoining room, if possible, and brought in only as needed. If the nurse grows very tired or feels ill, she should speak of it to the doctor or 79 PRIVATE DUTY NURSING to some member of the family, but not to the patient, if she can possibly avoid it. The care of the patient’s person should be as dainty as possible. In washing her face, her hair and nightdress should be protected from dampness; in pinning binders, the nurse should not pin part of the gown in and tear it; in adjusting vulva pads, she should make sure they are a per- fect protection. She should remember the finger bowl, or the washcloth and towel, after a meal. She should make sure that face and hands and teeth are cared for before breakfast, and, after these are attended to, take a moment to make the room attractive by smoothing the bed, removing signs of work or dis- order, and letting in some extra doses of fresh air. The sick-room should have some means of constant ventilation, arranged by the best means available, but in addition to this it is delightful to have occasional grand airings, lasting from a few mo- ments to an hour or two. The patient should be wrapped warmly about the shoulders, a hood-like covering is put on the head, extra covers are provided, and 80 THE NURSE AND HER PATIENT then every window and door is opened as wide as can be. This is a good cure for insomnia or depression, it is good to use when the sun is shining brightly or the last thing before sleep at night, it is suitable for old, for young, for children, and for little babies. A patient who is so well pro- tected rarely feels the least sense of being chilled or of any draught, but a thick screen may be placed between her bed and the nearest window if she wishes. One of the first lessons we learned in training-school days was how to give a bath to a patient in bed, yet many nurses in private practice do not give a bath com- fortably or acceptably. A person who is sick has a lowered vitality and is easily chilled, so everything should be arranged with a view to keeping her warm. The fresh sheet, nightdress, and towels should be hung near a radiator, or a hot-water bag placed on them. The hot water should be in a deep pitcher, and there should always be two basins, one for soapy water, the other for clear rinsing water, also two washcloths, or a washcloth and sponge. When all these are ready, fresh warm covers, preferably blankets, may be 6 81 PRIVATE DUTY NURSING put over the patient, and a blanket, or two large bath towels, placed beneath her. The usual covers are to be aired in an ad- joining room during the bath. As each part is bathed and dried, it should be tucked in snugly, the corners of the blanket being turned over the shoul- ders or wrapped close down the side of the leg or arm. In our zeal for thorough- ness the bath should not be made exhaust- ing. Patients who are very weak can sometimes endure only a partial bath and will be very grateful if the nurse extend the process to cover two or three days, making as little disturbance each time as possible. If a patient is to be kept in a sitting posture, or if the feet are to be braced, a sheet folded diagonally, its ends tied to the upper corners of the bed, makes a good support. If the sitting posture is to be retained for some time, a small rubber pillow, with a case over it, can be put within the sling formed by the sheet. A pillow beneath the knees will stay in place better if tied by bandages to the head of the bed. If a double bed must be used for a pa- 82 THE NURSE AND HER PATIENT tient, it is nice to keep one side of it for day and one for night. The change from one to another is almost as refreshing as to a fresh bed. If no bedside table can be had for meals, an ordinary sewing table, with two of the legs folded under, is not a bad substitute. This is good, if well propped, for a child’s playthings. Two other good props for a tray are a small pillow, of down prefer- ably, or a drawer from a small stand. If a bed-pan cannot be obtained, it is possible to make an ordinary hand basin answer for one, though it is not very satis- factory. The front edge of the basin must be held down firmly, to prevent its tipping. The lower part of an ordinary soap dish may be used in the various ways in which a pus basin is put to use in a hos- pital. As it is so shallow, it may be used when a patient brushes her teeth, instead of a basin. A rocking-chair makes a fairly good ve- hicle for moving a patient about until she is allowed to walk, especially on carpeted floors. On hard-wood floors the chair must be placed on a rug and moved with 83 PRIVATE DUTY NURSING that. Inventions often come to one as the need for them arises. In caring for a delirious patient, the nurse must have someone always within call to help if there is need. One never knows when delirium may become suicidal or when a patient may attack a nurse. These exigencies do not often arise, but should be kept in mind. A regular rest hour, where such can be established, is a good custom to inaugu- rate. At a certain hour each day, usually in the early afternoon, the room is dark- ened, windows are opened, every one is shut out, even the nurse, and the patient is left alone for an hour. Even if she does not sleep, the quiet and repose are soothing. A nurse is often called upon to think up occupations for her patient during con- valescence. If she can read well, and if the patient likes to listen, a never-ending source of pleasure is open to them both. The ability to read aloud acceptably is an almost indispensable requirement for the private nurse,—but there is no art or ac- complishment she possesses that will not be brought into use at some time or place. 84 THE NURSE AND HER PATIENT Sometimes a patient is wholly dependent on her nurse for suggestions, and she must try one thing after another until she dis- covers what interests her most without fatigue. Sometimes the patient has plenty of ideas and resources of her own, and only needs the interested co-opera- tion of the nurse to help carry them out. She should not say, “I don’t know how,” when a patient suggests a new occupa- tion, but show herself ready to learn, and if she makes mistakes at first, they may add a needed spice to the undertaking. Games are a great resource,—the many games of cards that may be played by two, or checkers, chess, backgammon, and word games played with letters. For a patient able to be out of doors, there are fascinating nature studies,—of birds, flowers, trees, shrubs, or stars. Children like making collections of all sorts of things. Women are diverted by new forms of sewing, if they are equal to them, and almost anyone enjoys paint- ing or pen and ink work when once started in it. For people who are physi- cally inactive, but whose minds are alert, the study of a new language is an absorb- 85 PRIVATE DUTY NURSING ing and fascinating pursuit. The nurse who is not naturally inventive should make herself familiar with the many good suggestions contained in Miss Tracy's “Invalid Occupations.” I was once puzzled as to how I could while away some of the long hours for a Swedish farmer who was recovering from pneumonia. He could not enjoy much English reading, and he was not strong enough for other diversions. One day, by chance, I told a story to a child who had come into the room, and found my patient so entertained that I called the children in several times a day there- after for tales I should have been loath to offer the man, but which he greatly enjoyed. Many such expedients will oc- cur to one as the need arises. A word about conversation may not be amiss. I am sure that most of us talk too much to our patients. We grow in- terested in some topic and keep on and on, long after their interest has waned. A nurse should keep a watchful eye on her patient, and when she ceases to keep up her end of the dialogue, it should 86 THE NURSE AND HER PATIENT cease, and restful silence should reign for a time. We are taught not to talk “shop” or to gossip. I have found it impossible wholly to avoid either, but it is possible to avoid gruesome shop talk or harmful gossip. There are many bits of knowl- edge about health and disease which it is well for a nurse to share with others. Every nurse should be a health mission- ary, telling how to keep well, how to avoid disease, how to aid in the great cam- paign for public health, good living and morality. Such topics are not only not forbidden, but are well introduced as oc- casion offers. Stories of hospital life, also, of a certain kind, are helpful, not injurious. One may tell of the childrens’ ward, of the touching old tramps whose stories have so interested her, of the way- ward girls, who are yet so kind to each other, and who have a real mother-love for their babies. She may arouse interest in visiting nursing, the tuberculosis cam- paign, or baby welfare work. As to gossip, the nurse will not air do- mestic details which should be kept sa- cred, but she can often help people to 87 PRIVATE DUTY NURSING understand and appreciate each other better, to see each other’s best side. As to her personal relations with her patients, many will become friends, and her stay with them will seem like a pleas- ant visit, but she should be careful not to presume on this cordial relationship. A nurse may respond gladly to all her pa- tient’s friendliness, but should let her take the initiative. She should not con- sider herself a privileged calling acquaint- ance because she has once been profes- sionally employed by a family. Thus far I have spoken of the patient as if she were always a woman, but often the nurse will be called upon to care for a man. If she has had her training in a general hospital she will feel no embarrass- ment in doing so. She is so used to car- ing for men, and is so absorbed in her work, that she forgets he is a man. To her he is a suffering human being, who needs her help. He is probably as un- conscious of her personality as she is of his. He is too sick to be anything but grateful. She should not forget, how- ever, that the family and friends of the man may have a very different view, and 88 THE NURSE AND HER PATIENT should conduct herself with the utmost discretion. It requires the highest moral and spiritual graces to carry a nurse through some situations without discredit to her calling or reflection upon herself. Sometimes a nurse is asked to stay in a house or apartment alone with a man patient. She should refuse to do this. There can be no circumstances that will excuse the sacrifice she makes of her repu- tation if she complies. The man may be upright, the nurse may be treated cour- teously from beginning to end of the case, but she is placing herself in a false light and some one, at however small a charge, must be hired to stay with the nurse to make the situation a proper one. She is endangering her own reputation and that of other nurses by doing otherwise. The same is true of travelling with a man, unaccompanied by some member of his family. A few hours’ journey may be made, or one taking daylight hours only, but no long trip should be taken and no stay at a hotel or sanitarium agreed to. What if a nurse finds herself taking care of an immoral woman? In this case much depends on the physical condition 89 PRIVATE DUTY NURSING of her patient. If she is desperately ill, and needs nursing care, and cannot be removed to a hospital, it seems to me the duty of the nurse to a suffering patient comes first, but if the illness is a slight one, and if the nurse is used in some way as a shield to cover wrongdoing, she should refuse to stay. No hard and fast rules of conduct can be given for these and similar situations, but it is wise to bear in mind the truth that it is rarely safe to disregard the con- ventions. A pure heart and earnest pur- pose are the best guides, and these should be in evidence from the beginning. A nurse who has a light frivolous manner may be shocked to find that she has been mistaken for one with loose morals. When any perplexing question presents itself, it is well, before deciding it, to think how her conduct will affect her pro- fession as well as herself. This will help her to a wise decision, sometimes, but in general it is better to use too great dis- cretion rather than too little. 90 CHAPTER IX SERVANTS AND GUESTS THE nurse’s attitude toward the ser- vants of a household will greatly influ- ence the comfort of the whole family. If it is a small family with one maid, that maid will be dreadfully overworked dur- ing illness, try as one may to save her. A nurse will naturally be sympathetic and helpful, but there are two sorts of sympathy, the kind that condoles, and the kind that encourages. If she chooses the former, she will make the maid feel herself an object to be pitied. A word of encouragement as to how well she is managing will help her much more. Sometimes, if the family is an unhappy one, and the members disagreeable, the maid will hail the nurse as a confidante and will wish to discuss with her the whole situation. There is great danger in such confidences, and they are to be avoided if possible. Some nurses are too familiar with the servants. I have heard of one who taught 91 PRIVATE DUTY NURSING the cook to dance, and of another who made eggnogs for the coachman. By such actions a woman shows her own status. Kindness, courtesy, and friendli- ness are most desirable, but not familiar- ity. In a large household, a nurse must learn to take the service which belongs to her as simply as possible, and to avoid an attitude of expecting to be waited upon. Nothing exasperates servants more. Or- ders should be given in the name of the mistress of the house, or in the form of a request from the nurse. Sometimes one will meet an upper ser- vant of great capability, who almost runs the house and its owner, and who will ex- pect to manage the nurse as well. The natural instinct of the nurse, used as she is to command, will be to try to suppress her. This is usually a mistake and will result in constant friction between the two which will cause annoyance and in- convenience to the entire household. Such a servant has good qualities or she would not have risen to her position of authority. If a nurse can tuck her pride in her pocket and go to the maid for her fresh 92 SERVANTS AND GUESTS linen, consult her about any new arrange- ments she wishes to make for the com- fort of her patient, and make her feel that they are working together for the pa- tient’s good, the autocrat will become her ally instead of her antagonist, and peace and harmony will result for all concerned. One is often called upon to care for servants in illness, and such care should not be grudgingly given. They are very forlorn and homesick when ill, and will appreciate a nurse’s care, even beyond its worth. The woman who has had part or all of her training in a charity hospital is not apt to fail in consideration for the working members of a household. She has learned to understand and like the working people, and can meet them with- out a trace of superiority or patronage; she can learn from them many a useful lesson. If a nurse is to do any work in the kitchen or laundry which requires much time, she should consult with the maids most concerned and try to make her work come at an hour when it will interfere least with theirs. For instance, the preparing of a baby’s food can usually be done at one of several times in the day. The time 93 PRIVATE DUTY NURSING should be a regular one, and should be selected first with reference to the nurse’s own work, but the convenience of the cook should not be overlooked. Just be- fore lunch is a rather good time for the nurse, but is a very bad one for the cook. 2 p.M. is usually just as convenient a time for the nurse and is much better for the cook. Should a nurse do any washing for her patient or a baby? This is a question over which hot discussions have always been waged, and it is probable that each nurse will reach her own conclusion and will cling to it, quite unmoved by any other person’s opinions. Time and experience, however, modify our views on this as on other subjects. There are times when the patient will actually suffer for what she needs in the way of clean linen unless the nurse can, and will, wash a sheet or a few towels. There are many homes in which the washing of a baby’s diapers is enough to send away an already over-worked maid of all work. In all such emergencies a nurse who has good sense, and who wishes to help in every possible way, will do the necessary washing rather than have her patient in need, or the entire household 94 SERVANTS AND GUESTS suffer from the ill temper of a maid who feels that she has been imposed upon. In a contagious case, it sometimes happens that no one can be found who will touch the clothing from the sick-room,—in such a case, a nurse will wash what is urgently needed, if she can be spared to do so. In all these cases, there is the question of the need of the nurse at the patient’s side. If that is greatest, the question of the wash- ing must be solved in some other way. It has been my experience that a family never expects a nurse to do any washing, and that the task is never put upon her except in case of urgent need, when, in- deed, she assumes it herself. The washing of soiled diapers is a dis- tasteful task to most laundresses, and the nurse should always give them a first rinsing. This is easily accomplished in a house where there is a water-closet and a bath spray. The diaper is held over the bowl of the closet, the spray held over it, and the fecal matter is washed away in an instant, leaving only a stained diaper. If this is put to soak with ivory soap, in a covered pail, the washing is easily ac- complished later. This is not only a help to the maid, but is a decent and sanitary 95 PRIVATE DUTY NURSING procedure. Wet diapers can be easily washed out by the nurse daily and hung out of doors to dry, but once a week, they should go into the general washing for a good boiling. Diapers that have been soiled should never be washed out without being also boiled. A nurse will occasionally find a patient who thinks a wet diaper can be dried and used again. This is a disgusting habit and should be discouraged. Visitors.—A nurse should make this general rule in regard to visitors for her- self, that she will receive none while on duty. Sometimes an exception can be made, if the patient is quite willing, in a matter of urgent business, but even then a nurse had better make an appointment away from the house if possible. On a long chronic case, where the nurse is making her home for months in the same place, this rule may be modified according to conditions. The patient’s visitors cannot be gov- erned by any set rule. The doctor is, of course, the authority first consulted, but after he has consented to having visitors admitted, he usually leaves the details to the discretion of the nurse, and she will 96 SERVANTS AND GUESTS need a great deal. The immediate rela- tives cannot be shut out, but often they are numerous and have such apparently equal claims that it is hard not to tire the patient, on the one hand, or to give of- fense, on the other. Sometimes, before general visitors are allowed, a patient will long to see some special friend whose presence is inspiring or restful, and the nurse should try to bring this about, as it may be just the tonic needed. Common courtesy demands that a nurse should leave the room when visitors are present. Her return, after an inter- val, will usually furnish the needed hint that the time allotted for visiting has ex- pired. We should watch the effect of different people on our patients as a guide to the length of their stay a second time. A nurse should take all responsi- bility in regard to visitors on her own shoulders, so that if any blame is to be placed, she and not the patient may re- ceive it. It is usually better to err on the side of admitting too few visitors rather than too many. An invalid will sometimes be anxious to see people when her strength is un- equal to visits, and will be hurt and dis- 7 97 PRIVATE DUTY NURSING appointed if refused, or she will worry lest her friends misunderstand their not being admitted. An untrained nurse, who was caring for a woman with a large family circle, adopted a device by which her patient’s feelings were spared. She had an understanding with all the rela- tives and intimate friends that before ringing the bell they were to look for a signal,—a little flag, placed in an incon- spicuous place. If the flag were up, they were to go away without ringing; if no flag appeared, they were to ring and in- quire as usual, and would, perhaps, see the patient. This is a plan worth keep- ing in mind. Some patients are over-in- quisitive and insist upon having an ex- planation of each sound in the house or near it. They must know who came in, who was at the telephone, what letters were left by the post-man, etc., on and on, day after day. Such people can- not get the rest they need and should have, and they are wearing to every one else, but such habits are usually life-long, there is little hope of altering them, and one can only put up with the endless in- quiries as good humoredly as possible. 98 CHAPTER X THE DOCTOR A NURSE meets many kinds of doctors during her training, and may think, by the time she graduates, she has exhausted the varieties, but there are yet more to come. There is no more interesting man to work with than the good country doctor. He has learned so much from experience, as well as from books,—he understands a good deal about nursing as well as medi- cine, and can make a poultice, prepare a bed for a confinement, and bathe a baby, if need be; he has usually a kindly heart and a keen insight into character. Un- fortunately it sometimes takes a young nurse many days to appreciate his worth, because he is not doing everything ac- cording to the latest hospital methods, so that, in her young ignorance, she judges him mistakenly. He will probably be tolerant of her, and in the end she will value his esteem and approval. There is a type of doctor, usually an old man, who has such respect for a 99 PRIVATE DUTY NURSING » “trained nurse” that he puts his own responsibilities on her shoulders. She asks for an order, and he tells her to use her own judgment or to do as she thinks best. She must not take advantage of his confidence and accept this responsibil- ity, for she has no right to step into his province and must not allow herself to be thrust into it. She must insist upon his outlining definitely the treatment he wishes given and giving explicit direc- tions for her guidance in an emergency. If trouble should arise from her going on alone, the blame will be put upon her by the family, the community, and pos- sibly by the doctor as well. There is another type of doctor who is unused to the trained nurse and who distrusts her. He addresses all his in- quiries to the patient, pays no attention to the record, takes the temperature and pulse himself, eyes the nurse suspiciously, and goes his way. There is no use in be- ing irritated by his actions, instead, there may be a real delight in winning his con- fidence, at the last, for herself and for her profession, by patience and tact. There are sometimes reasons beneath the 100 THE DOCTOR surface for distrust of nurses. A nurse: was once thrown with peopl | ‘who were: pleasant and courteous. but who: contin: : ally kept her in the place of a’ stranger, even after weeks of living together. It was not until she learned that a former nurse, from a good school, with the man- ners of a lady, had proved to be a klepto- maniac, that she understood their attitude. The previous nurse had been with them for months and had travelled with them,—not until the very last of her stay did they suspect anything wrong,—no wonder that they felt suspicious of every nurse there- after. Another type of doctor takes up a nurse with great zeal, and recommends her in such glowing terms that she is ham- pered in her work in her effort to live up to his eulogies. Finally, he is of- fended at something she says or does and drops her. Much more comfortable is the average physician, with whom we are all so familiar and with whom our lot is oftenest cast,—the honest, earnest worker, with his patient’s good at heart, who has no illusions in regard to us, but appreciates our efforts, though he may 101 PRIVATE DUTY NURSING -:he too busy to show that appreciation ex- ‘¢ept by sending for us again and again. ROBEY: is-glad :tg share his knowledge with us, and we are: glad to work hard in help- ing to make his work a success. The well-bred nurse will not forget hospital etiquette in the home. She will rise when the doctor enters the room, will bring the record to him, and will make sure that everything is at hand that he may want. If he is a homeopathist, she will have fresh glasses, spoons, and water ready for him. If a physical examination is to be made, sheets and towels will ap- pear without a request. If it is an ob- stetrical or surgical case, she will have ready all articles that may be needed for treatment: solutions, basins, sponges, dressings, sheets, towels, and a paper bag for soiled dressings, or an empty waste paper basket lined with newspaper. There should always be a fresh towel waiting for him in the bathroom, and both that and the sick-room should be made tidy before his arrival, if possible. On a long case, the nurse will know at about what hour in the day the doctor may be expected to arrive, and will try 102 THE DOCTOR to have the patient and room ready for him, but this air of expectation can be over-done. It is foolish, when a doctor is irregular in his visits, or not to be de- pended on, to keep a patient waiting in discomfort a whole morning for an enema or a bath because of a fear that the doc- tor may come in the midst of it. An enema and a doctor’s call are a very bad combination, for the patient feels hur- ried, it is hard to air the room properly, and the doctor is hindered. A small quantity of Platt’s chlorides may be put in the bed-pan before it is placed beneath the patient,—this helps diminish the odor. If the doctor arrives during bath time, it is easy to slip the patient’s gown on, and if the work is being done in a proper way the room will not be unpresentable. When the doctor is through with his questions to the nurse she should go her way, attending to her duties, leaving him to have a chat with the patient. It is very awkward for her to have no opportunity to speak with the doctor alone. The nurse should avoid, as much as possible, confidential conversations with the doctor outside the sick-room. If she 108 PRIVATE DUTY NURSING has some special report to make which should not go on the history sheet, she can write it on a separate slip of paper and leave it with the record for the doc- tor to read, and he can incorporate his reply with his orders. This will prevent her having to follow him from the room to discuss the matter. She must be sure, however, that the doctor understands this method. One who was not forewarned has been known to take up such a slip of paper and read it aloud. No patient likes to feel that she is being discussed outside the door or downstairs. When such a conference is absolutely necessary, let it be well beyond the range of the pa- tient’s hearing, which is sometimes abnor- mally acute during illness. One doctor told me that when he himself was criti- cally ill with typhoid he heard every word of a consultation held in a room with closed doors on another floor. One should make sure, too, that tele- phone conversation is not overheard, or if this is unavoidable because of the loca- tion of the telephone, it is sometimes pos- sible to arrange with the doctor that if he is called by the nurse, he is to ask 104 THE DOCTOR questions, and, if possible, guess at the cause for the call, which he can usually do from his knowledge of the case, ask- ing questions which the nurse can answer in a way which will convey information to the doctor without alarming the patient. A nurse will sometimes be closely questioned by a family as to a doctor’s merits, and she may find herself hard- pressed at times for a reply, but a gen- eral and safe rule is, that she must stand by him loyally or leave the case. If she does not understand why he is pursuing a certain course of treatment, she must continually remind herself that results may be obtained by different methods, that he probably knows what he is doing, though she may not, and that she must do everything in her power to make his work a success, both by her own faith- fulness and skill, and by the influence she has on her patient. A nurse is not always justified in leaving a case when she finds that a doctor is unethical, is careless, or is disregarding aseptic precautions; it may be her duty to give the patient the best of nursing care to make up for 105 PRIVATE DUTY NURSING what has gone wrong,—but when once the case is over she should not accept another for the same physician. If a doc- tor asks her why she refuses to work for him, it is her duty to tell him, though it is hard to do so. It is much easier to make some excuse than to face his indignation, but she is doing her duty if she replies truthfully to his questions. It is never her duty to gossip about him. Let her state the facts to him, or to the board of health, in an extreme case, but not to people who ask about him from curiosity or to other nurses, unless she may prevent one from falling into the same dilemma from which she has escaped. If a doctor gives an order which a nurse does not clearly understand; if he uses terms unfamiliar to her; if he asks her to make a solution of a certain per cent. and she does not feel sure she can do it; if he orders a fractional dose of medicine and the only tablets available are of another strength and the nurse is not good at fractions,—in all these cases no professional pride should keep her si- lent and make her pretend that she does 106 THE DOCTOR understand and can carry out the order. Unless she is perfectly sure of her ground she should ask him to explain to the last detail. The patient’s life may be endan- gered if she makes a mistake and nothing can excuse her for trying to carry out an order which is not clear to her mind. To be sure she should, if well trained, have fractions and percentages well in hand and understand how to make her calcula- tions for solutions or for hypodermic doses without possibility of error, but there is a distinct lack in many people’s minds in this regard, no amount of instruction makes them sure of themselves when try- ing to give a 1/400-grain dose from a 1/80-grain tablet, and the only safe thing for such a nurse to do is to ask the doc- tor to make the computation. He would rather do so than to have any risk about it, and a nurse should be more ashamed to run that risk than to ask for the in- formation. 107 CHAPTER XI THE RECORD Loose record sheets, or those in the form of a pad, are better than record books, unless one devotes an entire book to each case,—as it is not desirable to carry the record of one patient into the house of another. It is easy to forget the exact terms of an order, easy for the nurse and doctor, both. If she writes the order as he gives it, or if he writes it, as some prefer to do, there can be no question later as to what the order really was. Some record sheets contain no special heading for or- ders, but they can be written in the space devoted to “ Remarks,” always preceded by the word, “ Orders.” In looking back over the history of a case, it is a great help to see what the orders were and when they were given; for that reason it is much better to have them written on the record than in an order book or on slips of paper. A nurse should never fail to keep a 108 THE RECORD record. The doctor may not look at it, the case may seem too normal and uninterest- ing to require it, or a nurse may be called in for what seems like temporary service, likely to be soon over and to amount to nothing,—but it is a mark of carelessness to do without one, and we can never tell when it may be needed for reference. The slight case may develop into a severe one, the temporary engagement may be pro- longed, the early symptoms and tempera- ture charts may be of utmost importance in diagnosis. It is not necessary to run back for one’s chart when called to a neighbor in an emergency, but in any house a scrap of paper and pencil may be found and the history jotted down roughly until the real record is substi- tuted or the indisposition over. In a long case, lasting for months, the daily rec- ord may occupy only a line or two, but: those few lines should not be omitted. In an obstetrical case the mother’s and baby’s records should be kept separately, and the baby’s should show all details in regard to its feeding, its digestion, the character of its stools, its gain or loss in weight, etc. This record should, as a 109 PRIVATE DUTY NURSING rule, be left with the mother when the nurse leaves the case, with directions to continue it during the first year or two of the child’s life. In some later child- ish illness the doctor who is called in may find the early record a great help in his understanding of the situation. I once cared for a young mother whose father had kept a record of her early years. Some question arose as to a possible in- herited tendency in her child, and it was a great help to her physician when she sent for this old record and he could see, in black and white, just what he wanted to know. Another young mother of my acquain- tance keeps a ‘““Line-a-day” book for each of her children, having her trained nurse start it, in addition to her own rec- ord, with the first day of a baby’s life. These little books are very interesting and useful, as she can compare the con- dition of her children at similar ages and see what has helped or hindered progress. If a mother does not care to trouble to keep a baby’s record, a nurse maid will often carry it on faithfully. I remember one devoted nurse maid who was able to 110 THE RECORD begin each new page with the proud an- “nouncement, “ Slep well.” In some hospitals very elaborate sys- tems of printed charts and records are in vogue. Printing, if it can be done quickly, is a great improvement on bad writing, and every nurse should know how to chart neatly,—but outside the hos- pital, where one pair of hands must usu- ally do all the work, there is difficulty in finding time to record the many state- ments that must be made, even in the simplest way, and no nurse should make the mistake of neglecting any part of the care of her patient, or of cutting short her own hours of needed sleep, in order to produce an elaborate record or chart. The history should be perfect in its infor- mation, clear, to the point, and as full as is necessary, but it may have to be made hastily with a pencil, and can be copied later with ink, if that is desirable. It is not always possible to keep ink at hand in a small, crowded sick-room,—even a fountain pen may leak on a cherished table cover. Nothing should be put into the record which is not the exact truth. No under- 111 PRIVATE DUTY NURSING standing between physician and nurse can Justify the recording of a condition which does not exist, or the omission of any- thing which is of vital importance to the history of the case. The patient should not be allowed to read her own record, and should be gently and tactfully discouraged from inquiring about her pulse and temperature. No hard and fast rule can be made in re- gard to this, or in regard to the family’s seeing and reading the record. Some- times this is permissible; sometimes the doctor allows and encourages it; some- times it is harmful; sometimes the doctor absolutely forbids it. It is often a vexed question, requiring all a nurse’s art to settle comfortably. She should not start out by being obstinate and arous- ing unnecessary antagonism. Some- times a record may be kept out of sight, and the notes made without observation, so that it is not brought to the attention of the family at all, but usually it is far happier to have all things open and above board, and to explain courteously, at the start, that the record is kept for the doc- tor and is to be seen by him alone. All 112 THE RECORD well-bred persons will respect such a . request. Nurses’ records have sometimes been used as evidence in courts of law and the writers have been obliged to swear to the truth of statements contained in them. It should never be forgotten that these are important documents, not to be trifled with. To whom does the record belong when the case is finished? Naturally, the nurse thinks it is hers, and she takes the sheets away with her, to destroy,—or to preserve if she keeps them on file for reference in regard to her own work. Occasionally a doctor with a statistical turn of mind, who keeps his patients’ histories, will ask for the record when the case is over, or for a copy of it. He will ask as if he had a right to it, and the nurse will give it to him without question. The patient, her- self, has usually no interest in its fate, yet it has been decided several times in court that she is the lawful owner of it, she or her family, and this, too, should not be forgotten. 8 118 CHAPTER XII DIET Every private duty nurse should have had the training of a dietitian to be ideally equipped for her work, but there is not time for so thorough preparation in diet- etics, even in a three years’ course, and that nurse is fortunate who has had, not only a course of lectures on food princi- ples and their application, but has also served a term of six weeks in a diet kitchen, doing the actual cooking and serving. If, in addition, she was brought up with a knowledge of housework, and has done the catering, marketing, and cooking at home, before taking her train- ing, she will be well prepared to cope with the always-important subject of provid- ing the proper food for her patient. She will have been taught during her training how to cook easily-digested and nourishing viands and how to serve them attractively, but she may find herself, on her first case, in a farmhouse, far from grocery or market, where fried salt pork, 114 DIET hot bread, and bad coffee form the family menu three times a day, and where she must not only depend on the products of the farm for her patient, but must teach the family the value of eggs and milk as food, and must show the housewife in how many ways they may be prepared. Here her early training and her common sense will be of more value to her than a cook book. I shall never forget introducing an omelet to such a family. Its manufac- ture was eagerly watched by the entire circle, from the grandmother to the baby, including two hired men and two cats. I made enough, not only for my patient, but for a taste all around. It is quite as much a nurse’s duty to instruct an igno- rant woman how to choose and cook more wholesome food as it is to feed her patient properly, for all the doctor’s skill and her own care may be wasted when the salt- pork diet is resumed. Such teaching must be done tactfully, with no hint that the nurse herself is dissatisfied with the food offered her. Instead of the farmhouse, the nurse may have as the scene of her labors a small city flat where ignorance and dirt pre- 115 PRIVATE DUTY NURSING vail, and where the cheapest food is pro- vided and baker’s wares are largely de- pended upon. Here is work for an intel- ligent person for months, for not in a week or two can habits like these be trans- formed. It requires great patience to make suggestions which will be accept- able, to secure proper food for the patient and at the same time keep within the family income, and teach the first prin- ciples of cleanliness and good cooking. The nurse who has not been thoroughly taught will be completely at sea in such situations and her patient will suffer in consequence. It is fortunate that the de- mands of state registration have made dietetics a part of the curriculum of al- most every school for nurses and that the pupils are much better instructed than formerly, The amount of cooking a nurse will do, herself, depends upon many factors—such as the kind of cook who is in the kitchen, her willingness to have a nurse under foot, and upon how long the nurse can be safely spared from her patient’s side. If the person who is doing the cooking for a family, whether a maid or a mem- 116 DIET ber of the household, does not understand cooking, and cannot prepare food suit- ably, even with directions, the nurse must manage, somehow or other, to get away from her patient at least long enough to get things put together properly and the cooking started. If, on the other hand, an expert cook is in the kitchen, it is usually sufficient to give her directions and let her carry them out. In any case, the nurse should think out, early in the day, just what she will give her patient in the way of nourishment during the next twenty-four hours, should compare her plans with those of the housekeeper to make them coincide as far as possible, and should then make out two slips, one of the meals to be given and the hours at which they are to be ready, the other of the supplies to be ordered. This will simplify the housekeepers tasks greatly. There are very few homes in which the patient’s meals can be ordered without re- gard to those of the rest of the family. The patient should never be consulted as to what she would like. Two rules which can be safely followed in any case are that when a patient is in bed, the heavier meal 117 PRIVATE DUTY NURSING should come at noon, and that food which disagrees with a person ordinarily had better be tabooed, even though it may seem theoretically suited to her condition. In a family where there are children, who have a separate table, the invalid’s and children’s dinner can be served at the same time and can be almost identical, as the same things that one would plan for an invalid are good for children, also. A watchful eye should be kept on the cook, until one is sure of her. A nurse may explain to her that a white sauce should be made by cooking the flour and butter together, but in nine cases out of ten, she will find that the cook will make it by stirring the flour in cold milk. The reason for the more thorough cooking of the butter should be given, and in all simi- lar instances explanations should be made for following a particular process,—for cooks are human, and they will be more interested in carrying out directions if they see that they are based on common sense rather than being, as they had sup- posed, a whim of the nurse. In all those disorders in which diet plays an especially important part, it is necessary that the nurse should under- 118 DIET stand clearly the patient’s condition and the principles on which the feeding is based, that she may work intelligently in fulfilling the doctor’s wishes. By her skill and ingenuity she may make a lim- ited bill of fare less a burden to a patient and may even ensure the success of an ex- periment which might fail in the hands of one whose patience was not sustained by an understanding of the results to be attained. In most families, the nurse should pre- pare the tray and carry it to the sick-room, herself, making sure that it is as attrac- tive as possible. She should, however, use discretion in regard to the dishes she chooses for it. If she starts her career with the idea that the nicest china is to be used to delight the eye of the sick one, she may find one of her patients unable to en- joy her breakfast because she has put the cream into a valuable little pitcher which she fears may be broken. When fragile utensils are used, the nurse had better take the precaution of washing them herself, and putting them safely away after tak- ing the tray downstairs. Whether the nurse shall wash all the dishes used for her patient, both those on the tray and the 119 PRIVATE DUTY NURSING cooking utensils, depends on circum- stances. If she can be spared long enough to do so, and if the cook is glad of the help, it is nice for her to wash them. Sometimes maids are more grateful if she clears the tray, disposes of the bits of food, and leaves the dishes together in a convenient place. If nourishment is given often, the same dishes, for heating and serving, should be used each time and all put neatly back in place. Soiled glasses and spoons standing around are untidy to be- hold and are disheartening to the worker. ‘A nurse who must always have some one picking up after her is a great trouble in a house. Some servants have a feeling that all dishes used in a sick-room are con- taminated. If such a prejudice exists, it is well to respect it and to keep the dishes as separate as though the case were a con- tagious one. All such thoughtfulness for others adds to the harmony of a house- hold. If a patient is on fairly full diet, the ideal way to serve a meal is in courses, but if the nurse is so much on her feet that the extra trips she must make seem inadvisable, many devices must be re- sorted to to keep the food hot or cold un- 120 DIET til the patient is ready for it. In German hardware stores a hot-water plate is sold which is a boon to patient and nurse. It consists of a china plate, set into the top of an aluminum dish which may be filled with hot water through a spout in the side. The spout has a screw top, so the water cannot spill, nor the steam escape. Over all is a high metal cover. The plate is large enough to hold meat, potato, and one or two vegetables, and may be used to serve from, or as a plate from which the meal is eaten. A substitute may be made by placing a plate over a bowl or soup dish full of hot water, but in this case there is danger of spilling and the heat does not last as well. Tea or coffee should be served in a little pot, and cocoa in a pitcher. If any hot drink is poured into a cup on the tray, it is sure to cool before it reaches the patient. Sometimes one will find in a pantry a little gravy boat with a cover. This makes a good dish for soup or vegetable or for some hot supper dish. The nurse should always prepare and serve the meal as if it were a pleasure, whether it is or not, and she should never say that she dislikes planning or cooking a 121 PRIVATE DUTY NURSING meal. I have never forgotten my grati- tude to a nurse who said to me during an illness, “Oh, I hope you will have a full tray before I leave you, I should so like to fix one for you.” After such a wish I should have enjoyed anything she had brought me. If a patient is on liquid diet, every effort should be made by the nurse to vary it as much as possible within bounds, and not allow herself to lapse into a monotonous routine. In feeding a helpless person, every pre- caution should be taken by the nurse to make the process a pleasant one. Her hands should be washed the very last thing, even after the food has been brought; the patient’s head should be at a comfortable angle; her back well sup- ported; the food should be handled dain- tily, and full time allowed for eating. If possible, a diverting conversation should accompany the food to take the person’s thoughts from her helplessness. If a child is being fed, the nurse must make sure that he chews his food properly, and that it is really swallowed, not tucked away in his cheek. Sometimes the long monotony of meals in bed can be broken by allowing a child 122 DIET or some other member of the family to take an occasional meal with the invalid. The labor involved is well repaid by the pleasure it gives. Or afternoon tea, if allowed, may be shared with a guest. Perhaps the nurse will some time find herself with people who bring the patient some forbidden article of diet while she is out for her daily walk. In such a case, it is better to report the matter privately to the physician and let him deal with it. Hot words and reproaches are beneath one’s dignity, though a serious attitude toward the affair must be maintained. A nurse’s own meals are very apt to be late and cold. If people are doing their best, that best must be cheerfully ac- cepted, though a hint may occasionally be dropped as to how things can be better managed. If it is a long case and the family is deliberately careless of the nurse’s comfort, so that her welfare is really endangered, she should have a frank talk with the housekeeper, showing her that she must have proper food in or- der to do good work. Usually great pains are taken for a nurse’s comfort, and such discomforts as arise are temporary and need not to be minded. 123 CHAPTER XIII STERILIZATION AND CLEANLINESS Turse words should signify the same thing, for sterilization is but exaggerated cleanliness, and cleanliness, if complete, is almost an equivalent of sterilization. Unfortunately, there are nurses who think of sterilization as something totally different from cleanliness,—a profes- sional process, learned during training,— a mysterious rite, which must be carried out just so. These are the women who may fail in technique when they find them- selves far from the operating room with all its familiar apparatus. Their wits fail them, because they have learned a process without comprehending its un- derlying principles. A surgical nurse who can be trusted to carry out aseptic principles everywhere should come from a home where the housekeeping is of the finest order, so that it has become necessary to her peace of mind and comfort of body to have her surroundings spotless and fresh, and she 124 STERILIZATION should have the immaculate personal tidiness which accompanies such an up- bringing. Such a woman has the princi- ples of asepsis within herself, before she enters a hospital, and though she will need to study bacteriology and to learn the practical application of its teachings, her head nurse will not find her continually making slips,—seizing a sterile sponge with unsterile fingers, placing a thumb inside the basin she is carrying, brushing her hair from her face after her hands are scrubbed, ete. The difference in points of view regard- ing surgical cleanliness was well illus- trated to me once when a nurse who makes it her business to prepare surgical and obstetrical supplies went to the home of a doctor to prepare needed articles for his wife’s confinement. A small steam sterilizer was provided for her, and among the articles to be sterilized were six sheets, four of them old and clean, two of them new and shop-worn. The nurse protested that the two new sheets, which had not been washed or boiled, were not safe to use with the shop dirt on them, especially as the sterilizer was so small 125 PRIVATE DUTY NURSING that there was not much room for the steam to circulate. Unfortunately her positive assertion irritated the doctor, who commanded her to proceed with her work and sterilize all the sheets, just as they were. She did his bidding, but put the two offending sheets in a separate package, marked in large letters, “ Ster- ilized, but not clean. Use the others first.” The obstetrical nurse who came to the patient later was amused by the label, but trusted to the precaution and did not use the questionable sheets. A woman who is a good surgical nurse will manage, under the most untoward conditions, to run no risk of infection for her patient or to minimize it as far as pos- sible. She will not throw all precautions to the winds just because her surround- ings are not ideal. If she cannot get sterile sheets and towels, let her use clean ones, remembering that the inside of either has been protected from dust and handling and is cleaner than the outside. She should be just as careful not to let them drag on the floor or to touch any- thing unclean as if they were sterile. If there is no clean linen to be had, she can 126 STERILIZATION spread clean papers all about the field of operation, and keep these, or anything else, from touching the abraded surface. If she is confronted by a surgical or ob- stetrical emergency, so sudden that she cannot scrub her hands, she can some- times lessen the danger of contamination by covering each hand with a clean towel. Two nurses who owned a summer cot- tage had gone out there in the spring to put it in order for the season. While they were at work a lawyer, who had a cottage near them, came in with his hand bleed- ing, saying he had cut it in the lawn- mower, and seeking assistance. A hasty examination showed that one finger tip was so nearly cut off that it was hanging by a bit of skin. There was no medical help within ten miles. Everything in the house was covered with dust, and the nurses’ hands were thoroughly soiled from cleaning indoors and digging outdoors. But there were resources,—a small quan- tity of water which had been brought from a brook, a pair of scissors which had been used for trimming lamps, and two clean handkerchiefs, which one nurse hap- pened to have in her bag, 127 PRIVATE DUTY NURSING The lawyer was placed at the kitchen table, holding his hand up, and with a basin beneath it. One of the sisters has- tily made a wood fire and put water on to boil in two stewpans. Ome of these contained the two handkerchiefs, torn into pieces, the other held the scissors, which had been scrubbed as clean as possible first. While the water was boiling one nurse made her hands as clean as she could, but they were far from safe, even then, so she was careful not to touch the wound or the dressings with them. Us- ing the scissors as forceps, she cleansed the wounded finger thoroughly with the sterile water and bits of handkerchiefs, then applied a dressing like a cap to hold the finger-tip in place and bandaged it firmly. A pillow-case was torn and made into a sling. The lawyer walked two miles to the nearest car line, travelled into the city, and waited some time to see his doctor, who was greatly pleased at the condition of the wound and merely put on fresh dressings. It healed perfectly, without a sign of infection, in spite of the untoward circumstances. If these nurses had 128 STERILIZATION thought it hopeless to dress the wound in an aseptic manner, the man might have lost the perfect use of his finger. If a nurse thinks of sterilization not as a mystery, but as the last step in a cleans- ing process, she will not put water on to boil in an unwashed utensil, but will thor- oughly scrub it first, not trusting to the boiling until she has removed all visible dirt. She will not put a lump of unster- ile ice into an irrigator of hot sterile water to cool it, for her native good sense, as well as her training, will teach her better. I think there is no utensil with which nurses are more careless than with a bed- pan. It is very commonly kept on the floor of a bathroom or closet, often uncov- ered, and it is set on the floor of the pa- tient’s room both before and after being used. If we stop to consider, we must know that dust of all kinds gravitates to the floor, and that no part of the room is so thick with germs. For this reason, as well as for common decency, the bed- pan should be kept from touching the floor. It should be slipped into an old pillow-case, or wrapped securely in a towel, should be brought into the room so 9 129 PRIVATE DUTY NURSING wrapped, and set-on a chair near the bed, where the towel or pillow-case stands ready to receive it again when it is taken from the patient. The pillow-case is a more secure covering than a towel, and should be used, if possible. Sometimes one is careless, too, in keep- ing things sterile during the progress of a case. Everything is thoroughly steril- ized to begin with, and then, perhaps, the same basin or pitcher or fountain syringe is used again and again without the neces- sary reboiling. ven if they are closely covered and are carefully handled, it is safer to have a daily boiling. If two nurses are working together the utensils should be boiled each time they are used, for with two to handle things there are more chances of slips of which neither is conscious. The nurse who is acting as a teacher in a family must make sure that the person she is instructing grasps the fundamental idea of extreme cleanliness rather than learning by rote a certain process. For instance, many a young mother gains the idea that the baby’s nursing bottle and nipple are to be boiled, and that is all. 130 STERILIZATION She may not wash the bottle thoroughly, she may let milk stand in it after a feed- ing is over, she may change the baby’s diaper and then adjust the nipple, with- out first washing her hands,—but if she has boiled both bottle and nipple once that day she is sure she is doing exactly right. It is much harder to teach thor- ough cleanliness than a set process, for the mind grasps readily the few steps in- volved in a definite process and revolts at the trouble of thinking out for itself, not once, but continually, just what is in- volved in perfect cleanliness. Boiling is often made to cover a multitude of sins. We should teach the necessity of boiling as an addition to cleanliness, but not as a substitute for it. In preparing to modify milk, a time should be selected when one can be unin- terrupted, and a place chosen where all the surroundings can be made clean. A clean towel should be spread out for the utensils to stand on. The spoon used in mixing the food is usually laid on the table by the amateur who is being in- structed, and though she must be cor- rected each time she does it, it is well to 131 PRIVATE DUTY NURSING provide a safe place for it. All the uten- sils used should be kept neatly stored to- gether, and well covered, in a place free from dust, between the times of using. The same rule holds true for the care of utensils and dressings used daily in a surgical case. It would seem superfluous to speak of this did we not hear of nurses who leave such an article as a speculum, smeared with vaseline, lying about in a bathroom, uncovered, for days together. It is always disheartening to see hospital neatness and method abandoned by a careless nurse with untidy habits when she is her own mistress, for she is apt to endanger human life by her carelessness, and her laxness brings discredit to her profession. 132 CHAPTER XIV PREPARATION FOR SURGICAL CASES IF a nurse arrives at the home of a pa- tient several days before an operation, she will have time to choose the best room for the purpose, giving consideration to light, heat, ventilation, size, and conve- nience of location. With plenty of time for preparation, she will have furniture, carpets and drapery removed, the walls wiped down, the paint cleaned, and the floor scrubbed. The windows will be washed, and then the lower panes rubbed over with sapolio or bon ami. An operation in a home, however, is apt to be an emergency, and in this case the nurse must remember that she can- not possibly get all the dirt out of the room, and that if she makes an attempt to do so, she will only stir up dust and add to the danger of infection. Her object should be to keep the dirt undisturbed and completely covered, and for that rea- son she should accept the room as it is, covering all surfaces with clean sheets, 183 PRIVATE DUTY NURSING towels, or papers, thus making an upper layer of cleanliness, and keeping the air free from flying particles of dust. If the patient must remain in this unprepared room after the operation, the cleaning can be done later, a little at a time, with damp cloths, removing all movable furni- ture piece by piece for the purpose. A dust-laden carpet is a menace, but in an emergency a sheet can be pinned over it; it must on no account be taken up unless there is a good twenty-four hours to spare before the operation. Usually the nurse will have had an op- portunity to interview the surgeon and find out what supplies he wants prepared. He usually brings instruments, sterile dressings and sponges, and stock solutions of antiseptics. The nurse should always prepare quantities of sterile water, both hot and cold, saline solution (unless she is sure the surgeon will have it), and un- less he has definitely agreed to bring dressings, she had better prepare some from old clean cotton or linen on hand. The water must be prepared in two portions, one being boiled the day before for the cold water supply. The wash- 134 SURGICAL CASES boiler and the tea-kettle will be used for sterilizing the water, the boiler having been first well scrubbed. A large pitcher, or two, will have been previously boiled to receive the water for cooling, as the boiler cannot be spared for so long. All the available pitchers and basins in the house should be boiled, with some bowls for hand-brushes, and some flat dishes for instruments. As fast as these things are ready they are lifted from the water with dressing forceps, and are stored in sterile towels, pillow-cases or a sheet, un- til needed. The pitchers of boiled water must have sterile towels pinned tightly over the top. For the saline solution, nothing is better than a glass fruit can, washed and boiled. The solution, after being made in a clean sauce-pan and boiled the required length of time, is fil- tered into the jar through gauze and cot- ton. If the strength needed for one quart of solution is used to begin with, the water which has been boiled away can be accu- rately replaced by simply filling the jar to the top with sterile water. Six sheets, at least a dozen towels, a night-dress, binder, and stockings, and 135 PRIVATE DUTY NURSING two surgical gowns should be made sterile in the following manner: they are done up in small packages, with the cloth cov- ers basted, not pinned, as pins are rusted by the steam. The covers for the pack- ages should be old towels or any cotton or linen cloths that are clean and have been repeatedly boiled. Steam does not easily penetrate new cloth. The wash- boiler is made into a sterilizer as follows: a layer of cloth is placed over the bottom, and on this six fruit jars, filled with water, to prevent them from tipping over,—across the top of the jars, is placed a wire dish drainer. The boiler is filled to about four inches in depth with cold water, and the packages to be sterilized are put on the drainer, well above the surface of the water. The cover of the boiler must be put on tight. Only a few packages can be put in at once, for the steam must find its way between them easily to be effective. The water should boil for an hour, counting from the time the bubbling begins. If there is need of haste, and only one boiler-full can be ster- ilized, a sling may be made to fit the cover of the boiler, and into this the packages 136 SURGICAL CASES are put, the ends of the sling being tied over the top of the cover, not to the han- dles of the boiler, as nothing must inter- fere with the close fitting of the lid. While the packages are steaming in the sling, utensils can be boiled in the water below. If the fruit jars are used as described, they are themselves sterile, and can be used for making up stock solutions or for holding sterile water, or even as measur- ing glasses, where no graduate is at hand. All jars used for solutions should be labelled, and a box of labels is a good ad- dition to the nurse’s outfit, but if none are at hand, the gummed part of the flap of an envelope may be used. If bichloride solution is used, it is better to make it from the colored tablets, so that the blue color will distinguish it at a glance from water or salt solution. Carbolic, lysol, and formalin proclaim by their odor that they are dangerous, but they should be labelled, also. The recent graduate, fresh from the modern operating room with all its com- plicated apparatus, may doubt the ef- ficacy of such sterilization as this, but it has been used for many critical surgical 187 PRIVATE DUTY NURSING and obstetrical operations without an in- fection and does provide greater protec- tion than clean unsterilized goods and utensils could do. A quart cup, dipper, or small pitcher should be sterilized with the other uten- sils to be used in dipping the cold water from the boiler as it is needed. For an operating table, a kitchen table is by far the best for gynaecological or ob- stetrical cases. For operations where the patient must lie at full length, a dining table may be used. Several writers have described a convenient adaptation of the dining table, made by taking out the two middle leaves and placing them at right angles to their former position, thus mak- ing the centre of the table narrower and more easy of access. Foot tubs or port- able washtubs can be used for drainage and to receive soiled sponges. If there are in the house some strong plain stands which will not be hurt by heat or by solu- tions, they can be cleaned and brought in for solutions, instruments, and supplies. In the country, a wash bench can usually be found and is excellent for this use. If no suitable tables can be found, a table 138 SURGICAL CASES leaf can be placed, wrong side up, across two chairs or boxes or barrels of even height. Many of these minor arrange- ments must be entrusted to some mem- ber of the family, especially where there is limited time, and the nurse must select from those in the house the one who seems most intelligent and self-controlled as her assistant, letting her help as much as she can during the preparations, and hav- ing her stationed just outside the door during the operation, so that if anything has been forgotten she can bring it. The proper heating of the operating room is of the utmost importance and should be provided for early in the day by making some member of the family re- sponsible for having it at the desired tem- perature at a stated hour, whatever the heating arrangement may be. Some extra portable light is needed if the operation takes place at night or late in the day. An electric light on a cord, a good hand lamp, or a candle with a re- flector should be at hand and in good order. After the preparations are seemingly complete, the nurse should take time to 139 PRIVATE DUTY NURSING go over in her mind all the details of an operation, making sure she has on hand everything the doctor may not bring and which she can improvise from materials in the house. She can fashion an ether cone from an old newspaper or magazine, and can make firm bandages to be used in supporting the patient’s knees, if there are few persons to assist the surgeon. Her own hypodermic syringe should be made ready for immediate use and left safely covered in a convenient place. The patient is prepared according to instructions, and all these preparations are kept from her eye as far as possible. The nurse, though so busy and absorbed, must not forget the atmosphere of anx- iety which prevails and must do all in her power to bring courage to the troubled hearts about her. A gentle firmness usually helps a patient through a difficult crisis better than too frequently expressed sympathy, though the sympa- thy should be there, and should show it- self in little ways, so that there may be no doubt but that the sick one is in kind hands. If a doctor wishes to have a patients 140 SURGICAL CASES hips elevated for an examination, a wash- bowl turned upside down and made com- fortable by a folded sheet, will be found a better support than a pillow. If neither doctor nor nurse has a Kelly pad, a fairly good substitute can be made by rolling a blanket at one end and its sides, and covering it with a rubber sheet. A nurse’s duties during an operation in a house are so varied that it is impos- sible for her to be “clean.” She must continually remind the surgeon of this, if he forgets, and asks her to do some- thing which she cannot safely do. A man who is used to operating in houses knows exactly what he may expect and ask for, and a nurse who rises to his needs in all sorts of hard places is an untold blessing. A doctor who is often called out in this way learns to depend on the intelligence and skill of a nurse who has learned his ways, and there is great satisfaction to both in the good results which crown their efforts. When the operation is completed, the patient must be carried back to her room, which will have been prepared for her during the operation by some member of 141 PRIVATE DUTY NURSING the family who has been carefully in- structed in each detail. The carrying, too, should have been thought out ahead, and three persons should be ready to lift, all standing at the same side of the pa- tient, the doctor, probably, standing in the middle, as he will know just how to lift without doing injury. Those who carry must know which side of the bed is to receive the patient, so that there is no shifting of positions. It is almost im- possible to carry a patient safely or com- fortably if only two attempt it. 142 CHAPTER XV PREPARATION FOR OBSTETRICAL CASES WHEN a nurse is called to see a preg- nant woman, to make arrangements for her confinement, there are several topics she should discuss with her: the doctor, the care she is to give herself, the articles she must make ready for her confinement, and those she needs to provide for the baby. The Doctor.—Very often it happens that a nurse is called in before the doctor is chosen, particularly if the woman is a primipara and is nervous about her first interview with her physician. In such a case, it is the nurse’s most important duty to see that the matter of consulting the physician is no longer postponed. She can, without frightening the patient, tell her that the doctor can make many sug- gestions for her greater comfort, and that it is customary to have the urine exam- ined periodically. She may offer to go with her to the doctor’s office, or to come to the house when the doctor is sum- 148 PRIVATE DUTY NURSING moned, but unless she is sure that the pa- tient will follow her advice she had better see the husband, at some other time and place, and tell him how dangerous it may be to delay in this matter. Sometimes a nurse is asked what doc- tor should be engaged. She may not rec- ommend one doctor above another, but she is justified in urging that an obstet- rician be employed, if there is one within reach. So many obstetrical cases proceed normally that people grow careless about them, but a nurse can never forget what complications may arise requiring the greatest skill obtainable. Usually the doctor will have been con- sulted first, and he will have recom- mended the nurse or will have given his approval to the one chosen. If the nurse has not worked with him before on an obstetrical case, he will probably leave with the patient a request for an inter- view. If he does not, the nurse should visit him at his office, taking her list of articles needed for the confinement, and submit it to him for his approval before giving it to the patient. He may be able to suggest eliminations or additions, ac- 144 OBSTETRICAL CASES cording to his methods or the patient’s cir- cumstances, and he will tell just what he requires in the way of sterilization. Personal Hygiene.—An obstetrician will give very minute directions to his pa- tient as to the care she should give her- self, and the nurse will need only to go over the ground with the patient, explain- ing some of his directions in greater de- tail, and making sure that the patient is following them. If, however, the doc- tor is a general practitioner, giving little attention to his patient until the time of confinement, the nurse must instruct her as to the need of fresh air, sunshine, regu- lar exercise, the taking of simple whole- some food, daily bathing, the advantage of drinking more water than usual and of making sure that her bowels move regularly and thoroughly. She should help the patient to attain the happy me- dium of thinking of herself sufficiently to keep in good condition, but of attending to her usual tasks to such an extent as to keep from growing apprehensive or morbid. The diet will, of course, be regulated by the physician, but the nurse may sug- 10 45 PRIVATE DUTY NURSING gest that it is better to take the hearty meal at noon and only a light supper at night. If constipation is troublesome, he will outline the general treatment to be followed, but the nurse will not be going beyond her province in telling of the use of fruit juice—orange or lemon, or both—taken on first awaking in the morning or at bedtime. The amount of fruit juice taken can be increased until it has the desired laxative effect, or it can be taken both morning and evening. It should be taken in the morning at least half an hour before the regular break- fast, to be effective, and it is better to al- low a still longer interval. For nausea, the doctor will give defi- nite directions, and the nurse may be called in once or several times during pregnancy for a patient who has per- sistent vomiting. There are many small comforts the nurse can suggest which only a woman would know, such as the use of a small pillow to support the weight of the ab- domen in lying on the side. If the baby Is very active, a warm flannel placed over 146 OBSTETRICAL CASES the mother’s abdomen will sometimes quiet it and allow her to rest. If it is very difficult to urinate during the later weeks of pregnancy, she may be in- structed to kneel and lean forward, us- ing a very small chamber, as the shifting of the abdominal weight by this posture sometimes relieves the pressure on the bladder. The List—This will vary according to the doctor’s wishes, the patient’s means, and the nurse’s preference. An obstetrical case must be conducted with as great a regard for asepsis as a surgical case, yet doctors vary greatly in their requirements as to what shall be sterilized. The list which follows is adapted to a doctor whose demands are great and to a patient with ample means. All articles enumerated are to be sterilized, except the hot-water bag, alcohol stove, and drugs. From this list can be selected one which is much simpler for the patient who cannot afford so much. There is a light- weight, double-faced canton flannel, called daisy cloth, which may be used in- stead of flannel. 147 PRIVATE DUTY NURSING 6 sheets. 18 towels. 2 pillow-cases. 2 short nightdresses. (These can be made from old ones on hand, by shortening them.) 6 T-bandages. (One of them should be long enough to support the vulva pad which the patient wears during labor.) 6 abdominal binders. (If the doctor uses them.) 6 breast binders. (If the doctor uses them. They should be made by a good pattern, not a makeshift, from a towel, with shoulder straps.) 1 pair of white cotton stockings or regu- lar obstetrical leggins. 2 accouchement pads. (These are made of cotton and cheese-cloth, are one yard square, and are to be used during and after the confinement, then burned.) 4 pads of quilted mattress covering, one yard square. (These are of the great- est convenience all through the case and save much washing of sheets. One of them should be kept constantly un- der the patient during the first few days, when the lochial discharge is pro- 148 1 1 OBSTETRICAL CASES fuse; later, they can be slipped under the patient with a bed-pan each time it is used, and are a protection during the giving of an enema. Later they are of use for the baby’s crib. They are much more easily washed than a sheet, do not need ironing, but are slow to dry, so as many as four are needed.) dozen vulva pads, of cheese-cloth and cotton. a receiver for the baby (a square of flan- nel). pounds of absorbent cotton made into sponges, to be put into several differ- ent packages for sterilization. piece narrowest linen bobbin, cut into twelve-inch lengths. package of navel dressings (linen is better than gauze, as the latter ravels). 5 yards gauze for breast dressings. 200 applicators. (Tooth-picks wound with cotton, to be used for the mother’s nipples and for the baby’s navel; they should be made up into small pack- ages.) pieces of rubber sheeting. (One of these should be long enough to go across the bed under the draw sheet, and 149 PRIVATE DUTY NURSING to tuck under the edge of the mattress; the other should be a small square piece for use with the accouchement pad or quilted pad.) fountain syringe, or irrigator of enam- elled ware. hot-water bag. bed-pan. 8 hand basins. 1 four-quart agate pitcher. 8 oz. graduate glass. 3 jelly glasses with covers, for the breast tray. (One for boracic acid solution or sterile water, one for sterile appli- cators, one for used applicators.) 2 bowls for hand brushes. medicine glass and dropper. 1 wide-mouthed, deep bottle, such as an olive bottle (for dressing forceps and SCissors). glass douche and enema points. 2 new hand brushes. 1 bottle of vaseline (or albolene). 2 bent glass drinking tubes. 4 oz. boracic acid crystals. 8 oz. lysol (or formalin, or bichloride tab- lets). 8 oz. tincture green soap, 150 OBSTETRICAL CASES 8 oz. alcohol. 1 oz. olive oil. 4 oz. chloroform (unless the doctor pro- vides it). 1 oz. fluid extract ergot. alcohol stove. box of labels. This list can be cut down greatly for a patient whose means are limited. After giving the patient a copy of the list and talking it over with her, arrange- ments must be made for the sterilizing, which should be done at least six weeks before the probable date of confinement. The nurse who does much obstetrical work should have a portable steam steril- izer which she can take to her patient’s house for this work. It is not so very costly and is more satisfactory than the wash boiler, because the bundles can be both steamed and dried. If she has not one, she should try to have her sterilizing done by a nurse who makes that her busi- ness. If it seems best, however, it can be done in a wash boiler, in the same way that one prepares for a surgical case, only one must be sure that the packages, after 151 PRIVATE DUTY NURSING being taken from the boiler, are thor- oughly dried in a moderate oven. If a gas stove is used, it is safer to leave the door of the oven ajar, as the cloth covers of the packages scorch easily. They should be closely watched. If sunshine is available, the packages should have a thorough sunning, even after they seem dry. On the day after the steaming, if the packages still feel perfectly dry, they can be folded in a clean sheet and stored in a drawer or on a shelf, with the sterile utensils, which are also closely covered. The patient, if she is a woman of good sense, may be trusted to give the pack- ages their final sunning and to store them away, but it is not safe to entrust the whole process of sterilizing to any one but a nurse, no matter how eager she may be to carry out directions to the letter. One patient who sterilized dozens of vulva pads, exactly as she had been instructed, took them, when they were dry, out of their gauze covers and wrapped them in pink tissue paper. Some such slip is sure to occur. It is well to tell the patient how un- certain is the date of confinement, to tell 152 OBSTETRICAL CASES her that the reason the calculation is made from the last menstrual period is because the uterus is more likely to be active at that time of month, but that no one can ever tell the exact date of conception or whether the menstrual period just pre- ceding or just following the end of the nine months will be the one on which the confinement will be more likely to come. This may relieve her of the feeling of re- sponsibility for having made proper cal- culations. Articles Needed for the Baby.'—This is the pleasantest part of the planning, and every good nurse will enter into it with delight. The young graduate should take pains to find out from her friends longer in practice what they have found suitable, and to familiarize herself with patterns, materials, and prices. The fol- lowing list is suitable for patients who can afford an ample supply of clothing of good quality. 1The suggestions that follow are necessarily much like those given in a chapter contributed by the author to Dr. DeLee’s “ Obstetrics for Nurses.” Permission has been given for any duplication by Dr. Joseph B. DeLee and by his pub- lishers, W. B. Saunders Company. 158 PRIVATE DUTY NURSING 6 bands made of straight strips of flannel, unhemmed, though they may be pinked, if desired. 6 ribbed bands of silk and wool. (These bands quickly become stretched out and useless unless they are washed properly. They should be wrung out of the last rinsing water by twisting them, and should be laid down, still twisted, in a sunny or warm place to dry—never pulled out straight, and never hung on a line.) 6 silk and wool shirts, second size. (The first size of shirt is so quickly outgrown that it seems extravagant to provide it, as the shirts are expensive. Both shirts and bands may be knit by the mother, if she can knit well, at much less expense.) 100 diapers. (Three dozen of these should be made of cheese-cloth, in four thicknesses, and one-half yard square. These are of just the right size for a new baby, are soft, inexpensive, and need not be ironed after washing. To make them, fold one yard of cheese- cloth twice, run around the edges and diagonally with loose stitches, or stitch 154 OBSTETRICAL CASES with a loose tension. The other diapers should be of cotton diaper cloth, 24 inches wide, and the cloth should be washed and shrunk in the piece before the diapers are cut off, so that they may fold evenly. Kach diaper is made twice as long as it is wide. A baby wets through more thicknesses than can be put into the diaper that it wears at first, so the little diaper can be put on, and the other folded about its hips. Later, the small diapers are used in- side the larger ones.) 6 pairs socks or small white woolen stock- ings. 6 flannel nightdresses (made by a simple slip pattern). 6 flannel petticoats. (They should be made by a princesse pattern, buttoning in the back, not on the shoulders, as the latter cannot be put on with the dress and subject the baby to an extra turning.) 6 white petticoats. (If the mother wishes them. They should be made by the same pattern as the flannel skirts.) 6 slips. 6 dresses. (Both slips and dresses should 165 PRIVATE DUTY NURSING be made simply, without deep ruffles or heavy embroidery. The necks should be finished with a turned-down, tiny ruffle, or with narrow unstarched lace.) Several light, warm jackets, knit blan- kets, and cheese-cloth comforters. For a baby’s bed, a crib is best, but one hesitates in advising that it be purchased in advance, there are sometimes such sad endings to happy expectations. A clothes basket makes a good first bed, while the crib can be purchased later. If possible, either bed or basket should have a hair mattress, but if a pillow must be used for a mattress at first, as is often necessary, it should be covered with a folded quilt to make it firm. A firm mattress and no little pillow under the head are conducive to a straight spine in a baby and to absence of colds. If a baby sleeps on an ordinary feather pillow, with its head on a down one, it is so warm that it feels chilled when taken out of bed. No sheet is used over the baby at first, just little light blankets and comforters. A baby basket is needed for the toilet articles and may be an elaborate hamper 156 OBSTETRICAL CASES or an open willow basket. It should con- tain: one set of clothing, safety- pins in three sizes, a tube of vaseline or jar of albolene, spool of thread, needle, blunt scissors, several old handkerchiefs cut into small squares and sterilized, medicine glass and dropper, package of applica- tors, package of navel dressings, pack- age of cotton sponges, small brush and flat comb, talcum powder. The small wash stands made for babies are very convenient if they can be afforded. On this should be, in addition to the wash bowl and pitcher, sterile olive oil, castile or ivory soap, several small knit wash- cloths, a tiny sponge, 6 soft towels, old or new, a large bath towel, bath thermometer, 2 flannel aprons. Other nursery conveniences are a low straight chair without arms, a chiffonier, a screen made solidly and giving good protection from light or draughts, a bath- tub either of rubber or papier maché (those made of tin get too hot when placed near a fire), a tiny pair of clothes bars or a clothes rack for clothing and towels, a set of good scales, and an agate pail for diapers. 157 CHAPTER XVI BEFORE AND AFTER CONFINEMENT As the time for the confinement ap- proaches, the nurse is likely to be sum- moned to the house of her patient to stay, or is, at least, asked to sleep there and to keep within reach of a telephone call during the day. If she is in the house, there are two duties she should attend to regularly, the bathing of the patient and the sterilizing of water. The patient should be given a full bath in a bath-tub each night, before going to bed, and the nurse should give her the bath and help her to get in and out of the tub safely. Sometimes a low firm stool at the side of the tub is a great aid. The bathing helps keep the patient’s skin in better working order, it relieves many small discomforts, aids her to sleep, and if labor should begin during the night, when fires are low and a house somewhat cold, she is in thoroughly clean condition and need have only the special cleansing of the genital parts. 158 CONFINEMENT Sterile water is needed as soon as labor begins, and for many uses, and it is so convenient to have some already at hand, especially with a multipara, where there is always the possibility of a pre- cipitate labor, that a nurse should not begrudge the trouble of preparing it daily. Each evening the four-quart agate pitcher should be filled with water and put on to boil for twenty minutes, then covered with a towel closely pinned over the top, and set aside. The following evening the old supply is thrown out and a fresh one boiled. If the patient is a primipara, and has never had an illness serious enough to re- quire the use of a bed-pan, it is well to have her practice urinating in one at several different times during these wait- ing days. If she becomes accustomed to the awkward, unnatural position, and finds she can urinate when so placed, she may be able to do so more readily after delivery, as it is sometimes the new posi- tion as well as the temporary paralysis of the genital parts which makes the use of the catheter a necessity. There should be a perfect understand- 159 PRIVATE DUTY NURSING ing with the doctor as to whether he is to be informed as soon as labor has be- gun. With a primipara who has her first pains in the middle of the night, it is usually safe to wait until morning be- fore telephoning the doctor, at least it is safe as far as her needing him soon is con- cerned, but there is always the possibility of his being called out to another case, and if the two should conflict, he is bound to stay with the patient who called him first, so unless he is unwilling to be dis- turbed it is wiser to at least notify him that labor has commenced, so that he may know what is before him and plan his work accordingly. Kven with a nervous patient it is usually possible to let the doctor finish his sleep before making his first call. If there are two rooms at the patient’s disposal, one for herself and one for the nurse and baby, the nurse can prepare her as she has been taught, or as the doc- tor has directed, put upon her a sterile band and vulva pad, over that a clean, but not sterile, gown, and a soft clean wrapper, and leave her in the second room to lie down and get more rest, if possible, 160 CONFINEMENT while her own is prepared for the confine- ment. This is done in somewhat the same manner as for a surgical case, except that the room is not made so bare of furnish- ings, and no operating table is brought in. If the case is likely to be complicated, a table should be made ready and kept near at hand, but it should not be in sight of the patient or alluded to before her. The bed and room should be made ready, even though the labor is progressing slowly, and the sterile supplies should be brought out and arranged conveniently, but as few as possible should be opened until after the doctor has made an exami- nation and has pronounced the labor to be really in progress or until other un- mistakable indications make it certain. There are often times of more or less regular pain before labor sets in in earn- est, or the labor itself may be protracted over the space of a day or two, so the sterile articles should not be subject to contamination. If any are opened and handled ahead of time they should be re- sterilized, if the whole thing proves a false alarm. After the bed is made ready for the confinement, the patient should not be 11 161 PRIVATE DUTY NURSING allowed to lie in it until well toward the end, when she is to stay there. Another bed or a couch should be protected and used for examinations or for the short naps the patient may be able to take. If there is no such second bed available, the top of the patient’s bed can be used. In preparing the bed, the nurse should not forget to slip a table leaf or cutting board under the mattress, above the spring. A doctor works at a great dis- advantage when the patient’s hips are sagging down in the bed, especially if there are stitches to be taken, although in such a case she is put across the bed with her hips at the edge. Sometimes there is a firm high couch in the room which can be used as a confinement bed, leaving the patient’s bed clean and fresh to receive her when it is all over. In case of such an arrangement, or that of put- ting the patient on a table, the nurse will appreciate the value of having had ready two pieces of rubber sheeting and two ac- couchement pads. The patient should not be allowed to use the water closet after the membranes have ruptured, for two reasons: first, be- 162 CONFINEMENT cause she is then more easily infected, and second, because there may be a precipitate birth. It is almost impossible for her to use a bed-pan at such a time, but that is not necessary, as a high jar or a chamber set on a stool or on a low chair will serve. Another chair should be placed near the chamber to be used as a support in getting down or up. All possible work to be done by the nurse should be accomplished during the early stages of labor, as both doctor and patient will want her close at hand as it progresses. It gives some women great relief to have the nurse press with her hands against the lower part of the spine during a pain, but this had better not be begun till the nurse can give her time to it, as the patient will not want to spare her a minute if it helps her. When the baby is born it is the nurse’s duty to keep it warm, even before the cord is cut. It comes from a continuous warm bath, at a temperature of 99°, into a room not warmer than 80°, and with a wet body which is easily chilled, yet it may lie uncovered on the bed for several minutes while the doctor is preparing to 163 PRIVATE DUTY NURSING tie and cut the cord. The receiver with a sterile towel inside it, which has been kept warm by being wrapped about a hot-water bag, should be thrown over the baby at once, in a way that shall protect it, yet not hinder the doctor in his work. By this process the flannel will undoubt- edly get badly soiled, but that is a small matter. Another precaution sometimes neg- lected is that of shielding the baby’s eyes from the strong light with which the con- finement room is usually flooded. Oculists consider this important, and it can usually be managed by a deft folding of the bed- ding or of the flannel receiver so that the baby’s head lies in shadow. When the baby is finally placed in its own bed, the nurse should pause long enough to see that the hot-water bag is not too hot and that it does not press directly against the flesh. A watchful grandmother and an open fire are a great comfort at such a time. In the after-care of a patient, the young nurse may not know just how to manage the giving of treatments when the bath- room and her patient’s room are some 164 CONFINEMENT distance apart. When she is going to give a treatment, she should first collect all articles needed, make and warm the solu- tions to be used, and warm the bed-pan, then wash her hands ordinarily clean, remove the soiled vulva pad, and place the patient on the bed-pan. She should then drape the bedding over one knee, and an extra sheet or bath towel over the other, having all tucked away firmly from the genitals. Over all she should place a clean towel, in such a way that the patient is perfectly protected, and so arranged that she can pull it away without dis- arranging the other draperies. The bedroom door is left a little ajar, so that the nurse can open and close it with her foot, and she can then wash her hands properly in running water while the pa- tient is using the bed-pan. When the patient calls, the nurse can close the door with her foot, put on her rubber gloves, the patient pulls the towel away, and all is ready for the irrigation. The members of the family should understand that they are never to enter the room when they see the door left ajar in this way, but if anyone should go in by mistake, the pa- 165 PRIVATE DUTY NURSING tient is perfectly screened by the towel. The amount of rest and strength a pa- tient gains during her stay in bed or in her room depends to a large extent upon the management of the nurse. The pa- tient often over-estimates her strength, she is so relieved and so happy, but the nurse should keep in mind the mental and physical strain of the preceding nine months and the climax of great pain and exertion at the end and should guard her in every way possible from going too fast, for her own sake, the baby’s, and the fam- ily’s. The patient should return to her household a rested, well woman, and she cannot unless she takes proper time to recuperate. The doctor decides when she is well enough to sit up, to walk, and to go downstairs, and the nurse should never question his wisdom as to the pa- tient’s being in a physical condition to warrant these undertakings. There is another side to the problem, however, which he does not always see, and if he is a broad-minded man and if the nurse has won his confidence, he will not resent her putting it before him. The patient may be physically able to be out of bed and 166 CONFINEMENT on her feet at the end of ten days, and to go downstairs at the end of two weeks,— but as soon as she leaves her room, the re- sponsibilities of the house begin to rest upon her and the nurse can no longer shield her from over-fatigue, from too much company, or from household per- plexities. Her husband, her children, and her servants, unused to managing with- out her guiding hand, hail her return with joy, and she is asked to make Johnny be- have, to order the dinner, to entertain some business friend of her husband’s who is passing through town, ete. The nurse is considered an interfering person if she objects too much. The patient may feel loath to assume her old tasks so soon, but she unselfishly wishes to respond to the need,—and there is usually a relapse of some sort to follow. The baby’s milk sup- ply grows suddenly less, the lochial dis- charge lingers, or if that has stopped, the menstrual period suddenly returns. The patient feels weak and discouraged, she may have to go back to bed for a few days, and everyone wonders why she should have had a set-back. It is ever so much better to prevent all this discouragement, 167 PRIVATE DUTY NURSING if one can, by getting the doctor’s consent to keep the patient in bed a little longer and in her room, after that, before she tries to go downstairs. She may be a little bored, but her friends can come in to see her, and she will fare better to be well rested. When first allowed to go downstairs, she should not attempt to walk back, but should be carried by two persons who make a chair with interlocked hands. A patient who has had to have stitches taken in the perineum will feel some discomfort in that region when she first stands or walks and may worry about it without speaking of it. The nurse should think to tell her that every one has that feeling, who has had stitches, that it is perfectly normal and will pass away. She may find it comfortable to wear a simple abdominal support on first getting up, and many a doctor who objects to a binder while the patient is in bed, advises one during the convalescent period. 168 CHAPTER XVII THE TRAINING OF BABIES Nurses who care for children or who take obstetrical work come much in con- tact with nurse-maids and often work with them day after day. This may be made a very pleasant relationship if there is good- will on each side, but it sometimes fails of such a result, either because the nurse is dictatorial or tactless, or because the nurse-maid resents having anyone else in command and is determined not to be in- terfered with. Whenever we are brought into such a position, it rests with us, as having, supposedly, a broader point of view, to do everything in our power to make the wheels move smoothly, to give the nurse-maid consideration and kind- ness, and to relieve her as much as possi- ble of the harder tasks, that she may be rested and able to go on by herself when our time has come to depart. It is a great mistake for the nurse to assume that she has all to teach and nothing to learn. A good, conscientious nurse-maid can often 169 PRIVATE DUTY NURSING teach us many things, and we should not insist upon her doing things in our way if hers is just as good, though different. In obstetrical work a nurse is often called upon to teach a nurse-maid her methods, and she will find it often a deli- cate task. An old experienced nurse- maid will sometimes agree to every sug- gestion and will do as requested while the nurse is with her, but will revert to her old ways as soon as she has a chance. Many, however, have a keen sense of hy- giene, cleanliness and order, and welcome any fresh information. One excellent woman, who had cared for generations of babies faithfully, borrowed a copy of Holt’s “ Care and Feeding of Children,” read it all with great interest, and on re- turning it said: “I am glad to see that he does everything my way.” The most satisfactory pupil is a young girl who has never done such work, but has an aptitude for it, or a maid who has proved herself capable in other lines of work, but who is trying the care of a child for a change. When teaching such a maid, or the child’s mother, how to bathe a baby, or how to modify milk, both theory and prac- 170 TRAINING OF BABIES tice should be gone over and over, first by the nurse, then by the learner, until she is thoroughly at ease in the process. If she seems a little dull and makes the same mistake, over and over, the nurse should remember that many people seem dull when working under observation but will do better when alone. The baby’s father should be taught how to lift it properly, he will have to do it sometimes in the future and had better know how to do it safely and comfortably. In working with a nurse-maid the nurse should not grow lazy and leave her to do all the drudgery, but divide the work fairly, making sure that the maid has her portion of leisure, for she will have all the work to do alone later, and should be fresh and rested for it. ‘A nurse-maid who had been working with a nurse pleasantly for several weeks was asked why so many of her class dis- like trained nurses. She hesitated for a moment and then replied: “Well, so many trained nurses spoil the babies. They are not going to keep on with them, and they don’t care.” We can feel the justice of this when we remember hearing 171 PRIVATE DUTY NURSING nurses say that they love babies and can not leave them alone, or when we recollect that young mothers have told us that they liked their nurses very much, but that they had to begin to break the babies of their bad habits as soon as they left. It should be a matter of pride with us to leave our babies comfortable, happy, and well- established in the best of baby manners. There is no question more frequently put to an old nurse by a younger one than, What do you do for a baby when it cries? This is equivalent to asking, What do you do for a patient who is uncomfort- able? and every nurse knows that the an- swer to this depends upon the source of the discomfort. There are three great requisites to a baby’s comfort,—it must be well fed, warm, and dry. A baby whose food question has not been settled cannot be happy and good, and no one need expect it to be, but if these three wants are filled the baby should be con- tent with life if the parents are willing to have it left alone. Over-wrought, cry- ing, wakeful babies have not had a fair chance in life. No baby is naturally “bad” or “cross.” 172 TRAINING OF BABIES One cannot be too careful in holding to the monotonous round of sleeping and eating, with only its dressing and undress- ing for exercise and excitement. To be held too long, to be in a bright light, and, above all, to be talked to and coaxed to smile are an immense strain upon the new little brain, and it takes a long time after- ward to settle down sufficiently to go to sleep. Babies are often too nervously tired to sleep, just as grown people are. It is nice to have the flood of relatives and friends get the first glimpse of the baby in its bed, in another room than the mother’s, during the first week, while it is still rather deaf and blind and not easily disturbed. Then, later, when its faculties are acute, it can be left alone, and no one’s feelings are hurt. If a baby must be seen for a moment, later, it should always be before a meal, for there should be an invariable rule that after eating it is to be put quietly to bed, to go to sleep if possible, and when this is done from the first there is seldom any trouble. But suppose it frets after being put in its crib, what then? The diaper is prob- ably wet, and it can be changed without 173 PRIVATE DUTY NURSING taking the baby up, or there is a little gas which will not dispose of itself, and the baby must be held over the nurse’s shoul- der and gently patted to dislodge it. Then there are always wrinkles to be thought of, its clothes so easily get into ridges and bunches, and these must be made perfectly smooth. Sometimes a little milk has trickled from its mouth and has formed a damp, disagreeable spot under its cheek, sometimes a corner of its own or the bed’s clothing touches its lips, suggestive of another dinner, and it is hunting around to find it and will be much obliged to the nurse for removing the tantalizing suggestion. Sometimes a change of position diverts it from its trouble, sometimes a hot-water bag placed at its feet or at its stomach, outside of its clothes, is a comfort. If, after trying all one’s arts, sleep still seems afar, a drink of water is refreshing, but that too should be given while the baby is in bed. The nurse can hold the bottle comfortably for it and let it take as much as it will, if sufficient time, three-quarters of an hour, has elapsed since its last meal. 174 TRAINING OF BABIES Sometimes a baby is crying merely be- cause it is sleepy, and a very few minutes more will be enough to send it off’; but the nurse must learn to interpret very wisely, not to let it suffer any discomfort which can be relieved, and not to be so assiduous in her attentions as to keep dis- turbing it as it begins to feel sleepy. At night it is better to keep the light as low as possible while attending to the baby, and to put it out entirely as soon as it is not needed. There should be some means of good ventilation, for sleep in cool, dark rooms is sounder and more refreshing. Fresh air will not hurt a baby that is well covered and screened from draughts. If the nurse watches the thermometer and regulates the baby’s covers by that, it will be much safer than to depend on her own variable feelings. Regular hours for feeding are generally acknowledged to be essential to the baby’s welfare, but there has been a very decided change of opinion of late in regard to the interval between meals. For years it was supposed that every two hours by day, and every four hours by night, was the 175 PRIVATE DUTY NURSING ideal arrangement, but of late the lead- ing specialists have advocated three- or even four-hour intervals, giving six or seven meals in the twenty-four hours, in- stead of eight or ten. Nurses who have watched babies carefully for some years will realize that this is in accord with the desires of a normal well-fed infant. One must make sure that the baby nurses until perfectly satisfied at each feeding, from both breasts, if necessary. Most babies will sleep over the day-time period at night, and this should be encouraged, for the mother’s sake as well as for the baby’s, until it has learned to sleep soundly for six or eight hours during the darkness and quiet of night-time. If a mother has un- disturbed sleep for a long period at night she will be able to furnish a much better food supply in both quality and quantity. It is well for the nurse not to make too great a splurge at the start about “ train- ing the baby.” In the first place, she may not succeed, and then her discomfiture will be great. Not all babies are amen- able to training. Methods which succeed with one may fail with another. In the second place, the word training suggests 176 TRAINING OF BABIES to many people hours of crying on the part of the baby and of callous indiffer- ence on the part of the nurse. If the training can be carried on so easily and naturally that no one knows it is being done, the mother is spared any uneasy moments. The more one has to do with babies, the better she learns their ways and in- terprets their desires. It is an art which cannot be wholly communicated to another, but to one who loves them there is a great pleasure in learning to in- terpret their signals of distress and to bring content out of trouble. It is a satis- faction, too, when one returns to a family to welcome a second baby, to find the first one with regular habits, going happily to sleep by itself, and free from the fret- fulness which comes from overwrought nerves. To train a child to the use of a nursery chair would hardly seem to come within the province of the trained nurse very often, except as the head nurse of a chil- dren’s ward may labor with her little charges, but I think the obstetrical nurse may often start a baby on the right path, 12 177 PRIVATE DUTY NURSING and may inspire the mother or nurse-maid who is to succeed her to keep up the good work, if she will only take a little trouble. Mothers of all classes seem to be rather careless in the early teaching of regular and cleanly habits. The little children who are brought to our hospitals are often wearing diapers at the age of two and even three years, and in the homes of the well-to-do they seldom graduate from them before the age of a year and a half or later. The teaching should begin when a baby is three weeks old, if it is well and strong. Before that age it is better to be left with as little handling as possible, and its back is too weak for experiments. At three weeks the baby is having only a few movements a day, and one can encourage it to have two regularly, at the morning and evening toilet. When the baby is un- dressed the nurse leaves its shirt, band, and socks on, so that it may not grow cold, and holds it out over a chamber or basin. The attitude suggests what is expected, and the baby is almost sure to expel some gas and to have a small movement. Pos- sibly it will urinate also. If this habit is kept up regularly and persistently, it will 178 TRAINING OF BABIES gradually learn to have its movements at these times rather than at others. In another week or two it can sit on a small agate-ware chamber, which should be held on the nurse’s lap, so that the baby can lean back against her, its knees or feet in her hands. In all such trials the baby must be in a comfortable, unstrained po- sition, or it will ery and no good result will follow. To teach the baby to urinate in the chamber is not quite so easy, but it is pos- sible, if watchfulness and patience are used. Whenever the baby wakes from a nap or comes in from, a ride it should im- mediately be held out, and when it is old enough to be awake much, it can be put on the chamber at regular intervals for trial. It is amazing how soon the baby grasps the idea and waits to be put on, usually making some little signal of warn- ing, which the nurse must watch for and learn to interpret. Often a little, peculiar cry or grunt will announce its need. A Scotch nurse-maid, who had been left in charge of a baby, and warned to watch for his signal, when he should have evolved one, told with great pride, later, 179 PRIVATE DUTY NURSING that she had discovered that he put both thumbs in his mouth and looked in- tently at his fingers when he was ready. Children love cleanliness when they are brought up to it,and earlylearn to wait for help a few moments rather than have the discomfort of a wet diaper. Some babies are completely trained at six and seven months, and wear drawers at ten months or a year. Probably all normal children could have as good records, and how much pleasanter such habits are for all con- cerned—the baby, the mother, the nurse- maid, and all the baby’s family. As a child grows older it is more diffi cult to train it if it has been neglected. One is often in despair in hospital work over children old enough to talk who have no idea of telling of their needs. Re- wards and punishments are alike un- availing, they are so unused to self-con- trol. A nurse is sometimes in a house- hold where a child of a year or a little over is being taught. After it has learned to have its movement on its chair,—and that lesson usually comes first,—if it is slow about telling when it wishes to uri- nate, the lesson is sometimes learned more 180 TRAINING OF BABIES quickly if it is put directly into drawers. A few mishaps occur at first, but the wet drawers are so much more uncomfortable than a wet diaper that the poor baby soon tells for its own greater comfort. It is often through the ignorance of its care-takers that a child’s training is left until so late; its mother does not realize that earlier training is possible, and our duty in this line should include the en- lightenment of the baby’s guardians as well as care for the baby itself. 181 CHAPTER XVIII THE CARE OF THE BREASTS IN OBSTET- RICAL CASES THE care of the breasts and nipples should begin in youth, as too great a pres- sure from corsets or from tightly-fitting undergarments may, sometimes, result in flattened or depressed nipples. This hardly comes within the oversight of a nurse, however, except in the way of ad- vice to mothers regarding their young daughters; and fortunately the present mode in corsets supplies a very low bust which is no support at all, and which cer- tainly cannot make undue pressure. During pregnancy the breasts of a pa- tient are examined by her doctor, and if he finds the nipples inverted or flat, he usually tells her to manipulate them gen- tly, once or twice a day, drawing them out as much as possible. This handling of the nipples makes some women very nervous, or even nauseated, and such cases should be reported to the doctor, as most bad nipples can be improved later 182 CARE OF THE BREASTS by means of a nipple shield. Formerly, different washes for toughening the nip- ples and preparing them for nursing, were much used, such as alcohol, alcohol and water, a solution of tannic acid in glycerine, etc. Now, most physicians ad- vise the patient simply to keep the nip- ples perfectly clean by means of gentle bathing. If crusts form on the surface, they may be softened by using some emol- lient,—white vaseline, albolene, or cocoa butter. Every well-trained nurse is taught that, from the moment a child is born, the breasts and nipples are to be kept in as aseptic a condition as possible. The breasts should be covered with a broad strip of sterile gauze, ample enough to protect the whole breast surface,—over this is fastened the breast-binder. The breast-binder is a familiar article to most obstetrical nurses, but I have occasionally met one who thought a towel with shoul- der-straps just as good. The properly- shaped breast-binder is far more com- fortable than a towel. The long part of the binder is placed under the back, drawn under the arms, and is pinned in 188 PRIVATE DUTY NURSING front, the breasts, meanwhile, being lifted and held in place by the patient. The shoulder-pieces are pinned over after the rest is properly adjusted, and need not then be unpinned again until the binder is removed at bath time. At nursing time all the pins in front are removed, and the gauze is carefully rolled back and away from the breast to be nursed, not care- lessly brushed aside to collect stray germs and carry them back to the nipple again. The patient must be taught how to do this, and must be carefully instructed by the nurse, as soon as she is strong enough to listen, not to touch the nipple with her fingers and not to allow anything to brush against it when it is uncovered. When a baby is brought to its mother, she is apt to forget all precautions, and the baby’s shoulder, with its covering of knit blanket, is drawn across the nipple. The nurse must always be on the watch to prevent such accidents, for an ounce of prevention in these respects is worth a pound of cure later. The usual method of treating the nip- ple is to wash it with boracic acid solution before and after each nursing. The best 184 CARE OF THE BREASTS way of applying this is by an applicator. By using these, instead of sponges, and by being careful never to touch the cot- ton end of the applicator with the fingers, many chances of infection are excluded. A nurse should never, never change a baby’s diapers and then proceed to pre- pare the breast for nursing without first thoroughly washing her hands. As a rule, the baby’s mouth is let alone, but a few physicians still prefer to have it washed before a nursing. This must be done gently, as it is easy to cause an abra- sion of the mucous membrane, which is painful to the child and a starting point for trouble. The engorgement of the breasts on the third day, which often occurs, and is so painful, can sometimes be prevented by limiting the amount of liquids given dur- ing the first few days. The taking of much milk at this time will not hasten the arrival of the milk, but may aggravate the discomfort of the patient when it does come. This first engorgement, however, is not wholly caused by a flood of milk, but also by distended veins and lymph- atics. For this reason, the use of a breast- 185 PRIVATE DUTY NURSING pump relieves the patient only a little. A very firm breast-binder is the most ra- tional method of relief for a distention which will soon pass away of its own ac- cord. Even after nursing is well estab- lished, different portions of the breasts may at times seem hard. If the hard part is stroked gently while the baby nurses, it will usually become soft. The nipples are almost always sensi- tive for the first few days. They have to grow accustomed to their new task, and they are often particularly painful be- fore the milk supply is established. For this reason, it is better not to put the baby to the breast too often at first, and not to let it remain too long; a nursing once in six hours is enough to keep up the nurs- ing habit in the baby, and from three to five minutes is a sufficient length of time for it to remain. By the middle of the second day, the interval can be reduced to four hours, and when the milk appears, to three, by day. The milk supply depends, for its con- tinuance, upon good health in the mother, upon her having wholesome food at regu- lar intervals and in proper amounts, 186 CARE OF THE BREASTS plenty of sleep, and a quiet mind. Sleep is a most important factor. A mother who is wakened every two hours all night to nurse her baby, is too tired to produce a good food, and the baby may be wake- ful and fretting on account of the deterio- ration in quality, which could be reme- died by giving it hot water to drink, and letting the mother have the rest which is so needful for the good of both. To over- load the mother’s stomach with all sorts of liquids, many of which are distasteful to her, is a method of upsetting her diges- tion without aiding the milk supply. All good, wholesome food helps it, though probably milk, cocoa, cereals, and gruels are a more direct aid. Oatmeal and corn- meal gruel are appetizing if properly made. Many kinds of food which are not directly useful to the baby are so to the mother as an aid to her appetite, which must be carefully watched, as it is easily sated by a preponderance of milky viands. Foods which disagree with the mother in health must, of course, be omitted, but fresh ripe fruits, in season, can usually be given safely, and simple salads with a French dressing are a wholesome as well as 187 PRIVATE DUTY NURSING an appetizing addition to the diet. Lemon and orange juice do not affect the milk badly, but strong-flavored vegetables do, such as onions, cabbage, and cauliflower. Most vegetables are useful, particularly carrots and beets. A nursing mother can usually take three good meals a day, with an additional drink in the night. Many like also the morning or afternoon glass of milk, and this will digest better if crackers are given with it, or if it is mixed with oat- meal water, and warmed, but none should be given when the patient feels that to take it will be an effort. In providing a diet for a wet-nurse, a great many people make the mistake of giving her too delicate food. She is not used to it and longs for the heartier and plainer fare to which she is accustomed and on which she will really thrive better. To go back to the actus question of nursing. The position of the baby at the breast is a most important one. When the mother can sit up and hold the baby, she can usually adjust it comfortably, but when lying down she cannot judge as well how it lies, and often gets its head at a distressing angle, or has its body too low, 188 CARE OF THE BREASTS so that the baby is reaching up for its dinner. In such a condition the baby will stop nursing from sheer fatigue before its appetite is appeased. The most com- fortable position for the baby is to lie flat on the bed, the mother turning toward it to nurse it, but this proves tiresome to some women, as the arm nearest the baby has to be held up out of the way. If the baby lies on the mother’s arm to nurse, which is a more natural position, the nurse must see that it is properly held to begin with, and must look at it occasion- ally to adjust it, if it is slipping away from the breast. A pillow tucked at the mother’s back is a great relief to her, for she often holds herself in a strained posi- tion without realizing it, and is tired when the nursing is over. Toward the end of a nursing, or when the baby is not very hungry, it often slips away a little and bites on the end of the nipple. This is always painful and increases the sensi- tiveness of the nipple. The patient must be urged to tell when such “nipping” begins, for there is no virtue in bearing it heroically, as the baby is getting no food when doing this. The nurse must put her 189 PRIVATE DUTY NURSING finger gently between the baby’s jaws at the back of the mouth and remove it en- tirely from the nipple. If still hungry, it will soon take a new and better hold. If it is always removed when it nurses badly, it will soon learn to do better. If the nipples are very sensitive and painful at first, or if an abrasion appears, a nipple-shield of glass and rubber, of the simplest pattern, should be used. This should be thoroughly washed and boiled before being applied, and a finger-bowl containing boracic acid solution, enough to wholly cover it, should be in readiness to hold it after it has been used and washed thoroughly. In order that the nipple-shield may work well, the rubber tip must fit very tightly over the glass, and the glass part must be held by the mother tightly against the breast. Some- times it is necessary to wind the rubber part with silk thread to bind it tightly, though it is thus rendered difficult to clean. The shield should be filled with sterile water before being applied, and the mother must turn toward the child in such a way that it will be pulling straight and keeping its mouth directly against 190 CARE OF THE BREASTS the little bone shield which gives it a brace. If the shield is put on empty and the milk is hard to start, a listless baby will become discouraged and will not suck after the first few fruitless attempts, but the shield filled with warm water usually gives it courage to go on, and the milk, as a rule, begins to come before the water is gone. If the milk is very slow in start- ing, and the baby feeble or reluctant, hot sterile cloths can be applied over and around the nipple, for five minutes be- fore the nursing, after which the milk comes easily; or a breast-pump may be used just long enough to start the milk and to draw enough to fill the shield. This method may be tried, also, when a baby refuses to nurse from the breast, as sometimes happens. As a rule the nipple- shield need not be used through the whole nursing, except where there is an abra- sion on the nipple to be protected. If the nipple is merely sensitive or is flat so that the baby cannot grasp it unaided, five or ten minutes’ nursing with the shield will be enough and the baby can then be put directly to the breast to finish its meal. When a patient has a very abundant milk 191 PRIVATE DUTY NURSING supply, and the baby eats too fast, get- ting its whole meal in a few minutes and then crying from discomfort, the nipple- shield is of great use. If put on at the beginning of a nursing, during the first rush of the milk, the baby will get all it needs, but with greater moderation and comfort. I.ead nipple-shields, which are not perforated, are often a great comfort in preventing any pressure or rubbing from the clothing. These, also, are first washed and boiled and are then put over the nipples, held in place by the binder, and are worn all the time between nursings. If a fissure, however tiny, appears on the surface of the nipple, all precautions must be taken to guard it from infection and to prevent its becoming enlarged. The doctor will usually touch it with a weak solution of nitrate of silver or will order the nurse to do so, and the baby will either be taken from that breast for a time or nursed from it at longer intervals. A fissure will heal quickly with rest and care, unless the nipple is badly shaped, when it may be very obstinate. If a small red spot, feeling sensitive to 102 CARE OF THE BREASTS the touch, appears anywhere on the breast surface, the doctor must be notified at once, especially if the patient has also a chill and rise of temperature. If the trouble seems merely local, treatment by hot compresses, if instituted promptly, will often relieve it. If these are ordered, a compress of linen is boiled to make it sterile and is wrung out of hot water (not too hot to be borne by the hands), is put over the sensitive place and covered with oiled silk and flannel. The binder is then pinned as usual, and the compress is left alone until the next nursing, when another cloth is boiled to replace the first one. If the doctor fears mastitis he will order a saline cathartic for the patient; and for local treatment, either regular fo- mentation, changed every few minutes, or ice-bags. If ice is used, the patient feels chilly at first, until she is used to it, and must be kept warm with hot-water bags. She will sometimes need one at her feet while the treatment lasts, from twenty- four to forty-eight hours. The baby, in this case, cannot nurse from the affected breast until the trouble is over, and must be fed from a bottle, alternately with 18 193 PRIVATE DUTY NURSING nursing from the other breast. When the ice-bags are removed, the milk must be taken from the breast with a pump and discarded, as it will not agree with the baby. If the patient is a cleanly woman, and the nurse is conscientious and faithful in her care, there should be no chance of ex- ternal infection. Possibly inflammation may arise from conditions within the breasts, themselves, but the nature of it is not as yet clear. Very often a mother may honestly wish to nurse her baby and may be greatly discouraged because her food supply for it is inadequate. Every obstetrical nurse should believe with all her heart in the value of breast feeding and should use all her influence to encourage the mother to persist. She should not give up try- ing, even though the bottle must be used to piece out the scanty meals of breast milk. Where a baby must be fed from both the breast and the bottle, it is better to combine the two than to alternate them, for the breasts need constant and regular stimulation by nursing to keep them to their proper function. Some- 194 CARE OF THE BREASTS times people are afraid that the mixture of food will disagree with the baby, but just the contrary seems to be the case,— the addition of breast milk to the artifi- cial making the latter more digestible and more nourishing. The baby is, of course, fed from the breast first, until the mother feels that the supply is exhausted, and is then immediately given from the bottle sufficient food to satisfy it. This combi- nation feeding will, in most cases, be needed only during the time the mother is housed. As soon as she gets out-of-doors, and especially if she takes walks of in- creasing length daily, the milk supply will improve in both quantity and quality and the bottle feeding will not be needed. 195 CHAPTER XIX CONTAGIOUS DISEASES Most nurses in general hospitals have the opportunity for six or eight weeks’ training in the care of contagious dis- eases, and those in small or special hos- pitals have often the opportunity to take such training by affiliation of their school with some other, if they care for it. No nurse should take a contagious case in private practice without such careful spe- cial preparation, unless she finds herself in a community where she is the only nurse available, and in such an event she should explain to the physician in charge that she has had only theoretical, not prac- tical, training in this branch of work, as there are many points he must make clear to her as to the care of nose and throat, diet, ete., which will not be familiar to her from her general nursing. The most important requisite for a nurse who is to take contagious work is that she should be a person of cleanly per- sonal habits, for it is through her or the 196 CONTAGIOUS DISEASES doctor that the infection will be spread, if at all. It is now pretty well established in the minds of the foremost investigators that almost all contagion is caused by con- tact with a sick person or with something recently in contact with him, or that it is insect-borne, but that it is not air-borne, and that the germs of infectious diseases cannot live long or multiply on inanimate objects. This makes the care of such cases a simpler and more easily-understood problem, but it is not easier to carry out the necessary precautions, because the very thing required, absolute cleanliness of hands and person, is a thing unknown to most of us. We all think we are careful in our daily lives, yet how many of us make it a practice to wash our hands be- fore each meal we take? How many of us keep our fingers away from our faces and mouths? How many of us moisten our fingers to turn the pages of a book or magazine? Now that it is known that there are hundreds or thousands of ty- phoid carriers at large, the question of the prevalence of typhoid fever is no longer a mystery, and we know that the safe-guarding of milk and water sup- 197 PRIVATE DUTY NURSING plies and the slaughter of flies will not alone be sufficient to control it. These typhoid carriers cannot all be detected, isolated or controlled,—yet, if every per- son could be taught to wash his hands thoroughly after each visit to the water- closet, even typhoid carriers would cease to be a menace, and the disease would be much less frequent. It is estimated that, even among intelligent, apparently cleanly people, not more than 5 per cent. can be trusted to wash their hands before coming from the bath-room. Both in the prevention of disease and in actually caring for it, healthful living conditions, clean, carefully-handled, well- cooked food, sunshine, fresh air, soap and water, and boiling water are our safe- guards and allies rather than sprays and strong-smelling solutions. Let us see how this knowledge can be applied to the care in her home of a patient suffering from a contagious disease. If a nurse has any share in the choice of the sick-room for such a case, she will choose one with a sunny exposure, one which has more than one window, and one which is near the bathroom, if she can. 108 CONTAGIOUS DISEASES She must keep in mind the fact that it is through her handling of the patient and then of articles which are outside the room or which may be carried outside that the disease may be transferred to some other person. For this reason she should wear a surgical gown while actually caring for the patient and should wear rubber gloves for such procedures as can be carried on as well with gloved hands. She should guard her hands against abrasions and protect them if they appear. The rea- son for the gloves is that they are more easily cleaned than are hands, yet their use should not make the nurse careless about washing her hands after caring for the patient, before leaving the room, and before taking any food, herself. The gloves should never be taken from the sick-room, they can be scrubbed, scalded, and sunned sufficiently there. Outside the room, on a hook within reach from the door-sill, should hang another gown, and below it should be a pair of rubbers. Whenever the nurse leaves the sick-room she should remove the gown and gloves she has been wearing, wash her hands thoroughly, then put on the clean gown 199 PRIVATE DUTY NURSING and rubbers. She may then safely pass through the halls or go to bathroom or kitchen, but she should make her stay in the kitchen as short as possible. When- ever she is out of the room she should handle nothing with her hands that she can avoid, not touching knobs of doors or sliding her hand along the railing of the stairs. I have laid no stress upon her cap. She will naturally wear one as part of her uniform, and many nurses wear one that fits more closely, like a dusting cap, for contagious cases, yet there is lit- tle danger of infection from her hair. It does not touch the patient, and germs are not athletic animals able to leap to heights. They are subject to the laws of gravity, as is all matter, and there is much more danger from the feet of the nurse than from her head. The nurse should never, never touch the patient without washing her hands after- ward, and she should remember at all times to keep her fingers away from her face and particularly from her lips. Remembering that flies and mosquitoes are carriers of dirt and disease, the nurse should see that there is no flaw in the 200 CONTAGIOUS DISEASES screening of the windows of the sick-room in summer, and should kill any insect that eludes the barriers. According to the best authorities, boil- ing water is as safe a disinfectant as we have, and this being so, the expense and difficulty of caring for the excreta are sim- plified. If possible, the nurse should have in the bathroom or the sick-room a small oil stove or a good-sized alcohol stove, so that she may get plenty of boiling water without having to go to the kitchen for it, but if she is faithful and conscientious in her precautions, she can go to the kitchen if need be. Fecal matter or urine should be thoroughly mixed, in the bed-pan, with an equal amount of boiling water, before being emptied into the water-closet. The typhoid germ is absolutely killed at a tem- perature of 150 degrees, so that after this treatment it is safe to empty the contents of a bed-pan into the vault of an out- house, in a country case, without fear of spreading infection. Of course, in any case, city or country, if the attending physician does not believe in this simple method of disinfection, the nurse will use bichloride, carbolic, milk of lime, or what- 201 PRIVATE DUTY NURSING ever he prefers, just as he directs. If the bath water is to be disinfected, that, too, can be mixed with an equal quantity of boiling water before being poured out. The bed-pan or urinal should be scalded, inside and out, with boiling water after use, and is then as safe as if it had soaked for hours in some disinfectant solution. Paper napkins, or soft toilet paper, rather than handkerchiefs, should be used for the reception of all secretions from mouth, nose or throat,—particularly in diphtheria, scarlet fever, measles, or tuberculosis, and these paper napkins should be burned after using. If the patient is able to use these herself, a paper bag can be pinned to the side of the bed to receive them. If there is a fireplace in the sick-room, all such refuse, and all scraps of food left from the tray, can be burned there. If there is none, the small paper bags can be dropped into a larger one, which the nurse takes to the stove or furnace to burn. If there is need of reducing the laundry work as far as possible, a roll of tissue paper towels may be kept and used for the nurse’s hands and for numerous 202 CONTAGIOUS DISEASES other purposes where ordinarily washable towels would be used. Clothing or bedding to be washed should be soaked in cool water, in a cov- ered pail or jar kept in the room, before being taken to the laundry. The usual instructions are that they should be soaked in some disinfectant first,—but there is hardly one which will not coagu- late the albumin in the discharges which have soiled the clothes, and the stains are thus permanently imbedded in the linen. Unless physician, family, or servants are afraid of linen so treated, the soaking in plain, cool water is sufficient, and the or- dinary laundry processes complete the sterilization. If germs cannot live long in sunshine and fresh air, and if they are destroyed by an application of water as warm as 150° F., they cannot survive the scrubbing, boiling, and sunning processes. If it is necessary to use some disinfectant with an odor to appease the fears of a laundress, the very mildest solution of carbolic that will afford an odor should be used. Boiling water should never be applied to soiled clothing before washing, as it sets the stains. 203 PRIVATE DUTY NURSING The dishes used by patient and nurse should be scraped and then dropped into a pan or pail of water outside the door before being taken down to be washed. Like the clothing, they are safe if care- fully washed and scalded, but it is a good precaution to keep them separate for use in the sick-room. The sick-room should be kept clean by the nurse herself, and all sweepings burned. She should not shake rugs or clothing from the windows. When an acute contagious case is over, the nurse should not feel that her duties are ended until the room has been thor- oughly cleaned. The best disinfection of all is a thorough housecleaning,—scrub- bing, sunning, and airing. If, in addition to this, the health authorities or the at- tending physician require fumigation, the nurse will carry it out as faithfully and thoroughly as possible. Cases of typhoid and tuberculosis are not isolated, yet these diseases may be transmitted to others by carelessness of either patient or nurse, and it rests with the latter to see that not only are all dis- charges cared for properly, but that the 204 CONTAGIOUS DISEASES patient’s hands and her own are kept con- tinually clean and that no infective ma- terial is carried by them to door-knobs. furniture, utensils, food, or to others’ hands. A nurse who is handling bed-pans and infectious material should never wash the mouth of a patient by twisting gauze about her finger, but should learn to use a swab deftly and thoroughly. If she prepares the patient’s meals, and so han- dles food and cooking utensils, she should make her hands surgically clean before beginning her preparations. However well a nurse may care for her patient, she is not doing her whole duty on a contagious case unless she helps the doctor in his efforts to locate the source of infection and shares with him in the in- struction of the members of the family as to their health and habits, as a safeguard against contracting this illness at hand or against future illness. A nurse who is living in a household learns the habits of those about her and may detect some care- lessness which the doctor could not dis- cover in his daily calls. In farmhouses, the common drinking cup and the com- 205 PRIVATE DUTY NURSING mon towel are sources of danger. Very often the pail and dipper are the one common supply of water, and the sink and roller towel afford all the washing facilities there are for parents, children, and hired men. It is comparatively easy to substitute a cup, turned upside down on a plate, for the drinking utensil, and to drill each person to pour water from the dipper into the cup for drinking, and to rinse the cup inside and outside after us- ing, never dipping it into the pail, and never drinking from the dipper. It is harder to bring about separate washing arrangements, but a row of hooks near the sink, with a towel, piece of cheese-cloth, and tooth-brush for each member of the family, is not impossible of accomplishment if the nurse is tactful and friendly. This larger view of one’s responsibility makes all her work more interesting and more worth while. Nore.—My authorities for the views expressed in this chapter are Dr. George W. Goler, Health Officer of Rochester, N. Y., and Dr. Charles V. Chapin, Superintendent of Health, Providence, Rhode Island, whose book “The Sources and Modes of Infection” will be found of interest to any nurse who wishes to study the subject fully. 206 CHAPTER XX HOTEL LIFE AND TRAVELLING A CASE in a hotel is in some respects easier and in others harder than in a house. It is easier because there are no household complications, no family to be considered, no extra work. The nurse can devote herself wholly to her patient, and is not obliged to leave her room for any other task. A bell-boy or maid will bring what she needs, if it is to be had. On the other hand, hotels are not planned for sickness, and many comforts and ne- cessities are lacking. Bedding is apt to be poorly ironed and damp, and should be carefully aired and sunned before us- ing. If a patient is very ill, it is well on first arriving at a hotel, to ask the cham- ber-maid for half a dozen each of sheets, pillow-cases, and towels if they can be spared. Fach day thereafter, the nurse can ask for as many more as have been used, thus keeping a sufficient supply of dry linen ahead to draw upon in emer- gencies. Another good precaution is to 207 PRIVATE DUTY NURSING take with one a pair of summer blankets. These can be used for a patient instead of sheets until the hotel linen has been made acceptable, and they are also at hand for use for baths in bed. Hotel food, though of great abundance and variety, has not the appetizing or nu- tritious qualities of the simplest home- cooked viands. Many a nurse in a hotel has done all the cooking for her patient on a chafing-dish in order to have some- thing suited to her needs. It is necessary, too, to keep all sights, sounds, and suggestions of illness from other guests. If a nurse is alone with her patient, and if it is at all a critical case, it is impossible for her to be relieved for exercise or meals. She must eat from a tray in her patient’s room, or in one ad- joining, and she does not get the change of scene that is so restful. Sometimes, even though there is a competent person to relieve her, she cannot be spared long enough in safety for the long process of first dressing for the dining-room and then ordering and waiting, the eating be- ing the most quickly accomplished part of 208 TRAVELLING the process. She will, of course, not ap- pear in uniform. A nurse with good taste and good sense will make herself as little observed as possible in so public a place. There are some people who like to parade a nurse in uniform in the halls,—a very uncomfortable and embarrassing situa- tion, and one to be avoided. If a death occurs in a hotel, and a nurse is alone, with no member of her patient’s family at hand, she will need all her resources to make proper arrangements for the care of the body, to send notices to her patient’s friends, to care for her be- longings, ete. It will probably be neces- sary to have the body removed to an un- dertaker’s at once, within an hour or two of the death. One nurse who cared more for the distress of her patient’s wife than for her own comfort, accompanied the body of her patient to an undertaker’s in the middle of the night, and stayed there until relatives could be summoned and other arrangements made. No nurse should ask for or choose pa- tients who are to travel unless she has proved herself a good traveller in the past 14 209 PRIVATE DUTY NURSING and is used to the cares which will fall to her. The world is full of people who are “willing to travel.” Xvery paper or magazine one picks up contains generous offers from numerous impecunious indi- viduals who offer their services as com- panions and who modestly suggest that they have ““ no objection to going abroad.” One might think it an easy task, yet to be a good travelling companion requires special gifts. A nurse who is to travel with a patient must not be car-sick or sea- sick. She must be able to pack well, to make travelling arrangements, and to look after luggage; she should be used to hotel life to some extent, and should have that bump of locality which enables one to find her way about in a strange place. She should have an even disposition, be able to put up with discomforts, and should possess a quick wit which enables her to act promptly and wisely in an emergency. The nurse who travels with a patient is not going for her own pleasure, and she should put all thought of it aside, de- voting herself wholly to helping her com- panions to as great comfort and security 210 TRAVELLING as is possible. If pleasures do come to her, unexpectedly, she will enjoy them all the more, but with her mind in this attitude she will not be bitterly disappointed if she comes just within reach of places she has longed to visit without having an op- portunity to really see them, because she is needed by some ailing man or woman whom she has undertaken to serve. In planning for a journey, she should think ahead and plan for all possible emergencies. Four things are quite necessary to carry in most cases,—an al- cohol lamp, some extra food, a thermos bottle, and a hot-water bag. The lamp should be of the variety that burns vapor and will not explode or set fire to any- thing if it is overturned. The hot-water bag had better be a small one, which can be filled from the sauce-pan which comes with the lamp. The food should be in concentrated form, such as malted milk, chocolate, or a small box of crackers, in case of delays or overcrowded dining-cars. The thermos bottle can contain hot cocoa or chocolate or cold or hot milk. She should take as hand luggage all the things needed for her patient for 211 PRIVATE DUTY NURSING twenty-four hours, in case of separation from trunks. If medicines are carried, a bottle of drinking water should be packed with them, as it is not always possible to obtain pure water during the journey or immediately on reaching one’s destina- tion. A travelling rug and a cushion, which are so necessary for a trip abroad, may add much to a patient’s comfort in trips of any length in one’s own land, es- pecially if a long drive or boat trip is to be taken. If the nature of the patient’s illness re- quires the taking of many sick-room sup- plies, it is convenient to pack them all to- gether in one small trunk, rather than have several trunks filled with a mixture of clothing and supplies. For a helpless patient, a wheeled chair can be had at any large station by tele- graphing ahead to the station master. If a patient must be carried, but need not lie down, there are to be had little canvas chairs, carried on short poles. One of these can be made part of the travelling outfit. If a stretcher is used, it must be put through the car window, as the aisles of a car are too narrow to admit it. If 212 TRAVELLING an ambulance is needed, a nurse should try to get the kind that resembles a closed carriage. It is much less conspicuous than the ordinary ambulance and attracts less attention to the sensitive occupant. As soon as a halting-place is reached, even if it is temporary, the patient should be made comfortable, and her belongings arranged systematically and attractively, so that there will be a home-like air to her surroundings. A pretty travelling rug and a few photographs will transform a hotel room into an almost cheerful place and may help keep up the patient’s spirits. In regard to established customs, some patients need a vacation from their habits, and must be gently led into new interests and ways, either gradually or abruptly, according to circumstances. The change of scene may give an opportunity for a reform which could not have been carried out at home, indeed, the journey may have been advised by the physician with just this end in view. With other people the habits are harmless, are a part of their very existence, and must be continued un- der new and varying conditions, giving 213 PRIVATE DUTY NURSING the nurse a chance to exercise her ingenuity. In travelling with children and babies, the nurse should cling to their regular ways (if they are good ones) though the heavens fall. One of my patients taught me the advantage of this by describing the methods of an excellent nurse-maid she had had. They were obliged to travel a great deal with her baby, and she said they could always tell the time of day by Lizzie’s occupation. For instance, at 5.30 p.M., whether on boat or train or in a hotel, Lizzie was to be found undress< ing the baby, his little toilet articles spread neatly about her, and his bottle standing in hot water ready to help him off to sleep. I tried this plan afterward, under difficult circumstances, when trav- elling with two babies and an invalid mother, and found it excellent. The children’s meals, baths, and bed-times were arranged as they usually were at home. Even though we had to pick them up in their nightdresses from a hotel bed at 10 p.m. and transfer them to a sleeper, they were much less disturbed than they 214 TRAVELLING would have been by an undressing in the train at that late hour. The food of a child when on a journey should be either the same as usual or a little more simple and easy of digestion. It is distressing to one who cares for the welfare of children to see the steady eat- ing of indigestible stuff which seems to the lower classes an essential part of a trip of any kind. If food must be carried for a baby ar- tificially fed, it is well to procure one of the small portable ice-boxes furnished by the dealers in modified milk. This is a square wooden box, about the size of a hat box, lined with zine, having a central compartment. for ice, surrounded by spaces for nursing bottles, into which they fit tightly without tipping or jarring. There is no drainage, but when the ice needs renewing, the bottles can be taken out, the water emptied, and fresh ice put in. The box can be locked, and is car- ried by a handle on top; it is heavy, but I would rather carry an ice-box and a baby together, if necessary, than to be sepa- rated from this precious possession. I have seen distracted mothers, who had 215 PRIVATE DUTY NURSING lost connection with their checked ice-box, go hunting madly through a train for some one with milk to spare. A safe precaution in travelling with a baby, whether by land or sea, whatever be its food,—mother’s milk, or a carefully- pasteurized supply of cow’s milk,—is to carry also a bottle of malted milk which makes an excellent emergency food, as it needs only hot water to prepare it, and one can never tell when the other food supply may fail. A nurse should make sure, before be- ginning a journey, that she knows by sight every article of her patient’s lug- gage, so that a trunk may be singled out of a mass by its appearance before the baggage-man has found its check. This might not occur to the nurse new to travel until she went to check a trunk and found she did not know which it was. It is al- ways safe to take too many precautions, rather than too few, in looking after the belongings of another person. 216 CHAPTER XXI SPECIAL NURSING IN HOSPITALS GRADUATES are being called into hos- pitals for special duty more and more, partly because the pupil nurses cannot be spared from their regular work and from their classes for special cases, and partly because so many more people go to hos- pitals for surgical or obstetrical care that the staff of student nurses is not large enough to supply the demand. When a nurse goes back to her own hospital, where she had her training, she can fit into her environment naturally and easily. She knows the rules, she knows the ways, and can make herself at home at once. If she goes to a hospital which is strange to her, she should go with the intention of adjusting herself to its re- quirements if she can possibly do so. If & the call to the case comes from the super- intendent of nurses, she will probably meet her on her arrival and explain to her her duties, detailing some pupil nurse to show her her surroundings, point out 217 PRIVATE DUTY NURSING where supplies are kept and to put her in touch with the head nurse of the floor to which her patient has been assigned. If the nurse has been sent to the hospital by a doctor, who has not consulted the superintendent as to his choice, her path is not likely to be an easy one, for she shares, in the mind of the superintendent, the discourtesy of the act, and it is an unusual woman who can avoid showing | any prejudice against a nurse thrust upon ~ her in this way. Perhaps the hospital is not a very good one, and the nurse from outside has been put there because the doctor dare not trust his patient to the regular staff. This is a very embarrass- ing and difficult situation and one which no self-respecting nurse would choose. If she finds herself there, either because she was kept in ignorance of the true situa- tion or because a patient’s life is really en- dangered, she should accept it and make herself as little obnoxious as possible, co- operating with the hospital authorities as far as she can, and doing everything to make for peace. Usually she will win her way and will be tolerated, or even made 218 SPECIAL NURSING a welcome guest, before the end of the case. The courteous thing for a nurse to do when she goes into a strange institution is to seek its head, introduce herself to her, and ask what the regulations for special nurses are, thus showing her will- ingness to be a help and not a hindrance. If she cannot, or will not, conform to the rules of the place she most certainly should not take the case. In some hospitals, the arrangements for special nurses have been thought out with care and are excellent. There are lockers for their clothes, a room for dressing, a special dining-room where good food is served, and adequate arrangements for relief. Twelve-hour duty is the rule in many, and the nurses are sent home to sleep. To some nurses this is much easier, because of its regularity, than ordinary private duty in the home, and there are some who do no other kind of nursing. The hours for changing nurses are not quite as convenient as they may be made in the home where two nurses are em- ployed, as 7 A.M. and 7 P.M. are the usual times chosen. This makes it rather diffi- 219 PRIVATE DUTY NURSING cult for the day nurse to get the best use of her time off duty, as she has to rise very early to reach her patient at 7 a.m., and she reaches home too late and too tired for any enjoyment of the evening, especially as she must retire early to get needed sleep. The nurse who is on night duty, and who sleeps in her own room, finds it diffi- cult to adjust her sleep to the convenience of her room-mates, if she shares her room with others. Kither she is disturbed by their coming in through the day or, if they are very considerate and try to make arrangements to leave her undisturbed, she feels that she interferes with their use of the common room. In other hospitals there is really no pro- vision for the comfort of the special nurse, she must live in her patient’s room, sleep- ing and dressing there, and possibly hav- ing her meals sent to her there, unless she can be relieved for meals with the pupil nurses. She may be given very irregular relief for sleep or for exercise, and that by floor nurses who are already too busy, so that she feels uneasy about the care her patient receives in her absence. In some 220 SPECIAL NURSING places her compensation for a hospital case is less than the usual rate outside. In all hospitals, whether comfortable or otherwise, the special nurse is not alone responsible for the care of her patient. The house doctor, the superintendent, and the head nurse of the floor have each a share. To some nurses this is a great re- lief, to others it is a constant irritation. However she may feel about it, the spe- cial nurse must accept the situation as it is, and must consult the house doctor about small treatments which are to be given, must keep the superintendent and head nurse in close touch with her pa- tient’s condition, and must in all ways courteously acknowledge their share in the conduct of the case. I have known a hospital in which the orders for the pa- tient were given directly to the head nurse and were not passed on to the special nurse, who was obliged to do her work more or less in the dark, without intelli- gent understanding of the situation. In this special instance it was better to make no protest, but ordinarily a special nurse might choose a favorable time and have a frank talk with the superintendent, tell- 221 PRIVATE DUTY NURSING ing her why she thought the system an unwise one. If conditions are not reme- died after a reasonable remonstrance, a nurse need not make herself and her pa- tient uncomfortable by complaining, as that will not mend matters. She should endure as good-naturedly as possible the annoyances, taking the best care she can of the person entrusted to her, and at the conclusion of the case the remedy lies in her own hands, for she need not accept another case in that institution. If, how- ever, the conditions are such as to actually interfere with the patient’s welfare, or if the nurse herself is in danger of giving out from insufficient sleep, she should make the matter known to the doctor and quietly withdraw from the case when some one has been found to succeed her. She should never break over the rules of the institution in an effort to remedy mat- ters, and she should keep her troubles to herself and not share them with the pa- tient, for nothing so retards convales- cence as continual mental irritation. If a doctor takes a patient to a certain hos- pital, he naturally wishes her to be happy and content while there. Her special 222 SPECIAL NURSING nurse should feel it a part of her loyalty to the physician to help make her so. Continual comments on the management of the institution and unfavorable com- parisons between it and some others will, in time, undermine confidence. There is usually more or less red tape in regard to the securing of linen and other supplies needed by the special nurse, and this may be a source of constant trouble both to the authorities and the nurse, or it may serve to show how even a graduate can adjust herself to hospital requirements amicably and reasonably. The linen may be kept in a central linen room, and the nurse may have to make out requisition blanks daily for the amount she needs. She is naturally thinking of all possible emergencies that may arise and may order much more than is actually needed, keeping always a surplus stock on hand. As no hospital is over-stocked with linen, and as there may be several special nurses on duty at once, all using the same methods for the benefit of their patients, the result is that some other pa- tients must do without, which is certainly unfair, and the pupil nurses are kept in a 223 PRIVATE DUTY NURSING state of resentment, which is quite natu- ral. If a special nurse will keep this in mind and will order only what is neces- sary, the head nurse will undoubtedly ap- preciate her consideration and will do her best to help her should a sudden need arise. The systems of record keeping and charting vary in different institutions, and another way in which a special nurse may make herself a desirable guest is by her thoughtfulness in finding out just how the records are kept in the place where she finds herself and in keeping hers accurately and faithfully, so that no one need be inconvenienced when the case is over, and the records are filed away, in finding them incomplete or not in proper form. Usually the nurse may keep the record and chart in her patient’s room, just as she would in a private house, but occa- sionally the rules of the institution require that the record be kept with all the others at the desk of the head nurse. In such a case the special nurse will be much incon- venienced in keeping it satisfactorily, for she cannot keep leaving her patient to 224 SPECIAL NURSING make an entry. Probably the best way out of this difficulty is to keep two sets, one in her room which is accessible, and from which she may copy into the other as often as she can take the time to do so, being careful not to let it go long without writing up. Although the difficulties of the special case in a hospital are many, they are far outweighed by the educational advantage of being once more in the up-to-date in- stitution where the latest methods are being practised and where the nurse who has been some time out of training may put herself in touch with them. The at- titude of the special nurse, her adapta- bility and receptivity will all modify the kind of use she makes of these oppor- tunities. A stupid, unobservant woman may take a case in a modern institution and, unless some one is looking after her and pointing out to her what she should notice, may come away with very little benefit. A nurse who thinks she ““ knows it all ” will spend so much time in impress- ing the student nurses with her superiority that she will have little left for learning from them; also the nurse who is tactless 15 225 PRIVATE DUTY NURSING and selfish and who obtrudes herself and her questions when pupils are too busy to pay attention to her will get little more than she can see going on about her. The tactful, friendly nurse, who has won a place in the regard of those about her by her thoughtfulness, and who chooses wisely her time for asking questions, will find head and pupil nurses, house doctors, and, perhaps, the superintendent, all inter- ested in having her see the new ways and learn the new methods. She, in turn, can widen the horizon of the students by tell- ing of the great social and economic ques- tions of which nursing is a part and by deepening their interest in nursing litera- ture and organization life. It goes without saying that this acquisi- tion of new knowledge is never to be gained at the expense of her patient. She is there first of all to care for her, and should never leave her, either for friendly visiting or for the sake of seeing some spe- cial treatment given, unless there is ade- quate relief or unless she has the patient’s cordial consent to her absence for a short time when she is not needed. When a special nurse is sent off for 226 SPECIAL NURSING several hours for exercise or sleep, whether she is relieved by a second nurse or by a pupil, she should take great pride in leaving her patient and the room in good order, every treatment given up to the hour she leaves, every utensil clean and in place, and the patient fresh and comfortable, unless she is sleeping, when she should certainly not be wakened in order to be made ready for the next nurse. If the orders are not clear on the history sheet, a special set of written directions should be left for the substitute, and if the latter is a pupil nurse supplying the need temporarily, the record should be left intact and the history for the few hours kept on a separate slip of paper, which the regular nurse can copy into the record on her return. Usually a patient hates to be left in new hands and wants all important attentions given by her own nurse, especially if they are painful to her. A selfish or even a merely thought- less patient may keep her nurse long past the time for relief until everything she can think of has been done, but the faith- ful nurse will prefer to do a little more rather than a little less for the one depend- 227 PRIVATE DUTY NURSING ing upon her for care and she will enjoy her sleep and outing all the more if her conscience is clear as to her patient’s comfort. It seems unnecessary to say that a spe- cial nurse should never go off for a walk on her own initiative without consulting the head nurse as to whether it is a con- venient time for her to do so. If she does, the patient is almost sure to suffer, as the floor nurses have their own duties to per- form and may not be able to answer her call promptly. The influence of a special nurse from the outside on the pupils is great. If she disregards hospital rules, she helps to break down the discipline of a school. If she lends an ear to gossip and joins in it, she helps to foster disloyalty. If she is untidy in appearance and lax in method, the pupils feel that the requirements in regard to their dress and manner of work are severe and unnecessary. On the other hand, if she is a woman of fine character, who has not only kept up but improved her technic, the younger women will nat- urally look up to her and she can help en- force the lessons their superintendent is 298 SPECIAL NURSING trying to teach them. Such a woman will teach these lessons unconsciously, whether she does so deliberately or not. Sometimes the house doctors will con- sider a special nurse as a person with whom they may have good times, un- restrained by the rules governing pupil nurses. The special nurse who responds to their suggestions is harming her fellow nurses in the school, by her example, and is lowering herself in the eyes of every- one. These very men who are willing now to flirt with her may, later, be her superiors on some case outside. If she wishes to stand well in her profession, she cannot afford ever to lower her womanly dignity, nor should she be willing to use her influence with pupil nurses to do them harm, as she certainly will if she indulges in light conduct. One lesson the pupil nurses, most of them, will have to learn for themselves as they begin private duty, and that is that all the little attentions we learn to give our patients, which are not absolutely essential, but which make so much differ- ence in their comfort and happiness, are really worth while. To pupil nurses they 229 PRIVATE DUTY NURSING seem like fussing, because it is absolutely impossible to give that sort of care to the dozen or more patients for whom they are responsible. I remember the amaze- ment with which a pupil nurse regarded me when she found I was giving my patient an extra bath at night during very warm weather, just because it made her feel cool and rested. But I felt that the bread I had cast upon the waters had come floating back to me, when a special nurse I had, during an illness some years later, gave me an extra sponging at night, without a request from me, because she found it made it possible for me to sleep. She had been away from the hospital long enough to do more than was included in definite orders. The nurse on special duty in a hospital must keep in mind the patients all about her, other than her own, and must be quiet herself and keep visitors quiet for their sakes. She must also be considerate of the welfare of the whole institution by using its furnishings and supplies with the same care and economy as if they be- longed to her patient. She will not, of course, if she is at all a worthy nurse, 230 SPECIAL NURSING leave a trail of things to be picked up and cleaned, after she has been doing work in the lavatory or diet kitchen. There is no surer way of falling in the esteem of the students, and it is certainly worth while to be on good terms with those with whom we are associated, though that is not the highest motive for doing one’s duty. In a hospital where conditions have been uncomfortable, but not intentionally so, a special nurse may confer a favor on her successors if she will talk over the conditions with the superintendent when she leaves, pointing out where things have been hard for her and perhaps suggest- ing a way to improve them. If there is friendliness between them this should not be unpleasant for either, as it is done in a spirit of good-will. 231 CHAPTER XXII THE OLD NURSE Must the old nurse think of herself as useless lumber? Does the law concern- ing the value of experience hold good in other walks of life and fail in ours? The physician, the lawyer, the teacher may find it difficult to get the right start in his career, he may have to begin by fill- ing the position of an assistant, but if he has had good preparation and if his work is good, each year adds to his value to the community, and his age is crowned with honor. With nurses it is rather different. They are often most in demand during their first years after graduation, and may have their hard times as they grow old in the work, in spite of their accumu- lated knowledge. With those in execu- tive positions in institutions, or in social work, this is not as likely to be true, for the experience that they have gained is a help to positions of higher responsibility; it is the private duty nurse who most often seems to lose her hold on her work as time passes, 232 THE OLD NURSE I believe the explanation lies in the fact that the private duty nurse leads a more solitary life, from a professional stand-point. The teacher, the physician, and the hospital nurse are working shoul- der to shoulder with comrades. There is a continual inspiration from continual competition; there is a steady exchange of ideas. The private nurse, on the other hand, works largely alone. When she be- gins her career she is well versed in the latest methods, her mind is filled with the newest ideas, she is able, enthusiastic, and interested. No wonder the doctor is glad of her assistance; she needs no explana- tions or minute instructions; at a word she understands what he means and ful- fils his intentions. But the young nurse who considers this knowledge an inex- haustible store from which she may draw indefinitely is making the mistake which will by and by cause her to fall from the ranks or, at least, to lag in the rear. As the months go on she continues to use and add to part of her knowledge; the rest may be uncalled for and grow rusty or obsolete. She will at first be associated with many doctors, but as time goes on 238 PRIVATE DUTY NURSING she is better known and is demanded by a few who keep her busy, and these may or may not be progressive and a help to her own progress. Her intercourse with other nurses is rather limited. She has not new knowledge continually forced upon her, and if she wishes to rise, she must make the effort to do so, herself. I think it is true with all of us that the de- mands upon us are great and we grow so weary, physically, that we have little en- ergy left for mental improvement. How may a nurse overcome these very obvious difficulties? She must be ever watchful of herself, critical of her own defects, merciless to any spirit of indiffer- ence which may show itself, eager to learn, zealous to seize every opportunity to add to her knowledge. She must de- liberately keep herself in touch with her fellow nurses through whatever organiza- tion life is open to her, giving her own ideas to others and receiving theirs, get- ting the broader vision of our whole field of endeavor by attending state and na- tional meetings, when she can do so. Every call to service, whether to hold of- fice, to serve on a committee, to write a 234 THE OLD NURSE paper or to help in a discussion should be given consideration and complied with if possible, for all such effort will help keep a nurse abreast of the times and will be indirectly a help in her work. The private duty nurse is very apt to think that she cannot find time to attend meetings, yet, in many cases, she could do so if she wished to, even when on duty. By speaking of the meeting several days ahead and asking to be given her free time at that hour, it could often be accom- plished without discomfort to any one. Private duty nurses have been known to hold office satisfactorily as president, sec- retary, or treasurer of their alumna as- sociations, and I know from the character of these women that their patients were not allowed to suffer. She should also read the best of nurs- ing literature in both books and maga- zines. If she does not wish to buy books, because she has no permanent home in which to store them, she can read them in the library of some nurses’ home or some central directory. After she has chosen the nursing magazine which ap- peals to her own needs, and which repre- 235 PRIVATE DUTY NURSING sents the principles for which she is striv- ing, she should read it thoroughly each month. When she is on a long case, she should try to have it forwarded, for no one is likely to give careful reading to an accumulation of five or six copies. It is hard, sometimes, to read professional books or magazines when one is at home between cases, and certainly one’s read- ing should not be confined to these, but neither should they be neglected. Habits are so easily formed, and the person who says, “ I am too tired now to be interested in that,” should pull herself together by the reflection, “ When shall I be less tired or more likely to do it?” Occasional post-graduate work is an absolute necessity for the nurse who is intending to keep herself always well equipped for her calling. Many are very short-sighted in regard to this and feel that they cannot spare the time or the money. The unsuccessful nurse feels that she cannot give up so much earning time, and the successful one finds it hard to break away from her patients for the needed interval. In no other way is it as possible to renew one’s grasp of present 236 THE OLD NURSE methods. It is usually advisable to spend part of this term in general work as well as on her own specialty. It all has a bear- ing on her work and will all prove useful. On the other hand, a nurse may belong to her alumna association, subscribe to a nursing journal, take graduate work, and be little the wiser if she has not a recep- tive mind which is on the alert for knowl- edge and which grasps it at every oppor- tunity. There are many doors open for those who will enter. Let me give an illustration: A nurse had been working along the same general lines for several years, when she was called to a case for a young doctor with progressive ideas. He asked for a num- ber of things that were not at hand, and when she offered him the best substitutes she could get, he accepted them without comment. All went well, but during the weeks that followed, the nurse was haunted by the conviction that she had not been equal to the demands made upon her. As soon as possible, after the ter- mination of the case, she asked the doc- tor for an appointment at a time conve- nient for him, and asked him to tell her 237 PRIVATE DUTY NURSING just what he wanted on such a case and how he wanted his supplies prepared. “Good!” he replied, “ I am very glad to tell you,” and he went carefully over the whole ground of supplies, solutions, and sterilization, in detail. The result was that her work was revolutionized. She was most grateful to this doctor for meet- ing her so cordially half-way, and she was so pleased with her new discoveries that, like the Ancient Mariner, she but- tonholed every nursing friend who came her way and compelled her to listen to her tale. Some received it with a puzzled air, and said people had lived to this time without so much fuss and they were sure they would continue to do so. Others were eager for every detail, and put the new principles into practice. I think this difference of attitude illustrates well the difference in old nurses. Some move with the times, others stagnate. To the one who keeps her eyes open, small things are significant. She attends a clinic and sees the surgical nurses wearing rubber gloves or handling sponges with dressing-forceps in place of the surgically-clean fingers of the past. She makes inquiries and finds 238 THE OLD NURSE these methods generally adopted; there- fore her next shopping excursion includes the purchase of dressing-forceps or rub- ber gloves. One must, however, dis- tinguish between essentials and non- essentials. There are many devices in use in hospitals which cannot be dupli- cated outside or are not desirable. What we need is to grasp the principle involved and then use, as far as possible, the means at our disposal. Another obstacle in the way of the old nurse is the inclination, which grows on us with age, of thinking we ““ know it all.” Such an attitude of mind is fatal to a woman’s best usefulness in any line of work. If a woman has nursed typhoid according to a fixed system for years and has seen her patients do well on the whole, she may be very suspicious of a young doctor whose orders are completely at variance with her established custom. If the doctor sees that she is not with him in sympathy and interest, as well as in mechanical carrying out of set orders, he will feel that his treatment is not having fair trial, and he is right, for a nurse finds many a loop-hole for carrying out 239 PRIVATE DUTY NURSING her own ideas if she is set upon them. I think this is really a sign of having about outlived one’s usefulness,—this inability to remember that the doctor is the gen- eral, responsible for the whole conduct of the case, and that we must work with him, as well as under him, to insure suc- cess for his plans. Sometimes a temporary change of nursing work will renew one’s youth. The nurse who has grown weary of her fa- miliar round on private duty, and who does not feel rested after a vacation, might try the effect of work in a sanato- rium for tubercular patients, where the routine, the fresh air, the rest periods, and the complete change of thought and action will all refresh her and make her better able to take up her former work after a time. Or she might enter the army or navy service, or try some form of social work,—all these would refresh her mentally and make her better fitted to do her own work well. So far I have laid particular stress on the fact that a nurse must keep thor- oughly in touch with her profession, but every private nurse knows that, paradox- 240 THE OLD NURSE ical as it may seem, she will fail to suc- ceed unless she cultivate other sides of her nature also. She must have other inter- ests than professional ones; she must be well read and in touch with topics of the day in order to be companionable. This broad interest will help to preserve her youth, for it is often the nurse whose thoughts all run in one groove who comes to grief. The power to throw off care is another life-preserver; one must feel anxious when there is cause for anxiety, but there are dozens of nurses who sink under a load of care about what might happen, or who carry on their hearts a heavy load of responsibility which really belongs to the doctor. Given a nurse who has all the desirable attributes I have enumerated, I think anyone will agree that as years add to her experience, she becomes more valuable rather than less so. This fact is recog- nized by the public. The secretary of a nurses’ directory is always being asked: “Can you send me a nurse who has had experience with typhoid? Have you 16 241 PRIVATE DUTY NURSING some one who has proved successful in nervous cases?” ete. It is not always the old nurse who has outlived her usefulness,—one meets com- paratively young nurses who are out of touch with their work and with all that is happy in life, and there are women who have been nursing for twenty-five years or thirty who are still young in heart, active, interested, and in constant demand. Life has never palled on them, nor has their work grown stale. It is so full of interest, there is so much yet to learn that they begrudge the flying years, there isn’t time enough for half they want to do. I believe the greatest secret of contin- ued usefulness is a keen interest in one’s work and a sincere love for it, and it rests with ourselves whether we shall hold our own as well as do women of other vocations. 242 INDEX A Annoyances, 78 Arrangement of sick room, 26 B Baths, 81, 82 Between cases, 33 Breast and bottle feeding combined, 194, 195 C Call bell, 29 Callousness, 32, 33 Care of baby, at birth, 163, 164 of breast, 182-186 of obstetrical patient, 165-168 Charges, 45-29 for more than one pa- tient, 48 Children, 71-73 Clothing, 50-57 D Daintiness, 80 Date of confinement, 152, 153 Decency, 74 Delirious patients, 84 Diapers, washing, 95, 96 Diet, 114-116, 118 for nursing mother, 186— 188 Directories, 35-38 Disinfection of clothing, 202, 203 of excreta, 200, 201 Doctor, 99-107, 143 Doctor’s orders, 106, 107 visit, 102-104 E Economy, 69 Engagements, 43-47 Equipment, 58-64 Extravagance, 55 F Family customs, 66 Feeding a helpless patient, 122 G Gossip, 32, 87 H Heating appliances, 26 Home-made elevator, 27 Hotel cases, 207-209 Hygiene of pregnancy, 145, 146 L Laundry charges, 47, 48 work, 93-95 M Mastitis, 192, 193 Men patients, 88, 89 243 INDEX Modes of spreading infection, 196-198 Moral delinquency in another nurse, 42 N Nipple shields, 190-192 Nursing contagious diseases, 196, 198-205 0 Obstetrical lists, 148-151, 154-157 Occupations for convales- cence, 84-86 Odor from perspiration, 22 Operation, preparation for, 133-139, 141 Orderliness, 68, 69 Orders for meals, 117 Outgrowing one’s usefulness, 232-235, 239-242 Pp Patients’ comfort, 76, 77 Position of baby at breast, 188, 189 Post-graduate work, 236, 237 Preparation for confinement, 158-161 Private duty nurse, attri- butes, 15 care of feet, 34, 56, 57 diet, 81, 32 illness, 79, 80 importance of, 7 mental equipment, 23 moral equipment, 23 night costume, 30 out-door exercise, 28 personal habits, 21, 22 Private duty nurse, place for her toilet, 22, 24 nursing, problems en- countered, 16 R Records, 108-113, 224, 225 for babies, 109, 110 obstetrical, 109, 110 printed, 111 their ownership, 113 Rest hour, 84 S Servants, 91-93 Setting a tray, 119-121 Shoes, 56, 61 Sitting posture, 82 Sleep, 25, 29, 30 Special cases in hospitals, 217-223, 226-228, 230, 231 Sterilization, principles of, 124 -127, 129 of supplies, 184-138, 151, 152 teaching of, 130, 1381 Stimulants, 31 Strain, 25 Street dress, 52-54 Substitutes, 82, 83 System, 67, 79 T Talking shop, 32, 87 Telephone conversations, 104 Training of babies, 169-181 Travelling, 209-213 with children, 214-216 expenses, 47 y Ventilation, 80 Visitors, 96-98 244 U.C. ili LIBRARIES HIB C02930k453