Discard U, of C. R< e. / w COM PANY 1223 E 55 ST C H I C AC O VISITING NURSE MANUAL PREPARED FOR THE VISITING NURSE ASSOCIATION OF CHICAGO AND OTHER PUBLIC HEALTH NURSES By EDNA L. FOLEY , R. N. PUBLISHED UNDER THE AUSPICES OF THE NATIONAL ORGANIZATION FOR PUBLIC HEALTH NURSING BY THE VISITING NURSE ASSOCIATION OF CHICAGO 104 S. Michigan Avenue 1914 Digitized by the Internet Archive in 2017 with funding from University of Illinois Urbana-Champaign Alternates https://archive.org/details/visitingnursemanOOfole INTRODUCTION The object of the Visiting Nurse Association of Chicago is, first, to give skilled nursing care to the sick in their homes; second, to teach personal hygiene, cleanliness, and the prevention of disease. No calls are made outside the city limits. The following directions are intended to serve as a guide to new nurses and as a manual of reference for all the staff nurses. As visiting nursing implies that the patient will be seen probably once or at most only twice during the day by the nurse, some care must be given between visits; therefore the word “attendant,” used so con- stantly throughout the book, is meant to indicate the person (mother, husband, daughter or neighbor) to whom instructions for the patient's care are given. Not all problems can be foreseen and covered by the following rules. When in doubt, the Main Office should be consulted in emergency; the advice of the Supervisor may be sought at noon or night. Consultation is better than hasty judgment. The visiting nurse should remember that she is not an isolated unit giving nursing care in various homes, but the trusted representative of the Visiting Nurse Association of Chicago. Her uniform implies trained skill, intelligence and authority. When wearing it, she is the paid agent of citizens whose liberality enables her to give this skill and training to people unable to pro- vide it for themselves. GENERAL INSTRUCTIONS. Daily Routine. Hours of duty are from 8:30 a. m. to 5 p. m., with one hour for lunch at noon. Each district nurse should be in the home of her first patient at 8:30 a. m. Absences should be telephoned to Supervisors before 7 a. m. If for any reason the Supervisor cannot be reached, the Superintendent should be notified. This will ensure nursing care to all patients in the district of an absent nurse. Visitors may not be taken into the homes of patients except by permission from the Main Office. Plan for the Day. New calls received over night, all clean cases requiring care (delivered maternities, non- contagious, acutely ill, clean dressings, etc.) should be seen in the morning in the order of their need, thus leaving the afternoon free for new calls, instructive visits and general emergency work. Nurses should not promise to meet physicians or other workers in patients’ homes by appointments, for a visiting nurse’s day, no matter how carefully planned, is always subject to unavoidable delays and interrup- tions. As a rule, hospital and dispensary appointments can be kept. By careful planning, it may be possible to make calls to some patients at the same hours daily, but it is best to warn these patients that emergencies may arise to interfere with such a daily program. Number of Daily Calls. Nine is the average number of calls made daily in a Chicago district. In the smaller districts where many families live under one roof, it is possible to make from twelve to fourteen calls daily; whereas in the more scattered prairie districts six to eight is a fair average. Nursing Calls (other than T. P. R. only calls) require from one-half hour to an hour. General nursing care General Instructions 9 requires from 45 minutes to one hour. A few calls need more time. Instructive Visits are as important and should be as carefully made as nursing visits. They should never be hurried. Frequency of Calls. 1. All chronics at least once weekly. 2. All varicose ulcers daily, or as indicated. 3. All surgical dressings daily unless otherwise ordered. 4. Bed-ridden tuberculosis cases daily or every second day. 5. All maternity cases daily for the first ten days, then every second day until the mother is up and able to care for the baby. 6. New-born infants daily until cord is off and stump healed. 7. All acutely ill patients daily. 8. All acute and critically - ill patients running temperatures or requiring change of dress- ing, twice daily. 9. All “special nurse” cases every second day. 10. Never forward a patient without at least one monthly visit. 11. Instructive visits, frequently, until teaching is understood, then occasionally, to encourage and supervise. Sunday Calls. New maternity cases for whom no other care is provided, critically ill acute cases, and surgical dressings that cannot be left from Saturday afternoon to Monday morning, require Sunday calls. Plan to see your most urgent cases late Saturday and early Monday. District. A district is the amount of territory allot- ted each nurse. Districts are usually planned according to both population and area. Small districts are the rule in very congested parts of a city; large districts 10 Visiting Nurse Manual cover the outlying territories where the population is scattered, or not of the type requiring hourly or visiting nurse service. A nurse in charge of a district is responsible to her Supervisor, to the Superintendent of the Association, and to the Board of Directors, for all work (nursing, instructive and clerical) done in that particular terri- tory. Map of District. The boundary lines of every district are plainly marked in the district time book and on the maps at the substations. Each district includes the cases on its north and east boundary lines. The map of a district, cut from the map in the guide book, and pasted on heavy paper, is indispensable to a new nurse. By planning the work according to the geography of the district, keeping in mind the best transportation lines and transfer points, a new district soon becomes famil- iar territory. Chicago streets and distances are easily learned. East refers to all numbers east of State street. West refers to all numbers west of State street. North refers to all numbers north of Madison street. South refers to all numbers south of Madison street. Eight hundred numbers equal one mile. No. 1 of every street begins either at State or Madi- son. Odd numbers fall on the east and south sides of every street. A careful study of a map of the city will make the daily routine much simpler. A district should be studied by street numbers as well as by street names. Nationalities, conditions, circumstances, vary widely in each district. A nurse must be alert to sense these differences. There is no one more respected and beloved in these districts than a good visiting nurse whose desire to serve her patients is tempered with a wise sympathy and common-sense. New Calls will be telephoned to the substations before 1:30 p. m. and to the nurses’ homes after 4:30 p. m. Addresses. In taking or giving addresses over the telephone, repeat the number carefully, ascertain the General Instructions 11 part of the house, if east or west, north or south, street or place, diagnosis, doctor's name, and name and telephone number of person referring call. This last helps in tracing incorrect addresses. Wrong Addresses. If an address from the Main Office is inaccurate, telephone the office for correction. If the call was received from the substation, no correction can be obtained until the Supervisor can be reached by telephone. Always report wrong addresses at the ear- liest possible moment. Never wait until the following noon to do this. If the case was reported as urgent, report to the Main Office for further instructions. All wrong addresses not sent out from the Main Office should be reported to the Supervisor in the evening, or, if a morning call, at noon. Incorrect Metropolitan Life Insurance Company addresses should be reported to the Supervisor in the same way. Corrections of these must be obtained from the insurance agent by the nurse making a daily visit to the Metropolitan office. Calls Out of District. If asked to make a call outside of your district take the name, address and facts, and telephone these to the Main Office or report to the Supervisor at noon. If an emergency call but a few blocks out of your district, make the call yourself and then report to the Main Office. New Patients should be seen as early during the half- day following receipt of the call as possible. This is to insure prompt care to all very ill and to emergency patients. New calls not made promptly and new pa- tients not found at home should be reported to Super- visor at night or at noon. SUPPLIES. Uniforms. The out-door uniform (hat, coat and bag) is the property of the Association. The prescribed dress, blue chambray, with detachable cuffs and collars (Bishop or Eton cut) of white pique are supplied by each nurse. The pin and arm-bands are loaned by the Association. Jewelry should not be worn. Probably three-fourths of a visiting nursed day is spent walking or standing, therefore the kind of shoes worn is very important. No special shoe is prescribed; but thick-soled, well-cut high shoes are advised. After much unaccustomed walking, the feet may be tempor- arily enlarged, another reason for wearing comfortable, well-selected shoes. Tired or burning feet should be bathed (not soaked) at night in cold water to which alcohol or an astringent has been added, and afterwards well powdered with boracic. Car Tickets are given each nurse on her first morn- ing. Every ticket costs the Association 5 cents. Tickets should be carefully handled, and an exact accounting of the number used should be written on the daily report. Never fail to ask for transfers. In Chicago passengers may ride repeatedly on transfers within certain time limits if the direction of travel is not retraced. Car Ticket Requisitions (0. K’d by Supervisor) must be in the Main Office by Saturday noon of each week. Cash Accounts. All money used for telephoning and supplies for patients should be recorded on the daily re- port, and on the 18th of each month a statement of such expenditures should be written and given to the Super- visor. This amount, if 0. KM by the Supervisor, is added to the salary check. A watch with hour and minute hands and a fountain pen, the property of each nurse, should always be in good repair. Visiting Nurse Bags are lined with rubber and a Supplies 13 removable cotton lining. This latter should be changed twice weekly. The rubber should be scrubbed at least once a week. A well-kept bag is a fair index of the ability of a visiting nurse. Each bag is provided with: One fountain syringe (to be sterilized before using in clean cases) in a white cotton bag. One dressing basin, in white cotton bag. Gauze and bandages, in white cotton bag. Absorbent cotton, in white cotton bag. Instrument case containing Silver probe, Glass piston syringe, Forceps (artery and Glass douche point, dressing), Dressing scissors, Glass catheter, Rubber catheter, Glass enema point, Medicine dropper, Nail file, Spatula. Three thermometers (mouth, rectal and emergency) carefully labeled. Two-ounce bottles containing Lysol, Alcohol, Olive oil, Boric powder, Boric crystals. (These bottles should be plainly labeled and relabeled, P. R. N.) Ointment tins, containing Zinc oxide ointment, Vaseline, Green soap. Also, Tongue depressors (wrapped in paper), Short strips of adhesive wound on tongue depressor, Dressing towel, Hand towel, nail brush and soap in rubber-lined bag, Common scissors, Metal comb, Apron (of white cotton crepe). Bags will be inspected monthly or oftener. New equipment may be obtained from Supervisor only when old articles are returned. 14 Visiting Nurse Manual Hypodermic Syringe may always be obtained at the substation. Before giving subcutaneous injections, boil the needle, sterilize the barrel with alcholol, and cleanse the site of insertion with alcohol. Miscellaneous Supplies. Linen, rubber goods, sick- room utensils, etc., may be obtained from the substation loan closet. Thermometers. Mouth thermometers should be cleaned by being wiped with cotton saturated in alcohol before and after using, then washed in clean water; rectal thermometers with cotton saturated with lysol, then washed in clean water. A thermometer used by patients suffering from any communicable disease (typhoid, tuberculosis, diphtheria, scarlet fever, etc.) should be entirely immersed in a two per cent lysol solution while care is being given patient, then thoroughly washed in fresh water before being returned to case. Thermometers, dressing forceps, or scissors should never be dipped in alcohol or lysol bottles. Never leave a thermometer in a tumbler of any solu- tion, poisonous or otherwise, for a despondent patient or a child may drink the solution and alarm the entire family, if no more serious harm is done. Teach the patient to cleanse his own thermometer carefully, to dry it and to put it in the case or in a safe place. Rubber Gloves will be kept at the substation and may be left in the homes whenever necessary. Gloves should be worn for all extensive, profusely discharging dress- ings, both for the protection of the nurse and to pre- vent any cross infection. After using, gloves should be thoroughly washed, sterilized, dried and powdered. When necessary, gloves may be left in the homes until the case is terminated. No one pair of gloves should be used on two bad septic cases consecutively. All gloves returned to the substations should be given to the Supervisor and their previous use explained. In some cases it is better to destroy gloves than to return them to the supply closet, but this decision must be left to the Supervisor. PHYSICIANS, Family Physician. Urge the family to choose one physician and to retain him. See that no one is giving or carrying out orders for more than one physician at the same time for one patient. If the family insists upon changing the physician, see that all medicine pre- scribed by the first physician is thrown out before other medicine is taken. District families are notori- ously impatient and sometimes unwilling to give a physician time to improve a patient's condition. Do not make it too easy nor too inexpensive for such fami- lies to call new physicians every other day. Private. Refer ambulant cases able to pay for atten- tion to local physician's office, or advise the family to call in the physician of its choice. If the family does not know any physician, has no preference and there is time, advise it to call up the office of the Chicago Medical Society and a list of physicians residing in that locality will be sent it. Or give the family several names of neighborhood physicians and let it make its own investigation and select its own physician. Be sure before doing this, however, that the family is tell- ing you the truth and is not, at the same time, employ- ing a regular physician. Many patients seem to think that it is wise to be on the safe side and go to more than one physician at a time. Responsibility for this state of affairs is laid by them on the shoulders of the visiting nurse, to whom they appeal for advice. Standing Orders. If no orders have been left for the visiting nurse or no physician is in attendance, the printed standing orders may be followed, but the family should be instructed to summon a physician before the nurse’s next visit. Patients in need of medical super- vision other than cases for convalescent homes, vacation camps or dispensary care, may not be treated after the first twenty-four hours. 16 Visiting Nurse Manual STANDING ORDERS FOR THE VISITING NURSE ASSOCIATION OF CHICAGO. Corrected and Approved by the Chicago Medical Society. FOR ALL NEW PATIENTS. Cleansing Bath, P. R. N. Instruction in hygiene of the sick-room, with spe- cial emphasis on good ventilation, cleanliness, and diet suited to the patient’s conditions and needs. FOR PATIENT WITH FEVER, UNDIAGNOSED. Liquid Diet. Low S. S. Enema, P. R. N. when no abdominal pain or tenderness is present. Sponge for R. T. 102.5. FOR INFANTS AND CHILDREN, WITH FEVER, UNDIAGNOSED. Normal Salt Flushing, P. R. N. Diet — Boiled water for twenty-four hours. BURNS. Remove clothing if not attached to skin. If ad- herent, cut away as much as possible and apply normal salt or boric solution dressings. If severe burn, get into hospital as quickly as possible. COLDS. Low S. S. Enema. Liquid Diet. For adults, plenty of hot water to drink. INFANTILE DIARRHEA AND INFANTILE CON- VULSIONS. Normal salt flushing, P. R. N. No food. Boiled water for twenty-four hours. FOR INFECTIOUS DISEASES. Isolate. Boric solution for eyes and nostrils, P. R. N. Vaseline or cold cream for lips and nose, P. R. N. Oil Rub, P. R. N., for all desquamating cases. Liquid diet. Sponge for R. T. 102.5. Physicians 17 FOR DISCHARGING EARS. Cleanse the outer ear with moist boric solution swabs. Dry thoroughly. Do Not Irrigate. Emphasize need of prompt medical attention. FOR DRESSINGS, MINOR. (Cuts, Bruises, Infected Fingers, Scratches.) Apply hot boric packs. Advise medical attention. FOR PLEURISY. Apply tight binder to chest. PNEUMONIA. Cold air treatment if possible. Low S. S. Enema, P. R. N. Sponge for R. T. 102.5. Liquid diet. SORE THROAT. Liquid diet. Isolate, if possible, until physician sees case. TYPHOID FEVER. Low S. S. Enema, P. R. N. Sponge for R. T. 102.5. Milk diet. Emphasize need of screens, fresh air, cold drinking water (boiled, if possible), disinfection of stools. ULCERS, Chronic. Cleanse with lysol or boric solution. Apply hot boric dressings and firm bandage. OBSTETRICAL CASES. For the Mother. Cleansing bath. Local cleasing with lysol solution. Abdominal binder. Change pads. Breast binder, P. R. N. Low S. S. Enema, P. R. N. For the Baby. Alcohol dressing to cord. Oil and bathe. Soap suppository, P. R. N. N. B. — Any or all of these orders may be canceled or substituted for at any time by the physician on the case who prefers to leave specific written orders in each family. These standing orders are merely suggested as aids to both the physicians and nurses, and will be 18 Visiting Nurse Manual carried out when no other orders are left. Nurses will communicate with the physicians by telephone whenever possible, but the above orders are intended to serve for the interim. A request for diagnosis and instructions may be written on Visiting Nurse Association paper, signed and left for the physician. A direct communication is more satisfactory. It would be unwise to leave certain diagnosis in writing in patient’s home and equally bad to give others over the telephone, therefore do not ask this if you have reason to believe that the physician will refuse a diagnosis. Try to see him in his office and ask for the diagnosis. Explain that we have three reasons for desiring careful diagnosis: 1. To enable us to give as much and as careful nursing as is indicated. 2. To protect the nurses from the danger of infec- tion to themselves and others. 3. To enable us to show, by carefully kept sta- tistics, the kind of cases under our care and the approximate amount of nursing service required by the different types of case. Never give any patient a written statement that you are unwilling to show him or his family, for even a sealed envelope may be inspected and opened as soon as your call is over. Never carry a seriously ill patient several days with- out telephoning the physician or consulting with your Supervisor. Grave responsibility should always be shared. Except in serious emergencies, when there is no time to telephone a physician or the Main Office, do not initiate any treatment other than that permitted in the standing orders. These standing orders are for temporary use only, to save the patient unnecessary suffering and discomfort and the nurse’s time. The co-operation of physicians and family should be sought in persuading all seriously ill patients in con- gested homes to go to hospitals. When complications arise, all differences of opinion should be referred to the Supervisor. NURSING SERVICE. NURSING CARE. Good Nursing Care Includes 1. General care of the patient. 2. Bed-making. 3. Care of sick room. 4. Instruction of family. 1. General Care of Patient. Temperature, pulse and respiration; full or partial bath, care of hair, teeth, nails, etc. After the first call, instruct the family to have hot water, clean linen, newspapers, basin and soap ready for your next call. T. P. R. Always use watch to count pulse and respiration and length of time thermometer is held in mouth or rectum. Record before leaving house. Full bath includes bathing of entire body, care of teeth, hair and nails. Partial bath includes bathing face and hands, rubbing back with alcohol, care of teeth, hair and nails. In giving a bath use plenty of hot water and soap. Pay particular attention to pressure spots, back and axillae. In acute cases give bath or alcohol sponge daily. In dirty cases examine carefully for head and body vermin. Never permit unnecessary exposure. Respect mod- esty where it exists. Teach it by example where it is unknown. Hair should be combed daily. Protect the pillow with a towel; use alcohol for snarls. If this is left to the family, have someone watch, the process on the first day. Teach her how to avoid pulling, prevention of snarls and to braid in two braids. Use patient’s comb, if pos- sible. Sterilize the metal comb before returning to bag. Never cut a child’s or a delirious patient’s hair without permission from a responsible relative. 20 Visiting Nurse Manual Teeth. If the patient has no toothbrush, make cotton applicator and use boric solution or weak alcohol solu- tion as a mouth wash, daily. Advise family to pur- chase alkaline mouth wash and toothbrush. (Ask Super- visor for these if the family is too poor.) Insist upon the frequent use of a mouth wash and of the tooth brush if the patient is strong enough to do this. Teach the care of the teeth in season and out of season, and make the family see its importance. Bed-Sores. (Ref. Maxwell & Pope, pp. 71-73.) Bed- sores require daily care. The physician should be noti- fied of their first appearance. Thorough rubbing with alcohol and powder, and removal of pressure may pre- vent their development. If called to treat bad, slough- ing bed-sores and told by the physician to give the usual treatment, apply hot boric packs until the wound and surrounding area are in better condition, then use zinc ointment mixed with balsam of Peru or with castor oil. Remember that balsam of Peru stains bedding indelibly. Caution family and teach how to protect sheets and night dress. For reddened areas, a plaster made of old linen spread thickly with zinc oxide ointment and ap- plied to the affected spot may be all that is necessary. If the skin bruises easily, teach the family to turn the patient at regular intervals, at least every two hours, in order that pressure on the exposed surface may be frequently relieved. Demonstrate gentle massage (with alcohol preferably) of pressure area whenever patient is turned. Explain its action and the effect desired. 2. Bed-Making should be as complete as possible. Clean sheets, even washed and rough dried daily, are desirable. By using two sets one may be aired even if not laundered. Teach family the comfort and advisa- bility of having fresh night dresses, pillow cases and sheets each morning. Mattresses may be protected by newspapers, oil cloth or rubber sheeting. For children and chronic cases a draw sheet, also, is advisable. In making the bed, remove spread and blankets and make from the mat- tress up. Don’t forget to shake and turn pillows. Soiled linen should be folded and, if no other receptacle is Nursing Care 21 provided, rolled in newspapers. It should never be thrown on floor nor handled so carelessly that it touches the nurse’s uniform. 3. Care of Sick Room. (a) Choice of room is necessarily restricted. Be guided by light, ventilation and location. Do not use kitchen if possible to use any other room. Parlor is frequently best of all. Avoid dark room or stuffy alcove. (b) Removal of Superfluous Furniture. Rugs, carpet, upholstery, chairs, etc., should, if possible, be put in adjoining rooms. Clean towels or papers may be used to cover tables. If the case is contagious, protect heavy furniture and bookcases with cotton sheets or covers of some washable material. (c) Teach some member of the family the importance and method of damp sweeping and moist dusting. (d) Position of Patient’s Furniture. Move bed so that air may circulate thoroughly about it. Raise low bed on blocks. Arrange bedside table for use of patient only. Discourage leaving any food, candy or fruit on the table after the patient’s appetite is satisfied. (e) Ventilation. When teaching ventilation, teach a form that will freshen the air of the room, but not one that will chill the whole house and be disregarded as soon as the visiting nurse leaves. (Window-board, window open top and bottom, clothes- frame screen, foot or head of bed screened with shawl or sheet, large chair between bed and window, open umbrella over patient, two thicknesses of cheesecloth tacked in window, etc.) Recommend deodorizer only when natural ventilation is not sufficient to remove odors. Never go out of the sick room without leaving some visible evidences of the time spent there. Work swiftly but not nervously nor hurriedly. Let the patient see that you have all the time her welfare requires, but teach the family that your time is valuable and their help necessary. Instruct some one member in the care 22 Visiting Nurse Manual of the sick room, and by encouragement and occasional assistance, see that the room is kept bright and clean. No call is well made if this instruction is neglected. 4. Instruction of Family. Never leave written nor printed orders unless you are sure that they are under- stood. Select one responsible individual in the family, parent or older child, and teach very slowly and care- fully. Repeat this instruction at every visit. Remem- ber that you are trying to impart in a few moments facts that you spent months in acquiring, and do not expect too much from the average household. Don't attempt too much in one visit, particularly the first. For instance, in typhoid, emphasize care of hands, of excreta and reason for liquid diet. In tuberculosis, em- phasize care of sputum, dishes and sleeping room. Don't cover twelve points in one call, for the patient will be too confused to remember anything correctly. Have your points clearly defined and outlined in your own mind and teach the patient what he seems to compre- hend in one visit. Don't be misled by his apparent grasp of a difficult subject. Patients like to please and often pretend that they understand perfectly when in reality they have not been able to grasp half of what has been said to them. When teaching through an interpreter, demonstrate even little points i. e., open a window, prepare a gargle, dust something with a damp cloth, make strong soap- suds for dishes, etc.). In cases of infectious diseases, before warning and instructing the family in special precautions, communicate with the physician in attend- ance and ask if he would prefer to do this himself. 5. Amount to Be Left to Family, and Amount to Be Done by Nurse. (a) Nothing should be left to an already overworked woman. (b) If the patient is a man who prefers to have his wife or mother care for him, be sure that she has been very carefully instructed and understands clearly what to do. (c) When a treatment is left to the family, be sure Fees and Gifts 23 to teach the quickest, easiest and gentlest method of removing and destroying old dressings, caring for soiled linen, removing odors and protecting hands and furni- ture. (d) Nothing should be left to the family that is prop- erly the nurse’s duty, but every patient, particularly if bed-ridden, will require some, if not a great deal of attention, between visits. In most families your advice and help will be gratefully received and your instruction followed, if it has been understood. Explain and em- phasize (1) Value of fresh air; (2) Thorough and frequent washing of hands (pa- tient’s as well as attendant’s); (3) Need of sleep (of naps for convalescents and little children); (4) Preparation of clean and simple food. Respect racial and local traditions wherever you can. When these must be disregarded, let the family see that this is for the patient’s welfare, not for their or your convenience. Teach that we are all Americans and that American customs are the best to adopt in a new country. FEES AND GIFTS Nursing Service is furnished free to those unable to pay for it; to industrial policy holders of the Metro- politan Life Insurance Company; to members of the Royal Arcanum Hospital Bed Fund Association, and to employes of different firms in Chicago whose employers ask the Association to give these services at the firm’s expense. From all other patients remuneration to the extent of from 10c to 50c per visit is expected. These patients should be told that the money thus received enables the Association to extend its work among their less fortunate neighbors. If patients cannot pay the exact cost of service or supplies furnished, teach them that 10c pays the nurse’s carfare and enables her to go more quickly to another case. Fees thus received should be entered on a receipt card, which is left with the 24 Visiting Nurse Manual patient, on the patient’s record at the substation, and on the daily report. All money received from patients for supplies, services, or gifts to the Association should be given the Supervisor daily. If the patient gives money as a gift to the Association, acknowledgment is always sent through the Main Office. Patients able to pay $1.00 a visit should be referred to an hourly nurse. Arrangements for this should be made by the Visiting Nurse Association, in order that there may be no break in the nursing care. Hourly nurses may be secured from nearly all nurses’ regis- tries. If, however, such care cannot be obtained, the patient should be carried by the visiting nurse. Nurses should receive no gifts from patients for their services, but may accept such contributions as patients may wish to make to the Association. Any gifts (money, clothing, etc.) made to individual nurses for special patients should be reported for acknowledg- ment to the Main Office. RELIEF AND CO-OPERATION The Association is strictly non-sectarian and non- political. No money or other relief may be given pa- tients except in emergencies when patients are found suffering for food and fuel. Every case thus assisted should be reported immediately to the proper agency for further investigation and relief, and to the Supervisor during the next substation hour. Teach patients to value our care for its own worth. Our best influence in our districts depends largely upon personal service to our patients, who should be taught not to expect mate- rial relief from the Association. Public health nurses who must assume this responsibility should study to give relief wisely. Medical Relief. Baby outfits, surgical apparatus, wheel chairs, crutches, braces, binders, etc., are some- times supplied by the Association to patients carried in its districts. Special Nurses. When no other care can be arranged, the Association sometimes assumes the expense of a Relief and Co-operation 25 special nurse for an acutely ill patient. The following rules should be observed: 1. A special nurse should never be put on any case without consultation with the Supervisor, or the Main Office if the Supervisor cannot be reached. 2. Patients requiring special nurses must first be seen by a district nurse and should be seen by the Super- visor within twenty-four hours. 3. The nurse in the district should visit a “special- nurse” patient at least every second day and give a report of each visit to the Supervisor. 4. No special nurse may be left on longer than one week, unless the patient has been seen a second time by the Supervisor and there is some excellent reason why the patient cannot be moved to the hospital or left entirely in our care. 5. Special nurses may not be put on terminal chronic cases. 6. A special nurse should never be requested when the patient can be removed to an institution or cared for by some member of the family, with a twice-daily visit from the district nurse. On the other hand, every nurse should be very careful to see that the family is not breaking down under the strain of the care of an acutely ill person. To put a special nurse in a household requires the exercise of good judgment on the part of a district nurse, and to remove her sometimes involves more. Reports to Other Agencies. Before reporting, verb- ally or in writing, any patient other than an emergency case, to a co-operating agency, consult your Supervisor in regard to it. Never take time to put in writing what can be telephoned or personally reported. When making these reports, emphasize medical aspect of case and give your reasons for believing that aid (material or otherwise) is needed. The other society probably has or will obtain for itself social data. For example, don’t ask that special diet and fuel be given immediately to Mrs. White, a 26 Visiting Nurse Manual widow with seven children, living in a four-room, $8.00- a-month basement flat, income irregularly $3.50 a week from earnings of a fifteen-year-old girl. State that the third child has pneumonia, is in a critical condition, able to take very little nourishment of any kind, and cannot be moved to a hospital; that mother has diabetes, which also requires a special diet; then ask for specific kinds and amounts of food for both patients (1 quart of milk daily, 2 dozen eggs weekly, 1 pound beef daily for beef-juice, 5 pounds of diabetic flour bi-weekly, etc.). Later call at office and see if arrangements can be made to keep mother supplied with diet required in diabetes. Emphasize urgency in acute conditions (pneumonia, typhoid, nephritis, infection, etc.), but state when the investigation can be made more slowly (as in chronic conditions, rheumatism, paralysis, tuberculosis, etc.). Give all the facts you have if there is time, but put special emphasis on those of first significance to you. Registration. Before planning any action involving more than nursing care in a family, consult the Social Service Registration Bureau, Randolph 7160, to learn what other agencies are interested in this same family and to see if your plans will conflict with theirs. In reporting case to Registration, give, if possible, the Christian name of each parent, as well as address and part of house. If no other agencies have registered the case you are fairly safe in making plans. By knowing personally representatives of hospitals, schools, settlements, and other philanthropic agencies in your district, you will be able to act promptly in securing the needed co-operation of other social workers for your patients. Whenever possible, learn the names of these workers and keep them in your dairy or in some other convenient place. Delayed or poor co-operation is frequently caused by misunderstanding and lack of acquaintance between social workers. Remember that each social worker has, or should have had, a special training. One can seldom be expert Relief and Co-operation 27 in all lines of social work. Don't attempt to shoulder too much responsibility for your patient's needs. Give your very best service as a nursing expert and insist that other workers assume their responsibilities for relief, legal advice, police supervision, etc. Agencies that the visiting nurse should understand and co-operate with in her district work are: 1. Health Department. 2. Social Service Registration Bureau. 3. District Office of County Agent. 4. District Office of United Charities. 5. United Hebrew Charities. 6. Summer Outing Camps. 7. Illinois Society for Mental Hygiene. 8. Hospitals taking free patients. 9. Dispensaries, including tuberculosis and dental clinics, and Infant Welfare Conferences. 10. Police stations for ambulance and lung motor calls, and for leaving specimens for City Laboratory. 11. Public baths and playgrounds. 12. Public schools (open air schools, social centers and dental clinics, night schools, special classes for defectives, blind, deaf, crippled, mentally sub-normal). 13. Institutional churches and pastors of churches doing neighborhood work. 14. Settlements and day nurseries. 15. Local St. Vincent de Paul conferences. 16. Drug stores carrying Health Department anti- toxins and throat culture outfits. 17. Foreign local relief workers (German, Polish, Italian, etc.). 18. Institutional homes (for aged, children, unmar- ried pregnant girls, etc.). 19. Public baths. 28 Visiting Nurse Manual EMERGENCIES. (Maxwell & Pope, Chap. XI.). When treating any emergency, be sure that it is a real emergency entitled to medical relief, not a false alarm. When in doubt, treat the case as an emergency, but weigh the merits of each case as carefully as pos- sible. When in uniform never fail to offer your serv- ices, if needed, in any serious emergency, street car accident, fire, epileptic seizure, premature labor, etc. If not in uniform and your assistance seems advisable, offer it, stating that you are a visiting nurse. If a physician has been called and relatives can attend to patient, don't waste time unnecessarily. For street and any kind of fatal home accident, always summon a policeman. Before summoning a physician in minor emergencies, be sure that the patient is unable to go to the doctor's office. Do not summon a physician unnecessarily. A policeman is state witness and must be notified. Street Accidents. Send for Policeman. Send for physican if apparently necessary. Apply tourniquet, clean dressing, or give any other indicated first aid. Coroner's Orders. Never have an unconscious or a dead person removed from site of accident except to sidewalk or out of dangerous territory. Never take the responsibility of removing such a person to a hos- pital or undertaking establishment by street car, motor or any other vehicle before the arrival of a policeman. If the person is killed, you will doubtless be sum- moned as a witness before the Coroner's jury. Remem- ber that frequent discussion of such cases is confusing and may render your testimony valueless. Don't have opinions; state facts when you are asked. Coroner's Cases, other than fatal street accidents, are 1. Sudden deaths without medical attention. 2. Any undiagnosed death. 3. Any death resulting from injury (burns, acci- dents, homicide, etc.). Emergencies 29 4. Septicemia following criminal abortion. 5. Death following criminal abortion. If you are called to attend septicemia following sus- pected abortion, consult your Supervisor before making a second call. These cases should be reported to the Coroner's office by the attending physician, but in case he neglects to do this the nurse shares this responsi- bility and is summoned as a witness at the inquest if patient dies. Pulmonary Hemorrhage — Street. Have patient raised in semi-recumbent position. Keep crowd quiet. Home. Cold to chest. Cracked ice to swallow. Keep patient and family quiet while awaiting physician. (Unless death occurs within a few minutes pulmonary hem- orrhage is rarely fatal.) Patient in Labor. If head is on the perineum, send someone for the nearest physician. Scrub up as welJ as you can and take the delivery yourself. If pains are infrequent and the patient refuses to be sent to a hospital, see that a relative or neighbor calls a physi- cian and remains with the patient. If possible, call later in the day to see how the patient is progressing. Convulsions — Children. Undress and get into a hot bath quickly. Adults. Undress and put to bed. Try to ascertain cause in each case. If epilepsy, separate teeth and take usual precautions to protect unconscious patient from injury. Loss of Consciousness. Put patient in recumbent posi- tion. Loosen clothing. If fainting, lower head and bathe hands and face. Electric Shock. Asphyxiation (by drowning, hanging, stove or illuminating gas, smoke, etc.). Get the patient into the fresh air. Start artificial respiration at once. Have trustworthy person telephone nearest police am- bulance station for lung-motor. Have neighbor make strong black coffee for rectal enemata. Give every on- looker something to do and keep them all away from the patient. If crowd is large, have men form cordon around patient. 30 Visiting Nurse Manual Heat Prostration. Recumbent position. Keep people quiet. Apply cold to face and temples. Move patient into nearest cool place. Loosen clothing. If at home, give cold sponge with friction until doctor arrives. Hysterical and Epileptic Seizures. Get history of case from family before calling physician. If there is history of frequent similar attacks, let family call their own physician or carry out the treatment previously ordered. If no history can be obtained and no physician is indicated, have family or neighbor call one from the neighborhood. Internal Poisoning. If the poison is known, prepare and administer antidote while waiting for the physician. Remember that most cathartics and headache powders found in district homes contain dangerous stimulants and sedatives. Warn parents carefully and teach them how to stopper and label all poisonous drugs so that the receptacle may be detected in the dark as well as the daylight. The following is a list of poisons with their antidotes: Carbolic Acid. Whiskey or 50 per cent alcohol; lime water; olive oil. Washing Fluid (Alkali-Caustic Potash). Lemon juice or vinegar; heat and stimulants; no emetic. Fly Poison (Arsenic). Rough on Rats (Arsenic). Chalk and water, flour and water, magnesia and tincture or iron, followed by milk; then an emetic. Bichloride of Mercury. One egg to every 4 grains of mercury; emetic. Soothing Syrups (Opium). Black coffee, normal salt flushing; emetic as soon as patient can be suf- ficiently roused to swallow. Stings and Bites of Harmful Insects. (Bees, Mos- quitoes, Bedbugs, Flies, etc.). Frequent bathing with soda bicarbonate solution and light, moist bandaging with soda, witch hazel, weakened ammonia or alcohol solution for twenty-four hours may prevent scratching and subsequent infection. With babies and little chil- dren this is a very important item. Emergencies 31 Dog Bites. Send for policeman and physician. Do not let anyone kill dog if he can be restrained until arrival of police. Dr. A. Lagorio of the Pasteur Insti- tute, Chicago, advises the following, when nurse must give first aid: For superficial wound, cauterize with carbolic (95 per cent) and dress with boric solution pack. For deeper wounds, irrigate with lysol solution (2 per cent) or peroxide (50 per cent); pack wound with gauze dipped in boracic solution (saturated), and apply pack of equal strength. Dog bites should always be reported to the police, even if the wound is several days old when nurse first sees it. The police report to the Health Department when this is necessary. Death. If death occurs during the nurse's visit, help each family as occasion indicates. Let the family send for the undertaker, or if you do this, see that the under- taker understands clearly who is to make settlement for the funeral. If county or free burial is necessary, call the County Agent's Office and report the death, stating the nature of the case. When office is closed, notify nearest police station. Whenever any difficulty is experienced in disposing of a dead body, have the family notify the nearest police station. If foul play is suspected, notify Cor- oner's Office. In particularly distressing conditions, see if a relative or neighbor can be persuaded to remain with the be- reaved family. When death is anticipated by the fam- ily, discuss the funeral expenses with them, and try to persuade them that their responsibility in this regard is greater to the living than to the dead and that a modest funeral shows as much respect to the dead member as one that uses up all the savings and insur- ance or puts the family in debt. When visiting a terminal case, ask if the family de- sires a clergyman, and report the patient to the nearest representative of the denomination chosen by the fam- 32 Visiting Nurse Manual ily. If unexpected death in acute cases seems imminent, warn the family, summon the nearest physician, and give treatment as in any emergency. Relief Emergency. Fuel or Food. If you find case in late afternoon or on Saturday, purchase supply for over night or for a few hours. Call up the County Agent if a county family, or the United Charities or United Hebrew Charities, stating the need as you have seen it, and asking for immediate temporary relief and a more thorough investigation. Be careful not to give emergency relief in families already under the super- vision of a relief agency. If you differ with the other agency in regard to its treatment of any family group, go and talk the case over frankly with the worker. Do not upset her plans by giving unwise, although perhaps to you, clearly indicated, temporary relief. Housing Emergencies. Frozen Pipes. Report to the Sanitary Board of the Health Department, with the length of time frozen and state if this is the only water supply in the house. Water Cut Off. Report to the Water Department, City Hall. Plumbing Out of Order. Report to the Sanitary Bureau of the Health Department, with the length of time that the toilet and drains have been working badly or not at all. Dark Rooms, Unsafe Stairs and Elevators. Report to the Building Department, City Hall. Do not report by telephone any of the above condi- tions unless a real emergency. Report all cases (emer- gency or otherwise) by usual mailing card sent through Main Office. Eviction. Report to County Agent or United Chari- ties. Evicted families are usually old relief cases and known to above agencies. The process of eviction takes at least fifteen days from the serving of the first warning. Free Medical Service 33 FREE MEDICAL SERVICE. Free care of the indigent sick may be obtained through : 1. Physicians, county and private. 2. Hospitals, private and public. 3. Dispensaries. 4. Convalescent homes. 5. Infant Welfare Society (children under 2 years of age.) 6. Municipal Tuberculosis Sanitarium Dispensary Department. 7. Health Department. 8. Illinois Society for Mental Hygiene. Physicians. Before trying to obtain free service (except in emergencies) be sure that the family has not an attending physician, that no physician has been in attendance and that the family is unable to pay a local physician. (To decide this latter point the Social Service Registration Bureau may be able to help you.) If the family has had a physician in the past, talk to him and give him the opportunity to treat the patient without a fee. In doubtful cases, ask some member of the family to call the County Doctor. If, in your judg- ment, a free physician is not needed and the family insists upon receiving free treatment, let some member ask for it, thus putting the responsibility where it belongs. If a free physician is in attendance, do not send him unnecessary calls simply because the family or the patient desires to see him. Let such calls come from some member of the family. Unless you are sure the physician would change the treatment and wishes to be notified, do not ask any of his free time unneces- sarily. Local physicians are often willing to make free calls in cases of emergency, to carry patients, to see our patients at their offices and to take an occasional obstet- rical case. Many specialists are good enough to see our patients at hospitals or at their downtown offices. Before asking too much time from a busy man, talk 34 Visiting Nurse Manual over such cases with your Supervisor. Patients should be taught that this is valuable time and service, not too easily obtained and to be valued accordinly. County Physicians. To obtain, call the County Agent, Monroe 2608; say that you are a visiting nurse; ask to have a doctor sent to the patient, giving name, address, part of the house and your district number. If the County Agent's office is closed, call the police station nearest the patient. Do not send the County Doctor or any free physician to a patient able to go to a dis- pensary. Never refer a patient directly to the county physician. Whenever necessary, telephone the county doctor for conference in regard to a patient, but if calls for his services are given directly to him or to his office, they may never be made, for by ruling of the County Agent's department requests for free medical service must come through the County Agent's main office, Monroe 2608. Free Hospital Service. Except in emergencies, never send any physician's patient to a hospital without first consulting him. Cook County Hospital. To send patient to Cook County Hospital, call Health Department, Main 447, ambulance department, give diagnosis and ask to have the patient removed. See that the doctor has previously called and left an order for the County Hospital. Refer all cases of suspected contagion to the Health Department. Before trying to send contagious cases to Cook County Hospital, telephone and ask if there is a vacant bed. Oak Forest Infirmary. All cases for Oak Forest Infirmary (whether general or tuberculous) must be cleared through the County Hospital. All applications for admission should be made through the County Agent's office. Isolation Hospital. To send a case of diphtheria to the City Isolation Hospital or to Durand Hospital, call up the Health Department, ask for a vacant bed and ambulance service, giving name, address and facts. Free Medical Service 35 Private Hospitals. First ascertain if there is a vacancy. If the patient is able to walk or a child that may be carried, send with a note explaining all that you know of the case and ask for a free bed. If bed- ridden, call Main 447, Local 38, and ask if the police ambulance is available. This is a city ambulance and is obtainable for tree patients to private hospitals only when the distance between the patient's home and the private hospital is less than the distance between the patient's home and the County Hospital. Should you learn alter a patient has been sent out to a free bed in a private hospital that he is able to pay and not enti- tled to a free bed, telephone and explain your mistake to the hospital. If patient is able to make a partial payment ($5.00 rather than $8.00 weekly), explain this to hospital where obtaining a bed. Do not try to send patients suffering from venereal or contagious diseases, tuberculosis or alcoholism, or any typically County Hospital case, to private insti- tutions. Municipal Tuberculosis Sanitarium Dispensary De- partment maintains clinics for the treatment of tuber- culous patients in various parts of the city. Transfer all positive cases of tuberculosis and all suspected patients through the Main Office. (This precaution is taken in order that no patient may be lost between the two societies.) Do not carry any but terminal and surgical tuberculous patients. Advanced cases may be sent to Cook County Hospital, to the Home for Incurables (Otto Young Pavilion.) Hopeful sanitarium cases may be sent to Edward Sani- tarium, Naperville, 111., Winfield Sanitarium or to Oak Forest Infirmary. Edward Sanitarium. Visiting Nurse Association has the use of ten beds. Only incipient cases are received. There is always a long waiting list for these beds, and patients who will most respond to careful sanitarium treatment and whose home conditions will enable them to carry on this treatment after their discharge should be selected. Dr. Theodore B. Sachs is medical examiner 36 Visiting Nurse Manual for Naperville, and before seeing any patient for one of our free beds he desires a record of the afternoon temperature for three days, sputum analysis, a history of the case and the reason for its being sent to him. (It is advisable to have candidates for these beds sent through the Municipal Tuberculosis Dispensary.) Winfield Sanitarium. All free candidates should be referred to the tuberculosis clinic of the Jewish Aid Dispensary. Home for Incurables is a private institution taking only positively incurable cases. The tuberculous oa- tients are segregated in the Otto Young Pavilion. Ex- plain to the patient that a physician from the home will come out to examine him. Application should be made through the Main Office in writing. The following information is desired: 1. Name. 2. Address. 3. Diagnosis. 4. Urgency of case. 5. Name and address of nearest relative or friend. 6. Religious preference. 7. Social and economic condition. 8. Anticipated insurance. Dispensaries. Send free ambulatory patients to the nearest reliable dispensary. See that the correct day and hour is obtained for each patient. Send a note written on one of our small letterheads to the physician, telling him as much as is wise bearing on the situation. State that the patient cannot pay and ask him to return instructions and diagnosis if possible. (Remember that patient will probably read both notes.) It is well to enclose this in a sealed envelope on which should be plainly written the address of the dispensary and the car lines and transfer points. The envelope will probably be shown to several policemen, conductors and pedestrians before the patients arrive at their destination. Free Medical Service 37 Instruct the patient how to obtain a dispensary card and how to care for it. If the patient is a child and the nurse takes him, obtain permission from the parent or guardian and get written permission to have any treatment given (i e., tu- berculin test, tooth extracted, abscess opened, etc.) When working with difficult patients never put in writ- ing diagnosis of specific or other infectious trouble. Never repeat carelessly advice and warning of the phy- sician. Regard these as confidential and report only to people interested in doing the best for that unfortunate person’s welfare. Convalescent Homes. Grove House for Convales- cents at Evanston. The Visiting Nurse Association has the use of ten free beds to which it may send women and children who are able to go from their bed- rooms to the dining room and to take care of them- selves generally. Tuberculous, infectious and mental cases are not admitted. All applicants for admission must be examined by a physician selected by Grove House. To secure a vacancy for a patient, report name and address, present physical condition and previous diagnosis to the Registrar at the Main Office. Convalescing women and children may also be sent to the Chicago Home for Convalescent Women and Children, 1516 West Adams street. Application for this should be made directly through the superintendent of the home. Disposition of Children. Never send a mother to a hospital or home without being sure that minor children are being cared for. We may ask relatives, trustworthy neighbors who are friends of the mother, or institutions (the Home for the Friendless or St. Joseph’s Home for the Friendless) to care for children during the mother’s absence. Make application for the latter through St. Vincent de Paul Society. Delicate children may also be boarded in private families through the Illinois Home and Aid Society (Protestant), St. Vincent de Paul Society (Catholic) or the Jewish Home Finding Society. Children of school age, excluded from regular school 38 Visiting Nurse Manual work because of physical or mental defects, may be admitted to special rooms for crippled, sub-normal, blind or deaf children if application is made to the Child Study Department of the Board of Education. Feeble-minded children may be sent to the State School at Lincoln through the County Agent's office. Summer Outings may be arranged through the United Charities, various settlements, churches and other or- ganizations. Every child sent should be examined for pediculosis and communicable disease. If there has been a specific history of infection, vaginal smears should be taken. Sick children under 14 years of age may be sent to 1. Children's Memorial Hospital. 2. The Home for Destitute and Crippled Children. 3. Children's wards of various large hospitals. No child suffering from contagious disease or living in a temporarily quarantined house should be sent to any general institution. Previous arrangements should be made with each institution before a child is sent. Infant Welfare Society. For the care and super- vision of well and sick babies. Transfer all babies under 2 years of age to the Infant Welfare Society if living within the I. W. S. territory. Health Department. Report all cases of suspected contagion immediately to the Health Department. Re- port to the School Nurses of the Health Department such school children as are in need of school or dispens- ary treatment. The school nurses do not give home nursing care. Illinois Society for Mental Hygiene. Report to this society all cases of suspected insanity, where careful social investigation and advice are needed. Patients already diagnosed as positively deranged should be sent to the Detention Hospital for observation and disposi- tion. Admission to the Detention Hospital may only be obtained through a warrant issued by the County Clerk's office. To secure this warrant a doctor's written Maternities 39 and signed statement to the effect that he believes the patient to be of unsound mind must be taken to the County Clerk's office by a legally responsible person. Committment of this sort is a serious undertaking. The responsibility should be placed where it rightfully belongs, on the family of the patient. If, on the other hand, the family is trying to conceal the condition of an obviously dangerous patient, the case may be re- ported to the Society for Mental Hygiene or to the police, if so advised by the above society. Dismissed Patients. No patient of any age or sex in need of further care or change of scene should be dismissed from the books without a conference with the Supervisor or some interested person. A neglected convalescent is more difficult to help than a very ill typhoid, and the necessary diet, outing or rest is fre- quently overlooked because less easily obtained than hospital care. Fraternal orders, churches and relief agencies may all be asked to give this sort of help. Unless the need of special classes of cases are fre- quently brought before the public provision for them will never be made. Every case reported helps to emphasize this need. MATERNITIES Waiting Maternities. Never carry a pregnant woman indefinitely without some medical supervision. If the patient refuses to go to a physician, instruct her as carefully as you can and tell her that you will return when you know that she has had medical attention. If the patient cannot afford to engage a physician she may be referred to a lying-in out-patient department, or, with the aid of the Supervisor, medical attention may be obtained for her from some local doctor. It is best to refer patients to the nearest lying-in dis- pensary. The free dispensaries and hospitals sending out nurses and doctors for the confinement and after care are: Chicago Lying-In Hospital and Dispensary, 1336 Newberry avenue and 34 West Forty-seventh street. 40 Visiting Nurse Manual Rush Medical Dispensary, 1744 West Harrison street. Provident Hospital, 57 West Thirty-sixth street. Policlinic Hospital, 221 West Chicago avenue. The above out-patient departments send out physi- cians and medical students. All of these institutions wish to see the patient as long before the confinement as possible, and to keep her under observation by means of a monthly examination. Patients objecting to this sort of supervision should be taught how much this care means to them, how much under other conditions they would be obliged to pay for it, and the importance of having only the best kind of service for this and sub- sequent pregnancies. Women out of these territories may be referred to local physicians or to the Supervisors. When the home conditions are bad, it is well to persuade such patients to go to hospital lying-in wards for the confinement period. This insures the patient better care, rest and freedom from anxiety. Remember that every patient confined at home manages her household from her bedroom and gets very little rest. Explain that we do not come for delivery, but as soon as possible afterwards. Be sure that the patient has a visiting nurse card and knows how to reach us. If the case comes to you as a waiting maternity, try to make the mother feel that she should plan to save for the following supplies: Baby clothes, clean sheets, towels, night gowns, one pound of absorbent cotton, five-yard box of gauze, one pint of alcohol. She should also buy or borrow a bed-pan. Tell the patient that we will charge a small fee for our nursing care. The average woman has eight months in which to make these preparations. For her own and her baby’s sake she should be encouraged to plan for its advent and not to accept nor expect too much free service. Instruct her carefully in regard to: 1. Diet — amount, variety. 2. Exercise (warn against heavy lifting). Maternities 41 3. Bathing. 4. Sleep. 5. Clothing. 6. Observation of urine and stools. Make two or more pre-natal calls monthly and ques- tion her in regard to her care. Never frighten nor worry a pregnant woman about herself, but let her see that you are interested in her welfare and want to help her. Teach her to report promptly headache, vomiting, swollen feet, trouble with eyes, or too much pain. Unless you know that the patient has given history of previous pregnancies to a physician, question her regarding them and be sure that all abnormalities are reported. Pregnant unmarried mothers may be sent to the Foundlings’ Home (Protestant) or St. Margaret’s Home or St. Vincent’s Infant Asylum (Catholic) or to the Florence Crittenton Anchorage (non-sectarian). Labor. Tell the patient to send for a physician when pain begins or membrane ruptures. Instruct her to take a hot bath and an enema, to comb hair in two braids, to have boiling water and newspapers in readiness. After Care. T. P. R. daily. On first visit give general care, external lysol irri- gation of vulva; change obstetrical pad. On following visits give partial care. Give at least two baths weekly. Never give douche unless ordered by physician. If there are stitches, cleanse with lysol solution; dry care- fully; do not powder unless ordered. Make pads each visit and see that family keep them clean. Roll soiled dressings up very carefully and burn before leaving house if possible. See that some pro- vision is made for laundry work. 42 Visiting Nurse Manual Care of Breasts. Cleanse nipples with boric solution and explain this care and precaution to every mother. If milk comes rapidly, apply a comfortable breast- binder for a few days. Wet-Nurse. If a mother has more milk than her own child requires and can go out as a wet-nurse, report to any large obstetrical service (hospital or private) and ask if a wet-nurse is needed. Breast Feeding. Insist upon breast feeding and watch patient's diet carefully if milk supply is insuffi- cient. Never help any patient to dry her breasts unless physician so orders. Don't ever encourage this if baby is living and can nurse. Breast feeding is a mother's duty, but the baby's father or its legal guardian (a relative or the state) must make it possible for the mother to give this care to her child. A mother on an insufficient diet is not able to nurse her infant properly. Bottle feeding is sometimes made necessary because the mother's diet is overlooked. Always make sure that the breast milk cannot be im- proved or increased before you help to put a baby on bottle feeding. Inquire daily (and report to physician P. R. N.) con- cerning : (a) After-pains. (b) Amount and color of lochia. (c) Condition of breasts. (d) Urine and stools of both mother and infant. Midwives’ Cases. For obvious reasons, visiting nurses may not assume responsibility for, nor give nursing care to, midwives' cases unless midwife has been dismissed and doctor is summoned. Nevertheless, suspected mal- practice, septicemia, or infected eyes, if discovered dur- ing the first call in such cases, should be reported to the Health Department. Baby. 1. Dress cord. Oil rub, sponge bath and dress first day. Surgical Nursing 43 2. Cord. If no other orders are left, apply alcohol dressing daily. 3. Bath. Delicate babies, oil rub in place of bath for first week or longer. Others — sponge bath and oil rub until cord is off and stump healed; then tub. Do not use powder. 4. Eyes. Wipe lids gently with cotton wet with boric solution. Report all redness to physician. Report neglected or badly inflamed, discharging eyes to Health Department. 5. Mouth. No treatment; 2 drams water after bath. Baby Outfits, consisting of 3 flannelette dresses, 3 petticoats or pinning blankets, 4 binders and 6 napkins may be taken to any maternity case needing them after the baby is born. Outfits taken earlier are frequently lost or sold. Never promise an outfit to a mother months before delivery, but encourage her to prepare one. Send her patterns for this if necessary. Baby clothes may be given only to visiting nurse patients, not to dispensary or midwives’ cases. SURGICAL NURSING Dressings require: Newspapers, solutions, dressings (gauze, cotton and old linen), instruments and bandages. See that the family has newspapers to protect chairs, floor and bed and to receive soiled dressings. Never use expensive solutions, bandages and dressings when soap and water and old linen will suffice. For bandages substitute slings or manytailed; for oiled silk use oiled paper; for gauze use old linen; for absorbent use com- mon cotton. Never destroy any material that can be used more than once. By your own example teach each family ways and means of reducing the cost of illness. Study each dressing as a separate problem and methods of devising cheaper dressings will suggest themselves to you. 44 Visiting Nurse Manual Preparation. Prepare for dressings by covering the table with newspaper. Place solution basin, scalded before and after each using, dressing towel, bandages, etc., on this. Have second newspaper ready to receive soiled dress- ings. Never return to bag for extra supplies after treatment is once started without taking antiseptic pre- cautions. Make all preparations for each dressing be- fore removing soiled dressings. Thoroughly scrub hands with soap and water before and after care. Solutions. If irrigations are used, ask family to set aside a pitcher or a wide-mouthed bottle for this special use. When cold sterile water is needed, a supply may be prepared and left for the following day. The bottle or pitcher should be sterilized daily, filled with boiling water and securely stoppered with a cotton and gauze pad. A clean paper bag inverted over the top of the receptacle protects the stopper from dust and empha- sizes the importance of all these precautions in the minds of the family. No solution stronger than boric acid, bicarbonate of soda or saline should be prepared and left in the homes. If frequent irrigating with one of these solutions is ordered, prepare a sufficient amount daily and leave in sterile pitcher, properly protected. Teach the mother how to warm the solution by standing it in a deep pan of boiling water and how to apply without wasting solu- tion or wetting clothing unnecessarily. Poisons. If the physician orders a poisonous solution used, instruct the mother to ask him to write a pre- scription for the same, and have this taken by the family to a neighborhood drug store to be filled. Teach the mother to prepare the prescribed solution, warning her daily of the danger of leaving this within reach of children or irresponsible adults. Make as small a quan- tity of the solution as possible, and see that it is very plainly labelled “poison.” When the case is terminated or if the treatment is changed, ask the family to give you any of the solution that remains (this refers par- ticularly to carbolic acid, lysol, bichloride of mercury, Surgical Nursing 45 chloroform linament, argyrol, atropine, strychnia and opiates). Under no circumstances should a visiting nurse leave any poison from her own supplies in a district home. If top-dressings from a cancer or any septic case must be left in strong lysol solution for any length of time, the receptacle for this should be left in an absolutely safe place, or the solution should be so diluted just be- fore the nurse leaves that no serious trouble could follow its misuse. Supplies when left in the homes for extensive dress- ings, maternity cases, etc., should be rolled in a fresh towel and kept in a clean place. The attendant should be taught to wash her hands carefully before unrolling the towel. Whenever possible, payment should be col- lected for materials left in the home. If family cannot afford full price, partial payment may be made. (This refers also to rubber bandages, stockings, abdominal binders, eye glasses, crutches, braces or any supplies procured by the Visiting Nurse Association for the patient.) Instruments should be boiled before and after using. Forceps (a pair in each hand) should always be used to remove soiled dressings of any description. Never touch a soiled dressing with an unprotected hand. If the wound is septic, no antiseptic precautions in scrub- bing up in a district home, will sufficiently disinfect your hands. (Howell of Columbus, Ohio, believes that pus germs remain on infected hands for three days following infection.) Care of Soiled Dressings. All soiled dressings to be destroyed should be well wrapped in newspapers and then burned. Others should be put immediately in cold water and placed on stove for sterilization. All soiled dressings should be cared for promptly by the visiting nurse or a thoroughly responsible person. In apartment houses, see that the janitor under- stands the importance of cremating old dressings with- out opening the package to inspect contents. 46 Visiting Nurse Manual Never permit a family to throw dressings or pads of any kind in the ash barrel. Unless families are watched, offensive dressings may be thrown in the alley or a garbage heap. Patients should be taught how to wash bandages and slings in order to have them ready for the nurse on her next visit. Patients able but unwilling to make this effort should be made to pay for their own dressings. Burns should be visited daily or twice daily. To avoid unnecessary pain or hemorrhage, see that dress- ings are well moistened before removing. Always bear in mind the prostration following such treatment and remove and renew dressings in segments rather than by exposing the entire burned area at one time. Soft old linen or cotton cloths are better than gauze. Never apply cotton as a dressing to a burned area. Never further tire a patient by giving a full bath before or after an extensive, exhausting dressing. By partial bathing daily, the entire body can be kept clean and comfortable. When wet dressings are used, take special precau- tions to protect mattress and bedding. When the pa- tient cannot be turned he should be lifted daily in order that the sheets may be changed and the patient’s back and hips given care. If there is no one in family to lift an adult patient, see if neighbors cannot be called upon to help. When dressing burned hands and feet, fingers and toes should be carefully separated. Never bandage a burn that you can manytail. In severe or extensive burns, have the attendant save all urine passed between the nurse’s visits. This is safer than asking to have it measured. Ask the family to have some stimulating or soothing nourishment ready for the patient at the end of the treatment, hot coffee, broth, or a cooling drink of some sort. This takes the patient’s mind off his dressing and is always comforting. Surgical Nursing 47 Watch for deformity and notify physician promptly when contraction of skin or underlying muscles is threatening. Ulcers. Never change the treatment without con- sulting the attending physician or dispensary. Instruct the patient to keep the limb raised as much as possible. Apply bandage firmly from foot to knee. The foot and limb should be bathed in hot lysol solution (1 per cent) whenever the dressing is changed, and rubbed with alcohol. A lysol solution (2 per cent) for sponging and cleans- ing the wound should be prepared in a seperate recep- tacle. The wound and surrounding area should be thor- oughly cleansed from the center out. Every precaution should be taken to prevent cross infection. If physician is seeing wound infrequently, notify him whenever ulcer appears enlarged. Occasional stimulation and frequent changing of treatment hastens the healing of the most chronic ulcer. A neglected or slow ulcer requires daily treatment if recovery is desired. Unna’s paste bandages are prepared as follows: Heat the paste to liquefying point in a double boiler. Immerse a loosely rolled gauze bandage in this until thoroughly moistened. Then bandage foot and leg as if applying a starch or plaster bandage. Keep the limb quiet until the bandage is dried. Cases requiring elastic bandages or stockings should be referred to the Supervisor. Care of Eye. Removal of a foreign body. Turn the lid back or down, remove foreign body (if not imbedded) with moist, clean cotton. If delicate application does not remove this, bandage the eye lightly and send the patient to a physician at once. The eye should be bandaged to keep the patient from rubbing it. Do not irrigate. Infected Eyes should be visited daily. If the family seems irresponsible, try to get the case to a hospital. Impress upon the mother daily the necessity of follow- 48 Visiting Nurse Manual ing instructions promptly and accurately. Describe the process taking place in the eye and warn her of the economic as well as mental distress that total or par- tial blindness may cause the patient. Ophthalmia neonatorum is a reportable disease and should be referred to the Supervisor. When giving treatment in this and other septic cases, always wear rubber gloves. Eyes requiring glasses or surgical treatment should be carefully followed up. While the burden of respon- sibility for having such defects corrected falls upon the parents, a nurse should be sure that they understand the need for this correction. If they refuse to have the treatment given, the case, with doctor’s diagnosis and advice, should be dismissed to the Juvenile Court. Discharging Ears are always suggestive of past and future trouble. Delayed treatment may precede mas- toiditis and will eventually cause loss of hearing — a serious handicap to a working man or woman. No nurse should dismiss from her books a child hav- ing a discharging ear without having made every effort to impress upon the parents the importance of prompt action. When parents wilfully neglect troubles of this sort a minor child may be reported to the Humane Society or the Juvenile Court for protection. If irrigation is ordered, a fountain syringe is better than a hand syringe. It should be hung not more than 6 inches higher than the ear itself. The solution should be of temperature easily borne on the wrist; the shoul- der should be protected by a dressing towel and the patient taught to hold a dressing basin himself. The canal and outer ear should be thoroughly dried by soft cotton pledgets after any irrigation. Bladder Irrigation. Keturn-flow catheter may be obtained in loan closet. Fountain syringe should be boiled before each irrigation. Cold sterile water, boric or saline solution, should be prepared daily and left for next treatment. Medical Nursing MEDICAL NURSING 49 References — Maxwell & Pope, pp. 337-427. Rosenau — Preventive Medicine and Hygiene. Sanders — Modern Methods in Nursing, pp. 439-471, 387-439. Nursing in Communicable Diseases. In overcrowded and badly managed district homes perfect quarantine seems so impossible of attainment that there is danger that the visiting nurse may give but half-hearted and incomplete isolation instructions. An ignorant disregard of infection, an old-time belief that all children must sooner or later have the diseases of childhood, and a superstitious fear of fresh air, water and cleanliness in the sick room, will frequently be encountered. It is not unusual to find a scarlet fever patient on a cot in the kitchen or sharing the bed of an apparently well child. Occasionally a lying-in mother, a .young infant and a case of measles or scarlet fever may be found in the same household. Such cases have been nursed at home — by visiting nurses — in spite of seemingly insurmountable handicaps and the patients all dismissed “well.” On the other hand, an apparently mild attack of diphtheria or whooping cough has been the cause of death in many instances. Because a few patients have been known to recover when every sanitary precaution was apparently defied, hundreds of lives have been sacrificed because some one neglected quarantine rules. The danger of violating these rules should be repeatedly emphasized, and families warned that the Health De- partment has power to enforce hospitalization if quar- antine is impossible or broken. Always advise and urge hospital treatment whenever it is difficult to estab- lish isolation of patient, attendant and utensils. Never make light of contagion in a home where there are susceptible children, and do not make it too easy to care for contagious cases at home. Unless you know that the attending physician or a former nurse has reported patient and diagnosis to 50 Visiting Nurse Manual Health Department, this should be done on special form post card. If you suspect contagion and the case has not been reported and other children are being exposed, telephone your suspicions to the Health De- partment and ask that an inspector be sent out. Nursing and Visits. All nursing visits to . contagious cases by general nurses should be made at the end of each day. A long-sleeved gown and cap should be car- ried to each case and worn during treatment. Before donning gown, get everything needed (solution, tongue depressor, cotton, soap, nail brush, etc.) from bag, close it and leave it with outside uniform on porch or in room away from patient. Remove cuffs, roll sleeves up to elbows, prepare hand solution, collect everything needed for the sick room, and then put on cap and gown. After care is given, disinfect hands, remove gown, folding it so that inner surface is not contami- nated, and put in safe place within sick room. Dis- infect hands a second time and then scrub them thor- oughly with soap and water and brush. Let family see you scrub up and tell why you do it. Explain that infection follows careless contact of attendant’s hands or clothing with person and bedding of patient, and have her wear a long apron, an old wrapper or a folded sheet over house dress whenever she goes to patient’s bedside. Teach her to keep this wrap for the sick room only, and to so fold or hang it up that the inner surface remains uncontaminated. Observe the following precautions and teach them to attendant: Take nothing from the sick room that has not been disinfected. Care of Hands. Emphasize care of attendant’s hands and need of thorough scrubbing after disinfectant is used. Perhaps the safest disinfectant to advise for the hands is creolin or cresol. The basin, half full of a 2 per cent solution, should remain just outside door of sick room in a safe place. Attendant should be taught the importance of using the disinfectant after every treatment, no matter how slight, and always before Medical Nursing 51 uninfected articles (door knobs, bureau drawers, trays, etc.) are touched. This is difficult to teach, for too many people refuse to consider it worth while unless done in the nursed presence. Linen. Have a pail or wash boiler one-third full of cold water or disinfectant solution inside sick room. Roll soiled linen in cloth and immerse bundle in wash boiler. This should be carried at once to stove and allowed to boil before linen, is handled. Prompt sterili- zation by boiling is better than soaking in a disin- fectant. Too much precaution cannot be exercised in the matter of leaving disinfectants in district homes. Dishes. A large saucepan half filled with cold water should be kept to receive medicine glasses, spoons, cups, etc., from sick room. Dishes should be boiled before being rinsed or washed at sink. All uneaten food should be wrapped in newspapers before being carried from sick room, and then burned. Excreta. Expectoration should be received in soft cloths, which should be placed in paper bags or rolled in clean newspaper and burned promptly. Never use basin or cup for slight expectoration; give patient old cloths. Bedpans and urinals should contain small quan- tities of 2 per cent lysol solution or chloride of lime 5 per cent before being used and an equal quantity of same disinfectant should be added before urine or faeces is thrown into hopper. All bathing water should be boiled or disinfected before being discarded. Permit toilet to be used only for properly disinfected waste material. Nose and Throat Treatment. Before giving nose and throat treatment in any infectious disease, protect your own face with a mask that entirely covers mouth and lower half of nose. This mask had better be made of paper. A paper napkin folded diagonally may be se- curely pinned to the hair or contagious cap. An easier mask, if many treatments are being given, may be made of a diagonally folded doily-size paper napkin that has ear loops of fine bicycle wire in two corners. This can be slipped on easily and is less confining than a pinned mask. 52 Visiting Nurse Manual Be sure that patient's hands are wiped with disin- fecting solution after each throat treatment and that the tip of the atomizer is well wiped with 95 per cent alcohol sponge. Sterilization by heat is the best method of disinfec- tion in district homes, but in hot weather a large fire may heat the whole house for hours, or there may be no fuel for any sort of fire. Coal and wood can not be used too freely, but disinfection and sterilization should be insisted upon for the protection of the com- munity as well as of the rest of the family. This expense for fires is another reason for urging hospital care. Care of the Room. Teach damp sweeping and dust- ing with cloth wrung out of disinfectant. Broom and duster should remain in sick room until case ‘is term- inated. Disinfection. When any case is terminated, whether or not special fumigation is ordered and done, room should be thoroughly cleansed, walls wiped down, fur- niture, woodwork and floor scrubbed, bed linen and curtains washed, and mattress and carpet or rug sunned and aired before room is occupied by other members of family. The Chicago Department of Health has issued the fol- lowing regulations concerning quarantine, school exclu- sion of susceptible children, termination of case and disinfection. Placarded means that a Health Depart- ment warning is tacked on door of house or apartment. 1. Diphtheria. Placarded. Quarantine until two negative cultures have been secured on two consecutive days by the Health Officer. School exclusion for exposed children living in same apartment until quarantine has been lifted. Disinfection — Health Department. Antitoxin can be secured free for all contacts and all positive cases at the various state antitoxin sta- tions located throughout the city. Medical Nursing 53 2. Diphtheria Carriers. Placarded. Quarantine until negative culture has been secured by Health Officer. 3. Scarlet Fever. Placarded. Quarantine until a. Termination of desquamation. b. Cessation of all discharge from ear and nose. c. Disappearance of evidence of acute inflammation of tonsils, usually five weeks or longer, though if b. and c. are satisfactory at the end of five weeks a., desquamation, may be disregarded. Disinfection by Health Department. School exclusion as in diphtheria. 4. Measles. Placarded. Quarantine — 2 weeks maximum. School exclusion — susceptible exposed pupils and teachers eighteen days. Disinfection — none. 5. Whooping Cough. Placarded. Quarantine — 5 weeks, from first whoop (for 2 weeks in house or private yard, last 3 weeks at large if pa- tient wears “whooping cough” sleeve-band furnished by Health Department). Disinfection — none. 6. Epidemic Poliomyelitis. Placarded. Quarantine — rigid isolation 5 weeks, windows screened. School exclusion — until quarantine is lifted. Disinfection — by Health Department. 7. Epidemic Cerebro Spinal Fever. Isolation — at least 2 weeks, other precautions as in Epidemic Poliomyelitis. (Not placarded.) 8. Chicken Pox. Quarantine — 2 weeks or until through scaling. School exclusion — susceptible children 2 weeks. Disinfection — none. (Not placarded.) 54 Visiting Nurse Manual 9. German Measles. Quarantine — maximum 10 days. School exclusion — susceptible children 3 weeks. Disinfection — none. (Not placarded.) 10. Mumps. Quarantine — until all swelling has subsided. School exclusion — susceptible children 3 weeks. (Not placarded.) Other diseases to be reported to Health Department are: Tuberculosis (all forms). Typhoid Fever — Milkman’s placard on rear door only. Streptococcus Sore Throat — Milkman’s placard on rear door only. Smallpox — All cases taken to City Smallpox Hos- pital. Ophthalmia neonatorum Rabies Erysipelas Tetanus Not placarded. 11. Erysipelas. Always use gloves. Do not do dressing nor give nursing care when carrying maternities or clean sur- gical cases. Observe special contagious disease precau- tions. Specific Precautions. Always wear rubber gloves. In an emergency a pair may be purchased in the neigh- borhood. Teach the family 1. To keep separate utensils (dishes, etc.) for the patient. 2. The importance of protecting the toilet properly if the patient is allowed to go to a common bath room. 3. Careful disinfection or separate sterilization of all bed and personal linen. Medical Nursing 55 Unless thoroughly disinfected this linen should never be sent to a public laundry nor given an ignorant laundress. On the second visit to a case of this sort a contagious gown should be carried and left in the home. Vaginitis cases should wear pads, which should be burned after removal. In bad cases of this type some physicians de- sire to have the pads wrung out of a 1 to 10,000 bichlor- ide solution. Acute venereal cases should never be handled when a nurse is carrying maternities and clean surgical dressings. Whenever possible, adults should be taught to give their own treatment. When it is necessary for the nurse to give mercurial ointment treatments, gloves should always be worn. 13. Typhoid Fever. Transfer to hospital if possible. Few private houses have toilet or other facilities for treating typhoid at home. Always wear a contagious nursing gown if care is given in the home. Take T. P. R. and give daily or twice daily general care, paying particular attention to teeth, back and hands. Mouth should be cleansed at least three times daily. (If tooth brush is used, it should be kept immersed in saturated boracic solution.) This solution should be changed daily and the receptacle boiled. (Explain this detail to the attendant.) To prevent pulmonary hypostasis the position of weak or delirous patients should be changed occasion- ally from back to either side. Diet. Unless special diet is ordered, milk (diluted p. r. n. with carbonated or lime water) is most easily borne by patient and prepared by attendant, who should be taught to prepare other liquid diet, albumen water, lemonades, etc., and to keep a bowl of finely cracked ice by bed side. More liberal diet is given many typhoid patients and if soft diet (toast, eggs) is ordered, be sure that family does not give a general diet instead. 56 Visiting Nurse Manual Disinfection is of greatest importance and exceedingly difficult to teach lay people, hence the advisability of prompt hospital care. The safest as well as most inex* pensive disinfectant is “chloride of lime” (chlorinated soda, bleaching powder), which may be purchased in 10c tins. This loses strength rapidly if exposed to air or moisture, consequently it should be kept in a closed jar. All dishes, linen and other utensils coming in contact with patient should be sterilized by boiling or complete immersion for one hour in a 5 per cent chloride of lime solution. All excreta (urine, faeces and sputum) and all solu- tions used for patient (mouth-wash and bathing water) should be mixed with twice their volume of 5 per cent chloride of lime solution and allowed to stand one hour. 10 per cent formalin solution may also be used in the same manner but this is more expensive, (lib. of chlor- ide of lime to 2 gallons of water makes a 5 per cent solution). Teach all of these precautions and observe closely to see if attendant is faithful in carrying them out. A visiting nurse caring for typhoid cases should re- ceive anti-typhoid serum treatment. 14. Tuberculosis. Reference — Walters — The Open Air or Sanitorium Treatment of Pulmonary Tuberculosis. (Chapters 1, 2, 7, 10, 15, 18, 22, 25.) In caring for patients suffering from pulmonary tu- berculosis emphasize frequently the lack of danger to the well, if both patient and family are careful to prevent infection. On the other hand, remember that tuberculosis is not a disease that may be controlled or cured in the average home and never advise home treat- ment when good institutional treatment, private or pub- lic, is available. In congested homes, where good air and food are out of the question, always advise institutional care. If there is no suitable hospital or sanitorium, get in touch with the local or state anti-tubercu- Medical Nursing 57 losis society and ask their advice and help. When pa- tients must remain at home, be far-sighted in your planning; plan not only for the present but for the future as well. The case will probably be on your books for months if not years. Home Care. Teach the patient to be careful to cover his mouth with paper napkin when coughing or sneez- ing, to expectorate into paper napkin or cloths that can be easily destroyed, to use his own dishes, clothing, towels, pillows, bed, etc., exclusively, and to disinfect his hands frequently. The family should see that the patient's room and lounging-place ( porch, roof or yard) is comfortable and clean, that his food is well prepared and properly served (and the prescribed amount eaten daily), that his rest is not disturbed by visitors or family and that he is spared as much of the petty annoyances of daily life as possible. This program is not as utopian as it sounds. In all but the very poorest homes, much of it can be carried out if the family is earnest and unselfish and if the nurse will plan the system and daily routine that so many households lack. A written schedule for the tu- berculosis patient's day should be drawn up, and the family should be encouraged to help the patient make a perfect record. Teach the need of team-work as well as courage. Always make positive suggestions, never sympathize pessimistically. Tuberculosis is an expensive, exhaust- ing, discouraging disease, but in a large percentage of cases it can be cured. Never let any patient lose sight of this fact. It can't be cured singlehanded. Never let the family lose sight of this fact. And remember your own responsibilty — to instruct repeatedly and carefully, to report to Health Department, to obtain the wisest form of relief whether in home, in sanitorium or hos- pital and to maintain an intelligent helpful interest in each individual patient as long as he requires your aid. In watching for suspicious cases, remember that the early diagnosis of tuberculosis is based on 1. History of exposure, more or less prolonged. 58 Visiting Nurse Manual 2. Symptoms suggestive of tuberculosis (particu- larly recurring afternoon rise of temperature; with women particularly preceding or following menses). 8. Tuberculosis of other organs. 4. Examination of chest. 5. Tuberculin test. 6. Tubercle bacilli in sputum. Some of the characteristic symptoms of tuberculosis: 1. Persistent lassitude, fatigue, weariness, anae- mia, under weight or loss of weight. 2. Nervous symptoms — restlessness and irrita- bility. 3. Gastro-intestinal — loss of appetite, dyspepsia. 4. Afternoon or evening temperature. 5. Increased pulse rate (unstability of pulse char- acteristic of tuberculosis infection). 6. Sweats or tendency to perspiration that is not normal. 7. Dry cough. 8. Expectoration, especially in morning. 9. Blood spitting (always suspicious). Points to remember. Care of sputum: 1. The best method is to burn. 2. Lysol 2 per cent (add equal volume of solution, mix thoroughly; allow whole to stand two hours). 3. Carbolic 5 per cent. Do not use corrosive sublimate. Discourage use of handkerchief, metal or paper sputum cups. If rubber lining is used in pocket, it should be lined with waxed paper so folded that waxed paper and paper napkins may be burned together. If napkins are used in homes, have up-patients carry small paper bags (1-pound size). These, with the used napkins, should be burned. Medical Nursing 59 Bed patients should be given large bags of heavy paper or newspaper cornucopiae that may be pinned to mattress within easy reach of patient's right hand. The opening of either should be just large enough to receive crumpled napkin easily. In homes where there are no coal stoves the napkins should be burned in the furnace or in wire receptacles in alley or yard. Expert disposition of expectoration in its moist state must be insisted upon. Dried, pulver- ized sputum is the real menace in tuberculosis. Bedding. Bedding may be washed with family supply if patient is not expectorating much and is properly careful. Otherwise treat as in other contagious dis- eases. Dishes. Warn against family or public drinking cup. Advocate boiling or at least separate washing in hot, soapy water of all dishes used by patient. Clothing should be frequently aired in the sunshine, together with blankets and rug from patient’s room. Room. Best sleeping room in house, preferably an end room. Must have sunshine. Teach someone how to keep it clean and bright and cheerful. A flowering plant, white curtain and pictures all help. Rest. Warn convalescing patient against danger of decreasing rest without orders. Diet. (Reference, Walter, pp. 108-139; 237-261.) Don’t put a special diet in any home where the ordinary food supply is insufficient. An unselfish patient will in- evitably share it. Tuberculosis does not make any indi- vidual less human. Try to urge or force institutional treatment for such patients. Remember that an excessive increase over normal body weight is not desired, but the average patient should eat in twenty-four hours three generous, some- what concentrated meals, with a larger proportion of fat than is required in the diet of a well person. This fat may be given in milk, butter and its substitutes, oil and meats. Don’t encourage nibbling between meals. 60 Visiting Nurse Manual If necessary to tempt a failing appetite, advise crackers and milk, or eggnog or cocoa that is largely milk midway between meals or before retiring. Don't place undue emphasis on milk and eggs unless the patient is also going to receive meat, vegetables, fruits and other equally agreeable and necessary articles of food. Patients are seldom, if ever, cured by an insipid diet of eggs, milk and county supplies. Stimulants. Alcohol, strong tea or coffee are counter- indicated. Tea, coffee or cocoa may be given if served two-thirds milk or cream. Relief. Too much is worse than none at all. It is useless to develop dependence and indolence in people whose mental poise enables them to accept relief as their perpetual right. Unless a patient is faithful in his obedience to orders, give one warning and then have relief stopped. Recovery from tuberculosis is as much the patient's business as it is the community's. When others are being endangered by a tuberculous patient's carelessness or indifference, consult every available agency (medical, relief, legal, child-placing) before making a final plan. If, on the other hand, a patient is doing his best to carry out instructions, don't let co-operating agencies lose sight of this fact. Nursing. (Walters, 105-107.) General nursing care is indicated when patient is in bed. Oil rubs are frequently ordered for emaciated pa- tients. They should be preceded by a warm sponge or an alcohol rub and then given with gentle friction. Unless otherwise ordered, there is no special advan- tage to be gained in keeping advanced cases in bed all day. If patient is strong enough and desires it, it is well to teach the family to get her up for a few minutes night and morning while bed is being made. This change of position often insures a quieter night. Night sweats may be relieved by vinegar sponges. Equal parts of tepid water and vinegar should be used, with no friction. As these sweats usually occur when Nursing of Chronics 61 only the family can give care, a vinegar sponge might be given by the nurse as a demonstration instead of the usual bath or alcohol rub. Coughing. No medication of any description should be administered or advised without a physician’s orders. A healed lung and a fixed craving for opium is worse than tuberculosis. Much coughing can be eliminated if patients are taught to check the first cough. Hot water, sipped slowly, will often control painful morning paroxysms of coughing. Cold compresses over the throat sometimes give relief. Laryngitis. Chipped ice held in mouth just be- fore nourishment is taken, helps patient to swal- low. Cold liquids, concentrated, are more easily taken than hot. Broth or beef juice should not contain pepper and but a very little quantity, if any, of salt. A throat spray containing cocaine gives relief, but this should be carefully used and always by a physician’s orders. Common Colds. Most communicable during early stages. Keep patient isolated and in bed three days, if possible. Sequelae serious. Ascertain secondary cause (dust, bad ventilation, improper feeding, long hours), and help patient to overcome this tendency by more regular living, eating and sleeping. NURSING OF CHRONICS Care of the Aged. Whenever giving nursing care to old people, try to have someone watch every detail that good care may be given during your absence. Old people, as a rule, object to bathing and fussing; they like to be comfortable but not too clean. Don’t trouble them with a rigid routine or a bed made hospital fashion. See that the pressure areas (heels, elbows, backs, etc.) are well rubbed, that their linen is clean and that their diet is suitable (nourishing, somewhat concentrated and served warm). Constipation and retention of urine should be guarded against. If this cannot be regulated by diet and amount of liquids taken, the physician’s attention should be 62 Visiting Nurse Manual called to the patient’s need. The above is equally true of other chronic cases (paralysis, locomotor ataxia, tuberculous sinus, rheumatism, Bright’s disease, etc.). Our chronics (old and young) need our most gentle, considerate care, for in too many instances the visiting nurse’s call is the brightest spot in their lives. Each patient should be made as comfortable as possible. Special pads, cushions, bed-rests, etc., should be impro- vised for helpless patients. Be careful not to accept any condition, even of long standing, as incurable until physicians most able to aid each type of case have been consulted. Pulmonary Hypostasis. Be on the lookout for this con- dition in all feeble or bed-ridden cases, whether acute or chronic. Teach family how safely to change patient’s position, even when condition is critical. NURSING OF CHILDREN The nursing of children is one of the hardest prob- lems of a visiting nurse. Affectionate parents are suspicious of baths, treat- ments, dressings, etc.; indifferent parents will rarely take the trouble to carry out any orders at all. Some children requiring delicate, careful treatments (eye irrigations, extensive burn dressings, etc.) are so undisciplined that each visit is torture until the little patient accepts the inevitable or becomes accustomed to the treatment and the presence of the nurse. An ability to tell fairy stories, an occasional surprise and an unvarying, gentle firmness are the best methods of meeting this opposition. Never let parents frighten children, but see that prescribed amount of treatment is given as ordered. Let families see that the child’s future welfare is just as important as its present pseudo-comfort. Urge hospital treatment for all acute cases that may suddenly develop disastrous complications or infections, but do not send babies and little children if their treat- ment can possible be given at home. Poor homes are better than good institutions for most babies. Nursing of Children 63 Urge bed and a quiet room for all cardiac and chorea cases. Have abnormally acute, fidgety or dull children seen by children’s specialists. Be sure that orthopedic apparatus is properly adjusted and understood, and that patients wearing it are taken at proper intervals to clinics or the physician’s office. Watch for abnormalities (bowlegs, limps, hunchback, facial deformities, decayed teeth) and try to get some attention for each case as you find it. Many of these children (especially cases of spinal curvature, paralysis, or contracted muscles) require special corrective gym- nastics that can be obtained if patient lives near a small park center or a school gymnasium. Report the case to the instructor personally and enlist his sym- pathy and instruction. On the other hand, remember that children of school age are being watched by the school nurses, therefore do not duplicate nor interfere with their work. Pediculosis. Saturate hair with kerosene and olive oil, equal parts, and pin in towel turban for the night. In the morning shampoo with hot water and green soap, and use fine comb. If head is in bad condition, have mother cut hair. This treatment will need to be re- peated frequently, but mother should be taught to do it. Children with peduculi or nits in their hair are refused at all summer camps. Sore Throat. Never use gargle until after physician has seen throat. Isolate patient. Have dishes boiled. If child has been exposed to contagious disease, report case to physician or Health Department. Tonsil and adenoid cases should not be dismissed until every effort has been made to get advised treatment carried out. After the operation has been performed, caution mothers to guard against night mouth breath- ing, for this habit will not be cured, in most cases, simply by the removal of the obstructing tissue. 64 Visiting Nurse Manual TABLE SHOWING WEIGHT AND HEIGHT FROM BIRTH TO THE SIXTEENTH YEAR. Weight, Lbs. Height, In. *Age — Boys. Girls. Boys. Girls. Birth 7.5 7.1 20.6 20.5 6 months 16.0 15.5 25.4 25.0 12 months 20.5 19.8 29.0 28.7 18 months 22.8 22.0 30.0 29.7 2 years 26.5 25.5 32.5 32.5 3 years 31.2 30.0 35.0 35.0 4 years 35.0 34.0 38.0 38.0 5 years 41.2 39.8 41.7 41.4 6 years 45.1 43.8 44.1 43.6 7 years 49.5 48.0 46.2 45.9 8 years 54.5 52.9 48.2 48.0 9 years 60.0 57.5 50.1 49.6 10 years 66.6 64.1 52.2 51.8 11 years 72.4 70.3 54.0 53.8 12 years 79.8 81.4 55.8 57.1 13 years 88.3 91.2 58.2 58.7 14 years 99.3 100.3 61.0 60.3 15 years 110.8 108.4 63.6 61.4 16 years 123.7 113.0 65.6 61.7 Never dismiss a child needing further care (surgical or otherwise) without putting the case in your time- book (last page) in order that another attempt may be made (three or six months later) to obtain this special treatment. By putting name, address and facts on last page of time book, another nurse in that district will also be able to follow the case later. Always write reason for not securing treatment earlier on patient’s history card. NURSING OF INFANTS. Infants should be breast-fed during first year. In addition they may be given farina at 6 months; soup (and rice), 8 months; one year, finely minced vegetables *Birth to 5 years, without clothing — Holt; 5 to 15 years, with clothing — Bowditch; 15 and 16 years, with clothing — Holt. Nursing of Infants 65 — carrots or spinach, . V 2 ounce. Try to teach mother to nurse baby regularly at four-hour intervals during day and once at night (6 and 10 a. m.; 2, 6 and 10 or 11 p. m.) The baby should sleep alone and not be picked up whenever it cries. Teach mother to tub and sponge baby, to dress warmly but not too heavily, and to give plenty of water, fresh air and sunshine. Help her plan for at least one outing daily and to give its morning and afternoon naps in a well ventilated room — not in a hot kitchen. Mothers quite rational about fresh air for other children, are afraid of its effect on the baby. They should be taught that babies resist bad air less easily than do older children. Bottle Fed Babies. Emphasize care of bottles and nipples; of cleanly preparation and proper care of milk, and of giving a fresh bottle for each feeding. Show mother how to warm bottle without overheating milk and to test temperature of milk on wrist without put- ting nipple to her own lips. Encourage her to hold baby in her arms when feeding. Teach her the sig- nificance of increased weight, crying, stools and urine. Summer Diarrhoea. Stop all food. Give boiled water until further orders. All diapers should be placed in a 2 per cent cresol solution, then rinsed in cold water and boiled. Saline Flushing. Normal salt solution, one dram to a pint, at temperature of 100 degrees. Quantity 0 unless otherwise ordered. Protect table with blanket and news- papers, and use newspaper if no oilcloth is obtainable for an improvised Kelly pad. FLIES, INSECTS, VERMIN, ETC. Fly Breeding Places (manure heaps, loose garbage and very dirty yards and alleys) should be reported to the Health Department. Mosquito netting for windows will be provided at the discretion of the Supervisor. The netting should be tacked across windows on the outside of the house. In- side netting is often in the way and too easily torn off by children or impatient adults. 66 Visiting Nurse Manual Hot Weather Treatment. Teach the family to cover bed with mosquito netting. The following methods are practical ' for district use: 1. Gather round an ordinary barrel hoop five or six widths of green mosquito netting, stitched together along the sides. Cover hoop with the same material and suspend frame thus made from hook in the ceiling over the center of the bed. The strips of netting should be long enough to be tucked loosely under the mattress on all four sides of the bed and full enough so that no unnecessary strain is brought upon its seams. This makes a tent-like canopy that gives the patient a sense of air and space, and can easily be pushed aside during treatment. 2. Half hoops may be securely fastened to the head and foot of a small bed and supported by a rod or stout cord passed from the center of one hoop to the center of the other. Green mosquito netting may be draped over this frame and tucked in on all four sides of the bed. This net can be lifted to one side when any treat- ment is given. These bed canopies should not take the place of window screens, but in congested homes where the screening is improperly done and people are con- stantly passing through the rooms they will afford secondary protection to an adult or very sick child. Baby carriages should be covered with a canopy of double-width mosquito netting, made with a running string or elastic in hem. Teach each family that flies, mosquitoes, rats, mice and other house vermin are disease carriers, often at- tracted by uncleanliness of person, house or surround- ings. Enlist their help in keeping a neighborhood as clean as possible. House Vermin (Cock Roaches, Bed Bugs). A house overrun with these should be reported to the Health Department. When they are comparatively few, teach the family the value of clean sinks, pantries and bed rooms. Have them purchase roach powder for the kitchen and gasoline for bed and cracks in bed room moulding and floor. See that every precaution is taken 67 Flies, Insects, Vermin, Etc. in using either powder or gasoline. Emphasize the danger of fire in the use of the latter. Where there are tiny children, instruct mother to use powder late at night and to wipe it up carefully in the early morning. In nursing infectious diseases, especially typhoid and tuberculosis, every possible precaution should be taken to keep flies, mosquitoes and other vermin out of the sick room. Never have gasoline used unless the patient is in another room. When the patient is in infested bed and no other bed is available, use a hot lysol solution, strength 1-20, and apply this to bedstead, corners of mattress, etc. Repeated cleansing of bed in this man- ner will aid in eliminating the above condition. Home- made apparatus (bed rests and tables) should be in- spected daily. Wheel chairs should be inspected fre- quently and occasionally washed with lysol solution. When bed, bedding, chairs and garments seem to be infested, the whole room should be thoroughly sealed and fumigated with sulphur. (Sulphur is a good in- secticide, but a poor germicide — Rosenaw.) After a sulphur fumigation the room should be thoroughly cleaned and inspected before anyone, sick or well, is allowed to sleep in it. This can be done by family if well instructed. If the vermin is confined to one room and the family willing to do the work well, the condition need not be reported to the Health Department. Rooms of chronic patients, if neglected for any length of time, furnish breeding places for all sorts of vermin. INSURANCE AND INDUSTRIAL NURSING The general visiting nurses give care to the industrial policy holders of the Metropolitan Life Insurance Com- pany, to the members of the Royal Arcanum Hospital Fund and to employes whose firms desire to pay for the services of the Association. A visiting nurse calling on any of the above beneficiaries should explain at whose request and expense she has come. No service money is ever asked or accepted from these patients. 68 Visiting Nurse Manual Metropolitan Life Insurance Nursing Service. When making a first call on a policy holder, ask to see the policy to secure or verify the policy number and date of issue, and to assure yourself that the insured is entitled to the company's nursing service. If the patient is carrying more than one policy, take number and information from any industrial policy more than one year old. All industrial policy holders, with the two following exceptions, are entitled to a certain amount of nursing service. Exceptions. 1. Pregnant and lying-in women whose policies are less than one year old. 2. Holders of policies on which policy number is followed by letter “A” (indicating ordinary life); by letter “C” (indicating Intermediate); by letters “SC” (indicating Special Class). All policies of the various assumed companies (desig- nated by the other letters than the above after the policy numbers) are industrial and entitled to nursing care. All paid-up industrial policy holders 75 years old and older are entitled to nursing service. Physician. No case may be carried for more than one visit unless there is a physician in attendance. Number of Visits. The number of visits and amount of nursing care up to the twenty-fifth visit is left to the judgment and discretion of the nurse in all but maternity cases. Normal maternity cases whose policies have been in force more than one year may receive nursing care at the expense of the company. When a maternity patient requires more than eight post-natal visits, the reason for the need should be stated on the card. Cases of complicated pregnancy (albuminuria, placenta praevia, prolonged vomiting, etc.) may receive as many visits as the gravity of the situation indicates. (As the com- Insurance and Industrial Nursing 69 pany pays for no visits to uninsured persons, new-born babies are cared for at the expense of the Association or of their parents, as conditions warrant.) Never make unnecessary calls because the patient desires to see you for some trivial reason. If postal cards are sent too frequently, make the one visit indi- cated and dismiss the case. Number of Patients in Family. If you find several patients in one household, all insured and suffering from the same disease, but in need of advice rather than of actual nursing service, make out one report card for each patient. Make the instructions of your first call include each patient, specially, but when making additional instruct- ive visits to that household, record them as visits to one patient, rather than as several visits to several patients in the same family at one time. As the pa- tients recover and are dismissed, all but one case will have received two visits, one when each case was opened and one when the cases were dismissed, all intervening instructive visits should be made and re- corded as being made to but one patient. On the other hand, if you find several patients in one household requiring personal nursing service, make out a report card for each patient and record the necessary nursing visits. For example: Six ambulatory cases of whooping cough might require weekly visits for five weeks. On the card of the first patient should be re- corded five instructive visits; on the cards of the other five children should be recorded two visits each. Patient suffering from scabies, pediculosis, la grippe, measles, pneumonia or any other disease requiring individual nursing service should each receive a personal visit as frequently as condition warrants. An interested nurse will always include every needy member of a family in her instructions, whether she is especially paid to do this or not; therefore, instruct some responsible person in each household in whatever details are necessary to restore any member to better health. 70 Visiting Nurse Manual New Case. A new case is one never on the books before or one dismissed in a previous month or year. Reopened Case. A reopened case is one dismissed during the current month and reopened during that same month as again in need of care. If, however, a case is dismissed on the 23rd and taken again on the 26th, it should be classed as a new case and the usual procedure with new cases followed, as our fiscal month begins on the 26th. Closed Case. A closed case means a dismissed pa- tient whether closed a week or a year ago. Records. The following records are required: 1. Mailing card (postal) or report card. Postals are supplied to policy holders and mailed by them when nursing service is needed in their household. Report cards are similar forms but are filled out by nurse for patients found in district, telephoned in or referred by other agencies. Information is identical on both forms and if correct the following items should be red-checked by nurse mak- ing first visit: name, age and policy number. Each item red-checked by nurse making first visit indicates that it has been verified by visiting nurse. It is just as important that a nurse should red-check these three items on a report slip written by herself as it is that she should red-check the items on a mailing card written by a patient or an agent. This is of particular im- portance when postal is badly written. It is better to rewrite the postal card if it is very illegibly written. Whenever a card is rewritten, clip old and new cards together and turn in both forms. Always verify carefully: 1. Name. (For difficult foreign names, ask someone to spell or write names several times if necessary. Print first letter of surname.) If patient is a woman who has been married since taking out her policy, write married surname first; follow this with the maiden name as it appears on the face of the policy (e. g., for Mrs. Henry Smith, write Smith, Sarah Jones). Insurance and Industrial Nursing 71 Address. Do not abbreviate name of street. Age next birthday (calculate from face of policy). Sex. Write word “male” or “female.” Color. Write word “white” or “colored.” Physician. Give initials and office address. (Do not write “Brown,” “corner State and Madison.”) Case Number is assigned each new case taken on during year, is added to card at Main Office and used on every form written for this patient until case is dismissed. It is re-assigned to any patient dismissed and taken on during same month; and should be entered opposite patient’s name on time book of district. All open report cards must be turned in to Super- visors on the morning of the 26th. If report card is being held for Superintendent or Agent’s 0. K., this must be reported to Supervisor on morning of 26th. No mailing card or report slip should be sent to the Main Office for any reopened case or for any case being visited. (Occasionally a parent or an agent believes that a carried case should be visited oftener than the nurse deems necessary, hence, the receipt of mailing cards on open cases.) Policy Number should be taken by nurse from face of policy. It should be copied carefully and twice verified. If policy has been wet and number is blurred or ob- scure, write what seems to be the correct number and at foot of card make note of figures that are difficult to decipher. If family is unwilling to display policy, explain importance of getting correct number for your report. (Simple people are often suspicious and think that the nurse wants to take the policy away or change its value. Tell such people that verification is needed to show that only policy holders are receiving the benefits of this nursing service; that number in agent’s receipt book is occasionally incorrect; that nothing is deducted from the policy when care is given, and, last, that you cannot return unless you see the policy number yourself. Each case may require different handling, but a tactful nurse generally wins her point.) 72 Visiting Nurse Manual If policy is not in home and family say it is in another city, in a safety deposit vault or with a relative, make note to this effect on card and return it to the Metro- politan Life office for the Superintendent's or Agent's O. K. Never red-check a policy number or any item on a mailing card or report slip unless you personally have verified it. Kind of Policy. Industrial only. Date of issue — take from face of policy. Birthplace of policy holder, not of parent. District — means Metropolitan Life district, of which there are twelve in Chicago: (Chicago North, Chicago South, Englewood, Oakland, Dearborn, Humboldt, Lake View, Calumet, Roseland, Chicago, Garfield and North Shore.) Agent and debit number are both helpful facts in tracing incorrect policy numbers, but are required when policy number has to be 0. K.'d by agent who collects the premium. After card is properly filled and every item is red- checked, write words “first visit" with date, and sign your name along left end of card (e. g., First visit, 2-3-14, H. L. White). Then clip card to daily report and turn in. These cards are mailed to Registrar in Main Office and by her to New York office of the Metro- politan Life Insurance Company. (All incorrect cards are returned to Chicago for corrections and the time of at least eight people wasted if this is rendered neces- sary.) Delayed Cards. If a report slip is more than three days in getting to the Main Office, reasons for the delay should accompany the card. History Cards. On receipt of the mailing card, the Registrar assigns it a case number, transfers all in- formation on it to a patient's history card and mails postal to New' York. This history card is then mailed to the substations and kept on file until the patient is dismissed. Insurance and Industrial Nursing 73 At the end of the month all open cases should be sent to the Main Office with the monthly report. In “Treatments” space on each card should be noted the month and number of visits (e. g., June 6). N. B. Never change the number of visits recorded for a former month. If you discover a mistake, consult the Registrar before taking any action. When patient is discharged, the date of last visit, condition on dis- charge and total number of visits should be carefully recorded. The data asked on the history card is important. Every item should be filled in correctly. If you cannot obtain certain items, give reasons at foot of card or in special note. Occupation. If patient is not working, give last occu- pation. Diagnosis. In writing diagnosis on history: cards, put the diagnosis in the proper space. All explanatory notes as to cause, condition, symptoms, refusal of doctor to give give better diagnosis, should be put in the remark space. Do not insert more information in either the “Diagnosis” or “Complication” space than can be written legibly. Do not make the mistake of putting in a complication such as dropsy, gangrene, infection, etc., as a diagnosis. If a medical diagnosis is given and surgical treatment ordered, explain why (in re- marks space), if bed sore, vaccination, local infection, etc., make surgical treatment necessary. If no diagnosis can be obtained for a patient visited but two or three times, state symptoms. No patient should be carried indefinitely unless a diagnosis has been made by attending physician. Diagnosis of Open Cases. All open cases reported at close of month must state symptoms if no diagnosis has been made. The only exception to this rule is when the patient is dismissed after one call. If the patient is not found at home by the nurse or for obvious reasons does not need further nursing care or invests gation, the symptoms may be omitted from the card. 74 Visiting Nurse Manual Number of Visits should be filled in only when patient is dismissed. Give total number of visits, not number month by mpnth. Treatment. Treatment is to be given for every pa- tient visited more than twice. If “advised,” specify nature of advice. Whenever remarks pertinent to the case require more space than is allotted on mailing or history cards in “Remarks” space, a note should always be clipped to card. Partial History or Twenty-five Visit Card (yellow slip) should be filled in detail and sent to Main Office immediately after the twenty-fifth visit to patient. In order to send card in promptly, the attending physician should be asked before the twenty-fifth visit how much longer he deems nursing care necessary. In writing this, be careful to denote frequency as well as length of service estimated (daily visits for one week, bi- weekly visits for three months, etc.). These partial history cards are sent to New York and the usual care may be given the patient until further instructions are sent out by the Registrar. Home condition is asked on all open cases; designate this by use of terms “Good,” “Fair” or “Bad.” (In inspecting for this, differentiate between condi- tions under tenants’ control and those controlled by owner of property.) Good — Plumbing in order, adequate light and air, clean walls and ceilings. House dry and in good repair. Halls and stairways light and ventilated. Three hundred cubic feet of air per occupant. Fair — Rooms clean, plumbing in order, every room ven- tilated from outside, light enabling one to read ordinary print in daytime without artificial light. Disorder due to bad housekeeping rather than to landlord’s neglect. Bad — Damp, dark, no or poor ventilation, requiring arti- ficial light during day. Walls and ceiling very dirty. Rooms in poor repair. Plumbing out of order (toilet not flushing, faucet dripping, wood- work around pipes decayed, pipes leaking, vaults). Bad household management. Insurance and Industrial Nursing 75 Never make erasures on or copies of history cards. Send original card with corrections on other paper to Registrar. Do not take for granted that the Registrar or New York will understand any omissions. Write all necessary explanations plainly. Industrial Nursing. Term used to designate work done at shops or in the home for workers whose em- ployers bear the expense of the nursing service. In- dustrial nursing may be done by a nurse who devotes her whole time to the employes of one establishment or by the district nurse who makes occasional visits at the request of a firm. Industrial nurses (full time) arrange their work to best advantage in each district. As a rule, the nurse reports at 11:30 a. m. and until 1:00 or 1:30 holds dispensary or office hours for con- sultations and minor dressings. Physicians. All medical and surgical work done in the homes or at plants is done under a physician's orders. If the plant has no resident or attending physi- cian, all p. r. n. dressings and medication (iodine, boric dressings, aromatic spirits of ammonia, cathartics, etc.) should be given in accordance with the standing orders of a physician authorized by the firm. This cannot be too carefully followed. Plant dressings and medica- tions, however, are only a part of the work. Many employes come for advice concerning their teeth, eyes, throats or general condition, and need to be referred to other agencies (hospitals, dispensaries, etc.) for aid. Before referring such patients, get in touch with the physician or agency from whom they have been receiv- ing advice. Whenever an employe or his family requires aid (medical or material), report case to firm representa- tive before asking aid of a relief society, a hospital, etc. Dismissed Cases. Patients in need of further care to whom, for any reason, the industrial nurse may not return, should be dismissed to the general visiting nurses. Reports. Each industrial nurse keeps a time book and renders a monthly statistical report to the Asso- ciation, a duplicate of which is mailed to the firm. A 76 Visiting Nurse Manual written statement giving the amount and kind of work done during the month is also sent to the Main Office, In addition, each nurse keeps on file certain printed records for each patient, which are usually required by the firm. A daily report (written or verbal) is given the physician or other representative of the firm. New Calls are received from physician, foremen, superintendent, other employes. The type of home work depends on the desires of the firm. If the nurse is able to care only for the patient, rather than for any member of his family, others requiring care should be referred to the general nurses. Certain forms of benefit associations and group insurance give nursing service only to the beneficiaries. In these instances industrial nurses should work very closely with other local public health nurses. Welfare Work is a much abused term. Anything which increases an employe’s efficiency is a decided asset to both force and firm. To ensure freedom from mental or physical suffering is relief wisely administered. Industrial nurses should understand initial symptoms of occupational diseases, sanitation of factories and mills, and all first aid treatment. In addition, the methods of loan sharks, of garnisheeing wages, of pur- chase on installment basis and of cashing checks or granting credit to working men should be studied. A great deal of worry and subsequent ill health can be avoided if the nurse is a friendly adviser, as well as an administrator of minor remedies. Industrial nurses should be careful to give relief (advise, drugs or aid) wisely. Workers should be encouraged to remain independent, to aim at good standards and regular habits. A girl constantly asking for headache powders needs a careful physical exam- ination; a man always losing a little time needs more than advise regarding his diet and sleep or smoking. A nurse whose duties involve less nursing and more so-called welfare work is under a greater obligation to study each case carefully and to advise constructively. The first material aid given a working man may help him retain his independence or lose it. SUBSTATION DETAIL. Hours, 12:30 — 1:30 p. m. Nurses report in person daily, except on half days and when excused by Super- visor. Each nurse not making substation should tele- phone by 1 o'clock for instructions, new calls, etc. If unavoidably detained in her district, a nurse should telephone and not try to make substation after 1:30. If for any reason, the substation cannot be reached by telephone, notify the Main Office. This noon hour is used for clerical work, telephoning, conferences with Supervisor, receiving new calls, read- ing bulletin board, replenishing bag supplies, etc. Half Day. Every nurse is given one half day each week. This is assigned by the Supervisor, but may be given on Monday and Saturday only by special request. No new calls are assigned to nurses on half days, but old calls (except in twice-daily cases) must be made before the district is left. When the work permits, the half day begins at 1 o'clock. The usual daily report should be written and turned in for all Sunday work in the districts. Supplies. All bag supplies are kept at the substa- tions. Before taking fresh linen (bags, linings, towels, etc.), turn in soiled linen for laundry. Always scrub up before handling fresh linen, gauze or cotton. Never carry partly filled bottles of lysol, alcohol, etc., for emergencies in district work must be anticipated. Do not carry more drugs or other odds and ends than you are using. Avoid letting your bag become a catch-all. Old Linen may sometimes be obtained at the sub- stations. Use this economically and wherever possible, interest your friends in collecting this for you. Nothing so enables you to make a chronic patient with painful 78 Visiting Nurse Manual dressings comfortable, but so much is being used con- stantly that we must never lose a chance to ask for it. Sheets, pillow slips, table linen and nightgowns are especially serviceable. Clothing. Occasionally clothing for men, women and children is sent into the substation. These articles should be given wherever they will do the most good, but never give so frequently to the same family that its members will begin to expect clothing from the visiting nurse. Our relief giving is incidental. We give away old clothing simply because it is given us and we know a family in need at that particular moment. Always explain in giving clothing how you happen to have that especial outfit to give away. Loan Closets and Loan Book. Loan closets contain articles needed during illness in many of our homes and may be loaned to any reliable family. If you have reason to believe that the articles will be pawned or misused, don’t loan them. When promising loan closet supplies, leave written instructions of substation, ad- dress and hours, and arrange to have someone (family or neighbor) call at noon to get them. Every article loaned should be recorded in loan book, dated and signed by nurse making entry. Every nurse lending supplies is responsible for their return and should record them, with correct date, over her signature in the loan book kept at the substation for this purpose. When articles are returned, date and condition should be entered on same page. This book is inspected monthly by the Supervisor and an accounting asked of all articles. Whenever a nurse is assigned to a new district she should go through the loan book to see how many arti- cles are loaned in that district. Loan closet supplies include Linen — Sheets, pillow cases, contagious gowns and caps, nightgowns. Rubber Goods — Rings, draw sheets, ice caps, hot water bags. Utensils — Bed pans, urinals, douche pans. Wheel chairs. Substation Detail 79 Linen loaned to patients may be returned rough dried, but should always be clean. It should be sent to the laundry before being returned to the shelves. Rubber goods should be sterilized and cleansed thor- oughly. Wheel chairs need not be returned to the substation, but may be sent from one house to another as soon as the first patient is through with it. Blankets are sometimes loaned to patients, but their return is seldom or never asked. If returned, they should be sent to a laundry or to a dry cleaning estab- lishment. Dressing jackets, slippers, etc., are given if we have them on hand. CLERICAL WORK. Bulletin Board. All changes in district, class and other announcements are posted on a bulletin board in each substation. Every communication from the Main Office marked “Bulletin” should be signed by initials of each nurse reading it. The bulletin board should be read daily by every nurse in the substation. All im- portant notices are posted there. Permanent notices are also pasted in substation bulletin scrapbook. Call Book. A large note book in which the names and addresses of all new patients telephoned into the substation are written daily. The number of the dis- trict in which each patient lives is plainly marked in the right-hand column. Each nurse is expected to take her own calls from this book before leaving for her afternoon work. When taking the calls, sign initials to each call in checking space, thus -indicating that you have copied it into your own book, and then sign your name at the bottom of the page. The call-book is also the daily register of nurses’ at- tendance at the sub-station. Daily Report should be written at home and given daily to Supervisor after necessary items have been transferred from it to time book and records. Hours 80 Visiting Nurse Manual on duty should be correctly reported (i. e., 8:00-5:00, 8:30-7:30, 8:30-1:00, 8:30-4:30, etc.). This report should be written briefly, but every item asked is important and should be recorded when pos- sible. Names of streets should not be abbreviated. Service Money (fees from patients) may be given Supervisor with daily report. Amount, date received and number of district should accompany money. Never credit money on a daily report unless it has been received from patient. Page-a-Day Book is intended for convenience of each nurse, may be written in pencil and destroyed at the end of the year. It is particularly useful for record of future appointments for and with patients. Time Book is a calendar record of patients seen and calls made monthly. It is kept by the nurse in the district and serves as an address book, a guide to the need of each patient for frequent or infrequent visits, and a basis for the monthly statistical report. The district boundaries and rules for keeping time book are plainly marked on the cover of each. Upon the accuracy of every time book depends the value of the annual statistics compiled to show the work and growth of our Association, hence the importance of the slightest detail noted in this book. Name and address of every patient visited (even those not found) should be entered in the time books. Calls should be entered under proper date. Time book should be written daily, the calls being entered from the written daily report. Patients Forwarded, Transferred, Dismissed, Etc. All cases carried in time book for more than one visit require diagnosis and physician’s name. Every forwarded case must be visited monthly. Names and addresses of all patients to be dismissed to other public health nurses (tuberculosis, school, etc.) should be handed in writing to the Supervisor. Clerical Work 81 Patients transferred from other districts should be entered in time books as new or old, as date indicates. The total calls made in the first district should be trans- ferred with patient, in order that the total number of calls to each patient may be forwarded with name of patient. The calls made during- current month should be credited to the district in which they were made when monthly reports are being compiled. Thus calls are credited to the district in which they were made. Each district has two time books per year, used alternate months. The one not being carried is sent to Main Office with monthly report, and both are checked by filing clerk. All patients forwarded from one time book to the other are classified as old patients. All patients taken on the books between 8:30 a. m. of the 26th of the month and 5:00 p. m. of the 25th of the following month are new cases. Monthly Report. Our fiscal month closes with the 25th day of each month and each district is expected to submit a statistical total of the work for that period. Our statistics are compiled by districts. One or more nurses may make calls in a district during the month, but all figures are credited to districts, not to nurses. These reports should be given the Supervisors not later than the 28th of each month. If each nurse, in pre- paring this monthly report, is careful to balance the totals properly, a correct report will be submitted. For statistical purposes an incorrect report is as bad as an intentional deception. Patient’s Medical Record is made for every patient visited more than three times. Daily visits, co-opera- tion asked and secured, treatment and condition of patient, should be briefly recorded. Write facts, never opinions, but keep the history of the case in such a way that nurses or other workers using that card later will be able to render better service to each family because of your help. Confidential. No record card nor time book should ever be shown in a patient’s home. Make notes of 82 Visiting Nurse Manual figures, dates, etc., in page-a-day book and transfer to records m substations. All information regarding cases is conridential and our records are not open to inspection unless the patient may be directly benefited by this exchange of information. Commercial houses, money lenders, etc., are never allowed to consult our records, buch inquiries should always be referred to the Main Office. When dismissing, review case mentally and make sure that your work is completed. Don't waste your care and effort by dismissing a convalescent too soon or by neglecting to place family under supervision of the proper agency. Results, not numbers of visits or patients, are all that count in our work. Relief Nurses. A relief nurse is any nurse making calls in other districts. A nurse on full time relief worK maKes any calls assigned to her, but a nurse in a regular district frequently makes one or two after- noon renei calls to help out busier districts or to supply for a half day. A relief nurse calling on old patients should write a report of the work done in each district entered and give it to the regular nurse the following noon. If any unusual condition is found, she should report that evening to the regular nurse. A relief nurse making a new call is responsible for the “new patient data” (name, address, sex, age, occu- pation, doctor, diagnosis and by whom referred), the M. L. report card data, a telephoned report to the regu- lar nurse that evening, and a written report the fol- lowing noon. A relief nurse should know the home telephone of every nurse for whom she makes calls. A relief nurse is responsible for the new calls in the district in which she relieves during the regular nurse's half day. First impressions are just as lasting in district homes as in any other and a relief nurse should be as pains- taking and attentive in another district as she would be in her own. Clerical Work 83 A relief nurse should never dismiss a new patient except to an institution. When a first call has been made by a relief nurse, the regular nurse should see the patient within forty-eight hours. Transfer. A nurse transferred to another district should give her time book to her Supervisor and should arrange to receive the calls in her new district before the next morning. FAMILY BUDGET, By Florence Nesbitt, Field Supervisor, Funds to Parents’ Department, Juvenile Court of Cook County. Normal Standard of Living. An income of at least $75.00 per month is necessary to maintain a standard of living which will insure the health, efficiency and moral welfare of a family con- sisting of father, mother and three children of school age. The income in such a family should be divided among the different items of expense about as follows: Monthly Budget. 1 Rent $12.00 2 Food 29.00 3 Fuel, light and ice 5.00 4 Household expenses 1.00 5 Clothing and personal expenses 13.00 6 Carfare 2.50 7 Insurance 2.00 8 Furniture 2.50 9 Education 1.00 10 Care of health (including dental work) 4.00 11 Recreation ’ 2.00 12 Emergencies 1.00 Total $75.00 Adjustment of Lower Incomes. A family will remain self-supporting, however, on an income considerably below this by leaving uncared for the last four items on the budget, or by relying for them upon public agencies or private philanthropy. When the income is insufficient to cover adequately the first eight items on the budget the standard is necessarily lowered until it can no longer be considered Family Budget 85 normal. The furniture is left unrepaired, the clothing becomes insufficient or is provided by gifts, ice is dis- pensed with, fuel is gathered from neighboring railroad tracks or torn-down buildings. Food becomes mono- tonous in kind and barely sufficient in quantity to meet the fuel requirement, and rent is reduced by living in unwholesome quarters. By any or all of these means the struggle to maintain family unity and self-respect may be prolonged. By careful consideration of the income and the needs of the family, a nurse will be able to determine when gifts or relief are necessary and desirable. She will also be able to give intelligent advice to the housewife to help her guard against a disproportionately large expenditure for any of the items of the budget. Many mothers are failing to give their children the food nec- essary for proper growth and development in order that a rent which their income does not warrant can be paid, or that a home may be bought. Percentage of Income Allowable for Rent. The budget above allows 16 per cent of the income to be paid for rent and a higher proportion is seldom advisable in families belonging to the low income groups. When the income falls below the amount nec- essary to cover adequately the first six items of the budget, the rent is the safest item to reduce, pro- vided that light, clean rooms of sufficient size for the family can be secured at a lower price in a neighbor- hood which furnishes good advantages for the work of the bread-winner and for the development of the children. Amount Necessary for Food. The housewife can make a reduced allowance for food cover an adequate, well-balanced diet for her family only by the most careful and intelligent management. The problem of doing this would prove too much for many graduates of schools of domestic science, yet it is constantly forced upon women who not only are ignorant of food values, principles of economical buy- ing and sanitary science, but who also are untrained 86 Visiting Nurse Manual in methodical habits of thought and action. Moreover, their failure to solve it means disease, weakness and inefficiency for the families for whom they are respon- sible. As it is primarily a question of health, advice comes most naturally from the nurse. Important Things About Food Which Many Mothers Do Not Know Which Visiting Nurses May Teach Her. Coffee, tea and other stimulants stunt the growth of children, pervert their taste and, w T hen used in excess, may cause cardiac and nephritis complications. Food habits of children are what the mother makes them, and the forming of these habits is a serious and most important part of her work. By keeping from them stimulants, highly flavored foods and excess of sweets they may be led to like cereals, milk, eggs, vegetables and fruit, which should form the basis of every child’s diet. Breakfast is a very important meal for school chil- dren. Coffee with rolls and cake is insufficient in quan- tity and unsuitable in kind. Well cooked cereal and milk should form part of the meal. Monotony of Diet leads to anaemia, undergrowth, lack of energy, and resistance through the failure to provide proper nourishment to the body. To correct this, use whatever vegetables are in season and reasonable in price, and as much fruit as can be afforded. Immigrant parents do not understand our various foods, fruits and vegetables. They should be taught and coaxed to try other food preparations. Strong American citizens cannot be raised on a Southern Euro- pean diet given in a northern city, nor does our climate call for or tolerate a high proteid diet such as English- men eat constantly. COMPOSITION OF A CHEAP DIETARY Cereals (oatmeal, cornmeal, rice, including bread- stuffs) must furnish a large proportion of the food in a Family Budget 87 cheap dietary, as they are the foods which give the greatest amount of food value in proportion to the cost. They should be used in as large a variety as possible to avoid monotony of diet. Most of the large grocery stores keep several kinds of cereals in bulk, in clean, well-covered receptacles, and sell them at a much lower cost than the same cereal in packages. A half dozen or more equally valuable legumes can be found at most of these stores, and should be used instead of always using navy beans. The cheaper cuts of meat must be used and these contain, on the average, as much nourishment as the more expensive ones. Flavor can be developed in these meats and tenderness secured by proper cooking. To give variety to the diet and secure mineral bal- ance, fruits and vegetables are necessary. Whatever articles are cheapest at the time must be used. Often dried fruits or root vegetables (beets, carrots, turnips) must be substituted for fresh. These can be found in considerable variety at large stores. ECONOMY IN SELECTION OF FOOD MATERIALS Among the foods which command a high price in pro- portion to their value are: 1. Prepared Foods. (a) Cooked Foods. For example, bakery bread, buns, cakes, pies, etc., cost from two to three time,s as much, exclusive of cost of fuel, as the same quality of food prepared at home. (b) Canned Foods. For example, canned soups, canned baked beans, etc., cost three to six times as much as the raw materials. Canned vegetables cost about twice as much as fresh vegetables, and do not fill the same place in the dietary. For instance, use fresh beets or carrots instead of canned corn or peas. (c) Prepared Cereals. Prepared cereals cost three to five times as much as the same food material purchased 88 Visiting Nurse Manual raw in bulk. For example, cornflakes cost about four times as much as its nutritive equivalent of cornmeal. 2. Foods Out of Season. When foods out of season are bought, the cost of artificial production or of cold storage preservation must usually be paid; therefore, in late spring, apples will cost two to three times as much as fresh rhubarb. In winter, lettuce will cost three to six times as much as turnips. 3. Foods valued for flavor are expensive in propor- tion to their food vaiue. For example, fowl cost one and one-half to three times as much as its nutritive equivalent of beef or mutton. Butter costs almost twice as much as oleomargerine, whose food value is a little higher. 4. Imported Foods. When imported foods are bought, the cost of importation must be paid by the purchaser; therefore, Italian macaroni costs one and one-fourth times as much as the best American brand and imported legumes about twice as much as native ones. Imported cheeses cost one and one-half to three times as much as American and are only slightly higher in food value. Foreign people would profit greatly by learning to use the food materials of their adopted country. A fireless cooker can be made for 50 cents or less of a butter tub, with asbestos, crushed paper and a covered pail. Every family should be taught to prepare cereals, slow-cooking vegetables and meats in a cooker. This will save much in fuel. INDEX (Wherever a first page only is given.) Accidents Aged, care of Antidotes, poison...... Baby. See Infant. Breast-feeding 42 Burns 16, 46 Calls 8, 76 Cases 39, 70, 75 Children 37, 62 Chronics 61 Clerical work 79 Communicable diseases..34, 49 Contagious nursing 34, 49 Convalescent homes 37 Co-operating agencies 25 Coroner 28, 31 County agent 31, 32, 34, 38 County physicians 34 Death 31 Diagnosis 18, 73 Diet 55, 59, 86 Disinfection 52, 56 Dismissed cases 39, 75 Dispensaries 29, 36 District 9 Dressings 43 Ears 17, 48 Emergencies 28 — housing 32 — medical 28 —relief ; 32 Eviction 32 Eyes 47 Family, instruction of 22 Family budget 84 Family physician 15 Fees and gifts 23 Food 32, 85 Free medical service 33 General instructions 8 Gifts 23 Health Department 31, 32, 34, 38, 49, 52 Home conditions 74 Hospital service 34 Housing emergencies 32 Illinois Society for Mental Hygiene 38 Industrial nursing 75 Infant Welfare Society 38 Infants, nursing of....l6, 42, 64 Infectious diseases 16 Insurance and industrial nursing 67 Loan closet 78 Maternities 17, 29, 39, 68 Medical nursing 49 Medical relief 24 Metropolitan Life Insurance Nursing Service 23, 68 Mid wives 42 Muni c i p al Tuberculosis Sanitarium 35 New calls 10, 76 New cases 70 Nursing, — care 19 — contagious 34, 49 — medical 49 — of children 62 — of chronics 61 — on infants 64 — surgical 43 Nurses, —relief 82 —special 24 Obstretics. See Maternities. Ophthalmia neonatorum 48 Physicians 15, 33, 68, 75 Poisons 30, 44 Pregnancy. See Maternities. Private hospitals 35 Private physicians 15 reference runs over more than one page, the 28 61 30 Visiting Nurse Manual 90 Records 70 Registration 26 Relief 24, 60 — emergencies 32 — medical 24 — nurses 82 Reports 75, 79, 81 Sanitariums 35 Special nurses 24 Standard of living 84 Standing orders 15 Sterilization 52 Substation detail 77 Summer outings 38 Supplies Surgical nursing.... ....12, 45, 77 42 Teeth Thermometers .... Tuberculosis 20 14 35, 56 Uniforms 12 Ventilation 21 Vermin 66 Visiting Nurse Association, object of 7 Welfare work 76