'•mi '"•i;; % Principles of Surgical Nursing A Guide to Modern Surgical Technic By Frederick C. Warnshuis, M. D., F. A. C. S. Visiting Surgeon, Butterworth Hospital, Grand Rapids, Michigan Chief Surgeon, Pere Marquette Railway Secretary of the Michigan State Medical Society] Editor of the Journal Michigan State Medical Society Member of the Michigan State Board of Registration in Medicine With 255 Illustrations 1X1 il' A MAR 19 19 Philadelphia and London W. B. Saunders Company 1918 99 7xO Copyright, 1918, by W. B. Saunders Company PRINTED IN AMERICA TO THE SUPERINTENDENTS AND GRADUATE NURSES OF BUTTERWORTH HOSPITAL THE AUTHOR UTILIZES THIS MEANS OF EXPRESSING HIS APPRECIATION FOR THEIR COOPERATIVE EFFORT IN HIS WORK IN THAT INSTITUTION Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/principlesofsurgOOwarn PREFACE In presenting this volume to the nursing and hospital world, I do so with some trepidation. I am not so fatuous as to believe I am imparting information to such a degree as will enable the student or graduate nurse to gain possession of all that is requisite for a nurse engaged in surgical nursing. The foremost thought has been to impart essential basic principles that will enable a nurse to acquire a reliable fundamental knowledge. Possessed of facts and conversant with their administrative principles, the attainment of perfection will be readily acquired by con- scientious work, enlarged experience, collateral reading, and study. With but one or two exceptions I have purposely omitted all discus- sion of the literature devoted to surgical nursing. The subject matter may in places reflect previous expressions and opinions, but upon the whole the text is based upon the author's personal conclusions and experiences, and the views that have been acquired by perusal of the surgical literature which has appeared from time to time in current literature and proven satisfactory in our operative work. Throughout the presentation of this entire subject my endeavor has been to impart facts briefly and concisely, so that the instruction would not be lost in a maze of descriptive and lengthy text. Unusual, obsolete, and unimportant methods have been purposely omitted in an effort to present the primary and pertinent points. The sole purpose has been to describe recognized principles of technic, accepted plans of procedure and treatment as they exist in present-day practice of surgery and surgical nursing. To advance all the viewpoints and methods of surgeons and instructors of nurses would be impracticable. Instead, I have endeavored to present practical methods that would be applicable in the majority of instances. 12 PREFACE These explanations are not offered as apologies or to refute possible and probably justifiable criticism. They are recorded that the reader may understand the policy and plan pursued. In addition to the text I have resorted to illustrative features planned not only to elucidate the text but to serve as teaching illustrations. In their preparation studious attention has been given to their detailed features. I am indebted to the photographic artist, my hospital and nurse friends, and to my editorial assistants for their valuable aid in producing the illustrations, indexing, correction of manuscript, and proof reading. To the reader and student, I express the hope that this volume will serve two purposes : First, the presentation of guiding principles of surgical nursing technic of today; second, to stimulate a desire for further knowl- edge of the subject, thereby inducing the nurse to devote a little time each day to research and study. By so doing, she will increase her ability as a necessary and potent factor in the surgical clinic. The capable, de- pendable surgical nurse receives the esteem, commendation, and trust of both surgeon and patient. FREDERICK C. WARNSHUIS. Grand Rapids, Michigan, February, 1918. CONTENTS CHAPTER I Page Foreword 17 Surgical Nursing Outline 18 CHAPTER n Preparation OF THE Room AND Its Equipment IN A Private House 20 Utensils . 24 The Final Preparation of the Room — "Setting Up" 26 The Anesthetist's Table 28 Setting-Up 29 Laparotomy Kit 30 Setting Up the Supply Table of Sterile Goods , 30 Solutions and Supplies 32 Instrument Table 33 Dismantling the Room 36 CHAPTER III Methods or Hand Sterilization 38 Preparation of the Hands — Scrubbing Up 41 CHAPTER IV The Preparation oe the Patient 58 General or Constitutional Preparation 58 Schedule of Preoperative Procedure 63 CHAPTER V The Preparation of the Operative Field 64 Draping of the Field 66 Positions on the Table 67 CHAPTER VI Duty OF the Nurse DURING Operation 72 Instruments 79 Sutures and Needles 80 Operative Field 82 Sponges and Packs 82 Drains 84 Dressings 87 13 14 CONTENTS CHAPTER VII Page Post-Operative Nursing DURING First Twenty-four Hours 91 CHAPTER VIII Post-Operative Care in Normal Convalescence during First Twenty-eour Hours . . 108 Flatus no Cathartics in Catheterization 112 Dressings 113 Getting Up 117 CHAPTER IX Post-Operative Emergencies 120 Shock and Hemorrhage 121 Respiratory Failure or Collapse 125 Cardiac Collapse 126 Cardiac Exhaustion of the Second Period 127 Delayed Hemorrhage . . . , 128 Ileus 129 Acute Gastric Dilatation 129 Acute Anuria, Uremia 130 Peritonitis 130 Post-Operative Pneumonia , 131 Exhaustion and Toxic Singultus 131 Persistent Vomiting 131 Phlebitis 133 CHAPTER X The Process or Healing and Care or Wounds 136 Healing by First Intention 136 Healing by Second Intention 137 Healing by Third Intention ' 138 Scars 138 The Care of Wounds 140 Requirements for a Dressing 143 CHAPTER XI Anesthesia 151 Ether 152 Chloroform '. 152 Nitrous Oxide Gas 152 Spinal Anesthesia IS3 Local Anesthesia IS3 CHAPTER XII The Nurse's Chart in Surgical Cases 156 Temperature, Pulse, Respiration 157 CONTENTS 15 Page Bowel and Kidney Excretions 158 Nourishment 162 The Wound 162 Miscellaneous Details 163 CHAPTER XIII Formula 165 Mustard Plaster ; 165 Flaxseed Poultice 165 Mustard Poultice 165 Tincture of lodin 165 Turpentine Stupes 165 Chemical Disinfectants and Antiseptics 165 Methods of Disinfection 167 Temperatures of Water for Baths, Applications, Douches, and Enemas 168 Enemata 168 CHAPTER XIV Preparation of Surgical Materials 171 Making Gauze Dressings 173 Strips 177 CHAPTER XV The Surgeon's Hospital Kit 178 Contents 180 Uses 181 CHAPTER XVI The Plaster-of-Paris Splint . . , 183 CHAPTER XVII Catheterization 198 CHAPTER XVIII Operation for Appendicitis 202 Duties of Nurse in Preparation and during Post-Operative Period 202 Nature of Disease 202 Symptoms of Acute Attack 203 Complications 204 Operative Treatment 204 Nursing Care: Preoperative 204 Operation 207 Post-Operative Care 210 What to Watch for 211 Complications 211 Post-Operative Nursing 214 l6 ^ CONTENTS CHAPTER XIX Page Hospital Methods 217 Surgeon's Face Mask 217 The Morning Bath 219 Bed-making 229 The Slush Bath . 241 Tub Bath in Bed , 248 Hypodermoclysis 252 The Technic of Thyroidectomy 262 Index 269 SURGICAL NURSING CHAPTER I FOREWORD The recovery of a patient undergoing an operation is dependent to a large extent upon the technique that is employed and observed during the entire surgical procedure. It is by reason of the high development of present-day surgical technique that many of the operations now under- taken result in a low mortality, whereas, the same operations a few years ago either produced a high mortality or were not attempted. Further- more, many procedures are now possible which formerly were not to be •considered, because a fatal ending invariably resulted by reason of infection. The perfection of the technique is dependent upon two groups of in- dividuals — the surgeon and his assistants, and the surgical nurses. The training of either group determines the character of the surgical procedure, causing it to be all that it should be or but an inferior and defective sub- stitute. I do not believe that it is necessary to advance a single argument to substantiate the statement that every operation should reveal a rigid observance of modern surgical technique — the chain of asepsis should be kept intact in every hnk. Then, and then only, may we experience the satisfaction of knowing, no matter what the result, that our duty has been faithfully performed. Then, and then only, may we hope or expect to have our efforts attended with end-results that justify present-day statistics. The constantly changing methods of operative interference, occa- sioned by the investigations, studies, and experiments of surgeons, carry with them new refinements and the development of modern surgical principles that must be observed. What was considered essential but a 2 17 1 8 SURGICAL NURSING few months ago, may today be classed as obsolete and cast aside. What a nurse was taught during her days of training, in many instances, may, at present, be discarded. In view of this fact, it is imperative that a nurse keep abreast of the times and put forth such efforts as will enable her to become conversant with the progress being made in surgical technique, that she may apply the approved methods in her daily work. It will be my purpose to impart an understanding and a working knowledge of the guiding principles of present-day surgical nursing. While I realize that, in a measure, they will reflect a personal viewpoint, they will be based on present-day surgical procedures that have proved reliable in the practice of numerous surgeons. In the end, the nurse will, I trust, have gained a clear insight into the progress that is being made and will be enabled to apply any new knowl- edge she may gain so that, no matter how well or indifferently the surgeon may perform his part, she will have the personal satisfaction of knowing that her duties were performed in accordance with accepted principles. SURGICAL NURSING OUTLINE The work that is to be done in preparing for and during an operation — which duty is consigned to the surgical nurse — may be divided into the following stages or steps : I. The Preparation of the Operating Room (a) Selection of the room. (/) Supplies. {b) How to clean it. (g) Instruments. (c) Furniture required. (h) Final preparation. (d) Utensils. (i) Setting up. (e) Solutions. (7) Dismantling after operation. 2. The Preparation and Sterilization of the Hands (a) Consideration of wearing apparel, etc. (d) Precautions. (&) Solutions used in scrubbing. (e) Preparation and wearing of gloves. (c) Methods of scrubbing. (/) Refinement of technique. 3. The Preparation of the Patient (a) Physical or constitutional — general. (b) Local or operative field — the several methods as demanded by the nature of the operation. FOREWORD 19 4. The Surgeon and His Assistants (a) Orders. (e) Service entitled to. (b) Instruments. (/) Nurses' duties during operative work. (c) Scrubbing. (g) Post-operative nursing. (d) Gowns and headpieces. 5. The Operation (a) Positions of patient on the table. (d) Draping the patient. (b) The anesthetic. (e) Duties during the steps cf the operation. (c) The final preparation of the field. 6. Post-operative Nursing A consideration of the duty of the nurse and the things that require her watchfulness and alertness. Surgical chart. 7. Post-operative Emergencies The emergencies that may arise and the treatment that a nurse may institute before the surgeon's ■ arrival. 8. The Care of Operative Wounds A discussion of the course that a wound may take and how it may be best treated. It will be my purpose to develop these steps in the work and duty of a surgical nurse by giving essential details and facts and avoiding all sem- blance of verbosity. Whenever there may be a question of the preferable method, several methods will be given in order that the nurse may be conversant with those most frequently employed. At times, I shall advance the method that my personal inclination may fancy or approve. When advisable, however, the opinions of others will be quoted. In all our discussions I shall endeavor to bear in mind the possible surroundings that may exist and indicate where exceptions may or must be made. With this specific introduction, we dispense with further generalities and devote ourselves to the consideration of the first step. CHAPTER II PREPARATION OF THE ROOM AND ITS EQUIPMENT IN A PRIVATE HOUSE Hospital architects — these speciaHsts in the architect's profession have been called forth by the development of our modern hospital — ^in planning the operating rooms for a new and modern hospital bear in mind, while so doing, that the following essentials are deemed imperative for an operat- ing room: 1. An abundance of light; absence of the sun's glare; preferably, a northern light. 2. A room so located as to be distant from extraneous or distracting noise that may arise from street traffic, adjacent corridors, elevators, and visitors. 3. An abundant supply of pure air, free from dust and admitted without drafts. As these essentials are deemed important in institutional work, secur- ing like surroundings should be accomplished, in so far as possible, when- ever an operation is planned in a private home and a surgical nurse is sent to make these preparations. Therefore, in selecting a room in a home, the nurse must not be unmindful of these requirements. A careful inspection of the residence may often reveal what, at first glance, might have been considered impossible for the satisfactory arrangement of an operating room. The first requirement of an operation in a private home is a room that is distant from the noise of the street traffic and hidden from the idle gaze of inquisitive neighbors. It should have at least two, and preferably three, windows through which the direct sunlight may be excluded and still not deprive the room of sufficient light or prevent proper ventilation. Should the operative work be of such an emergent nature as to necessitate its performance at night, then the natural lighting of the room is to be ignored and attention directed toward securing the best artificial lighting. It is unusual to secure a room so wired as to give a sufficient amount of arti- ficial light, and one's chief consideration should then be a location close to several sockets to which the light cords of surgeon's lamps may be attached. PREPARATION OF THE ROOM AND ITS EQUIPMENT IN A PRIVATE HOUSE 2 I Most surgeons have equipped themselves with portable lights for night work. In homes that are without modern lighting conveniences, surgeon's lamps, which may be attached to the storage batteries of their automobiles or to small dry cells, will undoubtedly accompany the kit that is sent to the patient's home. There is little excuse nowadays for requiring people to hold lamps and candles during an operation. Such practice is relegated to the past. In selecting a room a nurse should always bear in mind what the re- quirements of the operation will be. Many steps may be saved if the room selected is located near a bathroom or water supply and a range or stove. Impossible as it often is to find a room that possesses all these desirable features, one must attempt to select one that has at least a good light and air supply; it should also be of reasonable size, so that the surgeon and his assistants may not be compelled to do the work in cramped quarters. All other features must be sacrificed to these requirements. The room selected, the attention of the nurse will then be directed to its preparation. Its extent will be determined by the time that remains at her disposal, and whether or not the operation for which she is preparing is one of an emergent nature. If twenty-four hours or more are allotted her for this preparation, she will have an abundance of time to accomplish an effective technique. The preparation begins with superintending the removal of all the furniture, pictures, drapes, curtains, and rugs or carpets. The room hav- ing thus been wholly dismantled by members of the family or servants, the nurse should request that the walls and mouldings be cleansed from any dust that may have accumulated upon or behind them, and that the wood- work, windows, and floors be washed with warm water and soap. In brief the room is to be given a most thorough cleaning. The foregoing steps having been performed, it is then that the nurse undertakes the direct work of final preparation. In order that this final preparation may be methodically and effectively worked out, I deem it wise to divide the procedure into seven stages or steps : First Step. — The glass in the windows is to be covered with thin, white 22 SURGICAL NURSING tissue paper held in place with ordinary flour paste. This aids greatly in shutting out any glaring light and serves also to obstruct the view of the room from without. In the event that tissue paper is not available, ordi- nary newspapers may be used. Second Step. — The lower third or half of the window casings are covered Pjq_ j_ — The Arrangement oe a Room eoe. Operation. — {Schematic.) A. Dinino- table arranged for use as an operating table. B. Small table for anesthetist's supplies. C. Table to contain unopened 'sterile supplies. D. Table with sterile supphes — sponges, sutures, and needles. E. Table for instruments. F. Board resting on two chairs to hold scrub basins, soap, brushes, solutions, and pitchers of sterile water, i. Surgeon. 2. Assistant. 3. Anesthetist. 4. Clean nurse. with a freshly laundered white sheet, maintained in place by tacks so driven as not to mar the woodwork. The object of thus draping the win- dow is to permit the lower sash to be partly raised, if necessary, during the operation and yet prevent dust-laden drafts from blowing in upon the sterile supphes, instruments, or operative field. Third Step. — Clean sheets are to be tacked or hung around the walls of the room, reaching from the floor to a height of four or five feet (Fig. 2). PREPARATION OF THE ROOM AND ITS EQUIPMENT IN A PRR'ATE HOUSE 23 Fourth Step. — The floor is to be mopped with a solution of bichlorid of mercury in the strength of i in 500 or with lysol. Fifth Step. — The floor is to be covered with sheets, tacked in a suffi- cient number of places to hold them securely in place and prevent anyone tripping. These sheets are temporarily covered with a loose sheet or Fig. 2. — Room in Private House Arranged tor Operation. The walls are hung with sheets, the tables are draped with sterile sheets, the window prepared by tissue paper pasted over and a sheet tacked over the lower third, the floors are covered with sheets, and the table is padded ready for a folded blanket at the foot and the rubber sheeting and sterile newspapers to prevent soiling the lower sheet while the remaining supplies and needed furniture are being carried in. Sixth Step. — Suitable tables will be required for the patient, the instru- ments, and the supplies. If these are not sent by the surgeon they are to be selected from the furniture in the home. After they have been thor- oughly cleaned, they are wiped off with a cloth wrung out frequently in a 24 ■ SURGICAL NURSING I in 500 solution of bichlorid, carried into the room, and arranged as shown in Fig. i, or according to the operating surgeon's preference. Seventh Step. — The windows should be closed and locked, and the openings between the sash and frame sealed with ordinary surgeon's adhe- sive plaster. A sufficient number of formaldehyde fumigators should be placed in tin pans and lighted, the door closed and locked, and its key- hole and margins sealed with adhesive plaster, thus subjecting the room to a thorough fumigation. The room may then be considered as prepared, and no one should be permitted to enter it until the nurse undertakes the final preparation for the actual operative work. By this method you will secure as ideal an operating room as is possible in a private home. True, it demands a vast amount of work, but this should not be begrudged if it advances the safety of the patient to a higher degree. We admit that in emergencies it will often be impossible to subject a room to such a thorough preparation, and necessity will compel a compromise. In this event, the nurse must be competent to carry out the essentials in so far as the time at her disposal permits. Reasonable security may be attained if, after the furniture is removed, the floor be covered with sheets moistened in a solution of bichlorid of mercury of i in 500 strength. The lower sash of the windows should be covered with sheets dampened in the same antiseptic solution. Time may also be found for a maid to dust the woodwork with a bichlorid moistened cloth. Your individual tact and executive ability will enable you to utilize the needed safeguards in emergency home operations. With the completion of these duties the nurse has still more work to perform before the preparation of the room is complete. These duties are to be performed in another part of the home and pertain to the utensils and water supply that will be demanded for expeditious operative work. UTENSILS In addition to the surgical suppHes, instruments and lighting apparatus, which will be sent by the surgeon in sterile containers from the hospital, certain utensils and water must be provided in a manner replete with surgical thoroughness. These consist of : PREPARATION OF THE ROOM AND ITS EQUIPMENT IN A PRIVATE HOUSE 25 Four hand basins, granite or porcelain, for scrubbing. Two hand basins, granite or porcelain, for hand solutions. Three pitchers for sterile water and saline solutions. Two enamel basins for sterile table for alcohol and saline. Three cups or glasses for alcohol, iodin, and carbolic acid. Ten gallons hot sterile water. Ten gallons cooled sterile water. One foot tub for soiled sponges, used solutions, etc. The hand basins, in fact all the basins, pitchers, cups, or glasses, are to be cleansed, rinsed off, and then boiled in a boiler for at least thirty minutes, after which they are to be submerged in a i in 500 bichlorid solution and permitted to remain there until needed. A suitable storing container for the bichlorid solution may be found in a wooden tub ; do not use a galvanized tub on account of the chemical action of the mercury. The water in which they are boiled may be used to make the bichlorid solution. They may also be left in their original boiler and extra handling avoided. When these utensils are finally needed, they are taken out of their con- tainer by means of a sterile forceps and thoroughly rinsed with sterile water. They are then ready for use but must be handled under all sterile precautions to prevent rendering them unsterile. Sterile Water. — Provision should always be made for an abundance of sterile water. It is secured by boiling for at least thirty minutes. It should be stored in sterile pitchers covered with sterile towels. Just preceding and during the operation there should be a boiler of hot sterile water on the stove. A quantity of cool sterile water should be held in reserve. Saline Solution. — The following method of preparing the saline solu- tion, or normal saline, is in general use : 1. Thoroughly clean a large utensil in which to boil the solution and the pitcher or bottles for storing the solution. 2. Fill this utensil nearly full of water and, after placing the cleaned pitcher or bottles in the utensil, cover, and boil briskly for thirty minutes. 3. While these are boiling add two small teaspoons of table salt to a quart of water and filter the mixture through filter paper or absorbent cotton. 26 SURGICAL NURSING 4. Remove the pitcher or bottles from the boiling water, leaving them filled with the sterile water in which they were boiled. Pour the remaining water out of the utensil. 5. Pour the filtered salt solution into the same utensil, cover, and boil for thirty minutes. Then add enough sterile (boiled) w^ater to supply the quantity lost by evaporation, so that you will have a full quart. 6. Pour the solution into the sterile pitcher after pouring out the sterile water it contained; cover with a sterile towel tied over the pitcher. 7. If the solution is to be kept for future use pour it into the bottles, after emptying the boiled water out of them. 8. Cork the bottles with plugs of cotton batting (not absorbent cotton) that have been sterilized by baking until brown. If the solution is not to be used the day it is sterilized, sterilize it twenty minutes for three consecutive days. This "fractional steriliza- tion" assures destruction of bacteria that may have developed from spores not killed by the first and second sterilization. The faithful performance of the foregoing tasks will witness the com- pletion of the first half of the preparation of the room on the day before the operation. The preparation of sterile water may be omitted until the morning of the operation. THE FINAL PREPARATION OF THE ROOM— "SETTING -UP" On the day upon which the operation is to be performed, the room, pre- pared according to the suggestions laid down, should be thoroughly aired for a sufficient length of time (four to six hours) to remove all traces of the formaldehyde fumes. The error must not be committed whereby an insufficient amount of time is allotted for this purpose. It is extremely uncomfortable, and at times impossible, to work in a room whose atmos- phere is laden with the irritating fumes of formaldehyde. Therefore, allow time for their complete removal by sufficient airing. While so doing, dust may be prevented from entering through the windows by covering the entire window frame with a sheet fastened to the top of the frame. The room having been thus subjected to a complete airing, and the hour for the operation but briefly distant, the final steps of preparing the PREPARATION OF THE ROOM AND ITS EQUIPMENT IN A PRIVATE HOUSE 27 room, or "setting-up," as it is commonly termed, are rapidly executed in an orderly, definite, and thorough manner. The woodwork should receive a final dusting with a cloth dampened in bichlorid. The tables and stands are to be gone over in like manner. The temporary sheet, which was placed over the permanent sheet tacked to the floor, is removed, and the permanent sheet is moistened with a solu- tion of bichlorid. The operating table is to be covered with a clean flannel blanket of sufiicient thickness to be comfortable. Patients, for months after, vividly Fig. 3. — Two Arrangements of Dining Table to Secure Trendelenburg Position. In both instances the blanket, rubber sheeting, and clean sheet are placed over the inclined boards or chair and the patient's knees so fastened as to prevent sliding. recall being placed upon a hard and uncomfortable table. This unpleasant recollection may be prevented if the nurse will but take the precaution to secure ample padding with blankets. Over these blankets is spread rubber sheeting, which in turn must be covered by a clean sheet. A small pfllow should be provided. In a subsequent chapter I shall fully describe the several positions that are required for different operations. While dis- cussing the final preparation of the table, however, it ma}^ be well to men- tion briefly one or two methods whereby one of the most common posi- tions — the Trendelenburg — may be arranged. Trendelenburg Position. — This position may be secured by placing at the foot of the table a block of wood of sufficient weight and thickness to secure the desired elevation of the hips. Over or on this block there are placed two leaves of the table, securely fastened as illustrated in Fig. 3, SURGICAL JNURSIKG and the padding, rubber sheeting, and sheet should be placed over these inclined table leaves. The position may also be secured by the use of a chair turned upside down and securely bound in place. A Kelly pad is placed as the nature and character of the operation will indicate. THE ANESTHETIST'S TABLE The anesthetist's table may be any small table or stand and is placed as indicated in Fig. i. On it should be arranged the following articles: Four cans, quarter pound, anesthetic ether. Bottle chloroform, four ounces. Jar or tube sterile vaseline. Tongue forceps. Mouth gag. Package sterile gauze. Castor oil, one ounce. Medicine dropper. Hypodermic syringe, loaded with the anes- thetist's preferred stimulant. Hypodermic syringe, empty. Glass sterile water, covered. Two anesthetic masks. Three small hand towels or napkins. Vomitus basin. Hypodermic tablets. Fig. 4. — Anesthetist's Table of Supplies. The table contains the following: Cans of ether, chloroform, vaseline, castor oil, medicine dropper, hypodermic syringes, hypodermic tablets, glass of sterile water, vomitus basin, anesthetic masks, towels, package of gauze, mouth gag, tongue forceps. The hypodermic syringe and tablets or stimulants are to be furnished by the anesthetist. It is incumbent upon the nurse to attend to the ar- rangement of the supplies of the anesthetist's table aside from the hypo- dermic syringes, unless she is instructed otherwise. PREPARATION OF THE ROOM AND ITS EQUIPMENT IN A PRIVATE HOUSE 29 The tables are next to be set in the position preferred by the operator. The table or board intended to hold the basins and solutions for scrubbing up are arranged last; the hand brushes and solutions are placed thereon and covered with sterile towels until ready to be used (Fig. 9). The storage containers of hot and cold water are brought in and placed in an out-of-the-way corner, but they should not be inaccessible. The "kit," containing the sterile goods received from the hospital, is unpacked and its contents arranged upon the table reserved for unopened supplies. Thus is the room prepared and arranged in a definite and painstaking manner. Up to this point all the work has been done by the nurse with- out personal sterilization. To complete the final and last steps of prepara- tion, it is essential that the nurse now "scrub up," don sterile headpiece, gown, and gloves, and perform the final and last work of preparation with the assistance of an "unscrubbed nurse," or some person who can intelli- gently aid her in the last details. The most approved methods of hand sterilization and robing oneself in a sterile gown well merit detailed consideration and discussion. I have deemed it of sufficient importance to devote a separate chapter to this subject alone. However, in order that I may not cause a break in the plan of preparing for an operation, our discussion will continue with the supposition that the "clean," "scrubbed," or "sterile" nurse has faith- fully prepared herself to proceed with the arrangement of the supplies. SETTING-UP The "clean," "sterile," or "scrubbed" nurse, however she may be designated, properly scrubbed, gowned, and gloved, from now on has the help of an "unscrubbed" nurse, or assistant, who aids her in the final "setting-up." Thus, the clean nurse will not be rendered unclean by coming in contact with unsterile articles or containers. The unpacking of the sterile'goods of the kit is next to be undertaken. This kit may be a general, laparotomy, appendectomy, or a gynecological kit, according to the nature of the operation. A laparotomy kit contains 30 SURGICAL NURSING the following articles, which are to be unpacked and piled upon the table set aside for holding unpacked sterile goods: LAPAROTOMY KIT Sterile towels 3 packages, i dozen each Sterile sheets 4 Sterile laparotomy sheet i Sterile laparotomy towel i Sterile gowns 5 Sterile dressings. . ., 5 packages Sterile powder for gloves Sterile cotton 2 packages Sterile sponges: 12 long 2 packages 12 square 2 packages 24 long 3 packages Medicated laparotomy 2 packages Vaginal 2 packages Sterile appendectomy strip i Sterile abdominal pads 2 Sterile perineal pad i Sterile applicators i package Sterile packing, plain, i-inch, 2-inch, 4-inch i each Sterile packing, iodoform, 2-inch, 4-inch i each Box containing: Razor Alcohol, large bottle Assorted sizes rubber tubing Green soap Rubber and glass catheters Ether, 4 cans Douche and irrigating points Chloroform, 2 bottles, 2 ounces each Safety pins, i dozen Sterile vaselin Adhesive straps, 2 sets Small chloroform mask Catgut Bandages, 2, 4, and 6-inch, 2 each Silkworm gut 6 Nail brushes and orange-wood sticks Pagenstecher 6 Face masks Silk, fine and heavy i Douche bag Black linen i Instrument pan Carbolic acid, 95 per cent. Hypodermoclysis needle CarboUc and iodin Surgeon's suits Oil of cloves 6 Basins Lime and Soda i Kelly pad Bichlorid tablets Instruments Collodion Needles Tincture of iodin Gloves Harrington's solution Drainage Tubes Formaldehyd SETTING UP THE SUPPLY TABLE OF STERILE GOODS The unclean nurse, who holds herself at all times ready to comply with the requests of the clean nurse, should know, or be instructed, how to open the containers holding the sterile goods in such a manner as not to con- PREPARATION OF THE ROOM AND ITS EQUIPMENT IN A PRIVATE HOUSE 3 1 taminate the contents and yet permit the clean nurse (Fig. 6) to remove the contents without becoming contaminated. The illustration (Fig. 5) demonstrates a reliable method. The first package opened should contain a sterile sheet, which is used Fig. s.— Method of Opening Package op Sterile Supplies by the Unsteeile Nurse. The ends of the package have been unpinned and unfolded. Grasping the sides of the package, the nurse, by a quick upward movement of the package, throws the wrapping open without touching the contents. \^ j.^.-., J Fig. 6. — Sterile Nurse Removing Sterilized Supplies from Package Previously Opened by Unsterile Nurse. The sterile nurse is wearing two pairs of rubber gloves. The cuffs of the outer pair are turned] back so that they may be removed without touching the surface of the inner gloves. to cover the open sterile supplies table and prevent the unsterilization of the articles that are piled thereon. With the table thus protected, place upon it, in an orderly and easily accessible arrangement, the following sterile goods: towels, sponges, packs, dressings, gowns, packing, drainage material, gloves, sutures, needles, needle holders, and scissors. Three 32 SURGICAL NURSING sterile basins must also be supplied to hold sponges, saline solution, and alcohol. Small cups for alcohol, iodin, carbolic acid, or any other solution employed, should be placed also upon this table. Tljis table is the nurse's work bench; it will be seen from the importance of the supplies thereon that the arrangement should be convenient and ample space allotted, so that when called upon, the work of the nurse may not be retarded by overcrowding or "cluttering up" of this table. The arrangement must, of necessity, be such that whatever is called for can be found instantly. As a suggestion for convenience, the fol- lowing schematic arrangement will be found very satisfactory in actual work (Fig. 7). Fig. 7. — Table of Sterile Supplies. The contents of this table are as follows: Upper row — Sterile towels, surgical gowns, dressings, packing, drainage tubes, iodin cup, alcohol cup, carbolic cup, novocain or special solution in bowl, dusting powder. Middle row — Alcohol basin for sutures, tray for sutures, soiled sponge basin, sponges, gloves, basin for normal saline. Lower row — Threaded needles, suture scissors, needle for- ceps, rubber gloves, reserve supply of instruments. This table set up, its contents are protected with sterile towels until the operation is begun. SOLUTIONS AND SUPPLIES There will be found in the hospital kit supplied by the surgeon the solutions and supplies listed on page 30. They are mentioned in this chapter in order that the nurse, in setting up the room, may make provision for their arrangement. PREPARATION OF THE ROOM AND IIS EQUIPMENT IN A PRIVATE HOUSE 33 INSTRUMENT TABLE The surgeon may or may not send with the kit the instruments he will require. In either event, there must be provided an instrument table, which is protected by a sterile sheet (Fig. 8). The instruments must, of course, be sterilized, and this is accomplished by boiling for at least twenty or, better, thirty minutes. Passing time has witnessed the proposal of this Fig. 8. — Table of Sterile Instruments. The instruments are grouped as follows: (i) Scalpels; (2) scissors; (3) pedicle clamps; (4) re- tractors; (5) Mayo-Ochsner's artery forceps, straight; (6) Ochsner's artery forceps, curved; (7) Thornton's artery forceps, curved; (8) special instruments; (9) tissue forceps; (10) sponge sticks; (11) Kelly-Hals tead artery forceps; (12) Pean's artery forceps. or that method of instrument sterilization, only to have it demonstrated in the end as unreliable and not as effective as the simple process of boiling. Almost any sort of container may be used ; a dish pan or bread tins will do. The instruments are to be submerged entirely in water. Here it is well to note that well or tap water is preferable to rain water. Rain water, as a rule, contains much organic matter and objectionable dirt. The well water or tap water used should be made slightly alkaline by the use of 34 SURGICAL NURSING soda, common washing soda or sodium hydroxid. When using the latter, an alkahnity of i in loo is recommended. There has been considerable discussion as to whether or not boiling destroys the cutting edges of knives or scissors. It is still a mooted ques- tion, and the nurse will find that some surgeons do not object to having their scalpels and scissors boiled, while others will strenuously object. In the latter event, the cutting-edged instruments must not be placed with the other instruments for sterilization by boiling. Such instruments are .ff.' Fig. 9. — Arrangement op Scrubbing-up Articles on Improvised Bench. The articles shown are as follows : Three basins for scrubbing, two pitchers of sterile water, three sterile brushes, cup for iodin, cup for hydrogen peroxid, bottle of hydrogen peroxid, bottle of green soap, bottle of iodin, basin of antiseptic solution, basin of alcohol, orange sticks. usually rendered sterile by immersion in antiseptic solutions. One of the most common methods is to immerse them for twenty minutes in 95 per cent, carbolic acid solution and then place them in 70 per cent, alcohol until called into use. Of the two methods, I believe that boiling and im- mersion in alcohol is the method that insures greater asepsis, and that this method does not in the least affect the cutting edge. You must be guided in this, however, entirely by the surgeon's wishes, and, if unfamiliar with them, it is your duty to ask him to express his preference. Having done so, you should follow it regardless of your personal opinions. After having been subjected to boiling for the allotted time, the instru- ments are removed under aseptic precautions and placed upon a sterile towel on one end of the instrument table. They are then to be dried with PREPARAIION OF THE ROOM AND ITS EQUIPMENT IN A PRIVATE HOUSE 35 a Sterile towel and laid out in order upon the table. A pair of scissors for cutting sutures, and the needles as well as the needle holders are trans- ferred to the sterile goods table. One who has had experience in various operations will know about how many of the different sutures will be required in the operation, and she will, of her own accord, before the sur- geon commences his work, thread the various needles with sutures, thus having them ready for the surgeon before he asks for them. It was a universal custom at one time for a nurse to have a basin of sterile water on the instrument table, which was used to remove blood- stains from the instruments. This is no longer considered good practice. Instruments that have been used once and laid down should be gathered up by the nurse, put aside, and not be permitted to be used again. The basin formerly used to wipe off these instruments is now used to hold the soiled or used instruments. This is the ideal practice and a distinct step in the advance of operative technique. Of course, if the surgeon has not provided himself with a sufficient number of instruments to permit such a practice, the nurse will then have to attend to keeping the instruments free from bloodstains. The operation completed, all the instruments, whether they have been used or not, should be boiled again in alkaline water and carefully dried. I wish to reiterate the caution- — carefully dried-, because it may be several hours before the surgeon is able to return the instruments to his private nurse or hospital, and in that time they may rust to such an extent as to damage the more delicate ones and render them unfit for future use. Therefore, exert sufficient effort to prevent such a mishap, and be sure that all the instruments are thoroughly dried before being packed in the surgeon's bag. Scalpels, scissors, and all cutting instruments should have their edges protected by means of cotton if they are without special carry- ing cases. The work of boiling and drying the instruments should take place immediately after the completion of the operation in order that the surgeon may take them with him. He cannot allow you to postpone this duty until a more convenient time, for he does not know at what moment he may be called upon to use them in another case. If needed soon, it would 36 SURGICAL NURSING be time-consuming and annoying to have to send or make a special call to obtain them. He will appreciate your promptness in this respect and also the care and neatness with which you pack them in his instrument case. DISMANTLING THE ROOM The operation completed, the patient returned to bed, the surgeon's instruments boiled, dried, and packed in his bag, the task of dismantling the improvised operating room should be undertaken immediately, and all traces of the use to which the room has been put should be speedily removed. Here, again, a methodical course will enable the nurse to complete this duty with the greatest speed. All the dressings that were not used should be given to the nurse who remains on the case for resterilization and use in subsequent dressings. Place a large newspaper in one corner of the room and upon this collect all the soiled and useless dressings and material to be destroyed. When all such material has been collected, it may be wrapped up and carried to a fire and burned. The surgical gowns, if badly soiled with blood, should be rinsed out in cold water and dried immediately by means of artificial heat, and then folded and packed in the kit. All the returnable goods are to be collected and returned to their containers, and the kit returned to the hospital as promptly as possible. It is unpardonable to retain possession of this kit for a longer time than is necessary to remove the bloodstains from the gowns and to pack it. The foregoing directions leave undisposed of only the furniture and sheets that were used in setting up the room. These should be taken down, folded, and given to a member of the family or servant to be sent to the laundry. In like manner, the utensils used are cleansed and returned to their sources. The assistance of members of the family is then secured and the room resettled with its customary furniture. A word of caution that should be ever in the nurse's thoughts while preparing an operating room in a private home — perform your work in such manner and with such care as to cause as little damage to the room as possible. While the owner of the home will usually consent to property PREPARAIION OF THE ROOM AND ITS EQUIPMENT IN A PRIVATE HOUSE 37 damage, if in so doing the safety of the patient will be enhanced, one should always remember that ruthless and needless marring of walls or furniture renders one culpable. In conclusion, the surgical nurse must remember that the safety of the patient depends upon her, as one of the group of actors in the operative drama, and that the faithfulness with which she discharges her duty will have a distinct influence upon the final result. The safety of the patient is dependent upon the thoroughness of your technique and your observance of the rules of asepsis. With this clear understanding before you at all times, there can be no hesitation as to the way you acquit yourself. You are intrusted with a sacred duty; you cannot afford to violate the trust imposed on you if you are desirous of gaining a reputation as a capable and efficient surgical nurse. CHAPTER III METHODS OF HAND STERILIZATION Present-day surgical procedures have been made possible and their detailed requirements perfected by reason of the development of an aseptic technique. It is not so many years ago that operative work, even in minor surgery, was an extremely perilous undertaking, being attended with a high rate of mortality due solely to wound infection. The dread of the operative risk caused many a patient to endure his condition rather than venture a chance; for it was chance which determined whether or not the work of the surgeon was undone by subsequent infection through a lack of knowledge and application of the principles of asepsis. Today all this is changed. The surgeon, physician, and nurse are in possession of knowledge that enables them to state that surgery may be resorted to with but little dread of septic catastrophe. They can make this statement by reason of their knowledge of bacteria and the known avenues by which infection is introduced. With a knowledge of the mode of transmission and implantation of bacteria and of the means by which they may be destroyed, it is possible to lessen the danger of their entrance and destructive action in the operative field or wound. To prevent infection and to observe an aseptic surgical technique, it is essential that one possess a fundamental knowledge of bacteriology. It is not within the province of this chapter to impart such knowledge in detail, but a few of the elementary principles of bacteriology are stated that later observations may be more clearly understood. Bacteria and their spores have been demonstrated as the exciting factors of infection and its subsequent train of symptoms. It is conceded that they are introduced from without and, in certain instances, may arise from within. It is their presence together with their products in the body that causes the several conditions known as septic infections. In surgery, the term sepsis or septic is a general one, employed to convey 38 METHODS OF HAND STERILIZATION 39 the information that microorganisms have appeared. The terms are void of specific meaning. To be exphcit one must determine the par- ticular form of organism. This is possible, in most instances, by means of a microscopical examination of the wound discharges or of cultures ob- tained from the blood stream or body secretions. It has been demonstrated that the results of sepsis are not due primarily to the bacteria but to the absorption of those products formed by the chemical action that takes place after the microorganisms multiply and grow in the wound and surrounding tissues. Our bacteriologists have isolated and described the following common forms of bacteria most frequently found in wounds considered as infected or septic: Staphylococcus pyogenes albus and aureus. Pneumococcus. Bacillus coli communis. Bacillus typhosus. Streptococcus pyogenes. Bacillus diphtherias. Bacillus pyocyaneus. Aerogenes capsulatus. Bacillus tuberculosis. Bacillus tetani. Gonococcus. The reader is referred to a textbook on bacteriology for the salient characteristics of these organisms. It was first demonstrated by Wright, and since confirmed by numerous investigators and clinicians, that there exists in the human body a force capable of producing certain substances called antibodies, or opsonins , which possess the power of inhibiting or rendering inert those microor- ganisms that bring about septic conditions. This is the barrier that Nature throws out for self-preservation and to ward off bacterial invasion. In the state of health such a defense, in most instances, is sufiicient. By reason of disease, however, or any undermining condition that deflects the physiological functions from the normal and so creates a lowered physical state. Nature is incapable of throwing out a sufficiently strong barrier to overcome microorganic invasions. The barrier is broken through, the infection gains a foothold, characteristic symptoms and conditions are produced, and then that state known as sepsis, or infection, is established, carrying with it its dismal troop of potential eventualities. When such a calamity — for the onset of an infective process is nothing 40 SURGICAL NURSING short of a calamity — occurs and gains a firm foothold, our duty lies in an endeavor to overcome and render innocuous the invading organisms. Many have been the plans of attack that have been devised; many of them have fallen short of being what may be termed reliably effective or dependable. For this reason the laboratory worker has been appealed to and urged to supply us with an effective combating agent. As a result, we have had presented to us the principles of serum therapy with its serums, antitoxins, and autogenous vaccines which, though not as yet completely understood, promise much toward supplying us with extremely potent combating agents. This brief explanation of bacterial infection is employed as an introduc- tion to this chapter for the purpose of impressing upon the reader the importance of a knowledge of bacteriology when preparing oneself for operative work. What has been aptly termed an aseptic conscience is imperative for the development of a modern surgical technique. Unless a nurse knows the cause, development, prevention, remedial agents, and methods for combating infection, she should not be intrusted with the duties a surgical nurse is called to perform. The principles of asepsis, therefore, merit your persistent study and observation. How may these infective organisms gain entrance into an operative wound? This is difficult to determine exactly, for there are times when, after the greatest precautions have been taken, the succeeding days reveal a septic infection. This is the reason that present-day methods call forth the need of exercising to the fullest extent the principles that have been established to prevent wound infection during any surgical operation. The most common routes of invasion are from the use of improperly sterilized instruments, sutures, drainage material, sponges, dressings, and the hands of the surgeon, his assistants, or nurses; in fact, anything that comes in contact with the wound or is touched while working in an artificial opening through the cutaneous surface may bear the germs of infection. Knowing this, no operative undertaking today may be ap- praised as safe until every act connected therewith has been safeguarded by those methods that have been proved efficient in preventing contamina- tion of a wound. It is this knowledge that has developed aseptic surgery METHODS OF HAND STI::R1LIZATI0N 41 and made imperative the institution of sterilization as a prophylactic measure. This prophylactic precaution is accomplished by means of certain fairly definite steps. One of these steps was described in our previous chapter devoted to the preparation of the operating room. The second step is the preparation of the hands of those who come in contact with the wound. The third step is the preparation of the patient and the field of operation, which will be taken up in our next chapter. This brings us then directly to our present subject: PREPARATION OF THE HANDS— SCRUBBING UP When it was first determined that the hands of the principals in an operation were carriers of infectious bacteria, many and various methods or procedures of hand sterilization were advanced. No sooner was a method proposed than its deficiencies were pointed out and another method was advocated. So the pendulum swung from one method and extreme to another. From all the discussion, experimenting, debating, and testing, however, there eventually emerged several methods that have with- stood the tests imposed and are conceded as dependable and reliable. Some of these are most elaborate and complex, others are comparatively simple, but none the less efficacious. In our leading clinics and hospitals today two methods are chiefly employed in the preparation or sterilization of the hands. It is essential that a surgical nurse be familiar with both methods. In referring to the hands, it must be understood that, in a surgical sense, we mean the hands and arms up to the elbows. Fig. 10. — Scrubbed Nurse IN Sterile Gown and Gloves Ready to Work. 42 SURGICAL NURSING All of the methods of hand sterilization call for scrubbing with soap and warm water for a period of at least ten minutes. In hospitals where scrub rooms are provided in the operating suite, the scrubbing is done under taps qf running cold and hot sterile water. In a private home, without these conveniences, we are forced to use hand basins containing the scrub water. In this event we must secure and provide a sufficient amount of water to allow frequent changes. Many brands of soap of various formulae have been marketed for this surgical procedure. Some of them are of value, others are valuable in Fig. II. — Nurse's Hands Showixg Two Pairs of Rubber Gloves. name only. The most satisfactory are our common tincture saponis viridis, or green soap, a standard soft soap, and ivory soap. The simple "soaping" of the hands is insufficient; hand scrub brushes are employed. While there are some who object to that use of scrub brushes for the reason that they are said to produce a trauma of the hands, the objection thus raised is trivial. These objectors employ a washcloth, but the use of scrub brushes is fairly universal. Before describing the methods of scrubbing up, it may be well to insert a brief paragraph on the wearing apparel of those engaged in an operation. The days are past when the good old doctor or professor entered the operating room wearing his street clothes, white boiled shirt, and starched collar, and simply laid his top coat and cuffs aside, rolled up his sleeves, METHODS OF HAND STERILIZATION 43 washed his hands in a Uttle water, and proceeded to operate. Surgery today demands that we give the same attention to the cleaning of our bodies and to the wearing of suitable operating-room clothes as we do to our hands and instruments. It is hardly necessary to mention that a general bath is essential on the day of opera- tion. Before entering the scrub room one should don an operating suit and shoes that are freshly laundered and which may well be sterilized the same as are the dressings. The surgeon and his assistants usually wear a shirt, white canvas trousers, and white canvas shoes during all major operations, and also in minor operations when a general anesthetic is used or sterile work is done. The nurse should wear a clean uniform and canvas shoes. She should be particular to be comfortably dressed; tight wearing apparel that restricts or retards free physical movements must be avoided. Before beginning the process of scrubbing, one should carefully mani- cure the finger nails. The nails should be kept trimmed round and close — not pointed. Just before scrubbing, what- ever dirt may have become lodged under the finger nails should be re- moved by means of an orange stick and peroxid of hydrogen. Next, the headpiece should be put on, one that entirely covers the hair, and following this the nose and mouth mask. In several places we have noticed that this covering for the hair, nose, and mouth is neglected until after the scrubbing process is completed. This is an error in technique which should not be overlooked. Thus clothed and prepared, one is ready to commence to scrub. Fig. 12. — Surgeon Properly Gowxed AND Gloved. 44 SURGICAL NURSING The scrubbing of the hands, necessarily, must be a perfunctory and ineffective proceeding unless we remain conscious of the purpose for which we are employing this precaution and endeavor to attain the bene- YiG. 13. — Preparation of the Hands When Running Water is Not Available. Nurse Scrubbing. Fig. 14. — Going through Solutions. Rinsing off Soap. ficial results of the method. It should be a procedure, therefore, charac- terized by methodical completeness. The materials and the 'preliminary scrubbing may be outlined as follows: METHODS OF HAND STERILIZATION 45 1. Running hot tap water or basins containing sterile water. 2. An ample supply of suitable soap. 3. Scrub brushes. 4. Wetting the hands and arms thoroughly. Fig. 15. — Applying 70 Per Cent. Alcohol. Fig. lb. — Scrub Room. Note one surgeon scrubbing up, dressed in duck shirt, trousers and shoes with face mask and headgear on. Note handles for controlling water by knee pressure. Note sand glass, 10 minutes, to accurately time scrubbing. The surgeon's assistant has finished scrubbing and is cleaning his hands in the antiseptic solutions. A section of supply cupboards. 5. Rubbing in an ample amount of soap, which is worked into a lather, covering the entire surface of the hands. 6. Rinsing off this first lather. 7. Resoaping. 46 SURGICAL NURSING 8. Scrubbing with a brush or cloth in a sj^stematic manner, commencing with the thumb, and in succession scrubbing the inner and outer surfaces of the thumbs and fingers of both hands, then the palms and dorsa of the hands and, lastly, the forearms. Ten minutes is to be thus employed, all the while using a sufficient amount of soap and water. The more thoroughly we scrub the more bacteria are removed. 9. Thoroughly rinse off the soap — not by a simple dab or splash in the water, but thoroughly remove every trace of soap. This is important. If it is not done, the antiseptic solutions subse- quently employed will be inert, for the almost indiscernible film of soap covering the skin will prevent antiseptic action. This precaution is frequently overlooked; therefore, be sure to secure a complete rinsing with as hot water as can be borne to remove all the soap and oils or fats of the soap which form a coating over the skin. • The next step in hand sterilization is accompHshed by the use of certain chemical antiseptic solutions of known germicidal power. They are Fig. 17. — Applying Iodin to Nails. demanded for the ideal procedure in our endeavor to secure as perfect aseptic preparation as possible. Their nature and chemical formulae are numerous and varied in character. Some of them are potent, some are not. Some are reliable, some only partially so; a few are wholly with- out antiseptic properties, either because of their nature or the manner in which they are used. The following are the more frequently used anti- septics in varying solutions: Carbolic acid. Tincture of iodin. Lysol. Alcohol. Bichlorid of mercury, or mercuric chlorid. Potassium permanganate. About ten years ago the late Nicholas Senn caused his assistants to undertake a series of experiments and investigations with the object of determining the length of time required for different chemical antiseptic agents of various strength and solutions to destroy bacteria and render METHODS or HAND STERILIZATION 47 them and their spores inert. The result of these experiments^ has been condensed as follows : The germicidal power of iodin is far superior to that of bichlorid of mercury, the acknowledged leader of all antiseptics. This was shown by experiments made with a i in loo solution of bichlorid of mercury on the streptococcus pyogenes. It was found that an exposure of fifteen minutes, al- though showing considerable inhibitory power, permitted a good growth of streptococci to appear. An exposure of thirty minutes gave no growth. The superiority of iodin is readily evidenced by the experiments that showed the destruction of the streptococci after two minutes' exposure in a 0.2 per cent, solution. A I in 40 solution of carbolic acid requires ten minutes to kill the streptococcus. It takes thirty minutes for a i in 1000 solution of bichlorid to kill the bacillus of anthrax. Ten hours are required for a i in 1000 solution of bichlorid to kill the tetanus bacillus. Alcohol, 70 per cent., requires five minutes to be effective. Iodin in 0.5 per cent, solution is amply strong enough for all uses. Thus was it demonstrated how utterly useless it is for one to immerse his hands or arms in a solution of bichlorid for but a minute or two and feel content and safe that infective bacteria are destroyed. To use a dis- infectant effectively demands that the hands and arms be immersed in it for the entire time required to destroy the several bacteria — from five to forty-five minutes — and then we are not sure that the tetanus bacillus or even the streptococci and staphylococci, if present, are destroyed. On the other hand, a solution of iodin kills and destroys the spores of every infecting organism in a space of two or three minutes if used in the recom- mended strength, many of them being destroyed at the moment of contact. Iodin has an additional value, namely, its penetrating property. I cannot but wonder how these conclusions will impress those who have been accustomed simply to dip their hands in a solution of bichlorid of mercury with the thought that by so doing they were rendering them free from bacterial contamination. Such a method is little better than employ- ing so much water. Thus, too, is it demonstrated that the mere trickling of a solution of bichlorid over the operative field is of little value. In this instance the scrubbing with soap and water is the most efi'ective antiseptic agent. The more thorough the scrubbing, the fewer bacteria will there be. There are some who depend upon scrubbing alone and do not use any bacterial destroying agents. The final process of hand sterilization should consist of the following: ^ Surgery, Gynecology, and Obstetrics, Vol. I, No. i, Jul}^, 1905. 48 SURGICAL NURSING 1. The introduction of a 50 per cent, tincture iodin solution in alcohol under the finger nails and around the matrices by means of an orange stick. 2. The rubbing into the skin of the fingers and palms of the hands this same strength iodin for a period of at least two minutes. Here it must be noted that iodin rapidly loses its full strength. The more recent its preparation the more potent. Iodin, thus employed, should not be more than one week old. This method does not cause exfoliation or blistering of the skin. 3. The bathing of the hands and arms in 70 per cent., alcohol for a period of at least three or four minutes. This is best accomplished by having a sterile sponge to apply the alcohol in a manner similar to the use of a washcloth. By this means all traces of the staining properties of the iodin are removed. The alcohol is not dried o£f by means of towels; it is allowed to evaporate, and while it is evaporating, one ma}^ proceed to put on the sterile gown. This is a reliable method of hand sterilization which repeated tests have proved entirely satisfactory and efficacious. The following methods will be found in use in several clinics : The Welch-Kelly Method. — After a thorough scrubbing of the hands and forearms, they are immersed in a saturated solution of permanganate of potassium for two or three minutes. This causes the cutaneous surface to become very dark brown. The hands and arms are then immersed in a warm solution of oxalic acid, of saturated strength, until all the stain of the permanganate is removed. They are then thoroughly rinsed in sterile water and immersed for two minutes in a i in 5000 solution of bichlorid, rinsed in sterile water, and dried on a sterile towel. For some, this method is very irritating to the skin and cannot be endured for any length of time. The Weir-Stimson Method. — After the hands are scrubbed, a table- spoon of chlorinated lime, a piece of crystalline carbonate of soda, and a little water are mixed in the palm of one hand, and the resulting creamy mixture is thoroughly rubbed into the skin until the rough granules of the soda are no longer felt. This requires from three to five minutes. The hands are then rinsed in sterile water. The disagreeable odor of the lime is removed by the use of sterile ammonia water in the strength of H to i per cent. The value of the procedure rests in the free chlorin that is thus liberated. The Sublimate -Alcohol Method. — After scrubbing, the soap is removed by dipping the hands in 95 per cent, alcohol. The hands are then immersed in 70 per cent, alcohol containing i part in 1000 of corrosive sublimate for a period of three minutes, using a piece of sterile gauze to work in the solution. Lastly, the hands are rinsed in sterile water. METHODS OF HAND STERILIZATION 49 Fig. 1 8. — Putting on Sterile Gown, Hands in THE Sleeves of the Gown. Fig. iq.^Sliding into the Gown ^^' Fig. 20. — Unsterile Nxirse Tying the Gown. Sterile NiiRSE Tying the Tapes of THE Sleeves. 50 SURGICAL NURSING Oil of Cloves Method. — After scrubbing, the hands are immersed in a I in 1000 solution of bichlorid. This is followed by rubbing in one or two drams of pure oil of cloves, which is subsequently removed by a vigorous washing in 70 per cent, alcohol. Lysol Method. — Immerse the hands in i in 1000 bichlorid, followed by a I in 10 solution of lysol and then 70 per cent, alcohol. '3J % ■* ' ■' "ittm^ t *>»-i mm^ Fig. 21. — Preparing for Operation. Note method in which nurse holds doctor's gloves to assist putting them on. Dry gloves. Unclean nurse fastening gown in back. Assistant ascertaining whether all necessary instruments are on the instrument tray. Many are of the opinion that the value of these methods lies solely in the protection that is afforded by the alcohol. This is a debatable ques- tion and, in spite of the evidence that is submitted, some will be found who will not desert the method which they have been accustomed to employ. Our aim should be to use as simple a method as is consistent with potency in attaining the desired end — hands that are rendered as sterile as it is possible to make them. You, as nurse, will be compelled at times to follow the fancy of the surgeon whom you are assisting and, since he is METHODS OF HAND STERILIZATION PUTTING UP DRY STERILE GLOVES 5^ Fig. 22. — Preparations Completed. On the table are boiled gloves (tied in pairs) in sterile basin, dusting powder, stack of towels> powder basin, and stack of glove envelopes, all sterile. Fig. 23. — Gloves, Towels, Basin, and Envelopes are Kept Covered with Sterile Towels During the Process. 52 SURGICAL NURSING Fig. 24. — Reaching under Protecting Towel for Pair of Gloves. Fig. 25. — Drying the Boiled Gloves with a Sterile Towel. METHODS OF HAND STERILIZATION 53 0-' ^C^ < Fig. 26. — DippixG Gloves ix Pot\'der Basix. i^^lS^^ Fig. 27. — TiTRXixG Glove that has beex Powdered ox Oxe Side so That the Other Side may EE Powdered Also. 54 vSURGICAL NURSING Fig. 28. — Putting the Gloves in a Sterile Cloth Envelope. Fig. 29. — Closing Cloth Envelope. METHODS OF HAND STERILIZATION 55 ii Fig. 30. — First Step of Wrapping Envelope in Protective Covering. Fig. ^i. — Pinning First Fold of Protective Wrapper. 56 SURGICAL NURSING responsible for the operative results and the acts of all those engaged in it, he may rightly dictate the method you are to follow. Others will rely upon your training and will tell you to employ the most effective means. Until within recent years it was customary to engage in surgical work with the hands thus prepared. Now an additional safeguard for surgeon and patient is utilized, namely, the wearing of sterile rubber gloves. Professor Halstead of Baltimore is to be credited with the institution of Fig. 32. — Sterile Gloves Packed in Peotectwe Outer Wrapper. this method, for it was he who first suggested it in 1889. The fact that gloves are worn must not cause one to feel oversecure or conclude that their protection permits a slighting of the enumerated details of hand sterilization. A rubber glove torn or punctured should be immediately replaced by a perfect glove. While their preparation and care occasion extra work for the nurse, they should certainly be worn. Dry gloves are preferable to wet ones, for wet gloves soon cause the fingers to become sodden like those of a washerwoman, and the delicacy of the touch is lost or impaired. Scrubbed, gowned, and gloved by these methods, one may consider METHODS or HAND STERILIZATION 57 himself as properly prepared to participate in an operation, provided the steps of preparation that have been advanced have been faithfully and conscientiously enacted. Hands may be made sterile, but they will not remain so unless we are constantly alert to keep them so. The scrubbed nurse must ever guard against coming in contact with anything that is not sterile. When not engaged in active work, the hands should be held above the level of the waistline. They are to be kept clean by washing in a basin containing a potent antiseptic, followed by rinsing in sterile water as frequently as they are badly soiled with blood or wound secretions. Some operators go to the extent of covering their rubber gloves with sterile cotton ones until the abdomen is open and then remov- ing them. This is partly to protect the rubber gloves from soiling before the intra-abdominal work is undertaken. If, perchance, one does acci- dently touch an unsterile object, the glove or gloves are immediately removed and a fresh pair put on. In gynecological surgery where both vaginal and abdominal work is done, fresh gloves are put on when trans- ferring from one field to another. Added security is attained if, just before putting on the second pair of gloves, the hands are run through the hand solutions. The gowns are, of course, always changed. It is an excellent step in technique for the nurse to wear two pairs of gloves while giving the field its final preparation and draping the patient, and then remove the outer pair when all is in readiness. Thus will she be provided with a clean pair of gloves when the real operative work is begun. If two operations are to be performed upon different patients in the same home, we must necessarily go through all the steps of hand preparation for each case. The recommendations and methods proposed and described in this chapter are commended with the caution that the mere knowledge of these facts is insufficient. To accomplish the most, they must be understand- ingly and systematically applied. This may be accomplished in the high- est degree only after repeated reflection. The subject demands one's close attention and study. Develop an aseptic conscience and remember at all times that you become an accomplice if a fatal termination may be traced to your acts of omission or commission while preparing to enact a part in any surgical operation. CHAPTER IV THE PREPARATION OF THE PATIENT Of all the preparative work essential to a surgical operation, no pro- cedure is more difficult or more diversified than the preparation of the patient. The nurse is necessarily compelled to correlate her efforts in such a way that, when the task is completed, the entire procedure centers around one point — complete asepsis. To secure in this task a thorough course of procedure, one is compelled to devote to it constant thought and study. Daily practice and frequent reviews are necessary to enable the nurse to carry out her work efficiently. None of the methods of surgical technique has changed so often as that of preparing the patient. One rule or another is being modified from year to year. Each new beam of scientific light creates new conditions, and we, perforce, must adapt ourselves and our work to comply with the require- ments of more recent knowledge. The tendency is to do away with the elaborate and time-consuming methods of the past whenever it has been satisfactorily demonstrated that a simpler technique is equally efficient and reliable. It is only by constant study and practice that we are enabled to adapt ourselves and our work to the latest demands of surgery. GENERAL OR CONSTITUTIONAL PREPARATION As all surgical work is occasioned by abnormal physical conditions, arising either as emergencies or as the result of a gradually developing pathology, it will be perceived that the general preparation of the patient will be varied, according to the amount of time allowed. Every individual submitting to surgical interference and its resulting confinement in bed for a longer or shorter period of time, should spend from at least twenty-four to thirty-six hours in bed in preparation for the ordeal. The advantages of such a preparatory rest have received con- siderable discussion, and varied opinions have been expressed regarding THE PREPARATION OF THE PATIENT 59 this requirement. As a result, some surgeons insist upon two or three days' preHminary rest in bed, while others are satisfied with but twelve hours. The argument advanced by the latter is that the longer a patient is confined to his bed the lower will be his physical resistance. On the other hand, those favoring a longer period of preoperative preparation maintain that their patients come to the table in better condition and, therefore, are better able to withstand shock, thus increasing their chances for ultimate recovery. The preliminary care must be of such a nature as to secure the fol- lowing results: 1. Complete emptying of the intestinal tract, not by one dose of a drastic cathartic, but by the use of milder drugs. To lowxr the physical resistance by means of a violent cathartic is to defeat the purpose of preparation. 2. A normal, or as nearly normal as possible, functioning of the kidneys. 3. Nourishment and elimination kept up by simple, concentrated, bland diet and an abundance of water. 4. A stimulation and equalization of cutaneous circulation and elimi- nation by means of baths and massage. 5. Accustom the patient to the use of bedpans, urinals, and douche pans. 6. That mental and physical condition of rest which tends to enable every patient to resist the operative procedure. If these are desirable features, and they have not been demonstrated otherwise, it is unreasonable to assert that they can be secured in the brief space of twelve or eighteen hours. Consequently, I am inclined to recom- mend from twenty-four to thirty-six hours of preliminary preparation, so that the patient may come to the table in the best possible physical condition. The indications for operative work may be so imperative, however, that the general physical state of the patient may be considered of lesser moment than the surgical need, and operative work must be instituted at once, regardless of the general physical findings. This is the only excep- 6o SURGICAL NURSING tion to the rule. At all other times we should endeavor to attain the greatest degree of physical normality and function. Before a surgeon recommends an operation, he should give due con- sideration to the patient's physical state, and should require a thorough examination, including a careful inspection of the lungs, heart, and elimi- nating organs, together with such laboratory analyses as may be indicated. By means of the knowledge thus obtained, the surgeon is able to determine what preoperative treatment will be required to enable his patient to come to the table in a satisfactory condition. In general, the following pro- cedures should be observed. The Teeth. — The condition of the teeth merits attention, and a visit should be made to the dentist for the removal or filling of decayed teeth and treatment of diseased gums. The teeth should be as perfect as mechanical skill can make them! Greater comfort for the patient during the post-operative days will thus be secured. Education has brought about a more general interest in the care of the teeth, and the toothbrush is in common use; still, the majority who neglect their teeth remains large. Upon assuming charge of a case, therefore, you may have to request the patient to attend to the care of the teeth. It is the duty of the nurse to insist upon the frequent use of a toothbrush, either with or without a dentifrice. Stomach and Bowels. — When placed upon an operating table the patient should, as a rule, have no digesting food in the stomach, and the large intestine must be empty. This does not imply that patients must be starved, nor does it mean that they are to be subjected to the action of drastic purgatives. The plan usually adopted consists of a course of calomel forty-eight hours previous to operation, followed by a saline. On the day following the use of calomel and preceding the operation, one ounce of castor oil should be given, usually at 4 p.m.; on the following morning (the day of the operation) one or two enemas are given. This treatment will produce a satisfactory emptying of the intestinal tract. When rectal or vaginal work is to be done, or in work upon the stomach, it is imperative that the colon be entirely empty. The nurse must be certain that all of the enema has been expelled. Nothing is more annoying THE PREPARATION OF THE PATIENT 6l or indicative of carelessness on the part of the nurse than to ha\^e the work of the surgeon delayed or interfered with by reason of bowel movements and the soiling of drapings in the midst of an operation. For two or three days previous to operation, the patient's diet should consist of bland and nutritious food, without bulk, and he should be encouraged to drink an abundance of pure water — at least a glass every two hours, to wathin one or two hours before the operation. The evening meal on the day before the operation should be light, consisting of broth, toast, soft-boiled egg, and milk or tea. A cup of broth or milk at nine and twelve o'clock at night is permissible. If the operation is planned to take place late in the morning or early afternoon, broth and toast may be served for breakfast, A safe rule to follow is to give no nourishment for six hours previous to the administration of the anesthetic. In operative work on the stomach at least ten hours should elapse after the last taking of food. The Kidneys. — Even though the surgeon or the attending physician may have made a urinalysis, a specimen of urine should be obtained and given to the surgeon or physician at the time of his visit on the day before operation. From a female patient, the specimen should be (Obtained by catheter. The object of securing a specimen of urine is to determine the state and activity of the kidneys. Kidney disease or deficient kidney secretion ma}^ at times, cause all operative undertakings to be either postponed or abandoned entirely. The presence of sugar, albumin, casts, acetone, diacetic acid, or marked indican reaction in the urine of the patient, as a rule, should cause the postponement of all but emergency operations. The presence of albumin alone, with an absence of granular or fatty casts, does not necessarily indicate a serious kidney lesion. It should put the surgeon on his guard, however, and influence him in the selection of the anesthetic agent. Baths. — During the preparative rest in bed two or three sponge baths a day may be given advantageously, followed by a general massage and rub with alcohol or cocoa butter. This will increase the cutaneous circula- tion and elimination and also be restful and comforting to the patient. 62 SURGICAL NURSING On the morning of the operation the bath should be given not later than two hours before the time set for the surgeon to commence his work. Under no circumstances should the nurse include the field of operation in thig last preoperative bath. The Night before Operation. — The patient should eat a light supper, as previously suggested. A warm sponge bath, followed by an alcohol rub, should be given at about nine o'clock, and the field of operation pre- FiG. 33. — Surgical Leggings. pared according to the surgeon's orders. If no other instructions are given, the field should be shaved. The ordeal that he is to undergo on the following morning often causes the patient to be more or less restless, and he finds it difficult to fall asleep. At least six or eight hours of continuous slumber should be secured if possible. The nurse will find that the bath and rub, followed by a cup of hot milk, will frequently be sufficient to induce sleep, especially if the house is quiet and an abundance of fresh air is admitted to the room. A tactful, reassuring nurse, with a timely word and an encouraging smile, can do much to maintain a quiet mental attitude in her patient. Secure the confidence of your patients; be frank and open with them. Do not tell a THE PREPARATION OF THE PATIENT 63 falsehood in reply to a patient's question, no matter how good your in- tention may be. SCHEDULE OF PREOPERATIVE PROCEDURE The following schedule of work for the day previous to the operation, if it is to take place in the home, is submitted as a suggestive outline of the nurse's activities. It must necessarily be altered in given cases. A.M. 7:00 Bath and general rub. 7:30 Breakfast. 8:00 Instruct servants or assistants to dismantle room selected for operation and clean it. 9:00 Begin preparation of operating room. 10:00 Cup of broth or milk. 11:00 Calomel, grains 2 or 5, if such is surgeon's order. 12:00 Operating room preparation complete. During morning patient has been given several glasses of water. P.M. 12:30 Lunch. 1 :30 Seal operating room and fumigate it. Patient induced to take nap. 2:30 Sterilize utensils and arrange for hot and cold sterile water. 4:00 Effervescent citrate of magnesia, or a saline cathartic if the patient has taken calomel. If calomel has not been administered, give castor oil, I ounce. 5 :oo Soapsuds enema. 6 :oo Light supper. 7 :30 Open operating room for airing. 8:00 Enema, douche, shave field, general bath, and rub. Make comfortable for night. Glass of hot milk. 9:30 Patient asleep; abundance of fresh air. 12:00 If patient is awake, cup of hot broth or milk is given. A.M. 5 :oo If awake give a cup of broth. 6 :3o General bath, rub, enema, douche. 7:30 Hypodermic of morphin, if ordered; put on leggings and headpiece. Catheterize. 8:00 Ready for operation. If the operation is to take place later in the morning the suggested outline may be changed so as to adapt it to the hour selected. CHAPTER V THE PREPARATION OF THE OPERATIVE FIELD The preparation of the field of operation calls for as careful and pains- taking technique as the preparation of the surgeon's and nurse's hands. The methods employed have been varied from time to time. Present-day methods are characterized by their simplicity. It was but a few years ago that the universal technique was outlined as follows: On the afternoon or evening previous to operation, the field was shaved and a soft soap poultice applied and permitted to remain from one to two hours. Then followed a thorough scrubbing with soap and water with the use of a brush. This, in turn, was followed by ether, bichlorid, and alcohol. The field was then covered with sterile dressings maintained in place by a binder or bandage. When the patient was placed upon the operating table, and coincident with the administration of the anesthetic, the final steps of preparation were taken. These consisted of again scrubbing the field with soap and water, followed by the application of ether, bichlorid and alcohol. The preparation was then considered complete. Today this method has been simplified and the general practice con- sists of the following: On the afternoon or evening previous to the day of operation, the field is shaved and cleansed by means of a simple bath of soap and water. No dressings are applied, and care is exercised that no water comes in contact with the field within six hours of the final preparation. When the patient is placed upon the table, and coincident with the administration of the anesthetic, the field is exposed and surrounded with sterile towels. By means of a sterile gauze sponge held in a sponge holder, the field is thoroughly gone over with pure benzin or benzin-iodin (iodin crystals, i part, to benzin, i ooo parts) . This solution of benzin is permitted to evaporate thoroughly, which requires about two minutes. The entire THE PREPARATION OF THE OPERATIVE FIELD 65 field is now gone over again with a 50 per cent, tincture of iodin in alcohol. The field may then be considered sufficiently prepared, and is ready for its final draping. In vaginal work the vagina is cleansed with alcohol, and the cervix and mucous membrane, as well as the labia and surrounding cutaneous surface, are painted with the iodin solution. In rendering this final preparation to the skin it is well to sterilize an area considerably beyond the proposed line of incision. For illustration, in a laparotomy for work upon the pelvic organs, the area prepared is bounded by a line across the abdomen an inch above the umbilicus, by a line extending across the thighs level with the pubes, and on either side by a boundary continuing in line with the trochanter of the femur. A similar area is prepared when the work is being done in the upper ab- dominal cavity. It is better to prepare too large a field than too small, for the exigencies of any operation may demand that the surgeon extend the incision beyond the length first planned, and he should not be delayed by being compelled to wait until the additional field is sterilized. When applying the benzin and iodin, the nurse should have the solu- tions in small sterile basins or cups. A sterile sponge is folded and held in a sponge stick. The benzin is first applied to the umbilicus. This sponge is then discarded. A fresh sponge is put into the holder, and with it the benzin is applied to the remainder of the field. One must remember that the object of using the benzin is to remove all cutaneous gland secretion. To accomplish this, light swabbing is ineffectual. Reasonable force and friction must be used. The benzin having evaporated, another fresh sterile sponge is placed in the holder and the iodin is applied to the umbilicus. This sponge is then discarded, and with a new one the iodin is applied to the remainder of the field. In executing this preparation the nurse should train herself to do it in a methodical and exact manner. After the navel has been cleansed with the iodin and the second sponge is secured, the nurse should cause the proposed line of incision to receive the first application of the iodin and then constantly work away from the site. Never paint the line of in- 5 66 SURGICAL NURSING cision, then on one side and then the other, finally giving the line of incision a last "dab" with the sponge, but apply the iodin to the line of incision first, and then avoid touching that area unless a new sponge is secured. A systematic plan is to cleanse the umbilicus, then discard the sponge, secure a fresh sponge, paint the line of incision, paint on both sides of this line, and then paint the pubes and thighs. In emergency operations the preparation of the field consists of a thorough cleansing with benzin, after which iodin is employed and the drapings adjusted. Shaving is done, of course, when necessary, but no water should be used. This method is now generally employed and is acknowledged as re- liably ef&cient. There are some surgeons, however, who direct that after the iodin has been applied the field be gone over with 70 per cent, alcohol. A few operators are found who do not employ the iodin but are content with the use of 70 per cent, alcohol. Here and there one will also find a surgeon who remains content with the technique of several years ago. DRAPING THE FIELD The operative field having been rendered sterile, the patient is now ready for draping with sterile sheets and towels, which are so placed as to expose only as much of the field as may be required for the work to be performed. Two sterile sheets are used, one above and one below, and these should be sufficiently large to cover the patient's entire body and hang well down over the edge of the table. The edges of these sheets nearest the field are further protected by additional towels, or small sterile sheets, so that there remains exposed only the actual surface of the skin demanded for the operative attack. The towels or small sheets are fas- tened in place by means of safety pins or towel clamps (Fig. 37). The foregoing technique having been rigidly observed, the surgeon may now begin his work, provided the patient is in a stage of complete anesthesia. If the stage of anesthesia has not been reached, or if the surgeon is not quite ready to commence the operation, it is desirable that the field be protected with a folded sterile towel until the actual operative work is begun. THE PREPARATION OF THE OPERATIVE FIELD 67 POSITIONS ON THE TABLE A folded towel is used as a covering for the patient's head. It pro- tects the hair and at the same time prevents the hair from annoying the anesthetist. The leggings (Fig. ^^) are employed as a means of providing added comfort and warmth. Whatever rings or jewelry the patient may have been accustomed to wear are to be removed. Because of the possible unconscious movements and struggles of the patient when in the excitement stage of the anesthetic, it is well to secure the patient's hands and limbs. This may be accomplished in several ways. Fig. 34. — Patient on Improvised Operating Table. The patient is dressed in a short nightgown and protective leggings. The hair is completely covered by a folded towel. The hands are held in place by a strap buckled around the wrist and passed under the patient's body to the other wrist. A bandage may be used instead of the strap. The legs are held in place on the table by a surcingle. Usually the hands are tied at the side of the table by means of a strap (Fig. 34), a gauze bandage, or padded leather cuffs that come as a part of the table equipment. In fastening the hands, care should be exercised that the wrists be not too tightly constricted and the blood supply thus in- terfered with. Another precaution is to make sure that the elbows do not extend over the edge of the table; if they do, the weight of the arms, and also the weight of the surgeon or assistant leaning against them, causes considerable pressure upon the inner sides of the arms against the sharp edges of the table. This frequently will cause a paralysis of the musculo- spiral nerve, which may become permanent. At best it is very annoying because it mav continue several weeks. The limbs should be restrained 68 SURGICAL NURSING by passing a surcingle over them and fastening it on the under side of the table (Fig. 34) or by tying the ankles to the foot of the table by means of gauze bandages. Operative work in different regions and upon the various organs re- quires that the patient be placed in certain definite positions upon the table. Skull and Brain. — Work in this region calls for the elevation of the head to an angle varying from twenty-five to forty-five degrees. The po- sition is obtained by placing sandbags under the patient's shoulders, neck, and head, if the elevation cannot be secured by adjustment of the operating table. Goiter. — In order that the thyroid gland may be thrown forward more prominently and to put the muscles of the neck on the stretch, a sandbag is placed under the nape of the neck and the head permitted to hang over this elevation (Fig. 35). Breast Amputation. — A board, six or eight inches wide and long enough to reach beyond the arm when it is extended, is covered with a sterile covering and placed at right angles with the table and under the patient's shoulder. Upon it the arm is extended so as to give ample exposure of the axilla. In preparing this field, the axilla and the arm halfway to the elbow is prepared. The remainder of the arm and the hand is covered with ster- ile towels or a sheet, or is enclosed in a sterile gauntlet. Gall-bladder Operation. — In order that the gall-bladder may be thrown into closer apposition to the anterior abdominal wall, a sandbag is placed under the patient's back. Modern tables have an elevating attachment to secure this position. Kidney Operations. — For this work the patient is placed in the lateral prone position, and the kidney to be operated upon is thrown more into prominence and its approach simplified by placing a sandbag under the side of the patient, so arranged as to cause an elevation of the kidney area (Fig. 36). Trendelenbtirg Position.- — This position is required in practically all operations upon the pelvic organs approached by the abdominal route. By means of this position the bowels fall back into the upper abdomen and THE PREPARATION OF THE OPERATIVE FIELD 69 , ' ' / '^ am imiiijii nil./ ^*«**... k •1 '^ Fig. 35. — Preparation for Goiter Operation. The shield of sterile cloth stretched over a wire frame prevents the patient's mouth and the anes- thetist's mask from contaminating the wound. The field of operation is clearly shown. A sand- bag under the neck elevates the field of operation, which is draped with sterile towels. Fig. 36. — Patient in Position for Kidney Operation. The patient's right arm rests on the far side of the table; the left arm is behind his back and is seen in the foreground of the picture. The area of operation is raised by a large sandbag under the pa- tient's waist. This view shows the first sterile towels in place, ready to be covered by the laparotomy sheet and the final towels. The lower margin of the exposed field of operation, which wiYi finally be surrounded by sterile towels, is indicated by the dotted line. 70 SURGICAL NURSING thus do not interfere with the surgeon's work. The position is secured by elevating the feet and the pelvis of the patient and by lowering his shoul- ders and head so that the body lies at an angle of approximately forty-five Fig. 2>1- — Patient in Trendeleistburg Position. For the improvised operating table a kitchen table and a smaller table were used. The lower end of the kitchen table was raised on blocks to give a better elevation for the Trendelenburg position. Fig. 38. — Many-tailed Abdominal Bandage in Place at the Completion of a Laparotomy, degrees. Operating tables are constructed so that the patient may be thrown into this position; if such an operating table is not used, the posi- tion may be secured by the use of boards, blocks, or chairs as depicted (Fig. 37)- The true Trendelenburg position is one in which the feet and legs are THE PREPARATION OF THE OPERATIVE FIELD 7 1 maintained in extension. There are some surgeons, however, who drop the feet and legs over the end of the elevation. The objection to this practice is that the flexing of the legs causes a rigidity of the abdominal muscles, which cannot be relaxed by the anesthetic. In this event the approach to the pelvic organs must be made through a rigid abdominal wall. Vaginal Work. — The hips are brought down well over the edge of the table and the thighs flexed upon the abdomen. The lower legs are flexed on the thighs and held in place either by stirrups and holders, or by a sheet or bandage fastened around one knee and passed around under the neck of the patient and fastened to the other knee. In these positions the draping of the patient is carried out as in the more common positions^ and the draperies so placed as to expose only as much of the field as is necessary. CHAPTER VI DUTY OF THE NURSE DURING OPERATION The patient anesthetized and the surgeon and his assistants ready, the time is at hand when, for a period of from fifteen minutes to two hours, the surgical nurse will be called upon to perform certain definite duties. The nature of these duties is predetermined, and familiarity with them will do much to expedite or retard the surgeon's work. To become a capable surgical nurse one must know not only what to do but how and when to do it, that the teamwork which is demanded and which should be enacted in every surgical operation may not be disrupted. For an operation to proceed in an orderly manner there must be a definite division of labor. The operation and all its attendant factors must at all times be subservient to the surgeon, upon whom rests the responsibility of the operation and of all the acts of those who participate in the work. The principals engaged in the work are, in the order of their importance and authority, surgeon, first assistant, anesthetist, second assistant, third assistant, surgical supervising nurse, scrubbed nurse or nurses, unscrubbed nurse, and orderly. For effective teamwork this is a sufficient number for an operating theater. For an operation in the home, however, the num- ber of assistants must necessarily be limited, and in this case the nurse may be called upon to perform some of those duties assigned to the sur- geon's medical assistant. The Surgeon. — He is the recognized head of the group to whom all others are subservient and to whom they must accurately and conscien- tiously render their services. It is he who directs every detail of the work that is done. First Assistant. — This assistant is the surgeon's immediate representa- tive and the one who, in many instances, will superintend the carrying out of the surgeon's orders as well as to be of immediate aid to him in each 72 DUTY OF THE NURSE DURING OPERATION 73 step of the operation. He anticipates the operator's desires and needs. During the actual operative work it is his duty to direct the assistants and nurses and indicate to them what is required from time to time as the work progresses. To him is frequently delegated the work of the final suturing of the wound and the application of the dressings. Second Assistant.^ — The second assistant aids to the extent of seeing that the required instruments, needles, and sutures are promptly provided Fig. 39. — The Operative Group. Note position of the two surgical nurses, one on each side of the table. The surgical supervisor stands in the right foreground. for the surgeon as he may require them. He holds retractors so as to better expose the site of operative attack and sponges away the blood. In general, he is an assistant to the first assistant. Third Assistant. — This person acts as an aid to the other two assistants, or he may assume the duty of the first surgical nurse. The third assistant performs the work of final sterilization and draping of the field. The Anesthetist. — As the term implies, the anesthetist has charge of and administers the anesthetic selected by the surgeon. 74 SURGICAL NURSING Fig. 40. — Operative Group. Laparotomy. Fig. 41. — Operative Group. Removal of Coccyx. DUTY OF THE NURSE DURING OPERATION 75 Surgical Supervisor. — This assistant, customarily a trained nurse who has received special training in surgical nursing, is in direct charge of nurses engaged in the operation and is held responsible for their work. The first and second clean nurses are the remaining important princi- pals in the operating team. It will be the object of this chapter to enlarge Fig. 42. — Patient Prepared for Laparotomy. The instrument tray is in place and the nurse is holding the scalpel in readiness to hand to the surgeon. Notice the protecting screen between the patient's head and the operative field. This serves as a barrier to prevent contamination of the operative field from the mouth of the patient and anesthetist. upon their duties and to describe in detail the methods whereby they may best perform their duties. A word of caution as to a nurse's demeanor and manner of personal conduct during an operation may not be amiss. From a lay viewpoint, submission to a surgical operation is a serious procedure. Daily famil- iarity with surgical work has a tendency to render a nurse somewhat callous toward the feelings of those less familiar with surgical procedures. 76 SURGICAL NURSING To circumvent such a possible attitude the nurse must constantly strive to conduct herself so that her demeanor throughout the entire operation will be characterized by dignity. The laugh, the joke, the story, or a careless light-hearted attitude should never be indulged in by a nurse while so engaged. This does not imply that she should perform her duties with a mournful, oversanctimonious air but with dignified activity. The nurse should speak only when necessary and then in a low, distinct tone. Fig. 43. — Instrument Stand with Instruments Arranged. Note two scalpels, three Mayo scissors, three tissue forceps, four Kelly curved hemostats, three Mayo curved hemostats, two straight Mayo hemostats, four straight Kelly hemostats, tAvo sponge sticks with sponges, two clamps, two pairs retractors, a blunt dissector, and an appendical tucker. An operation, except in a clinic, is not characterized by conversation. The best teamwork is done without conversation. Each participant is so trained as to anticipate his duty without waiting to be directed. The surgeon only is privileged to speak or carry on a conversation. Remem- ber that every act determines the nurse's qualifications. Let your methods reveal training and perfection as well as a dignified demeanor. The one word that may be selected to describe most fittingly the work of a clean nurse is anticipation. She must be ever alert to perform her duty and provide promptly for any emergency. To anticipate the wants DUTY or THE NURSE DURING OPERATION 77 of the surgeon or his assistants and so minimize delay and annoying moments of waiting, should be the guiding motive of her technique. It is well to familiarize yourself beforehand with the surgeon's prefer- ences and customs. You will be conserving time by having an ample supply of needles and sutures ready for his immediate use. The instru- ments are to be arranged in classified groups and so placed that those in most frequent use will be within easy reach (Fig. 43). (See also Fig. 8, page T,s.) The following is a practical classification of instruments by groups: 1. Holding or seizing instruments: tissue forceps, tenacula, and retractors. 2. Cutting instruments: scalpels, scissors, chisels, cutting forceps, mallet, saws. 3. Control of hemorrhage: artery snaps, clamps, and ligature carriers. 4. Needles, sutures, and needle-holders. 5. Special instruments. In considering the wo'rk of the surgeon and while assisting him one must remember that his operation is characterized by definite steps, and that these steps exist in practically every surgical procedure. They are, first, cutting through the overlaying structures to expose the part or organ to be operated upon. To do this the surgeon requires scalpels, scissors, tissue forceps, artery forceps, retractors, and sponges. These must, there- fore, be ready and supplied to him as required, and it is the nurse's duty to see that they are at hand. The seat of the lesion that called for surgical interference having been reached and exposed, the nurse anticipates the surgeon's next needs by handing to him or to his assistant such instruments, ordinary or special, as may be required to complete the work. For illustration : In an appen- dectomy, the abdominal cavity being opened, the nurse should have in readiness salt blocks or packing sponges to wall off the remainder of the abdomen. While the surgeon is delivering the appendix, the nurse prepares a ligature for tying off the mesoappendix. Next she has ready the intestinal needle threaded with silk or linen for the purse-string suture. This is followed by a small ligature to tie off the stump and a clamp for clamping the distal end of the appendix. The scalpel or cautery should be in readiness for severing the appendix, and also the "tucker." While the surgeon is returning the cecum to the abdomen and picking up the 78 SURGICAL NURSING peritoneum preparatory to closing, the nurse counts her sponges, packs, clamps, and artery forceps, and promptly reports whether they are ac- counted for. Then she hands to the surgeon the needle-holder which Fig. 44.— Standard Make or Needle-holder. Fig. 45.— Needle-holder with Large Full- Proper Way to Hold in Handing to curved Needle Threaded with Silkworm Surgeon. Gut. Forceps Attached eor Tension Suture. This shows the proper manner of holding the forceps when handing to surgeon. Note that the suture, when threaded in needle, is twisted two or three times. Fig. 46. — Hagedorn Saber-pointed Needle in Needle-holder and Threaded with Catgut Ready to Hand Surgeon eor Suturing Muscle or Fascia. contains the needle and suture for closing the peritoneum. Next there are in readiness several silkworm-gut sutures (Fig. 45) and in turn the catgut for closing muscle, fascia, and skin (Fig. 46). Finally, the dressings are given to the assistant for covering the wound. DITTY OF THE NURSE DURING OPERATION 79 This reveals the manner in which the alert nurse anticipates the needs of the surgeon. Equal proficiency should be revealed in every operation, whatever its nature. We have outlined the general plan of work of the scrubbed nurse. There are, however, certain finer points that a nurse must observe in order that she may secure pronounced efficiency and greater definiteness of purpose in her operative work. Some of these finer points of technique are acquired naturally, while others are acquired only after weeks of per- sistent study, observance, and practice. Persistent attention to details will alone enable her to possess them. While they may be described to a certain extent, it is impossible to give specific directions, and a nurse is therefore compelled to resort to her own ingenuity to acquire them in the performance of her surgical work. So far as possible we will advance general principles and suggestive ideas as to the salient features of this perfected technique. INSTRUMENTS Be sure that every instrument is in perfect working order; if it is not, discard it. An instrument once used is to be discarded, provided a sufficient num- ber of the same kind are available. If an instrument is laid down and the surgeon intends to use it later on in the operation, see that when he again needs it all stains have been removed. This may be accomplished by wiping with a moist sterile sponge. For cutting sutures do not use scissors that are to be used for cutting tissue. Have one pair of scissors on your supply table for your suture cutting. Always provide at least six artery snaps within easy reach for im- mediate use. Let the close of operation find your instrument tray and table in as orderly arrangement as when operation was commenced. The same orderliness should be maintained during the entire procedure. You should know the name of every instrument that is used. It will require constant study to possess this knowledge, for styles and forms of instruments are constantly changing. 8o SURGICAL NURSING Before an abdominal incision is closed be sure that all your clamps and artery forceps are accounted for. Instruments held in reserve should remain covered with a sterile towel until called into use. This protection should never be omitted. SUTURES AND NEEDLES The methods of suturing most frequently used are the continuous, glover's, interrupted, tension, Lembert, and everting. 1^ Fig. 47. — Continuous. Fig. 48. — Glover's. Fig. 49. — Interrupted. Fig. 50. — Everting. Methods of Suturing Wounds. The continuous is, as its name implies, a continuous or running suture extending the entire length of the wound (Fig. 47). The glover's is a continuous suture in which each stitch consists of a separate binding hitch (Fig. 48). The interrupted is one in which each stitch consists of a separately tied suture (Fig. 49). The everting is so placed as to evert the raw edges of the wound (Fig. 50). The tension is usually of silkworm gut and is interrupted. To prevent cutting into the tissue it is frequently tied over a roll of gauze (Fig. 51). DUTY OF THE NURSE DURING OPERATION 8 1 The Lembert is principally used in intestinal work. The suture is carried through the intestinal wall to the mucous coat and outward to the surface and then through the opposite intestinal wall in the same manner. It is then tied. Fig. 51. — Tension Suture Tied over Roll of Gauze. Test every suture before threading it in the needle (Fig. 52). In doing so do not use force beyond that which the suture is supposed to withstand. Fig. 52. — Testing a Ligature Before Handing to the Surgeon. Catgut sutures may be made more pliable by immersing in alcohol or by dipping for a moment in a saline solution. Annoying knots and tangles may be thus prevented. 82 SURGICAL NURSING No. I catgut is of ample size for tying small bleeding vessels. No. 3 is of sufficient size for the ordinary larger vessels. No. 3 is customarily used for tying off the mesoappendix and in tying the vessels of the broad ligaments. As a rule, each surgeon has a preference as to the size of suture he wishes for certain uses and will indicate this preference before beginning the operation if you ask him. Needle sizes and styles to be used will vary according to the surgeon's custom. Needles are usually carried in his instrument kit. The nurse must exercise care to the extent that every needle handed to the surgeon is sharp. Needles threaded with silkworm gut should have a forceps attached. Needles and sutures threaded before the operation should be protected with a sterile towel. OPERATIVE FIELD The drapings of the operative field may become badly soiled several times during the course of the operation. The nurse must ever be alert to replace soiled drapings with clean towels. It may be done without interfering with the work of the surgeon or his assistants. Soiled or not, when the surgeon is ready to close, the field should be surrounded with fresh towels. SPONGES AND PACKS Always have immediately available at least three sponge sticks with sponges (Fig. 53). Regulate size of your sponges according to the size of the wound and the purpose for which sponge is to be used. A sponge used once is to be discarded and replaced with a fresh one. Accurately ascertain the number of sponges you have when the opera- tion is commenced and have some one check your count. At the close of the operation and before the wound is sutured, be sure that every sponge is accounted for and that the same individual checks your final count. This precaution holds true of packs. Walling-off packs, salt blocks, or strips are used either moist or dry as the surgeon prefers. When used moist they are wet in normal saline at a DUTY OF THE NURSE DURING OPERATION 83 Fig. 53. — Sponge in Sponge Stick, Ready to Hand to Surgeon. Fig. 54. — ^Large Sponge, Uneolded. Fig. 55. — ^Large Sponge Folded por Use as a Small Sponge in the Sponge Stick, 84 SURGICAL NURSING temperature of ioo°. Packs covering exposed coils of intestine should be frequently changed so that the bowel does not become chilled. Attach a forceps to every pack that is in use (Fig. 57). Sponges in the abdomen should always be held in sponge holders or have forceps attached to them. Fig. 56. — Gauze Sponges. The oblong sponge, used either on or off a holder and sometimes called a wipe, is made from gauze which measures about 9 by 16 inches. After folding, the sponge is about 2 by 6 inches. For making the square sponge used in the sponge stick, a piece of gauze 16 inches square is required. After fold- ing, the sponge measures 4 by 5 inches. To make the small sponge use gauze 9 inches square. DRAINS The kinds of drains in common use are : Gauze, varying from a half to four inches in width and either plain, iodoform, carboHzed, or bichlorid. The plain and the iodoform are the kinds most frequently used. They are made in yard lengths (Fig. 58). DUTY or THE NURSE DURING OPERATION 85 Fig. 57. — Salt Block and Packing with Clamps Attached. Fig. 58. — Two-inch Gauze Drain or Packing. For photographing, the drain was taken from a sterile package and one end unfolded to show the width. The drain is cut in yard lengths, and folded back and forth upon itself before being placed in a wrapper for sterilizing. 86 SimGICAL NURSING Perforated rubber tubing of various sizes (Fig. 59), Split rubber tubing within which are placed several lengths of gauze (Fig. 59)- Cigarette drain, made by taking several strands of gauze and wrapping with several turns of gutta-percha or rubber tissue (Fig. 59). Manufac- FiG. 59.- — Rubber Drains. Perforated rubber tube, split rubber tubing with several lengths of gauze, cigarette drain of rubber tissue ^^^th gauze inserted. Fig. 60. — Silkworm-gut Drain. turers now supply thin rubber tissue of several sizes so that it is only neces- sary to pull the gauze through this thin tubing. This avoids the necessity of rolling. Silkworm-gut drain, consisting of ten to fifteen strands of silkworm-gut sutures (Fig. 60). DUTY or THE NURSE DURING OPERATION 87 DRESSINGS Various solutions and powders were formerly employed to bathe or dust over the wound. As a rule they are today abandoned. The suturing completed, the skin is cleansed from blood by means of a moistened sponge, dried, and sometimes painted lightly with iodin. Dry dressings of gauze are then applied. Some seal a clean wound with collodium. Fig. 61. — Dressing Made from Piece of Gauze 8 ~by 20 Inches. Fig. 62. — Abdominal Pad. The gauze so used is cut a sufficient size to amply cover the wound. The gauze is maintained in position by means of adhesive strips, tapes, binders, or bandages. ABDOMINAL DRESSINGS Cover the wound with five or six pieces of dressing (Fig. 6i). Place the first layers on each side of the incision to protect the skin from cut SURGICAL NURSING ends of sutures (Fig. 63). Hold in place with inch strips of adhesive that fasten the upper and lower ends of the dressing (Fig. 64) . Cover this with an abdominal pad (Fig. 62) held in place with adhesive tapes (Fig. 65). V-,. Fig. 63.— First Wound Dressings. Strips Fig. 64. — First Dressings, Held in Place by OF Gauze on Each Side or Incision to Keep Strips of Adhesive. THE Ends of Catgut from the Skin. Fig, 65. — Abdominal Pad Held by Adhesive Tapes. Cover all with a Scultetus binder (Fig. 67). If drainage is employed, fluff gauze around the drainage material and do not apply too snug a binder. Duty of the nurse during operation 89 Dressings of the head, face, chest, or extremities are maintained in position by adhesive or bandages. Wounds of the back are dressed the same as abdominal wounds. In major amputations see that the stump is well protected by a suffi- cient quantity of dressings and cotton pads. Fig. 66. — Scultetus Binder. In breast amputations the axilla should be well padded. In dressing scalp wounds pad back of the ears and then envelope the entire skull with a roller crown bandage. If splints or plaster casts are used always provide sufficient padding over bony prominences and for the heel, axilla, and popliteal space. Fig. 67. — Scultetus Binder in Place at the Completion of a Laparotomy. If an eye is to be covered see that plenty of cotton is used. Never leave skin in contact with skin. Always provide abundant padding. The operation completed, the final dressings in place, and the patient n bed, the nurse's first duty is to attend to the preservation or disposal of 90 SURGICAL NURSING the pathological specimen or part that was removed, according to the surgeon's instructions. This done, the instruments should be cleansed and the room dismantled. Of course, if one acts in the dual capacity of surgical nurse and nurse to the patient during convalescence, it will often be impossible to leave the patient immediately to perform this work. The anesthetist frequently remains with the patient for some time and, in this event, the opportunity may be seized to begin the work of cleaning up. In reviewing your work as a surgical nurse, keep in mind two points: first, to anticipate the requirements of the surgeon and his assistants; and second, to conduct your work by a systematic plan. Time is required to attain an advanced degree of perfection, and the nurse must ever remain studious and active in keeping herself informed regarding the most recent developments in surgical methods. CHAPTER VII POST-OPERATIVE NURSING DURING THE FIRST TWENTY-FOUR HOURS The operation over, dressings and bandages in place, tlie nursing care given a patient will be an important factor in determining the ultimate operative result. The alert attentive nurse can do much to influence favorably the patient's convalescence and add to his comfort. The first forty-eight to seventy-two hours will be the most trying and demand more or less of the nurse's time, depending upon the nature of the operation and the anesthetic employed. The patient does not fully rally from the depressing systemic effect of the operation and reaction is not completely established until the second to the fourth day. Patients often speak of these two or three days as a "dream" and recall but indistinctly what transpired or how they conducted themselves. In spite of this depression, their comfort must be conserved and such care administered as will enable them to pass through this period, which inaugurates their first stage of return to health, in the best possible manner. Before returning the patient to bed a dry, warmed, fresh nightgown should be put on him. During an operation a patient frequently will perspire profusely and his gown become wringing wet; again it may be- come soiled. At any rate he is to be robed in a clean gown. Before doing this the body should be thoroughly dried. If the leggings are wet or soiled, they are to be changed. The patient is now ready for bed. The time consumed in the foregoing work should be as brief as possible and every precaution taken to prevent chilling. The Bed. — If the nurse assisting in the operation is to assume the after-nursing of the patient, she will, before scrubbing up, arrange for some one to prepare the bed according to her directions while she is engaged in assisting the surgeons. A comfortable bed depends upon a good mattress and springs. These should be covered with a pad and a waterproof cloth (Fig. 68). These 91 92 SURGICAL NURSING in turn are followed by a sheet and a drawsheet (Fig. 69). The covering for the patient consists of a sheet, a woolen blanket or comforter, and a spread. Do not commit the error of using several heavy blankets. If Fig. -Mattress, Mattress Pad, Protective Rubber Drawsheet. necessary a light woolen blanket may be used temporarily over the spread. The under sheet should be covered with several hot-water bottles (Fig. 70) Fig. 69. — Under Sheet and Drawsheet in Place, Covering Mattress Pad and Protective Rubber Drawsheet. and the covers drawn over (Fig. 71) so that the bed will be thoroughly warmed before the patient is placed therein. Unless contraindicated, the patient should be laid upon his back. The water bottles are allowed to remain in the bed, but the nurse must POST-OPERATIVE NURSING DURING THE FIRST TWENTY-EOUR HOURS 93 be alert to keep them at least ten inches from the patienfs body. Should unconscious movements or tossing occur the nurse must exercise extra care to prevent burns. The pillow is dispensed with during the first few FtG. 70. — Bed with Hot-water Bottles in Place. Note Rubber Protective Sheeting and Towel at Head. hours except for patients with spinal deformity and the shoulder curva- tures of advancing age. The head is turned to one side and rests on a Fig. 71. — Bed Ready for Patient; Warmed and Kept Warm with Hot-water Bottles. towel covering the under sheet. A vomitus basin and two or three towels must be within easy access. The Room. — The temperature of the room should be 75°, and fresh air supplied in abundance but not directly upon the patient. A bright 94 SURGICAL NURSING light should not be admitted, and quiet is to be insisted upon throughout the entire house. The patient must not be left alone until fully conscious. Fig. 72. — Elevation in Abdominal Drainage Cases. A Fig. 73. — Elevation Demonstrating Pillow Pinned to Bed under the Buttocks and Pillow at Foot to Prevent Sliding. Elevation of the Head of the Bed. — In operative abdominal work in- volving the pelvis and lower abdomen where drainage is employed, the head of the bed is frequently elevated from six to twenty-four inches. POST-OPERATIVE NURSING DURING THE FIRST TWENTY-FOUR HOURS 95 The object of such elevation is to cause fluids and pus to gravitate to the lower abdomen and pelvis. It has been demonstrated that the pelvic peritoneum and that of the lower abdomen can better withstand and care for infectious organisms than the upper abdominal peritoneum. By- keeping the patient in an elevated position spreading peritonitis is limited in a vast majority of instances. Drainage by gravity is another reason for the employment of this position, especially in vaginal drainage through the posterior cul-de-sac. The position is secured by using bricks or blocks of wood under the legs of the head of the bed and by removing the casters from the foot (Fig. 72). Chairs may also be employed for this purpose. To overcome the tendency of the patient to slide to the foot, several de- vices are recommended. Of all such devices the most satisfactory and simple is to pin a pillow securely to the mattress just below the buttocks (Fig. 73). A foot support of pillows or an ordinary footstool is an additional aid. Another method consists in the use of a cradle sling that passes below the patient's buttocks and is fastened around or to the headboard. The elevated position is maintained for a period of three to fourteen days, depending upon the condition that indicates its employment. During the first one or two days patients frequently complain of this unnatural position. They soon accustom themselves to it, however, and experience no great discomfort or loss of sleep. Fowler's Position.^ — This is an exaggerated elevation of the patient's head and trunk so that he assumes practically a sitting posture. In this position the patient's body is supported at an angle of slightly more than forty-five degrees by a back rest and a cradle sling, the pelvis being the lowest point. Fowler's position is indicated in peritoneal in- fections where drainage is used. It is frequently employed in stomach resections, gastro-enterostomies, intestinal anastomoses, and in peritonitis arising from any source. Elevation of the Foot of the Bed. — This position is secured by placing bricks or blocks under the legs of the footboard and raising it to the desired height. A pillow is placed against the headpiece to prevent discomfort to the patient's head from resting constantly against the headboard. 96 SURGICAL NURSING Elevation of the foot of the bed is employed in shock and collapse with severe loss of blood. The position is contraindicated if drainage of the lower abdomen has been employed. The employment of mechanical restraining devices for delirium is but a confession of one's lack of familiarity with modern methods. Delirium, even of severe type, may be readily controlled by hydrotherapy and elimination. A patient recovering from an anesthetic should not be encouraged to change his position frequently during the first twelve hours. After that time he may be allowed to lie upon either side. The pain in the wound occasioned by changing to a new position may cause a patient to object, but his objections may be overcome by assuring him that after he is in the new position the wound pain will immediately disappear. One of the most trying conditions that a surgeon and a nurse have to contend with is the patient's complaint of post-operative backache. It is the result of two causes, the patient's position on the table and the relaxation of the spinal muscles produced by the anesthetic. While on the table the normal curvature of the spine is considerably lessened by relax- ation of the support offered by the spinal muscles. This throws a strain upon the intervertebral ligaments w^hich reflect the strain to which they have been subjected by causing a most annoying and disturbing backache, persisting from one to four or five days. This backache may be prevented or greatly lessened by having the operating table covered with a heavy padding six to eight inches in thickness. We are accustomed to use a six-inch hair mattress on the operating table, and its prophylactic effect has been demonstrated by the patient's freedom from this distressing backache. Some hospitals have plaster molds to support the hollow of the back and so relieve these liga- ments of the strain to which they would otherwise be subjected. The back may also be supported with pillows. When this condition occurs the only relief that can be secured is from massage and frequent change of position. Morphin or codein is indi- cated to induce sleep and thus bring relief from the "ache." Following an abdominal operation the extension of the limbs causes POST-OPERATIVE NURSING DURING THE FIRST TWENTY-POUR HOURS 97 tension upon the abdominal recti muscles, which produces an exaggera- tion of the pain in the abdominal incision. It may be relieved by elevat- ing the knees and permitting them to rest on one or two pillows (Fig. 74). In amputations of limbs, in fractures, or in other operative work upon the extremities additional comfort is secured for the patient if the involved limb or stump be elevated by means of a pillow. In passing from the subject of the patient's bed and his posture therein, let me add that the nurse may, by many little attentions, secure additional comfort for the patient. Above all, keep the bed clean, the covers ar- ranged, and a general appearance of tidiness. Fig. 74. — Tension on Abdominal Muscles Relieved by Elevation of Knees over Folded Pillow. Returning Consciousness. — A person recovering from an anesthetic should not be left alone until fully conscious. During the return to consciousness and even before, the relaxation from the anesthetic may cause swallowing of the tongue or a dropping of the jaw (Fig. 75), either of which will cause obstruction to breathing and, possibly, asphyxiation. Again, nausea or vomiting may be attended with inspiration of the vomitus, producing laryngeal spasm with serious possibilities of choking, or later, of inspiration pneumonia. Upon the patient's return to bed the mouth is to be cleansed of all mucus, and the head turned to one side. The respiration is to be kept free from all obstruction. As the conscious state approaches there may be one or two attempts to vomit, or vomiting of stomach contents or swallowed mucus may occur. If the preoperative preparation has been thorough and the anesthetic 98 SURGICAL NURSING skillfully administered post-anesthetic vomiting will be much lessened. In spite of every precaution severe vomiting is at times encountered. To insure greater freedom from nausea or vomiting some anesthetists are accustomed to perform a gastric lavage before the patient leaves the table (Fig. 76). If this practice is observed a stomach tube, a mouth gag, and one or two quarts of warm normal sahne will be required.. If vomiting occurs the nurse must support the patient's head, holding Fig. 75. — Recovering from Anesthetic. Supporting jaw of unconscious patient. Head turned to side; no pillow, towel to protect bedding; additional light blanket thrown over the bed for added warmth. On the table are shown hypodermic, glass sterile water, sponges, towels, vomitus basin. it to one side, and with a sponge or towel cleanse and free the mouth of all vomitus. In severe retching following abdominal operations, pain caused by straining may be lessened by supporting the abdomen with gentle pressure of the open palm over the dressings. After one or two periods of vomiting the patient will continue in a semiconscious state and be more or less listless. If he should attempt to roll or toss about, he should be restrained by reasonable force. An hour having elapsed, the patient should be well out of the effects of the anesthetic. These first moments should find the nurse in attend- POST-OPERATIVE NURSING DURING THE FIRST TWENTY-POUR HOURS 99 ance, for her presence is of assuring comfort to the patient. When the patient is capable of understanding, the nurse may well tell him that the operation is over, that he is back in bed, that everything progressed satisfactorily, and that he is to remain quiet and endeavor to sleep. At this stage the patient will not experience much if any pain, as the Fig. 76. — Gastric Lavage. Requirements: Two pitchers, vomitus basin, towels, gauze, stomach tube, mouth gag, jar. Note protection of bed with towels and rubber sheeting. Patient's head brought to side of bed. Nurse pouring lavage solution into stomach tube. preanesthetic opiate and the anesthetic still serve to cover sensibility to pain. The patient will, if encouraged, fall into a slumber that may last from one to two or more hours. During this period careful watch must be kept of the pulse, respiration, and general appearance. After the lapse of one or two hours, failure of returning consciousness, with a feeble, rapid pulse, shallow respiration, 100 SURGICAL NURSING and pale or blue appearance warrants prompt institution of methods of resuscitation. The only exception is in those patients who have had one to three preoperative doses of scopolamin or hyoscin without, or combined with, morphin. Such patients may sleep for six to eight hours after an operation. After a slumber varying from a half to two hours the patient will complain of thirst or dryness of the mouth and throat. Formerly water was denied for twelve to twenty-four hours. Now it is a common practice to permit drinking of small quantities of water at frequent intervals pro- vided no operative work upon the stomach contraindicates its administra- tion. True, the water first taken may be vomited in a few moments. This is really to be welcomed for it then serves as a gastric lavage, and the water subsequently given is retained. If vomiting occurs every time water is taken, all liquids should be withheld until the stomach is capable of retaining fluids. Persistent vomit- ing is an imperative indication to withhold all fluids. In the intervals the patient is allowed frequently to rinse his mouth and moisten his lips. - Drugs are of little value in controlling vomiting. While many and various measures are advanced to control stomach irritability, the most satisfactory and efficient is absolute rest of the stomach. If vomit- ing is not controlled in eight to twelve hours or if it increases in severity, other treatment must be instituted. The condition then becomes a surgical emergency. The patient will soon begin to complain of being in an uncomfortable position or of a tired back. A pillow, if desired, may now be given and added comfort secured by placing a pillow under the knees. Even with this attention evidence of restlessness will again soon appear and endure for a period of time. The patient will ask as to details of the operation. He may become very talkative ; fretting, or even hysterical manifestations may be shown. It is well for the nurse to analyze her patient's actions and to endeavor to control them by encouragement and reasoning. Familiarity with a patient's disposition will be of value in meeting these conditions. Pain and Rest. — After a lapse of a few hours the pain occasioned by POST-OPERATIVE NURSING DURING THE FIRST TWENTY-FOUR HOURS lOI the wound will become evident. In some patients the pain is severe, while in others it will occasion little or no comment. If the restlessness and pain are mastering the patient it is justifiable to administer the ordered morphin in dosage of an eighth to a quarter grain hypodermatically. One should never permit a person to suffer unnecessarily. Morphin should be administered judiciously; it prevents exhaustion, conserves strength, and induces beneficial rest. Usually the indications will be to repeat the dose in four to six hours and again in the evening and possibly toward morning. Do not give it unless indicated, but when indicated do not hesitate to give it. Of course, we realize that it has a constipating effect and may cause subsequent meteorism and difficulty in moving the bowels, but if employed with judgment these objections may be ignored. Codein is sometimes substituted. One must remember that codein will produce rest but has little effect on real pain, and, even if used, one will have to resort to morphin to attain the desired effect. Codein may well be employed after the second day if such a remedy is required and simpler measures are unavailing. Frequent bathing of the hands and face with cool water produces relaxation and comfort. Toward afternoon and in the evening an alcohol rub will be refreshing. A cold compress placed over the forehead and eyes is often agreeable. One should not neglect to change or shake up the pillows frequently and secure a change of the patient's position. Catheterization. — One need not worry or become anxious because the patient does not express a desire to urinate during the first eight, ten, or twelve hours. Some will even go for a longer period without danger or discomfort. As a rule, the patient is to be urged to urinate in ten or twelve hours. If unable to urinate and no discomfort is expressed, a patient may be permitted to go several hours longer before catheterizing. The only exception to this rule is in hysterectomies and bladder operations, when the bladder must not be permitted to become distended. Kidney secretion is always diminished during the first twenty-four hours. Nourishment. — In addition to the water that is given the patient to drink but little nourishment is to be permitted. Toward late afternoon or evening a cup of plain hot tea will do no harm and will be grateful. It 102 SURGICAL NURSING .... nm.o "T " :H en^ ,.o_ T^G S.a^.^ ».-., nnn.o^ 1 e-onrPn 0.. „..„ ■^^ 'z:: Hew „>.,c»™. «„„„,s„.,.>, ...... !:S „^T.«,T..^„U^„C l<