Nursing in the acute infectious fevers

Front matter

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COPYRIGHT DEPOSm

BOOKS

Preface To The Third Edition

The reception of the former editions of this work by members of the medical and nursing professions has been very gratifying to the author.

This third edition is in enlarged form. Two new chapters have been added; several chapters have been entirely rewritten and much new material has been introduced throughout the whole text.

It is the author's desire that this present volume will serve a greater need than its predecessors.

G. P. P.

Round Lake, New York, October, 1915.

Preface

The object of the author in preparing this book is to place before the nursing profession a volume which will be of practical service.

The subject-matter is written for the nurse, and not the medical graduate or scientific worker, hence all extraneous matter and useless discussions are not given place.

The treatment of disease by means of drugs and the physical signs are but little discussed, as these are of more importance to the medical attendant than to the nurse.

Great pains have been taken in preparing the sections on the Care and Management of each disease, as this relates directly to the duties of the nurse.

The book is divided into three parts : The first part treats of fever in its general aspects, which is necessary as a base to the study of each individual fever ; the second part discusses each of the acute infectious fevers as to their cause, signs and symptoms, course, prognosis, care, and management ; the third part deals with practical procedures and information necessary in the management of the foregoing diseases or of value in understanding the nature and course of such diseases.

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12 PREFACE

Only illustrations and charts of a specific value are included.

The author wishes to express his thanks to Susan D. Munroe, Assistant Superintendent, Samaritan Hospital, for her kind and candid criticism.

G. P. P.

Chapter I Fever In General

Fever is that condition of the human body in which the temperature is raised above the normal.

The normal human body temperature is 98.6°F., but it may vary a little either way, depending upon several conditions.

Physiologically, the temperature of a healthy adult is at its lowest between midnight and four o'clock in the morning. It is at this time, when the body functions are at their lowest, that patients ill with grave diseases are most likely to pass away. The temperature reaches its height between five and eight o'clock P. M., and then gradually decreases until early morning. In persons who toil at night instead of day this ratio may become reversed and the height is reached in the morning.

The normal temperature is lowered in several ways; insufficient diet may lower the temperature a fraction of a degree. In starvation the temperature may become very subnormal. In certain febrile diseases, either because insufficient nourishment is provided or because the patient swallows but little food, a subnormal temperature may result, especially in the beginning of 2 17 convalescence. One of my cases of typhoid fever at the beginning of convalescence had attacks in which he would enter a state of collapse, the temperature would become subnormal, the skin pale and moist, but the pulse would remain normal. By careful watching we learned that he would hold the milk in his mouth until the nurse turned her back or left the room, when he would expel it. This he kept up for a week or more, probably getting only a fraction of a glassful of milk in twenty-four hours.

Cold drinks lower the temperature temporarily; cold baths lower the normal temperature. After taking an anaesthetic the temperature is also lower than before; and certain drugs, such as morphine, quinine, large doses of alcohol, coal-tar preparations, as acetanilid, antipyrin, phenacetin, etc., will lower the bodily heat. During sleep the temperature is lower than in the wakeful hours.

The normal temperature is raised after partaking of a liberal diet, or hot drinks; during digestion; by increased function of the large glands of the body; by increased mental activity and muscular exertion. In summer the bodily temperature is a little higher than in winter. Such drugs as strychnine, atropine and caffeine will raise the temperature. This is a very important point, because the continued rise of temperature in the convalescence of certain diseases, as typhoid fever, may be due to the administration of strychnine.

Degrees of Temperature. — The normal temperature is q8.6°F. or 37°C. The normal temperature of an infant is about qq.4°F. and decreasing gradually to the normal adult temperature as full growth is obtained. After the age of 40 or 50 years the temperature decreases

FEVER IN GENERAL 1 9

to about 97.8°F. and in advanced age rises again to 99.4°F. Thus in both extremes of life the temperature is about the same and is above normal.

95°F. equals Collapse temperature.

97.5°F. equals Subnormal temperature.

98.6°F. equals Normal temperature.

99.5°-ioi.5°F. equals Subfebrile temperature.

io2°-io3°F. equals Moderately febrile temperature.

io4°-io5°F. equals Highly febrile temperature.

Over io6°F. equals Hyperpyretic temperature.

Detection of Temperature. — This is done by means of the clinical thermometer, the bulb of which is placed under the tongue and the lips closed, the patient being warned not to bite the instrument. The thermometer is left in position from one to five minutes, depending on the grade and sensitiveness of the instrument. As a general rule the temperature is taken by the mouth, but at certain times this is either not possible or desirable. For example, it is impossible to take the temperature in young children by mouth; in adults who are in a comatose or semi-comatose condition; and in insane patients. If the tongue be dry, the recorded temperature will not be accurate, nor if the patient had recently drunk cold or hot water. Other situations for taking the temperature are in the axilla, in the rectum, in the vagina, and in the passing urine.

Before placing the thermometer in the axilla, the armpit should be thoroughly wiped and dried. The bulb of the thermometer is then put well into the center of the axilla, and the hand of that side placed on the front of the chest so as to completely envelop the bulb of the thermometer with the axillary tissues. The instrument should be allowed to remain in position for five minutes. To the recorded temperature add about o.5°F., which will bring it up to the oral temperature.

The instrument may also be placed in the rectum or vagina. It is very seldom necessary to use this method except in children, or in adults who are unconscious, delirious, or insane. If used rectally, the rectum should first be emptied of fecal matter, for if the bulb of the thermometer be inserted into a mass of feces, an incorrect reading is obtained. The rectal temperature, when properly taken, is a true index of the degree of body heat.

Another method is by allowing the patient to urinate on the bulb of the thermometer. This is an accurate method, but applicable to only a few cases.

In febrile diseases it is best to record the temperature every four hours during the acute stage of the disease.

Prognosis. — The prognosis of febrile diseases does not entirely depend on the fever, but also on the concomitant symptoms. A fever of io6°F. for a brief period is not as grave as one of io5°F. for a more extended time. An evening temperature of i04°F. in typhoid fever is of more import than fever of io5°F. in pneumonia.

A temperature of io6°F. if continued for several days is fatal (Smith). In persons over 50 years of age a temperature of io3°F. is serious.

The relation of the pulse is very important in making a prognosis. If the evening temperature does not rise above io4°F. and the pulse is good, the prognosis is favorable. In diphtheria a temperature of ioi°F. and a pulse of 120 is grave. If the temperature con-

FEVER IN GENERAL 21

tinue at io5°F. for four or five hours in a case of typhoid fever, the prognosis is grave.

Children tolerate a higher fever than adults. A temperature of io4°F. in a child is of the same import as io2°F. in an adult. Disproportion between the surface and mouth temperature is serious.

Sudden and continuous rise of temperature in the course of a disease, if all complications can be excluded, is usually antemortem.

Stages of Fever. — Fever may be divided into three stages; namely, invasion, fastigium, and decline.

Invasion extends from the beginning of the febrile manifestations until the fever reaches its height. It varies in length, degree, and character in various diseases. In typhoid fever the invasion is of about ten days' duration. The fever gradually increases in a step-like manner, with diurnal remissions for seven to ten days, when it reaches its height. In pneumonia, on the other hand, the invasion is very abrupt and of short duration. The fever reaches its height, as a rule, in twenty-four or forty-eight hours.

Fastigium is that period when the fever is at its height, and extends from the end of the invasion to the beginning of decline. In typhoid fever the fastigium is about twelve days long. The evening rise reaches about the same height every day and the diurnal remission is less than the remission during the invasion. In pneumonia the period of the fastigium is shorter than in typhoid, lasting as a rule, from four to six days, with hardly any remission.

Decline of fever may take place in one of two ways: by lysis, that is, a gradual fall of the fever; or by crisis — a sudden fall to normal. The principal diseases in which the temperature falls by crisis are lobar pneumonia, typhus fever, erysipelas, measles, relapsing fever, and influenza. In most other diseases the fall is by lysis.

Types of Fever. — All fevers may be placed under three heads: continued, remittent, intermittent. In continued fever the temperature remains at a more or less constant height, with little or no daily remission. Examples of this type are lobar pneumonia and typhoid fever. In remittent fever, the diurnal remission is marked, but the lowest daily temperature is still above the normal, as in malarial remittent fever and in certain types of tuberculosis. In intermittent fever the temperature falls to the normal or subnormal diurnally and again rises, as in malarial intermittent fever, relapsing fever, and certain forms of tuberculosis.

Phenomena of Fever. — Rise of temperature may be the result or the cause of other concomitant symptoms. Among the common accompaniments of fever are headache, malaise, muscular pains, languor, chilly sensations, loss of appetite, coated tongue, tendency to yawn, flushed face, glistening eyes, nausea or vomiting, constipation as a rule, increased rate of pulse and respirations, hot and dry skin. The urine is concentrated, small in amount, dark in color, of high specific gravity and contains albumin.

Treatment of Fever. — There are eight divisions to the proper treatment of fever; namely, neutralize the poison; promote elimination; reduce the temperature if high; maintain nutrition; stimulate when necessary; relieve symptoms; prevent and counteract complications; use care in convalescence.

Neutralize poisons. — 'This is very difficult. In those diseases for which we have antitoxins thev should be

FEVER IN GENERAL used early and in sufficient quantity. Hypodermoclysis of normal saline solution is very useful in diluting the poisons in the blood and aiding in their elimination.

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Fig. 1. — Temperature chart of a continued fever

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Fig. 2. — Temperature chart of a remittent fever.

In those diseases in which toxins are formed in the intestinal tract, certain disinfectants as salol, creosote, guaiacol, and thymol are useful.

Promote elimination by the bowels with purgatives and enemata. By the kidneys in giving plenty of water to drink; also rectal infusions and hypodermoclyses of normal saline solution. By the skin with hot packs, hot dry air, and hot drinks.

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Reduce the temperature by hydrotherapeutic measures (see subsequent articles) and by means of drugs.

Maintain nutrition by food of proper quality and in proper quantity.

Stimulation and other headings under general treatment will be considered in subsequent chapters.

Chapter II Hygiene Of The Sickroom

Ventilation. — -One of the most important considerations of the sickroom is its ventilation. The refuse or altered products of all substances taken into the body for its nourishment are eliminated as worthless to the human economy and are not to be introduced into the system. This is just as true in regard to the respiratory system. Air rich in oxygen is inhaled; the oxygen is used to maintain the vital processes, and a combustion product, known as carbon dioxid, and certain organic materials worthless to the human being, are exhaled, and are not supposed to return to the body. This makes it necessary to provide a free exit for these substances from the breathing area of the person.

The oxygen of the inhaled air combines with certain elements of the blood and displaces the carbon dioxid of the blood. This latter has been carried by the circulation from the different parts of the body to the lungs, and is eliminated in the expired air, together with a small amount of organic material.

If a person be confined in a closed room, he will in a certain time, depending on the size of the room, have used all the available oxygen of the air and have replaced it with carbon dioxid and organic matter. These will begin to act as poisons and destroy the life of the person unless he be taken out of the room, or fresh air admitted.

The estimated amount of air space necessary for one person is about 2000 cubic feet with a supply of about 1500 cubic feet per hour.

Now let us consider the sick person. If a fresh supply of air be necessary for an individual who is physically strong and in perfect health, how much more necessary is fresh air to a person whose body is debilitated by illness, whose vital processes are being hampered by high fever and toxins? How necessary is it to give free exit to the expired air, not only containing carbon dioxid and organic matter, but also the products of bacterial life, and in some instances bacteria themselves?

Ventilation of rooms is brought about in several ways. By disproportion between the temperature of the rooms and that outside; by the natural diffusion of gases; by openings allowing the free entrance and exit of air. We will deal only with the last-mentioned means.

There is a vast difference between draughts and ventilation. The former are a source of injury but the latter is not only not injurious, but very necessary. Some people think that in order to ventilate a room it is necessary to create a draught.

There are two useful methods of supplying fresh air to the patient. The first is by continuous free ventilation; that is, by having a large supply of air entering the room constantly. The second method consists in having a more limited constant supply, and then several times a day, after covering the patient's body well and placing a thin cloth over his face, opening the windows widelv for a brief time.

HYGIENE OF THE SICKROOM

In many modern dwellings the system of ventilation is perfect and in these cases manipulating the windows is unnecessary, but as a general thing, ventilators in houses are such in name only.

Fig. 4. — Window ventilation. A, A'. Inserted boards.

A very practical method of arranging the windows is as follows: Lower the upper sash from three to six inches, raise the lower sash the same distance, and fill in the open spaces, above and below, with pieces of board that exactly lit the window frame. At the center of the window there is then formed an air space between the lower part of the upper pane of glass and the upper part of the lower glass, and this space com-

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Fig. 5- — Diagram of window ventilation (side view). A, A', window frame; B, B', inserted boards; C, C, window sash; E, E', window glass; H, H', currents of air going in and out.

municates both with the outside air and the inside of the room to be ventilated. (See illustrations.)

All kinds of flames, as in stoves, lamps, and gas jets, use up the oxygen of the air. These not only consume that which is of vital importance to the patient, but also vitiate the air with poisonous and oppressive gases.

HYGIENE OF THE SICKROOM 20.

Do not burn more gas or oil in a sickroom than is absolutely necessary. It is stated that an ordinary gas burner in use consumes more oxygen in one hour than a person would use in six hours.

Dr. Wm. P. Northrup, of New York, has said: "If you wish to kill a child who is sick with pneumonia, close your windows, start the gas stove, burn a few gas jets, have plenty of friends in the room to help use the air, and have the temperature of the room above 8o°F."

We have considered the quantity of air. Of next importance is its quality. The air should be of a certain temperature. If the person be very feverish, the temperature of the room should be between 65°F. and 68° F., and when the temperature of the patient becomes normal or falls below the normal, the temperature of the room should approach 7o°F.

Perfectly dry air is very irritating to the respiratory passages, and normally air should be a little moist. In houses heated by hot air furnaces it may be necessary to dampen the air. This is done by hanging in the room towels or cloths dampened with water; or in some cases, especially when the patient is ill with a disease of the respiratory tract, a steaming apparatus is very useful Moisture may also be furnished by simply boiling water in the room.

The Room and Its Furniture.— The room should be of fairly good size so as to provide plenty of air space. Southern exposure is to be selected if choice be given. Plenty of sunshine will not only enliven and brighten the patient, but it also acts as a bactericide. The eyes of the patient should not face the bright light. Only such furniture should remain in the room as is absolutely necessary — a bed, one or two small stands, and a couple of chairs. In cases of contagious diseases the pictures and curtain hangings should be removed.

Do not allow unused glasses of water to remain in the sickroom, and plants and flowers should be excluded. A very ill patient will not recognize or appreciate flowers, and if he wishes to see them they might be placed in an adjoining room within the sight of the patient.

During the insect season the windows and doors of the sickroom should be thoroughly screened. Mosquitoes and flies must be kept from the patient's room, because of their annoyance to the sick person and their likelihood to disseminate disease.

Preparation of Bed. — -The proper preparation and care of the bed is one of the most important duties of the nurse. The principal considerations are that the bed should be neither hard nor soft; the bedclothing should be smooth, and the coverings should be sufficient but light.

Over a good hair mattress are smoothly placed, first, a soft blanket, then a cotton sheet. A draw-sheet is a very convenient addition. This consists of a sheet so folded as to be about three or four feet wide, placed crosswise on the undersheet and tucked in under the mattress at the sides. It should be placed so the buttocks of the patient are midway between the upper and lower edges of the draw-sheet. If necessary, a piece of rubber sheeting or table oilcloth may be put under the draw-sheet to protect the under-bedclothing from discharges. Over the patient should be placed a soft cotton sheet and a light blanket or quilt. Do not tuck these top pieces of bedclothing tautly under the sides of the mattress, for it is very annoying for the patient

HYGIENE OF THE SICKROOM 3 1

to have the clothing weight down or pull on the toes when he is in the supine position.

The bedclothing of a fever patient should be changed without any active movement on the part of the patient. By means of a draw-sheet, the patient may be drawn from one side to another of the bed, when the soiled under-bedclothing may be rolled up as far as the body of the patient and the clean clothing be applied over the uncovered portion of the bed, with the excess folded and placed beside the patient's body; then, by means of a draw-sheet, the patient may be lifted over the pile of soiled clothing and the folds of new clothing on the freshly prepared portion of the bed, when the remainder may be adjusted and a new draw-sheet applied.

Probably the most convenient form of body clothing for the patient is a short cotton gown, fastened at the back with tapes.

Quiet. — -Quietness in a sickroom is very essential. Only those persons whose services are needful should be allowed in the room, and under no circumstances should any person outside of the immediate family and spiritual advisor be permitted to enter the room during the acute course of the disease.

Loud talking and noises of all kinds should be prohibited both inside and outside of the room. All conversation in the sickroom should be carried on in a low, soft voice, but not in a whisper. It is very unwise to converse in the sickroom in such a manner that the patient can not hear it, for it at once arouses his curiosity and may excite him. If you have anything to say to the physician or attendants which the patient should not hear, postpone saying it until you leave the room.

In the acute fevers of children probably quiet is even more necessary than for adults. The child should rest quietly in bed and not held in the laps of elders and passed on from one to another, as this is very enervating and exhausts the little patient, and may bring about a fatal issue which otherwise could be averted. Attempts should not be made to entertain small children ill with one of the fevers, neither should they be urged to look at pictures or read to. Every chance should be given the recuperative powers to bring the little patient again to the state of health.

The clothing of the child should be light, and swaddling be relegated to the domain of ancient customs. The feet of all ill children should be kept warm by means of the hot-water bags, hot foot-blankets or heated irons or cloths. The room should be well ventilated and the access of fresh air made free.

The child should be urged to drink sufficient water. A daily morning cleansing bath of warm water is required and a nightly warm bath is conducive of restfulness. A daily bowel movement is very important.

The febrile disturbance in children is best met by means of a cool or tepid-water sponge followed by an alcohol rub, and by the employment of cold chest and abdomen packs.

The diet, as in adults, should be reduced.

Chapter III Diet Of The Sick

A foodstuff is that substance which, when introduced into the human body, is digested and assimilated, aids in the formation of new tissues, prevents the waste of tissue, or helps in the production of heat and energy.

Food is a collection of foodstuffs to supply those elements necessary to maintain life. The five fundamental foodstuffs are nitrogenous bodies, as proteids, carbohydrates, fats, inorganic salts, and water. The principal elements found in foodstuffs are nitrogen, hydrogen, oxygen, carbon, phosphorus, and sulphur.

The proteids contain all the mentioned elements, and serve to form new tissues, supply nervous energy, and create heat.

The carbohydrates contain hydrogen, oxygen, and carbon, provide heat or at times form fat, but cannot form other tissues.

The fats contain the same elements as the carbohydrates, and perform the same functions.

The water and salts supply and keep up the normal percentages of these substances in the body.

From what has been said above it will be easily understood that an absolute diet of fats and carbohydrates will not suffice, as these bodies do not supply nitrogen 3 33 which is necessary for building new tissues. On the other hand, life may be sustained on a diet with these two foodstuffs omitted.

The chief requisites of food are that it be well cooked; that it be in good form; be pleasing to the eye; taste well, and contain in good proportion all those elements necessary to maintain life.

Frequency of Feeding. — In acute infectious fevers food plays as important a part as medicines. It is in these cases that "support" of the patient depends on the food.

During the course of the disease food must be given just as regularly as medicine, every two or three hours being usually frequent enough. About night feeding there is much debate, some authorities not wishing their patients awakened for food. It is an established fact that the vital functions are at their lowest in the early morning hours, and often a glass of milk or other nourishment has turned the tide for the better in adynamic conditions at this time. It is better to give the medicine and nourishment at the same time during the night, so as to avoid frequent awaking of the patient.

Milk. — No one substance forms an ideal food, but of all substances milk comes nearest to being perfect. In milk all the elementary foodstuffs will be found. Proteid in the casein; carbohydrates as milk sugar; fats in the cream; inorganic salts as calcium phosphate, potassium chlorid, etc.; and water represented by the fluid portion.

In fevers milk forms the sole diet. This subject has been the cause of much debate and good points have been brought up on both sides. Those in favor of a milk diet say that life can be supported indefinitely on milk, that it is not irritating to the intestinal tract, that it leaves very little residue, that it is easily obtained and is cheap, that it is readily digested by most persons and if not, it may be artificially digested. Other authorities say that to many individuals milk is distasteful, it causes the formation of gas and tympanites, that it does not contain in proper proportion the elements necessary to the sustenance of animal life, that the excess of lime salts predispose to thrombi formation, that in order to get sufficient nourishment enormous amounts must be given, which will overburden the digestive apparatus.

The daily amount of milk necessary is between three pints and two quarts. If five ounces of milk be given every two hours, it will, as a rule, be sufficient. Many persons cannot take undiluted milk. In these cases the milk may be diluted with lime water, barley water, oatmeal water, or vichy.

In profound conditions the process of digestion must be aided. This may be done by giving pepsin and dilute hydrochloric acid after the administration of the milk, or by digesting the milk wholly or in part (see peptonized milk below).

It is often necessary when nursing children are taken ill with a contagious disease, to cease feeding them with the milk from the mother's breasts, and to modify cow's milk so that it will approach the composition of the mother's milk. Following will be found a convenient scheme for modifying cow's milk.

MODIFICATION OF COW'S MILK FOR INFANT FEEDING

I. Compositions of the Various Milks.

Percentage of Fat. Sugar. Proteid.

(a) Cow's Milk, 44 4

(b) Gravity Cream, 16 4 4

(c) Human Milk (high), 47 2

(d) Human Milk (low), 36 1

II. Feeding at Various Ages.

(a) Birth to 1st Month, 1 6 1

(b) Birth to 1st Month, 2 6 1

(c) Birth to 1 st Month, 2 6 0.66

(d) 2nd to 4th Month, 36 1

(e) 4th to 1 2 th Month, 47 2

(f) After 1 2th Month, 44 4

III. Daily Feedings and Amount of Milk.

(a) 1st Month, 8 Day and 2 Night Feedings, each

(b) 2nd Month, 8 Day and 1 Night Feeding, each

(c) 3rd Month, 8 Day and o Night Feedings, each

(d) 4th Month, 7 Day and o Night Feedings, each

(e) 6th Month, 6 Day and o Night Feedings, each

(f) 10th Month, 5 Day and o Night Feedings, each

IV. Total Daily Amount of Milk.

(a) 1 st Month, 20 Ounces.

(b) 2nd Month, 27 Ounces.

(c) 3rd Month, 32 Ounces.

(d) 4th Month, 35 Ounces.

(e) 6th Month, 42 Ounces.

(f) 10th Month, 40 Ounces.

V. Methods of Obtaining the Various Compositions.

(a) Formula 1-6-1.

Parts. Fat. Sugar. Proteid.

Boiled Water, (6) o o o