Notes on Nursing by Florence Nightingale
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10 NOTES ON NURSING:
WHAT IT IS, AND WHAT IT IS NOT.
BY
FLORENCE NIGHTINGALE.
NEW YORK:
D. APPLETON AND COMPANY
72 FIFTH AVENUE
1898.
PREFACE.
The following notes are by no means intended as a rule of thought by
which nurses can teach themselves to nurse, still less as a manual to
teach nurses to nurse. They are meant simply to give hints for thought
to women who have personal charge of the health of others. Every woman,
or at least almost every woman, in England has, at one time or another
of her life, charge of the personal health of somebody, whether child or
invalid,--in other words, every woman is a nurse. Every day sanitary
knowledge, or the knowledge of nursing, or in other words, of how to put
the constitution in such a state as that it will have no disease, or
that it can recover from disease, takes a higher place. It is recognized
as the knowledge which every one ought to have--distinct from medical
knowledge, which only a profession can have.
If, then, every woman must at some time or other of her life, become a
nurse, _i.e._, have charge of somebody's health, how immense and how
valuable would be the produce of her united experience if every woman
would think how to nurse.
I do not pretend to teach her how, I ask her to teach herself, and for
this purpose I venture to give her some hints.
TABLE OF CONTENTS.
VENTILATION AND WARMING
HEALTH OF HOUSES
PETTY MANAGEMENT
NOISE
VARIETY
TAKING FOOD
WHAT FOOD?
BED AND BEDDING
LIGHT
CLEANLINESS OF ROOMS AND WALLS
PERSONAL CLEANLINESS
CHATTERING HOPES AND ADVICES
OBSERVATION OF THE SICK
CONCLUSION
APPENDIX
NOTES ON NURSING:
WHAT IT IS, AND WHAT IT IS NOT.
* * * * *
[Sidenote: Disease a reparative process.]
Shall we begin by taking it as a general principle--that all disease, at
some period or other of its course, is more or less a reparative
process, not necessarily accompanied with suffering: an effort of
nature to remedy a process of poisoning or of decay, which has taken
place weeks, months, sometimes years beforehand, unnoticed, the
termination of the disease being then, while the antecedent process was
going on, determined?
If we accept this as a general principle, we shall be immediately met
with anecdotes and instances to prove the contrary. Just so if we were
to take, as a principle--all the climates of the earth are meant to be
made habitable for man, by the efforts of man--the objection would be
immediately raised,--Will the top of Mount Blanc ever be made habitable?
Our answer would be, it will be many thousands of years before we have
reached the bottom of Mount Blanc in making the earth healthy. Wait till
we have reached the bottom before we discuss the top.
[Sidenote: Of the sufferings of disease, disease not always the cause.]
In watching diseases, both in private houses and in public hospitals,
the thing which strikes the experienced observer most forcibly is this,
that the symptoms or the sufferings generally considered to be
inevitable and incident to the disease are very often not symptoms of
the disease at all, but of something quite different--of the want of
fresh air, or of light, or of warmth, or of quiet, or of cleanliness, or
of punctuality and care in the administration of diet, of each or of all
of these. And this quite as much in private as in hospital nursing.
The reparative process which Nature has instituted and which we call
disease, has been hindered by some want of knowledge or attention, in
one or in all of these things, and pain, suffering, or interruption of
the whole process sets in.
If a patient is cold, if a patient is feverish, if a patient is faint,
if he is sick after taking food, if he has a bed-sore, it is generally
the fault not of the disease, but of the nursing.
[Sidenote: What nursing ought to do.]
I use the word nursing for want of a better. It has been limited to
signify little more than the administration of medicines and the
application of poultices. It ought to signify the proper use of fresh
air, light, warmth, cleanliness, quiet, and the proper selection and
administration of diet--all at the least expense of vital power to the
patient.
[Sidenote: Nursing the sick little understood.]
It has been said and written scores of times, that every woman makes a
good nurse. I believe, on the contrary, that the very elements of
nursing are all but unknown.
By this I do not mean that the nurse is always to blame. Bad sanitary,
bad architectural, and bad administrative arrangements often make it
impossible to nurse.
But the art of nursing ought to include such arrangements as alone make
what I understand by nursing, possible.
The art of nursing, as now practised, seems to be expressly constituted
to unmake what God had made disease to be, viz., a reparative process.
[Sidenote: Nursing ought to assist the reparative process.]
To recur to the first objection. If we are asked, Is such or such a
disease a reparative process? Can such an illness be unaccompanied with
suffering? Will any care prevent such a patient from suffering this or
that?--I humbly say, I do not know. But when you have done away with all
that pain and suffering, which in patients are the symptoms not of their
disease, but of the absence of one or all of the above-mentioned
essentials to the success of Nature's reparative processes, we shall
then know what are the symptoms of and the sufferings inseparable from
the disease.
Another and the commonest exclamation which will be instantly made is--
Would you do nothing, then, in cholera, fever, &c.?--so deep-rooted and
universal is the conviction that to give medicine is to be doing
something, or rather everything; to give air, warmth, cleanliness, &c.,
is to do nothing. The reply is, that in these and many other similar
diseases the exact value of particular remedies and modes of treatment
is by no means ascertained, while there is universal experience as to
the extreme importance of careful nursing in determining the issue of
the disease.
[Sidenote: Nursing the well.]
II. The very elements of what constitutes good nursing are as little
understood for the well as for the sick. The same laws of health or of
nursing, for they are in reality the same, obtain among the well as
among the sick. The breaking of them produces only a less violent
consequence among the former than among the latter,--and this sometimes,
not always.
It is constantly objected,--"But how can I obtain this medical
knowledge? I am not a doctor. I must leave this to doctors."
[Sidenote: Little understood.]
Oh, mothers of families! You who say this, do you know that one in every
seven infants in this civilized land of England perishes before it is
one year old? That, in London, two in every five die before they are
five years old? And, in the other great cities of England, nearly one
out of two?[1] "The life duration of tender babies" (as some Saturn,
turned analytical chemist, says) "is the most delicate test" of sanitary
conditions. Is all this premature suffering and death necessary? Or did
Nature intend mothers to be always accompanied by doctors? Or is it
better to learn the piano-forte than to learn the laws which subserve
the preservation of offspring?
Macaulay somewhere says, that it is extraordinary that, whereas the laws
of the motions of the heavenly bodies, far removed as they are from us,
are perfectly well understood, the laws of the human mind, which are
under our observation all day and every day, are no better understood
than they were two thousand years ago.
But how much more extraordinary is it that, whereas what we might call
the coxcombries of education--_e.g._, the elements of astronomy--are now
taught to every school-girl, neither mothers of families of any class,
nor school-mistresses of any class, nor nurses of children, nor nurses
of hospitals, are taught anything about those laws which God has
assigned to the relations of our bodies with the world in which He has
put them. In other words, the laws which make these bodies, into which
He has put our minds, healthy or unhealthy organs of those minds, are
all but unlearnt. Not but that these laws--the laws of life--are in a
certain measure understood, but not even mothers think it worth their
while to study them--to study how to give their children healthy
existences. They call it medical or physiological knowledge, fit only
for doctors.
Another objection.
We are constantly told,--"But the circumstances which govern our
children's healths are beyond our control. What can we do with winds?
There is the east wind. Most people can tell before they get up in the
morning whether the wind is in the east."
To this one can answer with more certainty than to the former
objections. Who is it who knows when the wind is in the east? Not the
Highland drover, certainly, exposed to the east wind, but the young lady
who is worn out with the want of exposure to fresh air, to sunlight, &c.
Put the latter under as good sanitary circumstances as the former, and
she too will not know when the wind is in the east.
FOOTNOTES:
[1]
[Sidenote: Curious deductions from an excessive death rate.]
Upon this fact the most wonderful deductions have been strung. For a
long time an announcement something like the following has been going
the round of the papers:--"More than 25,000 children die every year in
London under 10 years of age; therefore we want a Children's Hospital."
This spring there was a prospectus issued, and divers other means taken
to this effect:--"There is a great want of sanitary knowledge in women;
therefore we want a Women's Hospital." Now, both the above facts are too
sadly true. But what is the deduction? The causes of the enormous child
mortality are perfectly well known; they are chiefly want of
cleanliness, want of ventilation, want of whitewashing; in one word,
defective _household_ hygiene. The remedies are just as well known; and
among them is certainly not the establishment of a Child's Hospital.
This may be a want; just as there may be a want of hospital room for
adults. But the Registrar-General would certainly never think of giving
us as a cause for the high rate of child mortality in (say) Liverpool
that there was not sufficient hospital room for children; nor would he
urge upon us, as a remedy, to found an hospital for them.
Again, women, and the best women, are wofully deficient in sanitary
knowledge; although it is to women that we must look, first and last,
for its application, as far as _household_ hygiene is concerned. But who
would ever think of citing the institution of a Women's Hospital as the
way to cure this want? We have it, indeed, upon very high authority
that there is some fear lest hospitals, as they have been _hitherto_,
may not have generally increased, rather than diminished, the rate of
mortality--especially of child mortality.
I. VENTILATION AND WARMING.
[Sidenote: First rule of nursing, to keep the air within as pure as the
air without.]
The very first canon of nursing, the first and the last thing upon which
a nurse's attention must be fixed, the first essential to a patient,
without which all the rest you can do for him is as nothing, with which
I had almost said you may leave all the rest alone, is this: TO KEEP THE
AIR HE BREATHES AS PURE AS THE EXTERNAL AIR, WITHOUT CHILLING HIM. Yet
what is so little attended, to? Even where it is thought of at all, the
most extraordinary misconceptions reign about it. Even in admitting air
into the patient's room or ward, few people ever think, where that air
comes from. It may come from a corridor into which other wards are
ventilated, from a hall, always unaired, always full of the fumes of
gas, dinner, of various kinds of mustiness; from an underground kitchen,
sink, washhouse, water-closet, or even, as I myself have had sorrowful
experience, from open sewers loaded with filth; and with this the
patient's room or ward is aired, as it is called--poisoned, it should
rather be said. Always, air from the air without, and that, too, through
those windows, through which the air comes freshest. From a closed
court, especially if the wind do not blow that way, air may come as
stagnant as any from a hall or corridor.
Again, a thing I have often seen both in private houses and
institutions. A room remains uninhabited; the fireplace is carefully
fastened up with a board; the windows are never opened; probably the
shutters are kept always shut; perhaps some kind of stores are kept in
the room; no breath of fresh air can by possibility enter into that
room, nor any ray of sun. The air is as stagnant, musty, and corrupt as
it can by possibility be made. It is quite ripe to breed small-pox,
scarlet-fever, diphtheria, or anything else you please.[1]
Yet the nursery, ward, or sick room adjoining will positively be aired
(?) by having the door opened into that room. Or children will be put
into that room, without previous preparation, to sleep.
A short time ago a man walked into a back-kitchen in Queen square, and
cut the throat of a poor consumptive creature, sitting by the fire. The
murderer did not deny the act, but simply said, "It's all right." Of
course he was mad.
But in our case, the extraordinary thing is that the victim says, "It's
all right," and that we are not mad. Yet, although we "nose" the
murderers, in the musty unaired unsunned room, the scarlet fever which
is behind the door, or the fever and hospital gangrene which are
stalking among the crowded beds of a hospital ward, we say, "It's all
right."
[Sidenote: Without chill.]
With a proper supply of windows, and a proper supply of fuel in open
fire places, fresh air is comparatively easy to secure when your patient
or patients are in bed. Never be afraid of open windows then. People
don't catch cold in bed. This is a popular fallacy. With proper
bed-clothes and hot bottles, if necessary, you can always keep a patient
warm in bed, and well ventilate him at the same time.
But a careless nurse, be her rank and education what it may, will stop
up every cranny and keep a hot-house heat when her patient is in bed,--
and, if he is able to get up, leave him comparatively unprotected. The
time when people take cold (and there are many ways of taking cold,
besides a cold in the nose,) is when they first get up after the
two-fold exhaustion of dressing and of having had the skin relaxed by
many hours, perhaps days, in bed, and thereby rendered more incapable of
re-action. Then the same temperature which refreshes the patient in bed
may destroy the patient just risen. And common sense will point out,
that, while purity of air is essential, a temperature must be secured
which shall not chill the patient. Otherwise the best that can be
expected will be a feverish re-action.
To have the air within as pure as the air without, it is not necessary,
as often appears to be thought, to make it as cold.
In the afternoon again, without care, the patient whose vital powers
have then risen often finds the room as close and oppressive as he found
it cold in the morning. Yet the nurse will be terrified, if a window is
opened.[2]
[Sidenote: Open windows.]
I know an intelligent humane house surgeon who makes a practice of
keeping the ward windows open. The physicians and surgeons invariably
close them while going their rounds; and the house surgeon very properly
as invariably opens them whenever the doctors have turned their backs.
In a little book on nursing, published a short time ago, we are told,
that, "with proper care it is very seldom that the windows cannot be
opened for a few minutes twice in the day to admit fresh air from
without." I should think not; nor twice in the hour either. It only
shows how little the subject has been considered.
[Sidenote: What kind of warmth desirable.]
Of all methods of keeping patients warm the very worst certainly is to
depend for heat on the breath and bodies of the sick. I have known a
medical officer keep his ward windows hermetically closed. Thus exposing
the sick to all the dangers of an infected atmosphere, because he was
afraid that, by admitting fresh air, the temperature of the ward would
be too much lowered. This is a destructive fallacy.
To attempt to keep a ward warm at the expense of making the sick
repeatedly breathe their own hot, humid, putrescing atmosphere is a
certain way to delay recovery or to destroy life.
[Sidenote: Bedrooms almost universally foul.]
Do you ever go into the bed-rooms of any persons of any class, whether
they contain one, two, or twenty people, whether they hold sick or well,
at night, or before the windows are opened in the morning, and ever find
the air anything but unwholesomely close and foul? And why should it be
so? And of how much importance it is that it should not be so? During
sleep, the human body, even when in health, is far more injured by the
influence of foul air than when awake. Why can't you keep the air all
night, then, as pure as the air without in the rooms you sleep in? But
for this, you must have sufficient outlet for the impure air you make
yourselves to go out; sufficient inlet for the pure air from without to
come in. You must have open chimneys, open windows, or ventilators; no
close curtains round your beds; no shutters or curtains to your windows,
none of the contrivances by which you undermine your own health or
destroy the chances of recovery of your sick.[3]
[Sidenote: When warmth must be most carefully looked to.]
A careful nurse will keep a constant watch over her sick, especially
weak, protracted, and collapsed cases, to guard against the effects of
the loss of vital heat by the patient himself. In certain diseased
states much less heat is produced than in health; and there is a
constant tendency to the decline and ultimate extinction of the vital
powers by the call made upon them to sustain the heat of the body. Cases
where this occurs should be watched with the greatest care from hour to
hour, I had almost said from minute to minute. The feet and legs should
be examined by the hand from time to time, and whenever a tendency to
chilling is discovered, hot bottles, hot bricks, or warm flannels, with
some warm drink, should be made use of until the temperature is
restored. The fire should be, if necessary, replenished. Patients are
frequently lost in the latter stages of disease from want of attention
to such simple precautions. The nurse may be trusting to the patient's
diet, or to his medicine, or to the occasional dose of stimulant which
she is directed to give him, while the patient is all the while sinking
from want of a little external warmth. Such cases happen at all times,
even during the height of summer. This fatal chill is most apt to occur
towards early morning at the period of the lowest temperature of the
twenty-four hours, and at the time when the effect of the preceding
day's diets is exhausted.
Generally speaking, you may expect that weak patients will suffer cold
much more in the morning than in the evening. The vital powers are much
lower. If they are feverish at night, with burning hands and feet, they
are almost sure to be chilly and shivering in the morning. But nurses
are very fond of heating the foot-warmer at night, and of neglecting it
in the morning, when they are busy. I should reverse the matter.
All these things require common sense and care. Yet perhaps in no one
single thing is so little common sense shown, in all ranks, as in
nursing.[4]
[Sidenote: Cold air not ventilation, nor fresh air a method of chill.]
The extraordinary confusion between cold and ventilation, even in the
minds of well educated people, illustrates this. To make a room cold is
by no means necessarily to ventilate it. Nor is it at all necessary, in
order to ventilate a room, to chill it. Yet, if a nurse finds a room
close, she will let out the fire, thereby making it closer, or she will
open the door into a cold room, without a fire, or an open window in it,
by way of improving the ventilation. The safest atmosphere of all for a
patient is a good fire and an open window, excepting in extremes of
temperature. (Yet no nurse can ever be made to understand this.) To
ventilate a small room without draughts of course requires more care
than to ventilate a large one.
[Sidenote: Night air.]
Another extraordinary fallacy is the dread of night air. What air can we
breathe at night but night air? The choice is between pure night air
from without and foul night air from within. Most people prefer the
latter. An unaccountable choice. What will they say if it is proved to
be true that fully one-half of all the disease we suffer from is
occasioned by people sleeping with their windows shut? An open window
most nights in the year can never hurt any one. This is not to say that
light is not necessary for recovery. In great cities, night air is often
the best and purest air to be had in the twenty-four hours. I could
better understand in towns shutting the windows during the day than
during the night, for the sake of the sick. The absence of smoke, the
quiet, all tend to making night the best time for airing the patients.
One of our highest medical authorities on Consumption and Climate has
told me that the air in London is never so good as after ten o'clock at
night.
[Sidenote: Air from the outside. Open your windows, shut your doors.]
Always air your room, then, from the outside air, if possible. Windows
are made to open; doors are made to shut--a truth which seems extremely
difficult of apprehension. I have seen a careful nurse airing her
patient's room through the door, near to which were two gaslights, (each
of which consumes as much air as eleven men,) a kitchen, a corridor, the
composition of the atmosphere in which consisted of gas, paint, foul
air, never changed, full of effluvia, including a current of sewer air
from an ill-placed sink, ascending in a continual stream by a
well-staircase, and discharging themselves constantly into the patient's
room. The window of the said room, if opened, was all that was desirable
to air it. Every room must be aired from without--every passage from
without. But the fewer passages there are in a hospital the better.
[Sidenote: Smoke.]
If we are to preserve the air within as pure as the air without, it is
needless to say that the chimney must not smoke. Almost all smoky
chimneys can be cured--from the bottom, not from the top. Often it is
only necessary to have an inlet for air to supply the fire, which is
feeding itself, for want of this, from its own chimney. On the other
hand, almost all chimneys can be made to smoke by a careless nurse, who
lets the fire get low and then overwhelms it with coal; not, as we
verily believe, in order to spare herself trouble, (for very rare is
unkindness to the sick), but from not thinking what she is about.
[Sidenote: Airing damp things in a patient's room.]
In laying down the principle that this first object of the nurse must be
to keep the air breathed by her patient as pure as the air without, it
must not be forgotten that everything in the room which can give off
effluvia, besides the patient, evaporates itself into his air. And it
follows that there ought to be nothing in the room, excepting him, which
can give off effluvia or moisture. Out of all damp towels, &c., which
become dry in the room, the damp, of course, goes into the patient's
air. Yet this "of course" seems as little thought of, as if it were an
obsolete fiction. How very seldom you see a nurse who acknowledges by
her practice that nothing at all ought to be aired in the patient's
room, that nothing at all ought to be cooked at the patient's fire!
Indeed the arrangements often make this rule impossible to observe.
If the nurse be a very careful one, she will, when the patient leaves
his bed, but not his room, open the sheets wide, and throw the
bed-clothes back, in order to air his bed. And she will spread the wet
towels or flannels carefully out upon a horse, in order to dry them. Now
either these bed-clothes and towels are not dried and aired, or they dry
and air themselves into the patient's air. And whether the damp and
effluvia do him most harm in his air or in his bed, I leave to you to
determine, for I cannot.
[Sidenote: Effluvia from excreta.]
Even in health people cannot repeatedly breathe air in which they live
with impunity, on account of its becoming charged with unwholesome
matter from the lungs and skin. In disease where everything given off
from the body is highly noxious and dangerous, not only must there be
plenty of ventilation to carry off the effluvia, but everything which
the patient passes must be instantly removed away, as being more noxious
than even the emanations from the sick.
Of the fatal effects of the effluvia from the excreta it would seem
unnecessary to speak, were they not so constantly neglected. Concealing
the utensils behind the vallance to the bed seems all the precaution
which is thought necessary for safety in private nursing. Did you but
think for one moment of the atmosphere under that bed, the saturation of
the under side of the mattress with the warm evaporations, you would be
startled and frightened too!
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