Home Nursing: The Patient In Bed

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One of the first aid measures that may well be taken when first observing signs of illness is to put the patient to bed. In bed he will feel more comfortable; he will be warm, quiet, and relaxed, giving the body a chance to rest, build resistance, and help repair any damage. During the first few days in bed, sick people nearly always sleep more than usual, which is highly beneficial since sleep is a great healer. Complications or prolonged illness are often avoided by going to bed promptly when sickness occurs.

Perhaps the most important reason for urging anyone showing signs of illness to go to bed is to prevent the spread of a communicable disease. The early symptoms of many communicable diseases—fever, headache, nausea, sore throat, or running nose—may be the same as those for a cold, an upset stomach, or some other common ailment. To be on the safe side, therefore, the patient should be in a room by himself, if possible, until he feels better or until the doctor gives his diagnosis and orders for care. When the doctor tells a person to stay in bed, he is prescribing a form of treatment that is often as important as medicine, and without which sometimes his medicine can do little good. Sick children should always be put to bed and kept there if possible until the doctor gives his permission for them to get up.

Finally, it is easier for the home nurse to care for a patient who is in bed than to have to look after him as he wanders around the house.

SAVING THE STRENGTH OF THE HOME NURSE

Learning to make the best use of time, material, and money, as well as energy, will aid the home nurse to care for the sick at home as economically and efficiently as possible. Maintaining good posture at all times helps the body to function without unnecessary strain, thus saving the energy of the home nurse who, in all probability, also may have to carry responsibility for household work.

BODY POSTURE

Body posture means the position of the parts of the body, head, trunk, arms, and legs, and their relation to one another. Correct posture requires that in standing, sitting, or lying down the natural curves of the spine be maintained, the head be poised comfortably, and the arms and legs be in good alignment with the body.

Body Posture of the Home Nurse. The home nurse should maintain good body posture at all times in performing daily household tasks as well as when caring for the patient. Some important points to remember in maintaining good posture are:

1. Keep the chest up and forward to allow ample breathing space. Keep the head comfortably poised.

2. Take the proper stance by standing with the feet separated—toes pointing ahead—one foot forward for balance, when preparing to move a patient.

3. Prepare the muscles for action by taking the proper stance and tensing the abdominal muscles before moving or turning a patient.

4. Bend the knees, keep the back straight, and use the large leg and thigh muscles rather than the back muscles to save back strain when moving a patient.

5. Stand close and if possible have the work at about elbow height to save energy.

Body Posture of the Patient. Maintaining good body posture for the bed patient is the responsibility of the home nurse. Some fundamental principles for providing good posture for the patient in bed are:

1. Provide support for the back, shoulders, and head to maintain the natural spinal curves. Keep the chest up and forward to allow ample breathing space. Keep the head comfortably poised.

2. Support the large joints, such as the shoulders, hips, knees, and ankles, to prevent strain.

3. Change the position from time to time to avoid fatigue, prevent continued pressure on any one part of the body, avoid strain on the joints, prevent deformities, provide exercise, and promote circulation.

4. Support the feet at right angles to the legs for comfort and to prevent the tendons from tightening.

5. Encourage the patient to move about in bed if the doctor permits. This will help maintain good joint movement and good muscle tone, and improve the circulation of the blood. The nurse may need to give some passive exercise (exercising of a part of the body, as a muscle or a joint, by another person) to the patient.

THE SICKROOM

When selecting a room for the patient who is to be in bed for some time, it is well to consider the needs of both the patient and the home nurse and in so far as possible to provide:

1. A sunny, airy room.

2. A room convenient to the bathroom and to the home nurse.

3. Convenient and uncluttered arrangement of personal belongings and furniture, such as the bed, bureau, chairs, bedside table, washstand, washable curtains, and rugs.

4. Quiet.

The patient should be shielded from drafts; glaring surfaces should be avoided and direct lights kept from the patient’s eyes. If lights must be shaded, be careful of fire hazards. Rather than using cloth or paper to shade the bulbs, place the lights back of screens on or near the floor.

The sickroom should be kept at a temperature that is comfortable for the patient. It should be aired daily and precautions taken to prevent the patient from chilling. The room temperature should be especially warm when the patient is uncovered for treatments or baths. Gas and oil stoves are not desirable in a sickroom, as they use up oxygen.

Cleanliness and Order

Cleanliness and order are both important to the patient’s comfort and welfare. Cleanliness is a safety measure for the patient and other members of the family, while order is not only more pleasant for the patient, but also a timesaving convenience in getting work done. Cleanliness involves keeping the patient and his bed free from perspiration and body discharges, prompt removal of all soiled articles from the room (occasionally the doctor may suggest a deodorant when discharges are offensive), keeping down dust that might carry germs to the patient or from him to other people, and careful washing of the hands both before and after caring for the patient. Even though an illness is not known to be communicable, there may be disease germs that can be passed on to other people, and precautions must be taken by the generous use of soap and water.

The room should be cleaned in the morning as soon as possible after the patient has been bathed and his bed changed. In cleaning floors and in dusting, care should be taken that the bed is not bumped and that noise is kept to a minimum. The electric vacuum cleaner with its many attachments is ideal for removing dust unless the noise is too disturbing to the patient. If a vacuum cleaner cannot be used, small rugs should be taken from the room to be cleaned. Oiled or damp mops and dustcloths should be used to avoid stirring up the dust. A good dust mop may be made of old stockings or other soft material or an oiled or dampened cloth may be pinned around a broom.

Quiet

Small noises are often more disturbing than loud, accustomed sounds. Particularly disturbing noises are creaking doors, rattling windows, flapping shades, and the click of heels on bare floors.

Sitting on the bed, as well as jarring it, is also disturbing to a sick person, as is whispering or talking just beyond easy earshot. Conversation the patient should not hear should take place completely out of his hearing.

When complete rest in a quiet room is ordered as a part of the treatment, the home nurse should make every effort to see that it is provided for the patient.

THE PATIENT’S BED

The ideal bed for a sick person is one that is high enough to enable the home nurse to give care to the patient without straining her back and neck muscles. If the patient is to be in bed a long time, it is a good idea to get a hospital bed. Often these beds may be purchased or rented from a hospital or supply company. Such a bed has a metal frame, which is easy to clean; it is 36 to 40 inches wide and adjustable so that the patient’s head and feet can be raised or lowered mechanically. The legs have casters so that the bed can be easily rolled to a new position.

If a hospital bed is unnecessary or if it is impracticable to obtain one, the home nurse can find a number of ways to elevate a home bed to a height that will enable her to work with ease.

To make the bed higher, cinder blocks, large tin cans partially filled with sand, or specially built wood blocks may be used under each leg when the casters have been removed.

Bedstead and Springs

The standard size single bed is 39 inches wide and 6½ feet long. Longer beds are available for very tall people. A bed that is too short is uncomfortable and leads to bad posture. When necessary, added length may be provided by placing chairs and cushions or other support at the proper height at the foot of the bed if there is no footboard. The springs and mattress must be firm to maintain good body support; a bed that is too soft or one that sags is also uncomfortable and leads to bad posture; the bedpan may sink down or tip under the patient’s weight in such a bed. To prevent springs from sagging, a wide board may be placed under the mattress. This board should be the width of the bed and long enough to reach at least from the shoulders to the knees. Wallboard or stiff linoleum may be used for this purpose.

The Mattress

Mattresses may be made of rubber foam or filled with horsehair, felt and cotton, felt and kapok, straw, or corn husks. The two latter fillings grow bumpy with use and need to be renewed frequently. A good mattress pays for itself in comfort and durability.

Good care given to the mattress will prolong its life and help keep it in a sanitary condition. To keep a mattress clean, it should be enclosed in a muslin cover that can be removed and washed. Covers can be bought readymade with zipper closings or can be made at home from a good quality of unbleached muslin and fastened at the end with buttons, snaps, or tape ties. Waterproof coverings are also available.

The mattress should be turned regularly from end to end and from side to side so that pressure and wear will be distributed as evenly as possible. Exposure to the direct air and sunlight once a week will keep it fresh and clean smelling, and the air helps make the filling expand. A thorough brushing with a stiff whisk broom—or better, the use of a vacuum cleaner on the mattress—removes the dust and helps keep the mattress from packing down and growing hard.

If a special mattress is to be purchased for an invalid, the advice of the family doctor or the local hospital may be sought. It pays to buy a good mattress with durable, firm ticking if there is a bedridden invalid in the home. In addition to the mattress cover, a mattress pad of quilted cotton or a washable cotton quilt or blanket should be provided to protect the mattress from moisture or soiling.

Sheets

Sheets of ample size are necessary for both comfort and cleanliness. A safe rule is to have sheets a yard longer and a yard wider than the mattress. A sheet of such dimensions is large enough to tuck under the sides and leave 12 to 18 inches to tuck under the head of the mattress, providing good anchorage for the bottom sheet and sufficient length for the top sheet to fold over and protect the blankets at the head of the bed.

Pillows

The kinds and numbers of pillows will depend upon the patient’s needs and desires. A variety of pillows, such as hard, soft, large, and small, may be needed to provide necessary support. They should be kept covered, clean, and fluffed up. When possible, they should be aired in the sun occasionally.

Additional Bed Protection

Whenever a treatment is given in bed or the bedpan is used, or when there is vomiting or other body discharges are present, extra protection will be needed under the patient. This protection may be a sheet of rubber, oilcloth, or pliofilm, a piece of old sheeting or muslin, or several thicknesses of newspaper covered with a large piece of cloth, which can be removed and washed when soiled. Newspapers are not always satisfactory. They afford only limited protection, and the noise of their crackling and tearing may be disturbing to the patient.

Constant protection may be provided by a sheet or strip of oilcloth, rubber, or pliofilm wide enough to reach across the bed and tuck under the mattress and to extend well above and below the area needing protection (usually from the shoulders to the knees). Over this is placed a folded sheet, called a drawsheet, that can be drawn out easily and changed or moved from side to side to present a fresh surface; also, the patient may be moved with the aid of the drawsheet. The rubber sheet and drawsheet should be kept as tight, smooth, and dry as possible to insure the patient’s comfort. Sometimes the drawsheet alone is sufficient protection and saves frequent changing of the undersheet; this conserves the energy of both the patient and the home nurse.

Blankets

Blankets used in the sickroom should be clean, soft, light in weight, and sufficiently warm for the patient’s comfort. Extra covering may be needed for nights or cold weather.

A blanket should be 10 or 12 inches longer and at least 18 inches wider than the bed to allow for ample covering of the body and feet. Since some shrinkage must always be expected, buy the largest blanket available for each bed size. Wool blankets must be washed in warm (never hot), soft water and mild suds. They should be rinsed through clear warm water and then pressed or squeezed to get the water out. Wringing twists the wool fiber and is hard on the blanket. After as much water as possible is squeezed out, the blanket should, whenever possible, be hung outdoors in the fresh air and sunshine to dry.

Cotton blankets are useful in mild weather, but if used in sufficient numbers to be of any value in cold weather they are stiff, heavy, and uncomfortable. They do not absorb moisture as well as wool blankets, and unless the nap is brushed up after they are laundered, they may become rough and irritating to the skin. An extra blanket, which may be flannel or cotton, will be needed for giving treatments to the patient in bed.

Electrically heated blankets, comforters, and foot warmers are now available. If such appliances are used, care should be taken and directions for their use must be followed very carefully and exactly.

Bedspreads

White or colored seersucker or muslin bedspreads are light in weight, easily laundered, and inexpensive, and therefore more suitable for use in illness than a heavy elaborate spread.

THE PATIENT’S PERSONAL NEEDS

The bed patient will need special equipment and clothing to keep him comfortable and contented. Most of this equipment and clothing is available in every home; it is simply a matter of gathering it together and arranging it neatly within the patient’s reach or on a tray for the use of the home nurse. The essentials are:

1. Nightgowns, nightshirts, or pajamas. These should be of suitable material that can be washed easily.

2. Bedjacket, sweater, or shawl if the patient is allowed to sit up in bed.

3. A warm bathrobe or dressing gown.

4. Slippers.

5. Toilet articles.

6. Paper tissues and a wastepaper bag for their disposal.

7. Bell or other call system.

8. Footstool if the bed is high and the patient is allowed in and out of bed.

If the patient is not allowed to go to the toilet or use a commode, a bedpan and a urinal for a boy or man will be needed.

If the patient is not too sick, he should have something to read, writing materials, a radio, and other recreational material. Children may have toys.

The home nurse will find it a great timesaver to assemble on trays the things she needs most frequently; for example, a firm box top will hold the clinical thermometer, a jar of wipes (absorbent cotton, toilet paper, or pieces of clean gauze or rags) or paper tissues, the wastepaper bag, soap, and a jar or pitcher of water. A larger tray can be used for holding the equipment necessary to give a bed bath—towels, washcloth, soap, nail cleaner, rubbing alcohol or body oil, talcum, toothbrush (or other means of cleaning the teeth), dentifrice, brush, and comb. A bedside table is practically a necessity, but a straight chair or an orange crate can be substituted. A bag made like a shoe bag with small and large pockets for articles in constant use can be made and hung within the patient’s reach.

If water is not restricted, a covered container of fresh drinking water should always be within reach of the patient.

Often the secret of keeping a bed patient contented is to surround him with the things he needs so that he will not feel dependent on others to supply his needs.

VISITORS

Visitors may be a great comfort to the patient. However, until the doctor has seen the patient and made a diagnosis, visitors should not be permitted. A person with a communicable disease should not have visitors, for there is not only the danger of exposing the visitor to illness but the risk of the visitor’s bringing in a new infection to the already weakened patient. Many doctors forbid maternity patients to have any visitors (except the husband and perhaps close relatives) for the first week after the baby’s birth. The home nurse should get the doctor’s permission to ask visitors to leave or to bar visitors entirely when she sees the need. Friends will more readily accept the doctor’s orders without taking offense. If advisable, the visitor should be instructed before going in to avoid topics of conversation that might be too exciting or depressing to the patient, and it may be necessary to set a time limit on the visit in advance. If this is not done, the nurse should be on the alert for signs of weariness in the patient so that she may tactfully suggest that the visit be ended.

As a rule, visitors should not stay while the patient is eating. It is difficult to carry on a conversation and eat a meal while it is still hot, and also embarrassing to some people to be watched when eating. Visitors should not be present in the sickroom during treatments of any kind unless their help is needed.

The best time for a visit is late in the morning or after the afternoon nap. Visitors should come one at a time and should not stay more than about 20 minutes. The visitor’s chair should be placed at a safe distance to avoid direct contact with mouth spray and in such a position that the patient will be able to see his face easily. If the home nurse will speak in moderately low tones, the visitor will usually do likewise. As a rule, it is well to leave the patient alone with his visitor.

Occasionally, well-intentioned friends bring gifts of food and expect the patient to sample it at once. The most tactful thing for the home nurse to say is that she will save the dish for a later meal. But she may wish to prevent a repetition of the gift (which may be food not allowed in the patient’s diet) by calling the friend later, thanking her, and suggesting that perhaps the next time her patient would enjoy a particular dish that the doctor has approved.

As a rule, pets should be left out of the sickroom.

CARE OF THE PATIENT IN BED

The Patient’s Day

When the care of the sick must be added to household and family duties, establish a schedule that will make it possible to give care to the patient at the time he needs it, adjust the regular duties of the home to avoid conflicts with the patient’s care, and utilize the help of other members of the family at the time it is available.

Good planning should include time for the home nurse to get out in the fresh air daily and to have some temporary freedom from responsibilities. She can do her best for the patient when she keeps well and gets sufficient sleep, rest, food, and recreation. Obviously, the routine of the patient’s day will vary according to the nature and severity of his illness. But the schedule should cover in general the following things:

1. Before breakfast care: Use of the toilet or bedpan, the face and hands washed, the mouth and teeth cleaned, the hair brushed, a glass of water or a hot drink, and the bed straightened.

2. Breakfast.

3. Bath and grooming.

4. Temperature, pulse, and respiration, as ordered by the doctor.

5. Medicines and treatment as ordered.

6. Midmorning nourishment.

7. Rest period.

8. Toilet care.

9. Lunch.

10. Nap or rest period.

11. Midafternoon nourishment.

12. Visitors, if permitted, and in convalescence, some light occupation or diversion.

13. Patient and room put in order before supper.

14. Supper.

15. Evening and night care.

If these main responsibilities are arranged according to some schedule and other household duties fitted around them, the home nurse’s time can be used to better advantage and the patient will profit by the regularity and promptness of the service.

Preventing Bed Sores

The following precautions should be taken to prevent bed sores:

1. A smooth, clean, dry bed and taut undersheet.

2. A cleansing bath as needed.

3. Back rub and gentle massage of all areas on the body where the skin feels or looks irritated; for example, the base of the spine, the back of the heels, the knees, elbows, shoulders, and occasionally the back of the head or ears in babies and helpless old people. Olive oil or cocoa butter may be used for the massage.

4. Removal of the weight of the bedclothes from the body through use of a pleat for toe space, a foot rest, rolled pillows, or bed cradles.

5. An air ring or cushion under the base of the spine. This should be slipped into a pillow case and kept dry.

6. A circular pad or “donut” to relieve pressure.

7. Frequent change of position.

8. Great care in giving and removing the bedpan. The back edge of the bedpan may be padded with a folded towel, the outer edges powdered with talcum powder. The buttocks should be lifted high enough to avoid rubbing against the bedpan.

Care During Hot Weather

A bedridden person may become uncomfortable during hot weather. The home nurse should be aware of this discomfort and provide means of helping the patient to keep as cool as possible. She may use the following measures:

1. Use lightweight, moisture-proof material when bed protection is needed.

2. Use an electric fan with the air stream directed away from the patient.

3. Remove all but lightweight covering.

4. Provide a cotton bed gown.

5. Supply plenty of cool, fresh water and fruit juices if allowed.

6. Give a cool sponge bath (alcohol or water) several times a day if allowed and the time permits.

7. Apply ice to the head in a well-protected bag or other container.

Preparing the Patient for the Night

Everything possible should be done to keep the patient from getting too tired during the latter part of the day, because it may interfere with his rest at night. In general, visitors should be encouraged to come in the afternoon rather than in the evening. Light evening nourishment should be given according to the doctor’s instructions, after which the patient should be allowed to rest quietly for an hour or so. This may be a good time to put the room in order, remove the flowers and all unnecessary articles, and assemble the material for evening care.

If the patient is able to sleep well and is not seriously ill, it is better to leave him entirely alone at night and to go to him only if he calls. But if he is restless and wakeful or suffering pain, he needs companionship and care. Perhaps a hot water bag at his feet or an extra blanket may be needed. Sometimes a drink of warm milk is especially soothing. A shifting of pillows, a change of position, or a light back rub, using gentle, firm strokes the full length of the spine, may be restful and help to bring on sleep.

A state of mental calmness is as important as physical comfort in preparing the patient for a restful night. The home nurse should keep conversation and activities as restful and relaxing as possible during the latter part of the day and evening. She should assemble the equipment she will need in giving evening care to the patient. Usually this care will include:

1. Taking the temperature if ordered.

2. Giving medicine if ordered.

3. Giving nourishment if permitted.

4. Giving the bedpan.

5. Washing the patient’s face and hands and brushing his hair.

6. Helping brush the teeth.

7. Giving a back rub.

8. Changing the nightgown if desired, and putting on a bedjacket if needed.

9. Taking off the spread, putting on an extra blanket and placing a hot water bag to the feet if needed.

10. Arranging the pillows for correct support.

11. If light is needed, arranging it so that it cannot shine on the patient’s face, or providing the patient with a means of turning on the light, or giving the patient a flashlight.

12. Seeing that the call bell, fresh drinking water, and reading material (if desired) are handy.

13. Having a bedpan or urinal handy if the patient is able to help himself.

14. Taking flowers out of the room.

15. Putting a silencer on the door.

16. Adjusting the windows so that the air is fresh but not cold and does not blow directly on the patient.

17. Being sure the room is in order, and asking if the patient is comfortable.

18. Recording on the daily record the care given and comments on the patient’s day and general condition.

DAILY RECORD FOR THE DOCTOR

The home nurse will be expected by the doctor to keep a daily record of the patient’s illness. This record will indicate how the patient feels, behaves, and reacts to treatments during his illness and will include information as to what has been done for him, when it was done, and what was observed about him. The doctor should write his orders for the patient on this record. If he gives them by telephone, the home nurse writes them on the record and the doctor signs his name at his next visit. The home nurse then indicates when she carried out these orders and the results. The home nurse must not trust to memory. She must provide for the doctor an accurate statement of care given and of the patient’s reaction. As a patient’s condition changes from day to day, this information may have great significance to the doctor in diagnosing a condition and helping the patient get well.

When more than one person is giving care to the patient, this record is absolutely necessary to avoid confusion and misunderstanding in carrying out the orders for the patient, and it is a protection to both patient and nurse. It is well to keep the daily record out of sight of the patient and out of reach of children at all times.

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Ruth B. Freeman

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