The Recent State Examination of Nurses

Kai Tiaki : the journal of the nurses of New Zealand, Volume II, Issue 4, 1 October 1909, Page 159

The Recent State Examination of Nurses

Question 1. — What preparation would you make for the setting of a fractured femur ? Give an account of the nursing of a case. Candidate No. 5. (a) For setting a fractured femur the following appliances would be needed : — A small table at head of bed on which are chloroform mask, chloroform in dropper bottle, tongue forceps, gag, tongue depressor, sponge on holder, nitrite of amyl, hypodermic syringe and strychnine tabloids and medicine measure for distributing tabloid, towel and vomit bowl. Splints required would be four local splints, generally of gooch splinting ; a saw to saw it to right size ; padding of cotton wool ; a long L,iston's splint with a long binder, to reach from the arm-pits to the pubes, to fasten the piston's splint on ; appliances for extension. The leg is first shaved, then plaster strapping is put on from just above the knee, and cut long enough to reach down the leg and a few inches beyond, and up the other side of leg. A piece of wool (square) with a hole in centre, to go in the loop of plaster ; a strong cord and a bag of shot or weights up to ten lbs., should be ready. An upright with running groove for cord is fixed to foot of bed ; blocks about six inches in height are placed under the foot of bed to raise it, to cause counter extension to the weights. A long roller bandage is needed for binding the strapping on, also a long, well-filled pad to fasten on the Iiston's splint, and bandage for the foot ; a nest of cotton wool for heel and ankles, and binders or towels for the leg and the long splint ; a cradle to keep weight of clothes off, and sand-bags to stead}^ the limb, and safety-pins. (b) In nursing a case of fractured femur, a bed with a wooden framework, and firm mattress covered with a sheet, macintosh, and drawsheet well tucked in, would be needed. Great attention must be paid to the back and heels, so that no bed-sores form, by washing them daily with soap and water, and rubbing with methylated spirit and oxide of zinc powder, and seeing that there are no creases in the sheets, and no crumbs under the patient's back. He should be sponged

once daily, and a fresh shirt or jacket put on as often as necessary, and the sheets changed frequently to air the bed. Diet should be nourishing, and given every four hours. Attention should be paid to the bowels and bladder. If urine is not passed the doctor should be informed so that he may order the catheter to be passed. If bowels do not act an injection may have to be given, but they must act freely every day. Temperature, pulse and respirations must be taken, and noted for any increase, which might indicate the onset of pneumonia, caused by lying on the back. Examiner's note. — Mention might have been made of the use of a divided fracture mattress, also of later treatment, removal of splints, massage, when to get up, etc.

Question 2. — Describe fully the nursing of a case of appendicitis with peritonitis from immediately after operation until convalescence. Candidate No. 10. 2. After an operation for appendicitis with peritonitis, the most urgent symptoms are usually shock, and the chief treatment is application of heat ; warm blankets (two) next the patient, then at least four hot-water bottles, with a hot-water bag over the heart. The patient would most probably be nursed in Fowler's position, and great care must be taken to leave no cold, empty spaces at his back when arranging the pillows. Continuous saline injection may be ordered, and should be given at the rate of 1 pint an hour to begin with, and if patient cannot retain it at that rate, may be lessened to half-pint an hour, or may be discontinued for a time and resumed after about an hour's rest. The pulse must be carefully watched and any increased weakening reported. Vomiting may be treated by sucking tiny pieces of ice, or a cupful of water may be given warm, or with some soda bicarb, ldr. in it, to act as a washout for gastric mucous membrane. Wound must always be supported when patient vomits. It may be necessary to draw off fluid from drainage

tube, and after the first time this duty will devolve on the nurse. She must be very strict about her asepsis as regards her own hands, and her syringe and tube. Quantity and quality of fluid drawn off, to be measured and reported. Temperature, pulse and respiration to be taken four-hourly. Shock will have been overcome at the end of 2 hours. Give only water, lemonade, or albumin water, or rasin tea for 48 hours after operation ; after that may give well diluted milk, or cup of tea. If bowels have not moved at the end of|36 hours an enema is given, usually glycerine. After movement of the bowels light milk foods may be given. The wound is dressed every day, and at the end of ten days or a fortnight the tube may be removed and a smaller one, or gauze drain substituted. If bowels do not act naturally a glycerine enema should be given every other day. When tube is removed temperature need only be taken twice daily. The diet may be gradually increased from light milk foods, but a full or heavy diet should not be given for a month after operation. At the end of three weeks patient might be able to get up on a couch. Examiner's Note.- — Mere details might have been given of the Fowler position, how it is maintained ; also more details of the method of giving continuous saline. The quantity of urine passed during the first two days should be noted. Note should be made of the passage of flatus, etc.; number of times of vomiting and its character. Calomel in divided doses is more usually given than a glycerine enema.

Question 3. Give an account of the preparations you would make for an abdominal operation in a private house, including the preparation of the patient. Candidate No. 5. The extent of the preparations to be made in a private house will depend upon the time the nurse has before the operation. If she is able to have the room the day before she can prepare it thoroughly. A well ventilated room with plenty of light, and if possible with a fire-place, or some means of heating it, should be chosen. All superfluous furniture should be removed, the walls should be wiped over with a damp cloth wrung out of carbolic lotion (1-40). All articles of furniture re-

maining, dusted and wiped with a carbolic cloth. The blinds should be pulled up to the top ; curtains removed, the bottom window panes smeared over with whiting or sapolio soap, so that no onlooker can see in. If there is a carpet it should be removed, and the floor swept and scrubbed with water containing Jey's fluid. A table would be got ready with a blanket macintosh and sheet ; top sheet and blanket and pillow ready for the patient. A table, with basins for the surgeon to wash his hands with ; turpentine, sterilised nail brush, and antiseptic soap. A table for the anaesthetic requisites, with a bowl and towel in case of vomiting ; another table for the surgeon's instruments in pie dishes, or whatever the nurse can get suitable, and a table for the lotions, sterilized water and sponges. A bath or pails for dirty water and if possible a kerosene lamp for boiling the instruments as required, if one should fall on the floor. The nurse should boil the bowls and jugs in the morning, and wrap them in a carbolised towel. She should prepare plenty of towels, by boiling them and leaving them in hot carbolic lotion, to be wrung out as required. Sterilised macintosh guards must also be in readiness, and a plentiful supply of boiling water. A good fire should be made up beforehand, as no one has time to attend to it after. Dressings could also be got ready, and bandages and hot bottles ready in the bed when the patient is put back to bed. (b) The patient would be prepared by having a bath and put on clean clothes ; clean sheets for the bed ; skin first shaved from breasts to pubes, and scrubbed with ethereal soap ; the nurse now sterilises her hands with the same precautions she takes over preparing the patient's skin ; the skin is scrubbed with ethereal soap, then with turpentine to remove all grease from the sweat glands, next with methylated ether, to dry the skin and remove any grease, then swabbed with biniodide lotion (1-3000), or carbolic lotion (1-40), A sterilized pad or lint is wrung out of either carbolic lotion (1-40), of biniodide (1-2000) ; a piece of protective tissue and cotton wool are next applied, and all firmly bandaged on. The patient is given an injection of one pint !u a p'nt aid a half of warm water and soap, to empty the lower bowel 4 hours before the operation ; a cup of tea or beef tea are given four hours before the operation ; all false teeth are removed, and the catheter

is passed ; before going on the table the hair, (if a female) is plaited in two plaits, and all hair pins removed. Examiner's Note. — The preparation of gauze, sponges, abdominal packs, dressings, might have been mentioned. The patient should have an aperient on the day preceding the operation.

Question 4. What would you do for a case of severe lacerated wound of the leg with haemorrhage, the result of a street accident, while waiting for surgical aid ? Candidate No. 28. The patient, having been admitted to the ward, the clothing would be removed from the injured leg. If the haemorrhage is severe a firm antiseptic pad is applied and bandaged. If this does not stop the haemorrhage pressure will be applied to the groin of the injured leg, over site of femoral artery. If neither of these means succeed in arresting the flow of blood, a tourniquet should be applied between the wound and the heart. This should only be done when all other means fail — that is, without medical orders. The surrounding parts should be rendered as aseptic as possible. The patient should be sponged down, and a simple enema given. Prepare a table containing all the anaesthetist will require — chloroform, ether, oxygen and gas, and the apparatus necessary for their administration — mouth-gag, tongue forceps, wooden peg and sponges on spongeholding forceps, vomit bowl and towels, hypodermic syringes containing strychnine 5 min. of 1-100 solution, brandy 30 min; prepare also needles, needle-holders and suture material for sewing up the wound ; drainage tubes and antiseptic lotions ; an irrigator ; antiseptic dressings. The wound must be treated on antiseptic lines and not aseptic, for it is probably infected with septic material — perhaps the germs of tetanus. Examiner's Note. — In a case of emergency, a nurse would be quite right to apply an artery forceps to any obviously bleeding vessel. The giving of an enema to such a patient would probably not be advisable.

Question s.— Describe the nursing of a case of # excision of the tongue. What complications may arise ?

Candidate No. 32. On return to ward, patient when consciousness returns, should be propped up with head slightly forward and to one side, that saliva may flow out freely. Long forceps must be kept on locker in case of haemorrhage, and bowl and swabs in some antiseptic — as carbolic (1-200), or sanitas. The patient must never be left a moment for twelve days, in case of haemorrhage ; should it occur, the finger should be messed down the throat till the epiglottis is felt, and then pressed forwards and upwards, being held there until help arrives. The mouth must be constantly and gently swabbed out, and sprayed with bicarbonate of soda, to loosen saliva. Feeding must be done by the nose, with catheter and funnel for the first two days, every six hours ; after that, a feeder with six or eight inches of tubing may be used, the tubing being passed gently along one side of the mouth. After every drink the mouth must be well cleaned. The bowels should be opened on third day, with calomel or solution of magnesium sulphate. In five or six days patients should be got up in wheelchair, as they are generally old people, but should not be allowed to exert themselves at all for fear of haemorrhage. Complication. — Septic pneumonia ; haemorrhage.

QuKSTiONjo.JWhat are the chief symptoms of (a) intussusception, (b) ruptured ectopic gestation.. (c) strangulated hernia. Candidate; No. 35. (a) Patient is collapsed. Temperature is generally sub-normal ; pulse rapid, face pale, skin coldjjandjclammy. Vomiting, at first of stomach contents, later on becomes faecal in character. Motions nt first, contain blood and mucous, then there is complete constipation. The abdomen is tender and painful to touch, and is distended. (b) Patient is collapsed, temperature subnormal, pulse rapid and decreasing in volume, respirations sighing, face pale, skin cold and clammy ; abdomen is intensely painful and rigid. (c) Temperature is sub-normal, pulse quick and feeble, cold and clammy skin, vomiting, constipation, abdomen distended, painful, rigid, and a swelling mav b^ and felt at seat of injury.

Examiner's Note. —The important points to be mentioned are : — (a) Occurs usually in a baby ; griping, abdominal pain, vomiting, passage of blood and mucus per rectum ; collapse, (b) Usually occurs after a period of amenorrhcea. Sudden, abdominal pain, followed by symptoms of collapse ; vomiting often ; dark, vaginal discharge, (c) The presence of a swelling in the internal, femoral, and umbilical region which cannot be reduced ; acute abdominal pain ; vomiting.

Question 7. Describe how you would wash out the bladder of a female patient. Candidate No. 13. Have ready : Long tube and glass funnel '> soft, rubber catheter, sterilised ; sterilised oil ; basin of lotion (1-100) ; carbolic and sterile cotton wool ; receiver, and warm boracic lotion, strength 1-80, temp. 99 degrees Fahr.

First carefully wash genitals with warm, carbolic lotion, being careful to sponge from above downwards, so that discharge from vagina will not be washed over meatus. With thoroughly sterilised hand insert catheter, which is lubricated by oil. First drain off urine, then pour in boracic lotion about six oz. at a time, being careful to allcw no air to enter. Funnel must be raised to let fluid enter, and then lowered to let it flow back ; have basin on floor to receive, and see that quantity put in returns before adding more lotion to syphon. Continue this until water returns clear. Withdraw catheter, pressing it so that last drops do not remain in bladder, and wash and dry parts.

Kxaminer's Note. — The arrangements of bedclothes, towel, etc., should have been given In many of the answers to questions not nearly enough care was shown in stating the temperature of the water, and of the quantity to be used.