6 Cleanliness

Notes on Nursing — Florence Nightingale

Cleanliness of rooms and walls.

It cannot be necessary to tell a nurse that she should be clean, or that she should keep her patient clean, seeing that the greater part of nursing consists in preserving cleanliness. No ventilation can freshen a room or ward where the most scrupulous cleanliness is not observed. For a sick room, a carpet is perhaps the worst expedient which could by any possibility have been invented. If you must have a carpet, the only safety is to take it up two or three times a year, instead of once. A dirty carpet literally infects the room. And if you consider the enormous quantity of organic matter from the feet of people coming in, which must saturate it, this is by no means surprising.

Papers, plastered, oil-painted walls.

As for walls, the worst is the papered wall; the next worst is plaster. But the plaster can be redeemed by frequent lime-washing; the paper requires frequent renewing. A glazed paper gets rid of a good deal of the danger. But the ordinary bed-room paper is all that it ought not to be.

Air can be soiled just like water. If you blow into water you will soil it with the animal matter from your breath. So it is with air. Air is always soiled in a room where walls and carpets are saturated with animal exhalations. Want of cleanliness, then, in rooms and wards, which you have to guard against, may arise in three ways.

Dirty air from without.

Dirty air coming in from without, soiled by sewer emanations, the evaporation from dirty streets, smoke, bits of unburnt fuel, bits of straw, bits of horse dung.

Dirty air from within.

Dirty air coming from within, from dust, which you often displace, but never remove. And this recalls what ought to be a sine qua non. Have as few ledges in your room or ward as possible. And under no pretence have any ledge whatever out of sight. Dust accumulates there, and will never be wiped off. This is a certain way to soil the air.

Dirty air from carpet.

Dirty air coming from the carpet. Above all, take care of the carpets, that the animal dirt left there by the feet of visitors does not stay there. Floors, unless the grain is filled up and polished, are just as bad. The smell from the floor of a school-room or ward, when any moisture brings out the organic matter by which it is saturated, might alone be enough to warn us of the mischief that is going on.

Remedies.

Without cleanliness, you cannot have all the effect of ventilation; without ventilation, you can have no thorough cleanliness.

The well have a curious habit of forgetting that what is to them but a trifling inconvenience, to be patiently “put up” with, is to the sick a source of suffering, delaying recovery, if not actually hastening death. The well are scarcely ever more than eight hours, at most, in the same room. Some change they can always make, if only for a few minutes. Even during the supposed eight hours, they can change their posture or their position in the room. But the sick man who never leaves his bed, who cannot change by any movement of his own his air, or his light, or his warmth; who cannot obtain quiet, or get out of the smoke, or the smell, or the dust; he is really poisoned or depressed by what is to you the merest trifle.

“What can’t be cured must be endured,” is the very worst and most dangerous maxim for a nurse which ever was made. Patience and resignation in her are but other words for carelessness or indifference – contemptible, if in regard to herself; culpable, if in regard to her sick.

Personal cleanliness.

Poisoning by the skin.

In almost all diseases, the function of the skin is, more or less, disordered; and in many most important diseases nature relieves herself almost entirely by the skin. This is particularly the case with children. But the execretion, which comes from the skin, is left there, unless removed by washing or by the clothes. Every nurse should keep this fact constantly in mind, – for, if she allow her sick to remain unwashed, or their clothing to remain on them after being saturated with perspiration or other excretion, she is interfering injuriously with the natural processes of health just as effectually as if she were to give the patient a dose of slow poison by the mouth. Poisoning by the skin is no less certain than poisoning by the mouth – only it is slower in its operation.

Ventilation and skin-cleanliness equally essential.

The amount of relief and comfort experienced by the sick after the skin has been carefully washed and dried, is one of the commonest observations made at a sick bed. But it must not be forgotten that the comfort and relief so obtained are not all. They are, in fact, nothing more than a sign that the vital powers have been relieved by removing something that was oppressing them. The nurse, therefore, must never put off attending to the personal cleanliness of her patient under the plea that all that is to be gained is a little relief, which can be quite as well given later.

Just as it is necessary to renew the air round a sick person frequently, to carry off morbid effluvia from the lungs and skin, by maintaining free ventilation, so is it necessary to keep the pores of the skin free from all obstructing excretions. The object, both of ventilation and of skin-cleanliness, is pretty much the same, – to wit, removing noxious matter from the system as rapidly as possible.

Every nurse ought to be careful to wash her hands very frequently during the day. If her face too, so much the better.

Steaming and rubbing the skin.

One word as to cleanliness merely as cleanliness.

Compare the dirtiness of the water in which you have washed when it is cold without soap, cold with soap, hot with soap. You will find the first has hardly removed any dirt at all, the second a little more, the third a great deal more. But hold your hand over a cup of hot water for a minute or two, and then, by merely rubbing with the finger, you will bring off flakes of dirt or dirty skin. After a vapour bath you may peel your whole self clean in this way. What I mean is, that by simply washing or sponging with water you do not really clean your skin. Take a rough towel, dip one corner in very hot water, – if a little spirit be added to it it will be more effectual, – and then rub as if you were rubbing the towel into your skin with your fingers. The black flakes which will come off will convince you that you were not clean before, however much soap and water you have used. These flakes are what require removing. And you can really keep yourself cleaner with a tumbler of hot water and a rough towel and rubbing, than with a whole apparatus of bath and soap and sponge, without rubbing.

Helping the patient keep their body clean and well groomed

Cleanliness can be viewed from the two standpoints of its psychological and physiological values. Cleanliness and grooming are outward signs of a person’s state of mind, and therefore closely related to a person’s morale and state of mind. Thinking or seeing oneself as unkempt or unclean saps the spirit, especially for a patient suffering from an injury or illness. The role of the caregiver in cleanliness and grooming of a patient varies with each patient, and even over time with specific patients. However, it is generally best that patients be encouraged to assume as much responsibility as possible for their own cleanliness and grooming. This will necessarily change over time, and it is the job of the caregiver to assist in the transition towards diminishing or increasing levels of assistance.

The caregiver needs, in all cases, to ensure some basic conditions that favor cleanliness, and the independence of the patient in ensuring it is maintained. The patient should be provided with such facilities, equipment and assistance as needed to clean the skin, hair, nails, nose, mouth and teeth. Concepts of cleanliness vary, but patients should not have to lower their personal standards of cleanliness because they are sick.

Bathing and personal grooming •••

A patient’s condition may impose some changes on their grooming routine. For example, it may not be desirable to give a full bath daily – although most patients would enjoy it and benefit from it. The number of complete baths is, ideally, determined by the patient’s physical needs and wishes. However, the bathing routine is also subject to instructions from a physician or nurse. In most cases, baths should be sufficiently frequent to give the appearance of cleanliness, to control body odors and to protect the skin from maceration and other forms of irritation.

Most patients in relatively good physical condition will prefer an immersion bath or shower, rather than a bed bath. Once again, the treating physician and nurse need to be consulted. In some cases the caregiver will need training or assistance in bathing a patient, or special equipment will need to be obtained, as recommended by the physician or nurse. There is a skill to making a bed bath both pleasurable and efficient, which the caregiver will need to acquire.

Personal grooming is also part of the psychological support provided for a patient. In most cases the caregiver can simply ensure everything is available for the patient to assume this task. Once again there are some simple guidelines. The hair should be thoroughly brushed at least once a day and kept well groomed according to the patient’s standards. Washing the hair should be done according to the patient’s wishes, but frequently enough to prevent disagreeable odors, and to keep the hair and scalp clean. A caregiver can give a shampoo to most bed patients without unduly tiring them and regardless of their position in bed. Once again, a nurse can provide guidance on the techniques the caregiver can use to do this properly, without discomfiting the patient.

Most men benefit from shaving daily. If able, they usually prefer to shave themselves. The caregiver should ensure all the proper materials are available. In some cases special instructions from a health professional will need to be respected, such as the use of electric shavers rather than sharp instruments. The caregiver also needs to provide implements or help in keeping the nails and cuticles in good condition.

Figure 6.1 Personal grooming is important for the patient’s psychological well-being as well as for hygiene

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