Observation of the Sick

8 Observation of the Sick




imageNotes on Nursing — Florence Nightingale



What is the use of the question, Is he better?


There is no more silly or universal question scarcely asked than this, “Is he better?” What you want are facts, not opinion – for who can have any opinion of any value as to whether the patient is better or worse, excepting the constant medical attendant, or the really observing nurse?


The most important practical lesson that can be given to Nurses is to teach them what to observe – how to observe – what symptoms indicate improvement – what the reverse – which are of importance – which are of none – which are the evidence of neglect – and of what kind of neglect.


The vagueness and looseness of the information one receives in answer to that much abused question, “Is he better?” would be ludicrous, if it were not painful.


I can record but a very few specimens of the answers which I have heard made by friends and Nurses, and accepted by physicians and surgeons at the very bed-side of the patient, who could have contradicted every word, but did not – sometimes from amiability, often from shyness, oftenest from languor!


“How often have the bowels acted, nurse?” “Once, sir.” This generally means that the utensil has been emptied once, it having been used perhaps seven or eight times.


“Do you think the patient is much weaker than he was six weeks ago?” “Oh no, sir; you know it is very long since he has been up and dressed, and he can get across the room now.” This means that the nurse has not observed that whereas six weeks ago he sat up and occupied himself in bed, he now lies still doing nothing; that, although he can “get across the room,” he cannot stand for five seconds.


Another patient who is eating well, recovering steadily, although slowly, from fever, but cannot walk or stand, is represented to the physician as making no progress at all.



Leading questions useless or misleading.


Questions, too, as asked now (but too generally) of or about patients, would obtain no information at all about them, even if the person asked of had every information to give. The question is generally a leading question; and it is singular that people never think what must be the answer to this question before they ask it: for instance, “Has he had a good night?” Now, one patient will think he has a bad night if he has not slept ten hours without waking. Another does not think he has a bad night if he has had intervals of dosing occasionally. The same answer has actually been given as regarded two patients – one who had been entirely sleepless for five times twenty-four hours, and died of it, and another who had not slept the sleep of a regular night, without waking. Why cannot the question be asked, How many hours’ sleep has — had? and at what hours of the night?


How few there are who, by five or six pointed questions, can elicit the whole case, and get accurately to know and to be able to report where the patient is.



Means of obtaining inaccurate information.


I knew a very clever physician, of large dispensary and hospital practice, who invariably began his examination of each patient with “Put your finger where you be bad.” That man would never waste his time with collecting inaccurate information from nurse or patient. Leading questions always collect inaccurate information.



As to food patient takes or does not take.


It is useless to go through all the particulars, besides sleep, in which people have a peculiar talent for gleaning inaccurate information. As to food, for instance, I often think that most common question, How is your appetite? can only be put because the questioner believes the questioned has really nothing the matter with him, which is very often the case. But where there is, the remark holds good which has been made about sleep. The same answer will often be made as regards a patient who cannot take two ounces of solid food per diem, and a patient who does not enjoy five meals a day as much as usual.


Again, the question, How is your appetite? is often put when How is your digestion? is the question meant. No doubt the two things depend on one another. But they are quite different. Many a patient can eat, if you can only “tempt his appetite.” The fault lies in your not having got him the thing that he fancies. But many another patient does not care between grapes and turnips – everything is equally distasteful to him. He would try to eat anything which would do him good; but every thing “makes him worse.” The fault here generally lies in the cooking. It is not his “appetite” which requires “tempting,” it is his digestion which requires sparing. And good sick cookery will save the digestion half its work.


There may be four different causes, any one of which will produce the same result, viz., the patient slowly starving to death from want of nutrition:


Defect in cooking;


Defect in choice of diet;


Defect in choice of hours for taking diet;


Defect of appetite in patient.


Yet all these are generally comprehended in the one sweeping assertion that the patient has “no appetite.”


Surely many lives might be saved by drawing a closer distinction; for the remedies are as diverse as the causes. The remedy for the first is to cook better; for the second, to choose other articles of diet; for the third, to watch for the hours when the patient is in want of food; for the fourth, to show him what he likes, and sometimes unexpectedly. But no one of these remedies will do for any other of the defects not corresponding with it.


I cannot too often repeat that patients are generally either too languid to observe these things, or too shy to speak about them; nor is it well that they should be made to observe them, it fixes their attention upon themselves.


Again, I say, what is the nurse or friend there for except to take note of these things, instead of the patient doing so?


For it may safely be said, not that the habit of ready and correct observation will by itself make us useful Nurses, but that without it we shall be useless with all our devotion.


I have known a nurse in charge of a set of wards, who not only carried in her head all the little varieties in the diets which each patient was allowed to fix for himself, but also exactly what each patient had taken during each day. I have known another nurse in charge of one single patient, who took away his meals day after day all but untouched, and never knew it.


If you find it helps you to note down such things on a bit of paper, in pencil, by all means do so. I think it more often lames than strengthens the memory and observation. But if you cannot get the habit of observation one way or other, you had better give up the being a nurse, for it is not your calling, however kind and anxious you may be.


Surely you can learn at least to judge with the eye how much an oz. of solid food is, how much an oz. of liquid. You will find this helps your observation and memory very much, you will then say to yourself, “A. took about an oz. of his meat today;” “B. took three times in 24 hours about ¼ pint of beef tea;” instead of saying “B. has taken nothing all day,” or “I gave A. his dinner as usual.”



Superstition the fruit of bad observation.


Almost all superstitions are owing to bad observation, to the post hoc, ergo propter hoc; and bad observers are almost all superstitious. Farmers used to attribute disease among cattle to witchcraft; weddings have been attributed to seeing one magpie, deaths to seeing three; and I have heard the most highly educated now-a-days draw consequences for the sick closely resembling these.



Physiogonomy of disease little shewn by the face.


Another remark: although there is unquestionably a physiognomy of disease as well as of health; of all parts of the body, the face is perhaps the one which tells the least to the common observer or the casual visitor. Because, of all parts of the body, it is the one most exposed to other influences, besides health. And people never, or scarcely ever, observe enough to know how to distinguish between the effect of exposure, of robust health, of a tender skin, of a tendency to congestion, of suffusion, flushing, or many other things. Again, the face is often the last to shew emaciation. I should say that the hand was a much surer test than the face, both as to flesh, colour, circulation, &c., &c. It is true that there are some diseases which are only betrayed at all by something in the face, e.g., the eye or the tongue, as great irritability of brain by the appearance of the pupil of the eye. But we are talking of casual, not minute, observation. And few minute observers will hesitate to say that far more untruth than truth is conveyed by the oft repeated words, He looks well, or ill, or better or worse.


I have known patients dying of sheer pain, exhaustion, and want of sleep, from one of the most lingering and painful diseases known, preserve, till within a few days of death, not only the healthy colour of the cheek, but the mottled appearance of a robust child. And scores of times have I heard these unfortunate creatures assailed with, “I am glad to see you looking so well.” “I see no reason why you should not live till ninety years of age.” “Why don’t you take a little more exercise and amusement,” with all the other commonplaces with which we are so familiar.

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Dec 3, 2016 | Posted by in NURSING | Comments Off on Observation of the Sick

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