Nursing today is a complicated, technological process involving multiple disciplines, technology and advanced fourth generation antibiotics, none of which will be available in a TEOTWAWKI situation. It stands to reason that we have to prepare ourselves mentally for the fact that none of the equipment or drugs that are such an integral part of medicine and nursing today, will be available for our use. There will be no antibiotics for chest infections, no IV fluids for dehydration, no advanced medical treatments for wound infections; It will be a return to nursing at the level of the 19th century. Now that in itself is not necessarily a bad thing. Nursing during Florence Nightingale’s day was exciting and cutting edge. There were advances being made in hygiene and sanitation and the general logistics of caring for multiple illnesses and infections of whole groups of people being cared for in enclosed spaces. Florence Nightingale focused on hygiene and organization of the ward. These were essential areas that needed close attention. For our purposes these will also be the focus of this article; to prepare ordinary folk with the skills to nurse a sick relative or loved one in their own home without benefit of advanced medical care or treatment. It can be done.
The Sick Room
The first thing to concentrate on is the area in which a sick person is to be nursed. If possible, the room should be separate from the remainder of the general living quarters; a separate bedroom or a ground floor family room or recreation room with a dedicated use of separate bathroom would be ideal. These areas would be off limits to general household use and only those directly involved in nursing care would have access. This prevents the cross-contamination of surfaces and materials through multiple use by many people. It is probable that there will be limited or no running water so the bathroom, per se will be of limited use. However, it can be used as a depository of soiled linens, body wastes etc, until they can be contained in buckets and carried out doors for disposal or decontamination. (To be discussed later in this article)
The room should be light and airy with access to a functioning window. Cold air returns and heat vents, though not in use should be sealed off with heavy duty plastic and duct tape to prevent the spread of germs throughout the rest of the house. The window will supply fresh air as needed. Furniture can be functional and minimal. There should be no surfaces that are cloth covered or not easily cleaned. Eliminate all soft furnishings, rugs and wooden tables. If possible, use a metal table or one with a wipeable surface. The bed mattress should be covered, if possible, in a waterproof barrier. Several sets of sheets should be dedicated for the use of the patient only and not mixed in with regular washing. A shelf located just outside the sick room could provide linen storage for this purpose, covered with a cloth to keep clean.
Any equipment brought into the sick room should be dedicated solely for the use of the sick room. A bucket with a small amount of sodium hypochlorite or bleach in clean water can be kept in the bathroom to sterilize or clean utensils or other washable items used by the patient once the general soil has been cleaned off them. Mugs, spoons, plates and dishes can soak in this solution overnight and then be drained dry on a clean counter. A second ‘dirty’ bucket can be used for toileting articles once they have been cleaned out. Tea towels to dry dishes etc can be used but these items also need to be washed and disinfected every 24 hours at a minimum. The door to the sick room should be kept closed if the patient is suffering from a respiratory tract infection as this will keep the spread of germs throughout the rest of the house to a minimum. A window can be opened an inch or two, even in cold weather to provide fresh air to the room as long as the patient is not in direct line of airflow. Window coverings in the sick room should also be washable, or preferably wipeable such as blinds. Curtains can be used but would have to be washed and disinfected between patients as these can become grossly contaminated with airborne droplets through coughing or spray contaminants from wounds, human waste, blood etc. The floor surface of the room should be disinfected daily with a mild soap solution in hot water and air-dried quickly. Shoes worn outdoors or in other areas of the house should be left outside the sick room door on a dedicated mat and dedicated shoes for the nurse/attendant can be put on a clean mat just inside the doorway for use in the room .
Disposable coveralls or gowns that protect the caregivers clothing whilst in direct contact with the patient can be hung up in this area (back of the door) when exiting the sick room. These should be changed /washed daily and changed if moving from patient A to patient B. Again this prevents the spread of contaminants between patients and throughout the rest of the house. If the patient is suffering from an upper respiratory infection it would be ideal to hand a thick, preferably 30mil plastic sheeting over the doorway. This would help to contain airflow when moving in and out of the room.
A small table outside the room should be set up which contains an anti-bacterial solution for cleansing hands upon leaving or entering the room. If these are not available, plain soap and a bowl of fresh water for thoroughly washing the hands can be used. Again, the towels need to be changed every 24 hours or even more frequently to prevent the spread of germs. Hands should be washed for 20 seconds including the webbing between the fingers and thumbs, over the back of the hand and up the forearms to the elbow. Towels should be nurse specific and identifiable as such for each person, again to prevent cross-contamination. No nurse or attendant should wear clothing that can touch surfaces, i.e. loose or baggy clothing, Arms should be bare to the elbows to prevent contamination with body fluids.
Urine and stool collected from the patient could be flushed down the toilet if the sewer system is not compromised. A bucket of clean water can provide the ‘flush’ mechanism to evacuate the toilet bowl. If this is not possible, the waste products should be taken outside and buried in a deep pit at least l00 feet away from any source of water, water collection system or vegetable patch. The pit should be at least 4 feet deep and a layer of lime (if available ) sprinkled over each deposit. The pit should be covered and separate from regular household waste dumping. The bucket should be kept clean and covered outside the house and dedicated solely for this purpose. Soiled linens should be washed separately from regular household laundry. A separate bucket or washtub should be set aside for this purpose.
Once bed linen is washed it should be hung out to dry on a clothesline so a good supply of laundry soap and clothespins may be necessary if bed linens need to be changed more than once a day. If the patient is incontinent a plastic ‘draw sheet’ and runner sheet can be placed directly under the patient at hip level. It is easier to clean/disinfect a small sheet and wipe down a rubber mat than to handle full sheets. The plastic sheeting will keep the bottom sheet clean and minimize full bed changes; a lifesaver when the washing machine doesn’t work! Sunlight will not only sanitize linen it will also bleach any residual staining that may occur. In warmer weather it may be easier to wash contaminated sheets outside on a porch or patio.
The Patient with a Respiratory Illness
Turning our attention now to the sick patient. I am going to talk about care based on the assumption that there are little if any, medications available and certainly no antibiotics. The method of nursing will depend upon the illness but of course, universally, a clean room and a clean patient is to be understood for all situations! For upper respiratory tract infections there will be possibly fever, congested cough, shortness of breath, malaise and restlessness and insomnia (due to cough etc.) If the patient exhibits a fever, and it is to be hoped that you have prepared your emergency medical supplies with a least one thermometer!, take the patients temperature routinely in the morning, afternoon and evening. Fevers tend to rise in the afternoon and peak in the evening/overnight. If you do not have anti-pyretics available in your medical stores you will need to alleviate the core temperature by removing excess bed clothes, pajamas etc and using tepid sponging techniques across forehead, forearms and upper chest. Small cloths wrung out and placed/replaced every 5-10 minutes will help. Cotton wool, soaked in methylated spirits (denatured alcohol) and applied to the inner wrists and temples can also help. If the patient is short of breath, nurse him/her in an upright position with the arms elevated above waist level, resting on a table or several pillows will help. This helps to raise the diaphragm and relieve pressure encouraging better air entry into lungs.
If the patient is congested with a dry hacking cough that is non-productive, a poultice can be made with linseed. Boil 2 cups of water and put in a half cup to one cup of linseed, cook it until it becomes a porridge consistency and then pour into a double thick towel and wrap up. If you have a piece of waxed paper or plastic this can help to prevent leakage through the towel by placing the ‘porridge’ onto the plastic/waxed paper first. Once the poultice is wrapped securely apply gently across the patient’s uncovered chest. You may want to check that the heat from the poultice is not too hot or it may scald the patient. Check by placing poultice across your own forearm first . If it’s too hot for you, it’s too hot for the patient. These poultices can be changed as they cool and they can help to loosen secretions and assist the patient to expectorate the phlegm. Remember that milky foods, products can increase the tenacity and viscosity of secretions so it is best to give thin broths and clear fluids until the patient is breathing easier. On this point, it is worth mentioning that the ubiquitous chicken broth is the number 1 oral fluid for helping to loosen secretions.
If the infection is affecting the upper airways of the nasal/pharyngeal/laryngeal area then a soothing inhalation can be prepared using a large bowl of steaming hot water and a few drops of eucalyptus oil. The patient can then inhale the vapors from the bowl while a towel is draped over his head to concentrate the vapors towards the patient and prevents them dissipating into the air. There are other natural remedies such as turmeric which may promote healing of congestion but as I am not entirely familiar with this area of herbology I will only recommend that you acquire a book which deals with this subject as an adjunct to practical nursing.
Another area of discussion, that, while distasteful, has to be dealt with; what to do with the secretions. Initially, the infection will not produce much in the way of phlegm but during the recovery stage there may be copious secretions that the patient will need to expectorate. In a post collapse situation the luxury of boxes of clean white tissues in unending supply will not be available. What you can do is provide a cup with a lid. It is best to stockpile a few of these plastic denture-type cups with lids now, to store away when needed. These sputum cups will contain the secretions and can be cleaned out as often as needed. Phlegm, by its nature is a very sticky, tenacious substance and it will be difficult to pour out of the container. I suggest lining the container with a small amount of newspaper or other paper. It need not be sterile but it will help prevent ‘cling-ons’ and make a distasteful job easier. These secretions will be highly infective and need to be disposed of as carefully as other human waste. If you have disposable gloves or even several sets of dishwashing gloves that can be cleaned in between patient use, it would be wise to stockpile some of these for this type of care. To help the patient during this period, frequent oral care, rinsing of the mouth with bicarbonate of soda in warm water, or salt water rinses (1 tsp of salt or soda bicarb in 1 cup of warm water) will keep oral hygiene tolerable and prevent build up of materials in the mouth and keep the patient more comfortable. Plenty of fluids offered frequently will keep them hydrated and while they may not be hungry for several days, beef broths and other light foods will help to keep their strength up.
If electrolyte balance is an issue, and this may not be easy to detect, due to dehydration, a solution of salt/sugar in water ( 1/2 tsp salt and 2 tbsp sugar in 1 quart water) with a little honey to taste and glycerin to sooth, will help with rehydration. While it is not possible to always stockpile a supply of antibiotics due to prescription restrictions and/or due to the perishable nature of the drug, or it being in short supply due to high demand or lack of availability, there is one treatment that you must have in your medicine cabinet; silver solutions. There are several good companies online that deal in the production or sale of silver ion solutions. Silver is a super antibacterial, antifungal that can be used in the topical treatment of wounds, abrasions, ulcers and can even be inhaled. I have found that though ionic silver may not cure a chest infection, it may help reduce the bacterial load that the patient has to deal with and may shorten the infective process. The shorter the illness, the less likely complications from bed rest will affect the patient. On this note, it is important to remember to keep the patient moving passively whilst on bed rest. Frequent turning, side to side and passive movement of ankles and legs will prevent the development of blood clots in the legs which can occur due to stasis of blood in the veins from inactivity. Frequent turning can also prevent the development of pressure sores which are prevalent in undernourished or malnourished patients, those who are elderly or who have pre-existing skin conditions. In a post-collapse situation you can be sure that undernourished people will be the first to succumb to infection and disease. If the primary cause of disease can be addressed with proper nutrition then many of these conditions can be ameliorated.
Whilst this area of nursing is complex and extensive, I will only cover the general nursing care of bed rest acquired sores and the more superficial wounds and abrasions. I leave trauma management for other more qualified persons to elaborate on. The primary principle to remember in treating any wound or sore is to keep it clean and to support wound healing. The body can do a great job with minimal assistance if the right techniques are used. As mentioned previously, pressure sores arising on the boney prominences from unrelieved pressure due to bed rest can become tricky to treat and chronic if left uncared for. The primary method of preventing these is by movement, one-two hourly turning and relieve of pressure on the affected area. Pressure sores can develop in as little as a few hours if they conditions are right; the patient is malnourished, the skin is friable, the patient is not moving (i.e. may be unconscious). Once a pressure sore has developed the skin is broken there may be sloughing material that needs to be removed from the area. The wound can be irrigated with a solution of boiled salt water that has cooled to tepid (in the absence of sterile saline solutions for irrigation) If the underlying skin is pink and looks healthy it is enough to cover it with a clean, wet saline dressing and then apply a dry dressing on top. These wet to dry dressings need to be changed daily after cleansing/irrigating the sore. A wet dressing soaked in a silver solution may also be used to clean the affected area. These dressings create an environment that encourages healing as long as dirt and infection are cleaned out regularly, daily at the very least. There may occur an area of necrosis around the healing pressure sore, a blackened area that will need to be cut away using a sharp scalpel. This necrotic material will have to be removed in order for the tissue to granulate properly from the base of the wound upwards and thus close the wound. A sharp, small pair of scissors (pre-cleaned) will do as good a job if the area is small.
Dealing with daily dressing changes can eat up supplies very quickly and in a TEOTWAWKI situation you may want to conserve supplies. You can use materials found around the house to make bandages and absorbent pads for wound coverings. They should be non-dyed, white cotton, with no added lycra/nylon or foreign materials in them. Anyone who sews or is handy with a needle can sew several thicknesses of these materials cut to size for dressing materials. The usual sizes for wound dressings are 2″x2″ and 4″x4″ pads and 2″ and 3″ bandages. Thicker absorbent pads can be made out of the same cotton materials folded over and over and sewn together. It is important that no loose threads or debris from these dressings get lodged in wounds as they can become a focus for infection and set up an inflammatory response in the area. If the wound is suppurating or draining a large amount of fluid a wick can be made from the same materials, just longer and narrower. Wicks of 1″ thickness can be dipped in a solutions of saline (salt water) or iodine and then carefully packed loosely into the wound bed. The wound can then be covered as usual with a dry dressing. The wick will literally wick away the drainage and promote healing of the wound better. These wicks can be discarded (ideally) or thoroughly washed and soaked in a weak bleach solution over night and then rinsed again thoroughly and hung to dry on an outside clothesline. Sunlight and air are great antiseptics. All bandages and dressings that are clean and dry should be packed away in a sealed plastic bag to keep as clean as possible for future use.
Although I have only touched on a couple of issues that are of concern in caring for the sick I believe that they are the most prevalent and the principles of caring are generally the same for most conditions; dedicated use of space and materials, good hygiene both for the patient and the caregiver and supportive measures to help the person heal and overcome their illness with minimal complications and shortest duration.