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Nursing care given by general staff hospital nurses to a selected group of patients who had experienced… Patrick, Geraldine Grace Louise 1970

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NURSING CARE GIVEN BY GENERAL STAFF HOSPITAL NURSES TO A SELECTED GROUP OF PATIENTS WHO HAD EXPERIENCED A CEREBROVASCULAR ACCIDENT by GERALD IN E GRACE LOUISE PATRICK B.Sc.N., University of B r i t i s h Columbia, 1959 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in the School of Nurs ing We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA OCTOBER 1970 In presenting th i s thes is in pa r t i a l fu l f i lment of the requirements for an advanced degree at the Un ivers i ty of B r i t i s h Columbia, I agree that the L ibrary shal l make it f ree l y ava i l ab le for reference and study. I fur ther agree that permission for extensive copying of th i s thes is for scho lar ly purposes may be granted by the Head of my Department or by his representat ives. It is understood that copying or pub l i ca t ion of th is thes i s fo r f i nanc ia l gain sha l l not be allowed without my writ ten permission. The Univers i ty o r B r i t i s h Columbia Vancouver 8, Canada Depa rtment Date &j6lLt' ABSTRACT NURSING CARE GIVEN BY GENERAL STAFF HOSPITAL NURSES TO A SELECTED GROUP OF PATIENTS WHO HAD EXPERIENCED A CEREBROVASCULAR ACCIDENT GERALDINE GRACE LOUISE PATRICK The purpose of this study was to identify the nature of nursing care given by general staff hospital nurses to a selected group of patients who had experienced a cerebro-vascular accident. Six hemiplegic patients who had experienced a cerebro-vascular accident one to three weeks before the period of observation were selected for the study. The data were com-piled from direct observations and from a nursing history which included an interview with theopatient and/or his nearest relative, and data from his chart. The observed be-haviour of twenty-nine general staff hospital nurses, six patients, and other members of the rehabilitation team were recorded in the form of anecdotal notes by the non-particip-ating nurse-researcher. Each patient was observed for two days, the mean length of observation time per day was 6 hours and 49.4 minutes. The data were categorized into ten basic nursing care a c t i v i t i e s . Basic nursing care as defined by Henderson, meant helping the patient with activities related to his basic needs or providing conditions under which he could perform them unaided. The data were further organized into desirable a c t i v i t i e s , as outlined in the literature, and undesirable ac t i v i t i e s that were observed. It was demonstrated that many nurses in the study helped patients with most of the ten a c t i v i t i e s , however, few nurses provided conditions under which they could perform them unaided. Food and fluids were fed to patients who could have fed themselves with a l i t t l e encouragement. Bowel and bladder training was not seen as an important factor in the care of the patient who had experienced a cerebrovascular accident. Nurses seldom included exercise during the bath and frequently l e f t the patient in the chair for prolonged periods. Nurses demonstrated that they did not understand the importance of communication with patients who had experienced a cerebrovascular accident, nor did they appear to be aware of the concept of a rehabilitation team. The recommendations were: 1. that an orientation to the total picture of rehabilitation of the patient who had experienced a cerebrovascular accident, in the acute hospital, specialized unit and in the home, be provided for graduate general hospital nurses. 2. that existing knowledge in relation to the nurse's role in the rehabilitation of the patient who had experienced a cerebrovascular accident be compiled and made accessible to general staff hospital nurses. It is now primarily in journals that these nurses do not normally see. that general staff hospital nurses learn to communicate more effectively with patients who have experienced a cerebrovascular accident, with their families and with other members of the rehabilitation team. 304 pages ACKNOWLEDGEMENTS I wish to express my gratitude to the following persons for making this study possible: Margaret Allemang, whose research inspired the study; the Director of Nursing and the Nursing Supervisors of the hospital used in this study for making it- possible for the nurse-researcher to meet patients; the assistant and head nurses, doctors, patients, their families, and general staff hospital nurses for their cooperation; my friends who have helped in so many ways; Mrs. Jessie Hibbert, a member of my committee for her continuing interest and readiness to help; Dr. Bernice R. Wylie, a member of my committee for giving so generously of her time and for her constructive suggestions; and to Miss Elizabeth Cawston, my committee chairman for the many hours she spent reviewing each phase, for her constructive suggestions, continued support and encouragement throughout the duration of this study. TABLE OF CONTENTS Page ACKNOWLEDGEMENTS . . i i Chapter I. INTRODUCTION . . . . . . . . . . . . . . . . . . . . 1 The Choice of the Problem 2 The Problem Objectives of the Study . . . . . . . . . . 4 Limitations of the Study . . . . . . . . . 5 Definition of Terms . . . . . . . . . . . . . . . 5 Basic nursing care . . . . . . . . . . . 6 Observable nursing care . . . . . . . . . 7 Cerebrovascular Accident . . . . . . . . 8 Hemiplegia 8 Aphasia 9 Dysphasia . . . . . . . . . . . . . . . . 9 The Rehabilitation team . . . . . . . . . 10 Anecdotal notes 10 Nursing History 10 Overview of the Remainder of the Study . . 10 II. REVIEW OF THE LITERATURE 11 Introduction. 11 The Medical Literature 11 Nursing Literature. . . . 24 Breathe normally . . . . . . . . . . . . 24 Food and Fluids . 25 Elimination . . . . . . . . . . . . . . . 26 Exercise, Transfer and positioning. . . . 28 Sleep and Rest. . . . . . . . . . . . . . 31 Maintenance of body temperature ....... 32 Bathing and grooming, . . . . . . . . . . 33 Skin care 34 Safety. 35 Commun icat ion . 36 Summary 40 iv Chapter Page III METHOD . . 40 General Procedure . . . . . . . . . . . . . 44 Compilation of the Data . . . . . . . . . . 48 Summary. . . . . . . . . . . . . . . . . . . f 50 IV INTERPRETATION OF FINDINGS . . . . . . . . . . 51 Introduction 51 Analysis of the Nursing Activities . . . . . 52 Food and Fluids , 52 Elimination . . . . . . . . . . . . . . . 60 Exercise Transfer and Positioning . . . . 64 Sleep and Rest . . . . . . . . . . . . . . 70 Maintenance of Body Temperature . . . . . 73 Bathing and Grooming . . . . . . . . . . . 75 Skin Care. 77 Safety . . . . . . . . . . . . . 78 Communication 81 Health teaching 85 Demonstration of Awareness of the Specific Phenomena Peculiar to Cerebrovascular Accidents 86 Aphasia and Dysphasia 87 Unilateral Visual Agnosia . . . 87 Other Phenomena 89 Relationships of General Staff Nurses to other members of the Rehabilitation Team . . 89 Summary. 91 V SUMMARY, RECOMMENDATIONS: AND AREAS FOR FUTURE INVESTIGATION 93 S u m m a r y . . . . . . . . . . . . . . . . . . . 93 Recommendations . . 95 Areas for Further Investigation 97 V Page BIBLIOGRAPHY . . . . ..... . . .. ... ..... . . 98 APPENDIX A. Some Points of Caution in Relation to the Care of Hemiplegics . . . . . 104 APPENDIX B. One Popular Transfer Technique . . . . 108 APPENDIX C. Information made Available to Members of the Rehabi l i t a t i o n Team and to Other Patients in close Proximity to . the Patient Observed 113 APPENDIX D. The Nursing History form Used in the Study 115 APPENDIX E. Nursing Care Studies of Six Patients Who had Experienced a Cerebro-vascular Accident 120 LIST OF TABLES TABLE PAGE I Observation of Six Patients Who had Experienced a Cerebrovascular Accident by the Nurse-Researcher Recorded as to date, day of Il l n e s s 53 II Time Spent by Graduate Staff Nurses with Six Patients Recorded in Minutes During the Period of Observation 54 III Meals i n Which General S t a f f Hospital Nurses were Observed to have Assisted Six Patients Who had Experienced a Cerebrovascular Accident . 55 IV Meals in Which General Staff Hospital Nurses were Observed to Feed (F), to Encourage (E). or to Give Inadequate Assistance (I) . . . . . 57 V Fluids Provided Between Meals by General S t a f f Hospital Nurses who Spent 19 Minutes or more per day with a Patient who had Experienced a Cerebrovascular Accident During the Period of Observation. . 61 VI Number and Percent of Observed A c t i v i t i e s of General S t a f f Hospital Nurses who Assisted Six Patients who had Experienced a Cerebrovascular Accident with the A c t i v i t i e s of Exercise, Transfer and Positioning. . . . . . . . . 66 VII Number and Percent of A c t i v i t i e s of General Staff Nurses who Helped the Six Patients who had Experienced a Cerebrovascular Accident Meet Their Need fo r Sleep and Rest .... . 72 VIII Number and Percent of General Staff Hospital Nurses Performing A c t i v i t i e s Helping to Maintain the Body Temperature of Six Patients who had Experienced a Cerebrovascular Accident . 74 v i i TABLE PAGE IX Observed Activities of Twelve General Staff Nurses who Assisted Six Patients who had Experienced a Cerebrovascular Accident With Ehe Activities of Bathing, Grooming and Skin Care by Number and Percent . . . . 76 X Number and Percent of Observed Activities of Safety Precaution Performed by General Staff Hospital Nurses who Spent 5 Minutes or more Giving Nursing Care to Six Patients Who Had Experienced a Cerebrovascular Accident . . 80 XI Observed Patterns of Communication of Nineteen General Staff Hospital Nurses who Spent more than 5 Minutes with Patients who have Experienced a Cerebro-vascular Accident Presented by Number and Percent 82 l CHAPTER I INTRODUCTION Exploration of the surface of the moon by humans on foot became a r e a l i t y in 1969. Medicine entered the space age approximately ten years ago. Organ transplants have been i n the news for more than a decade and are here to stay. A prediction of these events in 1900 would have brought laughter, because then, they were thought impos-s i b l e . The predictor would probably have been c a l l e d insane or a dreamer who had read too many Jules Vern s t o r i e s . Medical s c i e n t i s t s could not even ponder the p o s s i b i l i t y of transplants because they did not know very much about the organs themselves. The leading causes of death in that day were pneum6-n i a , tuberculosis, and enteric diseases. Deaths s t i l l occur from these diseases but mortality from them has been d r a s t i c a l l y reduced since the development of a n t i b i o t i c s and immunizations. People who would have died from these three and other communicable diseases are now l i v i n g to develop long term i l l n e s s e s such as heart diseases, cancer, and cerebrovascular disease. Nursing care f o r people with these diseases must include long range planning with an emphasis on r e h a b i l i t a t i o n rather than concentrating 2 mainly on the acute phase of the illness, as was necessary with the communicable diseases and enteric diseases. This study was undertaken in an attempt to identify the nature of nursing care given to people who have expe-rienced a cerebrovascular accident. The Choice of the Problem The cerebrovascular accident was chosen for this study; f i r s t , because the nurse-researcher was concerned with the disparity between the nursing care described in nursing journals and nursing care observed, second, because the cerebrovascular accident ranks third as a cause 1 2 3 of death * » ' and third, because i t occurs suddently with l i t t l e or no warning drastically changing a person's whole way of l i f e . The application of findings of medical research ACanada Dominion Bureau of Statistics, Health and Welfare Division, Causes of Death. Canada 1958-1964 (Ottawa: Queen's Printer, November, 1965), p. 13. 9 B r i t i s h Columbia Department of Health Services and Hospital Insurance, V i t a l Statistics Report (Victoria: Queen's Pointer, 1967), p. T40. 3 United States Department of Health Education and Welfare, Public Health Services, National Center for Health Services, V i t a l Statistics of the United States. II Part A (Washington: Government Printing Office, 1967), p. 1-6, Table 1-6. 3 in the care of patients who have experienced cerebrovascular accidents has increased the number of survivors.^ Eighty percent"* ©f these patients, who were fortunate enough to be in relatively developed centres, have become reasonably active especially in the area of self care and have not required custodial care in chronic hospitals. It has been roughly estimated that there are approximately 5,000 people in British Columbia who have experienced a cerebrovascular accident. One of the present p i t f a l l s in the nursing care of patients who have experienced a cerebrovascular accident, has been that hospital nurses seldom see patients with: residual d i s a b i l i t i e s after their discharge from hospital. Present day hospital nurses, by and large, have been educated mainly within acute hospital settings and have been prim-a r i l y oriented to acute illnesses. They may not have been ^Charles M. Wylie, "Rehabilitative Care of Stroke Patients," American Medical Association Journal. CXCVI, (June 27, 1966), p. 1117. ^President's Commission on Heart Disease, Cancer and Stroke: Report to the President - A National Program  to Conquer Heart Disease and Stroke (Washington, D.C.: U.S. Government Printing Office, I, December, 1964), p. 12, Brock M. Fahrni, personal interview, September 4, 1970. 4 aware of the implications of the nursing care given in hospital as i t reflects on the future well-being of the patient who has experienced a cerebrovascular accident. It has been stated that one third of the time of therapists, trained in physical medicine has been spent counteracting problems acquired during the period of acute care. 7 I. The Problem Statement of the Problem. It was the purpose of this study to identify the nature of nursing care given by general staff nurses in hospital to a selected group of patients who had experienced a cerebrovascular accident. Objectives of the study. The objectives of the study were: To determine the extent to which general staff nurses in hospital: 1. give nursing, care, as described by Henderson,® to patients who have experienced a cerebrovascular accident. Bernice R. Wylie, quotation of a statement made by Paul M. Elwood, Jr. in 1967, in a personal interview, September 1, 1970. g ... Virginia Henderson, The Nature of Nursinfi York: The Macmillan Company, 1966), p. 16. 5 2. are aware of some of the s p e c i f i c phenomena peculiar to brain damage caused by cerebrovascular accidents. 3. r e l a t e to other members of the r e h a b i l i t a t i o n team. II. Limitations of the Study The study was limited to: 1. observable nursing care given by general s t a f f nurses in h o s p i t a l to s i x hemiplegic patients who had expe-rienced a cerebrovascular accident. 2. the nursing care given to the patients between the hours of 7 A.M. to 11 A.M.; 11:30 A.M. to 12,30 P.M.; 1:30 P.M. to 3:00 P.M. and 3:30 P.M. to 5:30 P.M., depending on the schedule of meals in the h o s p i t a l and the a c t i v i t i e s of the patient. 3. the needs of the patients that could be met by the general s t a f f nurses during the periods of observation. 4. the medical wards of one acute general h o s p i t a l . 5. the perceptions of one nurse-researcher who had read widely on the subject of nursing care of hemiplegic patients who had experienced a cerebrovascular accident. In addition she has had experience in the p a r t i c i p a t i o n and teaching of basic nursing care. I I I . D e f i n i t i o n of Terms For an understanding of the terms used in t h i s 6 study, they were defined as follows: Basic nursing care. Basic nursing care as defined by Henderson5 meant helping the patient with the following acti v i t i e s or providing conditions under which he could perform them unaided.9 1. Breathe normally. 2. Eat and drink adequately. 3. Eliminate body wastes. 4. Move and maintain desirable postures. 5. Sleep and rest. 6. Select suitable clothes - dress and undress. 7. Maintain body temperature within normal range by adjusting clothing and modifying the environ-ment. 8. Keep the body clean and well groomed and protect the integument. 9. Avoid dangers in the environment and avoid injuring others. 10. Communicate with others in expressing emotions, needs, fears or opinions. 11. Worship according to one's faith. 12. Work in such a way that there is a sense of accomplishment. 9 I b i d . 7 13. Play or participate in various forms of recreation. 14. Learn, discover, or satisfy the curiosity that leads to normal development and health and use of available health f a c i l i t i e s . Observable nursing care. For the purpose of this study, only observable nursing care act i v i t i e s were con-sidered. These have been referred to in an abbreviated form and have been categorized as follows: 1. "Eat and drink adequately" - - - - Food and Fluids. 2. "Eliminate body wastes" - - - Elimination. 3. "Move and maintain desirable postures" - -Exercise, Transfer and Positioning. 4. "Sleep and rest" - - - Sleep and Rest. 5. "Maintenance of body temperature within normal range by adjusting clothing and modifying the environment" - - Maintenance of Body Temperature. 6. "Keep the body clean and well groomed" - -Bathing and Grooming. 7. "Protect the integument" - - - Skin Care. 8. "Avoid dangers in the environment and avoid injuring others" - - - Safety. 8 9. "Communicate with others in expressing emotions, needs, fears or opinions" - - -Commun ica t ion. 10. "Learn, discover, or s a t i s f y the c u r i o s i t y that leads to normal development and health and use of the a v a i l a b l e health f a c i l i t i e s " - - -Health teaching and re-enforcement of teaching of other team members by general s t a f f nurse* Cerebrovascular Accident. This term was used i n t h i s study i n preference to the term "stroke" which " i s no more a diagnosis than i s hemoptysis or hematuria."^ Cerebrovascular accident, as used i n t h i s study, referred to stroke symptoms caused by intracerebral haemmorrhage, or eschemia caused by cerebral i n f a r c t . Adams has defined a cerebral " i n f a r c t " as an area in the brain in which the blood flow has f a l l e n below the c r i t i c a l l e v e l necessary to maintain the v i a b i l i t y of the t i s s u e . " * * Hemiplegia. For the purposes of t h i s study, t h i s term referred to a paralysis or severe weakness of the muscles a f f e c t i n g one hal f of the body, i . e . one arm and 10W. B. Jennett, "Ischaemic Carotid Strokes," S c o t t i s h  Medical Journal. XII (October, 1967), p. 368. * * J . H. Adams, "Patterns of Cerebral I n f a r c t i o n , " S c o t t i s h Medical Journal. XII (October, 1967), p. 340. 9 one leg. Aphasia. This term referred to a phenomena due to brain damage caused by a cerebrovascular accident in which the individual had lost the usual a b i l i t y to use or to understand the spoken word and written language. Recep-tive aphasia referred to auditory aphasia, d i f f i c u l t y in understanding the spoken word, arid/or alexia, a d i f f i c u l t y in reading. Expressive aphasia referred to motor aphasia, d i f f i c u l t y in speaking, and/or agraphia, a d i f f i c u l t y in wr i t i n g . ^ Dysphasia. Dysphasia was defined as an impairment 13 of speech resulting from a brain lesion. Unilateral visual agnosia. This term, referred to the phenomenon in which the patient neglected one-half of space, treating the visual f i e l d on his affected side as 14. i f i t did not exist. 1 2Dorothy W. Smith and Claudia D. Gips, Care of  the Adult Patient (Toronto: J.B. Lippincott Company, 1966)7 p. 366. ^Clarence Wilbur Taber, Tabers Cyclopedic Medical  Dictionary (Philadelphia: F.A. Davis Company, 19697T p. D-55. Bernard Isaacs, "Disorders of Cerebral Cortical Function Associated with Strokes," Physiotherapy LI1 (February 10, 1966), p. 41. 10 The Rehabilitation Team, For the purposes of t h i s study t h i s term referr e d to the patient, family, doctor, nurse, a u x i l i a r y s t a f f , physiotherapist, public health nurse, occupational therapist, speech therapist, clergy-man and s o c i a l worker working together as a team to help the patient f a c i l i t a t e his r e h a b i l i t a t i o n . Anecdotal notes. This term indicated a f a c t u a l report of what was said and/or what was done in a s i t -uation, not what the observer thought about it*15 Nursing History. This was a term used to r e f e r to a systematic method of obtaining information needed to plan pers ona1ized nurs ing care.1^»1 7 Overview of the Remainder of the Study The study i s organized i n the following way: Chapter II consists of a selected review of the l i t e r a t u r e on the care of the hemiplegic patient who has experienced a cerebrovascular accident, often referred to by authors l^Grace F i r a r s and Doris Gosnell, Nursing Evaluation: The Problem and The Process (New York: The Macmillan-Company, 1966), p. 137. l ^ L . McPhetridge, "Nursing History: One Means to Personalize Care," American Journal of Nurs ing. LXVIII (January, 1968), 68-75. 1 7Dorothy W. Smith, "A C l i n i c a l Nursing Tool." American Journal of Nurs ing. LXVIII (November, 1968;, 2384-2388. 11 as "stroke". Chapter III discusses the methodology used in carrying out this study. Chapter IV discusses the interpretation of the findings, and Chapter V the sum-mary, recommendations and areas for further investigations. CHAPTER II REVIEW OF THE LITERATURE Introduction A review of the l i t e r a t u r e which provided the neces-sary background of knowledge has been included in thi s chapter. Two areas were considered, (1) the medical l i t e r a t u r e and (2) the nursing and related l i t e r a t u r e . I. The Medical Literature There has been a change of att i t u d e toward cerebral vascular disease during the past f i f t e e n to twenty years, from an att i t u d e o f - d i s i n t e r e s t and neglect to one of 1 2 active study. There was now a promise of therapy; the development of modern techniques of r e h a b i l i t a t i o n 3 has demonstrated that prognosis i s not always gloomy. Spectacular advances have also been made i n both diagnostic and s u r g i c a l techniques. Moreover, there has been a J . Marshall, "The Diagnostic Problem in Cerebro-vascular Disease," S c o t t i s h Medical Journal. XII (October, 1967), p. 335. 2 I b i d . 3 R.D.M. McLeod and J . Williamson, "Problems of Stroke Assessment and R e h a b i l i t a t i o n , " S c o t t i s h Medical Journal. XII (October, 1967), p. 384. 13 development of s o c i a l agencies which o f f e r supportive care in the community. The use of r e h a b i l i t a t i v e techniques has not been the answer to a l l the problems of patients who have had cerebrovascular accidents. Rusk found in a follow up study of 3,000 stroke patients, 35% went back to g a i n f u l work (a n y t h i n g from doing c e r t a i n household tasks to f u l f i l l i n g the demanding r e s p o n s i b i l i t i e s assumed by a federal judge ) ' and 85% were able to meet the needs of d a i l y l i v i n g enabling them to l i v e beyond the confines of an i n s t i t u t i o n . He pointed out c l e a r l y however, that there were three i n -stances where r e h a b i l i t a t i o n was not f e a s i b l e . Two of these rested on other factors that l i m i t a person's l i f e span; uncontrollable malignant hypertension and severe cardiac damage that severely l i m i t s h i s a c t i v i t y . The t h i r d rested on a diagnosis of severe brain damage where the patient could not remember yesterday's lesson, but t h i s , he emphasized, could not be diagnosed "under 16 to 20 4 weeks a f t e r the o r i g i n a l i n s u l t from stroke." The Pres-idents Commission on Heart Disease, Cancer and Stroke i n 1964 stated that eighty percent of a l l people who survive Howard A. Rusk, "Methods and Techniques of R e h a b i l i t a t i o n , " Comprehensive Services i n Long Term Care (New York: National League of Nursing, 1969), p. 17. 14 a stroke could become r e l a t i v e l y active e s p e c i a l l y i n the area of s e l f care.5 The cerebrovascular accident i s not the only disease process that manifests the stroke syndrome. Some others are neoplasms (benign and malignant), aneurysms, in f e c -t i o n s , subdural hemorrhage and extra c r a n i a l vascular oc-cl u s i o n , a l l of which can be treated s u r g i c a l l y . ^ in some instances surgery such as a carotidendarterectomy can a l l e v i a t e the e f f e c t s of a cerebrovascular accident by preventing complete occlusion, improving blood flow and by removing a source of micro-emboli. 7 Accurate diagnosis i s essen-8 t i a l in selecting candidates for surgery. Some of the diagnostic procedures that were included President's Commission on Heart Disease, Cancer, and Stroke: Report to the President - A National Program  to Conquer Heart Disease. Cancer and Stroke. (Washington, D.CTJ!UTS. Government Prin t i n g O f f i c e , I(December 1964), p. x i . 6Leonard D. P o l i c o f f , "The Philosophy of Stroke R e h a b i l i t a t i o n , " G e r i a t r i c s . XXV (March 1970), p. 99. 7 W.B. Jennett "Ischaemic Carotid Strokes," S c o t t i s h  Medical Journal. XII (October 1967), p. 373. o H.C. Stansel J r . , M. Hume, and W.W.L. Glenn,"Sur-g i c a l Management of Cerebrovascular Insufficiency" -The New  England Journal of Medicine CCLXIX (October 3, 1963), p. 722. 15 in the l i t e r a t u r e were: the lumbar p u n c t u r e , 9 * 1 0 angio-graphy, 1 1 echoencephalography, 1 2 electroencephalography, 1 3 and radio-active brain scanning. 1 4 Even with these diag-no s t i c tools Florey, et a l . discovered that 79% of the cases that they studied had h o s p i t a l records that agreed with the autopsies and only 65% of the death c e r t i f i c a t e s and the autopsies were i n agreement. 1^ Studies have also been done to estimate the number of survivors in the h o s p i t a l and in the community. One of these was by Wolanin and Wagner who sent questionnaires to physicians asking them to enumerate t h e i r present case load of "stroke" cases and to estimate during a s i x month period, the number of patients, in hospi t a l s , i n nursing homes or V F . J . Gillingham, "The Management of Ruptured Intra-c r a n i a l Aneurysms," S c o t t i s h Medical Journal. XII (October 1967), p. 378. 1^Marshall, op. c i t . . p. 336. i l j e n n e t t , pj>. c i t . p. 371. l 2V.S. Achar, R.P.K. Coe and John Marshall, "Echoen-cephalography i n the D i f f e r e n t i a l Diagnosis of Cerebral Haemorrhage and Infarction," The lancet. I (January 1966), p. 163. 1 3 J e n n e t t , pj>. c i t . , p. 317. 1 4 I b i d . 15charles Du. V. Florey, Margaret G. Senter and Roy M. Acheson, "A Study of the V a l i d i t y of the Diagnosis i n Stroke Mortality Data," American Journal of Eoedemiologv. L(January 1969), 15-23. 16 at home. A major flaw in this study was that the re-searchers could not get cooperation from the Veterans Administration. However, they assumed that there were at least 7,000 patients with "stroke" in Arizona, which has a population of 1,690,000.I 6 Another similar type of study was carried out by Acheson and Fairbairn to assess the "Burden of Cerebro-vascular Disease in the Oxford Area in 1963-1964." They stated that: "If a l l strokes in the community are taken into account the one-month survival rate is estimated as 437o as compared with 70% in hospital-treated cases, and the one-year sur-vival rate in the total community 30% as com-pared with 49%, for the hospital cases. "17 One of their interesting findings was that: "after the age of 45 a woman with cere-brovascular disease makes much heavier-demands on the hospital service than a man of the same age, and that the difference lies almost en-t i r e l y among those at present married, would indicate that this is a social phenomenon. Apart from the few cases of subarachnoid haemorrhage already discussed, there is no other indication in the data that the natural history of cerebrovascular disease differs enough between men and women in this age group to account for their different service 16Mary Opal Wolanin and Albert G. Wagner, "Survey of Stroke Patients," Arizona Medicine. XXVI. (November, 1969), 869-871. *^Roy M. Acheson and A.S. Fa i r b a i r n , "Burden of Cerebrovascular Disease i n the Oxford Area in 1963 and 1964," B r i t i s h Medical Journal. II (June 13, 1970), 621-625. demands. It seems that a married middle-aged or e l d e r l y man i s less w ell able to cope with a semi-paralysed spouse than a woman i n t h i s age group, so that a stricken wife must stay in h o s p i t a l but a husband can go home. This problem might lend i t s e l f to a more economical and acceptable solution than the prolonged occupation of a general h o s p i t a l bed..."l° Another important finding was the fact that 27% of cases occurred i n persons of working age. These persons not only burdened society with t h e i r need f o r prolonged medical care, but also through a considerable loss of working c a p a c i t y . 1 9 The physician's r o l e has been described by Dervitz and Z i s l i s as follows: "The physician's r o l e i n treating cerebro-vascular disease when i n f a r c t i o n has occurred i s e s s e n t i a l l y a matter of attempting to keep the patient a l i v e . This i s accomplished by minimizing cerebral damage by providing adequately oxygenated blood to the brain, maintaining an adequate airway, prompt treatment of pneumonia or other i n f e c t i o n by appropriate a n t i b i o t i c s when indicated and maintaining a homeostasis of f l u i d and e l e c t r o l y t e balance.20 They emphasized the re-establishment of bowel and itRoy M. Acheson and A.S. Fa i r b a i r n , "Burden of Cerebrovascular Disease i n the Oxford Area i n 1963 and 1964," B r i t i s h Medical Journal. II (June 13, 1970), 621-62T. 20 Hyman L. Dervitz and Jack M. Z i s l i s , "A Medical Perspective of Physical Therapy and Stroke R e h a b i l i t a t i o n , G e r i a t r i c s . XXV (June, 1970), p. 123. 18 bladder function as they were "powerful hindrances" in carrying out a rehabilitation program. They also stressed that "scrupulous care of the skin is mandatory to prevent 91 decubitus ulcers." L "Physiological bed positioning" and passive range-of-motion exercises were directed toward prevention of con-22 23 tractures, postural deformities, and edema. ' As soon as the patient's medical condition was stabilized, an active rehabilitation program was recom-mended. This program was suited to the physical cap-a b i l i t i e s of the patient and increased gradually as he learned to carry on the act i v i t i e s of daily living: to move about in bed, to feed himself, to s i t , to stand, to walk, to dress and to carry out hygienic measures.24,25 The pharmacological management of the cerebro-vascular accident might have included anticoagulents, corticosteroids, vasodilators and antihypertensive drugs, a l l of which became controversial. Anticoagulents, once 2 1 I b i d . 2 2 P o l i c o f f , op_. c i t . . p. 102. 2 3 D e r v i t z and Z i s l i s , op_. c i t . , p. 125. 2 ^ P o l i c o f f , o£. c i t . et. passim. 25 Dervitz and Zisliis. op. c i t . . p. 126 19 thought to have a limited effectiveness,, have been found "26 27 almost useless, except i n a very limited number of cases. * Corticosteroids have been employed to reduce cerebral edema 2® on a short term basis. Vasodilators have been employed but they were not useful."- 7» J U Anti-hypertensive drugs, when used with survivors of cerebrovascular accidents were 31 not e s p e c i a l l y u s e f u l e i t h e r . The r e h a b i l i t a t i o n of hemiplegic patients who had experienced cerebrovascular accident had more aspects than those mentioned above. One e s s e n t i a l aspect of r e h a b i l i t a t i o n was team work. Everyone concerned with the patient's care should have known what was expected. If there was team work, the r e l a t i v e s of the patient would be involved, the nurses would know that constant encouragement was expected, and °Alan F. Lyon and Arthur C. DeGraff, American  Heart Journal. LXXVII (January, 1969), p. 133. 27 Jennett, OJD. c i t . . p. 372. 2 8 P o l i c o f f , OP_. c i t . , p. 101. 29 I b i d . J Jennett, l o c . c i t . 3 lA. Bamham Carter, The Lancet, I (Saturday 7 March, 1970), et. passim. 20 the physiotherapist, speech and occupational therapist would be f u l l y aware of the neurological and psychological d e f i c i t so that they could properly plan their programmes-. The social worker likewise was involved at an early stage against the day when thoughts of return to work or going 32 home could be seriously entertained. Before this time came, a predischarge v i s i t by the physiotherapist and medical social worker was important as i t might indicate the need for structural changes in 33 the home. The patient and his family are important aspects of this rehabilitation team. Policoff emphasizes this by saying: "The emotional problems of the stroke patient and his family and how they are man-aged may play a significant role in recovery potential. The f i r s t emotional response which occurs is the fear of impending death. This may be disguised in the form of petty, nagging demands on the nurse and physician for constant attention. The problem is not helped when the patient's demands are simply rebuffed. What he needs at this stage in his illness is a frank although guarded discussion of the meaning of his symptoms, reassurance as to survival, and a r e a l i s t i c plan for his res-toration which appears to him to be achiev-able. If goals are set too high for his 32 McLeod and Williamson, oj>. c i t . . p. 384. 33P£* cit-» P. 389. 21 energy resources, he may withdraw from e f f o r t . Optimistic over-reassurance which does not seem compatible with the f a c t s , as he sees them, may frighten and confuse rather than help the p a t i e n t . " 3 ^ "The r e l a t i o n s h i p of the family to the patient i s most important in his recovery pro-cess. Because of g u i l t feelings induced by previous family schism, family members may tend to overprotect and overindulge the pat-ient, producing a dependency state which smothers his i n i t i a t i v e and prevents progress. In other instances, they cannot accept t h i s new drooling, mumbling substitute f o r a f o r -merly dynamic i n d i v i d u a l , and t h e i r obvious r e j e c t i o n destroys the patient's desire to recover and reenter family l i f e . The family physician can do yeoman work in giving them an understanding of the problem and helping them to accept the situation."35 P o l i c o f f a l so emphasized the importance of the nurse, who eould reinforce the patient's desire f o r s e l f care and independence or could smother i t ; the occupational therapist, who concentrated on therapeutic a c t i v i t i e s de-signed to restore hand function and worked with the nurse to help therpatient learn to cope with d a i l y l i v i n g act-i v i t i e s ; and the speech therapist, whose absence should not be an excuse for f a i l u r e to work on the communication problem. In expressive aphasia, a family member or l o c a l ^ school teacher can help with simple repetitious verbal 3 ^ P o l i c o f f , op., c i t . . p. 104. 35 Ibid. e x e r c i s e s . J D Wylie stated that because of improved medical care during the acute stage, more patients who had experienced a cerebrovascular accident were discharged a l i v e from gen-e r a l h o s p i t a l s . 3 7 The President's Commission stated that about 8 out of every 10 people who had experienced a cerebrovascular accident survived the i n i t i a l phase of the disease. But studies by Boyle and others showed that in some areas of the United States the mortality during the i n i t i a l phase was 33% 39»40 and in other areas even h i g h e r . 4 1 These studies Of. J O P o l i c o f f , Q£ . c i t . . et passim. 3 7 C h a r l e s M. Wylie, "Rehabilitative Care of Stroke Patients," American Medical Association Journal. CXCVI (June 27, 1966), p. TTTT. ^ P r e s i d e n t ' s Commission, op. c i t . , p. 12. 3Q J'Robert W. Boyle and Peter D. S c a l z i t t i , "A Study of 480 Consecutive Cases of Cerebro Vascular Accidents" Archives of Physical Medicine (January, 1963), p. 19. 40 Henry Eisenberg, John T. Morrison, Paul S u l l i v a n , Franklin M. Foot, "Cerebrovascular Accidents," American  Medical Association Journal. CL (September 21, 1964), p. 883. 4 1 P e t e r P. LaTorre and Robert W. Boyle, "Prognosis for S urvival a f t e r a Stroke," G e r i a t r i c s . XXIII (October, 1968), p. 106. also showed that 33 4 2-34%^3 of cerebrovascular accident patients survived f i v e years or longer. One of Boyles' studies showed that about 407. of these were moderately to severely limited i n t h e i r a c t i v i t i e s . 4 4 A 1948-1959 study by Adams and Merrett demon-strated a mortality of 19% (within 2 months of the onset); 42% were c l a s s i f i e d as recovered, but t h i s included those who needed some help with dressing and t o i l e t . More than 38% were bed fast or chair fast and remained confused and incontinent a f t e r three months of active treatment. It was also observed that "the e a r l i e r physical r e t r a i n i n g begins a f t e r a stroke the better the result." 4-> Wylie suggested the l i k e l i h o o d that the long term care of patients with cerebrovascular accidents would form an increasing health problem in coming decades. He emph-asized that s c i e n t i f i c study and improvement of techniques must be accompanied by more abundant and higher q u a l i t y r e h a b i l i t a t i v e services and that the use of these services 4 2 B o y l e and S c a l z i t t i , oj>. c i t . . p. 210. ^ E i s e n b e r g , et a l . op. c i t . . p. 885. 44 Boyle and S c a l i z i t t i , l o c . c i t . 4~*G. F. Adams and J . D. Merrett, "Prognosis and Surv i v a l in the Aftermath of Hemiplegia," B r i t i s h Medical Journal, I (Saturday, February 4, 1961), p. 310. 24 must be stimulated.** 0 I I . The Nursing and Related Literature There had not been a vast amount of l i t e r a t u r e written by nurses on the care of patients who had exper-ienced a cerebrovascular accident or a "stroke", p a r t i c u l a r l y in Canada. This section included a r t i c l e s appearing i n nursing journals by doctors, psychologists and nurses; information c i t e d in nursing text books; and a r t i c l e s in physiotherapy journals and texts. Reference was also made to two pieces of nursing research]? one a doctoral d i s -sertation and the other a master's t h e s i s . The contents of t h i s section have been arranged in r e l a t i o n to Henderson's l i s t of basic needs.^ Breathe normally. The need to breathe normally was often a major problem to s a t i s f y i n i t i a l l y , i n the care of the unconscious, or the conscious "stroke" patient who may have l o s t his swallowing r e f l e x . The nurse must have done whatever she could to maintain a c l e a r a i r way and promote 4 6 t f v l i e . OP. c i t . . p. 1120. 4 7 - -V i r g i n i a Henderson, The Nature of Nursing (New York: The Macmillan Company, 1966), p. 16. 25 drainage.^»^9 Respiratory, complications were extremely serious for immobilized patients who have had neurological damage and were unable to change po s i t i o n , breathe deeply, or cough. Stasis of secretions was soon followed by a t e l e c t a s i s of small lung areas establishing a perfect medium fo r b a c t e r i a l growth. The nurse must have been sure that the patient breathed deeply, changed position often, coughed frequently and that she used the suction equipment properly and when-ever necessary to keep a cle a r airway. Food and F l u i d s . The need to eat and to drink adeq-uately was the second need that had to be met to sustain the l i f e of a "stroke" patient. Hydration and the r e -establishment of his f l u i d and e l e c t r o l y t e balance were of serious importance e s p e c i a l l y when the patient was uncon-scious or had l o s t h is swallowing r e f l e x . The doctor ordered intravenous f l u i d s and blood chemistry t e s t s ; then i t became the duty of the nurse to make sure that these orders Eleanor G. Smith, "Nursing i n Acute Stroke," Proceedings of the National Stroke Congress. Ralph DeForest, editor ( S p r i n g f i e l d , I l l i n o i s : Charles C. Thomas Publisher, 1964), p. 81. 49Helen Large, Joseph E. T u t h i l l , F. Bryan Kennedy, Thomas J . Pozen, "In the F i r s t Stroke Intensive Care Unit," American Journal of Nursing. LXIX, (January, 1969), p. 78. Ibxd. 26 were carr i e d out.51,52 When the f l u i d and e l e c t r o l y t e balance had been s t a b i l i z e d the doctor ordered o r a l f l u i d s , to be given by nasogastric tube i f the patient had lo s t his swallowing r e f l e x or by mouth i f he was able to swallow. Oral intake was obviously a better route, i f the patient could swallow, to ensure that the patient obtained adequate hydration. The nurse t r i e d to prevent a need for the patient to return to the parenteral route to a t t a i n f l u i d s . J J When the patient was able to have o r a l f l u i d s he had< a jug of water, or other f l u i d , on his bedside table54 so that he could drink his d a i l y requirement of f l u i d (1,500-3,000cc)55 a g w a g o r < j e r e < j by the doctor. The d i e t ordered by the physician was served and an adequate explanation given regarding the food that was prescribed. The patient's l i k e s , d i s l i k e s and his food habits were learned soon a f t e r his admission so that he would not be served foods that he d i s l i k e d . The patient was placed in a proper and comfortable position where he 51Ibid.. p. 77. 5 2Smith., i o c > C i t . 53Ruth Perin Stryker. Back to Nursing (Philadelphia: W.B. Saunders Company, 1966), p. 217. ^Nancy Roper, P r i n c i p l e s of Nurs ing. (London: E.S. Livingstone Limited, 1967), p. 30. 55norothy W. Smith and Claudia D. Gips,,. Care of the  Adult Patient (Toronto: J.B. Lippincott Company, 1966), p. 123. 27 could manage to feed himself.56 Whenever possible the patient assisted with his own feeding, but the nurse should 57 stay with him i n i t i a l l y to make sure he ; did not choke. Elimination. It was the r e s p o n s i b i l i t y of the nurse to see that the f l u i d s were given as ordered and to ac-curately record the t o t a l intake and output. These duties were extremely important, p a r t i c u l a r l y in the f i r s t c r i t i c a l days.-**5 Smith states that: The genitourinary and g a s t r o i n t e s t i n a l functions are frequently affected in the ac-u t e l y i l l patient. Urinary output must be observed and measured for the f i r s t twenty-four hours; severely l i m i t e d , or absence of, urine i s an indication of shock whereas blad-der distension due to i n a b i l i t y of the patient to void may require periodic catheterization or the use of an indwelling catheter. One caution - the use of the l a t t e r must be limited to the period of need and not be misused as a convenience to nursing care. The patient should also be watched fo r abdominal distension or loose stools as these may indicate an impaction. 9 Bowel-and bladder-training were of p a r t i c u l a r importance to the "stroke" patient. When he was aware of M. Esther McClain and S h i r l e y Hawke Gragg, The  S c i e n t i f i c P r i n c i p l e s In Nursing (St. Louis: The C.V. Mqsby Company, 1962), p. 166-167. 5 7Smith, op., c i t . . p. 82. 58 Large, et. a l . o£. c i t . . p. 77. 5 9Smith, loc. c i t . 28 His incontinence he was embarrassed and often became ashamed, disgusted, or angry, and might have lost interest in things around him. The cost of changing beds and bathing the patient was secondary to the coat of personal f r u s t r a t i o n and the cost of the patient's self-esteem.^0 Exercise, transfer and positioning. The need to move and maintain desirable postures was e s s e n t i a l i n order 61 to prevent contractural deformities, x e g . foot drop, frozen shoulder or shoulder-hand syndrome,^2 a n ( j t o maintain and restore functional a b i l i t i e s . ^ 3 Large, et. a l , gave t h e i r routine for positioning as follows: Leg - The affected leg i s supported in a position that i s neutral for r o t a t i o n by a trochanter r o l l or sandbag to prevent outward ro t a t i o n of the hip, when the patient i s supine. A foot-board helps prevent drop foot. Arm and Hand - Using pillows, we place the affected arm so that the hand i s higher than the wrist; the wr i s t , higher than the elbow; and the elbow, higher than the shoulder. A r o l l keeps the hand i n a functional p o s i t i o n . 6 0 J u d i t h H. Stanton, "Rehabilitation Nursing Related to Stroke", C l i n i c a l Orthopaedics and Related Research, LXIII, (Toronto: J.B. Lippincott Company, 1969), p. 44. 61 Stanton, op. ext., p. 40. 62 Large, et. a l . , o£. cit.« p. 80 Stanton, oj>. c i t . . p. 39 The arm i s kept 90° away from the body to prevent frozen shoulder and sympathetic dystrophy or shoulder-hand syndrome. We believe three general facts about position-ing are of great importance. F i r s t , the patient should not be l e f t on the affected side f o r more than 20 minutes four times a day. Second, as soon as the patient responds to commands, deep breathing and coughing should be encouraged each time he i s turned. F i n a l l y , range of motion should be started,on the day of admission for a l l e x t r e m i t i e s . 6 4 Hudson, Hood and Fahrni stressed several points in. relation..to the care of hemiplegics. J See Appendix A, page 103. One of these, was that one of the main aims of the foot board was to keep the covers o f f the patients feet and legs so that he could move in bed more e a s i l y and i f the foot was constantly pressed against the foot board further s p a s t i c i t y i n plantar flexors could occur. Hudson, et. a l . , also made s p e c i a l mention of the "prone p o s i t i o n " since t h i s p osition had many advantages and h o s p i t a l nurses seemed slow to adopt it.°^ Stanton Large, et. a l . , loc. c i t . Jane Hudson, Margaret R. Hood, and Brock M. Fahrni, "HospitalManagement of Hemiplegia," The Canadian  Nurse. LXII (July 1966), p. 22. Ibid, p. 21. 30 also l i s t e d i t s advantages.67 i n this position the airway was more e a s i l y maintained and i t allowed secretions to drain f r e e l y . There was much less concern about pressure points, the patients position was shifted r e a d i l y by one person, and i t helped.to prevent hip and knee f l e x i o n . It was used f o r both conscious and unconscious patients.^8,69 stanton pointed out that patients who are aware of t h e i r sur-roundings are often frightened in t h i s p o s ition. She suggested that the simple act of making the bed with the patient's head at the opposite end allowed him to see what was going on and helped to minimize t h i s fear.70 A questionnaire survey by G u e r r i e r i , of nurses' know-ledge of proper bed positioning of patients with hemiplegia, revealed that nurses lack basic knowledge i n t h i s a r e a . 7 1 At t h i s point, the patient's need f o r physiotherapy was examined. The physiotherapist was frequently a member 67 Stanton, gjo. c i t . . p. 47. 6 8 I b i d . ^Hudson, et. a l . , og. c i t . . p. 23. 7 0Stanton, loc. c i t . 7 l B e l g a O. G e r r i e r i , "Survey of the Knowledge of the Nurse i n Direct-Care Services Concerning Proper Bed Posit-ioning of the Patient with Hemiplegia," Nursing Research. XVII (March-April, 1968), 157-159. of the r e h a b i l i t a t i v e team from the day of admission. Bobath, a physiotherapist, recommended that treatment be given immediately a f t e r the onset of hemiplegia, or as soon as p o s s i b l e . 7 2 The n u r s e s , i n units for the intensive care of stroke patients, were aware of the exercises that t h e i r patients were receiving and were ready to learn and to administer these exercises i f the physiotherapist requested t h e i r a i d 73 74 during evenings or on weekends. » Safe and proper tran s f e r r i n g of the patient from bed to chair and from chair to bed was another important aspect to be considered when caring f o r hemiplegic stroke p a t i e n t s . Q n e popular transfer technique 7** i S contained in Appendix B, pages 109-112. Sleep and Rest. The need for sleep and r e s t as 7 2 B e r t h a Bobath, "Observation on Adult Hemiplegia and Suggestions f o r Treatment," Phvsiotb.era.py/-.' XLVI (January, 1960), p. 5. 7 3 H e l e n Large, et. a l . , "In the F i r s t Stroke Intensive Care Unit," American Journal of Nursing., LXIX (January, 1969), p. 80. 7 4 J u d i t h H. Stanton, "Rehabilitation Nursing Related to Stroke", C l i n i c a l Orthopaedics and Related Research. LXII1, (Toronto: J.B. Lippincott Company, 1969), p. 46. 7 5 I b i d . , p. 47. 7 oKenny Reha b i l i t a t i o n , A Handbook of Rehabi1itation  Nursing Techniques i n Hemiplegia.(Chicago: Kenny Rehabil-i t a t ion ,nf964Tr^2"-77* 32 specially related to the patient who has experienced a cerebrovascular accident with hemiplegia, was neglected in the literature. General measures such as good body align-ment, properly placed pillows, a comfortably made bed, good ventilation, and the c a l l light within reach were important for rest and sleep. 7 7> 7 8 The need for an hour or so of unbroken rest during the day, in addition to the normal need for eight hours of sleep, was also mentioned in the textbooks. 7 9* 8 0 However, patients who had experienced a cerebrovascular accident needed to have frequent rest periods on the bed during the day, especially during the time that they were on an acute medical ward. They were not to be l e f t in the chair for long periods and allowed to sleep.81 Maintenance of Body Temperature. Ambulant patients could usually maintain their body temperature within.normal 7 7Dorothy W. Smith and Claudia D. Gips, Care of the  Adult Patient (Toronto: J.B. Lippincott Company, 196677 131-133. 7%ancy Roper, Principles of Nurs ing. (London: E.S. Livingstone Limited, 1967), 43^ *45. 7 9Smith and Gips, loc. c i t . 8 0Roper, loc. c i t . 81 Bernice R. Wylie, personal interview. 33 range, but, the nurse had to adjust the heating and vent-i l a t i n g devices and clothing for the bed patient. She had to learn to interpret the wishes of the hemiplegic aphasic 82 patient from signs and therefore must have been observant. Bathing and Grooming. The need to keep the body clean and we l l groomed was said to be ". . . e s s e n t i a l to the comfort and well-being of the patient."83 Bathing was ess e n t i a l to good skin care in that i t removed d i r t and waste products from the skin and stimulated c i r c u l a t i o n . There was an opportunity to a s s i s t the patient through a range-of-motion exercises as the nurse gave the bath. As the patient became more active he helped with his bath and did "self-ranging" (range-of-motion exercises) under the guid-84 ance of the nurse. The bath a l s o gave the nurse an opportunity to l i s t e n to the patient's complaints and to observe his body. McClain and Gragg stated that "cooperation of the"patient f o r almost the whole day's a c t i v i t i e s may be 82R 0per, o p # c i t . , p. 163. 83M. Esther McClain and Shirley Hawke Gragg, The  Scientific Principles in Nursing (St. Louis: The C.V. Mosby Company, 1962), p. 137. Stanton, oj>. c i t , , p. 42 34 e l i c i t e d at the time of the bath.85 Care of the ha i r was important, e s p e c i a l l y to female patients. "The object of combing and brushing i s to r i d the hair of accumulations of foreign matter, dandruff and so on, and to exercise the s c a l p . " 8 6 During i l l n e s s the scalp wasooften tender so the nurse was c a r e f u l how she removed 87 tangles. The hair required washing and cutting from time to time to clean the h a i r and scalp and to promote the comfort of the p a t i e n t . 8 8 The former might have been done by the nursing s t a f f , but, the l a t t e r was usually done by a ha i r d r e s s e r . 8 9 Skin Care. Skin care was part of bathing, but, must be considered at least every two hours for the hemi-plegic who had experienced a cerebrovascular accident.and 0 0 9 1 9 2 could move himself, to prevent decubitus u l c e r s . »*» 85McClain and Gragg, o£. cit.« p. 145. 8 6 M c C l a i n and Gragg, op., c i t . . p. 149. 8 7Roper, op. c i t . . p. 9. 8 8 M c C l a i n and Gragg, loc. c i t . on Roper, loc. c i t . 9 0 R u t h Perin Strvker. Back to Nursing. (Philadelphia: W.B. Saunders Company, 1966;, p. 142. 91-Stanton, op., c i t . . p. 44. 9 2Roper, op. c i t . , p. 20. Even i f he was conscious and was able to move w e l l in bed the hemiplegic who had hemianesthesia would not turn 93 himself s u f f i c i e n t l y . Stryker suggested that when the patient was turned his pressure areas should have been 94 gently massaged. McClain and Gragg suggested that the c i r c u l a t i o n was increased by rubbing the skin with al c o h o l , and that too much alcohol or o i l y lubricant might have lessened the f r i c t i o n so much that the deep tissues could not have been manipulated. J Safety. Safety was an important factor f o r the hemiplegic patient. He was paralyzed on one side which Of. was usually associated with a defect in his balance. " 97 Side r a i l s helped him to f e e l safe while he was in bed. QQ He f e l t safe i f he could reach his c a l l l i g h t . He also f e l t safe i f the other things that he needed, water, glasses, book 93 Bertha Bobath, "Observations on Adult Hemiplegia and Suggestions f o r Treatment," Physiotherapy, XLV (December, 1959), p. 279. 9 4 S t r y k e r , l o c . c i t . ^ M c C l a i n and Gragg, op. c i t . , p. 143. ^ J a c q u e l i n e Montgomery and Margaret Inaka, C l i n i c a l  Orthopaedics and Related Research. LXIII (Toronto: J.B. Lippincott Company, 1969), p. 60. 9 7 S m i t h and Gips, op., c i t . . p. 1083. 9 8 S m i t h and Gips, op_. ext., p. 132. etc., were where he could reach them. The wheelchair brakes had been locked when the p a t i e n t was being transferred from or to a w h e e l c h a i r . " -Patients who had the perceptual defect or u n i l a t e r a l v i s u a l agnosia, had to be watched c a r e f u l l y when they began to walk. They did not see door jambs, beds, chairs, etc. that were on t h e i r affected side and stumbled into them. 1 0 0 Communication. One of the major problems f o r patients with hemiplegia, caused by a cerebrovascular accident i n the dominant side of his brain, was aphasia or dysphasia. 1°1 The patient was encouraged to es t a b l i s h communication, by squeezing a hand, pointing, nodding, grimacing, or whatever means was easiest for him, as soon as possible a f t e r the 102 onset of his i l l n e s s . * ^ The adult aphasic could not aff o r d unnecessary s o c i a l i s o l a t i o n . He had to maintain his r e -maining verbal a b i l i t i e s by constant verbal stimulation and "Kenny R e h a b i l i t a t i o n , op. c i t . . p. 74. lO^Bernard i s a c c s Disorders of Cerebral C o r t i c a l Function Associated with Strokes" Phvsio-Therapy. LII (February 10, 1966) p. 42. 1 0 1 S m i t h and Gips, pjg. c i t . . p. 366. 102 Jon Eisenson, "Speech Therapy," Proceedings of  the National Stroke Congress. ed. by Ralph De Forest ( S p r i n g f i e l d , I l l i n o i s : Charles C. Thomas Publisher, 1964), p. 98. 37 therefore had to be encouraged, to communicate. 1 0 3 Roper had included an i l l u s t r a t i o n of a communication device i n her book. 1 0 4 The aphasic patient was not spoken to loudly as i f he were deaf. If he did not have auditory aphasia he would have been able to hear people speaking at t h e i r ordinary voice volume. He might have been insulted by shouting. People had to speak slowly, and use sentences so that i f he could not get every word he could f i l l in the blanks by guessing. Sometimes the aphasic said "yes" when he meant "no" because the word "no" would not come out. 1 0-* Communication with the family was also very important in the care of the patient who had experienced a cerebrovascular accident, whether he was aphasic or not. The nurse who spent a l i t t l e time l i s t e n i n g , understanding and interpreting to the patient's family more often than not developed a u s e f u l therapeutic resource f o r the 1 0 3McKenzie Buck, "Adjustments During Recovery from Stroke," American Journal of Nursing. LXIV (October, 1964), p. 93. 1 0 4Roper, o£. c i t . , p. 259. 105 Isaacs, loc. c i t . 38 p a t i e n t . 1 0 6 The need to "learn, discover or satisfy the curiosity that leads to normal development and health and use of ava i l -able health f a c i l i t i e s was a need of the family as well as the p a t i e n t . " 1 0 7 The family should be taught what to watch for and how to assist the patient. They should have been given the reasoning behind the instructions and have been allowed to do the things that they were capable of doing. They would then have been more confident later when they cared for the patient at home.108 It was very important that before he le f t the hospital, both the patient and his family understood exactly how much he could have done for 1 09 himself and how he needed to be helped. The patient and his family knew how to contact the public health nurse; this actually was explained to them by 1 r\fi Margaret A. Kaufmann, "Nursing and the Early Care of the Stroke Patient," Proceedings of the National Stroke  Congress. ed. by Ralph Be Forest (Springfield, I l l i n o i s : Charles.C. Thomas Publisher, 1964), p. 95. 107Virginia Henderson, The Nature of Nursing., (New York: The MacMillan Company, 1966), p. 16. 1 0 8Margaret A. Goode, "The. Patient with a Cerebral Vascular Accident," Nursing Outlook. XIV (March, 1966), p.61 1 0 9Genevieve Waples Smith, Care of the Patient with A Stroke. (New York: Springer Publishing Company, Inc., 1967), P. 7. the h o s p i t a l nurse before the patient was discharged. The public health nurse worked with the family in the areas of d i e t , therapeutic bathing, exercise and mental health. She interpreted the services of other community agencies and worked with them as needed. 1 1 0 She or the ho s p i t a l nurse saw that the patient and his family were given or made aware of pamphlets such as Do It Yourself AgaJLn;lll Adjusting to S t r o k e ; 1 1 2 'Stroke' Illness 20 Questions ; 1 1 3 When Words Are Missing A f t e r a S t r o k e : 1 1 4 S t r i k e Back at S t r o k e : 1 1 5 a m j HOHarriett L. Wilcoxson, "Cerebrovascular Accident: The Role of the Public Health Nurse," Nursing C l i n i c s of  North America. I (March, 1966), p. 67. 1^American Heart Association, Do It Yourself Again. (New York: American Heart Association, 19677. H 2The Chest and Heart Association, Ad justing To A ^Stroke' Patient. (London: The Chest and Heart Assoc-i a t i o n ) . 1 1 3 T h e Chest and Heart Association, 'Stroke' I l l n e s s . 20 Questions and Answers. (London: The Chest and Heart Association). 1 1 4 T h e Chest and Heart Association, When Words are Missing A f t e r a 'Stroke'. (London: The Chest and Heart Association). 1 1 5U.S. Public Health Service, Chronic Disease Div-i s i o n , S t r i k e Back At Stroke. (Washington, D.C.: Publication No. 596, U.S. Government Printing O f f i c e , 1958). 40 Up and A r o u n d 1 1 6 and guide them in t h e i r use. Summary Two main areas of the l i t e r a t u r e in r e l a t i o n to the care of patients who have had a cerebrovascular accident, were considered in t h i s section. The medical l i t e r a t u r e was reviewed f i r s t . Reference was made to the necessitynof accurate diagnosis and s u r g i c a l treatment of certa i n path-o l o g i c a l lesions which have manifested hemiplegia which were not true cerebrovascular accidents. Accurate diagnosis was also necessary for the prescription of a sound rehab-i l i t a t i o n program as there were some instances where rehab-i l i t a t i o n techniques were not f e a s i b l e . It was recommended that the r e h a b i l i t a t i o n program be i n s t i t u t e d , whenever f e a s i b l e , as soon as the medical condition had s t a b i l i z e d , and that the members of the r e h a b i l i t a t i o n team function as a team i f the program was to be meaningful to the patient. S t a t i s t i c s were also reviewed i n an attempt to demonstrate the need f o r early comprehensive medical and nursing care of the patient who had experienced a cerebrovascular i l l n e s s . The nursing l i t e r a t u r e was reviewed i n the second Public Health Service, Chronic Disease D i v i s i o n , Up and Around. (Washington, D.C.: Publication No. 1120, U.S. Government Printing O f f i c e , 1964). 41 part of this section. This material was viewed in relation to the c r i t e r i a of basic needs. The problem of maintaining a clear airway and the essential balance of fluids and nutrients were mentioned. The need for bowel and bladder training was emphasized. The importance of positioning and transferring were included and reference was made to additional material in Appendix A,105*107 , and Appendix B, 1095?-112. The needs of sleep, maintenance of body temp-erature, grooming, bathing and safety were also referred to in this review. The need for communication was also emphasized as many patients who have experienced a cerebrovascular accident are disphasic or aphasic. There seemed to be a f a i r amount written regarding the medical and the nursing care of patients who had exper-ienced a cerebrovascular accident, but, most of this l i t -erature was in journals where the average general staff nurse would not see i t . Seedor conducted a study of the nursing care needs of hemiplegic patients and interviewed patients and their families. She found that they f e l t that their physical needs were adequately met, but, that their psychospiritual, social and informational needs were only partially or inconsistently met.**7 Gerrieri's survey, H 7Mary Seedor, "Hemiplegia Patient's Nursing Care Needs and Their Implications for Curriculum Development" (unpublished Doctoral Dissertation, the University of Pennsylvania, Philadelphia, Pennsylvania), p. 38. 42 revealing that nurses lack basic knowledge in the area of proper bed positioning of patients with hemiplegia, does not contradict Seedor's study because this is an area that patients and their families are unable to a s s e s s . 1 1 8 i l oBelga 0. Gerrieri, "Survey of the Knowledge of the Nurse in Direct-Care Services Concerning Proper Bed positioning of the Patient with Hemiplegia," Nursing  Research. XVII (March-April, 1968), 157-159. CHAPTER III . METHOD General Procedure The descriptive method of research was used for the study and a nursing history was developed as an additional data gathering device to supplement the direct observations. The nursing history was based on pertinent literature in relation to the construction and use of nursing histories. It included an interview with the patient and data from his chart (history, medical findings, doctor's orders, recorded medical observations of rehabilitation team members, etc.) Were also taken. This was to provide an assessment of the patient's nursing care needs as seen by the nurse-researcher. Nursing care given by general staff hospital nurses to six selected hemiplegic patients who had experienced a cerebrovascular accident was observed and recorded by the nurse-researcher in the form of anecdotal notes. The data were categorized into the ten basic a c t i v i t i e s , as previously defined. One to three days before the observation commenced the head or assistant head nurse, the physician, the patient, physiotherapist, and the nearest relative, where possible, were contacted. The study was explained and permission 44 was obtained for the observation. The project was also explained to the other patients in close proximity so they would not be suspicious of the observer nor of the patients being observed. In addition, a statement was prepared and mimeographed so that each member of the r e h a b i l i t a t i o n team, and the other patients, could have a printed copy of the explanation of the study. In most situations t h i s state-ment, i l l u s t r a t e d i n Appendix C, page 114, was.'.placed on the front of the patient's chart by the head or assistant head nurse, one to three days before observation commenced. Patient a c t i v i t y / a c t i v i t i e s and the a c t i v i t i e s of other r e h a b i l i t a t i v e team members were also recorded when they were observed and when they had implications related to nursing care, e.g. the physiotherapist's treatments gave an in d i c a t i o n of how much the patient could do fo r himself. Nursing care and patient a c t i v i t y were observed and recorded for approximately 8 hours at peak periods of patient a c t i v i t y 1 between 7:00 a.m. and 5:00 p.m. for two con-secutive days which had been decided on the basis of the t r i a l run. The T r i a l Run The nurse-researcher met with the d i r e c t o r of the Breakfast, lunch and supper. Morning nursing care (or bath), v i s i t s by physician, physiotherapist, other therapists, family and friends. Change of nurses* s h i f t . 45 hospital, explained the proposed study, and a medical ward ?. was chosen for the t r i a l run. On this ward there were two patients with a diagnosis of cerebrovascular accident. One of these patients refused to participate. The other patient had had a l e f t hemiparesis eight days previously, but had recovered the use of her l e f t leg and l e f t arm, having only paresis in her l e f t hand and considerable loss of balance. It was decided to limit the t r i a l run to observations carried out on this patient. As a result of these observations the following guide lines were identified: a) two consecutive days of observation seemed to be adequate for the purposes of this study; b) some participation by the nurse-researcher in the provision of small services to the patient would probably be necessary as there were long periods where the patient and the nurse-researcher were alone, eg. putting on the c a l l light, i f i t was not within reach and the patient was in distress.; c) a clear understanding of the routine times for ' nursing care had to be established by the nurse-researcher the day before observation commenced, e.g. nurse-researcher was told that 46 breakfast was not served u n t i l eight o'clock and that she would not need to come to the ward before that time. Therefore she did not come un t i l seven f i f t y a.m., the patient was up in a chair and the bed was being made. Selection of the Study Group The selection of patients for this study was based on: a) a diagnosis of cerebrovascular accident with the presence of hemiplegia; b) the cerebrovascular accident must have occurred from one to three weeks prior to the period of observation; c) co-operation of the attending physician; d) the willingness of the patient, or his nearest relative, to participate; e) the ava i l a b i l i t y of general staff nurses to give nursing care to the selected patients. The. selection of six patients on the basis of the above c r i t e r i a and on the limitations previously defined, was thought to be a -fairly easy procedure. It was hoped that two patients could be observed each week for three weeks. However, this was not so. Observations were 47 started May 5, 1970 and were not completed u n t i l June 26, 1970. On one occasion, one week elapsed between the time that observations were completed on one patient and the admission of another patient, r e s u l t i n g i n two weeks between observations. One patient was selected and a f t e r the patient had been observed f o r about half an hour, an aide came in and t o l d the patient that she was going to wash her face and hands before breakfast. She washed the patient's face and hands, then proceeded to give the patient a bath without st r i p p i n g the bed, and had i t almost half finished before the nurse-researcher r e a l i z e d what had happened. She d i s -covered that part of her verbal instructions to the a s s i s t -ant-head nurse had been misunderstood, or that the general s t a f f nurse team leader had misunderstood the a s s i s t a n t -head nurse, and an aide had been assigned to care for the patient. The nurse-researcher l e f t and came back the next day. Observations went smoothly on the second day, but the nurse-researcher r e a l i z e d that she had been misunder-stood once again, when she discovered that the general s t a f f nurse who had been assigned to care for the patient that day, had been assigned to care f o r her the following 48 day a l s o . The nurse-researcher did not go to the h o s p i t a l that day. A s i m i l a r incident occurred on another day thus eliminating the data that had been obtained. On another occasion, one patient had been observed for four hours and then death occurred. Compilation of the Data The data were recorded on the nursing history form, i l l u s t r a t e d i n Appendix D, p.116 to 123, and observations made in rough form. The time that the nurse-researcher arrived each morning was recorded i n a column i n which the time that every person who came to the patient's bedside, and the time when most people l e f t , was recorded. A c t i v i t i e s and conversations were recorded in another column. It had been planned that other a d d i t i o n a l observations be recorded in a t h i r d column, as i l l u s t r a t e d i n Appendix E pages 126-305, but, were written elsewhere on rough paper when the a c t i v i t i e s occurred more r a p i d l y than the recorder could write. Before the data were analyzed a nursing approach was compiled on the basis of the data obtained from the nursing his t o r y . This i s included in Appendix E, The data were re-written in columns and typed. They were then xeroxed and the xeroxed copy was cut into pieces 49 with one piece for each activity representative of each of the ten basic ac t i v i t i e s previously defined. The pieces were then sorted into the ten categories. The categories were then sorted further into the act i v i t i e s performed by individual nurses and the nursing care performed. This analysis appears in Chapter IV. Early in the compilation of the data, but after a l l the observations had been completed, an attempt was made to copy out the numerous act i v i t i e s performed by the various nurses on 3 x 5 cards. This method was abandoned as i t was found to be too time consuming. The data was expected to show: 1. which basic and specific needs were met; 2. i f the nursing care given was related to the needs that the nursing history revealed; 3. i f nurses appeared to be aware of the patient's specific needs in relation to manifested phenomena peculiar to brain damage caused by cerebrovascular accident; 4. how nurses related to other members of the rehabilitation team at the bedside; 5. i f there was continuity between the care given by the general staff hospital nurses and other rehabilitation team members, e.g. did the nurse 50 appear to know what the physiotherapist taught the patient. Summary The descriptive method of research was used for this study employing direct observations, anecdotal notes, and a nursing history. The c r i t e r i a for selection and the d i f -f i c u l t i e s in obtaining six patients for observation were described. The method of compilation of the data was out-lined. The analysis of the data is in Chapter IV. CHAPTER IV INTERPRETATION OF FINDINGS Introduction This study was undertaken in an attempt to i d e n t i f y the nature of nursing care given to people who had experienced a cerebrovascular accident by general s t a f f h o s p i t a l nurses. It was limited to s i x patients on medical wards of one h o s p i t a l . It was also limited to patients who had experienced t h e i r cerebrovascular accident one to three weeks before the observations took place and who were cared f o r by graduate s t a f f nurses. Each graduate s t a f f h o s p i t a l nurse had an op-portunity to read the statement explaining the study, as i t was fastened to the front of the patient's chart one to three days before observations began. However, ver-bal communication between the nurse-researcher and the graduate s t a f f nurses was not entertained. The nurse-researcher began observations on May 5, 1970 and completed them on June 26, 1970. The maximum time of observation per day, was 8 hours and 34 minutes andtfche minimum length of time was 5 hours and 35 minutes. The average length of observation time per day was 6 hours and 49.4 minutes, as i l l u s t r a t e d in Table ' 1^ page 53. The time that each general s t a f f h o s p i t a l nurse spent with each patient was computed and i s i l l u s t r a t e d i n Table II page 54. The mean time spent by graduate s t a f f h o s p i t a l nurses with s i x patients was 25.3 minutes. However, of the 29 nurses observed only 13 spent more than 19 minutes with a patient. Ten general s t a f f nurses spent more than 30 minutes with a patient and 12 spent less than 10 minutes with a patient. The median length of time that nurses spent with patients was 15 minutes. Analysis of the Nursing A c t i v i t i e s The nursing a c t i v i t i e s of basic nursing care, as previously defined, were analyzed separately. Foods and F l u i d s . T h i r t y s i x meals were served to the s i x patients i n the study during the period of observation.* Fourteen general s t a f f h o s p i t a l nurses assisted the patients with nineteen of these meals, as i l l u s t r a t e d i n Table I I I , page 55. Other people helped the patients with the remaining seventeen meals. Each 53 TABLE I OBSERVATION OF SIX PATIENTS WHO HAD EXPERIENCED A CEREBROVASCULAR ACCIDENT BY THE NURSE-RESEARCHER RECORDED AS TO DATE, DAY OF ILLNESS Patient Date Day of Hours of Illne s s Observation 3 A May 5 12 7 hr. 17 min. May 6 13 6 hr. 46 min. B May 25 9 5 hr. 37 min. May 26 10 7 hr. 38 min., C June 9 13 6 hr. 40 min. June 10 14 8 hr. 39 min. D June 11 21 7 hr. 45 min. June 12 ' 22 6 hr., 22 min. E June 23 14 5 hr. 35 min. June 24 15 6 hr. 13 min. F -June 25 15 6 hr. 45 min. June 26 16 6 hr. 45 min. N = 6 aMean length of observation time per day was 6 hr. 49.4 min. 54 TABLE II TIME SPENT BY GRADUATE STAFF NURSES3, WITH SIX PATIENTS RECORDED IN MINUTES DURING THE PERIOD OF OBSERVATION' -Patients Nurses A Day Day 1 2 B Day Day 1 2 Day 1 C Day 2 Day 1 D Day 2 E Day Day 1 2 F Day Day 1 2 N XA B- F 19 3 2 - 86 1 39 - 48 31 -N 2A - F 27 21+ 72 - 1 - 1 3 1 - 4 -N 3A - F 3 2 17 - 2 - - 41 - 47 11 6 N4A - F - 7 66 2 - - - - 1 - 3 N5A - F - 21 - - - 88 - - - 28 N 6 A - F - 13 N7A - F 8 Total 49 54. 91 66 91 106 40 44 49 48 46 50 N = 29 aThe mean time spent by graduate s t a f f nurses with s i x patients recorded in minutes during the period of observation was 25.3 minutes and the median time was 15 minutes. F ref e r s to the f i r s t nurse to come to the patient's bedside during the period of observation F r e f e r s to the second nurse to come to the patient's bedside during the period of observation. ^ A -N 2A -55 TABLE III MEALS IN WHICH GENERAL STAFF HOSPITAL NURSES WERE OBSERVED TO HAVE ASSISTED SIX PATIENTS WHO HAD EXPERIENCED A CEREBROVASCULAR ACCIDENT Meals Patients Receiving Meals A B C D -- E . F. . Breakfast a 0 N2B N ^ NrD HjK 0 Lunch N2A N3B 0 NlD 0 0 Supper N3A 0 0 0 0 0 Breakfast N4A N4B N5C N3D N3E 0 Lunch N4A 0 N5C 0 N3E N 6F Supper N5A 0 0 0 0 N6F aO refers to other people who assisted patients with their meals. patient had the assistance of one or more general s t a f f nurses f o r two or more meals. Ten of the. meals were fed to patients by the general s t a f f h o s p i t a l nurse as shown i n Table IV, page 57. Seven meals were arranged so that the patient could feed him/her s e l f . One meal was placed i n front of a patient by the kitchen maid, a portion of i t was eaten before the nurse arr i v e d to a s s i s t as i l l u s t r a t e d i n Appendix E, page 223 . Another meal was arranged by the nurse, in such a way that the patient only had the f l u i d part of i t . See Appendix E page 143. Only one of these s i x patients, Mr. C, who was fed three meals by general s t a f f nurses, was not observed to use his sound hand fo r some a c t i v i t y . Five of the s i x patients could have been encouraged to eat a l l of t h e i r s i x meals with minimal help on the part of the nurse. This indicated that part of the basic need for food and f l u i d s was met at meal times as patients were helped with a c t i v i t i e s of acquiring adequate food and f l u i d s , but that inadequate emphasis was placed on "providing con-diti o n s under which he (the patient)can perform them unaided. n l 1 V i r g i n i a Henderson, The Nature of Nursing (New York: The Macmillan Company, 1966), p. 16. 57 TABLE IV MEALS IN WHICH GENERAL STAFF HOSPITAL NURSES WERE OBSERVED TO FEED (F), TO ENCOURAGE PATIENTS TO FEED THEMSELVES (E), OR TO GIVE INADEQUATE ASSISTANCE-(L) Meals A Patients B Receivin C g Meals D E - . F. ... Breakfast -a F F E E -Lunch E F - E - -Supper E - - mm - -Breakfast I F F I E -Lunch F mm F - E F Supper F - — mm F a - refers to other people who assisted patients with their meals. 58 Mrs. D. had a specific problem which interfered with her enjoyment of meals. At 2:52 P.M. the dietitian visited Mrs. D. to ascertain her likes and dislikes as' her diet had been increased from a f u l l fluid diet to a low salt-diet. Mrs. D's new diet arrived at 4:35 P.M. that afternoon: chicken leg, whole beans, apricot halves and cookies. The preliminary student could not find Mrs. D's dentures. The next morning the nurse-researcher made special note of a denture cup containing dentures on Mrs. D's bedside table. N3D said to Mrs. D., who was eating her breakfast toast with d i f f i c u l t y , "Are you s t i l l nibbling?" N3D did not check to see i f Mrs. D. had her dentures in at lunch time either. A practical nurse did help Mrs. D. with her lunch, but N3D com-mented to her that she had not had much milk to drink at 12:07 P.M. before the tray was removed. There was no mention on the charts of any of the six patients, of their likes, dislikes, or appetite, except for a record of general fl u i d intake. On three occasions general staff nurses added milk, cream and/ or sugar to tea, coffee, or porridge without asking the patient, as illustrated in Appendix E, N t j C , pages 196-197, NjD page 215, and N4A page 153. On one oc-casion a graduate staff nurse fed a patient orange juice, and after a few minutes when he did not drink i t very quickly, she asked him i f he did not like orange juice and he clearly indicated that he did not. This is iindicated, in Appendix E, on page 188. On another occasion a graduate-staff hospital nurse f i l l e d out a patient's menu for the next day without a word to the patient. See Appendix E page 145. These examples demonstrated that some graduate staff nurses did not consider the patient's personal preferences for food and fluids. Fluids were rarely offered to patients between meals by general staff nurses, nor were they placed within their reach. There was an order to encourage or to push fluids for three of the six patients, Mr. C , Mrs. D. and Mrs. B. Five of the six patients, that is a l l but Mrs. A., had Foley catheters in situ at the beginning of the observation period, making fluids important for Mrs. E. and Mr. F. Mrs. A's behaviour indicated that she liked fluids between 60 meals, see Appendix E page 140 and page 148. Fluids were offered between meals by N2B, N4B, NjC and NjE. Practical nurses gave between meal fluids to patients cared for by NjA and N5C.' On the whole, however, an effort to ensure that fluids were easily available to the patient between meals, was not made by general staff nurses, as illustrated in Table IV page 61. Elimination. The most obvious observation in relation to meeting the basic need for elimination was the almost total lack of attempts toward bowel and bladder training. Five of the six patients, that is a l l but Mrs. A., had Foley catheters in situ at the beginning of the observation period. Mrs. E's catheter was removed on the afternoon of the fifteenth day of her illness, which was the f i r s t day of observation. Mrs. A. was put on a commode twice on each day of observation; Mrs. E. was put on a commode, given a pan or taken to the t o i l e t when she asked to be or when i t was time for her urine specimen; but the other patients were not offered commodes or pans, nor were their catheters clamped every two hours. Mrs. A. was put on a commode by NjA and N2A, twice on May 5, The f i r s t time she was lef t there for 30 minutes, from 9:50 A.M. to 10:2>0 A.M. and the second time she was there for 16 minutes, from 1:31 to 1:47 P.M. 61 TABLE V FLUIDS PROVIDED BETWEEN MEALS BY GENERAL STAFF HOSPITAL NURSES WHO SPENT 19 MINUTES OR MORE PER DAY WITH A PATIENT WHO HAD EXPERIENCED A CEREBROVASCULAR ACCIDENT DURING THE PERIOD OF OBSERVATION Nurses Who Spent 19 Minutes Or More Per Day With A Patient NjA -N2A N5A N 2B N 4B NjC N5C NXD N3D NjE N3E NjF N5F Fluids Placed Within Easy Reach Of. A Patient No No No No No No No No No No No No No Fluids_ Of fered Between Meals To Patients No No No Yes Yes Yes No No No Yes No No N = 13 Two hours and ten minutes later, however, the physio-therapist discovered that the bed was wet. The next day, May 6, Mrs. A. was put on a commode before breakfast, for 15 minutes, and five hours later, for 11 minutes. N3A discovered that Mrs. A's bed was wet two hours and forty-five minutes later. There was no observable reference to Mrs. A's bowel function during the hours of observation. See Appendix E 135rl50. . The only activities in relation to Mrs. B's bladder and bowfels on the two days of observation, was on May 25, 1970. NjB emptied Mrs. B's urine drainage bag at 7:35 A.M. and an aide discovered that Mrs. B. had had a bowel move-ment in her bed at 4:45 P.M. There was no reference made to Mrs. B's bladder or bowels on May 26th, 1970, See Appendix E 168-179. Mr. C. had his Foley catheter changed and was given an enema by an orderly, on June 9, 1970. However, no ref-erence was made to Mr. C's bladder bowel function by graduate staff nurses during the periods of observation on June 9 and June 10, 1970. See Appendix E 188-205. Mrs. D. had a Foley catheter in situ on June 11 and June 12. NjD discovered that Mrs. D. had had a bowel movement in her bed at approximately 8:40 A.M., June 11, 63 1970. On June 12, N3D discovered, at approximately 9:00 A.M., that Mrs. D. had been lying on her catheter and that i t was by>-pass ing. She pressed on her abdomen and urine was seen to flow faster through the catheter. Except for handling the catheter equipment during transfer, there were no other observable a c t i v i t i e s in r e l a t i o n to Mrs. D's bladder and bowels by general s t a f f nurses on June 11 or 12, 1970. See Appendix E 215-234. Mrs. E's Foley catheter was removed at 2:15 P.M. on June 23, 1970, the f i r s t day of observation. At 7:30 A.M., on the morning of June 24, 1970, Mrs. E's bed was very wet. Later on that morning she had d i f f i c u l t y t e l l i n g N3E that she had to go to the bathroom; at 10:50 A.M. she asked N5E to take her to the bathroom before she was taken to the speech therapist. She was asked to use the pan at 3:54 P.M. f o r a specimen, but was unable to use i t u n t i l 4:55 P.M. Mrs. E. had an enema at 2:30 P.M., June 23 and t h i s i s the only reference made to Mrs. E's bowel function during the periods of observation. See Appendix E,245-274. Mr. F. had a Foley catheter i n s i t u on June 25 and June 26. NjF examined the contents of Mr. F's drainage bag at 11:44 A.M. on June 25th. She commented to the orderly as he gave Mr. F. crotch care, "I must check on his l a s t B.M. I'm not sure She did not r e f e r to 64 the matter again but, N-R noted that he was given an enema that evening. On the morning of June 26, the head nurse looked at Mr. F's large abdomen and at his urine drainage bag, but graduate s t a f f nurses made no observable reference to Mr. F's bladder or bowel function. See Appendix E, 286-305. Most of the general s t a f f nurses i n t h i s study, seemed unaware that basic nursing care included "providing conditions under which he (the patient) can perform them (the a c t i v i t y of the elimination of body wastes) unaided." Bowel and bladder t r a i n i n g was of p a r t i c u l a r importance to the "stroke" patient as he became so disgusted and embarrassed that he l o s t interest i n things around him. 3 This was an i n d i c -ation that general s t a f f nurses caring f o r patients who had experienced a cerebrovascular accident did not help to meet the basic need of elimination and did not under-stand the s p e c i a l needs of these patients. Exercise. Transfer and Pos i t ion ing. General s t a f f h o s p i t a l nurses did not seem to be aware of the importance Ibid. 3 J u d i t h Stanton, "Rehabilitation Nursing Related to Stroke," C l i n i c a l Orthopaedics and Related Research. LXIII, (Toronto: J.B. Lippincott Company, 1969j^ p. 44. 65 of exercise, transfer and positioning in the care of patients who had experienced cerebrovascular accidents. The need to move and maintain desirable postures was e s s e n t i a l in order to prevent contractural deformities and to maintain and re-store functional a b i l i t i e s . 4 Functional a b i l i t i e s w i l l not be restored unless nurses include exercise, positioning and proper transfer techniques into t h e i r nursing care of pat-ients who have experienced cerebrovascular accidents. The observation revealed that s i x , or 42.8% of the fourteen general s t a f f h o s p i t a l nurses, who helped these patients with t h e i r meals, encouraged them to feed them-selves. See Table VI page 66. Three of the twelve nurses who bathed patients encouraged them to help themselves with bathing or dressing. Six or 50.0% of these twelve nurses encouraged patients to turn themselves over in bed. These are basic s e l f - c a r e a c t i v i t i e s that can be important factors i n the patient's r e h a b i l i t a t i o n as w e l l as "providing conditions under which he can perform them unaided." 5 It has been emphasized that another important aspect of nursing care i s changing the patient's position every two hours. This i s done to prevent contractural deformities 4 I b i d , 39-40 66 TABLE VI NUMBER AND PERCENT OF OBSERVED ACTIVITIES OF GENERAL STAFF HOSPITAL NURSES WHO ASSISTED SIX PATIENTS WHO HAD EXPERIENCED A CEREBRO-VASCULAR ACCIDENT WITH THE ACTIVITIES OF EXERCISE, TRANSFER AND POSITIONING Activities of Number of Nurses Who Nurses Who Exercise, Nurses Who Performed Did Not Transfer and Had an Op- the Activ- Perform the Positioning portunity to ity Activity Perform the Activity Number Percent Number Percent Encouraged the patient 1U 6 U2.8 8 57.2 to feed himself Encouraged the patient 12 3 25.0 9 75.0 to help himself with bathing and/or dressing Encouraged the patient to 12 6 5o.o 6 5o.o help turn himself in bed Changed the patient's pos- 12 7 58.5 5 Ul.5 ition every 2 hours Positioned the patient's af-22 k 18.2 14 63.6 fected arm on a pillow with the hand higher than elbowa Pulled on the patient's af- 22 8 34.9 15 65.1 fected arm, allowed his hand and/or arm to flop or dangle, or allowed feet to drag on the floor Allowed the patient to 1U 8 57.2 6 42.8 sleep or slump in the chair Worked with the physio- 11 3 27.3 8 72.7 therapist Transferred the patient 15 from bed to chair and from chair to bed,b a. alone 2 13.6 13 86.4 b. lifted with an orderly h 26.6 11 73.4 c. lifted with another 5 33.U 10 61.6 nurse or aide d. helped the patient to i i 73.3 h 26.7 pivot with another nurse, aide or orderly a h, or 18.2$ of the 22 nurses positioned the patient's hand higher than the elbow, but on something other than a pillow. b Some nurses participated in more than one transfer technique. and to maintain and restore functional a b i l i t i e s . 0 Yet only seven or 58.57o of the nurses who had the opportunity, changed the patients positionsevery two hours. See Table VI, page 66. There were no observed instances where the nurses u t i l i z e d the prone position. Positioning the patient's affected arm on a pillow with the hand higher than the elbow was emphasized by Large, e t . a l . 7 This prevents edema in the hand. Four of the twenty-two nurses who had an opportunity to perform th i s a c t i v i t y positioned the hand on a pillow. Four of the twenty-two, positioned the hand on the patient's abdomen, hip or arm of a chair. A l l eight however did elevate the affected hand higher than the elbow. Fourteen did not position the affected hand i n t h i s manner. Eight of the twenty-two general s t a f f h o s p i t a l nurses who had an opportunity to position the patient's affected limbs pulled on the patient's arm, allowed his hand and/or arm to f l o p or dangle or allowed the patient's feet to drag on the f l o o r . These findings add emphasis to Elwood's state-ment that one t h i r d of the time of therapists in physical StantGn^loc.' c i t . 7Helen Large, Joseph E. T u t h i l l , F. Bryan Kennedy, Thomas J. Pozen, "In the F i r s t Stroke Intensive Care Unit, American Journal of Nursing. LXIX, (January, 1969), p. 78. 68 medicine has been spent counteracting problems acquired during the period of acute c a r e . 8 One of the duties of the nurse who cares f o r a patient who has experienced a cerebrovascular accident i s to be aware of the exercises that the physiotherapist teaches the patient. Eleven general s t a f f nurses had an oppor-tunity to work with the physiotherapist, however, only three, 27.3% a c t u a l l y did. On two occasions nurses were observed to exercise patient's limbs during the bath, N5F put Mr. F's r i g h t , affected arm through an almost f u l l range of movements and encouraged him to l i f t i t off the bed about 2". She also encouraged him to r a i s e his r i g h t leg o f f the bed 3" and his l e f t leg o f f the bed 6". Passive exercises to r i g h t arm had been ordered by the doctor, however, the other exercises may have been suggested by the physiotherapist. On the other occasion N3D passively exercised Mrs. D's affected arm. This was not a doctor's order and therefore may have been suggested by the physiotherapist. Safe and proper tran s f e r r i n g of the patient from bed to chair and from chair to bed was another important Bernice R. Wylie, quotation of a statement made by Paul M. Elwood, J r . in 1967, i n a personal interview, September 1, 1970. 69 aspect of nursing care. 9 Fifteen nurses had an opportunity to transfer patients: two, or l3.67o, transferred the patient alone; four, 26.6%, l i f t e d the patient with the help of an orderly; five, or 33.5%, l i f t e d the patient with the help of another general staff nurse or aide; eleven or 73.5% pivoted the patient into the chair with another nurse or orderly. It must be noted however, that some nurses par-ticipated in more than one transfer technique. This is illustrated in Table VI, page 66. General Staff hospital nurses were not observed to use the popular transfer tech-nique included in Appendix B. 109-112. The activity of sitting in the chair for the patient, is an exercise in maintaining desirable posture. The patient should not be allowed to slump or sleep in the c h a i r . 1 0 Eight or 57.2%, of the fourteen nurses who had the opportunity, allowed the patient to sleep or slump in the chair for periods of more than ten to twenty minutes. General staff hospital nurses demonstrated that they were not aware of the importance of encouraging the patient to exercise by helping to look after his own feeding, dressing and bathing. They had not seemed to realize that ^Stanton, op. c i t . . p. 47. l 0Wylie, o£. c i t . 70 the affected hand should have been elevated on a pillow. One third of the nurses were not aware that they could prolong the patient's period of rehabilitation by pulling on his affected arm, allowing i t to flop or dangle, or allowing his feet to drag on the floor. The general staff nurses demonstrated that they did not know how to transfer patients from bed to chair or from chair to bed in an ef-fective manner. Less than one third availed themselves of the opportunity to learn by observing or working with the physiotherapist. Sleep and Rest. The patient who had experienced a cerebrovascular accident required periods in which he could sleep and rest. He needed at least one hour of unbroken rest during the day and should be returned to bed for a rest after he had been up in the chair twenty to thirty minutes. 1 1 Twelve general staff hospital nurses had an op-portunity to make sure that this aspect of care was con-sidered. Eleven, or 91.57o of the nurses returned their patient to bed at an appropriate hour so that this could occur. One, or 8,5% of the nurses did not give her patient an opportunity to sleep for one hour undisturbed. At some Bernice R. Wylie, personal interview. 71 point a f t e r 1:00 P.M. the physiotherapist treated Mrs. E., she l e f t at 2:00 P.M. At 2:13 NjE came into the room and explained to Mrs. E, that she was going to remove her catheter and give her an enema. It was 2:38 before Mrs. E. was f i n i s h e d . There was a v i s i t o r i n Mrs. E's room when NR returned from tea at 3:25 P.M., therefore i t may be assumed that Mrs. E. did not get an hour of unbroken r e s t that day. Fourteen general s t a f f h o s p i t a l nurses had an op-portunity to provide adequate rest periods for the s i x patients in the study. A l l of these nurses allowed t h e i r patients to stay up in the chair for more than t h i r t y min-utes. This included Mr. C. who was up i n the chair for two hours on his f i r s t day out of bed since his cerebro-vascular accident fourteen days before. One patient was observed to be returned to bed a f t e r having been in the chair for approximately one hour, however, three patients who had not been up for one hour were s t i l l in a chair when NR l e f t in the evening. Table VII, page 72, i l l u s t r a t e s that s i x , or 42.8% of these fourteen nurses allowed the patient to s i t i n the chair f o r three hours or more. Seven, or 50% of the nurses allowed the patient to sleep i n the chair and eight or 57.2% allowed the patient to assume a 72 TABLE VII NUMBER AND PERCENT OF ACTIVITIES OF GENERAL STAFF NURSES WHO HELPED THE SIX PATIENTS WHO HAD EXPERIENCED A CEREBROVASCULAR ACCIDENT MEET THEIR NEED FOR SLEEP AND REST A c t i v i t i e s That Influence Sleep and Rest Number of Nurses Who Had An Opportunity to Perform The A c t i v i t y Nurses Who Performed The Act-i v i t v Num- Per-ber cent Nurses Who Did Not Perform The A c t i v i t y Num- Per-ber cent Allowed patient to have at least 1 hour of unbroken r e s t during the day Returned Patient to bed f o r a r e s t a f t e r he had been i n the chair for 20 or 30 min. Returned the patient to bed a f t e r approximately 1 hour. Allowed the patient 14 6 42.8 8 57.2 to s i t i n the chair . for 3 hours or more. Allowed the patient to sleep i n the chair. 14 7 50.0 7 50.0 12 11 91.5 .1 8.5 14 0 0.0 14 100.0 14 13 92.5 1 7.15 73 slumped p o s i t i o n , whether he was asleep or not, as i l l -ustrated i n Table VII. These findings indicated that nurses did not under-stand the patients need for rest and sleep, nor did tthey understand the purpose of s i t t i n g the patient in a chair. Maintenance of Body Temperature. The patient with problems that c u r t a i l e d his mobility would have been unable to adjust e i t h e r his clothing or the heating devices i n his room. This meant rel i a n c e on another person for assistance. The general s t a f f h o s p i t a l nurse had the a d d i t i o n a l problem of interpreting the wishes of the aphasic patient who had experienced a cerebrovascular accident. The majority of the twelve nurses who bathed patients, 83.4% had the windows closed as they worked. See Table VIII,p.74. One nurse, N5C, bathed Mr. C. with the window at the foot of the bed open, which may or may not have caused him to be cold, e s p e c i a l l y when he was bare to the waist. On another occasion, Mrs. E. asked N2E to close the window about a half hour before NjE began to bathe her. A f t e r N^E had completed Mrs. E's bath and had s e t t l e d her i n a chair, she opened Mrs. E's window, without a word to her. There were only two incidents of nurses either leaving the window open during the bath or opening the window without con-s u l t i n g the patient. 74 TABLE VIII NUMBER AND PERCENT OF GENERAL STAFF HOSPITAL NURSES PERFORMING ACTIVITIES HELPING TO MAINTAIN THE BODY TEMPERATURE OF SIX PATIENTS WHO HAD EXPERIENCED A CEREBROVASCULAR ACCIDENT A c t i v i t i e s to help patients maintain t h e i r body temperature Number of Nurses Who Had An Opportunity to Perform The A c t i v i t y Nurses Who Nurses Who Performed The Act-i v i t y Num- Per-ber cent Did Not Perform The A c t i v i t y Num- Per-ber cent Windows were closed 12 when nurse gave bath Covered patient with top sheet or bath 12 blanket during his bath Covered patient with a housecoat or blanket 14 when he was up i n the chair. 2 16.6 10 83.4 10 83.4 2 16.6 14 100.0 0 0.0 75 A l l of the fourteen nurses who had an opportunity to put a blanket and/or a housecoat around the patient when he was up in the chair did so. One nurse, N3F, who did put a blanket over the patient's knees, did so after the patient had been sitting in the chair for 10 minutes with bare legs. Another nurse, N5C, who did not get the patient up asked Mr. C. i f he was warm. General staff hospital nurses demonstrated that they understood that the patient had a need to maintain his body temperature, however, they seldom discussed the patient's comfort in relation to temperature with him. Bathing and Grooming. Twelve general staff hos-p i t a l nurses were assigned to bathe the six patients who had experienced a cerebrovascular accident, during the period of observation. It was stated that the bath gives the nurse an opportunity to e l i c i t the cooperation of the patient for the whole days a c t i v i t i e s . 1 2 However, eight, or 66.6% of the nurses explained to the patient that they were going to bathe him and only two, or 16.7% talked to the patient during his bath. See Table IX page 76. There-fore i t may be concluded that nurses do not see the bath as 1ZM. Esther McClain and" Shirley Hawke Gragg, The Scientific Principles in Nursing (St. Louis: The C.V. Mosby Company, 1962), p. 127. 76 TABLE IX OBSERVED ACTIVITIES OF TWELVE GENERAL STAFF NURSES WHO ASSISTED SIX PATIENTS WHO HAD EXPERIENCED A CEREBRO-VASCULAR ACCIDENT WITH THE ACTIVITIES OF BATHING, GROOMING AND SKIN CARE BY NUMBER AND PERCENT Nurses Who Nurses Who Performed Did Not A c t i v i t i e s of Bathing, The Act- Perform The Grooming and Skin Care iv i t y Activity Num- Per- Num-• Per-ber cent ber cent Explained to patient that she was 8 66.6 4 33.4 going to bathe him. Talked to patient as she bathed him. 2 16.7 10 88.3 Encouraged the patient to assist with part of his bath. 1 8.3 11 91.6 Included dressing, Table VI Shaved or combed hair where 6 50.0 6 50.0 appropriate. Gave mouth care 4 33.4 8 66.6 Back Care: a» b a. washed 10 83.5 0 0.0 b. powdered 2 16.7 -c. alcohol 2 16.7 50.0 d. lotion or cream 3 25.0 Special skin care to other parts of the body. 3 25.0 9 75.0 Changed patients position every two hours - . .. -;: .. 7 • 58.5 , 41.5 ,. w j D washed 1/2 of Mrs. D's back and N5F asked a practical nurse to wash Mr. F's back, therefore these were not included in the figures. b507o of the nurses used something in addition to soap and water when they gave back care during the bath. 77 an opportunity to gain the patient's cooperation through verbal communication. One nurse encouraged the patient to help bathe him-self and three, or 25% of the nurses, encouraged the patient to help himself with dressing, The majority of the nurses in the study, did not see the bath as an opportunity to help the patient learn self care a c t i v i t i e s . Six, or 5O.07o of the nurses either shaved the men or combed the women's hair. Nurses were not observed to wash or curl the women's hair nor did they comb the men's hair. Mouth care was one aspect of bathing and grooming that was badly neglected. Three, or 25.0% of the nurses gave patients mouth care. They did not set up the equip-ment so that the patient could look after this part of his care himself. In one instance mouth care was i n s t i -gated without an explanation to the patient u n t i l the pro-cedure was almost completed. See Appendix E, N^Q^ page 190, The majority of the nurses in the study, did not seem to realize that a clean mouth was important to the patient's comfort and feeling of well-being. Skin Care. Skin care was observed, primarily, only during the bath and has been included in Table IX p. 76 with bathing. Seven, or 58.57o of the twelve general staff 78 hos p i t a l nurses who bathed the s i x patients in the study, changed t h e i r position every two hours. The majority of these nurses did not give skin care to stimulate c i r c u l a t i o n , except at bath time. N5C, who was assisted by N^c, was one nurse who rubbed her patient's back, hip and ankles with alcohol two hours a f t e r she rubbed them with l o t i o n during his bath. This i s i l l u s t r a t e d in Appendix E, page 199. A l l twelve nurses saw that at least part of t h e i r patient's backs were washed. Ten, or 83.5% of the nurses washed the patient's backs; one washed one half of her patient's back and another asked a p r a c t i c a l nurse to wash the patient's back. During the bath, two, or 16.7% of the nurses powdered the patient's backs; two, or 16.7% applied alcohol to the patient's back; and three, or 25.0% applied l o t i o n or cream to the patient's back. See Table IX page 76 Special skin care to other parts of the body was c a r r i e d out by three, or 25.0% of the nurses. Graduate s t a f f h o s p i t a l nurses did not demonstrate that skin care other than bathing was important i n the nur-sing care of patients who had experienced a cerebrovascular accident. Safety. Safety was an important factor i n the care of patients who had experienced a cerebrovascular accident 79 with hemiplegia and defective balance. 1 3 Side r a i l s helped them to feel safe when they were in bed. 1 4 Nineteen general staff nurses had an opportunity to go out of the room while the patients were in bed. A l l beds had side r a i l s up on the patient's affected side when they l e f t . Patients f e l t safe i f their c a l l light was within reach. 1 ^  <jhe nurses in the study were not concerned with this factor. One hundred percent of them neglected this aspect of care. Four, or 28.47o of the fourteen nurses who had an opportunity to get patients up into chairs, restrained them so that they would not f a l l out. Three, or 21.5% made sure that the patients socks or slippers were off when she transferred him from bed to chair and from chair to bed. See Table X, page 8Q. None of the six patients had shoes with good support for walking. These findings indicate that general staff nurses do not consider safety precautions important when they care for patients who have experienced a cerebrovascular accident. _ 1 3Jacqueline Montgomery and Margaret Inaka, C l i n i c a l  Orthopaedics and Related Research. LXIII (Toronto: J.B. Lippincott Company, 1969), p. 60. 1^Dorothy W. Smith and Claudia D. Gips, Care .of the  Adult Patient (Toronto: J.B. Lippincott Company, 19667, p. 1083 1 5 I b i d . , p. 132. 80 TABLE X NUMBER AND PERCENT OF OBSERVED ACTIVITIES OF SAFETY PRECAUTION PERFORMED BY GENERAL STAFF HOSPITAL NURSES WHO SPENT 5 MINUTES OR MORE GIVING NURSING CARE TO SIX PATIENTS WHO HAD EXPERIENCED A CEREBROVASCULAR ACCIDENT -A c t i v i t i e s of Safety Precaution Number of Nurses Who Had An Opportunity To Perform The A c t i v i t y Nurses Who Performed The Act-i v i t v Num- Per-ber cent Nurses Who Did Not Perform The A c t i v i t y Num- Per-ber cent Side r a i l s were on the patients bed, 19 19 100.0 0 0.0 p a r t i c u l a r l y on his affected side, when the nurse l e f t him i n bed. Made sure that c a l l l i g h t was within patient's reach 19 0 0.0 19 100.0 Restrained patient in chair 14 4 28.4 10 71.5 Made sure that patient's shoes were on or that 14 3 21.5 11 78.5 his sox or slippers were o f f before trans-f e r r i n g him. 81 Communication. One of the major problems of patients who had experienced cerebrovascular accident and had hemi-plegia was dysphasia and aphasia. 1 0 The patients needed to establish communication by whatever means was easiest for them as they could not afford unnecessary social i s o l a t i o n . 1 7 They had to maintain their verbal a b i l i t i e s by constant verbal stimulation and therefore had to be encouraged to com-municate!-8 A l l of the patients in the study had some degree of dysphasia or aphasia. The data in Table XI were based on observed patterns of communication of nineteen general staff nurses who spent more than five minutes with patients who had experienced a cerebrovascular accident. Henderson implied that helping the patient communicate with others in expressing emotions, needs, fears, or opinions was part of basic nursing care. 1 9 Seven, or 37.0% of the nurses frequently allowed the patient to do this; six, or 31.5%, occasionally allowed i t ; 16 Smith and Gips, op. ext., p. 366. 1 7Jon Eisenson, "Speech Therapy," Proceedings of the  National Stroke Congress, ed. by Ralph De Forest (Spring-f i e l d , I l l i n o i s : Charles C. Thomas Publisher, 1964), p. 98. 1 8 -McKenzie Buck, "Adjustments During Recovery From Stroke," American Journal of Nurs ing. LXIV (October, 1964), p. 93. 19 Henderson, Op_. Cit.. p. 16. TABLE XI OBSERVED PATTERNS OF COMMUNICATION OF NINETEEN GENERAL STAFF HOSPITAL NURSES WHO SPENT MORE THAN FIVE MINUTES WITH PATIENTS WHO HAD EXPERIENCED A CEREBROVASCULAR ACCIDENT PRESENTED BY NUMBER AND PERCENT-Communication Patterns Nurses' Communications in Each Pattern by Number and Percent Always Frequently Occasionally Seldom' Num- Per- Num- Per- Num- Per- Num- Per-ber cent ber cent ber cent ber cent Never Num- Per-ber cent Allowed the patient to express emotions, needs, fears and opinions» Encouraged the patient to express emotions, needs, fears and opinions. Talked to patient. Talked to patient as she cared for him and he appeared to hear and to understand . Allowed patient sufficient time to process the message and to respond appropriately. Explained what she was going to do before she did i t . Talked to someone else in the patients presence ignoring the patient . Demonstrated respect for the Patient as a person. 0 0 0 0 0 0 7 37.0 6 31.5 4 21.0 3 15.9 6 31.5 4 21.0 1 5.3 10 52.5 5 26.3 2 10.5 3 15.9 6 31.5 5 26.3 4 21.0 0 0 6 31.5 7 37.0 4 21.0 5.3 6 31.5 5 26.3 6 31.5 2 10.5 6 31.5 1 55i3 1 5.3 2 10.5 1 5.3 5 26.3 7 37.0 2 10.5 5 26.3 1 5.3 5 26.3 6... 3.1.5 5 26.3 10.5 83 then four, or 21.0% seldom allowed i t , and two, or 10.57o never allowed i t . Nobody always allowed i t . On the other hand, only three, or 15.9% frequently encouraged the patient to express emotions, needs, fears or opinions; six, or 31.5%, occasionally encouraged i t ; and four, or 2l.07«, seldom encouraged i t . Nobody always encouraged such expression. Some nurses talked to the patients. One, or 5.3% of the nineteen nurses talked to the patient a l l the time; ten, or 52.5% talked to the patient frequently; five, or 26.3% occasionally talked to the patient; and two, or 10.5% seldom talked to patients. One nurse never talked to the patient. Other nurses may not have talked to the patients as frequently, but, they talked to patients as they cared for them and the patients appeared to hear and understand. Three, or 15.9% of the nurses always talked so that the patients appeared to hear and understand; six, or 31.5% frequently did this; five, or 26.3% occasionally did this; and four, or 21.0%, seldom did this and one nurse or 15.3% never did talk to the patient. Sometimes patients apeared to hear and understand the nurse, but they did not always have time to process the message and respond appropriately. One example of this was during Mr. G's breakfast, on the f i r s t day of observation. NjC asked Mr. C. i f he would like his tea. Mr. C. answered 84 "Tea?" Then NjC asked him i f he would l i k e cream and sugar. Mr. C. answered "yes". One wonders, however, i f he answered the f i r s t question or the second question because he drank his tea with persuasion. See Appendix E, page 189. Of the nineteen nurses none always allowed the patient s u f f i c i e n t time to process the message and respond approp-r i a t e l y ; s.ix, or 31.5% frequently allowed the patient time; seven, or 37.0% allowed i t occasionally; four, or 21.0% seldom allowed i t ; and two, or 10.5% never did allow i t . One nurse never talked to patients at a l l . See Table XI, page 82. One nurse, 5.3% of the nineteen who spent f i v e min-utes or more with the patients i n the study, always ex-plained what she was going to do before she did i t . How-ever, s i x , or 31.57. frequently explained what they were going to do; f i v e , or 26.3% occasicmalL^ s i x , or 31.5% seldom explained and one nurse who never explained anything to patients. Nurses often talked to someone else in the patient's presence without involving the patient i n the conversation. Nobody did t h i s a l l the time, but f i v e , or 26.3% frequently di d ; seven, or 37.0% occasionally did, two, or 10.5% seldom did and f i v e , or 26.3% never did t a l k to another person in front of the patient. 85 Some nurses demonstrated respect f o r the patient as a person. One, or 5.3% always did; s i x , or 31.5% freque-n t l y did; f i v e , or 26.3% seldom did; and two, or 10.5% never did. See Table XI, page 82. These findings indicate that the general s t a f f hos-p i t a l nurses, who cared for patients who had experienced a cerebrovascular accident with hemiplegia and dysphasia or aphasia, did not understand the importance of communication for these patients. Health teaching and re-enforcement of teaching of  other members of the team by the general s t a f f nurses. It has been stated that team work i s an e s s e n t i a l aspect of 20 r e h a b i l i t a t i o n . u Team work was seldom observed in thi s study other than between members of the nursing s t a f f . Eleven general s t a f f nurses had an opportunity to work with the physiotherapist, however, only three or 27.3% a c t u a l l y d i d . See Table VI page 66 . On f i v e occasions nurses had an opportunity to accompany the doctor when he v i s i t e d the patient, however, he was unaccompanied. On s i x occasions v i s i t o r s were observed to come to see patients. Except for one occasion, the NR did not observe during t h i s period. 20R.M.D. McLeod and J. Williamson, "Problems of Stroke Assessment and R e h a b i l i t a t i o n , " S c o t t i s h Medical Journal. XII (October, 1967), p. 384. 86 Three patients had requisitions for speech therapy, however, only one was on an active program of speech therapy with daily appointments. She was taken from the ward to the speech therapist. One nurse, NjE was aware of the patients destination, but N3E was not. General staff hospital nurses did not appear to realize that health teaching and re-enforcement of teaching of other members of the team by the general staff nurses was part of basic nursing care. They did not appear to be aware of the concept of the rehabilitation team nor seemed to be aware that team work was a necessary aspect of the nursing care of the patient who had experienced a cerebro-vascular accident. Demonstration of Awareness of the Specific Phenomena Peculiar to Cerebrovascular Accidents. An awareness of specific phenomena peculair to cerebrovascular accidents was not demonstrated by the general staff hospital nurses, except in relation to dysphasia and aphasia which they did not appear to under-stand. Doctors did not make comments in relation to specific phenomena that the patient may have manifested, other than dysphasia and aphasia. 87 Aphasia and Dysphasia: Some degree of aphasia and/ or dysphasia was manifested by a l l s i x patients who had experienced a cerebrovascular accident. Doctors did not c l a r i f y the degree of aphasia manifested. On one occasion the doctor diagnosed aphasia, but the speech therapist's diagnosis was dysphasia. Speech therapy r e q u i s i t i o n s had been made out f o r three of the patients, two of whom had been v i s i t e d by the speech therapist. Therefore there was no second diagnosis indicating the degree of speech impair-ment of four of the s i x patients in the study. The general s t a f f h o s p i t a l nurses did not appear to understand the phenomena of aphasia and dysphasia. One nurse, N5A, interpreted Mrs. A's gesture, i l l t i s t r a t e d in Appendix E, page 149, as a request to write a note. N5A obtained paper and pen c i l and encouraged Mrs. A. to write. N5A attempted to interpret the message. When she r e a l i z e d that she could not she l e f t the note at Mrs. A's bedside for* her daughter tossee. N5A was the only nurse who en-couraged a patient to write. Another nurse, N3E» was not aware that Mrs. E. had an appointment with the speech therapist on the day that she cared for Mrs. E. M3J kept r e f e r r i n g to the physio-therapist. This i s i l l u s t r a t e d on Appendix E, p.264 & 267. U n i l a t e r a l Visual Agnosia. The NR observed that occasionally two patients did not seem to be aware of 88 objects on their affected side. This was particularly not-iceable in Mr. F's behaviour on the second day of obser-vation. N5F approached Mfv F. from his affected right side at 9:45 A.M., June 26. She spoke to him and he appeared to look right past her. Another explanation for this behaviour could have been that Kei'may have f e l t neglected. N^F told him that there weren't any nurses that day and N5F told NR that she was going to coffee before she bathed Mr. F. In addition, N5F spoke to NR before she spoke to Mr. F. This is illustrated in Appendix E, page 297. Later at 4:10 P.M., N3F came to his affected right side and asked him how he was feeling. He did not answer. She asked him another question. His eyes did not appear to focus on her and he did not respond to her questions. This behaviour may have been because he did not see her, however, he may have beenaannoyed by her questions. On another occasion, at 5:00 PVM.,N6F. sat in a chair to the right of Mr* F. and fed him. She asked him i f he had had enough. He looked directly forward and nodded neg-atively. She spoke to him again and he looked to the l e f t . The communication problem could have been caused by both unilateral visual agnosia and aphasia. However, i t could well have been caused by the events of the day. This is illustrated on Appendix E, page 305. 89 Mrs. A. did not appear to see the food on the l e f t side of her tray, however, t h i s occurred on only one occasion. N4A was feeding her lunch on May 6 , 1970, even though Mrs. A. could feed herself.very wel l . She put a glass of milk i n the l e f t corner of the tray and l e f t Mrs. A. for a minute or s l i g h t l y longer. During t h i s time Mrs. A. did not reach for the glass. Other Phenomena. There were no other indications of s p e c i f i c phenomena peculiar to cerebrovascular accidents observed. Relationships of General S t a f f Nurses to Other Members of the Rehabil i t a t i o n Team. General Staff nurses demonstrated that they had only minimal relationships with other members of the r e h a b i l i t a t i o n team. Eleven general s t a f f nurses had an opportunity to work with the physiotherapist, however, only three, or 27.3% a c t u a l l y d id. There were no occasions when the nurse ac-companied the doctor to the patient's bedside. The speech therapist had a d a i l y appointment with one patient. One nurse was aware of t h i s , but the nurse who cared f o r the patient the next day indicated that she thought that the patient was going to see the physiotherapist. Possible interactions between the nurses,;families and 90 other visitors were not observed. General staff hospital nurses did not appear to be aware of the activities of the other members of the rehabilitation team nor did they seem to be aware that teamwork was necessary. There was l i t t l e indication, however, of any of the members of the rehabilitation team working together. The lack of an adequate nursing care plan, nursing history and a planned rehabilitation program was a factor that emphasized the absence of coordinated effort. There were many details that were not available on the patient's chart when the nurse-researcher compiled her nursing histories. Appetite, likes, dislikes and other comments in relation to foods and fluids were not recorded by the nurses. There were no suggestions by the physiotherapists to guide nurses with exercise or transfer a c t i v i t i e s . Mrs. E. did not have a physiotherapy requisition on her chart, however, the physiotherapist did v i s i t her. There were no comments 'by the doctor in relation to alexia, agraphia, unilateral visual agnosia and hemianesthesia. The general staff hospital nurse should know a l l these details when she cares for patients who have exper-ienced a cerebrovascular accident. 91 Summary Data were compiled from the observations and categorized into the ten basic a c t i v i t i e s , as previously defined. Nursing care given by general staff hospital nurses to patients who had experienced cerebrovascular accidents was analyzed in relation to the ten basic a c t i v i t i e s . It was demonstrated that many of the nurses in the study helped the patient with most of the ten a c t i v i t i e s , however, few nurses provided conditions under which he could perform them unaided. Food and fluids were fed to patients who could have fed themselves with a l i t t l e encouragement. Conditions were not provided to help the patient regulate his elimination adequately. Nurses seldom included exercise during the bath and frequently l e f t the patient in the chair for prolonged periods. Nurses seldom worked with the physiotherapist and Were seldom aware of the exercises that she taught the patient. Sixty percent of the nurses l i f t e d the patient from bed to chair or from chair to bed with the help of another person and 73.3% helped the patient to pivot into the chair with the help of another person. Skin care was observed, primarily only during the bath and mouth care was frequently omitted. Nurses showed 92 consideration for the patient's need to maintain his body-tempera t tire, but they did not consider safety precautions adequately. Nurses demonstrated that they did not under-stand the importance of communication to patients who had experienced a cerebrovascular accident. And they did not appear to be aware of the concept of a rehabilitation team. The data were also examined for indications of a demonstration of an awareness of the specific phenomena peculiar to cerebrovascular accidents. There were few comments in relation to these phenomena recorded by the doctor, apart from aphasia, and there were few observations to indicate the presence of specific phenomena apart from aphasia. CHAPTER V SUMMARY, RECOMMENDATIONS, AND AREAS FOR FURTHER INVESTIGATION I. Summary The stated purpose of this descriptive study was to identify the nature of nursing care given by general staff hospital nurses to a selected group of patients who had experienced a cerebrovascular accident. Consideration was given to two main areas of the literature in relation to the care of patients who had had a cerebrovascular accident: the medical literature, and the nursing and related literature. The medical literature gave a broad overview of cerebrovascular accidents including diag-nosis, acute care and rehabilitation of the hemiplegic patient. The nursing literature was examined in relation to the c r i -teria of basic needs. This literature emphasized rehabil-itation of the hospitalized patient. Most of the literature reviewed was found in journals which were not readily a v a i l -able to the average general staff hospital nurse. The data were compiled from direct observations and from, a nursing history which included an interview with the patient and data fromhhis chart. Nursing care given by 29 general staff hospital nurses to six selected patients who had 94 experienced a cerebrovascular accident was observed and recorded by the non-participating nurse-researcher in the form of anecdotal notes. The nursing history was to provide an assessment of the patient's nursing care needs as seen by the nurse-researcher. The nursing approach suggested by the nurse-researcher was not only based on the nursing history, but i t also was based on the literature reviewed. See Appendix E p. 128-134, 152-157, 183-187, 209-214, 238-244, and 278-285. The data wereecategorized into the ten basic act-i v i t i e s as previously defined, and organized in relation to desirable activities as outlined in the literature, and undesirable acti v i t i e s observed by the nurse-researcher. The anticipated length of time for the data collection was doubled for two reasons. F i r s t , therewasf, a lack of appropriate patients for approximately two weeks. Second, Itherejwere communication problems between the nurse-researcher and some assistant and head nurses, and/or between the assis-tant and head nurses and the nursing team leaders. On the whole, however, nursing supervisors, head nurses, doctors, patients, relatives, physiotherapists and general staff nurses were very cooperative. From the analysis of the data the following con-clusions were drawn. General staff hospital nurses gave partial basic nursing care, as defined by Henderson, by helping the patient with most of the ten basic a c t i v i t i e s . 1 However, they seldom provided conditions vmder which he could perform them unaided. They did not understand the importance of bowel and bladder training, exercise, or com-munication to patients who had experienced a cerebrovascular accident. Nor did they understand the concept of the rehabilitation team. II. Recommendations The data demonstrated that general staff hospital nurses were not aware of the implications of the nursing care given in hospital as i t reflected on the future well being of the patient who had experienced a cerebrovascular accident. The following recommendations were made: The f i r s t recommendation that evolved from this study was that general staff hospital nurses needed an orientation to the total picture of rehabilitation of the patient who had experienced a cerebrovascular accident. This included the periods of acute care, early rehab-i l i t a t i o n phase, rehabilitation in a specialized unit, and the continuation of rehabilitation at home. Virginia Henderson, The Nature of Nursing (New York: The Macmillan Company, 1966), p. 16. 96 The second recommendation is that the existing know-ledge in relation tothe nurse's role in the rehabilitation of the person who had experienced a cerebrovascular accident be compiled and made accessible to general staff hospital nurses. The third recommendation that evolved from this study, was that general staff hospital nurses must be made aware that patients who had experienced a cerebrovascular accident, had a future. And further, that the nursing care given to the patient in the f i r s t few weeks had an influence on this future. The nurse and the other rehabilitation team members must work together to train and educate the patient and his family in self care a c t i v i t i e s , in anticipation of his discharge home." This study demonstrated that daily hospital l i f e for patients who had experienced a cerebro-vascular accident was d u l l , depressing and encouraged the patient-to continue to~be dependent on the nurse. A dep-ressed, dependent patient usually is discharged to another institution. Discharge to an institution hastens death, i f not physical death, psychological death: death of hope. Independence and self care mean ; hope of home and effective liv i n g . The fourth, and perhaps the most important recom-mendation was that general staff hospital nurses learn to 97 communicate more effectively. They must communicate with each other, with doctors, physiotherapists, and other therapists. But, above a l l they should learn to com-municate with the patient and his family. Patients who had experienced a cerebrovascular accident, especially those with aphasia or dysphasia, had a v i t a l need to com-municate. III. Areas for Further Investigation This was a small limited study and could be duplicated on a larger scale. More patients could be observed for a longer period, i f a team of observers was used. The data could be analyzed a step further to demonstrate the nursing care given by each individual nurse. The f e a s i b i l i t y of establishing an extensive program for the continuing education of the general staff hospital nurse in order to take action on the above recommendations, could be investigated, implemented and evaluated. Barriers to communication between nurses and other members of the rehabilitation team and methods to overcome them could also be studied. This study clearly demonstrated that the nursing care given by general staff hospital nurses to patients who had experienced a cerebrovascular accident was inadequate. BIBLIOGRAPHY 99 BIBLIOGRAPHY A. BOOKS De Forest, Ralph (ed.). Proceedingsof National Stroke Congress. S p r i n g f i e l d , I l l i n o i s : Charles C. Thomas Publisher, 1964. F i r a r s , Grace and Gosnell, Doris. Nursing Evaluation: The Problem and The Process. New York: The Macmillan Company, 1966. Henderson, V i r g i n i a . The Nature of Nurs ing. New York: The Macmillan Company, 1966. McClain, M. Esther and Gragg, S h i r l e y Hawke. The S c i e n t i f i c  P r i n c i p l e s i n Nursing. St. Louis: The C.V. Mosby Company, 197J2~. Roper, Nancy, P r i n c i p l e s of Nursing. London: E.S. L i v i n g -stone Limited, 1967. Smith, Dorothy W., and Gips, Claudia D. Care of the Adult  Patient. Montreal: J.B. Lippincott Company, 1966. Smith, Genevive Waples. Care of the Patient With A Stroke. New York: Springer Publishing Company, Inc. T967. Stryker, Ruth Perin. Back to Nursing. Philadelphia: W.B. Saunders Company, 1966. Taber, Clarence Wilber, (ed.) Tabers Cyclopedic Medical Dictionary. Philadelphia: F.A. Davis Company, 1969. B. PUBLICATIONS. OF THE GOVERNMENT AND OTHER ORGANIZATIONS American Heart Association. p_o It Yourself Again. New York: American Heart Association, 1967. B r i t i s h Columbia Department of Health Services and Hospital Insurance. V i t a l S t a t i s t i c s Report. V i c t o r i a : Queen's Pr i n t e r , 1967. 100 Canada Dominion Bureau of Statistics, Health and Welfare Division. Causes of Death: Canada 1,95891964. Ottawa: Queen's Printer, November, 1965. Kenny Rehabilitation. A Handbook of Rehabilitation Nursing Techniques in Hemiplegia. Chicago: Kenny Rehabilitation,1964. -National League for Nursing. Comprehensive Services in Long Term Care. New York: National League for Nursing, 1969. President's Commission on Heart Disease, Cancer and Stroke: Report to the President. A National Program to Con-aiidr Heart Disease. Cancer, and Stroke. Washington. . D.C.: U.S. Government Printing Office, I (December), 1964. The Chest and Heart Association. Adjusting To A Stroke'. London: The Chest and Heart Association. The Chest and Heart Association. When Words are Missing After, a 'Stroke'. London: The Chest and Heart Association. The Chest and Heart Association. 'Stroke' Illness. 20 Questions and Answers. London: . The Chest and Heart Association. United States Department of Health, Education and Welfare, Public Health Services, V i t a l Statistics of the  United States. 11 Part A. Washington: Government Printing Office, 1967. U.S. Public Health Service, Chronic Disease Division, Up and Around. Washington, D.C.: Publication No. 1120, U.S. Government Printing Office, 1964. U.S. Public Health Service, Chronic Disease Division, Strike  Back at Stroke. Washington, D.C.: Publication No. 596, U.S. Government Printing Office, 1958. C. PERIODICALS Achar, V.S., Coe, R.P.K. and John Marsha11;"Echoencephography in Differential Diagnosis of Cerebral Hemorrhage arid 101 Infarction." The Lancet. I (January, 1966), 161-163. Acheson, Roy M. and Fairbairn. "Burden of Cerebrovascular Disease in the Oxford Area in 1963 and 1964." British  Medical Journal. II (June 13, 1970), 621-625. Adams, G.F. and J.D. Merrett' "Prognosis and Survival in Aftermath of Hemiplegia," British Medical Journal. I (Saturday, February 4, 1961), 309-314. Adams, J.H.5 "Patterns of Cerebral Infarction," Scottish  Medical Journal. XII (October, 1967), 339-347. Bobath, Bertha g "Observations on Adult Hemiplegia and Suggestions for Treatment," Phvsiotherapy XLV (December, 1959), 278-282. ' Bobath, Bertha. "Observation on Adult Hemiplegia and Suggestions for Treatment," Phvs iotherapy. XLVI (January, 1960), 3-6. Boyle, Robert W. and S c a t z i t t i , Peter D. "A Study of 480 Consecutive Cases of Cerebrovascular Accidents," Archives of Phvsical Medicine. XLIV (January 1963), 19-25. Buck, McKenzie. "Adjustments During Recovery from Stroke," American Journal of Nursing. LXIV (October, 1964), 92-95. Carter, A. Barham. "Hypotensive Therapy in Stroke Survivors The Lancet,I (Saturday, 7 March, 1970), 487-489. Dervitz, Hyman L. and Z i s l i s , Jack M., "A Medical Per-spective of Physical Therapy and Stroke Rehabilitation Geriatrics. XXV (June 1970), 123-132. Eisenberg, Henry, Morrison, Paul, and Foot, Franklin M. "Cerebrovascular Accidents," American Medical  Association Journal CLXXXIX (September 12, 1964), 883-888. Florey, Charles Du. V., Senter, Margaret G., and Acheson, Roy M. "A Study of the Validity of the Diagnosis in Stroke Mortality Data," American Journal of Epidemiology, L (January, 1969) 15-23. 102 Gerrieri, Belga 0. "Survey of the Knowledge of the Nurse in Direct-Care Services Concerning Proper Bed Positioning of the Patient with Hemiplegia," Nursing  Research. XVII (March-April, 1968), 157-159. Gillingham, F.J. "The Management of Ruptured Intracranial Aneurysms." Scottish Medical Journal. XII (October 1967) ,377-383. Goode, Margaret A. "The Patient With a Cerebral Vascular Accident," Nursing Outlook. XIV (March, 1966), 60-62. Hudson, Jane, Hood, Margaret, and Fahrni Brock M. "Hospital Management of Hemiplegia," The Canadian Nurse,1X1I (July, 1966), 21-23. Isaacs, Bernard. "Disorders of Cerebral Cortical Function Associated with Strokes," Phvsiotherapy. LII (February 10, 1966), 40-42. Jennett, W.B. "Ischaemic Carotid Strokes," Scottish  Medical. Journal. XII (October, 1967), 368-375. Large, Helen, T u t h i l l , F., Bryan,Kennedy, and Pozen, Thomas. "The F i r s t Stroke Intensive Care Unit," American Journal of Nurs ing. LXIX, (January, 1969), 68-80. LaTorre, Peter P., and Boyle, Robert W. "Prognosis for Survival After A Stroke," Geriatrics. XXIII (October, 1968), 106-111. Lyon, Alan and DeGraff, Arthur C. American Heart Journal. LXXVII (January, 1969), 132-136. McLeod, R.D.N, and J. Williamson. "Problems of Stroke Assessment and Rehabilitation," Scottish Medical  Journal. XII (October, 1967), 384-384. McPhetridge, L. "Nursing History: One Means to Personalize Care," American Journal of Nurs ing. LXVIII (January, 1968) , 68-75. Marshall,J. "The Diagnostic Problem in Cerebrovascular Disease," Scottish Medical Journal. XII (October, 1967), 335-337. 103 Montgomery, Jacqueline and Inaka, Margaret. C l i n i c a l  Orthopaedics and Related Research^LXIII Toronto: J.B. Lippincott Company, 1969, 54-67. P o l i c o f f , "The Philosophy of Stroke R e h a b i l i t a t i o n , " G e r i a t r i c s . XXV (March 1970), 99-107. Smith, Dorothy. "A C l i n i c a l Nursing Tool fAmerican, Journal  of Nursing. LXVIII (November, 1968), 2384-2388. Stansel, H.C.J., Hume, M., and Glenn, W.W.L. "Surgical Management of Cerebrovascular Insufficiency," The New England Journal of Medicine CCLXIX Toctober 3, 1963), 716-72T. ' Stanton, Judith H. "Rehabilitation Nursing Related to Stroke," C l i n i c a l Orthopaedics and Related Research. LXIII Toronto: J.B. Lippincott Company, 1969, 39-53. Wilcoxson, H a r r i e t t L. "Cerebrovascular Accident: Role of the Public Health Nurse." Nursing C l i n i c s of North  America. I (March, 1966), 63-71. Wolanin, Mary Opal and Albert G. Wagner, "Survey of Stroke Patients," Arizona Medicine. XXVI (November, 1969), 869-871. Wylie, Charles M. "Rehabilitative Care of Stroke Patients," American Medical Association Journal, CXCVI (June 27, 1966), 1117-1120. D. UNPUBLISHED MATERIALS Seedor, Mary. "Hemiplegia Patient's Nursing Care Needs and Their Implications f o r Curriculum Development." Unpublished Dissertation, The University of Pennsylvania, Philadelphia, Pennsylvania. APPENDIX A SOME POINTS OF CAUTION IN RELATION TO THE CARE OF HEMIPLEGICS 105 SOME POINTS OF CAUTION IN RELATION TO THE CARE OF HEMIPLEGICSl 1. Passively moving a j o i n t through greater than normal range (check with normal arm) producing damage through overstretching. 2. Passive movement done too quickly and f o r c i b l y , thus causing an increase i n pain, muscle spasm and spas-t i c i t y . 3. Lack of f u l l support of j o i n t s above and below the j o i n t being moved so that strains on ligaments and tendons occur. 4. Over-exercise of limbs, which also may lead to increase in muscle spasm and i n t e r f e r e with locomotion and s e l f - c a r e . 5. Moving the patient by p u l l i n g on the affected arm. 6. Not encouraging conscious patients to spend part of the day i n prone lying which would r e l i e v e pressure on susceptible areas. 7. Using footboards that are not wide enough fo r length of foot, permitting toes to c u r l over the top. 8. Not r e a l i z i n g bh^tofr the^T main aims of the footboard i s to keep the covers o f f the patient's feet and legs so that he can move in bed more e a s i l y , and that the foot constantly pressed against the footboard can cause f u r -ther s p a s t i c i t y in plantar f l e x o r s . 106 9. Not remembering that the patient may have a loss of kinesthetic sense and so may not be aware when his lying and s i t t i n g position i s wrong. These patients need constant reminding and correction of position or contractions and deformities may develop. 10. L i f t i n g patients bodily into wheelchairs or bedside chairs. Most hemiplegic patients are capable Of standing on t h e i r unaffected leg long enough to transfer e a s i l y . This prevents nurses from hurting t h e i r backs and patients gain confidence i n t h e i r own a b i l i t i e s . Usually i t i s best f o r the patient to get out on his unaffected side, but t h i s does vary with patients. 11. Rushing the patient through nursing care not allowing him time to learn or to practice helping him-s e l f . This often reduces the one chance the patient has f o r recovery of function. 12. Allowing patients to s i t i n chairs which are too s o f t or too deep, so that the s i t t i n g posture is not w e l l supported and pressure may occur i n the p o p l i t e a l space leading to thrombophlebitis. Do not r e l y on a pillow to prevent t h i s . 13. Placing the bedside table on the blind side or out of reach of the good arm. This may r e s u l t i n seeming lack of motivation. 14. Walking patients to the bathroom "hanging".on.the nurse's shoulder when support to the affected knee in most cases would make i t possible f o r them to walk r e -l a t i v e l y w e l l . 15. Not making f u l l use of available; therapists i n under-standing, evaluating and; demonstrating the c a p a b i l i t i e s of each i n d i v i d u a l patient. 16. Demanding too much of a patient a l l once, leading to extreme fatigue. A c t i v i t y in stages of slow prog-ression often gives better r e s u l t s . 17. Giving the patient a rubber b a l l to squeeze i n his hemiplegic hand. This frequently leads to increased s p a s t i c i t y and may damage weakened palmar structures. % . Jane Hudson, Margaret R. Hood, and Brock M. Fahrni, "Hospital Management of Hemiplegia," The Canadian Nurse. LXII (July, 1966), pp. 22-23. APPENDIX B ONE POPULAR TRANSFER TECHNIQUE 109 APPENDIX B ONE POPULAR TRANSFER TECHNIQUE A. Transfer from the bed to the chair. 1. Bed - must be immovable and approximately same height as chair. 2. Chair - at a s l i g h t angle facing the foot of the bed. - foot rests moved aside , - chair is placed on the patient's sound side 3. Coming to a s i t t i n g position a. The patient begins t h i s sequence lying i n the center of his bed. b. He (the patient) picks up the wrist of his involved hand withlhis sound hand and places his forearm . across his abdomen. c. He places his sound foot underneath his involved leg and s l i d e s his foot down to his ankle. d. He turns toward the chair and grasps the side of the bed and turns to his side. One of the main problems here i s his shoulder, " I t acts l i k e a block of wood."2 The nurse should be ready to give i t a push and say, "I w i l l give your shoulder a l i t t l e boost and you t r y to p u l l i t forward." 3 e. He then pushes his body up on his elbow by leaning his head forward then bounces backwards on his Kenny R e h a b i l i t a t i o n , A Handbook of R e h a b i l i t a t i o n  Nursing Techniques in Hemiplegia" (Chicago: Kenny , R e h a b i l i t a t i o n , 1964), p. 72. 2 M. Croucher, Rehabilitation Nursing Consultant f o r the V i c t o r i a n Order of Nurses, Personal interview and demonstration, May 16, 1969. 3 Ibid. 110 elbow and leans on his hand. f. His sound foot i s s t i l l tucked under his involved ankle ready to swing his involved leg over the side of the bed as he pushes up on his sound hand. g. He pushes up with his sound hand and swings his legs over the side of the bed simultaneously. h. The nurse may need to p u l l gently on the shoulder again. i . Then the patient uncrosses his feet and puts them both on the f l o o r ; the nurse must check to be sure that his feet are firmly placed on the f l o o r for good balance. j . He secures s i t t i n g balance. 4. Coming to a standing position a. Both patient and nurse must check to be sure that the brakes are on (or that the chair w i l l not move when they push against i t . ) b. The patient flexes both knees more than 90 degrees and moves his sound foot s l i g h t l y ahead of his involved f o o t . 4 1) pushes down with his sound arm on the bed. 2) moves his trunk forward 3) bearing on both legs 4) nurse may support patient's involved leg with her knee-> Louise McGregor, Senior Instructor, School of R e h a b i l i t a t i o n Medicine, University of B r i t i s h Columbia, Personal interview and demonstration, May 12, 1969. ^U.S. Public Health Service, Chronic Disease D i v i s i o n , S t r i k e Back At Stroke: Washington, D.C.; Publication No. 596, U.S. Government Printing O f f i c e , 1964, p. 34. I l l c. He grasps the rear arm of the chair, at the middle, and brings himself to a standing position. d. The Nurse must be sure that the involved leg is firmly oh the floor and bears weight. e. Nurse encourages patient to stand erect and gain balance. 5. Sitting down in chair - patient may grasp the middle of the far arm of the chair. a. The patient is helped to pivot, (or take small steps i f the nurse knows that the physio-therapist lets him do this) u n t i l he is in position to s i t down. b. He places both hands on both arms of the chair and lowers himself into i t . B. Transfer from chair to*the bed. 1. Bed - same as above. 2. The patient's sound side is nearest the bed so that he w i l l be moving toward his sound side. 6 3. Chair - close to and angled slightly toward the bed :and close enough to the head of the bed so that the patient can reach i t easily. 4. The brakes are locked. 5. The foot rests are swung aside. 6. The patient moves forward in chair so that his feet w i l l be under him. 7. He flexes both his knees more than 90 degrees, sound foot slightly ahead. 8. Then he places his sound hand on the middle of the armrest, the nurse stands on the affected side. 9. The patient leans forward, pushes down on the arm 6This is an essential point. 112 of the chair, bears weight on both legs (involved foot must be firmly on the f l o o r and bearing weight as above procedure) and stands. 10. A f t e r coming to an erect p o s i t i o n , he transfers his sound hand to the bed f o r support. The nurse a s s i s t s him to pivot using both hands i f possible. He gently lowers himself on to the edge of the bed (with the support of the nurse i f necessary). Patient s i t s well back on the bed. 8 11. A f t e r the patient i s s i t t i n g down the chair must be moved away so that he can swing his legs onto the bed and l i e down. 12. The nurse must remember that i t i s d i f f i c u l t for a hemiplegic to move his weak side. He must lay his head down on the pillow, put his sound foot under his involved ankle and put his sound hand on the mattress to steady himself as the nurse helps him to l i f t h is leg up and over. 13. He must then r o l l onto his back. 14. As he i s very close to the edge of the bed he must bend his knees, r a i s e his buttocks, moving them toward his uninvolved side then lower them. The nurse w i l l help with the shoulders. The patient w i l l then move his legs into alignment with his body. He is now in the center of the bed. APPENDIX C INFORMATION MADE AVAILABLE TO MEMBERS- OF THE REHABILITATION TEAM AND TO OTHER PATIENTS IN CLOSE PROXIMITY TO THE PATIENT OBSERVED 114 Miss Geraldine Patrick, who is a nurse and currently a university student, is writing a thesis concerning the nursing care given by general staff nurses in hospital to patients who have experienced a stroke. This is a request for your cooperation in her collection of data. She wishes to interview some people who have experienced a stroke, and to s i t quietly at the bedside for two or three days observing and recording the activi t i e s of the nurse, patient and others- caring for the patient. She w i l l not partake in nursing care of the patient as her role is research-observer and not partic-ipant-observer. Names of patients, nurses, doctors, physiotherapists, relatives and other people caring for the patient w i l l be held confidential and not be used in the study. 1 APPENDIX D THE NURSING HISTORY FORM USED IN THE STUDY 116 NURSING HISTORY Code Name Age Primary Medical Diagnosis, Date Secondary Medical Diagnosis DateA Additional Medical Diagnosis Date. A. Patient's Understanding of Illness 1. Why did you come to the hospital? 2. What do you think caused you to be sick? 3. How did your illness effect you? 4. Could you speak? 5. Were you frightened? 6. What is i t like for you to be in hospital? 7. How long do you expect to be in hospital? 8. What effect has your coming into the hospital had on your family (or person closest to you;? This nursing history was adapted from L. McPhetridge, "Nursing History:. One Means to Personalize Care," American  Journal of Nursing. 68: 68-75, January, 1968; and Dorothy W. Smith, "A C l i n i c a l Nursing Tool." 'American Journal Of. Nursing. 68: 2384-2388, November, 1968. 117 B. Socio-Cultural Aspects 1. Whom do you see as the most important person in your li f e ? 2. What family members come to see you in hospital? 3. What friends come to see you in the hospital? 4. How do you pass the time here? 5. What things did you like to do before you became i l l ? 6. Would you t e l l me about your schooling. 7. How could we help you feel more comfortable? C. Specific Basic Needs 1. Respirations - observed a) Color i ) face pale ashen i i ) lips pale , red , i i i ) n a i l beds pale , Pink Cont. i ) face cyanotic , pink i i ) lips cyanotic I i i ) n a i l beds cyanotic b) Breathing i ) in no apparent distress ii.) irregular i i i ) rapid (22-30) iv) slow (10-16) 118 b) Breatfcing(cont.) v) labored vi) stertorous v i i ) is receiving oxygen 2.. Food and, Eluids a) Teeth 1) dentures (refer to chart) i i ) is mouth sore? i i i ) does the condition of your mouth inter-fere withy your eating (ask only i f yes to (i) and/or ( i i ) ) b) How is your appetite? c) Are you on a special diet? Yes. No If yes, what kind is it? d) What foods do you eat usually? e) Are there any foods that you do not like? If yes, what are they? f) Are you getting more or less fluids since you came to hospital? g) What are your favorite fluids? h) Do you get them frequently? i ) What fluids do you dislike? j) From the chart: i ) Special diet i i ) Appetite i i i ) Likes iv) Dislikes v) Other 119 3. Elimination a) Bowels 1. Has being sick changed the way your bowels function in any way? If yes, describe. 2. Do you have constipation at home'- : • . in hospital 3. Do you have diarrhea at home . in hospital 4. Do you take laxatives at home . in hospital 5. How often do you usually have a bowel move-ment? 6. What time of day do you normally have a bowel movement? h) Bladder 1. Do you have any d i f f i c u l t y in passing your urine (water)? i ) at home _ _ i i ) in hospital If yes, describe. 4. Exercise. Transfer and Positioning a) From chart: i ) degree of hemiplegia i i ) degree of spacticity i i i ) degree of flaccidity iv) degree of r i g i d i t y 120 4. Exercise. Transfer and Positioning (Cont.) b) Do you have any d i f f i c u l t y walking about? c) Did you have any d i f f i c u l t y walking before you came to the hospital? d) Do you have any pain? e) What do you think about staying in bed? f) What do you think about getting out of bed? i ) ©o you have trouble getting in and out of bed? i i ) Are you comfortable when you are sitting in a chair?. i i i ) W i l l your limbs do what you want them to? iv) Can you t e l l what your foot and/or hand is doing i f you do not watch it? v) Medical findings g) What do you think of your exercises? h) Can you turn over byyyourself? 5. Sleep and Rest a) How do you sleep here? b) If appropriate ask - Do you usually have trouble going to sleep? If yes, describe. c) What did you do at home when you had d i f f i c u l t y sleeping? Was i t effective? always usually sometimes never d) What would you like the nurse to do to help- you get more rest and sleep while you are in the hospital? Maintenance of Body. Temperature a) Do you get cold (chilly) in hospital sometimes? When? b) Do you get very warm in hospital sometimes? When? c) Have you noticed more changes in temperature lately? Bathing and Grooming a) How often do you like to take a bath? i ) daily (a) in the morning? (b) in the evening? i i ) every other day i i i ) weekly iv) no .paeference b) Do you prefer a tub bath or shower? c) What do you think of your bath in hospital? d) How often do you like shaving or having your hair done? i ) daily (a) in the morning? (b) in the evening? i i ) twice a day i i i ) every other day iv) weekly _ e) What else would you like done? Skin Care a) How does your skin usually feel? dry . oily normal _ 122 8» Skirt Care (Cont.) b) Do you use anything on your skin? c) Do you have any bruises or sore areas on your body? Where are they? d) May I look at your back, arm, and leg? i ) back bruise sore i i ) arm bruise sore i i i ) leg bruise sore e) Skin appears: drv oi l y , normal _____ f) Degree of feeling in affected side from medical findings: 9. Safety a) How do you feel about sides on your bed? b) What kind of shoes do you wear when you get up? c) What do you think about getting in and out of bed? d) Do you wear glasses? e) D o you. have any d i f f i c u l t y seeing? As observed by nurse-researcher: Medical findings: If yes, how does this effect you? f) Do you have any d i f f i c u l t y in hearing? If yes, how does this effect you? 10. Communication a) Do you have any d i f f i c u l t y understanding what people say to you? Pat ient * s res pons e: 123 10. Communication (Cont.) a) Cont. Observation: Medical findings: b) Do you have any d i f f i c u l t y reading? Patient's response: Observation: Medical findings: c) Do you have any d i f f i c u l t y writing? Patient's response: Observation: Medical findings: d) Are you able to say the things you want to say when you want to say them? Patient's response: Observation: Medical findings: e) Do you have d i f f i c u l t y getting people to under-stand what you are saying? 11. A d d i t i o n a l material from chart a) B r i e f medical h i s t o r y b) Doctor's orders c) Comments by physiotherapist d) Comments by other team members APPENDIX E i NURSING CARE STUDIES OF SIX PATIENTS WHO HAD EXPERIENCED A CEREBROVASCULAR ACCIDENT BASED ON THE NURSING HISTORY AND OBSERVATION OF PATIENT CARE 125 CODE USED TO IDENTIFY PERSONS COMING TO THE PATIENT'S BEDSIDE A nurse's aide Diet, dietitian Dr. doctor H husband HN head nurse Lab. laboratory technician M minister or pastor NjA -NjF f i r s t nurse to come to patient's bedside during period of observation N2A -N 2F second nurse to come to patient's bedside during period of observation NR nurse-researcher O orderly PN practical nurse PSN preliminary student nurse PT physiotherapist SPN student practical nurse W wife V vis itors 126 Nursing Care Study I: Mrs. A. Mrs. A. is an 87 year-old widowed lady who enjoyed watching hockey and other programs on T.V., reading and going to the movies with her daughter and granddaughter, before she became i l l . She had been looking a f t e r her daughter's apartment and cooking her meals up u n t i l the morning of A p r i l 22, 1970. On the morning of A p r i l 22, Mrs. A. woke up and found that her l e f t arm and legJwere weak. She required her daugh-ter's assistance to stumble to the bathroom. Her speech was slurred, but understandable. She was able to swallow f l u i d s and soft foods. The next morning Mrs. A's l e f t arm and leg were useless and she was unable to speak. She could under-stand when others spoke to her and she would move her head to indicate appropriate r e p l i e s . The doctor's examination revealed an e l d e r l y womam who had a l e f t hemiplegia and a bladder which was distended up to the l e v e l of the umbilicus. Mrs. A's daughter t o l d him that Mrs. A had not pased her water since the morning of A p r i l 22, but Mrs. A^had not complained of any pain or d i s -comfort. Mrs. A. was catheterized for 1400cc. According to the daughter, Mrs. A. had not had any bladder problems previously. The doctor's examination revealed: 127 "Eyes - move normally, no jaundice. Mouth - dry and tongue furred. Face - drawn to r i g h t side. Left Arm - f l a c c i d p a r a l y s i s . Left Leg - paralysis more spastic - bladder was up to the l e v e l of the umbilicus. Now down a f t e r catheterization. Diagnosis: Left Hemiparesis, CerebraL Thrombosis, Urinary Retention." The doctor stated that Mrs. A. was somewhat deaf, but responded by looking at the examiner and shaking her head to indicate a reply. He noted on A p r i l 26, "improving mentally - l e f t paresis remains". There was no comment regarding perceptual d i f f i c u l t i e s . During the period when Mrs. A. was being observed the following orders were in e f f e c t : 24-4-70 Sodium Luminal. 200 mgm. I.M. 9.4.h. p.r.n. for restlessness. Intake and output. 26-4-70 Mu l t i v i t e d a i l y : Ascorbic Acid 200 mgm. t . i . d . S-..S* enema p.r.n. 30-4-70 Physiotherapy please. Up in chair. 4-5-70 Soft d i e t 128 Mrs. A. i s in a four bed room, halfway down the h a l l of a medical ward. Two of her roommates are chron-i c a l l y i l l e l d e r l y ladies and the other i s a middle aged ambulatory lady. Nursing History Code Name: Mrs. A. Age: 87 Primary Medical Diagnosis: Left Hemi- Date: A p r i l 23, plegja 1970. Secondary Medical Diagnosis: Aphasia Date: A p r i l 23, 1970. A d d i t i o n a l Medical Diagnosis: Urinary Date: A p r i l 23, Retention 1970. Most of the following information was obtained from Mrs. A's daughter, observations, and the chart. NR had d i f f i c u l t y communicating with Mrs. A. as she was aphasic and very deaf. Part A: Patient's understanding of I l l n e s s , was unattainable. Daughter answered Part B as well as possible. Mrs. A. l i v e s with t h i s daughter and has for several years. She was a c t i v e , looking a f t e r the apartment and cooking supper up u n t i l A p r i l 21st. Her most enjoyable ;pastiinei was watching hockey on T.V. She also enjoyed watching T.V., reading and going to movies with her daughter and grand-daughter. Mrs. A's daughter v i s i t s Mrs. A every evening, frequently bringing her daughter and other r e l a t i v e s and 129 friends. Mrs. A's daughter could not r e c o l l e c t anything about her mother's schooling. She did not know how to help her mother to f e e l more comfortable. Nursing Approach Suggested by Part C. S p e c i f i c Basic Needs NR. based on Data Obtained From Nursing History. 1. Respirations a) Color Face-pale Lips-pale N a i l beds-pale b) Breathing - rapid Maintain a cle a r airway. En-(22-24), but, i n courage her to breath deeply no apparent and to cough when turning her. ; d i s t r e s s . 2. Food and Fluids Soft foods would be easiest a) Teeth: has dentures f o r Mrs. A. to eat. (chart) but they are not i n . Tongue - smooth and red with some coating i n the middle of her tongue. b) Appetite - daughter has been with her mother at suppertime. Says appetite i s good but, has only been on f l u i d s u n t i l day of interview. c) Daughter was not sure i f her mother was on a spe c i a l d i e t . She wondered i f her mother was d i a b e t i c . d) Said that her mother . usually ate f r i e d foods. Help her to cut up her own food, butter bread and pour her tea and coffee: put foods on r i g h t side of her tray so that she can reach them. Encourage her to feed he r s e l f . Position her so that she can feed herself comfortably. Observe to see i f there i s anything Mrs. A. does not eat and record. e) Did not know of any 130 foods or f l u i d s that her mother did not l i k e . j ) From the Chart 1) Special d i e t - s o f t 2) Appetite 3) Likes Not 4) D i s l i k e s Recorded 5) Other 3. Elimination a) Bowels 1) Daughter does not think that being s i c k has changed her mother's bowel functions. Give Mrs. A. extra f r u i t juices and other f l u i d s . Ask doctor about a s t o o l softener. Give magnolax or cascara. 2) She has had a problem with constipation a l l her l i f e , daugh-Take her to bathroom or put ter s a i d . her on a commode t . i . d . Daughter could not answer remaining questions. b) Bladder 1) At home, Mrs. A. did not have trouble with blad-der u n t i l the day of A p r i l 22 when she could not pass water. 2) In Hospital, Mrs.A was catheterlzed with Foley cath-eter. This was r e -moved A p r i l 28. She voided w e l l for 2 days and then ran into problems of being unable to void. Foley was reinserted May 1 and i t was r e -moved again on May 4. When catheter i s out get her up to the bathroom q. 2h during the day and u n t i l H.S. and pan her q. 3.h. during the night. Encourage her to drink f l u i d s . Let water run a t r i c k l e when she i s i n the bathroom. 131 4. Exercise, Transfer and Positioning. a) From Chart Turn q.2.h. while Mrs. A. i s 1) Degree of hemiplegiain bed. Position Mrs. A. - complete i n good body alignment, when 2) Degree of Spact- she i s i n bed. Support her i c i t y - l e f t leg- l e f t leg to prevent outward s l i g h t l y (20%). r o t a t i o n of the hip. 3) Degree of F l a c c i d i t y - l e f t leg-moderate Put foot board i n bed, but - l e f t arm-almost do not l e t feet touch foot-completely, board. Position l e f t arm on 4) degree of r i g i d i t y - pillows so that hand i s higher no note of t h i s . than wrist and wrist i s higher than elbow to prevent edema. c) Daughter said that Mrs. A. had no d i f -f i c u l t y walking about before p a r a l y s i s . NR could not f i n d the information to answer the remaining questions; except that Mrs. A. could not turn over i n bed by her s e l f . See Appendix B for instructions for one popular transfer tech-nique. Check with physio-therapist to see i f t h i s i s her method fo r tr a n s f e r r i n g Mrs. A. It i s necessary for a l l team members to be con-s i s t e n t . Help Mrs. A. gain confidence i n her a b i l i t y to transfer e a s i l y . 5. Sleep and Rest. a) Daughter could not Mrs. A. should be positioned answer. i n good body alignment with pillows and sandbags to achieve b) Daughter said that t h i s comfort. Mrs. A. occasionally had d i f f i c u l t y going to sleep at home. 132 c) Mrs. A. takes a milk sleeping p i l l which her daughter says was always effective. Maintenance of body temperature. Unable to answer these questions. > Check ventilation and be sure that bed is comfortable. Be sure that c a l l light is within reach. Help her to have an hour or so of unbroken rest during the day. Observe for signs that indicate that she is c h i l l y or over-heated . Bathing and Grooming. Daughter says that Mrs. A.Offer Mrs. A. washwater every has a tub bath once a day and encourage her to do week at home. a l i t t l e more of her bath each day - supervise. This is a training opportunity toward Mrs. A's rehabilitation, Aim to get Mrs. A. into bath tub as soon as possible. Daughter says that Mrs. A.Comb hair when you get her up likes to have her hair in the chair morning and after-done every morning and noon. Comb i t again before evening. her daughter arrives, (approx. 6 P.M.) Encourage Mrs. A. to comb her own hair. Encourage her to dress herself. 8. Skin Care. Mrs. A's daughter thought A drop of bath o i l in Mrs. A£s that her mother's skin was a l i t t l e dry, but she did not use anything on i t . bath water may be useful. Use a l i t t l e cream or lotion when rubbing Mrs. A's back and boney protuberances« On examination there weren't any bruises or sores on Mrs. A's body. She had feeling on her affected side, but there was no notation of this in the medical history. Turn q.2.h., as Mrs. A. cannot turn herself over in bed even though she does have feeling in her left side. 133 Skin appeared quite dry. 9. Safety The only information that Mrs.AA's daughter could give in t h i s section was that Mrs. A. wore strong glasses with very t h i c k lenses and that she was quite deaf. Be sure that c r i b sides are up at the head end of Mrs. A's bed, when she i s i n bed. Put her glasses on while she i s up i n the chair or s i t t i n g up i n bed i f she wishes. Take extra care to see that they do not break. Be sure that c a l l l i g h t i s within reach at a l l times. Be sure that Mrs. A. has supportive shoes on before you get her up. 10. Communication a) Do you have any d i f -f i c u l t y in understanding what people say? Mrs. A. nodded "yes." Mrs. A's daughter said that Mrs. A. Speak to Mrs. A. i n a loud, understood most things but not high, c l e a r voice, she said to her. NR observed that Mrs. A. had d i f f i c u l t y hearing, but when she did hear she seemed to under-stand. Dr. t o l d NR but did not note i t on chart, that Mrs.A. could under-stand quite w e l l when she could hear. b) Do you have any d i f -f i c u l t y reading? Mrs. A. did not answer.Let Mrs. A. t r y to read a l i t t l e 134 Daughter said that her mother had d i f -f i c u l t y reading for 3-6 months before the "stroke." each day however, do not necessarily expect Mrs. A. to read f o r purposes of communication. Observat ion: Appeared to have d i f f i c u l t y reading NR's explan-ation sheet. Medical findings: No note. c) Do you have d i f f i c u l t y writing? Nurse wrote on chart that Mrs. A. wrote a few words on paper A p r i l 30. Do not r e l y on written com-munication but, l e t Mrs. A. tr y to write notes f o r com-munication. Give her paper andppencil and l e t her prac-t i c e , but do not l e t her get too frustrated. Observation: In answer to question Mrs. A. wrote her name on a piece of paper. Medical findings: No note. d) Are you able to say the things you want to say when you want to say them? Not answered. e) Do you have d i f f i c u l t y getting people to under-stand what you are saying? Obs ervat ion: yes. Speech therapist noted that Mrs. A " appeared to be dysphasic rather than aphasic. Unable to test on May 2." 135 Time Day XI in the Hospital Life of Mrs. A Day J. of the Observation of Mrs. A. Person Activities Other Obser Vations  7:30 A.M. Mrs. A. Lying on l e f t side-asleep. 7:40 NjA N IA Gomes in, says "Good morning" to Mrs. A. and proceeds to get wash basin. Tells Mrs. A. that she is going to give her a quick bath. Washes Mrs. A's face and hands. Then turns back the bed clothes and washes her chest and underarms -dries. Washes her legs and dries. Turns her on to her le f t side,-tells Mrs. A. to hold on to the side r a i l and help pull herself over. Mrs. A. Does not seem to understand. May 5, 1970 NR arrives. Bedside table and overbed table on Mrs. A's l e f t . The bed is a high-low bed and is in the lowered pos-itio n . There is no foot board on the bed. NjA Puts Mrs. A's hand on the crib side and turns Mrs. A. Mrs. A. Holds on to side r a i l . 7:50 NjA 8:00 8:10 pN Washes back, turns Mrs. A. back to her back and pulls up the bed covers. Leaves. (10 min. with Mrs. A) Breakfast arrives. Comes in and arranges Mrs. A's tray. Puts tea into large styrofoam jug-like container. Puts her porridge closer to front of tray. Butters toast, cuts her 136 Time Person A c t i v i t i e s Other Obser-vations 8:30 8:40 8:45 egg up. Rolls bed up and places overbed:! table in front of Mrs. A. Mrs. A. S i t t i n g watching P.N. f i x her Appears corn-breakfast, fortable. Mrs. A. Ate everything on her tray by he r s e l f . P I T . PN-, 9:30 Dr. 9:43 N]A Marks down f l u i d intake. Rolls down bed; positions Mrs. A. on l e f t side. Puts pillow behind her back and leaves. V i s i t s . Comes into room with med-i c a t i o n . Puts a p i l l cup to Mrs. A.'s mouth. Pours contents into her mouth; then s t i c k s her finger into Mrs. A's mouth. She was on her l e f t side at 7:30 A.M. C a l l l i g h t not within reach. Not accom-panied by nurse. Mrs. A. on l e f t side leaning s l i g h t l y t o-ward her back. 9:46 9:50 Mrs. A. Begins to cough and sputter. NjA Gives her some j u i c e . Mrs. A. Coughing and sp l u t t e r i n g . NjA Leaves, (2 min. with Mrs. A.) Mrs. A. Stops coughing and spluttering, NlA + N 2A and PN NXA PN N 2A Bring commode to Mrs. A. Takes Mrs. A's feet. Takes Mrs. AI-under the arms. Stands beside the chair and takes Mrs. A's buttocks. 137 Time Person A c t i v i t i e s Other.Obser-vations They swing Mrs. A. out of bed on to the commode. Leaves, Curtain at the NjA (2 min. with Mrs. A.). end of the bed not drawn. PN S t r i p s the bed. N2A Gets Mrs. A's comb and combs her h a i r . N2A Leaves, (2 min. with Mrs. A.). 10:00 PN Pushes Mrs. A. on commode into the bathroom. 10:20 N2A , Returns Mrs. A. on the commode v> to the end of her bed. 10:22 N2A + L i f t Mrs. A. onto a chair from PN commode. Mrs. A. Smiling. Looking comfortable in c hair. Chair moved to face door. N2A Leaves, (2 min. with Mrs. A.). PN Brushes Mrs. A's hair and puts on a purple bow. 10:24 PN Gives Mrs. A. her rosary beads and puts pillow under Mrs. A'sHand 3" below l e f t arm. Leaves. elbow. Mrs. A. Lying back in chair, eyes closed. 10:26 PN Returns with tray with tea pot and.cup, puts tray on Mrs. A's overbed table and pu l l s i t up beside Mrs. A. Pours tea. Puts kleenex and paper bag (taped to table) on table. C a l l l i g h t not within reach. Mrs. A. Drinks the tea herself. Wipes her own mouth with kleenex. Appears com-fortable. 138 Time Person A c t i v i t i e s Other Obser-Nations  10:30 NR to coffee. 11:25 Mrs. A. In chair same position as NR returns from above. Exercising l e f t hand coffee, with r i g h t hand. 11:31 Mrs. A. Now exercising r i g h t hand. 11:35 Mrs. A. Appears to be dozing in the chair. 12:00 NjA Comes i n . Begins to r e -arrange Mrs. A. i n the chair; takes pillow from under a f -fected l e f t arm and puts i t under right,, good arm; then r o i l s up a bath blanket and Left hand not puts i t under l e f t arm. supported; i t is dangling. 12:02 NjA Leaves, (2 min. with Mrs. A). 12:07 PN Comes in cuts up food and Lunch a r r i v e s , arranges everything so that Mrs. A. can reach i t . 12:15 N2A.7 Helps Mrs. A. to eat her sherbet";, Talks to her. Mrs. A. Does not appear to understand N2A. Mrs. A. Has eaten a l l her food. 12:30 N2A Leaves a f t e r recording on intake sheet, (15 min. with Mrs. A.). 12:50 Mrs. A. Dozing i n chair. 12:51 Mrs. A. Pul l i n g pillow out from under her r i g h t hand and holds i t to the r i g h t side of her face. 1:05 Takes pillow from Mrs. A 139 Time Person A c t i v i t i e s Other Obser-vations  NjA Puts p i l l cup to Mrs. A's mouth. NR cannot (1 min. with Mrs. A.). see contents. Mrs. A. Watches while N2A gives p i l l Seems a l e r t to cups to other patients. surroundings. 1:31 NjA + N2A + A Come i n and put Mrs. A. onto a commode, and push i t into bath-room. NjA + N2A + A Talk together and decide to get orderly to put Mrs. A. back to bed. Leave,. (2 min. with Mrs. A.). 1:47 N2A Returns, pushes Mrs. A. on Does not attempt commode back to her bedside, to t a l k to Mrs. A. 1:49 NjA + 0 A r r i v e and pick Mrs. A. up and l i f t her into bed. Position her on affected l e f t side. Pillow behind back but none between legs or under l e f t hand. "That's the way you l i k e i t C a l l l i g h t not is n ' t i t ? " Puts c r i b sides within reach, up. Props up a c r u c i f i x against Mrs. A's water jug and leaves the room, (5 min. with Mrs. A.). Mrs. A. Eyes open. Appears comfort-able. PN 1:52 N 2A 2:20 Mrs. A. Eyes closed. Appears to be asleep. NR to lunch. 140 Time Person A c t i v i t i e s Other Obser-' ; vations  3:10 NR returns. Mrs. A. In same position as above. Appears to be sleeping. 3:57 PT Comes and discovers that the bed is wet. Mrs. A. Says something to physio that sounds l i k e "cup of tea". PT S i t s Mrs. A on side of bed and s l i p s her down onto her feet. Mrs. A. L i f t s l e f t foot o f f the f l o o r when physio asks her to. Left hip s l i g h t l y red-dened . PT Puts Mrs. A. back to bed her-s e l f . Mrs. A. Answereu one of physio's questions with "yeh". 4:15 PT S t i l l with patient. NR for cold drink. 4:30 NR returns. Mrs. A. Back in bed on her l e f t side. Water not in reach nor is c a l l l i g h t . 5:00 N3A Comes i n and puts Mrs. A. in a semi-back lying position. Rolls up bed. Pushes over-bed table in front of Mrs. A. and leaves, (1 min. with Mrs. A.). Mrs. A. Sees a glass of water on the table, reaches out with her ri g h t hand and drinks i t . 5:02 Dinner arrives, 5:05 N3A Comes in and arranges tray. 141 Time Person Activities Other Obser-vations  5:07 5:08 Mrs. A. Eating her supper. N3A Leaves, (2 min. with Mrs. A.). Appears com-fortable. Day XII in the Hospital Life of Mrs. A. 7:20 A.M. 7:30 Day II of Observation Mrs. A. Asleep on her back. N2A 7:40 N2A May 6, 1970 NR arrives. Arrives and gets wash basin then goes to bathroom. Re-turns with water in basin. Talks to NR over the patient. Says very l i t t l e to Mrs. A. Washes Mrs A's face and hands and dries. Then takes Mrs. A's le f t arm, washes and dries i t , bends i t at the elbow and puts arm up beside her head. Washes under Mrs. A's arm and her chest and dries. Turns Mrs. A. on her right side, - washes her back and gives i t a rub. Turns Mrs. A back on her back and washes her legs and dries. Interrupted by PSN - leaves, (10 min. with Mrs. A.). N2A on le f t of bed, NR on right, NR responds non verbally and then refuses to answer. Appears to be very awkward positioning. Hand is semi-clenched, palm upward on her shoulder. Approx. 20 seconds. Does not speak to patient. Arm in above awkward pos-ition through-out bath and now. Only a sheet over her, 9There is a win« dow open 2" on other side of the room. 142 Time Person Activities Other Obser- -vations  7:50 N2A Returns. Tells Mrs. A. that she is going to put her on theSpeaks quietly, commode. PN Comes and helps N2A put Mrs. A. on the commode. 7:55 Mrs. A. Taken to bathroom on com-mode . N2A Leaves, (5 min. with Mrs. A.). PN Leaves. 8:07 Breakfast arrives and is put on overbed table. 8:10 PN + N 4 A Come and get Mrs. A. from bathroom. 8:11 PN + N4A Put Mrs. A. into a chair. N4A pulls on le f t arm. PN Leaves. N4A Speaks quietly to Mrs. A. and moves her in the chair behind Mrs. A. looks the door. into room from beside doorway. N4A Places overbed table in front of Mrs. A. Arranges breakfast tray in Call light not front of her. Puts porridge within reach, at front of tray and leaves, (3 min. with Mrs. A.). Mrs. A. Eating porridge. N4A Returns. Speaks quietly to 143 Time Person A c t i v i t i e s Other Obser-vat ions  8:25 8:45 8:50 9:23 9:33 Mrs. A. Mrs. A. Does not answer. N4A Pours tea into regular cup; puts in cream and sugar and leaves, (one min<.i with Mrs. A. Mrs. A. Manages tea in regular cup without s p i l l i n g . Mrs. A. Has fi n i s h e d tea and porridge Mrs. A. In chair i n same position as above. Mrs. A. Puts edge of blanket that is around her knees around her l e f t hand. Comes with tray of medication cups. Gives Mrs. A. some-thing out of medication cup. Gives Mrs. A. rosary and eye glasses. Mrs. A. Points to newspaper. NjA Gives newspaper to Mrs. A. Leaves, (2 min. with Mrs. A. ), Did not ask Mrs. A. ). Right hand quite steady. .Si t t i n g and watching K i t -chen Aide takes breakfast tray. Does not look under l i d over dinner plate. NR to chart room. Returns from chart room. Overbed table beside her. No water glass on i t . C a l l l i g h t not in reach. Had back to NR and stood in front of Mrs. A. Time Person A c t i v i t i e s Other Obser-vations No water be-side patient, c a l l l i g h t not within reach. 10:00 N2A Comes and begins to brush Mrs. A's hair, (2 min. with Mrs. A.). 10:05 PT Comes, puts a pillow under Mrs. A's l e f t hand and l e f t . 10:10 PT Returns with another physio. They help Mrs. A. to a standing position and make her sway back and f o r t h 2 times. 10:15 PT Return Mrs. A. to bed. Pos- Left hand i t i o n her on r i g h t side. elevated on a pillow. Looks comfortable. C a l l l i g h t cord not i n reach. 11:15 Mrs. A. Asleep in above position. 12:10 Mrs. A. Is being pulled up in bed by N4A and N5A. Lunch i s placed on overbed table which i s pulled up in front of Mrs. A. NR to lunch. NR returns. N4A Puts soup into a cup and proceeds to hold i t up to Mrs. A's l i p s . 12:12 Mrs. A. Drinks. N^A Puts cup i n f a r l e f t corner of the tray and leaves the room, (2 min. with Mrs. A.). 12:13 N4A Returns and l i f t s cup up to Mrs. A's mouth. 145 Time Person A c t i v i t i e s Other Obser-vations Mrs. A. Drinks from the cup. N 4A Asks Mrs. A. i f she can hold the cup he r s e l f . Mrs. A.^Proceeds to hold cup and drink from i t herself. N4A Helps Mrs. A. to eat chopped creamed dinner. L i f t s spoon to Mrs. A's mouth. Mrs. A. Reaches out her r i g h t hand toward the spoon. N 4A Asks Mrs. A. i f she wants s a l t and pepper. Mrs. A. Nods, yes. N 4A Puts s a l t and pepper on Mrs. She feeds her A's dinner. Continues to 4 spoonfuls feed Mrs. A. of dinner. 12:14 N 4A Is c a l l e d away, (1 min. with Mrs. A.) 12:15 12:16 12:17 12:18 12:43 Mrs. A. Proceeds to feed h e r s e l f . PN Brings a styrofoam cup and pours tea into i t . N 2A Comes i n , f i l l s out menu for tomorrow. Mrs. A. Drinking tea out of spout of styrofoam cup. With a spout l i k e a cream pitcher. Without a word to Mrs. A. A H nurses and PN's are gone. Mrs. A. Eating dessert. PN Tidies up patient. Pulls over-bed table with tray on i t to 146 Time Person A c t i v i t i e s Other Obser~- . vations  the l e f t side of the bed. Takes styrofoam cup of f tray and puts i t on table. 12:45 NjA Comes i n , gives Mrs. A. the Does not check contents of a medication cup. name band. Gives her some tea. Appears to be pouring tea, Mrs. A. Coughs and sp l u t t e r s . l e f t over from lunch into Mrs. A. 12:46 NjA Wipes Mrs. A's mouth. Puts Approx. 30cc styrofoam cup out of Mrs. A's of tea i s s t i l l reach. Leaves, (1 min. with in i t . Mrs. A.). 1:03 Mrs. A. Pulls herself to l e f t side C a l l l i g h t cord holding on to l e f t c r i b s i d e . not within reach. 1:05 Mrs. A. Puts hand under the sheet. Appears to be res t i n g . 1:10 N 2A Rolls down bed. . PN + N 2A Come in and help Mrs. A. out Without of bed onto a commode. speaking to Mrs. A. Does not explain 1:11 PN Pushes Mrs. A. on commode in'^oto Mrs. A. what to bathroom. they are doing. At 1:00 PN ca l l e d to Mrs.A. from other side of the room where she was helping another patient onto the commode, "Your turn next!". 1:22 N 2A + PN Bring Mrs. A. back to bed-side, t e l l her to stand on her feet, then they swing her into bed. 147 Time Person A c t i v i t i e s Other Obser-________________________ ; vat ions  Mrs. A. Sighs as she gets back into bed. N 2A "Is that a sigh of r e l i e f ? " Mrs. A. Says something that sounds l i k e "hard". N2A Says to PN that she could probably t a l k better with her dentures i n . Speaks into Mrs. A's ear. N2A "We w i l l put your dentures i n tomorrow." "Would you l i k e that?" Mrs. A. Shakes her head negatively. N 2A Positions Mrs. A. on her l e f t C a l l l i g h t cord side and puts a pillow be- or water not hind her back. within reach. 1:28 N 2A Leaves, (6 min. with Mrs. A.). 1:30 NR T e l l s Mrs. A. that she i s going away for awhile but w i l l be back l a t e r . Mrs. A. Looks up at NR Seems to smile. NR Asks her to s t i c k her tongue out. Mrs. A. Sticks her tongue out. Tongue red and .shiny- with yellow spots on i t . 3:00 NR returns Mrs. A. Appears to be asleep. Pos-i t i o n the same as above. No water or c a l l l i g h t within reach. Small paper cup of f l u i d on over 148 Time Person A c t i v i t i e s Other Obser-• vations  bed table at end of bed. 3:40 Mrs. A. Pulls covers back, pulls at side r a i l s . Puts r i g h t leg close to the edge of the bed. NR puts on c a l l l i g h t then feels bed be-side Mrs. A's buttocks. Bed is dry. 3:43 A Comes i n , turns out l i g h t and leaves. 3:45 A Returns with a commode. States that she i s waiting for a nurse. 3:55 N^A Turns down the covers. Begins to move Mrs. A., then says "The bed i s wet". A Changes Mrs. A's bed and gown. 4:00 NR to another ward. 4:10 PT Exercises Mrs. A's l e f t arm NR returns and leg. Puts pillow under 4:15 l e f t arm before she leaves. Hand about 2" 4:20 Mrs. A. Points to paper cup on the table at the end of the bed. above elbow. NR Gives cup to Mrs. A., she drinks. 5:00 N 3A + Pulls Mrs. A. up in bed. N5A N3A Pulls pillow out from under l e f t arm. Lets i t f l o p on the bed. 1 4 9 Time Person Activities Other Obser-___ vat ions  5 : 0 1 N 3 A + N 5 A Leave, ( 1 min. with Mrs. A.). 5 : 0 2 Supper tray arrives. Is placed on over bed table out of Mrs. A's reach. 5 : 0 4 N5A 5 : 1 0 5 : 1 2 5 : 1 6 5 : 1 8 Mrs. Mrs. N5A N5A Mrs. N 5A Sits on Mrs. A's bed and begins to feed her soup with a spoon. A. Wipes her face after each spoonful. A. Indicates that she has had enough soup. Feeding Mrs. A. Dinner consists of ground beef and vegetables. Holds glass of Milk to Mrs. A's l i p s . A. Drinks. Begins to feed Mrs. A. desert. Gives Mrs. A. her milk glass Holding the glass to hold and lets her drink in her right one or two mouthfail&G be- hand, tween spoonfuls of dessert. Mrs. A. Points at N R then at her head then at N5A and then at her chest. Then she wiggles her finger in ci r c l e s . N5A "Do you want to write?" Gets her pencil and paper. Mrs. A. Writes "Mrs. Bake word hope the hope home I ask Ann" 150 Time Person A c t i v i t i e s Other Obser-vat ions  N5A Looks at Mrs. A ' s name band. "Your name i s Mary." Then says to NR, "I w i l l go and look at her chart to see what her daughter's name i s . " 5:21 N5A Leaves, (17 min. with Mrs. A . ) . 5:22 N 5 A Returns, "The chart says that her daughter i s E l l e n . " N5A I w i l l leave t h i s paper here on your table and we w i l l ask your daughter when she comes i n . 5:25 N^A Pours tea into styrofoam jug Shows her the "Do you take sugar?" sugar. Mrs. A . Nods no. NcjA "Do you take cream?" Shows her the cream. M r s . A . Nods no. N5A Puts tea within Mrs. C's reach and leaves, (3 min. with Mrs. A.). 5:30 Mrs. A. Drinking tea. NR home. Time spent, in minutes with Mrs. C. by general s t a f f nurses. May 5, 1970 May 6, 1970 N j A - 19 min. N j A - 3 min. N 2 A - 27 min. N 2 A - 21 min. + N 3 A - 3 min. N 3 A - 2 min. N^A - 7 min. % A - 21 min. Nursing Care Study II; Mrs. B. Mrs. B. is a 73 year-old widow, who has been a diabetic for many years. She has been in and out of hos-p i t a l frequently in the past and was usually discharged to her own home u n t i l recently, when her daughter-in-law encouraged her to go to a private hospital. In addition to diabetes she has arteriosclerotic heart disease and some evidence of cerebral vascular dis-ease with episodes of semi-coma. Recently she has been quite alert. Twenty-four hours prior to her admission to hospital she became drowsy and disoriented. She then proceeded to become progressively more drowsy and disoriented with a weakness developing in her right arm and right leg. On admission Mrs. B's doctor reported*: that'" she was semi-comatose, with weakness in her right arm and right leg. Her pupils reacted equally to light, but deviated to the l e f t . Her chest was clear, heart apex was 8 8 b.p.m. and irregular; and her blood pressure was 2 1 0 / 1 1 0 . She moved her l e f t arm only and spontaneously. Very weak and flaccid right arm and right leg. Mrs. B. Was in a private room. During the period in which Mrs. B. was being observed the following orders were in effect: 152 16- 5-70 20 units NPH Insulin daily in a.m. Intake and output. Foley catheter. Digoxin 0.25 mgm (h) daily. Sparine 50 mgm I.M. p.r.n. for severe restlessness. 17- 5-70 Diabetic urine testing Q.I.D. Suppository, enema or laxative p.r.n. Fluids as ttoSerated. 20-5-70 Push oral fluids. May get up in chair. 25-5-70 Regular insulin 5 u. per. + in urine at lunch and dinner today. Note: No order for physiotherapy or occupational therapy. Nurs ing History Code Name: Mrs. B. Age: 73 Primary Medical Diagnosis: Diabetes MelTitus:Date: many years. Secondary Medical Diagnosis: Cerebrovascular Accident-Right Hemiplegia. Additional Medical Diagnosis: Arterosclerotic Heart Disease. Date: not given. Most of the following was obtained from observations and the chart. Mrs. B. found speech d i f f i c u l t and answered very few of the questions. 153 Mrs. B*s daughter-in-law worked during the day. She was interviewed briefly during her lunch hour by the nurse-researcher. However, the interview was too brief to ask many of the questions contained in the nursing history. Mrs. B. was unable to answer Parts A and B of the history, except to say that her daughter-in-law, grandson and granddaughter visited her in hospital. Part G. Specific Basic Needs Nursing Approach Suggested by NR based on data obtained from Nursing History. 1. Respirations a) 60lor face-pale lips-pale n a i l beds-pale b) Breathing - in no appar- Encourage to breathe deeply ent distress. and to cough when turning her. 2. Food and Fluids a) Teeth 1) dentures - yes (in box at bedside at time of inter-view. ) i i ) mouth sore - "no" b) Appetite - "good" c) Are you on a special diet? - "Yes." What kind is it? -"D—Diab-b-b- No sugar" 154 d) What foods do you eat? No answer Observe the foods that Mrs. B. likes and record. e) Are there any foods Observe the foods that Mrs. that you do not like? B. does not like and record. No answer. Did not answer the rest of these questions. j) from the chart i) Special diet- Encourage fluids. Fluids as t o l -.erated, encour-age (Diabetic) i i ) Appetite- f l u i d intake recorded but no record of food intake. no I i i ) Likes iv) Dislikes record v) Other Elimination a) Bowels i ) Looked puzzled at "Has being sick changed the way your bowels func-t i o n ? " b) Bladder i ) did not answer question re passing water at home. i i ) has foley catheter in hospital. Observe Mrs. B's appetite, likes and dislikes and record. Dr.'s order is for suppository, enema or laxative. Give a stool softener p.r.n. and encourage fluids. Ask doctor about bladder training, by clamping catheter q.2.h. and after 24 hours remove catheter. Then bedpan must be offered q.2.h. 155 Exercise, Transfer and Positioning a) From Chart i ) degree of hemiplegia not clearly indicated "weak flaccid right arm and leg." i i ) degree of spasticity - not noted. Turn q.2.h. when inbbed. Position Mrs. B. in good body alignment. Support her l e f t leg to. prevent outward rotation of the hip. i i i ) degree of flaccidity "weak flaccid right arm and leg." There was no requisition for physiotherapy. b) Do you have any d i f -f i c u l t y walking? Yes. c) Did you have any d i f f i c -ulty walking before you came to hospital? Yes. d) Said that she was "sore a l l over." e) K> ^ comment- re staying in bed. Put foot board in bed, but do not allow her feet to touch i t . Position right arm on pillows so that hand is higher than wrist, to prevent edema. Check with Mrs. B's doctor regarding popular transfer technique recorded in Appendix B. Did not answer the following of these questions. There were no medical notes Do not leave her up in chair regarding Mrs. B's a b i l i t y for more than 20 minutes to to know what her arm and 30 minutes at a time, leg were doing i f she did not watch i t . g) No requisition for phys iotherapy. Turn Mrs. B. q. 2.h. h) Can you turn over in bed? "No." 156 Mrs. B. turned away from NR and did not answer any more questions. 5. Sleep and Rest. Did not answer. 6. Maintenance of.body Temperature Did not answer these questions. 7. Bathing and Grooming. Mrs. B. did not answer these questions. 8. Skin Care Skin appeared dry. Bruises were observed on both arms. Check ventilation and be sure that the bed is com-fortable. Be sure that c a l l light is within reach. Help Mrs. B. to have an hour or so of unbroken rest during the day. Ask Mrs. B. i f the temperature in the room is comfortable for her. Encourage Mrs. B. to do part of her bath every day. Aim to get Mrs. B. into the tub as soon as possible. Encourage her to help dress herself. Comb her hair whenever you get her up in a chair and before her daughter-in-law comes. Teach her how to comb her hair with her left hand. Use a l i t t l e lotion when giving skin care to back and boney protruberances. Rotate injection sites for insulin to legs and give Mrs. B's arms a rest. Turn Mrs. B. q.2.h. 157 . Safety Mrs. B. did not answer these questions. Be sure that crib sides are up at the head end of Mrs. B's bed when she is in i t . Be sure that c a l l light is within reach at a l l times. Make sure that Mrs. B. has on supportive shoes before you get her up. 0. Communication The doctor did not make any comments on the chart in relation to com-munication. a) Mrs. B. appeared to understand everything that was said to her. b) Do you have any d i f -f i c u l t y reading? Mrs. B. could not seem to focus on NR's infor-mation sheet. c) Do you have d i f f i c u l t y writing? d) Refused a pencil and paper when i t was offered. Mrs. B. does not seem to have any d i f f i c u l t y hearing so do not speak to her in a loud voice. Explain what you would like her to do or what you are going to do. Talk to her as you give her nursing care and whenever pos s ible. Ask the Dr. about Mrs. B's vis ion. 158 Day IX in the Hospital Life of Mrs. B Day I in the Observation of Mrs. B. Time Person Activities Other Obser-vations 7:30 A.M. Mrs. B. Lying on back right hand on her abdomen. 7:35 N IB 7:40 Mrs. B, May 25, 1970 NR arrives. Bedside table on right side of bed. Light cord not within reach. Wearing a jacket re-straint tied to bed frame. Crib sides up. Empties urine drainage bag. Writes on the intake and output sheet. Leaves, (1 min.) Did not speak to Mrs. B. Moving restlessly in bed, l i f t i n g l e f t arm and head in direction of the right side of the bed. Does not l i f t right hand off abdomen. Mrs. B. Rubbing face and forehead with left hand. Moving left leg up and down. Does not move right leg. 8:15 NjB Comes to right side of the bed, says "Hi, I am going to give you some insulin-;." Checks right arm, walks around bed and gives i t in l e f t arm. (1 minute). 8:25 N2B Comes in and says "Good mor-ning"to Mrs. B. Gets basin out of bedside table and f i l l s i t 159 Time Person Activities Other Obser-vat ions  with water. Mrs. B. Says "good morning." N2B Tells Mrs. B. that she is going to bathe her. Begins Did not use to bathe Mrs. B's face, abdo^ebath blanket men and chest, back, feet or sheet to and legs. cover Mrs. B. during bath. 8:40 Dr. "Good morning, Mrs " Mrs. B. "Good morning." Dr. Puts his hand in her right hand and asks her to squeeze. She does not squeeze Dr.'s hand. Dr. Asks Mrs. B. how she is and she says "fine." 8:42 N^ B Arrives, saying that she is going to help N 2 B put Mrs. B. into a chair. Chair moved to foot of right side of the bed. NjB Takes Mrs. B's right arm. N2B Stands in front of Mrs. B. and they pivot Mrs. B. into the chair. N2B Positions Mrs. B. in the chair, puts a pillow under her right N^B arm. Leaves (3 min.) Hand is about 3" below elevated elbow. N2B Asks Mrs. B. i f she has a sore leg. Mrs. B. Says that she is sore a l l over. 160 Time Person A c t i v i t i e s Other Obser« vat ions . 9:00 N 2B Asks Mrs. B. to put her l e f t hand into her bed jacket. Mrs. B. Does so with much encourage-ment from N 2B. N 2B Puts blanket over Mrs. B's knees. Puts overbed table with breakfast tray on i t i n front of Mrs. B. Holds a paper cup for Mrs. B. to drink from. N2B Leaves, (35 minutes). N3B Comes i n and t e l l s N 2B that she w i l l f i n i s h giving Mrs. B. her breakfast. v N3B Holds cup with porridge in i t so that Mrs. B. can drink. Breakfast i s porridge, j u i c e and tea. Mrs. B. Talking to N3B. Does not en-courage Mrs. B. to hold paper cup in her own hand. NR cannot hear her words. N 3B Mrs. B. 9:07 N 3B Does not answer. Talks f a i r l y c l e a r l y when NR can hear her. S i t t i n g holding paper cup f o r Mrs. B. to drink from. Kitchen g i r l comes and takes tray away. No observable 161 Time Person A c t i v i t i e s Other Obser-vat ions 9:10 N 3B Puts pillow under Mrs. B's ri g h t arm. Marks on paper. Leaves, (10 minutes ). 9:15 Mrs. B. Ro l l i n g her head. Making puffing noises, groaning. Wiggling l e f t foot on the f l o o r . 9:25 Mrs. B. Has l i f t e d r i g h t hand up under her chin. 9:26 Mrs. B. Returns i t to her lap. 9:27 Mrs. B. Turns head to r i g h t side, r i g h t hand does not move up under chin. 9:35 Mrs. B. Head turns to l e f t , closes eyes. 9:36 N 2B 10:20 Comes in and begins to make bed. Mrs. B. In chair, appears to be asleep. attempt to record f l u i d intake before tray l e f t the room. Hand 1/2" above elbow. 250 cc on f l u i d intake sheet beside 9:00 A.M. Has lost the pillow. No l i g h t cord or s i m i l a r c a l l device within reach. Nothing on table beside chair. NR to coffee. NR returns. Intake sheet states 10:00 A.M. 150 cc. Pillows under head on r i g h t 162 Time Person Activities Other Obser-• vat ions  side, right arm straight by her side. Pillow tinder left arm. Blanket partly off her knees. Left side of left buttock bare and against metal support for arm rest. 10:21 N2B Comes in, looks at Mrs. B. and leaves. 10:22 Mrs. B. Restless-moving in chair, eyes open, running fingers through her hair. 10:28 Pillow under lef t arm has fallen on the floor with the blanket. Mrs. B. Discovers that her buttock is bare and is rubbing i t . Tries to pull gown over i t . 10:30 Kitchen g i r l brings milk and puts i t on table be-side Mrs. B. but not within her reach (on right side). N2B "Ooo you are showing your leg." She covers i t with the blanket. "Rest your Puts left hand hand on the pillow." "Would on the pillow, you like to go to bed soon?" Mrs. B. "Yes." 163 Time Person Activities Other Obser-_____ vat ions  N2B Holds glass to patient's lips so that she can drink. Mrs. B. Drinks. Rubs le f t eye with l e f t hand during pause between drinks. Moves left arm toward glass, but does not grasp the glass to hold i t for herself. 10:40 Mrs. B. Finishes milk. N2B Writes on intake s l i p and leaves room, (5 minutes). 10:47 N2B; 4, Come in to room and move N3B Mrs. B's chair beside the bed. Chair faces foot of bed. 180 cc written on intake s l i p . Head of bed is raised before they l i f e - Mrs. B. back to bed. N3B Takes the legs. N2B Puts her arms around Mrs. B's arm pits and they swing Mrs. B. onto the bed. N 3 B 10:54 N 3 B + N2B Puts a pillow under Mrs. B's right arm and says, "This Right hand swelling w i l l not go down about 6" to i f we don't keep i t elevated."8" above elbow. Leave, (7 minutes.) 10:55 Mrs. B. Lying on right side. Mrs. B. appears comfortable. 164 Time Person A c t i v i t i e s Other Obser-vations 11:55 Mrs. B. Resting on back. 12:20 NR to chart room. Appears to have turned her-s e l f . Pillows on each side. NR to lunch. NR returned from lunch. Mrs. B. Appears to be i n same position as above. 12:38 N2B 12:40 12:41 N 2B 12:50 N 2B 12:55 NjB 12:58 N 2B F l u i d intake states that she had 180 cc intake and 100 cc output at 12:00 Noon. Comes i n , l i f t s Mrs. B.up in bed and puts pillow under her ri g h t hand. Arrives and begins to feed Mrs. B. her lunch. Leaves, (9 min.). Comes i n . Lunch a r r i v e s . Asks NR i f Mrs. B. i s eating her lunch. NR re p l i e s "yes" she i s i n the middle of i t . Returns and feeds Mrs. B. the remainder of her lunch. Positions Mrs. B. on her l e f t side, elevates her r i g h t hand 165 Time Person A c t i v i t i e s Other Obser-vations on a pillow. Mrs. B. appears comfortable. N 2B Asks Mrs. B. i f she i s comfort-able. Mrs. B. "Yes." 1:10 N2B Records intake and leaves, Intake s l i p (15 minutes). says 1300: 300 cc. NR goes for a walk. 2:10 Mrs. B. Appears to have r o l l e d on to Appears to be her back. re s t i n g com-fortabl y . 2:20 N 2B Comes i n , r o l l s bed up and gives Mrs. B. a glass of j u i c e . 2:30 N 2B Positions Mrs. B. on her r i g h t side. Records 180 cc on intake s l i p . 2:48 V Grandson a r r i v e s . NR leaves the room. 3:15 Grandson leaves. NR returns. Mrs. B. Lying on her back, eyes closed. 3:30 V Lady v i s i t o r a r r i v e s . NR leaves room. 3:50 Mrs. B. Lying on back, eyes open, NR returns, moving l e f t hand and arm from time to time. 4:05 A Aid gives Mrs. B. some j u i c e . 180 cc on intake Rolls up her bed and holds s l i p , glass with a straw in i t to her l i p s . 4:10 A Rolls bed down and leaves. 166 Time Person Activities Other Obser-vations 4:25 4:35 4:45 Aid comes and collects sample of urine. Aid comes with linen in her arms. Asks NR to leave. Mrs. B. has had an in-voluntary B.M. Mrs. B. Lying on right side, appears comfortable. 5:00 5:30 5:40 5:45 Mrs. B. Dozing. Mrs. B. Moving l e f t hand up to her face and then down to her abdomen. Moving onto her back. Mrs. B. Has rolled back to her right side,above movements con-tinue. -5:48 Comes and begins to feed Mrs, B. NR leaves. NR returns. No pillow under right hand. Right hand on bed, fingers slightly curled.. Palm upward s. Pi1low behind her back. Pillow has been pushed to lef t side of the bed. Supper arrives, Is put on overbed table at foot of the bed. NR goes home. 167 Day X i n the Hospital L i f e of Mrs. B Day II in the Observation of Mrs. B Time Person A c t i v i t i e s Other Obser-vations 7:45 A.M. 7:50 Mrs. B. Sleeping on back, r e s p i r a t i o n noisy. A Aid comes i n and speaks to NR. T e l l s Mrs. B. that she i s going to take her temper-attire. Mrs. B. Does not wake up. A Turns Mrs. B. onto her r i g h t side, c a l l s her name twice. Mrs. B. Opens her eyes. A Says, "Good morning, Mrs. May 26, 1970 NR a r r i v e s . Appears very pale. Mouth open, tongue almost pro-truding. Right hand not e l e -vated on a pillow. C a l l l i g h t cord not within reach. Crib sides up. Mrs. B. Replies "good morning" then goes r i g h t back to sleep. Mrs. B. Sleeps while her temperature i s being taken. A Puts pillow under Mrs. B's r i g h t hand in a slurred manner. Right hand elevated. 168 Time Person A c t i v i t i e s Other Obser-vations  8:27 Respiration 20 quiet. 8:15 N 4B Enters room with bottle of rubbing alcohol. N 4B Mrs. B. N 4B N 4B Mrs. B. N 4B Mrs. B, N4B Starts to s t r i p bed. Speaks to Mrs. B. Does not respond. Uses sheet for wash blanket. Asks Mrs. B. to r a i s e her arms up to her head. Moves l e f t arm up to her head but does not move her r i g h t arm. Washes back and gives back rub. Does not respond when N speaks to her. Goes to bathroom and empties wash basin. Returns and begins to give Mrs. B. mouth care. Gets wash basin and f i l l s i t with water. Throws bed-spread onto the f l o o r . Mrs. B. Closes her mouth. N 4B does not t o l l Mrs. B. what she i s going to do. N 4B Asks Mrs. B. to open her mouth. Mrs. B. Turns her head away from K. Eyes s t i l l closed. N4 B Goes around to other side of Does not t e l l 169 Time Person A c t i v i t i e s Other Obser-vations 8:31 8:32 N 4B N 4B N 4B Mrs, A N 4B the bed and begins to brush Mrs. B's h a i r . Lowers bed. Mrs. B. what she i s going to do. An e l e c t r i c bed does not t e l l Mrs. B. what she i s going to do. Comes in and asks N^B how they are going to get Mrs. B. up. Are they going to l i f t her d i r e c t l y ? Does not t e l l Mrs. B. that they are going to get her up. L i f t s Mrs. B. to a s i t t i n g p o s ition and t e l l s her that they are going to get her up. Puts r e s t r a i n t on. Brings chair to the end of the ri g h t side of the bed, (facing head of the bed). B'. Opens her eyes and mutters something. "What did you say?" "Does i t hurt?" N 4B + A Pivot her into the chair and t i e her i n . Put r i g h t arm on a pillow and blanket around knees. Hand about 2" below elbow. Do not say anything to patient. 8:35 N 4B + A Leave, (20 minutes). 1 7 0 Time Person Activities Other Obser-• vat ions Mrs. B. Eyes closed again. 8 : 3 6 Breakfast tray is brought into room and put on table at the end of the bed. 8 : 4 7 N^B Comes in, puts a towel around Mrs. B's neck; gets a small paper cup from the tray, Does not speak and puts a straw in i t . to Mrs. B. N4B "I have some orange juice here Mrs Would you like some orange juice?" Mrs. B. Opens her eyes and says "yes'.' Closes eyes and sucks on the straw, when she is told to. Drank a l l of the orange juice. N^ B Feeds Mrs. B. porridge from a spoon. Mrs. B. Appears to enjoy the porridge.Has some d i f -f i c u l t y with her tongue. It protrudes when she opens her mouth to receive the spoon. N^B Gets a straw and puts i t in the porridge. 8 : 5 6 N4B Leaves room, returns directly with Aid. N4B Tells Aid that Mrs. B . is slipping out of the chair. 171 Time Person Activities Other Obser-vations  A +.N4B Pull Mrs. B. up in chair. N4B Mrs. B. Resumes feeding Mrs. B. Por-ridge through a straw. Stops sucking through the straw. Pours porridge into a paper cup. Mrs. B. Drinks about 1/2 the con-tents of the paper cup then asks for tea. They don't say a word to Mrs. B. N4B Mrs. B. N4B9 Tells her that she has coffee on the tray, and would that be a l l right? "Yes." "How do you like i t , with cream or black?" Mrs. B. "Black." N4B Pours coffee into cup and gets a straw. Asks Mrs. B. to suck i t up on straw. Mrs. B. Does not. N4B Persuades her to suck on the straw. Mrs. B. Sucks, but pulls her head away abruptly when the fluid reaches her mouth. Mrs. B. Says something to N4B. N4B Asks her to say i t again. 172 Time Person A c t i v i t i e s Other Obser-yations Mrs. B. Says i t again. N4B Leans closer to Mrs. B. Mrs. B. Drinks a small amount of coffee. Does not seem to understand what Mrs. B. is saying. 9:15 9:19 N 4B N 4B N 4B Gets up, s t r i p s and makes the bed. Walks over to Mrs. B. with a h a i r brush and brushes her h a i r . Walks out of the room, (28 minutes). Mrs. B. Raises her l e f t leg and moves in her chair s l i g h t l y (as N 4B walks out of room) moves her head to the r i g h t , l i f t s hand toward her head, then slumps back into her chair. N 4B + A Come into room saying, "Yes, l e t ' s put her back." N 4B To Mrs. B., "We w i l l l e t you res t now and get you up again l a t e r . Pulls chair over to bed and pulls Mrs. B. toward her i n chair. A "We are going to put you back into bed now." Does not say a word to Mrs. B. Puts on a clean bed-spread. Does not t e l l Mrs. B. what she is going to do. Without a word to Mrs. B. Is semi-covered, one leg exposed. A Gives directions to N 4B on how 173 Time Person Activities Other Obser-vations to put Mrs. B. back into bed. Both l i f t e d together, N^ B taking her under the arms and A taking her legs, and swing Mrs. B. into bed. Mrs. B's head misses hitting the top of bed by about 2". A Leaves room. N4B Tells Mrs. B. that she is Head turned to going to put Mrs. B. on her the right and side, but positions her more a pillow at on her back than on her side, the back holding her shoulders off the bed. 9:28 9:30 10:00 N4B Pours a glass of water and puts i t beside r a i l s , then Right hand not elevated on leaves the room, (9 minutes), pillows. Mrs. B. Appears comfortable and almost asleep. Mrs. B. Asleep in same position as above. NR to coffee. NR returns. Intake and output sheet states: 0800, 200 cc intake and 500 cc output. 10:14 N4B Comes in with a syringe and needle and takes Mrs. B's pulse. Says "Mrs I have a hypo for you." Mrs. B. Does not respond. N4B Puts needle into Mrs. B's l e f t arm. Mrs. B. Screws up her face. Does not open 174 Time Person Activities Other Obser-vations her eyes or say anything. N.B Goes around to the other side of the bed and speaks loudly to Mrs. B. "Mrs." and gently touches her eyes. Mrs. B. Does not open her eyes. 10:17 , N4B Leaves room, (3 minutes). NR to coffee. 11:04 NR returns. N4B Feeding Mrs. B. milk in a paper cup. Mrs. B. Drinks. N4B "I w i l l turn you to the other side now." Does so. Right hand not elevated. 11:08 N4B Leaves room, (4+ minutes). 11:09 Mrs. B. Almost on her back again. Right shoulder elevated and resting more on l e f t hip than on sacrum. 11:15 Mrs. B. Completely on her back now. Left arm and leg moving up and down. Pulling her nose. 11:17 Mrs. B. Repeats above movements. 11:18 Moves her leg and arm up and Does not move down. right arm or leg. 11:20 Mrs. B. Pulls her head toward the left side r a i l u n t i l neck is almost Does not move 90° t o s i d e r a i l . Rubbing right arm or forehead and. moving left leg. arm and leg. 175 Time Person Activities Other Obser-vations  11:30 Mrs. B. Seems to be asleep. 12:10 Mrs.B, 12:14 N4B 12:37 12:42 A Mrs, A Mrs, A In this appar-ently uncom-fortable position. NR to lunch. On back, eyes open. Moves NR returns, le f t arm and leg occasionally.Pillows now on l e f t side of bed. Appears to be more color in cheeks than previously. Comes in and says, "I have come with your insulin Mrs. ". Gives i t and leaves, (1 minute). Lunch arrives. Is placed on table at end of bed. Comes to the side of the bed. "Are you awake?" B. Opens her eyes. "Are you hungry"? B. Murmurs, "yes." "Let's try some lunch on you." Positions Mrs. E. on her back and raises the head of the bed slightly. NX comes in and asks Aider to help with another patient, 12:48 A Aide returns, pours soup into cup. Holds paper cup to Mrs. B/s 176 Time Person Activities Other Obser-vations l i p s . A Asks Mrs. B. which hand is her good hand and points to the right one. Mrs. B. L i f t s up her le f t hand. A Talks to Mrs. B. as she feeds her. A "Is i t good?" Mrs. B. "Not very good soup." A "You like your drinks cold don't you?" Mrs. B. "Yes." A "Could I try some ice cream on you?" Mrs. B. "Yes" and eats i t . " A l l gone. Would you like some tea now?" Mrs. B. "Yes" A "What would you like in your tea?" Mrs. B. "Cream and sugar." A Pours tea "we w i l l leave i t to cool for 5 minutes." Appears to have some d i f f i c u l t y drinking. Eats ice cream with apparent enjoyment. Opens mouth for each spoon-f u l . Quietly. Very clearly. 177 Time Person A c t i v i t i e s Other Obser-vations  1:05 1:17 1:18 1:28 Leaves room. Mrs. B. Is slumped forward dozing, 1:38 Mrs. B. Awake Tray with tea on i t taken from the room. NR retr i e v e s tea. Head of bed remains up. NR to Bathroom. NR returns.'. Mrs. B. looks uncomfortable. Tea on table. 1:40 A Returns. Apologizes,says she was detained. "You l i k e your f l u i d s cold don't you?" Mrs. B. "Yes." A Holds cup with straw in i t to Mrs. B's l i p s . Mrs. B. Drinks a l l of i t . A Asks Mrs. B. i f she knows where she i s . Mrs. B. "I am in the Hospital." A "Where do you stay?" Mrs. B. "I l i v e i n a h o t e l . " A Asks Mrs. B. i f she can see her quite c l e a r l y . Mrs. B. "Yes." A "Which side would you l i k e 178 Time Person 2:15 3:25 3:45 Activities Other Obser-vations  to turn to?" "Right." Mrs. B. Turns to the right herself. A Puts a pillow behind her back, writes on intake s l i p and and leaves. 2:00 Mrs. B. On right side sleeping. On intake s l i p 290 cc. Appears com-fortable. N^ B Comes into the room. Mrs. B. Asleep. N4B Does not speak Walks to right side of bed and picks up Mrs. BJs head andto Mrs. B. puts i t on the middle of the pillow. Then runs her fingers through Mrs. B's hair. "How are you Mrs ? " Mrs. B. Screwed up her face, and whim-pered. Moves her head back to the right side of the pillow. 2:45 K4B Watches Mrs. B. then walks away, (1 minute.) Mrs. B. Asleep in same position as above. Orange fl u i d (in clear plastic glass) arrives, put on table at the end of the bed. NR to tea. NR returns. Orange fl u i d s t i l l on table. 4:05 Mrs. B. Opens her eyes, rubs her nose then rubs her body under the covers. 179 Time Person Activities 5::46 Other Obser-vations 4:55 Mrs. B. Dozing 4:06 Mrs. B. Appears to be dozing. 4:42 Mrs. B. Kicks l e f t leg out from under the covers and puts i t on top of the bedspread. Moving le f t hand, arm and leg-no move-ment from right leg and arm. 1/2 of her body is uncovered. NR to see an-other patient. NR returns. Orange flu i d Is gone, nothing marked on intake s l i p . Supper tray at end of bed on table. 5:42 Mrs. B. Covered up, sleeping. Comes and begins to feed Mrs. B. her supper. Time spent, in minutes with Mrs. B. by general staff nurses. May 25, 1970 NjB -% min. N2B -72+ min. N3B -17 min. NR home. May 26, 1970 N4B - 66 min. 180 Nursing Care Study III; I:Mr>. C. Mr. C., a 90 year old r e t i r e d minister, collapsed on the morning of May 27 as he returned from the bathroom. When he was helped back to bed i t was noted that he was weak (could not stand) and was unable to speak. He was nauseated and vomited and remained very r e s t l e s s during the night. Mr. C. enjoyed excellent health a l l his l i f e and did not have any operations or serious i l l n e s s e s . The Dr. noted that since approximately the beginning of the year, he had become increasingly t i r e d and had l o s t weight. In the past he had had anaemia of unknown etiology, but, his hemoglobin was approximately 14 gms. Recently, he had been taking "Tonic c Fe." The doctor also noted that "he had occasionally had B.P. up to 200/100, but i t generally was approximately 140-160/88. On May 28th the physician noted that Mr. C. was a white male in good nutrition. He was sleepy (yawning), h i s face was flushed and that his l e f t p u p i l was s l i g h t l y larger than his r i g h t , which was deviated s l i g h t l y l a t e r a l l y . He moved his l e f t arm, hand and leg very l i t t l e . His blood pressure was 190/85, heart rate 76 with occasional intrasys-t o l e , and there was no J.V. d i s t e n t i o n . His lung bases were cl e a r , his abdomen s o f t , but had fullness suprapubically which was s l i g h t l y tender (doctor notes that t h i s was 181 probably the bladder). The neurological aspect of the doctor's notes state that Mr. A. i s conscious, obeys commands, and responds to questioning with garbled speech and an occasional approp-r i a t e word. Both pupils responded to l i g h t and the r i g h t eye was deviated s l i g h t l y toward the r i g h t , l a t e r a l l y . He "has r i g h t f a c i a l weakness", but found that the tongue deviated to the r i g h t . The l e f t arm and leg were very weak but was able to move them weakly, movement in the r i g h t extremities "O.K." His impression was cerebrovascular accident with l e f t hemiparesis. The doctor notes further that on May 29 Mr. G*s speech was becoming more coherent but he was very sleepy; on May 31 his speech was garbled again, but the doctor was able to understand the occasional word. The physician also stated that on May 29 he planned to d i g i t a l i z e Mr. C. because he found Mr. C's heart f i b r i l l a t i n g and added that he was becoming chesty and was very drowsy. On June 9 he notes that there had been very l i t t l e change, that he was very drowsy; that his speech was mostly garbled; and that he was taking f l u i d s with persuasion. Physiotherapist noted that his l e f t upper limb appeared flaccid with a minimal amount of flexor capacity. She also noted that she meets some resistance when giving passive exercises to his l e f t lower limb. 182 During the period when Mr. C. was observed the following medical orders were in e f f e c t : Date Ordered Order 27- 5-70 Valium 50-100 mgm. h.s. p.r.n. and may repeat. 28- 5-70 D.A.T. Foot board please. Encourage o r a l f l u i d s . Physio do l e f t arm and leg passive and active movements. 29- 5-70 Enema or Dxilcolaxsupp. p.r.n. Digoxin 0.25 mgm. tab. 1 d a i l y . 9- 6-70 Change catheter weekly. Discontinue I.V. today and encourage o r a l f l u i d s . Try to get 1500 cc p.o./24 hours. Serum e l e c t r o l y t e tomorrow and B.U.N. 10- 6-70 May t r y to get himuup in a chair i f tolerated. Mr. C. i s i n a room with 2 beds (one other patient in i t . ) Nurs ing History Code Name: Mr. C. Age: 90 Primary Medical Diagnosis: C.V.A. l e f t Hemiparesis. 183 Date: May 27, 1970. Secondary Medical Diagnosis: Anemia (unknown origin) Date: approximately one year. Most of the following was obtained from observations and the chart. Mr. C. found speech d i f f i c u l t and did not answer the questions. NR was unable to discuss these with his daughter as she worked in another city and did not come to the hospital when NR was there. Therefore, Parts A and B of the nursing history were not answered. The patient in the next bed, however, volunteered that Mr. C's two daughters and one son visited him on the previous Sunday. Part C Specific Basic Needs. Nursing approach suggested by NR based on data obtained from nursing history. 1. Respirations-observed: a) Color Face-pink lips-red n a i l beds-pale b) Breathing-rapid, 22 Maintain clear airway. En-in no apparent courage deep breathing and distress. coughing each time he is turned. 2. Food and Fluids a) Teeth - has about 1/2 oRequires mechanically soft of his own foods when diet is advanced bottomssand a from f u l l fluids, few here and there on top. b) Appetite-history not taken at meal 184 time. Unable to answer the re-maining questions. J) From the chart: 1. Special d i e t -D.A.T. En-courage f l u i d s -i s now on f u l l f l u i d s . 2. Appetite-not r e -corded on chart except f o r f l u i d intake. 3. Likes - not on chart. 4. Dislikes-not on chart. No other Comments re food on chart. Encourage f l u i d s up to 1500 cc in 24 hours. Find out what his l i k e s and d i s l i k e s are from his family. Ask v i s i t o r s i f they know what his s p e c i a l l i k e s are. Record the foods that he seems to enjoy and the ones that he refuses to eat. Encourage f l u i d s up to 1500 cc/24 hours. Give ducolax suppositories or enema p.r.n. as ordered. Check fo r impaction 2 times a week. 3. Elimination a) Bowels 1. Bowel function before i l l n e s s not given. 2. Constipation i n h o s p i t a l . 3. No record of d i a r r -hea . 4. Takes laxatives i n h o s p i t a l . b) Bladder 1. U r o l o g i c a l function Change catheter weekly, p r i o r to i l l n e s s not given. 2. Retention on Check to see that drainage admission. tubing i s not kinked and i s always below pubic l e v e l . 3. Foley catheter i n s i t u . 185 Question continued need for catheter. Ask doctor i f bladder t r a i n i n g i s fe a s i b l e . 4. Exercise, Transfer and Positioning. a) From chart: degree of hemiplegia-able to move l e f t arm and leg weakly. Degree of s p a c t i c i t y not re-corded . Degree of F l a c c i d i t y -l e f t upper limbs moderately f l a c c i d (Minimal flexor cap-a c i t y . ) Left lower limb minima] degree of f l a c c i d i t y . (Physio meets some resistance when giving passive exercises). Position as though he had a complete hemiplegia. Keep body in good alignment. Support l e f t leg to prevent outward rotation of the hip. Foot board. Keep l e f t hand higher than wrist, wrist higher than the elbow and the elbow higher than the shoulder. Support on pillow. P u t l r o l l of c l o t h i n l e f t hand. Turn at least q. 2.h.; a s s i s t physio with passive movements of l e f t limbs and know the exercises Mr. C. receives. Degree of r i g i d i t y not recorded. Remaining questions are not answered by patient nor on chart. 5, Sleep and Rest. Recorded on chart that Mr.Position in good body a l i g n -C. sleeps w e l l at night ment; place pillows to achieve and o f f and on during t h i s and comfort, the day. Check v e n t i l a t i o n and that bed Other questions not asked.is w e l l made. Be sure c a l l l i g h t i s within reach. 6. Maintainance of Body Temperature. Observe f o r signs of need f o r warmth or overheating. Is These questions were not the patient in the next bed asked. 186 7. Bathing and Grooming. These questions were not asked. warm enough or cool enough? Ask Mr. C. He might answer you. Mr. C. is a retired minister. Assume that he likes to be shaved for Sunday mornings, at least, and oftener. Ask hishdaughter. Find out how he fe l t about bathing at home, 8. Skin Care Questions not asked. No Keep pressure off l e f t lateral bruises or sores on malleolus. Support l e f t leg back or arm, but there is on pillow in such a way that a sore on the le f t lateralpressure is not exerted on malleolus: reddened area sore area, with a scab on i t in the middle of i t . There is no record of the degree of feeling in Mrs left side. Skin appears dry. C's 9. Safety Questions not answered, and answers not observed or on chart. Seems to have d i f f i c u l t y in hearing. Does not respond to verbal com-mands i f spoken to in normal volume. When command is repeated loudly w i l l obey some-times. Hearing problem not recorded on chart. Turn at least q. 2 hr. assume that Mr. C. has hemianesthesia as well as hemiplegia. Bathe q. 2 or 3 days. Use a small amount of lotion or cream when gently rubbing around pressure areas and when giving back rubs. Keep side r a i l s up on bed. Speak to Mr. C. loudly. Ask daughter or other visitors about his hearing. Call light should be within reach at a l l times. 187 10. Communication Sometimes seems to under- Speak slowly and loudly, but stand what i s said to not in a high voice, to him and sometimes he does Mr. C. not (hearing?) Explain what you are going Mr. C. does not read to do. NR's explanation sheetnnor does he seem interested Talk to Mr. C. whenever he in i t . No comment on has nursing care. chart. The remaining questions were not answered, not observed and no inform-ation recorded on chart. 188 Day IX i n the Hospital L i f e of Mr. C_ Day I In the Observation of Mr. C. Time Person A c t i v i t i e s Other Obser-vations 8:15 A.M. Mr. C. Sleeping. June 9, 1970 NR a r r i v e s . Is propped up with pillows on his l e f t side. An I.V. i s run-ning into his r i g h t arm ( i t appears to be swollen). Cath-eter draining into urine bag. Has a footboard holding the covers o f f his feet. 8:25 NjC N,C O Come into room and turn Mr. C.onto his back. They t e l l him that they are turning him f o r breakfast. Looks at Mr. C's r i g h t arm. T e l l s him she i s looking to see i f the needle i s s t i l l in his arm. 8:30 Breakfast tray a r r i v e s . NjC Asks Mr. C. to open his mouth, that she has some orange jui c e fo r him. A f t e r a few minutes of encouraging and pouring i t into his mouth she says, "Mr. C , don't you l i k e orange j u i c e ? " Mr. C. Opens his eyes and shakes his Time Person A c t i v i t i e s Other Obser-vat ions  head negatively. N.C " W i l l you l e t me shave you today?" Mr. C. "It's not Sunday i s i t ? " Nj^ C "Today i s Tuesday. I would l i k e to shave you today." Mr. C. Did not -says anything more. N^c "You w i l l have to open your mouth t h i s time, i t ' s your porridge.V 8:40 NjC "Wake up, open your mouth." 8:43 NjC "Open your mouth that's better." NjC "It's raining out today." 8:47 NjC "Would you l i k e your tea?" Mr. G. "Tea?" N^C "Would you l i k e cream and sugar?" Mr. C. "Yes." Drinks tea with persuasion. NjC Writes 100 cc on intake s l i p . N 2C Comes i n with a medicine tray in her hand and hands a very small paper cup to NjC. (1 minute). NjC Pours powder from the cup onto a spoon and t e l l s Mr.*.C. to open his mouth. 190 Time Person Activities Other Obser-vations  NjC "1 have something for you-i'1' and gives him the powder. Gives • /. him a l i t t l e drink of tea. Asks him i f he would like to f i n i s h his tea later. Mr. C. Says something that NR does not hear. NjC Asks Mr. C. to stick out his tongue. Mr. C. Sticks out his tongue. 9:02 NjC Leaves room and returns with some mouth care sticks. 9:03 N l C Begins to poke mouth care Does not t e l l stick:;into his mouth. "I him why. want to see i f your tongue is c lean." 9:04 N i C Leaves. (39 minutes). 9:05 NjC Returns with N3C. Both turn Mr. C. onto his right side. N3C Put a pillow behind his back. Positions l e f t leg on a pillow and his l e f t arm on his hip. Did not look at his back. 9:12 HN + PN Came in with Physio and l e f t . Right arm, with the I.V. does not appear swollen now. PT Exercises Mr. C's le f t arm. 9:34 PT Leaves. 9:40 NjC Returns with bath water. She strips Mr. C's bed and puts a bath blanket on. Mr. C. Eyes shut. 191 Time Person Activities Other Obser-vations  NjC Washes his face. Did not t e l l him that she Washes arms and under arms, was going to. dries and puts powder on his arms. Washes chest and stom-ach. Dries. Washes legs and feet, dries. Takes a band-age off his right ankle. PutsThere is a red-silicone cream on ankle. dened area on the lateral mal-Replaces the bandage. leolus with a scab in the middle. Bandage con-sists of a do-nut which is placed around the reddened area and bandaged on with a kling bandage. PN Comes in and helps N i C turn Mr. C. N^ C Washes Mr. C's back and applies silicone cream. Rubs i t into No bruises or the skin on his hips, sacrum reddened areas and back. on his back. 10:02 Dr. Examines Mr. C's eyes and mouth, says that this I.V. is to be the last. NjC Finishes bath. Puts folded cloth in patient's l e f t hand. Asks PN i f orderly is on the floor to do peri-care. PN Says that she saw him go off the floor. 10:08 Mr. C. On his back sleeping. 192 Time Person A c t i v i t i e s Other Obser-vations  NjC Leaves. (28 min.) 10:11 NjC Has a basin of water, shaving cream and a shaving brush. NjC "Mr. C , I am going to shave you." 10:25 NiC Proceeds to shave Mr. C. Finishes. Takes water and shaving materials out of the room. (14 minutes). 10:35 NjC Brings some milk. C a l l s to Mr. C. and asks him to wake up and drink the milk by sucking i t out of the straw. Mr. C. Seems to go back to sleep. Does not suck on the straw. NjC C a l l s to Mr. C. to wake up and suck on the straw, ( c a l l s 3 more times). NjC Leaves room and returns with a cup with a spout. C a l l s him again to wake up and drink the milk. (4 minutes). Mr. C. Refuses to drink. 10:40 O Comes in and says that he i s going to change Mr. C's cath-eter. NR to coffee. 11:30 NR returns. Mr. C. Lying on l e f t side sleeping. Left hand approximately 8" above elbow with folded c l o t h in his hand. Looks comfortable. 193 Time Person Activities Other Obser-vations  11:55 N3C Discontinues I.V. (1 minute), 12:00 -12:30 SEN Feeding Mr. C. lunch. 12:30 1:15 1:17 1:25 2:00 3:14 Mr. C. Resting on right side. Comes in and t e l l s NR that Mr. C. has just had an enema, Turns out the light. Mr. C. Sleeping. PT Exercises l e f t arm and leg. N4C + 0 Arrive and l i f t Mr. C. up in bed then turn him onto his lef t side. I.V. almost finished. NR to lunch. NR returns. Left hand approx. 8" below elbow. Light shining in his face. Blinds pulled 7/8 of the way down. Fluid intake s l i p indicates that Mr. C. had 120 cc for lunch 3:45 Reddened area on right but* tock. Patient covered. N4C & 0 leave room. Left hand approx. 6" higher than elbow, is propped on his knees. NR to tea. 194 Time Person Activities Other Obser-vations  4:30 Mr. C. On his l e f t side. 4:55 PN + O Come in and turn Mr. his right side. C. onto NR returns. His position does not appear to have changed from above. Right hip no longer reddened, Left hip and lateral aspect of l e f t ankle reddened. 4:58 PN Proceeds to feed Mr. C. Asks him to sip on the straw. Places small amounts in his mouth using the straw (puts finger on top of i t . ) Then puts soup into a feeder cup and pours i t into Mr. C's mouth. 5:15 Card on tray says tea please and I.D. and extra milk for breakfast. Dfeinks soup and tea quite well. Fluid s l i p states 225 cc. NR l e f t . 7:50 A.M. Day X in the Hospital Life of Mr. C_ Day II of the Observation of Mr. C_ Mr. C. Lying on his back. N5C June 10, 1970 NR arrives Washing Mr. C's face. Washes care-Soaps her own hands well then f u l l y 2 times, rubs the soap on his hands Dries carefully and puts them in the basin. 2 times. 195 Time Person Acti v i t ies Other Obser-vations 8:13 8:13 8:19 Mr. C. N5C N 5 C 8:10 N 5c N5C N6C N5C N6C 8:22 N5C Has his eyes shut. He appears to cooperate. Speaks quietly to Mr. C. Tells him that she w i l l give him a bath before breakfast. Then proceeds to strip bed, except for the top sheet. Washes then dries, chest, arms and underarms, powders underarms; washes legs and feet. Takes bandage and do-nut off cright ankle. Tells Mr. C. that she is going to get some warm water. Arrives with water and linen. Accompanies N5C. Helps N5C turn Mr. C. onto his l e f t side and holds him while Nr;C washes his back. talks Applies hand lotion to Mr. C's back, shoulder, elbow and heel. Rubs back. Window at foot of bed is open. Mr. C. is bare down to his waist, but he is not directly opposite the window. NR i s . Does not talk to Mr. C. as she helps, but to N 5 C Leaves. (6 min.) N5C informs NR that Mr. C. had mouth care and peri-care about 7:45 a.m. Tells Mr. C. that she is going to;-get his breakfast. (9 minutes). Mr. C. Lying on his back. 8:24% Lab. Comes to take blood. 196 Time Person A c t i v i t i e s Other Obser-vations 8:25 N 5C Arrives with breakfast. T e l l s Mr. C. what lab. g i r l i s going to do. 8:27 N 5c Asks Mr. C. i f he w i l l drink his j u i c e . Mr. C. Says something. NcjC Says, "It's apple j u i c e , tea, and porridge. T e l l me when you have had enough. Say "yes" when you have had enough." N5C Would you l i k e sugar with your cream of wheat? Mr. C. "Yes." Eyes open most of the time. NcC To other patient i n the room, "It's not too cold for you i s i t Mr ?" Other Pt. "No." N^C Asks Mr. C. to open his mouth a l i t t l e b i t wider Eating well, occasionally. NeC Asks him i f he i s f u l l . Approximately 7/8 of the porridge i s gone. Mr. C. Mutters something. N5C Says that she cannot under-stand him. Asks him i f he would like.some tea. Mr. C. Mutters something. N5C Begins feeding him tea. Did not ask him 197 Time Person A c t i v i t i e s Other Obser-vat ions  8:43 8:55 9:00 9:01 i f he" wanted cream and sugar. Mr. C. Closes his eyes and stops drinking. N 5C Do you want some milk? Mr. C. "No." "Do you want some tea?" "No." Leaves the room. (18 min.) N 5C Mr. C. N 5C 8:45 N5C N 5C PN PT NiC 9:02 PT N 5C 250 cc i s re-corded on f l u i d intake s l i p f or breakfast. PT Returns with PN to help her. They turn Mr. C . on to his r i g h t side and change the bed. Rubs Mr. C's l e f t hip, shoulder and elbow with hand l o t i o n . Positions him on his r i g h t side with pillows behind his back and another between his knees. Puts r i g h t ankle on donut but does not bind i t on. Leaves with s o i l e d l i n e n . A r r i v e s . Arrives with medication tray. Gives medication cup to N5C who gives the contents to Mr. C . Suggests to Ne-C that sandbags should be at Mr. C's feet. "There aren't any on the ward." Points out area on r i g h t There i s a 198 Time Person A c t i v i t ies Other Obser-vations 9:14 9:35 10:14 N 5C N 5C PT N 5C Mr. C. 9:29 HN PT HN 9:33 PT ankle where the donut was. Says that she i s going to see i f she can find some sponge. Returns with one piece approximately 3" x 1/4". Says that she could f i n d some sponge in the Department of Phys ica1 Med i c ine.) Leaves. (29 minutes). Moans when physio moves his l e f t knee, hip and shoulder, but he does not when his arm and hand are moved. Comes i n . Says that she would l i k e to get Mr. C. up in a chair. Says that she thinks t h i s i s a good idea and leaves. Leaves, saying that she w i l l be back to get Mr. C. up in the chAir this afternoon. Mr. C. Eyes are open. reddened area on ankle and an indentation around the area where the donut was. The area sur-rounding the indentation appears to be swollen, leaving a ridge. Left hand on a pillow, elbow and hand are on a l e v e l . NR to coffee. NR returns. Mr. C. Eyes open, moving r i g h t hand up to face from where i t lay on the bed. 10:20 Dr. V i s i t s . 199 Time Person A c t i v i t i e s Other Obser-vations  10:30 HN 10:32 N 5C + N 6C Comes i n and t e l l s Mr. C. that they w i l l be getting him up in a chair l a t e r and that the Dr. said that i t was a l r i g h t . Come and turn Mr. C. to his l e f t side. Rub his r i g h t elbow, hip and shoulder with alcohol. Do not t a l k to Mr. C. but ta l k to each other. 10:35 N 6C N 5C 10:38 N 5c 10:55 PN 11:11 PN 11:45 PT 12:04 N7C Leaves, (3 minutes). Wipes Mr. C's eyes. Gives him mouth care. Leaves, (6 minutes). Arrives with orange j u i c e with a straw in a paper cup. Leaves. Comes and puts 2 (approx. 6" x 4") sandbags at Mr. C ' I feet. There i s a reddened area on his ri g h t hip. Left hand on abdomen approximately 1" higher than elbow. 30 cc recorded on his intake s l i p . Lunch tray a r r i v e s . With PN and O arriv e s and t e l l s him that they are going to get him up i n a chair f o r lunch. Chair brought to the l e f t side of the bed. 200 Time Person Activities Other Obser-vations N7C At his head. O At his hips. PN On the side. Swing Mr. C. into the chair. 12:08 N7C Puts blanket around Mr. C's * _ . . w._ • 1 „ 12:09 PN 12:14 N5C knees and puts Mr. C's right arm on a pillow and leaves. (4 minutes). Begins to feed Mr. C. lunch. Arrives. Says that she was surprised that Mr. C. is up in a chair. Chair is then dragged toward the end of the bed. Mr. C's left foot drags on the floor. Mr. C. moans. Orderly straightens the foot, then proceeds to drag chair again. Mr. C's left foot bends and the top of the foot drags on the floor again. Orderly straig-htens foot out. Chair must be where he wants i t because he stops dragging i t . PN "We got him up about 10 min. ago." 201 Time . Person A c t i v i t i e s Other Obser-vations  N 5C 12:20 HN 12:23 0 N 5C Mr. C. N 5C Mr. C. N 5C Mr. C N 5C Mr. C. N 5C "I w i l l feed him now i f you l i k e . " S i t s down on another chair and begins to feed Mr. C. V i s i t s . T e l l s Mr. C. that the orderly i s coming to take the wheels o f f his bed. Orderly taking wheels o f f Mr. C's bed. Asks Mr. C. i f he wants some Feeding from ice cream. "Yes." "You w i l l have to open your mouth then." Opens his mouth, eats a l l his ice cream. "Would you have some more tea?" "No." "Would you have some more milk?, "No." "Would you have some more j u i c e ? " the l e f t side. When she said "Open your mouth" into his l e f t ear he did not. When she said, "open your mouth" i n his ri g h t ear he did. NcC moves to ri g h t side to feed him. Drinking with a straw. Mr. C. "No." 202 Time Person Activities Other Obser-vations  N5C Mr. C. N5C Mr. C, N5C Mr. C. N5C 12:40 N5C 12:41 1:10 1:10 Mr. C. "Have you had enough?" "Yes." "We are going to let you s i t up a l i t t l e bit then put you to bed in a while. O.K.?" "Yes." "Are you warm enough?" "Yes." Wipes his eyes and gives him mouth care, t e l l i n g what she is going to do at each step. Leaves room, (26 min.) Up in chair sleeping. 1:35 Mr. C. Mouth open, sleeping. 2:05 N7C ± PNPull chair beside bed, then one says to the other that she is going to get the Writes 100 cc on his f l u i d sheet. NR to lunch NR returns. Breathing deeply, and regularly. R-22. Is tied in his chair. Feet on the floor, wrapped in a bath blanket, which is also around his knees. Left hand is approx. 4" below his elbow. Rolled up cloth is in his l e f t hand. Did not speak 203 Time Person Activities Other Obser-vations  orderly (1 min.) 2:07 N7C Returns with orderly. 2:10 directly to Mr. C. N7C, PN, + O L i f t Mr. C. into bed. Position Appear to do Mr. C. on his l e f t side. so with l i t t l e Position his l e f t hand approx.effort. Sacrum 4" above his elbow on his slightly reddened, abdomen. N7C + PN + O 2:12 N 5c 2:12% N 6c Leave, (3 minutes). Arrives, looks at Mr. G. in bed and looks at NR. "Who put him to bed? I have been trying to round up people to help me to put him to bed." NR shruggs her shoulders. Arrives and laughs, leave. Both 2:20 2:44 2:45 3:15 Mr. C, PT 2 V Sleeping. Arrives. Patient in the next bed t e l l s her that Mr. C. has been up in the chair. She exclaims with surprise. Says Jihat she has come to get Mr. C. up. Says that he is sleeping and leaves. A man and a woman arrive. Woman t e l l s NR Woman speaks to Mr. C. in his that she is right ear. Mr. C's niece. Mr. C. Does not awaken. Because NR has not been able to contact Mr. C's daughter she asks his niece i f she knows him very 204 Time Person Act i v i t ies Other Obser-vations  3:30 3:34 4:30 4:31 4:45 5:00 5:05 5:25 5:30 well. She replies that she lived with him once and is like a daughter to him. States that her uncle never drinks juices or cream soups. Just tea and milk. PN O Mr. C. M Mr. C. O + PN M Mr. C. M. M PN Mr. C. PN PN Comes in and takes pulse. Comes in and takes temp. Continues sleeping. Comes and speaks to Mr. C. Does not awaken. Come and turn Mr. C. onto his back and raise his bed, saying that supper w i l l be coming soon. Talks to Mr. C. Opens his eyes, but does not speak, he closes them again. Prays for him. Leaves. Supper tray arrives. Feeds Mr. C. soup. Opens his mouth. Feeding him custard. Feeding him tea. 205 Time Person A c t i v i t i e s 5:34 Other Obser-vations 5:32 Mr. C. Stops opening mouth. PN Asks him i f he wants more tea. Mr. C. No. PN Roll s bed down, moves overbed table away, leaves. Mr. C. Closes eyes. Resting. Time spent i n minutes with Mr. C. by general s t a f f h o s p i t a l nurses. June 9, 1970 NjC-86 min. N2C-I min. N3C-2 min. N4C-2 min. Appears Comfor« table. NS home. June 10, 1970 NjC-1 min. N5C-88 min. N6C-9 min. N7C-8 min. ; 206 Nursing Care Study IV - Mrs. D. Mrs. D. i s a 79 year-old lady who has been l i v i n g at home. She has been e s s e n t i a l l y bed ridden because of advanced generalized atherosclerosis of long duration with severe peripheral vascular i n s u f f i c i e n c y in her feet. She has been nursed by her daughter. The doctor stated that she had recently become an unmanageable nursing problem at home because of confusion, panic states, and incontinance of feces and urine. In 1966 she had a mild C.V.A. with l e f t hemiparesos from which she had a good recovery. From time to time she had experienced cerebral ischemic episodes. On the day of admission, May 20th, 1970, Mrs. D's doctor wrote that she had developed pneumonia twice i n the past and had recently acquired an upper respiratory i n -fection and l e f t v e n t r i c u l a r f a i l u r e . She did not t o l -erate digoxin w e l l (nausea and vomitting) and i t was nec-essary to control the f a i l u r e with d i u r e t i c s . SHe also stated that Mrs. D. has had recurrent bouts of diarrhea and con-s t i p a t i o n and her appetite i s poor with gradual weight loss. However, there was no s p e c i f i c g a s t r o i n t e s t i n a l upset causing her upset and her f l u i d intake i s poor. In addition she recently became c l e a r l y depressed and was an unmanageable problem for her daughter. She was admitted to h o s p i t a l 207 with C.H.F. with a view to discharge as soon as possible to a nursing home. On May 21, an entry on the doctor's hi s t o r y stated that Mrs. D. had a sudden choking s p e l l 15 minutes before he ar r i v e d , and that she had become comatose, unresponsive and appeared to have had an acute C.V.A. She had cheyne-stokes re s p i r a t i o n s . There was generalized f l a c c i d i t y on the r i g h t side and a less marked f l a c c i d i t y on the l e f t and there i s a f a c i a l weakness on the r i g h t . The next day Mrs. D. was s l i g h t l y more responsive. She opened her eyes and responded vaguely to commands. The doctor stated that i t was evident that Mrs. D. had a r i g h t hemiparesis. On May 25, the doctor stated that Mrs. D. was awake, but appeared to have motor aphasia. A marked weakness remained on the r i g h t side, however she moved her l e f t side a b i t . She was taking a few sips of f l u i d s . Mrs. D's r i g h t side remained completely f l a c c i d on May 27th and she was taking only minimal o r a l f l u i d s . On May 28th, Mrs. D's doctor observed that she had had 1300+ cc o r a l l y during the past 24 hours and suggested that Mrs. D. should t r y to manage without I.V.'s. Mrs.D. was a l e r t and bright on June 2nd, but, motor aphasia and r i g h t f l a c c i d paralysis persisted with no c l i n i c a l improvement. The s i t u a t i o n was s t a t i c , the doctor stated on June 4, there i s "no change i n Mrs. D's 208 neurological state. : She i s taking f l u i d s and d i e t w e l l . It i s doubtless that she w i l l require nursing home care, an application has been made for s o c i a l service to see her." 1 During the period when Mrs. D. was being observed the following medical orders were i n e f f e c t : 20- 5-70 Doriden 500 mgm H.S. p^r.n. Colace caps T - H.S. p.r.n. for con-s t i p a t i o n Fleet enema p.r.n. Intake and output 21- 5-70 Foley catheter to continuous drainage. 27- 5-70 Encourage f l u i d s please. 28- 5-70 Try on o r a l f l u i d s only. 29- 5-70 Dangle p.r.n. Physio f o r passive exercises. 31-5-70 F u l l f l u i d d i e t . Encourage to 1000 cc a s h i f t , 1- 6-70 Continue f l u i d d i e t . 2- 6-70 Up in chair. Physio therapy please. 4-6-70 S o c i a l service to see., 11-6-70 Low s a l t d i e t . Phys iotherapy Requis i t ion Order: Physio f o r passive exercises, progress as tolerated. Doctors History in Patient's chart 209 Physiotherapist's notes: June 1 Right CVA with congestive heart f a i l u r e , speech slurred, motor aphasia. Left side moves quite w e l l . Right side f l a c c i d . June 4 No improvement - f l a c c i d r i g h t side. Very loathe to cooperate. June 9 More cooperative and assisted with arm and leg exercises. S t i l l f l a c c i d and speech slur r e d . Mrs. D. i s on an open 24 bed medical ward with other e l d e r l y ladies with chronic i l l n e s s e s . Nursing History Code Name: Mrs. D. Age: 79 Primary Medical Diagnosis: Generalized j..AtherQ»' s c l e r o s i s with severe •^eripheraU vascular insuf-f i c i e n c y . Date: a very long time ago. Secondary Medical Diagnosis: Right Cerebrovascular Accident. Date: May 21, 1970. Add i t i o n a l Medical Diagnosis: Left Ventricular F a i l u r e . Date: Exact date not given. In May, p r i o r to May 20. Most of the following was obtained from observation and the chart. Mrs. D. had motor aphasia and can only nod 210 to yes and no questions. Therefore, parts A and B of the nursing hi s t o r y were not answered. Part C: S p e c i f i c Basic Needs Nursing Approach Suggested by NR, based on data obtained from nursing history 1. Respiration a) Color face - pale l i p s - pale n a i l beds - pale b) Breathing - i r r e g u l a r , Maintain cl e a r airway. En-16-20 per. min. courage her to cough and sometimes deep, some- breathe deeply each time she times shallow. In no i s turned, apparent d i s t r e s s . Food and Fluids a) Teeth - has dentures b) Appetite - observed to be good. (Even though Doctor's hi s t o r y says that i t was poor.) Meat, etc. w i l l need to be cut up but not minced. Mouth care t . i . d . Right hemiplegic, needs help with meals. Food should be on l e f t side of the tray so she can feed h e r s e l f . Cut food up, pour tea and coffee. Encourage her to help h e r s e l f . Position her so that she can eat comfortably. Unable to answer remainingEncourage f l u i d s up to 1000 questions re-foods and cc a s h i f t . f l u i d s . j ) From the Chart: 1) Special d i e t - f u l l f l u i d s 2) Appetite 3) Likes 4) D i s l i k e s 5) Other Question c a r e f u l l y r e - l i k e s and d i s l i k e s and observe foods that she eats. Ask daughter when she comes to v i s i t . Record appetite, on chart l i k e s , d i s l i k e s and other except comments re foods and f l u i d s f l u i d on the chart, intake. Not r e -corded • 211 Elimination a) Bowels - Doctor's history states that Mrs. D. had involun-tary BM's at home Record time of involuntary BM's and offer bed pan before that time the next day and explain why to Mrs. D. before the CVA. Check for impaction when diarrhea occurs. Doctor's history also indicates that Mrs. D. had recurrent bouts of diarrhea and constip-ation at home. Mrs. D. has colace capsGive colace cap at h.s. when p.r.n. and fleet Mrs. D. does not have a BM enema p.r.n. ordered, for 2 days; colace caps at h.s. when Mrs. D. does not have a BM for 3 days; and a fleet enema the next evening i f Mrs. D. does not have a BM on the fourth day. Offer bed pan t . i . d . during the day. b) Bladder Mrs. D. was incontinent Ask Doctor i f the catheter of urine at home, and can be removed and bladder had a Foley catheter training attempted, in hospital. Exercise, Transfer and Positioning. a) From Chart: i ) degree of hemiplegiaA complete hemiplegic re-- complete quires careful positioning to i i ) degree of spacticityprevent contractural de-- not noted. formities, and edema and to i i i ) degree of flacciditymaintain and restore func--complete. tional a b i l i t i e s . Right leg iv) degree of r i g i d i t y must be positioned to prevent -not noted. outward rotation of the hip. Unable to answer the Foot board. following questions. Place right hand on a pillow with hand higher than wrist, and wrist higher than elbow. 212 5. Sleep and Rest The questions in this section were unanswered. Mrs. D. is to get up in a chair, take wheels off bed. Help her to s i t on edge of bed and to stand on her feet (support her well). Pivot her into a firm chair with a level seat (wheelchair best), which is waiting, immob-il i z e d , at the foot of the bed, facing the head of the bed. Help her to help her-self. Move chair to a place where Mrs. D. can see act-iv i t i e s of other people on ward. Observe how the physio-therapist transfers Mrs. D. from bed to chair and from chair to bed. Keep feet elevated on footstool when in chair. See Appendix B, 105^.107. Position Mrs. D's body in good alignment, place pillows to achieve this and comfort. Check ventilation and that bed is well made. Be sure that the c a l l light is within reach. Help her to have an hour or so of un-broken rest during the day. Do not keep her up in chair for long periods. Let her rest on her bed during the morning, afternoon and evening after periods o f being up in chair. 6. Maintenance of Body Temperature. Unable to answer these questions. 7. Bathing and Grooming Observe for signs of need for warmth or of overheating. Ask her, she can indicate yes and no. Ask Mrs. D's daughter how often Mrs. D. likes to take 213 These questions were not answered. a bath. Mrs. D. i s involuntary some-times and requires enemes other times. Possibly she would l i k e a bath a f t e r these. Comb Mrs. D's h a i r whenever she gets up into a chair. 8. Skin Care Mrs. D's skin appears dry.Bathe q 2 or 3 days. Use a There i s a bruise on the inner aspect of Mrs. D's r i g h t foot. Otherwise no bruises or reddened areas. (Mrs. D. i n bed in the morning.) Other questions not answered. small amount of l o t i o n or cream when gently rubbing back and bony protuberances, Turn at least q>.2.h. 9. Safety Mrs. D. was unable to answer these questions. NR could not f i n d any shoes. Has glasses and a hearing aid i n the drawer. No notes pertaining to hearing and eyesight on the chart. Keep side r a i l s up when Mrs. D, Is in bed. Tie her into chair when she is up to pre-vent her from f a l l i n g out of the chair. C a l l l i g h t should be within reach at a l l times. Contact daughter to bring in firm shoes for Mrs. D. See that Mrs. D. has her hearing a i d i n place before ta l k i n g to her. Check to see i f she would l i k e to wear glasses when up in a chair. 10, Communication Make sure that Mrs. D. has hearing a i d i n before you a) Observation: Seems to speak to her. understand i f her hearing a i d i s i n and 214 sometimes i f i t is not.Explain to her what you are Medical findings: not going to do. Make oppor-noted. tunities to talk to her, especially when giving nursing care. b) Did not seem interested in trying to read even when her glasses were on. c) Attempted to write Do not expect Mrs.D. to write for NR but writing was notes to communicate. very large and very shakey. " M I S S " . No medical note. d) Mrs. D. can indicate yes and no. Medical Findings: Motor Aphasia. e) Sometimes makes sounds that cannot be under-stood. Only ask questions requiring a yes or no answer, after you have tried to encourage her to answer. Do not ask too many questions at one time. 215 Time Day XI In The Hospital Life of Mrs. Day I of Observation Person Activities D. Other Obser-vations  7:30 A.M. =7:45 Mrs. D. Is lying on her back, eyes open. Answers "Oh yes" to NR's greeting. 7:35 NjD NjD Rolls bed up. Pulls up overbed table in front of Mrs. D. (1 min.) June 11, 1970 NR arrives. Right side of mouth droops and does not open when she speaks. Mouth dry and lips stick together. Does not speak to Mrs. D. Breakfast arrives, Puts juice where Mrs. D. can reach i t with her le f t hand. (1 min.) 7:47 N D Goes to right side of bed, NR on l e f t side, puts porridge into plastic glass, and puts milk and sugar in i t . Puts tea into Does not speak another and adds cream and to Mrs. D. sugar to It also. (2 min.) Milk is in a 3rd plastic glass. Mrs. D. Drinks her breakfast by her- Manages with self. apparent ease. 7:53 NjD Returns and t e l l s Mrs. D. to finish her porridge. (1 min.) Mrs. D. Finishes her porridge and milk and is drinking her tea. Time Person Activities 216 Other Observations 8:03 NiD 8:20 8:38 N2D NjD Talking to Mrs.D. about the porridge on her l i p , "a mustache", and t e l l s her to finish her €ea. (1 min.) Comes along and adds up Mrs. D's intake. S t i l l has 1/2 glass of tea. Writes down 160 cc, does not know how much patient actually drank. Odes not know about milk or tea Mrs. D. actually had taken. NjD points out error to A. Neither consult Mrs. D. about how much tea she drank. Comes, strips bedspread and blanket from bed onto a chair then leaves. Returns with a basin of water. Gives Mrs. D. a wet washcloth and asks her to wash her face and Mrs. D. begins to wash her chest. Looks in drawer of bedside table, finds hearing aid. Attempts to put i t in Mrs. D's ear. Says that she knows i t is not in right, but asks i f Mrs. D. can hear. 1 Mrs. D. Said i t is alright. NjD Proceeds to wash chest and right chest and right arm. Begins to wash legs and discovers that Mrs. D..has had a bowel movement. Small scab on lef t nipple of breast. Time Person A c t i v i t i e s 217 Other Observations NjD Leaves. Returns with fresh wet drain-age pads. Asks Mrs. D. to turn onto her side. Mrs. D. Grabs the c r i b side with her l e f t hand and nurse pushes r i g h t (paralyzed arm). Right arm drops over her chest, dangling on the bed with the hand bent over i n an awkward looking pos-i t i o n . Bathes buttocks with the drainage pads and puts pad in paper bag. Washes r i g h t side of her back with bath wash c l o t h . Does not rub back. 8:58 0 0 + N p NjD A r r i v e s , brings a chair to the bedside. N l D Swings Mrs. D. from bed into Hearing aid a chair. drops to f l o o r . They s i t her on her catheter. Picks up hearing a i d . Fixes catheter. Mrs. D's feet drag on the f l o o r . Backwards. Drags chair into the middle of the room. Puts on s l i p p e r s . 9:10 NiD Puts on housecoat. Gets a r e s t r a i n t . Explains to Mrs. D. that she i s tying her into the chair so she w i l l not f a l l out. Puts pillow under r i g h t arm. Leaves. (32 minutes). Hand approximately 8" lower than elbow. 218 Time Person Activities Other Observations Mrs. D. Appears to be comfortable No water, table, a n and aware of her surroundings.or c a l l light cord within reach. 9:45 Feet have become progressively blue in the last 1/2 hour. 9:50 Mrs. D. Dozing in chair. Sleeping in chair. Feet on floor. Slumped toward right side. NR to coffee. 10:50 Mrs. D. S t i l l slumped toward right side. Eyes open. 10:55 Mrs. D. Straightens her head and 0 looks around. Closes eyes again. 11:10 Dr. Arrives. Examines Mrs. D. in the chair. Listens to her heart, takes her pulse, looks at her legs and feels them. NR returns. Appears alert. Paper cup with orange juice is on table near bed, well out of reach. Feet and legs appear unchanged from observation at 9:45. Right hand is s t i l l about 8" below elbow. 11:13 Leaves. 11:17 PSN Gives Mrs. D. orange juice. 11:23 PSN Asks Mrs. D. i f she would like her hair combed. Mrs. D. "Yes." PSN Gets comb from drawer in bedside table. Combs Mrs. D's 219 Time Person Activities Other Observations hair. 11:25 PT Comes in, exercises Mrs. D's arm and hand. Explains to student that i t is necessary to keep her hand up or i t w i l l swell. Says that she would get a sling and also a requisition for Mrs. D's speech. Mrs. D. Seems to understand and to fdllow physio's requests. Li f t s her legs when asked. 11:30 PT Leaves. Mrs. D. Returns to drinking her Drank 180 cc. juice. Right hand on pillow about 3 " below elbow. 11:35 PSN Rolls down overbed table and puts i t beside Mrs. D. 11:36 Lunch arrives. It is put on table beside Mrs. D. Mrs. D. Reaches out for glass of juice. PSN Puts table with tray on i t in front of Mrs. D. Pours soup into empty juice glass. Mrs. D. Drinks soup from glass with her l e f t hand. 11:42 N i D Brings fresh glass. Pours tea into i t and walks away. 11:50 PSN Helps Mrs. D. to eat her custard. Writes on Mrs. D's intake s l i p . 420 cc. Time Person Activities 220 Other Observations 11:56 PSN Finds Mrs. D's glasses, puts them on her. 12:20 12:28 12:35 1:10 1:12 1:45 Mrs. D.* Asleep in her chair. 2 PSN's Drag Mrs. D's chair over be-side her bed, then one leaves. Says she is going to find the orderly. Both PSN's leave the ward. O + NjD Arrive and l i f t Mrs. D. on to the bed. The hearing aid f a l l s out of Mrs. D's ear. Then she is put on top of i t . N]D Puts hearing aid in drawer. Pulls up covers and the crib sides. Then goes to another patient. (1 min.) Mrs. D. On her back. Mrs. D. On back-in same position as above. Sleeping. Just as she was swung into her bed. NR to lunch. NR returns. Call b e l l cord not within reach. 2:45 PSN 2:50 2:52 PN Diet. Awakens Mrs. D. with a rose bud in a paper cup. Shows i t to Mrs. D. and asks her to smell i t . Says, "It's for you." Takes temperature Comes and t e l l s Mrs. D. that her doctor wants her to have a low salt diet. Asks her i f she likes various foods. Mrs. D. Yes 221 Time Person A c t i v i t i e s Other Observations Diet. Soup? Mrs. D. Nods head, yes. Diet. Cheese? Mrs. D. Nods head, yes. Diet. Canned f r u i t ? Mrs. D. Nods, yes. Diet. Cream of wheat? Mrs. D. Nods, yes. Diet. Coffee? Mrs. D. "No." Diet. Eggs? Mrs. D. "No." Diet. Pudding? Mrs. D. Muttered answer. Not understood by NR 2:58 Diet. l e f t . PSN Talks to Mrs. D. about her d i e t . Mrs. D. Answers yes at times, and no at other times. 3:05 Mrs. D. Asleep again. 3:43 PN + A A r r i v e at bedside Busily t a l k i n g to each other. PN Begins to p u l l sleeping Mrs. D. out of bed - to a s i t t i n g p osition on side of bed. Mrs. D. Awakens with a s t a r t . PN T e l l s Mrs. D. that they are Time Person A c t i v i t i e s 222 Other Observations going to get her up into a chair. A Drags chair to bedside. PN + A P u l l Mrs. D. o f f the bed and pivot her into the chair. Sacrum reddened. PN + A Drag chair into the middle of the room. PN Puts slippers on. Puts feet on s t o o l . Puts r i g h t arm on Hand 3" lower a pillow. than elbow. A Goes to bedside table and gets hearing a i d , glasses and comb. Puts on hearing aid and gl a s -ses, combs h a i r . 3:47 PN + A Leave 3:50 NR to tea. 4:15 NR returns. Mrs. D. In same position as above i n chair. 4:30 Mrs. D. Looking around at other pat-ients eating t h e i r supper. Tray has not ar r i v e d . No water nearby. 4:35 N2D To PSN, "Hasn't she got i t yet?" "I know that they changed her d i e t but i s n ' t t h i s a b i t r i d i c u l o u s ? " PSN S i t t i n g beside Mrs. D. "When your tray comes I w i l l help you with your supper." 4:40 PN Comments on the fact that Mrs. D. does not have her supper yet and says that she i s going to the kitchen. 4:45 Supper a r r i v e s 223 Time Person A c t i v i t i e s Other Obser-vations PSN Helps Mrs. D. Supper con-s i s t s of chicken leg, whole Unable to chew, beans, diced soft potatoes, Seems to enjoy 3 cookies, 3 apricot halves, the potatoes tea. very much. PSN Looks i n drawer. T e l l s Mrs. D. she i s looking f o r her teeth. Does not fin d teeth. Mrs. D. Drinks a l l of her tea. Ate potatoes, cookies, some chicken cut up fine by PSN. 5:00 NR home. 7:45 A.M. 7:53 7:58 8:01 Dav XII i n the Hospital L i f e of Mrs. D. Day II of the Observation of Mrs T D. Mrs/ D. Smiles. Mrs. D. Slumped down in bed and leaning over to the l e f t . June 12, 1970 NR a r r i v e s . Mouth does not seem as dry as yesterday. Overbed table pushed over bed. Breakfast a r r i v e s . Put on overbed table. Mrs. D. Reaches for milk. Uses her l e f t hand and begins to drink. Mrs. D. Drinking porridge from her bowl. No one has come to f i x i t for her. N3D Comes to help Mrs. D. She says, "You drank a l l of your milk. There i s n ' t any for 224 Time Person A c t i v i t i e s Other Obser-vations your porridge." Ro l l s up bed. Mrs. D. Drinks her porridge from the bowl. N3D Straightens Mrs. D. up i n bed. Gives Mrs. D. her ju i c e from Does not speak the r i g h t side of her tray, to Mrs. D. Fixes her toast and puts the re s t of the porridge i n a glass so that Mrs. D. can eatDentures at bed-by her s e l f . side in denture cup. 8:15 N3D Puts tea into a glass. Reminds Mrs. D. that she drank a l l her milk e a r l i e r . Tea i s c l e a r . 8:29 PN Asks Mrs. D. i f she is going to drink a l l her tea. Mrs. D.: "Yes." PN Writes on intake s l i p and 315 cc. walks away. NR observes that Mrs. D. has had 450 cc. 8:33 NgD Comes to bedside. Looks at intake sheet. Looks at Mrs. D. then walks away. 8:34 N3D Returns and begins to r o l l Does not say a bed down. word. Does not look at patient drinking tea. N3D Called away. 8:40 Mrs. D. Eating toast. Having d i f -f i c u l t y . Does not have Time Person A c t i v i t i e s Other Obser-vations 225 8:48 8:49 8:53 dentures i n . N3D Mrs. D. N3D Mrs. D. N3D Mrs. D. N3D N3D Mrs. D. N3D Mrs. D. N3D :• N3D N3D "Are you s t i l l n i bbling?" Mutters something. Leans closer. Mutters again. "You want milk?" "Yes." Leaves ward. Returns with glass of milk. Cl min.) Drinks milk Comes to bedside. "Do you think you have had enough now?" Laughs gently. Writes on intake s l i p . 180 cc. N3D Mrs. D. Takes breakfast tray and table away. R o l l s bed down, s t r i p s bed, except f o r top sheet. "Poor thing, how did you ever Mrs. D. i s eat l i k e that?" lying 1/2 on her r i g h t side, r i g h t leg abducted, knee bent with pillow on top of i t . Slowly straightens r i g h t leg. Moans gently. 226 Time Person Activities Other Obser-vations K3D N3D "You have been lying this way too long." Bed is wet. "Why is your catheter bypas- Legs appear to sing? ! Probably because you be the color of have been lying on i t . " the rest of her body today, (pale white normal skin color.) Mrs. D. Moaning. N3D Puts in Mrs. D's hearing aid.Scab like scale "What is bothering you? remains On Mrs. Pauses - your leg?" D's l e f t breast, Mrs. D. "No.", and puts her hand on her abdomen. Looks distended, NoD N3D Pushes on abdomen. Urine is seen to flow faster through catheter. Passively exercising Mrs. D*s affected arm as she washes i t . 9:05 N3D Tells Mrs. D. that she is going to turn her over and wash her back.. Then does so. Mrs. D. Helps to pull herself over by holding on to the l e f t side r a i l with right hand. N3D Tells NR that there is a reddened area on Mrs. D's sacrum. NR on le f t side. Cannot see her back. NR did not re-quest this information, nor did she speak to N3D. N 3D Rubs back with cold cream : 227 Time Person A c t i v i t i e s Other Obser-vations a f t e r washing i t with soap and water. 9:18 O Comes over and says, "Can I help you?" N«D "No. I was going to get Mrs. up but I think I w i l l l e t her res t a while. She was up so long yesterday." HN Comes along. N3D To HN, "She was lying with her leg a l l twisted and i t hurt her to have i t straightened out." Mrs. D. On her back. Looks comfort-able. 9:19 NgD Leaves. (26 min.) 9:20 NR to coffee. 9:39 NR returns. Mrs. D. S t i l l on back. Right foot mod-erately abducted. Left foot s l i g h t l y abducted. No foot board. 10:08 Mrs. D. Has her eyes open, looking around her. 10:09 Mrs. D. Closes her eyes. 10:15 Mrs. D. Eyes open, looking a t patient in next bed and at s t a f f who walk by the end of the bed from time to time. 10:17 N^D Asks another patient to move out of a so f t chair into a ^ 228 Time Person A c t i v i t i e s Other Obser-vations  firm one and brings sof t chair to the end of Mrs. D's bed. N3D Begins to put Mrs. D's house-coat on. Mrs. D. Has her eyes closed. % D Gets one arm into housecoat then says, "I am going to put th i s on you once I get you s i t t i n g up." Mrs. D. Eyes open. , N3D Tries to s i t Mrs. D. up, then says, "I know, r o l l over that way (points to l e f t of bed) so I can put on your house-coat.!? Mrs. D. Rol l s to the l e f t . N3D Ro l l s her to the r i g h t and pu l l s coat through, then r o l l s her onto her back. Buttons up her housecoat. Without speaking to Mrs. D. 10:23 N3D Leaves. (6 min.) 10:25 N3D Returns with O. 0 Says, "We w i l l get you o f f of the bed then stand you up Mrs. D. i s and swing you into the chair.barefoot. Okay?" N3D To O, "She i s deaf. Just a moment, I w i l l put her Hearing a i d hearing a i d i n . " had f a l l e n "Mrs. - — c a n you hear me?" out. Mrs. D. Nods, yes 229 Time Person A c t i v i t i e s Other Obser-vations  N3D O Repeats what O has said. Gets Mrs. D. out of bed as he said he would. Pivots her into the chair. N3D Combs Mrs. D's h a i r , puts on her glasses, and pins her hearing a i d battery onto her housecoat. Puts r i g h t arm on pillow. Hand approximately 6" below elbow. Mrs. D. Eyes and mouth open. 10:30 10:50 11:30 11:45 N3D Leaves. (5 min.) Mrs. D. Slouched i n chair toward r i g h t side, asleep. Soft chair seat i s s l i g h t l y slanted toward the back of the chair. The firm chair has a straight seat. Hearing a i d appears to be in Mrs. D's ear properly. Legs f l a t on the f l o o r , has slippers on. Looks f a i r l y comfortable. Water and c a l l l i g h t not within reach. NR to chart room. NR returns. B l u i s h patches on her feet. Lunch a r r i v e s . PN Arranges lunch for Mrs. D. Puts i n hearing a i d , butters Hearing a i d had bread. f a l l e n out. 230 Time Person Activities Other Obser-vations  11:48 Mrs. D. 11:55 12:01 12:05 12:07 Feeds herself scrambled eggs. Appears to be slipping down in chair. Table on which lunch tray rests is about the same level as her chin. PN Mrs. D. Pours tea into Mrs. D's glass. Tries to eat bread. Dentures on table beside her bed, in denture con-tainer. 12:00 PN Mrs. D. Mrs. D. N3D Helps Mrs. D. with the last of her egg. Moves bread onto egg platter. Drinks milk. Sits ; looking at her tray. 3/4 of her milk gone. Bread s t i l l on egg plate. "You haven't had much to drink," and l i f t s up her glass of tea. Mrs. D. Nods head negatively. N3D "Why not?" Mrs. D. is slumped to the right of her chair. She appears tired. Mrs. D.9Groans. PSN Asks Mrs. D. i f she would like some more. Mrs. D. "No." and groans. Tray removed. 231 Time Person Activities Other Obser-vations  12:26 12:27 12:40 N3D Writes on flu i d s l i p . N3D Drags Mrs. D's chair over to the bedside. Does some-thing to her slippers. N3D Leaves. 100 cc. Slippers are s t i l l on. 0 Gomes to bedside and turns back the bedcovers. PSN Takes off hearing aid. A Takes off housecoat. O Takes Mrs. D's trunk A Takes Mrs. D's legs.They swing Legs only her into bed. slightly bituish today. Sacrum quite reddened. Area larger than yesterday. A Talks to Mrs. D. about the decorations on the collar of her housecoat. Mrs. D. Lies on her back. 12:50 1:05 1:30 Mrs. D. Asleep with glasses on. Mrs. D. S t i l l asleep on back. Mrs. D. Asleep on right side. Appears com-fortable. Glasses s t i l l on. Intake recorded-180 cc. NR to lunch. NR returns. Appears very pale. Glasses off. 232 Time Person Activities Other Obser-vations  2:15 3:00 3:05 3:40 3:45 3:50 4:20 Mrs. D. S t i l l in same position. Awakens Mrs. D. and takes her temperature. Mrs, Mrs, Mrs, Mrs, 4:15 N2D OS N2D N2D O N2D PT NR to chart room. NR returned. Glass of juice at end of bed. D. Asleep. D. Eyes open. D. Eyes shut. D. Eyes open, watching the activity on the ward. "Hi, Sweetie, Hi. You haven't got your hearing aid i n . " Gets hearing aid out of drawer and puts i t on Mrs. D. Comes over. + 0 Decide to let Mrs. D. stand and pivot into the chair. Which they do. Puts Mrs. D's housecoat on while she is sitting on edge of the bed. Drags chair into the middle of the room and leaves. Puts feet on a stool and leaves. (2 min.) V i s i t s , examines right arm through f u l l range of motion, Right hand not supported. Arm flops onto the chair Time Person A c t i v i t i e s Other Obser-vations Helps her to s i t up straight in the chair. Does balancing exercises. Shows her how to exercise her arm and her leg by herself. PT Gets Mrs. D's comb and gives i t to her. Moves the overbed table beside Mrs. D's chair. Puts the mirror up. 4:28 4:30 4:35 Mrs. D. Combs her own h a i r . PT Leaves. Mrs. D. Finds glass of ju i c e and drinks i t . Mrs. D. S i t t i n g s traight i n her chai r looking around. PSN Cuts up food. 4:37 Mrs. D. Eating a l l by her s e l f . It was put on overbed table when i t was at the end of her bed. Appears quite a l e r t to her surroundings. Supper tray a r r i v e s . White f i s h , mashed potato, pureed peas. Food f a l l s o f f fork. 4:39 Mrs. D. Eating with fork better now. S i t t i n g up i n chair. Table i s about l e v e l with mid-chest. 4:48 FN Comes to help Mrs. D. Suggests that she use a spoon. Spreads and cuts her bread. Dentures on bedside table. 234 Time Person Activities Other Obser-vations  4:49 4:52 PN PN Mrs, Walks away. Returns and feeds Mrs. D. her About 1/2 s t i l l dinner. Hands her tea in on her plate, a cup. D. Refuses i t , but accepts milk in a glass. 4:55 Mrs. D. S t i l l eating. Mrs. D. Sipping milk. 5:00 Mrs. D. Finished fish. PN Feeding Mrs. D. pudding. Mrs. D. Sipping milk from time to time. 5:07 Mrs. D. Eihishfea pudding. PN Left Mrs. D. to finish her milk. Seems to enjoy solid food. Fluid intake s l i p says 250 cc. NR home. Time spent in minutes with Mrs. D., by general staff hospital nurses. June 11, 1970 NjD - 39 min. N2D - 1 min. June 12,1970 N2D - 3 min. N3D - 41 min. 235 Nursing Care Study V: Mrs. E. Mrs. E., a 61 year old c h i l d l e s s married lady had been a well controlled diabetic for many years. Her doctor reported that she had had mild hypertension for some time; t h i s gave her serious trouble four months ago when she developed myocardial i n f a r c t i o n and concomitant cardiac f a i l u r e . She made a s a t i s f a c t o r y recovery. The morning of June 11 Mrs. E. f e l l out of bed and could not use her l e f t arm and leg. On examination the doctor found her to have a l e f t hemiparesis with garbled speech and confusion. For the f i r s t while there were random movements of her l e f t arm and leg, but, when the doctor examined her i n ho s p i t a l he found that her condition had se t t l e d down to a f u l l p a r a l y s i s . On admission to h o s p i t a l , June 11th, Mrs. E. was con-fused, v.dysphasic and flushed. Her abdomen and chest were c l e a r , her blood presure was 180/80. Her neurologic paresis was described as being i n her l e f t face and l e f t extremities which had:flaccidref lexes. She had been diagnosed as having diabetes m e l l i t u s , cardiac vascular disease, e s s e n t i a l hypertension and cerebrovascular accident. The doctor noted on June 13 that there had been no e s s e n t i a l change. Heparin was begun because of varying paresis, but has been stopped because of hematurea following 236 catheterization. On June 18 he noted that she was responding more, speaking a l i t t l e and was able to s i t up. The speech therapy r e q u i s i t i o n stated: "Condition requiring treatment: dysphasia. Treatment required: Speech assessment and therapy." 1 The speech therapist wrote on the r e q u i s i t i o n that Mrs. E. had an 11:00 A.M. appointment d a i l y . Physiotherapy: No r e q u i s i t i o n on chart. X-Ray report stated: "Pelvis and both hips very minor degenerative changes are present i n both hip j o i n t s . No other bone, j o i n t or soft tissue pathology i s detected. In p a r t i c u l a r no fracture i s i d e n t i f i e d . 1 , 2 During the period when Mrs. E. was being observed the following orders were i n e f f e c t : Date ordered Order 11-6-70 "-Mercuhydrin l c c q2 days May insert Foley catheter i f necessary. 18-6-70 Dig. Pulv. gr. JUL o.s. d a i l y F u l l f l u i d low s a l t d i e t . •••Patient's chart. 2 I b i d . 237 20-6-70 N.P.H. i n s u l i n 20 u. q. a.m. 23-6-70 Diet 1500 c a l . , d i a b e t i c . Remove catheter. 238 Nurs ing History Code Name: Mrs. E. Age 61 Primary Medical Diagnosis: Diabetes Meliitus Date: many years. Secondary Medical Diagnosis: Cerebrovascular Accident -Left Hemiplegia. Date: June 11, 1970 Additional Medical Diagnosis: Cardiac-vascular Disease, Date: February, 1970. The following was obtained from Mrs. E., obser-vation and the chart. Part A and B were not answered because Mrs. E. found them d i f f i c u l t to answer and ap-peared to become very frustrated because she could not make sentences. Mrs. E. had d a i l y appointments with the speech therapist for her dysphasia. She did not t e l l NR that she could not speak when she became i l l (this question required a yes-no answer). S p e c i f i c Basic Needs Nursing Approach Suggested by NR based on data obtained from Nursing History 1. Respirations - observed. a) Color face - pink l i p s - red N a i l beds - pink ~>b) Breathing - i n no apparent d i s t r e s s . 2. Food and Fluids 239 a) Teeth - dentures - no Encourage regular dental mouth sore - no hygiene. b) Appetite - good c) "Are you on a s p e c i a l Make sure that she gets the diet?"-"Yes." proper d i e t at the proper time. d) "What kind i s i t ? " -"Diabetic 2000 c a l o r i e . " Check i n s u l i n order and urine (note: was not on t h i s t e s t before meals, die t when hist o r y taken) e) "Are there any foods Find out from husband what that you do not l i k e ? " foods that Mrs. E. d i s l i k e s . "Yes." "What are they?" Not able to name them. Cut up Mrs. E's food. Put food on r i g h t side of tray Did not answer the rest of where she can reach, i t more these questions. e a s i l y . Cut her food, and pour her tea and coffee. From the chart: Encourage her to feed her-s e l f . 1. Special d i e t - f u l l f l u i d low s a l t d i e t . Make sure she gets t h i s d i e t as ordered. 2. Appetite - no record except of f l u i d intake. Record appetite. Diabetic sheet only used f o r i n s u l i n admin-i s t r a t i o n as not on diabetic d i e t . 3. Likes 4. D i s l i k e s No record. 5. 3. a) Bowels Unable to answer the f i r s t question. Had constipation at home and i n h o s p i t a l . Find out l i k e s and d i s l i k e s and record. Ask Dr. re a s t o o l softener for Mrs. E's constipation. Give enema i f s t o o l softener f a i l s Other Elimination 240 Said that she took a laxative at home "some-—times" and that she took them in hospital. Did not answer how often or when she had bowel movements. b) Bladder "Do you have d i f f i c u l t y Ask Mrs. E*s doctor i f the passing your urine at catheter can be removed and home?""No" bladder training attempted. (In hospital she had Foley catheter.) 4. Exercise, Transfer and When Mrs. E. is in bed keep Positioning her body in good alignment. Support l e f t leg to prevent a) From Chart: outward rotation of the hip. 1) degree of hemiplegia?Put footboard in bed. Pos-"F u l l " ition l e f t arm on pillows so 2) degree of spasticity that the le f t hand is higher - not recorded. than the wrist and the wrist 3) degree of flaccidity is higher than the elbow. - "has flaccid reflexes" but degree not re-corded. b) "Do you have d i f f i c u l t y walking about?""Yes" c) "Did you have d i f f i c u l t y walking before you came to hospital?""No." d) "Do you have pain?" "Yes" - pointed to l e f t leg, hip and lower back. e) "What do you think of staying in bed?""More comfortable." f) "What do you think of Mrs. E. has her own wheel-getting out of bed?" chair (notation on Kardex). No answer. When getting Mrs. E. into the chair, bring the wheel-chair to the foot of bed 241 1) "Do you have trouble getting out of bed?" No answer. 2) "Are you comfortable when s i t t i n g i n the chair?" "No", (note: s i t t i n g i n chair during interview). 3) " W i l l your limbs do what you want them to do?" "No." 4) "'Can you g e l l what your foot and/or hand i s doing i f you do not watch it?"No answer. g) "What do you think of your exercises? "No answers. h) " Can you turn over by yourself in bed?" Interview was interrupted at thi s point by a v i s i t o r . Mrs. E. appeared t i r e d by questions, questions resumed l a t e r . <S. Sleep and Rest Mrs. E. did not answer these questions. The chart states that she Position Mrs. E. in good body "slept w e l l " . She does alignment with pillows to not have an order f o r a achieve t h i s comfortably, sleeping p i l l . An order for sodium luminal f o r pain or restlessness, which she did not use since Check v e n t i l a t i o n and that June 15 according to bed i s made comfortably, nurdes notes, was d i s -continued. facing the bed. R o l l high-low bed down. Help Mrs. E. s i t on edge of the bed. Check to see that brakes are locked and footrests are up. Help Mrs. E. stand up and pivot her into wheelchair. Help her to do as much as she can f o r hers e l f , but support her as we l l . See Appendix B, 105-1-07. 242 6. Maintenance of body temperature. Mrs. E. did not answer these questions. 7. Bathing and Grooming. Mrs. E. did not answer these questions except to say that she liked her hair done daily in the morning. 8. Skin Care Be sure c a l l light is within reach. Help her to have an hour or so of unbroken rest during the day on the bed. Do not leave her up in chair for periods longer than 30 minutes to 1 hour. Observe to see i f Mrs. E. seems cold or overheated. Ask her i f you are in doubt, she w i l l t e l l you. Ask Mrs. E. i f she would like a bath today before you de-cide to bathe her. En-courage her to help herself to bathe and dress. Comb and/or brush Mrs. E's hair as she wishes every morning. 'How does your skin usually feel? ""Normal." Body was not checked for bruises or sores as Mrs. E, was up in the chair. Skin appears dry. Use lotion or cream when rubbing Mrs. E's back and boney protuberances.. Medical history does not indicate degree of feeling in l e f t side. When asked Mrs. E. stated that she has pain in l e f t leg, hip and lower back. 9. Safety The only question Mrs. E. Check to see i f Mrs. E. would answered in this section like to wear her glasses when 243 was that she wore glas-ses. Did not have them on and did not seem to have trouble seeing. No comment re. sight in medical notes. She did not seem to have any d i f f i c u l t y hearing. NR observed that Mrs. E. was wearing heavy grey socks. she is up in the chair. Be sure that the c a l l light is within reach at a l l times. Ask Mrs. E. and/or her hus-band to get some firm shoes. Communication a)"Do you have any d i f -f i c u l t y understanding what people say to you?" Explain to her what you would like to do or are going to do. Talk to her as you give her nursing care and whenever possible. . ,Mrs. E *s response: "No". Observation: Seemed to understand every-thing NR has said to her. Medical findings: No comments by doctor. b)"Do you have d i f f i c u l t y Encourage her to read printed reading?" Mrs. E. "No".or written material. Observations: Seemed to read NR's explan-ation sheet. Medical sheet findings: No comment. Speech therapist: "She had some d i f f i c u l t y with written symbols." c)"Do you have d i f f i c u l t y Encourage her to write notes, writing? " but do not expect i t for c ommun ica t ion. No answer. 244 No observations. No medical comment. No speech therapy comment. d)"Arejyou able to say Encourage her to talk to you. the things you want to Perhaps she could be en-say when you want to couraged to t e l l you something say them?" that interests her, for con-versation. Patient's response: "not...everything." Observations: Halts and could not seem to find words to answer a l l the above questions, did try. Medical findings: no comment. Speech therapist: "She is s t i l l dysarthic. Slow in her speech, she is trying very hard." 2 4 5 Time Day XIV In TJie Hospital Life of Mrs. Day I of Observation Person Activities E. Other Obser-vations 7 : 1 5 A.M. 8 : 0 6 Mrs. E. Lying on le f t side moving about in bed. Right arm and leg moving. 8 : 0 4 NjE June 2 3 , 1 9 7 0 NR arrives. Bedside table on right side of bed. Call light cord is within reach. 7 : 2 0 Mrs. E. 7 : 2 5 Mrs. E. 7 : 3 0 Mrs. E. 7 : 4 0 Mrs. E. 7 : 4 3 Mrs. E. 7 : 4 5 Mrs. E. 7 : 5 5 Mrs. E. 8 : 0 0 8 : 0 3 NjE Fresh water comes. Arrives with medication. "Mrs. ....I have insulin here for you, Pet". Proceeds to inject insulin into l e f t arm. Says, "Your skin is getting tough." Swabs arm, mutters, " . . . w i l l have to wash your face and hands." Comes in, "I w i l l get some-one to help pull you up in bed." Breakfast arrives. 246 Time Person A c t i v i t i e s Other Obser-• vations Goes to door and stands there. 8:08 N 2E Comes and helps A p u l l Mrs. E. up i n bed, then leaves. (1 min.) A Rolls up bed. Organizes food on tray, puts ' spoon & por-ridge i n front of Mrs. B. Leaves. 8:10 N,E Comes i n , pu l l s up bli n d s . Speaks to NR. Who said, "I am not supposed to t a l k ? 1 " Does not speak Leaves. to Mrs. E. 8:11 Mrs. E. Feeds herself porridge with a Slowly, spoon. 8:18 Mrs. E. Stops eating, both hands are Head to r i g h t , on the bed at her sides. eyes shut. 8:25 Mrs. E. Seems to be asleep. 8:34 Comes in and awakens Mrs. E. Takes small paper cup and holds i t to Mrs. E's l i p s . Mrs. E. Drinks contents. NjE Feeds Mrs. E. the rest of her porridge and her egg. Pours her tea and asks Mrs. E. to take tea cup in her hand. Mrs. E. Takes i t . NjE "You drink i t for me." Mrs. E. "Mhum." (Yes?) NjE "I w i l l be back in a minute to see how you are getting along" and leaves. (3 min.). 247 Time Person A c t i v i t i e s Other Obser-vations  8:38 8:42 8:45 8:46 9:00 9:10 9:13 Mrs. E. NjE. NjE Mrs. E. N XE NiE NjE Mrs. E. Mrs. E. Pushes overbed table away. "Now l i s t e n here, you promised me that you would drink t h i s . " "Here you take i t . You can do i t yourself." Gives tea cup to Mrs. E. Takes cup and drinks tea. "There that i s a l l there i s to i t . " Moves table with tray on i t to space beside her bed and wa l l . Takes a paper o f f the tray and says, "I w i l l put t h i s milk over here and you can drink i t l a t e r . " Puts milk on table and leaves. (3 min. ) Turns onto her l e f t side. R o l l i n g from side to back and back to side again. Table i s about 3' from bed. By the water jug. Asks NR to reach c a l l l i g h t f o r her. Mrs. E. Mrs. E. Puts c a l l l i g h t on. N 2E Answers the l i g h t . Mrs. E. Asks f o r the window to be closed. N 2E Turns o f f l i g h t , closes the window and leaves. (1 min.) It i s under her pillow. NR does so. She has an indwelling catheter. Breakfast tray is taken away. Time Person Activities Other Obser-vat ions  Mrs. E. Turns to her left side and moves her head from side to side. 9:40 N^E Arrives with medication tray. "Here is your p i l l , Pet." Takes medication cup off her tray and starts to give i t to Mrs. E. Then she stops and takes Mrs. E's pulse. Mrs. E. "Have...to....eat." NjE "I have to eat? I have just been to coffee." Mrs. E. "No, I.•..have...to....eat." NjE "You have just had breakfast. There w i l l be nothing more u n t i l lunch at mid-day." Gives Mrs. E. p i l l with milk arid says, "I w i l l be right back to wash you. You w i l l be going to the speech ther-apist this morning. Do you remember the auburn haired girl ? ...Oh! maybe that's not the one. Maybe i t ' s this afternoon that you are going. Anyway I w i l l be right back to wash you." Leaves. (3 min.). Milk is sitting on tab let" From breakfast. 9:46 Comes in with a basin of water and begins to strip the bed. Washes Mrs. E's face gently. "Your eyes are a l l sticky." Washes chest and comments on clouds covering the sun. Li f t s Mrs. E's armsup and wipes them off quickly with damp washcloth, then dries them with towel. Washes and dries chest. Puts soap and water on'washcloth and washes legs, front and back then foot, Time Person Activities Other Obser-vations^ wrings out cloth in water. Dries legs with towel. Pow- Mrs. E's own ders chest and under arms. powder. NjE "Going to r o l l over that way for me." pointing to le f t side of bed. "Put your good hand on the r a i l . " Mrs. E. "Yes," puts right hand on r a i l and turns to her l e f t . NjE Washes and dries back. Powders back. Begins to put Mrs. E's own gown on her. "Put this" - points to left hand -"into your gown." Mrs. E. Starts £o put her right hand in. NjE Says, "No this one," pats left hand. "Pick i t up with your good hand and put i t in . " Mrs. E. Does as directed. NjE "Good g i r l , that's i t . " "Now put i t in the other one." Mrs. E. Puts right hand in gown. N_E Pulls Mrs. E. to a sitting position and puts on gown. Puts heavy grey socks on Mrs. E's feet. N l E "Now w i l l you s i t up in the wheelchair so that you w i l l be ready to go to the physio-therapist." Takes water out of the room. Returns immediately. Puts pillow on seat of the chair Asks Mrs. E. i f she would 250 Time Person Activities Other Obser-• vat ions like the pillow there or i f i t w i l l be too high. Mrs. E. Says, yes that she wants the pillow. N^E Puts on wheelchair brakes. Sits Mrs. E. on the side of the bed. NxE Tells Mrs. E. to "Put your good arm around my waist." N^E Puts her own arm under Mrs. E's lef t arm and pivots her into the chair. NjE does this Arranges Mrs. E. in the atone, wheelchair and releases the brake and pushes chair. To space at Gets her housecoat. right of foot of bed in cor-NjE "Pick up your bad hand and ner of room, put i t in this sleeve." Mrs. E. Does i t . NjE "Good." Then swings coat around Mrs. E's back. Mrs. E. Puts her good hand into the other sleeve. E\E Folds housecoat over Mrs. E's knees and arranges Mrs. E's catheter. Combs Mrs. E's hair. Suggests that she have a hair dresser come to washN-her hair. NjE Finds Mrs. E's slippers under the big chair. "When did these come in? Last night?" Mrs. E. "Yes".! nil Puts them on. Puts a blanket around Mrs. E's knees. 251 Time Person A c t i v i t i e s Other Obser-vations w l E Goes to Mrs. E's drawer and gets some perfvane and puts some of i t on Mrs. E. Picks up milk glass and says, " W i l l you take some more of t h i s milk for me?" and hands glass to Mrs. E. Mrs. E. Takes milk i n r i g h t hand and drinks i t . 10:08 NjE 10:09 KjE Stri p s bed and takes linen out of the room (19 min.) Returns and opens window. Beside NR, without a word to Mrs. E.1 Asks NR i f win-dow w i l l be too cold for her. NR suggests that nurse ask Mrs. E. NjE " W i l l t h i s window be too cold f o r you?" (1 min.) NR does not hear Mrs. E's reply. Window l e f t open. 10:11 N J E Returns. Mrs. E. Has finished her milk. N^E T e l l s her that she i s a "good girl'.' then proceeds to make her bed. Mrs. E. Wiggling i n her chair. N XE Mrs "There i s your fr i e n d back." E. Says, "Mhum." Male patient comes down h a l l i n wheelchair 252 Time Person A c t i v i t i e s Other Obser-vations and into his room across the h a l l . 10:14 NjE "You don't look comfortable on that pillow. I w i l l take i t out." Mrs. E. Continues to wiggle i n chair. N l E Goes to the door. N2E Comes i n . N^E Gives directions and they stand Mrs. E. on her feet. NR hears her ask somebody to come and help her. N l E P u l l s out the pillow. "That's more comfortable?" Mrs. E. "Yes." Points to legs, h i t s l e f t then r i g h t knee. Quite firmly. NjE "Oh, do you want that leg over the other one?" Crosses Mrs. E's legs f o r her. That's not a good position for i t . " Points to thigh on l e f t leg. " I t i s sore up here and that's not a good position f o r i t , " and puts both feet on metal foot rests of chair. NjE Leaves. (9 min.). 10:20 Mrs. E. S i t t i n g i n chair - not wig- Neither c a l l g l i n g both hands i n her lap. l i g h t cord nor 253 Time Person Activities Other. Obser-vations water are within reach. 10:21 Mrs. E. Right hand on face sitting upright not leaning on hand. 10:25 Mrs. E. Slumped over toward le f t side then pulls herself upright. Holds her head. Calls NR to pull c a l l light cord. 10:27 Dr. Dr. V i s i t s . 10:30 A Asks Mrs.E. what she would like. Mrs. E. "I...would...like...to..." A "Go to bed?" Mrs. E. No answer. A "Go to the t o i l e t ? " Mrs. E. "Yes.1" 10:31 A Returns with NjE, brings a commode, t e l l s A that they w i l l have to put the brake on the wheelchair so that i t w i l l not slide. A Puts brake on. NjE + A Eivot Mrs. E. onto a commode. Mrs. E. Moans. A "What's sore?" "Is this leg sore?" Looks distressed. Which NR does. Mrs. E. '"Yes to 254 Time Person A c t i v i t i e s Other Obser-vations A P u l l s catheter tubing out from under Mrs. E's buttocks. NjE T e l l s A to put c l o t h t i e around Mrs. E's waist so that she w i l l not f a l l f o r -ward and t e l l s her how to do i t . 10:40 10:55 11:00 11:55 12:04 NjE S i t s on Mrs. Mrs. E. E's bed beside Mrs. E. Not i n her room Mrs. E. working to have bowel movement. NR to bathroom NR goes to chart desk. Mrs. E's chart not there. Clerk t e l l s her that she has gone to speech therapy. NR to lunch. NR returns. Appears com-forta b l e . Lunch tray on overbed table at end of the bed. Mrs. E. Has taken blanket o f f her knees and is playing with her Appears restless, catheter. Mrs. E. In wheelchair by window. 12:06 A Comes in and t e l l s Mrs. E. that lunch i s here. Proceeds to bring table to Mrs. E.'s chair and organizes the food on the tray so that Mrs. E. could manage i t . 12:09 Mrs. E. Feeding herself with a fork. Cuts up turkey, butters bread, etc. 255 Time Person A c t i v i t i e s Other. Obser-vations 12:10 A Putting turkey on fork f o r Mrs. E. 12:12 Diet. V i s i t i n g . "I have come to f i n d out what you l i k e ? " She l i s t s o f f the following: pork, lamb, chicken, milk, eggs, f i s h , tea a l l the time, peas, brown bread, carrots, beans, asparagus and bananas. Orange j u i c e , apple j u i c e , pineapple juice? Mrs. E. Says yes to each one. Diet. "Is there anything that you don't l i k e ? " Mrs. E. No answer. Diet. " I f there is anything that you get that you don't l i k e , t e l l the nurse." 12:30 A S i t t i n g on edge of bed helping Mrs. E. to feed h e r s e l f . A Holds the cup to her l i p s . Mrs. E. Is eating turkey on her own. 12:23 A Leaves room saying, "I w i l l be back i n a minute." 12:46 A Returns and l i f t s cup to Mrs. E's l i p s . Mrs. E. Drinking tea. A Talking to Mrs. E. Pleasantly. Then asks-her i f she would l i k e to go to bed or to s i t in the chair a f t e r lunch. Mrs. E. " S i t . . . i n . . . . a . . . . c h a i r . " 256 Time Person A c t i v i t i e s Other Obser-vations 12:45 12:47 12:50 12:55 A Mrs. E, A Mrs. E, A A. A PN N i E Tries to get Mrs. E. to eat more lunch. "What would you l i k e to do now?" Points to sof t chair. "Would you l i k e to s i t i n that chair? "Yes". Unfastens urine bag, pins i t to housecoat. Asks Mrs. E. to put her good arm around A's neck, and t r i e s to p u l l Mrs. E. to her feet. Discovers that Mrs. E. i s t i e d i n . Takes o f f t i e and says, "I w i l l go and get some help." 1:00 Mrs. E, Comes and helps A. Puts Mrs. E. into the chair. They stand her xxp and swing her into chair. PN leaves. Puts blanket around Mrs. E's knees, and places the urine bag at the .side of her chair and leaves. Comes i n . Exclaims over Mrs. E's empty dinner plate and leaves. (1 min.). Has l e f t foot over her r i g h t ankle and i s swinging i t up and down. Do not have brakes on wheel-chair. Appears com-forta b l e . NR leaves to go to chart desk. 2:00 PT Just leaving room. 257 Time Person Activities Other Obser-vations Mrs. E. In same chair. Appears com-fortable. Left hand res-ting on a p i l -low about 2" above elbow. 2:13 N p Comes in with A. "Mrs. E. we are going to put you to bed and take the l i t t l e tube out and then give you an enema." Takes pillow out from under arm and blanket off her knees. NjE "When we take the l i t t l e tube out you w i l l have to ask for the bed pan and I w i l l pin this string to the pillow so that you can turn on the light." Draws chair up beside the bed. Chair facing the head of the bed. NjE Tells Mrs. E. to put her hand around NjE's neck and pivots her from chair to bed. Helps her to l i e on her back. 2:16 NjE Leaves the room. (3 min.) Mrs. E. Pulls light cord. 2:17 NjE Returns. "You pulled your light string already, are you testing?" Mrs. E. No answer. N]E "Did you want me?" Mrs. E. "Yes." NjE Puts a tray on the overbed Sterile syringe table. Puts K basin between (wrapped), rec-Mrs. E's legs. Takes water t a l glove, 258 Time Person Activities Other Obser-vations out of Foley catheter bag with fleet enema syringe. Drains water into and K basin. K basin. Removes catheter, p puts i t into K basin and puts K basin on tray. Puts up l e f t side r a i l . "Put your hand on the le f t bed side and pull yourself over on the side. I am going to give you an enema." Mrs. E. No response. NjE "Do you hear me?" and re-peats what she has just said. Mrs. E. "Oh, yes", and pulls herself over. NjE Gives fleet enema. "Try to hold i t inside a wee while and I w i l l come back and put you on a bedpan. Mrs. E; "Oh!" NjE "I won't be long; here I w i l l f i x your light cord so that you can reach i t . " 2 : 2 3 N J E Leaves the room. ( 6 min.) 2 : 2 4 Mrs. E. Puts light on. A Comes in and looks under the Sounds as i f covers. "Didn't she put you Mrs. E. is re-on a pan when she gave you leasing the an enema? contents of her bowels in the.bed. 2 : 2 5 A Returns almost immediately with a bedpan and places Mrs. E. on i t , and leaves. 259 Time Person A c t i v i t i e s Other Obser-vations 2:31 Mrs. E. Puts l i g h t on. PN Comes i n almost immediately. Mrs. E. Points to bed pan. PN Looks under the covers. "I w i l l be back i n a minute." Returns with some u n s t e r i l e pads and removes pan and puts pads under Mrs. E. Turns Mrs. E. on her back and puts a pillow under her knees. Mrs. E. Asks for " a i r . . . " then makes a c i r c l e i n the a i r with her finger. PN " A i r freshener?". Mrs. E." "Yes." 2:37 PN Leaves room with bed pan. 2:38 PN Returns with a i r freshener and sprays the room. 2:40 PN Gives Mrs. E. 1/2 glass of water to drink and leaves. Mrs; E F l a t on back, head on pillow. 2:42 Ice cream a r r i v e s . 2:45 Appears com-forta b l e . NR to tea. 3:25 V i s i t o r With Mrs. E. NR returns but does not enter room. S i t s at chart desk. 260 Time Person A c t i v i t i e s Other Obser* vations 3:45 3:46 4:00 4:10 4:20 4:45 5:00 5:05 V PN PN H H H H Leaves. NR goes into room. Facing the Comes i n and t e l l s Mrs. E. that she i s going to get her up into a chair. Lowers the bed, pu l l s the wheelchair up beside the bed, puts pillows into the chair. Tells head of the bed. Mrs. E. to put her arm around PN's neck, stands her up, then pivots her into the Does not put chair. brakes; on wheel-chair. Places blanket over her knees and puts a pillow on her knees and l e f t hand on pillow. Brushes Mrs. E's ha i r . Leaves. Comes to v i s i t . Pushes Mrs. E. around the h a l l s i n a wheelchair. S t i l l v i s i t i n g . Helping Mrs. E. with her supper. NR goes to chart room. Supper a r r i v e s . NR home. Day XV i n the Hospital L i f e of Mrs. E. Day II of Observation June 24, 1970 7:30 A.M. Mrs. E.Almost i n tears. Seems to be very agitated when she sees NR. NR a r r i v e s . Bed appears very wet, bed spread and a l l . 261 Time Person Activities Other Obser-vations NR moves to a vantage point out of Mrs. E's sight. 7:40 N3E Enters the room. Goes to Mrs. E's bedside. "Did you go in the pan so we could have a specimen?" Mrs. E. "No." Sounds almost in tears. N3E Slips pan out from under Mrs. NR can see that E. "I w i l l be back to wash you i t is empty, and get you out of that wet bed in 'Just a minute. Leaves. (1 min.) 7:41 N^E Comes in with a syringe. "Are you having troubles Mrs. E?" Mrs. E. "Yes, I am." N4E "I have brought your insulin." Examines Mrs. E's l e f t arm. "You have a bruise on that arm." Examines right arm. "You have a bruise on this arm too." "Here's a place where there isn't., a bruise." Gives insulin. Leaves. (1 min.) 7:43 N 3 E Returns. "Do you have den-tures?" -Mrs.' E. Nods. N3E "Will you take them out so that I can clean them for you? " Mrs. E. Pulls at her teeth, then 2 6 2 Time Person Activities Other Obser-vat ions , smiles N3E "Those are your own, aren't they?" Mrs. E. "Yes," and smiles again. N3E "Where is your tooth brush and tooth paste so that you can do your teeth? Can you do i t yourself?" Mrs. E. "Yes." N3E Finds tooth brush and paste and gives them to Mrs. E., with a glass of water and a K basin. Mrs. E. Brushes teeth, rinses out mouth and spits into K basin. N3E "Rinse out your mouth once more." Mrs. E. Complies. N3E "Good." N3E "Do you ever wash your own face?" Mrs. E. "No." N3E "You can't manage with one hand, eh?". Washes Mrs. E's Bruise on right face and arm. upper arm the size of the c i r cumf eren ce of a golf b a l l . Mrs. E. "I w i l l be 50.....20...." "When is your birthday?" 263 Time Person Activities ... . . Other Obser-vations Mrs. E."February 17." N3E Washes Mrs. E's l e f t arm. "Is Bruise on l e f t this arm sore?" upper arm from elbow almost Mrs. E. "Yes, i t i s " "and my " to shoulder and extends around N3E "Your side?" the back of Mrs. E. "And my chest too." the arm. N3E "Is your heel sore?" says nurse as she washes right foot. Mrs. E. "Yes, my whole side is sore." N3E Washes l e f t leg. Mrs. E. Moans. N3E Goes to door. Looks out into h a l l where there were some noises. N3E Comes right back and washes perineum. R3E "Do you usually feed yourself your breakfast?" Mrs. E. "I don't think I w i l l have breakfast." N3E "We w i l l get you out of that wet bed and into a chair while we change i t . " "I w i l l find out i f they put you in the wheelchair or in the big chair." 8:00 Takes wash basin and goes out. (17 min.) 264 Time Person Activities Other Obser-. vat ions  8:02 N 3E Returns, says "W® w i l l get you up in the wheelchair then after breakfast you w i l l be ready to go to the physio." Gets Mrs. E's housecoat. Brings Mrs. E. to a sit t i n g position. Puts housecoat on Mrs. E. Mrs. E. Helps. N3E Leaves., l e f t half of bed side up. "Can you stand on the floor a minute?" Mrs. E. "Yes." N3E Holds Mrs. E. under her arms. Mrs. E. Puts her arm around N's neck. N3E Pulls Mrs. E. to a standing position and pivots her into wheelchair. Brakes on wheelchair. N3E "Do you like a pillow or something under your arm?" Mrs. E. "Yes, I do, yes." N3E "There you are, a l l ready for Puts pillow breakfast." under Mrs. E's arm. Hand approximately 2" above elbow. N3E Wheels Mrs. E's chair over to wall at foot of bed. "Let's comb your hair too." Pro-ceeds to do so. 8:05 Breakfast comes 265 Time Person A c t i v i t i e s Other Obser-vations N3E Takes things o f f the overbed table so breakfast can be put on i t . 8:06 N3E Leaves room. Breakfast tray i s on overbed table next to Out of Mrs. E's the w a l l . (4 min.) reach. Mrs. E. Leans over i n chair to watch Looks puzzled at nurse. N3E*s d i s -appearance . 8:07 N3E Returns and brings overbed table with breakfast over Mrs. E's knees. Gives her her j u i c e glass and says, "I w i l l get your cereal ready." Pours milk on cereal. Butters toast. K3E "Go ahead and have your jui c e and your ce r e a l and I w i l l be back to help you again." 8:11 N3E Leaves. (4 min.) 8:12 Mrs. E. Looks at breakfast tray and says, "Oh, my." 8:15 N3E Returns. "How are you doing?" Looks at tray. Mrs. E. Has started to eat. But hasn't eaten much yet. W3 E "That's good. Keep going. I w i l l be back again. Do you l i k e cream i n your tea?" Mrs. E. "Yes." 8:16 N3E Leaves. (1 min.) 8:18 Mrs. E. Holding head with hand. Has stopped eating. Time Person A c t i v i t i e s Other Obser-vations 8:20 A Asks Mrs. E. how she s l e p t . Mrs. E. "Not too w e l l . " A "S h a l l I cut th i s egg up f o r you?" Cuts her egg. "Do you l i k e s a l t ? " Mrs. E. "Mumm" A "Better too?" Mrs. E. "Yes." A "Is your tea the way you l i k e i t ? " Mrs. E. "No." A. "Do you take cream?" Mrs. E. "Yes." 8:22 A Puts cream i n tea and leaves. 8127 N3E Returns. "How are you doing?" Points to 1/2 glass of j u i c e and says, "Don't you l i k e your j u i c e ? " ' Mrs. E. "No." 8:28 N 3E Leaves. (1 min.) 8:30 Mrs. E. Moves i n chair, bangs feet on f l o o r , mutters; moves dishes from time to time. 8:35 Mrs. E. Continues above behaviour. 8:40 N3E Returns. Looks over tray, looks into tea pot, etc. "Would you l i k e to f i n i s h t h i s milk?" Holds up . 1/4 glass of milk. 267 Time Person Activities Other Obser-vations Mrs. E. "No." 8 : 4 1 N 3 E Records f l u i d intake and leaves. ( 1 min.) 8 : 4 5 Mrs. E. Asks NR to put on c a l l light. C a l l light cord not within Mrs. E's reach. 8 : 5 5 HN Answers light. Mrs. E. Says that she has "pain." HN "Where?" Mrs. E. "From neuritis." HN "Where you s i t ? " Mrs. E. "Yes." HN Physio w i l l be here soon to take you. Mrs. E. "I can't go like thi s . " Hangs her head.1 HN Do you want something for pain? Mrs. E "Yes." 8 : 5 7 HN Leaves. ( 2 min.) 9 : 0 0 N3E Comes in with medication tray. "Do they come the same time every day to take you to physio?" Mrs. E. Looks at watch, "Yes." N 3E "at 1 1 : 0 0 . " Mrs. E. "Yes. It's only 9 now, 1 1 a long....." Time Person Activities Other Obser-vations  N3E "Do you have any pain?" Mrs. E. "No." W3E "We w i l l give you your p i l l s then put you to bed for a while." N3E Gives Mrs. E. her p i l l s one at a time. N3E "Would you like to go to the bathroom?" Mrs. E. "Yes." N 3E Takes Mrs. E. to BR in wheel-chair. "Can you walk that far?" Mrs. E. "Yes." N3E "Stand up f i r s t , bring your le f t foot forward, that's i t . Bring your right foot forward-good, can you just turn around? That's i t . Now s i t down." Mrs. E. Crying.' Sitting on t o i l e t . N3E "Are your feet sore?" Mrs. E. Crying. "Oh, oh, oh." 9:08 N 3 E "Are you done?" Mrs. E. "Yes." N 3E "Good for you." A Comes and helps Mrs. E. off of the t o i l e t into wheelchair. N3E Asks Mrs. E. i f she wants to go to bed or s i t in the 2 6 9 Time Person Activities Other Obser-vations big chair. Mrs. E. "Big chair." A + N3E Wheel Mrs. E. to the big chair and begin to transfer her. N3E Slips her arms under. Mrs. E's and holds on to her back. Mrs. E. Stands on her feet. A Guides Mrs. E. into the chair from behind and helps her to lower herself. N3E Places pillow under Mrs. E's le f t arm. Hand approx. 2" above elbow. A Puts strap around Mrs. E's waist - "So you won't f a l l out." 9:13 N3E Tells Mrs. E. and aide that she is going to fi n i s h giving out her p i l l s and leaves. (13 min.) A " I ' l l make Mrs. -—-*s bed. "Are you comfortable Mrs. — ?" Mrs. E. "Yes." 9:15 A Makes bed. Mrs. E. In chair. Appears com-fortable. Pillow under arm, blanket over her knees. NR to coffee. 9:45 Mrs. E. In same position. Smiles. NR returns. Mrs. E. looks comfortable. 270 Time Person A c t i v i t i e s Other Obser-vations 10:50 A N 5E + PN N 5E A u N 5E T e l l s Mrs. E. that she has come to take her to speech therapy. Comes and helps Mrs. E. into wheelchair. Unties the strap. N5E + PN each take one side, hold Mrs. E. firmly under the arms and pull^her up onto her feet and help her walk 2 paces to the wheelchair, where she s i t s down. Holding wheelchair. Tucks Mrs. E's housecoat around her. Puts pillow under her l e f t arm. Mrs. E. Points to bathroom as she i s wheeled by the door. PN "Do you want to go to the bathroom?" Mrs. E. "Yes, I am a d i a b e t i c . " PN + N 5E PN N5E Help Mrs. E. onto a pan on the wheelchair. Takes out pan. fin i s h e d . Mrs. E. i s Replaces the pillow under Mrs. E's arm. Water and c a l l l i g h t not within reach. 271 Time Person Activities Other Obser-vatlons  10:58 11:58 11:59 12:12 12:13 12:20 12:23 12:30 12:45 1:10 Off to speech therapy. NR leaves for lunch. PT Mrs. E. N 3E N3E N 3 E N 3 E Mrs. E« NoE Just leaving Mrs. E's room. NR returns. Sits in wheelchair, eyes closed. Comes in and pulls overbed table with lunch closer to Mrs. E. Prepares her soup. Lunch arrives. Where she can reach i t . So she can eat i t by her-self. Leaves, (1 min.) Comes in. "How are you doing?" Tells her that she does not want her meat dish i f she eats the soup. Stands patiently while Mrs. E. says each word clearly -when Mrs. E. stumbles, N 3E says, "go slowly now" and Mrs. E. does. This continues u n t i l Mrs. E. completes the message. N 3E A Mrs. E. A Mrs. E. N 3E Leaves. (3 min.) Comes in and puts Mrs. E's meat plate in front of her. Does not complain, picks up her fork and eats. Comes in. "How are you doing?" "Fine." Comes in and writes down 272 Time Person A c t i v i t i e s Other Obser-vat ions  f l u i d intake. (1 min.) 1:20 Mrs. E. S_ts ... in chair holding her Rubs her eyes. head from time to time. Shuts eyes. Shaking her head, mutting "oh my, oh my." Runs her f i n -gers through her h a i r . 1:40 Mrs. E. Continues the above move-ment. 1:42 Mrs. E. Head down on r i g h t hand, Elbows on chair eyes closed. arm. Opens eyes, l i f t s head, looks around. Shuts eyes, let s head f a l l back on head of chair then shuts her eyes again and r o l l s her head around. 1:43 Mrs. E. Appears to be asleep. 1:50 A C a l l s to Mrs. E., puts a thermometer i n her mouth and takes her pulse. Says, "Are you t i r e d of s i t t i n g up?" Mrs. E. "Oh, yes." A "Would you l i k e to go to bed?" Mrs. E. Sigh, "Yes." 1:52 A Leaves room. 2:10 Mrs. E. Nods head with eyes shut. 2:15 N 3E + A Put Mrs. E. back to bed. Pulls Mrs. E's chair up to bedside. Asks Mrs. E. to stand and pivots her on to bed. Lowers her on to her back. £3 min.) 273 Time Person A c t i v i t i e s Other Obser-vations 2:20 2:40 PT A r r i v e s . Mrs. E. Sleeps. Lying on back, head s l i g h t l y r a i s e d . 2:50 2 V Come into room. Speak to her s o f t l y . Mrs, E. Does not awaken. 2 V Leave notes f o r Mrs. E. 3:40 Mrs. E. Asleep, lying on l e f t side. 3:54 PN Awakens Mrs. E. Places her on a bedpan f o r a specimen. Mrs. E. Very sleepy. 3:56 PN Leaves. Mrs. E. Eyes closed. 3:59 PN C a l l s gently to Mrs. E. "Have you used the pan?" Mrs. E. "No." 4:00 PN Leaves. Mrs. E. Shuts her eyes again. 4:10 PN Returns again, asks her i f she has used the pan. Mrs. E. "No." PN T e l l s Mrs. E. that she w i l l take the pan away fo r now, and bring i t back l a t e r . NR to tea. NR returns. Mrs. E., i s asleep. Right knee s l i g h t l y bent, Does not appear i n t e r -ested. Appears to be asleep on pan, 274 Time Person A c t i v i t i e s Other Obser-vations  4:12 4:15 4:55 5:01 PN Takes pan to bathroom. Pulls Mrs. E. up i n bed with her help and turns her onto her l e f t side. Places a pillow at her back. Mrs. E. Shuts her eyes immediately. PN H PN Leaves. Husband comes i n . Gomes i n to see i f Mrs. E. can use the pan. Mrs. E. Does. Husband, begins to feed her. Looks com-for t a b l e . NR to desk. Supper arrives, Time spent, i n minutes with Mrs. E. by general s t a f f nurses NjE 48 N 2E 1 N 3E N 4E 47 1 275 Nursing Care Study VI: Mr. F. Mr. F. i s a 62 year old obese, married man with grade school education. He was quite w e l l u n t i l two years ago when he experienced a cerebrovascular accident, with a l e f t hemiplegia, i n A l e r t Bay. He recovered from t h i s , but, was unable to return to logging, so he r e t i r e d and moved to Vancouver. Mr. F. collapsed in his home about 2 o'clock on the morning of June 11, 1970 and was found by his wife unable to stand or speak. He was brought to the emergency depart-ment where he was found to be e n t i r e l y aphasic, r e s t l e s s , his r i g h t p u p i l ,6 m.m. i n diameter and his l e f t ,3 m.m. in diameter. His eyes and head deviated to the l e f t side and there were no obtainable reflexes or motor movements in his r i g h t extremity. His blood pressure was 150/90 and his pulse was 78. Intravenous f l u i d s were given. Mr. F. was examined by a s p e c i a l i s t in i n t e r n a l medicine, i n h o s p i t a l , on June 11th. His blood pressure was now 180/100-200/110 and his pulse was regular at 90 per minute. His chest and abdomen were cle a r except f o r marked obesity. He was semi-conscious, responding only to deep p a i n f u l s t i m u l i and had a dense r i g h t hemiplegia involving his arm, face and leg equally. He was t o t a l l y aphasic and had a r i g h t pharyngeal palsy. 276 His right pupil was about 5 m.m.'s in diameter and reacted slowly to light, the l e f t pupil was pin point and non-active. Doll's head movements demonstrated that his conjugate eye movements were intact in a l l directions although he was unable to f u l l y abduct his right eye. His superficial temporal and f a c i a l pulses were equal bilaterally and.he had a good bounding carotid pulse in the neck, without cranial orbital or cervical bruits. There was a slight stiffness of his neck but without any significant limitation. The consultant stated that he thoughtthat Mr. F. had probably occluded his internal carotid artery on the le f t side and infarcted the left hemisphere. He thought that i t was unlikely that he had a sub-arachnoid hemor-rhage, and that a l e f t carotid arteriogram would c l a r i f y the issue. He recommended that Mr. F. be examined by a neurologist and arrangements made for placement in a re-habilitation f a c i l i t y . A l e f t carotid arteriogram was done on June 11th and an occlusion of the left internal carotid artery at its; origin 11 was seen.. Mr. F's attending physician noted that his prognosis for recovery seemed poor. The next day Mr. F. was conscious, but, there was no return of speech. He remained on intra-venous fluids and had a suction machine beside his bed because he was s t i l l 277 unable to swallow. He had a Foley catheter because he was unable to void. The attending physician noted on June 15th that Mr. F. •was brighter, more alert:, and was able to follow a few simple commands and to repeat his name. He was able to swallow water with some coughing i n i t i a l l y but was later able to swallow water well. He ordered clear fluids p.o. as tolerated, and i f he tolerated clear fluids without choking he was to progress gradually to a soft diet. Mr. F. was on a f u l l f l u i d diet during the period of observation, the fifteenth and sixteenth day after his cerebrovascular accident. Mr. F. was in a 16 bed medical ward with acute and chronically i l l patients. The patient on one side was totally ambulatory while the patient on his other side was acutely i l l l w i t h I.V. therapy, oxygen and requiring con-siderable nursing care. The orderly had d i f f i c u l t y inserting a catheter, when changing Mr. E's catheter, on June 19th. The Intern was called to examine Mr. F. He discovered an enlarged prostate and inserted a #16 catheter. He also recommended B. and 0. suppositories for bladder spasm. The attending physician noted on Mr. F's chart that there had been no further return of function in Mr. F's right side or speech and that he appeared to have a f a i r 278 amount of comprehension. He stated that Mr. E. was to be gradually mobilized and to have progressive physiotherapy, as tolerated. During the period in which Mr. F. was observed the following medical orders were in effect: 11- 6-70 Catheterize with Foley catheter. 12- 6-70 To have chest physio only. 15- 6-70 Clear fluids p.o. as tolerated. If tolerates the above without choking progress gradually to a soft diet. V i t a l signs 2 x daily. 17-6-70 Passive exercise to right arm. 19-6-70 B. and 0. suppositories for bladder spasm. 23-6-70 Up in chair and progressive physio as tolerated. 16- 6-70 Speech therapy please. Nursing History Code Name: Mr. F. Age: 61 Primary Medical Diagnosis: Carotid Occlusion of le f t internal carotid artery. Secondary Medical Diagnosis: Cerebrovascular Accident with right hemiplegia. Date: June 11, 1970. 279 Most of the following was obtained from Mrs. F., from observation and from the chart. Mr. F. could only answer yes and no, and was asked a few of the questions requiring yes and no answers. Part A: Patient's Understanding of the Illness: Mrs. F. was unable to answer these questions, except for the fact that Mr. F. was unable to speak directly after his cerebrovascular accident and they were too complicated for Mr. F. to answer. Part B: Socio-cultural Aspects: Mrs. F. answered that she is his only family, that she v i s i t s him daily in the afternoon and that he has several friends that v i s i t him in the evening. She said that he had a grade school education and had worked up u n t i l two years ago. Mrs. F. told the nurse-researcher that his most enjoyable pastime was "drinking beers". She was unable to t e l l the nurse-researcher any other of her husbands interests or what other things he did to pass the time. Part C: Specific Basic Needs Nursing Approach Suggested by NR based on data obtained from nursing history. 1. Respiration - observed a) Colour face-pink lips-red n a i l beds-pink b) Breathing - rapid-22 stertorous at times. Maintain a clear airway. Position to eliminate 280 2. Foods and Fluids a) Teeth dentures-No (has own teeth) "Is your mouth sore?" No - Mr. F. nods. b) "How is your appetite?" Yes - Mr.' F. nods. c) "Are you on a special diet?" No answer. d) "What foods do you eat usually?" Mr. F. did . not answer, but Mrs. F. says that he eats almost anything. Questions e) to i ) not answered by Mr. F." nor by his wife.' j) From the chart: 1) Special diet- on June 15 Dr.'s order states "clear fluids p.b. as tolerated. If tolerated with-out choking progress gradually to a soft diet. stertorous breathing. Mouth care p.r.n. Right hemiplegia! Needs help with tray. Food should be on l e f t side of tray so that he can manage to feed himself with his le f t hand. Needs food cut up, tea and coffee poured into a cup, and encourage-ment to help himself. Position him so he can eat comfortably. Fluids must be nourishing as they are his only source of food, and should be offered between meals. Watch for choking1 If he can manage a f u l l f luid regimen without choking his diet may be increased to a soft diet. I I 2) Appetite-not recorded except as f l u i d in-take. 3) Likes Not 4) Dislikes recorded 5) Other. Mrs. F. was asked the following questions: 3. Elimination a) Bowels 1) "Has being sick chan-ged the way that 281 Mr. F's bowels fun-c t i o n , i n any way?" "I don't know." 2) "Does he have con- Give f r u i t j u i c e and extra s t i p a t i o n at home?" f l u i d s . This problem needs "No." to be discussed with the In Hospital? Yes. doctor. Has not had s o l i d food or exercise since 3) "Does he have d i a r - J u n e 1 0 » 1 9 7 0 » a n d d o e s n o t rhea at home"-"Yes." ^ v e a n order for laxatives. In Hospital?-"Yes." (There was no record of t h i s . ) 4) "Does he take lax-atives at home?"-"No." In hospital? No order. 5) "How often does he usually have a bowel movement?" Mrs. F. did not know. 6) "What time of day does he normally have a bowel movement?" Mrs. F. did not know. b) Bladder 1) Does he have d i f f - Foley catheter-change on i c u l t y passing his Tuesdays, urine?" i ) "at home"-"No." i i ) " i n hospital? "Yes." (Has urinary reten-t i o n , has enlarged prostate gland). 4. Exercise, Transfer and Positioning a) From Chart Position to prevent con-i ) Degree of Hemiplegia-tractural deformities and Complete. edema and to maintain and restore functional a b i l i t i e s , i i ) Degree of Spacticity?Turn q.2.h. when in bed. Minimal in leg. G i i i ) Degree of f l a c c i d i t y ? R i S h t les-must be positioned Extensive. to prevent outward r o t a t i o n of the hip. Footboard. 282 iv ) Degree of r i g i d i t y ? Right hand must be placed on No comment. a pillow so that the hand i s higher than the elbow. b) "Does he have any d i f -f i c u l t y walking about? (The doctor's orders include: Had not been out of bed (1) F u l l range of motion since admission, at thatpassive exercises t . i . d . time .he was unable to (2) Up in chair and prog-walk.5 ressive physiotherapy as tolerated.) c) "Did he have any d i f -f i c u l t y walking before Take wheels of f bed. Help you came to hospital?" him to s i t on the edge of Wife says that he could his bed, to stand on his only walk one block be- feet (support him), to pivot fore h i s legs ached. into a firm chair with a l e v e l seat (wheelchair best). The d) "Does he have any pain?" bed and the chair (especially Not that wife knows. wheelchair) must be im-mobilized. See Appendix B, Questions e to g omitted page 105-107. as are too complicated for Mr. F. and Mrs. F. cannot answer them. h)"Can you turn over by yourself i n bed?" (Yes-this was ob-served). 5. Sleep and Rest. a) "How does he sleep here? Mrs. F. does not know. b) "Does he usually have trouble going to sleep?" 1 Position in good body a l i g n -ment, place pillows to achieve t h i s and comfort. Check v e n t i l a t i o n and that bed i s comfortable. "No, not at home." Be sure c a l l l i g h t i s within reach. c) "What did he do at home i f he had d i f f i c u l t y Help him to have an hour or sleeping?" so of unbroken r e s t during the day on the bed. "Sometimes he takes sleep-ing p i l l s , but only on rare occas ions." d) What do you think that the nurse could do to 283 help Mr. F. get more rest and sleep while he is in hospital? "I don't know." 6. Maintenance of Body Temperature. These questions were not asked. 7. Bathing and Grooming, a) b) "Tub bath." c) Questions not asked. d) "How often does he like to shave?" "Every other day." "What time of day does he like to Shave?" "Depends on when he is going out." 8. Skin Care a) "How does his skin usually feel?" Wife says normal. Observe for signs of need for warmth or of overheating. Ask him, he can indicate yes and no. Encourage him to learn to shave himself. Give skin care (1) wash daily (at least pressure areas). (2) rub pressure areas with small amounts of alcohol or lubricate 2-3x per sh i f t . "How often does he like to take a bath?" Wife says weekly, in the morning. "Does he prefer tub bath or shower?" He may refuse bath occasion-a l l y . Bathing should be a time for exercise as well as washing. Encourage him to bathe and dress himself, under close supervision. When he is stronger ask doctor re. tub baths. 284 b) "Does he use anthing on his skin?" "No." c) Mr. F. was asked i f he had bruises or . sores on his body. No answer. d) "May I look at your back, arm and leg?" Does not have bruises or sores, but back is reddened where he has been lying on i t . e) Skin appears - normal. f) Degree of feeling on affected side from medical findings? No comment in doctor's history. 9. Safety a-c not asked (has not been out of bed yet.) d) Do you wear glasses? Mr. F. did not answer. Wife says for reading. e) c.Do you have any d i f -ficulty seeing? No answer. As obser-ved by N-R - No. Medical findings - no note. f) Do you have any d i f -f i c u l t y hearing? Mr. F. did not answer. Wife says no. Turn q.2.h. and encourage him to do this himself more frequently. Be sure that Mr. F. has supportive shoes for walking. Losssof balance often pre-sent in hemiplegia; restrain in chair so he w i l l hot f a l l out. When he has acquired a sitting balance do not restrain but encourage him to s i t up in chair properly. Call light should be within reach at a l l times and make sure that he knows how to use i t . 285 Conrmun icat ion a) Do you have d i f f i c u l t y Speak slowly and give corn-understanding what plete explanation to Mr. F. people say to you? Talk with Mr. F. whenever Wife says that she thinkshe has nursing care and that he understands but oftener i f possible, seems slow to grasp what is sa id. Observation: Appears to understand what is said to him. b) Do you have d i f f i c u l t y reading? Wife says yes. Observation: Looked at NR's explanation sheet but did not seem to be reading i t . Medical findings: no note. c) Do you have any d i f f -iculty writing? Wife does not know. Observation: Right hemipleg ia-right handed? Does not use lef t hand much. Not interested when offered a pencil and paper. d) Are you able to say the things that you want to say? No. " Obs erva t ion: Seems aphasic. Medical Findings: "No return of speech." 286 Day XV In The Hospital ___£_ £tl Ifc* Day I Of The Observation of Mr. F. Time Person A c t i v i t i e s Other Obser« vations  June 25, 1970 7:50 NR A.M. Mr. F. Says good morning to Mr. F. Is awake, lying on back, not speak, but nods when spoken to. Does PN Explains to patient. He pulled up in bed f a i r l y e a s i l y . is NR a r r i v e s . 3 Appears to be aware of sur-roundings. Has thick cream coloured d i s -charge i n the r i g h t corner of his mouth. Is blowing out of r i g h t side of mouth when he breathes. Has catheter con-nected to s t r a -ight drainage. Suction machine on r i g h t side of bed. Mouth care equipment on bedside table at r i g h t of bed. 7:45 . PN + 0 Attempt to p u l l Mr. F. up i n bed. 7:46 A Says he can do i t himself i f you w i l l t e l l him what to do. Right hand at side on bed, fingers curled 287, Time Person Activities Other Obser-vations tinder. 8:00 Breakfast tray placed on over-bed table at end of bed. 8:01 HN Speaks to Mr. F. Wipes the material from his face with a paper wipe and uncovered and stretched the fingers of his right hand. 8:08 A Rolls Mr. F. up in bed and brings the table and trayito Does not speak the right side of his bed and to him. proceeds to feed him. Pours milk on porridge. Draws up approx. 3cc porridge into a syringe, puts i t into his mouth and ejects the contents. Holds a small paper cup of juice to his mouth. He drinks. Feeds him porridge with a Wipes his: mouth spoon. with the spoon when i t s p i l l s , onto his cheek. 8:13 A Talking to another aide while she feeds Mr. F. Other aide l e f t . 8:16 A Puts another 3 cc porridge into his mouth with a syringe as before. 8:17 A Feeding him coffee in a plas-t i c glass. Tells him that Standing on he is drinking very well. Mr. F's af-fected side. 8:20 A Aide leaves. 8:30 A Returns and gives Mr. F. the remainder of his fluids. Wrote 330 cc on his fluid s l i p . 288 Time Person A c t i v i t i e s Other Obser« vations  8:47 NjF Says "Hello Mr.---- you are looking better today." Walks around to the l e f t side of the bed and says, "I w i l l r o l l you down a b i t Mr.----, so that you w i l l not be so high." Leaves, (1 min.). 9:05 Right side of bed. Fingers one r i g h t hand curled -r e s t i n g on bed. NR leaves. NR returns. 9:55 NjF 10:00 0 NjF O NjF Puts basin of water onto bed-side table. Says, "Squeeze my hand as hard as you can. Good. Sque-eze with t h i s other hand, can you? No?" NjF proceeds to wash Mr. F. Removes covers, except f o r top sheet, o f f Mr. F. Pulls curtains around bed. She washes face, chest to waist, underarms, both arms then dries t h i s area with towel. Comes to bedside. Says to O, "I must check on Washes legs, his l a s t BM. I'm not sure." then dries legs. Washes crotch area. "Put your arm around my neck. I am going to p u l l you over on your side." Pulls patient toward her on r i g h t side of bed. Washes his buttocks. O leaves. "Now with your l e f t hand on the r a i l , you help turn your-s e l f away from me. That's N on r i g h t side 289 Time Person A c t i v i t i e s Other Obser-vations. good." NjF 10:15 N 2F N 9F of bed. Pat-ient does most of the work of turning. Washes, dries and powders Back s l i g h t l y back. Rubbing i t b r i e f l y reddened be-and gently, then goes to the tween the other side of the bed. "I shoulder blades am going to r o l l down the bed arid buttocks, and change your bed." Patient lying on l e f t side. Sheet put on bottom of the bed. Comes to bedside. NjF asked her to help her so that she could make the l e f t side of the bed. "To give your back a r e s t , Mr. ." Bottom of bed made and pat-ient p o s i t -ioned with pillows, sli-=; -ghtly on his r i g h t side. "Isn't there a footboard t h i s bed?" i n NjF "I w i l l see about getting one today. We have been using a pillow at the foot up to now." A second pillow was put between Mr. F's legs. His legs are fixed to give about a 120° angle. The bed is f l a t , his head does not look comfortable. N 2F Asks i f he would l i k e the head 290 Time Person A c t i v i t i e s Other Obser-vations  Mr. F. N 2F Mr. F. NjF 10:18 N 2F 10:20 NjF of his bed up. Nods, yes. Rolls the head of the bed up and asks him i f i t i s high enough. Nods negatively. Says, "this pillow might help" and puts pillow under his head. Patient nods yes. Leaves, (3 min.) Leaves a f t e r emptying bath water and tidying the u n i t , (25 min.). 10:25 Mr. F. Sleeping. Patient s l i g -h t l y on r i g h t side. Head of bed raised about 20° with 2 pillows under his head. Appears com-fortable now. Taking the syringe with her. Right wrist elevated from bed, hand rest i n g on bent fingers. G a l l l i g h t cord not i n reach. Bedside table with water on i t on r i g h t side of the bed. 10:30 NR to coffee. Time Person 11:20 Activities 291 Other Obser-vations NR returned. Mr. F's posi-tion etc. appears as above but he is now awake. Comes to l e f t side of Mr. F's Mr. F. facing bed and begins to r o l l up his right, nurse sleeve. Then t e l l s him that behind him. she is going to take his blood pressure. Puts the cuff on and takes i t . (2 min.) 11:41 Mr. F. Breathing noisy. 11:44 N^F Examines urine bag, (1 min.). Urine tannish-amber in color with some sed-iment. 11:3.8 NjF 11:55 N XF N 2F NjF Comes to l e f t s ide of bed and pulls the pillow from behind Mr. F's back and the one from behind his legs, and r o l l s the bed up approx-imately 15° more, then asks N 2F who is passing to help her to prop Mr. F. up for lunch. Helps her prop Mr. F. up. (1 min. ) Puts extra pillow beside his feet on top;of the covers and leaves, (2 min.). NjF does not speak to Mr. F, Right hand is on bed beside him, resting in a relaxed f i s t . 12:10 Lunch arrives and i t is put on table at 292 Time Person A c t i v i t i e s Other Obser-vations  12:15 PN 12:35 12:55 1:15 1:20 2:20 3:30 PN Mr. F. Mr. F. 2:40 PT the foot of the bed. Feeds Mr. F. soup with a spoon. Mr. F. l i f t s his l e f t hand to his mouth and PN pushes i t away and continues to feed soup. Returns and feeds him tea in a p l a s t i c glass. Lying on back looking around room. Hasn't moved any part of his body, other than his head, for approx. 30 minutes. Intake s l i p 1200-43Occ. Tray taken to kitchen. Wipes his mouth, mouth care. Gives him Has been turned to his r i g h t side. Wife i s v i s t i n g . NR to lunch NR returns NR to chart room. Physio dangles Mr. F. on side NR watches from of bed. doorway. (Physio states to nurse i n chart room that Mr. F. has some power in his r i g h t shoulder.) (NR overhears.) NR returns as wife leaves. Mr. F. on back, pillow on top of the bed on his feet. Left hand on his chest holding the covers. Right hand i n a f i s t 293 Time Person A c t i v i t i e s Other Obser-vations  beside him on the bed. Eyes closed, r e s t i n g , appears com-fortable. 3:40 4:10 N 3F 4:08 N3F N3F + O + PT PT + 0 Comes to r i g h t side of bed and says, "Hello, how are you Mr. F. does today?" (20 s e c ) . not smile, he just loOks at her, he shuts his eyes. Comes and t e l l s Mr. F. that Left side of they are going to get him up back s l i g h t l y and that she was going to get reddened, the orderly to help her. Help Mr. E. to get up and into a chair. Physio t e l l s Mr. F. that he has "one good leg and one bad l e g " and that he w i l l be slipped down o f f the bed onto his two feet. Help him walk 4 paces and turn him around and rlower him into a chair. NoF Mr. F. Brings over bed table to the chair and Mr. F. puts his feet on the bar at the base of the table. (7 min.). Holding his gown on his l e f t knee. He i s wearing grey socks. S i t t i n g in chair with only a gown on. Looks comfortable. Right hand is r e s t i n g on arm of chair. 4:19 N3F Asks Mr. F. i f he can feed himself with his l e f t hand. Mr. F. Nods yes. 294 Time Person Activities Other Obser-vations 4:22 4:56 5:00 5:00 5:07 5:08 5:10 5:12 5U5 N3F Mr. F. N 3F Mr. F. A. A A. Mr. F. A A Mr. F. A Mr. F. A "Are you right handed or le f t handed?" Moves his le f t hand. "You're le f t handed?" Shakes his head no. Puts cover over his knees and leaves. (3 min.). Supper tray is put on table in front of Mr. F. Puts soup into plastic glass and holds i t to Mr. F's mouth. Drinks. Puts tea into plastic glass with cream and sugar. Feeds him his custard. Feeding him tea. Splutters and coughs. Wipes up bit he spits up. Goes to another patient. Coughs and spits up. Hurries back and wipes his mouth. Returns to another patient. Does not speak to him. Giving him tea Finishes tea. Adds up fluids Lips bluish. Eyes appear frightened, face flushed. Eyes no longer frightened. Face loosing flush. Lips loosing cyanotic look. Seems to tolerate i t . 390 cc. NR home. 295 Day XVI in the Hospital Life of Mr. F. Day II of the Observation of Mr. F. Time Person Activities Other Obser-. vations  June 26, 1970 7:45 A.M. NR arrives. Patient lying on his right side uncovered, blowing out of the right side of his mouth. Catheter remains in place. Suction machine at bedside. No footboard in bed. 8:05 Mr. F. Eyes shut. Appears to be asleep. Break-fast arrives. Is placed on overbed table at end of bed. 8:10 PN L i f t s Mr. F. on to his back and up in the bed with the help of an orderly. 8:11 PN Raises head of bed. 8:12 PN Feeding Mr. F. cereal with a spoon. Cereal s p i l l s onto the right side of hie chin. 8:20 PN Wipes cereal off of his chin. Holds tea to his lips in a plastic glass. Mr. F. Drinks. 296 Time Person Activities Other Obser-vations 8:23 PN Leaves. 8:25 Mr. F . Looking intently at serviette in his left hand - just holding i t . Upper arm resting on the bed, fore-arm perpen-dicular to bed. 370 cc intake on s l i p . 8:35 HN Says good morning to Mr. F. Looks at his large abdomen and looks at his urine drain-age bag. Remarks that he feels hot and wipes some moisture from his forehead. Asks him how he is feeling. Mr. F . Says something that sounds like a l l right. HN "He needs a bath" HN says to N 4F who is passing the foot of Mr. F's bed. HN Asks Mr. F . i f he has had breakfast. Mr. F . Says something that sounds like yes. 8:50 Mr. F . Sleeping on his back. 9:03 N4F Calls out to PN, "is Mr. your patient?" PN . "No". N ^ F "I think we ought to turn him. He can't stay like that for 297 Time Person A c t i v i t i e s Other Obser-vations  long." Turns him with help of PN to his r i g h t side and puts a pillow behind his back. Right arm at ri g h t side, elbow on the bed. Wrist arched and fingers curled under. 9:06 N^F "This i s a bad day for nurses, there aren't any" and walks away. (3 min.) 9:09 Mr. F . Looking at name band on his l e f t arm. 9:20 Mr. F . Sleeping. 9:3,0 0 Does peri-care. 9:25 NcjF T e l l s NR that she i s supposed to go for coffee now and w i l l "do Mr. F . afterwards." Says "Hello I how are you to- He appears to day?" to Mr. F . Puts her look r i g h t by hand on Mr. F's affected her. She i s r i g h t hand. Then leaves. on the r i g h t (1 min.). side of the bed. 9:45 Mr. F . Sleeping. 10:25 Mr. F . Sleeping - respirations noisy. 10:27 N5F Asks orderly to wash Mr. F . O Washes front. PN Washes back. 10:35 N5F Examines Mr. F's back. Puts r i g h t arm passively through an almost f u l l range of Does not move 298 Time Person Activities Other Obser-vations  movements. Asks Mr. F. to arm across to do i t himself. chest to left shoulder. Mr. F. Li f t s arm about 2" off bed unaided. N5F Asks him to l i f t up his legs arid move them over. Mr. F. Lifts right leg approximately 3" off bed. Lif t s l e f t leg approximately 6" off bed. 1 0 : 4 0 N« - F Comments to PN that they really need two orderlies to get Mr. F. out of bed. PN Tells NcF and orderly that Mr. F. can stand on his feet. N5F Says she has not seen Mr. F. do i t . PN Pulls chair to foot of bed. Does not t e l l Mr. F. what O Pulls Mr. F. to sitting pos- they are doing, ition on the edge of the bed. N5F Says, "we won't put his socks on now, he might s l i p . " N 5p + 0 Slip Mr. F. off of the bed and on to the floor. Right side of back reddened. Mr. F. Begins to walk. N5F + O Take Mr. F. for a walk. Mr. F. is bare-foot. He walks N 5F Tells Mr. F. that he is doing about 3 0 feet. very well. Helps him to s i t in a chair. 10:45 N5F Puts a restraint jacket on 299 Time Person A c t i v i t i e s Other Obser-vations Mr. F. "Are you fee l i n g better today? You are doing quite w e l l , you know." Continues to t a l k to Mr. F. Puts on grey socks and a blanket over his knees. 10:47 PT "Just got up i n a chair?" N5F "We had him walking." PT "Good." Says to Mr. F., "You have a r e s t now and I w i l l be back l a t e r to exercise your le g . " N5F Leaves. (15 min.). 10:50 Mr. F. S i t t i n g i n chair, feet f l a t on the f l o o r , hands clasped together on chest. NR to coffee. 11:30 NR returns from coffee. Mr. F. S i t t i n g in chair. Arms at his sides. 11:40 Mr. F. Has slipped down in chair. Does not appear Looking around, eyes following comfortable, the movements of people i n the room. 11:45 A Puts towel under Mr. F.'s chin and brings overbed table to his chair. 12:00 PN Taking Mr. F's blood pres- Does not speak sure. to Mr. F. 12:13 Lunch put on overbed table 12:14 N 6 F With help of PN pu l l s Mr. F . in front of Mr. E. 300 Time Person A c t i v i t i e s Other Obser-' , vat ions  up i n the chair. "Do you think you could t r y to eat l e f t handed?" Mr. F. Does not answer. N 6F Feeding Mr. F. soup with a spoon. 12:18 N 6F T e l l s Mr. F. that she w i l l be back in a few minutes as she has to give another gentleman some soup. (4 min.). 12:20 Mr. F. S i t t i n g looking at tray. The tea i s s t i l l in the tea pot. Tray has not been arranged so that he can help himself. 12:45 PN Feeds him tea i n a p l a s t i c Did not ask him glass. i f he took cream or sugar. 12:50 Intake s l i p says 1300-550 cc. 1:00 NR to lunch. 1:30 NR returns. Mr. F. S i t t i n g i n chair. Feet on bar under overbed table. Has slumped down i n the chair. 1:40 PT Has a 4 point cane. Helps Mr. F. back to bed with NgF assistance from N5F. Mr. F. Walks back to bed with physio, using cane, about 20 feet. NgF + Help Mr. F. back on to the PT bed and lay him on his back. Mr. F. Clears his throat and blows 3 0 1 Time Person Activities Other Obser-vations out of the side of his mouth. Breathing is stertorous. 1 : 4 6 N 5 F + N 6 F Turn Mr. F . onto his l e f t side. Put a pillow behind his back and flex his knees. Breathing is not as ster-torous . N5F Raiseshead of bed about 3 " . Breathing is now f a i r l y quiet. 1 : 5 0 N 5 F Guides his right arm through a range of movements. Talking to him about exercising his arm. Telling him he is doing well. 2 : 0 0 Wife Is smiling. Tells NR that she 2 : 0 5 has been talking to the physio-therapist. NR to tea. 3 : 3 0 Mr. F . Sound asleep. Snoring on NR returned. back. Mouth (face) clean. 3 : 5 8 Mr. F . Opens his eyes, 4 : 1 0 N3F "Hello, Mr.---- how are you Nurse is on today?" patient's right side. Mr. F . His eyes do not appear to focus on her. ' N3F "Were you up walking today?" Mr. F . Does not respond. N3F "How about getting up in a few minutes for supper?" Mr. F . Shakes his head slightly negatively and forms what 302 Time Person A c t i v i t i e s - Other Obser-vations  appears to be No on his mouth. 4:11 N 3F "We w i l l be back shortly to get you up." Leaves. (1 min.). 4:18 Mr. F. Sleeping. 4:30 N3F Arrives with orderly and explains to Mr. F. what they are going to do. N3F Gets socks from cupboard and orderly puts them on. O Pull s Mr. F. to a s i t t i n g p o s ition on the edge of bed and explains what he i s doing. N3F + 0 S l i p him d i r e c t l y onto the f l o o r and walk him about 8 feet to a chair. N3F "Can you eat with th i s hand? We want you to t r y to do as much as you can with t h i s hand. We w i l l get your tray ready and you t r y to eat.: as much as you can." 4:35 N3F Asks Mr. F. to squeeze her hand with his l e f t hand and she t e l l s him that i t i s strong. (5 min.). O Sets Mr. F's urine drainage Right arm and bag i n a cardboard stand palm are rest i n g by the chair. on the arm of the chair. Places overbed table in front of Mr. F. 4:45 Supper arri v e s and i s put on overbed table 303' Time Person A c t i v i t i e s Other Obser-vations 4:50 4:51 4:52 4:54 4:56 5:00 5:01 Mr. F, A Mr. F. A A whl6h i s just out of Mr. reach. E's Does not t r y to "lean forward and bring the 'table closer to him. Puts pillow behind Mr. F's back. Pulls up a chair on the r i g h t of his chair and begins to feed him soup. i s c a l l e d away. Just s i t s . Is back and feeding Mr. F. Called away Returns and feeds Mr. E. Talks to other patients and continues to feed Mr. F. Turns her head away from Mr. F. but continues to feed him. Pours tea in the p l a s t i c glass. Adds cream and sugar. Holds glass to Mr. E's mouth. Called away. Leaves tea i n the glass on the tray. Tray has not been organized so that he can help himself. Does not speak to Mr. F. Does not speak to Mr. F. Does not ask Mr. F. i f he wants cream and sugar. Mr. F. Does not make any motion to-ward the glass. It i s f a r to the r i g h t side of the tray. 304 Time Person A c t i v i t i e s Other Obser-vations  •5:07 N 6F N 6F Mr. F. N 6F Mr. F. N 6F Holding tea glass to Mr. E's l i p s so he can drink. S i t s i n chair on the r i g h t of Mr. F. Asking patient i f he has had enough tea. Nods negatively. "Do you not l i k e cream?" "Would you prefer coffee at supper?" Does not answer. Holds his head i n his l e f t hand. "Do you want to go to bed, Mr. .?" "Almost a pot of tea, you did pretty w e l l . " Mr. F. Looks upset. N 6F Adds up Mr. F's intake and leaves. (6 min.). Looks d i r e c t l y forward. Looks to the l e f t . 5:15 NR home. Time spent, i n minutes with Mr. F. by general s t a f f h o s p i t a l nurses. June 24, 1970 N XF - 31 min. N 2F - 4 min. N3F - 11 min. June 25, .1970 N3F N4F N5F N6F - 6 min. - 3 min. -28 min. - 6 min. 

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