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daily baths and sponges and whatever hydriatic measures are prescribed. After a cool sponge or a prolonged bath the mental symptoms may be so allayed that the patient goes off into sound and refreshing sleep. An ice bag applied to the head, or cold compresses over the forehead and eyes, will sometimes do much to lessen the mental activity. Every source of sense stimulation should be eliminated and absolute quiet should prevail. Do not permit conversation in the room and move about as quietly as possible. Keep the patient from injury during the periods of excitement and depression. As much fresh air as possible should be provided, and whenever feasible the patient should be sufficiently protected and the bed rolled into the open air, or placed close to an open window.

Occupation. Convalescence is very slow and the patient is usually much weakened and is easily fatigued, and upon the nurse devolves the duty of arousing interest by reading aloud and telling stories, exhibiting pretty and useful articles which have been made in the occupation department, etc. As the physical strength is regained the desire to do something is usually expressed, and some forms of light handiwork which make little demand on the physical strength, may be given for short periods. Gradually more time each day may be spent in this way.

CHAPTER XII

NURSING IN THE CONSTITUTIONAL PSYCHOSES

MANIC-DEPRESSIVE PSYCHOSIS

This disease is characterized by recurring attacks of acute emotional disturbance, elation or depression, without deterioration, and by recovery from the attack. The attacks are in one of four forms, manic (excited), depressed, mixed (comprised of both manic and depressed), and circular (characterized by a manic attack followed by a depressed attack).

Manic attacks: Physical symptoms. There is motor restlessness and general overactivity. The face is flushed; the eyes may be more or less injected; the mouth and lips are dry, or the mouth may be frothy from incessant talking; the skin feels hot and dry; the temperature may be slightly elevated and the pulse rate increased.

Mental symptoms. Emotionally the patient is happy and elated, and may be playful and mischievous, or combative and antagonistic. Disturbances of attention and the stream of thought as shown by distractability and flight of ideas are prominent. The patient is almost incessantly chattering and the speech is characterized by an excessive flow of words which are glibly spoken. The conduct is overactive, and may be impulsive, violent and destructive. Memory shows no impairment; hallucinations are rare and fleeting; delusions are few; consciousness remains clear except in great excitement when there may be clouding and the speech may be incoherent.

Nursing procedures. These patients are kept in bed during the period of acute excitement, isolated in a room where quiet is possible and all sources of sense stimulation

are reduced. Unnecessary furniture, articles and pictures should be removed and visitors excluded, except when authorized by the physician, for these patients are so impressionable that the least sound, movement or change is noticed and immediately calls forth some response. Special care should be given to the mouth, tongue and teeth, and the lips should be kept moist by the application of glycerine or vaseline. The usual baths will tend to relieve the dryness of the skin. The fingernails should be closely trimmed to prevent scratches. Special attention should be given to the diet, for in all cases of overactivity nourishment and fluids must be taken in sufficient quantities to make up the depletion. Often the patient is too busy to eat, and much time and perseverance are required to accomplish results. Utilize the factor of distractability by diverting the attention in ways already described, and spoon-feed the patient. By taking advantage of every opening a full meal may sometimes be administered. Avoid, in so far as possible, everything which tends to irritate the patient. Do not enter into discussions and keep in mind that abrupt, sharp or sarcastic answers are a frequent source of irritation. Tactfully avoid answering questions which would lead to discussions by diverting the attention to something else or by asking a question which demands an immediate answer. Control the activity by distracting the attention to something else or suggesting some other form of activity, and avoid peremptory commands to desist or to do, for these too often have the effect of strengthening the determination to persist in the undesirable activity and make management much more difficult. Sharp answers, peremptory commands, discussions and conflicts frequently lead to violent attacks, for the power of inhibition is so diminished that the patient does the first thing which comes into mind without considering the consequences. Prolonged and continuous baths and wet packs are usually prescribed by the physician to aid in reducing the excitement. Too often patients in hospital receive the impression that the pack is a form of

punishment, and every nurse should do all in her power to banish this idea and establish the correct one that it is a valuable measure of treatment which the physician alone prescribes. When baths and packs have been continued over a considerable period of time, the skin may become excoriated from the friction against the wet sheets and hammock, and special measures must be taken to prevent this condition. Upon removing the patient from the pack, a shower or sponge bath should be given, the skin thoroughly dried and rubbed well with alcohol and a dusting powder applied to any parts which are reddened. If there is evidence of rash or other unusual condition, the physician should at once be notified, for packs and baths may be contraindicated. The measures which may be employed during periods of excitement have already been described in a previous chapter, and these should be made use of when indicated. Sleep is of the utmost importance, and the nurse should exhaust every means at her command to induce it, and only as a last resort should she make use of the drugs which have been conditionally prescribed. There is, perhaps, no surer test of good nursing than to be able to get one's patients comfortable and quiet without sedatives, and to sleep without hypnotics.

Occupations. As soon as possible, try to direct the activity of the patient, for the restlessness and constant movements are merely the outlets for the increased mental activity. Only those forms of work which make use of the coarser movements should be attempted; tearing rags for rugs and rolling them into balls, tearing bandages and later rolling them, rake knitting and knitting on large needles with coarse yarn may be tried. Some tasks in the housekeeping, brushing the floor, sweeping a rug, washing small articles, scrubbing a table top or shelf and pushing a floor polisher, may also be given. Destructive tendencies can be directed to picking hair, ravelling old stockings and bed spreads and tearing strips for rugs. As the acute symptoms subside, long walks in the open air, skating, gymnastics,

bowling, weights, dancing, etc., may be permitted. In the choice of games it is better to avoid those which have a competitive element in the beginning, as this is likely to prove too stimulating and precipitate excitement. Gradually, as emotional control is gained, this element may be introduced with benefit. Music and dancing are always enjoyed, and when the activity can be directed in no other way, the patient will dance, and finally sit quietly and engage in some form of handiwork.

Restraint in many and various forms was once much employed for the control of maniacal and delirious patients, but it is a form of treatment which has gradually been discontinued and many hospitals to-day do not permit its use. Hydrotherapy has been substituted with gratifying results. In hospitals where it is still employed the rules governing its use and application are very strict. The forms which are authorized are prescribed, as well as the duration of the treatment and the keeping of records regarding the same. Only in extreme cases of excitement, when no appeal is comprehended, and the patient becomes a danger to himself and to other patients, the physician orders the application of the protection or safety sheet. This allows some freedom of movement, but at the same time controls the aimless, violent activities. Not infrequently the patient is so exhausted that he will go to sleep soon after being placed in the protection sheet, and will wake up quiet and manageable.

During this treatment the patient must be watched carefully, the pulse and respiration should be taken frequently and water given freely. The face and neck should be bathed with cold water and an ice bag applied to the head. When removed from the sheet, the patient should be given a bath, fresh bed gown and placed in a bed which has been newly made.

Depressed attacks: Physical symptoms. The skin looks dull, feels cold and is usually moist; the hair is dry and the fingernails are brittle; the temperature may be slightly subnormal; the pulse is slow; the tongue is coated; the

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