NURSING CARE

Increased physical activity imposes a demand which is met by increased
cardiac output and thus physical rest as a cardinal principle in the management of heart failure is well founded. In many cases rest in bed in a position of optimal comfort and the securing of sleep may result in the rapid onset of diuresis, loss of oedema and a general return of well-being. The position of the patient should be that which he finds most comfortable : patients with con¬gestive failure are unable to lie flat. They should be propped up with a sufficiency of pillows or a backrest, day and night. Many, particularly the obese and those distended with ascites, are better to be nursed either sitting in an old-fashioned armchair with high back and sides, or in a cardiac bed, the head of which may be raised and the foot dropped, so that cedema tends to gravitate to the legs and buttocks, and relief of pulmonary congestion with corresponding increase in comfort results. In extreme cases, a bed table well padded with pillows can be placed in front of the patient, who can then lean forward with his folded arms resting on this support. The patient at complete rest must have meticulous nursing care, attention being paid particularly to the pressure sites liable to necrosis and to bed sores, to w^ich the oedematous unhealthy condition of the skin of the''back and heels is particularly prone. To reduce energy expenditure to the minimum, skilled nursing is essential; these patients must be washed and fed and attended to in every way. While the use of a bed pan is usual, it should be remembered that the energy expended by a stout elderly person in attempting to-use it may be greater than that involved in lifting him gently over the bed on to a night commode. In patients with gross genital cedema, urination may be difficult and recourse must on occasion b'e~made to an indwelling catheter despite the formidable attendant risks of infection.
The duration of rest in bed is variable and depends in large measure on the response to treatment. In patients in whom. the signs of congestive failure resolve within a few days and particularly in those in whom a remediable cause has been found and treated, the period of bed rest may be no more than ten days. More commonly improvement occurs more slowly and a month in bed may be required before a gradual return to activity is permitted. When oedema is resistant to treatment, the period of rest in bed may be indefinitely prolonged. It should not be forgotten that patients confined to bed for prolonged periods—and particularly those in whom the circulation is slow as in congestive failure—are liable to develop venous thrombosis, commonly in the legs. This complication must be sought for by daily examination of the limbs and shoui'd be treated energetically with anticoagulants if detected (p. 589). Neglect of this precaution may lead to serious or fatal pulmonary embolism. It is important that a patient confined to bed for a considerable time should have appropriate physiotherapy to prevent excessive wasting of his muscles.
Restless nights with at best brief snatches of sleep are the common lot of the patient in cardiac failure. Much distress and exhaustion ensue, and the securing of adequate sleep is of major importance. In general morphine is the most satisfactory drug for the purpose, at least in the early stages of the illness. With it a patient may be afforded untroubled sleep throughout the night with relief of distress and benefit to his general condition. The usual dose is from 10 to 20 mg. (^ to ^ gr.) hypodermically; in adults of large build up to 30 mg. (- gr.) may be required. For most patients who have suffered a myocardial infarction or have been precipitated into failure by one cause or another it is perfectly safe, but there are certain contraindications to its use. It is not a drug to be given thoughtlessly to those in whom a respiratory infection plays a major role in the production of failure, and above all it must not be given to a patient suffering from cor pulmonale or bronchial asthma. In such cases morphine may be lethal. It is also dangerous and occasionally fatal to the patient in cardiac failure secondary to gross spinal kyphoscoliosis. For those who are sensitive to morphine (and they are more numerous than is generally supposed) another analgesic may be substituted, such as methadone or pethidine, or cyclizine can be given along with the morphine.
In many patients sleeplessness is due to dyspnoea, and therapy for the relief of breathlessness may lead to peaceful sleep without the use of hypnotics. For this purpose, aminophylline is the most satisfactory drug : in a dose of 0-5 g. intravenously, given slowly and well diluted, it commonly gives dramatic relief. It is particularly valuable in the patient suffering from dyspnoeic failure in the later stages of hypertensive heart disease and it is specific in the treatment of Cheyne-Stokes respiration. Oral treatment with aminophylline (0-25 g.) is less effective and is apt to be defeated by production of nausea. When sleeplessness is due to pain, morphine or its analogues are, of course, indispensable.
While at the outset morphine is invaluable, it is not suitable for continuous therapy during the course of a long illness. Sleep may be promoted in the long-term case by milder hypnotics. Among these, chloral hydrate has a deservedly high reputation, though it is greatly disliked by some patients on account of its unpleasant taste. The average dose is 0-6 to 2 g. (10 to 30 gr.) well diluted with water. The stabilized solid derivatives dichloralphenazone in a dose of 0-6 r:
2 g. (10 to 30 gr.) and trichlorethyl phosphate, i g., are useful preparatioci Alternatively one of the barbiturate drugs may be used such as amvlbar-bitone, quinalbarbitone sodium, or some: equivalent preparation with the action of which the' doctor is familiar. In critically ill patients in whom the use of morphine is for one reason or another inadvisable, an intramuscular injection of 8 to 10 ml. of paraldehyde is a safe hypnotic, 4 to 5 ml. being injected into each buttock