(a) List the food used in the treatment of enterocolitis; outline the method of administering the diet.(b) Formulate a convalescent diet for diarrheal cases.(c) List the foods used in chronic constipation; list the avoidable ones.
(a) List the food used in the treatment of enterocolitis; outline the method of administering the diet.
(b) Formulate a convalescent diet for diarrheal cases.
(c) List the foods used in chronic constipation; list the avoidable ones.
FOOTNOTE:[94]Malted foods are contraindicated, as malt exerts a very laxative effect.
[94]Malted foods are contraindicated, as malt exerts a very laxative effect.
[94]Malted foods are contraindicated, as malt exerts a very laxative effect.
Fever is an abnormal condition characterized by an elevation of body temperature, quickened respiration and circulation, and a certain amount of tissue waste. This elevation of temperature may be due to various conditions, such as local inflammation, infectious diseases, disturbed metabolism and food poisoning (ptomaine).
Tissue Waste in Fevers.—Fevers of short duration, such as accompany colds, tonsillitis, chicken pox and intermittent fever, remittent fever, and at times malarial fever, do not cause sufficient tissue waste to make the nutrition the important feature of the treatment. In ptomaine poisoning the tissue waste may be great, but it is the result of the poisoning, as is the fever, so that the diet needs to be adjusted only after the disturbance has abated. In the beginning, starvation is instituted and the fever disappears when the poisoning is controlled.
Treatment of Fevers of Short Duration.—In all fevers of short duration then, the treatment is directed with the following points in mind: (1) relieving the cause, (2) preventing gastro-intestinal disturbances, (3) saving the heart, kidneys, etc., extra strain.
Dietetic Treatment.—In doing this the diet is so formulated as to meet the above-mentioned conditions, and fluids seem the best form in which food can be given to bring about the desired results. The quantity of fluids should be small and the intervals between feedings short. Two-hour intervals seem best in the beginning. These intervals are lengthened as the fever decreases and theamount of food at each feeding increased. When convalescence is established, semi-solid, soft or convalescent diet may replace the fluids and the patient gradually brought back to a normal diet.
Fluid Diet.—The following foods constitute a fluid diet: milk, whole milk, plain, peptonized, or albumenized, buttermilk, koumiss, malted milk, milk shake, milk punch, cream, whey; fruit beverages, plain, albumenized, or mixed with whole raw egg; eggnog, milk and ginger ale, cocoa, strained gruels, broths reënforced with egg or plain. Carbonated water may be added to milk or fruit beverages.
Schedule of Feeding.—The following schedule may be used as a guide in fevers of short duration:[95]
I
The above furnishes approximately 750 calories.
II
Furnishing approximately 1500 calories.
III
Furnishing approximately 1460 calories.
The two night feedings may be omitted if patient is asleep.
These diets will be seen to be below the maintenance requirements in health, but the need for care in preventing gastro-intestinal disturbances makes it safer to have it so for a few days, especially if the elevation of temperature is great. After the temperature becomes normal the following foods may be added to the diet:
Soft or Convalescent Diet.—Cream soups, soft-cooked, creamed, or poached egg, soft or baked custard, junkets, egg, cocoa, or plain vanilla ice cream, soft toast, milk or cream, buttered toast, cereals, gelatin jellies, fruit, wine, or meat jellies, vegetable purées, baked white potato, apple sauce,baked apple, fruit whip, blanc-mange, broiled lamb chops, beefsteak, or chicken, sweetbreads, broiled or creamed brains.
Sample Menus.—The following menu is a sample convalescent dietary:
Breakfast
Dinner
Supper
The return to normal diet is made with caution that the digestion of the patient may not be upset or the temperature raised again by over-feeding.
Energy Requirements.—In fevers of short duration it is not difficult to regulate the amount of food necessary for the maintenance of the patient, since the body will, as a rule, adjust itself when the cause of the fever has been removed. At times, however, it is necessary to make an effort to tempt the appetite of the patient when convalescence is established, that recovery may be made more rapid and complete.
Care of the Mouth.—Probably there is nothing more essential in the treatment of fevers in general and typhoid fever in particular than the care of the mouth. Well-nourished patients rarely ever show the dry, cracked tongue and lips that was formerly one of the common occurrences in typhoid fever. However, in any febrile condition the mouth is apt to acquire a disagreeable taste; this “bad taste” is so prominent in certain cases as to render it difficult for the patient to eat. This can be, to a great extent, eliminated by the use of aseptic mouth washes. When the patient is not strong enough to rinse the mouth before and after eating, the nurse must use a swab for the purpose. The food must be carefully selected and attractively served and every effort made to make food as dainty and palatable as possible.
Thirst.—Thirst is relieved with crushed ice, fruit beverages, and carbonated waters. In certain conditions it is necessary to limit the fluids, but in typhoid fever the giving of the requisite amount of liquids is one of the most difficult tasks confronting the nurse. It is wise to find out the beverages particularly liked by the patient and, whenever it is possible, make use of them. As a rule alcohol is not necessary in the diet of typhoid fever patients. However, in certain cases of that disease, as well as in febrile conditions induced by other causes, the use of alcoholic stimulation may be necessary; it must be left to the discretion of the physician to prescribe it.
Intestinal Disturbancesare accountable for the majority of the fevers of short duration during infancy and childhood, and in many of those cases in adults.
Malariacauses an elevation of temperature which is, as a rule, of short duration.
Contagious Diseases, such as scarlet fever, measles, whooping cough, and mumps, are likewise accompanied by more or less elevation of temperature.
Treatmentconsists of a period of rest in bed, with an abstinence from food, in order that the disease may manifest itself, and also that any offending food material which may cause the fever may have an opportunity to pass out of the body.
The Heart, in some of the diseases accompanied by an elevation of temperature, is more or less strained; this is particularly true in tonsillitis, diphtheria, etc.
The Kidneysare likewise taxed in certain diseases, even when the fever is not great or lasting; this is found to be the case in scarlet fever, tonsillitis, etc.
Dietetic Treatmentconsists in giving no food for a period lasting from twenty-four to forty-eight hours. This is followed by a liquid diet, milk and broth particularly, which is continued as long as the fever remains.
Convalescent Dietis instituted as soon as the fever has disappeared and acute symptoms subside.
Thirstis apt to be great with any elevation of temperature. It is relieved by water, crushed ice, and fruit beverages.
The Mouthrequires much care, even in fevers of short duration. A simple antiseptic wash should be used several times each day.
Nitrogen Equilibriumis not sufficiently disturbed in such cases to require taking into account. Should thedisease, however, develop into one causing a material breaking down of the body tissues, measures must be instituted to prevent the upsetting of the nitrogen balance in the body.
(a) Outline the dietetic treatment for malarial fever.(b) Outline a diet order, using liquids only. Show method of reinforcing this diet.(c) Show how the solids are added as convalescence progresses.
(a) Outline the dietetic treatment for malarial fever.
(b) Outline a diet order, using liquids only. Show method of reinforcing this diet.
(c) Show how the solids are added as convalescence progresses.
FOOTNOTE:[95]In scarlet fever and other conditions in which the kidneys may be involved the above diet is not given unless advised by physician in charge.
[95]In scarlet fever and other conditions in which the kidneys may be involved the above diet is not given unless advised by physician in charge.
[95]In scarlet fever and other conditions in which the kidneys may be involved the above diet is not given unless advised by physician in charge.
Definition.—Typhoid fever is an acute infectious disease excited by specific bacteria (Eberth). The intestines become the seat of ulcerations (Peyer’s patches), which at times perforate. The chief symptoms of the disease are fever, headache, abdominal distention and tenderness, more or less diarrhea and a rose-colored abdominal rash. The source of infection is found in the intestinal contents of a typhoid fever patient, which in some way come in contact with and infect drinking water, milk, etc.
Energy Expenditure in Febrile Conditions.—In febrile conditions the energy expenditures increase as much as twenty-five per cent. In some cases, and when bacterial activity is added to this, as is the case in typhoid fever, the tissue waste becomes correspondingly greater; hence the nutrition assumes the chief rôle in such cases, for in no other way can the tissue waste and energy expenditure be met and overcome.
Energy Expenditures in Typhoid.—In typhoid fever the problem of meeting these expenditures, and at the same time protecting the heart and kidneys from the abnormal strain placed upon them in handling the toxic substances produced as the result of bacterial action in the intestines, becomes very real. It requires eternal vigilance and patience not only from the physician but especially from the nurse, with whom so much responsibility rests. The dietetic treatment necessarily is the principal point to which all efforts must be directed. By this is understood not only the type and amount of food given the patient, but the behaviorof this food in the body as manifested by the symptoms, namely, the appearance of the patient, the condition of the mouth, the abdominal distention, tenderness, diarrhea, nausea, and vomiting, the hemorrhage which at times occurs in spite of all care, and perforation which sometimes results in death, and acidosis or acetonuria. All of which makes this disease one requiring the most efficient attention from a nutritional standpoint.
Energy Requirements in Typhoid Fever.—In a previous chapter the energy expenditures of the normal individual were dealt with; it was seen that a man at rest, that is, in bed, not rising for anything, had a normal expenditure of energy requiring from 1900 to 2200 calories per day. Now, if these expenditures were increased twenty-five per cent. by the fever and still more by the bacterial activities, it is clearly seen that the diet must be increased in proportion if the tissue waste is to be prevented and the normal body weight of the patient maintained.
High Calorie Diet.—Dr. Warren Coleman,[96]to whom we owe so much for his pioneer work in feeding in typhoid fever, devised the so-called “High Calorie Diet.” This consists of foods of the most digestible type prepared in the simplest way. The weight of the patient is considered and the diet directed with the following points in view: (1) to cover the energy requirements of the body; (2) to make good the tissue waste which at times amounts to a loss of from 15 to 20 grams of nitrogen a day (or from ¼ to ¾ pound of muscle);[97](3) to check or prevent the development of serious complications, kidney, heart, etc.
In the Metabolism Ward at Bellevue Hospital, New York,[98]the best results are obtained by the giving of dietsfurnishing from 60 to 80 calories per kilogram per day, or from 4000 to 5500 calories.
Fluid Diet.—It is clearly seen that it would be practically impossible to obtain a sufficient number of calories by using milk alone or even a mixed fluid diet to supply the above requirements. Since milk alone in such a diet would probably cause such discomfort as to make it unwise to continue it, the ideal diet would seem to be one in which the fats, proteins and carbohydrates are furnished in a semi-solid or solid form, together with a sufficient amount of liquids to prevent too great concentration in the food, to relieve thirst, and to act as a carrier of reënforcing substances, such as lactose, eggs, casein products, etc.
Absorption Food.—The question as to whether the food is absorbed when given to typhoid fever patients has often been asked. That it is has been proved in the series of calorimeter experiments conducted in the Metabolism Ward, Bellevue Hospital.[99]Here it was demonstrated that under the high calorie diet the patient consumed large amounts of food with relish and that which was not utilized by the organism immediately was stored for future needs.
Diarrhea and Tympanites.—Constant attention and study of various typhoid patients taking a maximum amount of food a day has proved that the diarrhea and tympanites which at times occur in these as well as other cases are due to too much of one or another of the food constituents rather than to the general amount of the diet. Diarrhea may then be traced to an excess of cream, and the tympanites to an excess of lactose, and a reconstruction of the dietary will often obviate the trouble.
Increasing the Diet.—It is always advisable to “go slow” in adding new foods to the diet; milk, cream, eggs and lactose are the principal articles constituting the diet.To this are added fine cereal gruels, well-cooked rice, rice custard, tapioca custard, junket, ice cream, wine or fruit jellies, toast, eggs (soft-cooked, poached, creamed, or raw, in milk), or fruit beverages, cocoa, buttermilk, koumiss, certain proprietary infant foods such as Mellin’s Food, Eskay’s Food, Racahout and malted milk, with a well-baked potato, milk, cream or buttered toast added as the condition and appetite warrant.
Milk Diet.—The following milk diets[100]were devised by Dr. Coleman to be given in certain cases of typhoid fever during the acute stage. These formulas consist of milk, cream and lactose and furnish from 1000 to 3000 calories per day.
Calories1000 calories per day—Milk, 1000 c.c. (1 qt.)700Cream, 50 c.c. (1⅔ oz.)100Lactose, 50 gm. (1⅔ oz.)200This furnishes eight feedings, each containingMilk, 120 c.c. (4 oz.)80Cream, 8 gm. (2 dr.)15Lactose, 6 gm. (1½ dr.)242000 calories per day—Milk, 1500 c.c. (1½ qt.)1000Cream, 240 c.c. (8 oz.)500Lactose, 125 gm. (4 oz.)500This furnishes seven feedings, each containingMilk, 210 c.c. (7 oz.)140Cream, 30 c.c. (1 oz.)60Lactose, 18 gm. (4½ dr.)723000 calories per day—Milk, 1500 c.c. (1½ qt.)1000Cream, 480 c.c. (1 pt.)2000Lactose, 250 gm. (8 oz.)1000This furnishes eight feedings, each containingMilk, 180 c.c. (6 oz.)120Cream, 60 c.c. (2 oz.)120Lactose, 30 gm. (1 oz.)120
Varying the Diet.—It has been found possible, even advisable, to vary the above diets in many cases. The disease extends over such a long period that if a fluid diet is adhered to the patient would grow exceedingly tired and even disgusted if milk alone was given, hence a mixed fluid diet such as is used in the Presbyterian Hospital, New York City is suggested.[101]
PRESBYTERIAN HOSPITAL DIET LIST
15 gm. (½ oz.) of lactose added to each of the four milk feedings.
The following foods and diet lists are used with success in various hospitals:
From 1 to 1¼ quarts of milk and 1 pint of cream and lactose, beginning with 1 tablespoonful in each milk feedingand raising the amount day by day until the patient is taking 2 oz. (4 tablespoonfuls) at each milk feeding, given in eight feedings. This may be given as milk, hot or cold, or it may be made into cocoa, soup, ice cream, junket, or on the cereal.
Milk.Cream.Buttermilk.Whey.Koumiss.Zoolak.Fermillac.Albumenized fruit juices, egg, and orange juice.Milk shake.Broths (chicken, beef, mutton or clam), reënforced with lactose or egg or given plain.Proprietary infant foods.Cream soups, beef juice, liquid peptonoids, panopepton.Orangeade.Lemonade.Eggnog.Milk punch.Malted milk.Malted milk shake.Albumenized milk.Strained gruels (except oats).Cream, egg and vichy.Chocolate malted milk.Milk gruels.
Eggs—creamed, soft-cooked, poached, custards, baked custards.Toast—milk or cream toast.Gelatin—meat, fruit, or wine jellies.Junkets—plain, egg, or cocoa.Cereals—fine, strained cereals, except oats.Rice—boiled or in custard.Tapioca—custard.Baked or mashed potato.Cornstarch or arrowroot pudding.Ice cream.
Meat is not given until convalescence is established, and then in only the most digestible form, such as rare beefsteak or lamb chop or a small piece of broiled breast of chicken.
TimeMaterialAmountCalories6A.M.Hot milk4 oz.78Cream2 oz.76Lactose½ oz. (15 gm.)608A.M.CocoaMilk3 oz.59Water3 oz.Cocoa2 tsp.35Cream1 oz.38Sugar2 tsp.40Lactose½ oz. (1 tbs.)60Egg160Toast1 slice (well moistened)73Butter½ oz.7310A.M.Buttermilk6 oz.5612M.Cream of pea soup6 oz.300Mashed potato20 gm.28Toast1 slice73Butter20 gm.84Coffee and milk3 oz. each59Cream2 oz.76Sugar2 tsp.40Lactose20 gm.80Orange juice and eggOrange juice3 oz.383P.M.Egg160Lactose30 gm.1205P.M.Farina3 oz.102Milk2 oz.59Cream2 oz.76Lactose20 gm.80Egg160Apple sauce1 oz.30Cream1 oz.38Cocoa6 oz.108orTea and3 oz.0Milk3 oz.78Sugar2 tsp.40Toast1 slice737P.M.Gruel4 oz.102Cream2 oz.76Lactose15 gm (½ oz.)609P.M.Broth6 oz.18Egg white11312M.Milk4 oz.78Cream2 oz.76Lactose20 gm.803A.M.Milk or4 oz.78Malted milk1 tbs.58Cream2 oz.76Lactose20 gm.80Total calories3145
Advantages of Newer Treatment.—A marked difference is noticed in the patients treated by the old starvation diets and those given the high calorie diet. Dr. Coleman states[102]that while the range of temperature is apparently unaffected, the total duration of the disease is shortened in some instances by months through the shortening of convalescence. He further states that certain symptoms which have hitherto been attributed to the specific action of the typhoid bacillus have been discovered to be due to faulty methods of treatment, particularly to an inadequate or improperly balanced diet. The various investigators who have made the study and treatment of this disease a lifework claim that the mortality from this disease has been tremendously reduced by the use of the high calorie diets which maintain the nutrition of the patient throughout the disease, thus eliminating the horrors of the long, tedious convalescence which tried the nerves and patience of the patient, the nurse, and the physician. There is no doubt that so far as the administering of this diet is concerned it requires more effort on the part of the nurse than the old treatment of a glass of milk every two or three hours. It is necessary for the nurse to be able to carry out theorders as expressed in the diet lists, to be able to compute the proteins (nitrogen), fats, and carbohydrates in a food or recipe. But this is readily done by studying the tables given in the first section of this text. She must likewise be able to recognize the symptoms as they arise. In hospitals, the urinalysis is made as a routine procedure. In private cases the physician will either have the analyses made or expect the nurse to be able to make the simple tests.[103]
One of the greatest difficulties attending the administering of the high calorie diet is persuading the patient to take sufficient food for his needs. The fluids are often more difficult to give in quantity than the more solid foods, and it requires much tact on the part of the nurse to prevent a refusal of the necessary fluids. However, if the patient is possessed of even ordinary intelligence, an explanation of the reasons for the large amount of food will as a rule be all that is necessary. Few individuals will willingly prolong an illness attended with the discomforts generally present in typhoid fever.
Hemorrhageoccurs in a certain percentage of cases of typhoid regardless of the diet, whether it be a strictly milk diet or the high calorie diet just described. The measures to combat them are essentially the same. It is necessary to guard against excessive tympanites since the pressure therefrom against the ulcerated intestinal walls may cause perforation resulting in hemorrhage. Lactose at times causes an evolution of gas as do fats under certain circumstances. Hence it is necessary to follow symptoms and watch the stools in order to determine which food material is to blame for the tympanites and reduce the allowance of that food in the diet.
Idiosyncrasies against Milk.—Certain individuals manifest an inability to take milk. This may be real or imaginary. When it is a true idiosyncrasy, it may be foundnecessary to substitute some other food for the milk in the diet, but great care should be taken to determine the real character of the disagreement before eliminating so invaluable a food from the diet. When the disagreement proves merely a distaste for milk, some of the different methods used in disguising it, such as flavoring or coloring, may be practiced. Otherwise, it is well under the circumstances to use some of the pre-digestive methods in order to increase its utilization. It is well to emphasize the value of accurate data on this subject as it is exceedingly difficult to administer a high calorie diet without milk in some form.
Essential Points.—Thus the dietary in typhoid fever is seen to be the most important part of the treatment. A careful study of the tables will enable the nurse to do her part in nourishing the patient. It is necessary that she be able to compute the nitrogen, carbohydrates, and fats in a diet and arrange these constituents in such a way as to give the desired amount of each in the dietary and in a form acceptable to the patient.
Rate of Metabolismis greatly increased in typhoid fever even over other febrile conditions, not only on account of the elevation and duration of the fever, but also on account of the activities of the specific bacteria in the intestinal tract which differentiate this disease from other febrile conditions.
Energy Expenditures and Requirementsof the body in typhoid fever, on account of the character of the disease, are much greater than those of the normal individual and must be met by an increase in the diet if the body is to be saved from destruction.
The Bowels.—Diarrhea develops during any period of the disease due to excess amount of fat or to a disagreement of some of the other food constituents. It is advisable tocut down the allowance of cream temporarily and to watch stools and other symptoms for evidences of dietetic errors.
Hemorrhagemust be guarded against by eliminating, as far as possible, all substances liable to cause an excessive gas formation in the intestines.
Absorption of Foodis as a rule good. The patient is usually able to handle a large quantity of food provided it is judiciously administered with a due regard to the symptoms manifested at the time.
Simplicity of Dietis absolutely essential. All the materials must be selected carefully according to the physician’s orders and prepared with the greatest care in order to prevent digestive disturbances.
High Calorie Dietis one in which the fuel value of the food ingested meets or exceeds the energy expenditures of the patient. Foods composing the diet are, milk and eggs for the proteins, with carbohydrates and fats in their simplest and most digestible form to balance the diet.
Administering a High Calorie Dietis accomplished successfully provided the nurse exercises care with regard to the symptoms arising from time to time. These must be carefully noted and reported to the physician, for in this way only is it possible to give a sufficient quantity of food to cover the excessive breaking down of the body due to the disease.
Fluid Dietis at times necessary since certain patients cannot tolerate a high calorie diet, but this is a point decided by the physician. A fluid diet consists of fluids alone, milk in particular, with broths and fruit beverages as ordered. The milk is given in definite amounts and at stated intervals.
Milk Dietis one consisting solely of milk or in which the bulk of the nourishment is furnished by milk. It may be reënforced or not as desired. Lactose is the substance commonly used as a reënforcing agent. It is impossible tocover the energy expenditures of typhoid fever with a milk diet even if it is perfectly administered, but certain complications make it, at times, the only rational method of feeding.
The Advantages of High Calorie Dietover other diets are distinctly noticeable in typhoid fever patients. Those treated by this method are more comfortable during the course of the disease and are saved a long, tedious convalescence which has made the starvation treatment a thing of horror in the past. The return to health is attended by a much better physical condition when the patients are well nourished than is possible when they are kept on practically a starvation ration. The mortality from the disease has been materially lessened by the administration of the high calorie diet.
Acidosismay develop in typhoid fever patients and must be guarded against. The behavior of the fat in the body should be carefully watched and the amount reduced at the first evidence of acidosis. At the same time an increase in the carbohydrates may assist in overcoming the condition. This adjusting of the diet, however, is entirely in the hands of the physician.
The Kidneysin typhoid fever patients are under a great strain, chiefly on account of the increased rate of metabolism. Great care must be exercised in the dietetic treatment to prevent these organs from being overworked with a consequent development of nephritic conditions.
Care of the Mouthin any febrile condition is important, but especially so in typhoid fever, where the disease itself causes a most unpleasant taste in the mouth. This prevents the taking of nourishment with any degree of comfort, hence the mouth should be cleansed before and after each feeding. Any of the aseptic mouth washes may be used.
Thirstmay be relieved by plain or carbonated waters,fruit beverages, and crushed ice. When in certain complications the fluids in the diet are in a measure restricted, ice is used and water is given in spoonful doses. This, however, is the exceptional, rather than the ordinary state of affairs.
Increasing the Dietafter a fluid diet must be made with great care in order to prevent a relapse. Following the high calorie diet the increase is simple. The patient passes from the prescribed foods to meat with apparently no effort. The increase should not be made, however, until convalescence is firmly established.
Reënforcing the Diet.—On account of the great increase in the rate of metabolism and because of the difficulty of furnishing the requisite number of calories in the diet, reënforcing agents such as lactose, eggs, some forms of casein, or beef preparations are used.
Idiosyncrasiesagainst certain foods are, at times, manifested by patients. Efforts must be made to determine whether they are real or imaginary before eliminating any food which may be of importance to their future welfare.