Dietetics for Nurses

Chart Used in Johns Hopkins Hospital.—The following chart is inserted here to show the method used in the Johns Hopkins Hospital for carrying out the Two-hour Renal Test:

Urine to be collected punctually every two hours and kept in the ice-box, every specimen having twenty drops of tutuol added to insure preservation.

Another modification of the Hedinger-Schlayer diet is used in the Peter Bent Brigham Hospital,[131] Boston, Massachusetts, as follows:

On two days previous to the test the patient usually had a diet containing 2000 calories, 75 grams of protein, 4 grams of sodium chloride.

The test diet is a mixed diet containing known amounts of water, nitrogen, and chloride, together with the food diuretics (purins, salt, and water), as can be seen. The diet is divided into unequal portions containing known but varying amounts of fluid, nitrogen, and salt. Two-hour specimens are collected from 7 A.M. to 9 P.M., and one night specimen is obtained containing all the urine passed between 9 P.M. and 7 A.M. Each specimen is analyzed for volume, specific gravity, total nitrogen, nitrogen concentration, total chloride, and chloride concentration.

Purpose of Tests.—The purpose of the test is to find out to what extent and in what manner the diseased kidney under stimulation by the various diuretics taken in the food reacts in putting out the varying amounts of salt.

Dr. O’Hara likewise describes another test known as The Added Urea and Salt Test, which was first described by von Monakow and also carried out in the Peter Bent Brigham Hospital. The method used was as follows:

ADDED UREA AND SALT TEST

Patient is given 75 grams of protein, 4 grams of sodium chloride, and 1500 c.c. of water, with a caloric value of from 2000 to 2200 calories. After the output of fluid, salt and nitrogen reaches an equilibrium on this diet on one day 10 grams of additional salt is given and several days later the patient receives 20 grams of urea. This order may be reversed. The daily output of urine, salt, and nitrogen is determined and charted. After the salt and nitrogen is added to the diet in normal individuals, their excretion after forty-eight hours returns to its previous level. In diseased kidneys this may not be the case.

Value of Tests.—Thus it is seen that in these tests for kidney functions, an effort is made to determine the extent of damage wrought by the disease upon the renal organs and the manner in which they react under definite circumstances. However, it is not so simple as it would seem to formulate a dietary based on the findings resulting from the renal tests. Notwithstanding this, these tests are coming more and more into use, both in hospitals and private practice, and a nurse must understand just how they are carried out, and must realize that unless her part is performed with absolute accuracy the entire value of the test will be obliterated. Too much stress cannot be laid upon this phase of the test, if it is to be of any value whatsoever in determining the condition of a diseased kidney.

CHRONIC INTERSTITIAL NEPHRITIS

This form of nephritis is more insidious in character, developing more slowly and manifesting different characteristics, than those seen in some of the other types already mentioned. The condition is, as a rule, associated with heart symptoms and high blood pressure. The blood shows an increase in urea and other end-products of protein metabolism, whereas there is no manifest change in the metabolism of salt or water. The great increase in volume of urine voided would show an inability on the part of the kidneys to eliminate a highly concentrated urine. This hypothesis is further demonstrated in the urine tests.

Urinalysis.—Upon analysis the urine in these cases shows less albumen and fewer casts than found in other types of nephritis. The disease is manifested by slight headache, gastric disturbances, and a frequent desire to urinate.

Dietetic Treatment.—The treatment here depends upon the extent of the impairment of the functions of the kidney. If the damage is not extensive and the diagnosis has been sufficiently early to insure prompt improvement upon treatment, the diet is so directed as to prevent the occurrence of any of the acute symptoms. The patient is warned against overeating and drinking, over-exercise and nervous excitement. When it is possible, a change to a warm, dry climate is advisable with more rest and sleep and less work and worry. He is advised to eat less at meals and if hungry to eat a light lunch of milk or buttermilk with crackers in the mid-morning. The same dietary precautions must be taken in these disturbances as in other nephritic conditions, keeping always in mind the fact that the kidneys are the chief organs of excretion in the body, and through them must pass the majority of all end-products of nitrogen metabolism.

Limiting the Nitrogen.—The nitrogenous foods cannot be eliminated entirely, especially if, as is often the case, the individual suffers from chronic nephritis and is up and about attending to business; but they can be judiciously regulated in the diet. All such foods as fried foods, rich pastries, rich sauces and gravy, spices of all kinds, tea and coffee, celery and asparagus, must be avoided.

Limiting the Fluids.—von Noorden limits the amount of fluid to 1¼ liters per day. This does not include the water content of the various foodstuffs. He advises a period of observation to determine the amount best suited to the condition of the patient and reducing this amount from 250 to 150 c.c. a day until the desired quantity is reached. He advises a drinking day once a week, allowing the patient to drink as much water as he likes.

Development of Uremia.—Whenever evidences of uremia appear the treatment must be changed to meet the condition. It is necessarily more strenuous than that used ordinarily in the chronic nephritis. If the uremia becomes positive, then the treatment laid down for acute nephritis already described must be at once instituted. The patient must be put to bed at once and every effort made to assist the body in getting rid of the causes.

In certain cases of nephritis, in which uremic poisoning is due to the retention of the end-products of nitrogen metabolism, or to the toxins formed as a result of the tissue changes due to the disease, the water then instead of being restricted in the dietary is greatly increased to encourage a free diuresis with a consequent washing out of the accumulated poison. Certain authorities recommend a strict milk and water diet, as has already been described in the beginning of the chapter. A light or soft diet is advised until the condition improves, resting the renal organs as far as possible. This diet may consist of fruit juices, strained cereals with cream, cocoa, milk, buttermilk, toast, butter, strained apple sauce, cream soups, except those made with beans or peas. The above diet is gradually increased by adding a mashed or baked potato, well-cooked green vegetables, stewed or raw fruit, rice and tapioca pudding, and chocolate blanc-mange.

Selection and Preparation of Food.—The preparation of foods for the nephritic differs in certain particulars from that used in other pathological conditions, namely, the restriction of certain food constituents; dishes made with meat and eggs are cut out of the diet, and salt is used as sparingly as possible, when it is used at all. The nurse must weigh or measure out the maximum quantity allowed and divide this in portions for each feeding, measuring carefully any that is not used and charting it. In this way it is possible to increase or decrease the amount according to the symptoms of the individual. The water content of the various foods comprising the diet is, as a rule, not considered, but it is necessary to adhere strictly to the orders of the physician and to curtail the beverages, water, tea, coffee, etc., until the amount conforms to that laid down in the dietary.

The nitrogenous foods, with the exception of milk, are as a rule eliminated from the nephritic diet. The nurse must study the tables and learn which food materials come under this head. It may seem difficult to prepare diet for the sick without eggs, but it is possible and at times obligatory.

Combating Anemia.—In chronic (ambulatory) nephritis the anemia must be reckoned with. It is not safe to upset the nitrogen equilibrium of the body, but it has been proved that this may be maintained on as little as 30 or 40 grams of protein a day. This will be seen not to be difficult to obtain when milk forms an important part of the diet. The wheat and oat cereals, as well as the bread, contain protein, and a judicious use of these foods will enable the nurse to give her patient the necessary quantity to offset, in a measure, the anemia which is at times most troublesome.

Advice to Patient.—One important point must be observed by the nurse and impressed upon the patient when he leaves her care. This is moderation in the amount of food eaten. The kidneys must never be overtaxed, even with foods which in themselves seem harmless. As danger lies in overindulgence, this point cannot be too strongly emphasized.

Advice to the Nurse.—The use of the formulas included in this text is left to the discretion of the nurse. In those calling for seasoning, such as pepper, mustard, etc., the condiments must be omitted. A small amount of celery salt may be substituted in certain instances if the dish is unpalatable without something of the kind. In cases where the salt is restricted the dishes are prepared as directed, with the exception of the salt. The recipes calling for eggs and meat are not to be used unless directed by the physician. Cornstarch, sago, and tapioca may be used instead of gelatin. The following menus may be used as guides in selecting foods to prepare for the nephritic patient after the rigid régime is to a certain extent relaxed:

FULL NEPHRITIC DIET (NITROGENOUS FOODS RESTRICTED)

Breakfast

Grapefruit, orange, prunes, pears, peaches, or strawberries.
Cereals: cream of wheat, farina, Pettijohn’s, Ralston’s, hominy, grits, and oatmeal with cream.
Toast, buttered or creamed.
Cocoa, tea, or coffee, as directed by the physician.

Dinner

Milk or cream soup, well-cooked green vegetables with butter or cream sauce.
Potatoes, white or sweet, baked, mashed, or boiled, with butter, bread or rolls.
Stewed tomatoes, rice.
Salads: lettuce, tomato, romaine, chicory, or fruit salad, with a dressing of oil and lemon, or cream and lemon.
Simple desserts: junkets, cornstarch, sago or tapioca pudding, baked bananas, rice pudding, apple tapioca, orange tapioca, and ice cream.
Beverages: cocoa or tea, as directed by the physician.

Supper

Cereals and cream.
Baked or escalloped potatoes.
Baked or stewed apples.
Salads, excepting those made with meat or eggs.
Junket, raw or stewed fruit.
Toast or rolls with butter.
Cocoa.

Meat, fish or poultry once a day.[132]

Breakfast

Stewed or fresh fruit.
Cereals with cream.
Toast with butter.
Cocoa, milk, or tea.

Dinner

Cream soups.
Boiled chicken or fish.
Potatoes, white or sweet.
Green vegetables.
Salads, except with meat or eggs.
Simple desserts.
Rolls or bread and butter.
Milk or buttermilk.

Supper

Cereals or rice with cream or butter.
Baked or escalloped potatoes.
Stewed or escalloped carrots.
Salads, except those made with meat or eggs.
Fresh or canned pears, cherries, or pineapple.
Bread pudding, junkets, or cornstarch blanc-mange.
Bread, rolls, or toast, with butter.
Cocoa, milk, tea, or buttermilk.

TABLE

Salt Content of Food[133]

According to Leva

Analysis marked thus: * from Atwater & Bryant.

SUMMARY

The kidneys find difficulty in eliminating certain substances, namely, the end-products of protein metabolism—urea, water, salts, and purin bodies.

The Urine constitutes the chief point of investigation. Analysis shows the presence of albumen, casts, blood cells, and pigments, with a corresponding deficiency in the normal constituents, water, urea, and salts.

Volume of Urine.—The volume of urine is reduced, and at times suppressed, owing to the difficulty with which the kidneys eliminate water in nephritic conditions.

The Blood shows the presence of the toxic substances on account of the inability of the kidneys to eliminate them properly.

Edema is a common symptom and is probably due to the retention of salts and water by the tissues of the body. It is treated and at times relieved by limiting the intake of fluids and reducing the amount of sodium chloride in the diet.

Uremia is the most dreaded symptom and develops as a result of the retained toxins in the blood. Its development is prevented, if possible, by reducing the amount of fluid and food, even of milk, in the diet.

Uremic Poisoning is an acute intoxication due to the abnormal retention of these poisons and the inability of the kidneys to eliminate them. It is combated by instituting a starvation treatment which is followed by the above-mentioned restricted diet.

Gastro-intestinal Disturbances, especially diarrhea, are apt to develop in chronic nephritis. Care must be taken to keep the meals small in size, simple in proportion, and constituted only from the allowed foods.

Anemia follows the acute attack and is especially noticeable in those cases in which a rigid starvation régime has been found necessary. It may likewise be the result of a long-continued diet in which the proteins have been reduced to the lowest possible amount. The simple proteins in the diet must, at times, be increased and the patient advised to take plenty of fresh air and sunshine, in order to overcome this progressive anemia.

Restrictions in the diet are essential. These consist of limiting the amount of food and fluids as well as the type of food ingested.

Restricting the Proteins.—Proteins are restricted on account of the difficulty with which the end-products are eliminated by the kidneys, also on account of the toxic character of these substances.

Restricting the Fluids.—It is necessary, on account of their difficulty of elimination and because they impose an excessive tax upon the circulatory organs.

Treatment is largely dietetic in character by reason of the advantages just mentioned.

Starvation Treatment is instituted in order that the work of the kidneys may be lessened. This treatment consists of abstinence from food with a definite reduction in the fluid intake. It is found to be necessary during the acute stage of the disease.

Extreme Thirst, which is apt to be an annoying symptom at this time, is relieved, as far as possible, with small sips of water or ice pellets held in the mouth.

Nephritic Cures are devised, as far as possible, to relieve the acute symptoms and to prevent the disease from developing into a chronic condition. Milk is the basis of most of these cures. It is given in definite amounts at stated intervals; the quantity and frequency with which it is given being adjusted to the state of the disease and the condition of the patient.

The Karell Cure is one of the best known diet cures used in the relief of acute nephritis. It consists of the giving of skimmed milk three or four times a day in doses ranging from three to six ounces for one week, at the end of which time, provided the stools remain solid, an increase to two quarts a day is made.

Constipation under the circumstances is a favorable symptom, indicating as it does the agreement of the milk.

Diarrhea as a result of gastro-intestinal disturbances has directly the opposite indication. In these cases the milk must be reduced. Karell advises the boiling of milk and relieving the constipation by means of mild laxatives or enemas.

Duration of the Karell Cure is from four to six weeks, after which a gradual return to a normal diet is made.

Hunger is apt to be prominent at this stage of the treatment and is relieved during the second or third week by giving a small piece of dry bread and milk, soup thickened with a cereal, once a day.

Functional Kidney Tests are made to determine the character and extent of the impairment of the functions of the kidneys. The diets used in these tests contain definite amounts of certain diuretic substances, and the analysis of the urine voided during the twenty-four-hour period required by the test shows the nature of the impairment and furnishes, in a measure, a means of determining the amount of food and fluid which is safe for the patient to take. It likewise shows the extent to which the restrictions in the salt and proteins are necessary.

Salt-free, or Salt-poor Diets are necessary in some cases. While restriction in the amount of salt used in the preparation of food for the nephritic patient is always advisable, if there is a tendency to edema, the salt shaker should be left off the tray, and when there is a definite amount of salt prescribed, it should be weighed or measured for the day rather than for the meal, and the amount consumed recorded after each feeding.

Special Points for the nurse to remember are the necessity for an early recognition of unfavorable symptoms—of instructing the patient upon leaving her care in the need for keeping the size of the meals small;—of the danger of indulging in alcoholic or other stimulating beverages;—of eating highly spiced foods, or of eating anything which may cause gastro-intestinal disorders.

She should emphasize the need for regular examination of the urine and the value of rest and freedom from nervous excitement, and the need of living in the sunshine as much as possible.

The nurse should study the diet list and become familiar with the foods allowed and those to be avoided. The tables show the foods which are rich in salts and proteins. She should likewise understand and be able to make the simple test for albumen in the urine and the method of collecting the urine for the test made in the laboratory.

PROBLEMS