Dietetics for Nurses

CHAPTER XIX

DISEASES OF THE HEART

Dietetic Treatment.—No matter what has caused the impairment of the heart functions, the treatment must necessarily remain the same as far as diet is concerned. The patient is no longer able to handle a full and unrestricted diet. As long as compensation is good, the restrictions are scarcely noticeable; alcoholic beverages and possibly tobacco may have to be, to a certain extent, curtailed, and in some cases avoided altogether. However, if the individual desires to live and be comfortable while so doing, he must lead a wholesome, simple life, since he cannot with safety indulge in any excesses, either in diet or in any other particular.

Diet in Second Stage.—When the second stage sets in, that is, when the heart muscle is unable to perform its normal function, attention must be directed toward two main points; first, the work of the heart; second, the pressure upon that organ from other sources, namely, the stomach and intestines. As long as the food does not disagree, that is, so long as there is no fermentation or putrefaction of the food material in the stomach and intestines the flatulence arising from the evolution of gas in those organs is slight and the pressure upward upon the heart inconsiderable.

Restricting the Fluids.—The heart must be spared all unnecessary work. This can only be accomplished by limiting the amount of food and fluids ingested. The latter imposes an extra burden upon the impaired organ to eliminate. Consequently, the amount of fluid should be limited to 1500 c.c. a day at most, and in many cases considerably less than that quantity.

Regulating the Meals.—The meals should be small and the intervals of feeding regular. It has been found best to give the fluids between meals rather than with the food. In many cases of heart disease, as in certain nephritic conditions, edema is a prominent symptom, so that it is necessary to direct our efforts toward overcoming that particular condition. The Karell Cure[134] and the salt-poor diet are used with excellent results. The latter is not so low as the former, and in many cases will accomplish all that is required. A modified Karell diet is used in the Michael Reese Hospital[135] in Chicago as follows:

“MODIFIED KARELL TREATMENT”
(Salt-free)

“Milk 200 c.c. at 8 A.M., 12 M., 4 P.M., and 8 P.M., for five to seven days.

Eighth day—Milk same as above.

10 A.M. one soft egg; 6 P.M. 2 slices of dry toast.

Ninth day—Milk as above.

10 A.M. one soft egg and 2 slices of toast.

Tenth to twelfth day—Milk as above.

12 M. chopped meat, rice boiled in milk, easily digested vegetables.

6 P.M. one soft-boiled egg.

The diet is gradually increased until a full tray is reached. All meats and vegetables should be chopped or scraped at first, and the heavier foods should be given only when the heart is practically compensated.”

Rules and Regulations.—There are a few general rules which it has been found advisable to impress upon individuals suffering from a disease in which the muscles of the heart have become weakened. The compensation of the organ may improve, but there is still a danger of a reoccurrence or a further development more or less serious, and at times fatal. So for this reason, certain rules must be observed throughout life:

First: the necessity for keeping the meals small, simple, and digestible. Death at times occurs with symptoms of gastric disturbance, which is, after all, due to the heart. Consequently it is not wise to invite such disaster by overeating, or by the partaking of any food which is liable to bring about indigestion, either in the stomach or in the intestines. Most authorities advise four or five meals a day rather than the regulation three, and limit the fluids at meal time to a few ounces only, when any are allowed, and to a maximum amount of 1500 c.c. during the day, chiefly between meals.

Second: the need for limiting the amount and type of exercise taken, especially after eating, since the work of digestion requires all the power and strain of which the heart is capable, and since an additional tax placed upon it by muscular exertion might readily be just the final straw, the added fraction which weighs down the balance on the scale of life.

Third: the advisability of abstaining from alcoholic beverages, unless specially prescribed by the physician in charge.

Certain elderly people suffer from a condition known as senile heart, which is more or less associated with arteriosclerosis and high blood pressure. These individuals should be prevailed upon to take the precaution of regulating their habits of life, avoiding excesses of all kinds, not only on account of the weakened condition of the heart, but also on account of the condition of the arteries. They should avoid excitement and worry, since the very fact that they are worrying increases the blood pressure. Simple foods in limited quantities, five meals a day instead of three, and an avoidance of too much fluid, should be the keynote of their daily régime.

Tact on the part of the nurse is necessary in all cases, both young and old. It is often more difficult to instill good dietary habits in heart patients, after acute symptoms have subsided, than to carry them out during the acute attack, when the life itself depends upon a rigid adherence to the diet prescribed. But as these rules and regulations are essential to the future welfare of the patient, he must be taught with care, and in such a way that he will not be alarmed to an extent when more harm than good will come of the teaching.

The diet should consist chiefly of milk, eggs, rare meat in moderation (mutton, chicken, fish, and oysters), well-baked bread, well-cooked cereals, potatoes and green vegetables, and simple desserts. All foods which in any way cause gastric or intestinal disturbances must be avoided. If these disturbances arise during the course of the disease, the patient should be promptly returned to the strict milk diet. When edema is prominent, it is treated as already described in the treatment for the like condition in nephritis by the Karell or salt-free diet.

The dietetic treatment given here is merely a guide to be used under certain conditions. The physician formulates the diet, and the nurse must understand what to expect and how to apply the treatment as the symptoms arise.

SUMMARY

Dietetic Treatment, adjusted to relieve the weakened heart muscles and to save the organ from all possible strain.

Three Stages, during which the treatment changes according to the extent and progress made by the disease.

First Stage: The diet is practically normal. Compensation is good, consequently no dietary measures save the limiting of alcoholic beverages are necessary.

Second Stage: The compensation is only moderate and the heart cannot perform its normal functions, hence the diet must be directed toward relieving any pressure upon the organs from other organs and toward lessening the work of the heart itself.

Third Stage: In which the compensation is decidedly impaired and for this reason the dietetic treatment undergoes a decided change.

Digestional Disturbances in which there is an evolution of gas in the stomach or intestines may cause a pressure against the heart which is distinctly bad for it.

Limiting the Fluids in the diet in heart disease is necessary when the compensation is only moderate, as they impose an extra burden upon the organ to eliminate them.

Amount of Food must also be limited. The meals must be small and taken without fluid. The latter should be taken between meals.

Edema occurs in a number of cases and must be treated as in nephritic conditions by limiting the fluids and by confining the diet to “salt-poor” foods.[136]

Karell Cure or modification thereof has been used with good results in many cases of heart disease.

Exercise must be limited in amount and confined to types which will not impose a tax upon the weakened heart muscles. Exercise after eating is especially to be discouraged, as this, together with the efforts required for the digestion of food, might readily prove too much for the heart to accomplish.

Elderly Patients must be warned against exercises of all kinds, not only on account of the condition of the heart, but also on account of the condition of the arterial walls. These harden with age and break down under undue pressure.

The Nurse should instruct the patient on the points necessary for the saving of the heart. She should teach the necessity for keeping the meals small and having them more frequently if necessary; of limiting the fluids at meals to a few ounces or leaving them out altogether at this time. She should know how necessary is the reduction of the fluid. She should also warn against the taking of alcoholic beverages except with the permission and advice of a physician.

Excitement and Worry increase the blood pressure, hence must be avoided by individuals suffering with any form of heart disease.

PROBLEMS

CHAPTER XX

DIABETES MELLITUS

True Diabetes.—Allen claims that true diabetes may always be distinguished from nervous glycosuria by the application of the laws governing these conditions (Allen’s Paradoxical Law[137]), which is “whereas in normal individuals the more sugar given the more is utilized, the reverse is true in diabetes.”

Manufacture of Sugar from Other Foods.—If the carbohydrate foods alone caused all the trouble in diabetes, the disease might be more easily controlled. This, we found, however, not to be true, since in certain conditions the body utilizes the protein foods for the manufacture of glucose also. Consequently in diabetes if the absolute sugar output of the body is to be controlled, the intake of nitrogenous foods must be likewise adjusted.

Functions of Carbohydrates.—In the chapter describing the functions of the carbohydrates in the human body it was demonstrated that their energy-producing properties did not cover the extent of their usefulness. It has been proved that this food constituent normally acts as neutralizing agent for the toxic acids produced within the organism as a result of the breaking down of the fats. Hence, when this function of the carbohydrates becomes impaired, these acids, Oxybutyric acid, Diacetic acid and Acetone, fail to be neutralized and are consequently absorbed into the blood stream, giving rise to a form of intoxication known as acidosis. When acidosis becomes extreme, the diabetic patient is apt at any time to succumb to the dreaded diabetic coma.

Keeping Urine Sugar Free.—Thus it is seen that the treatment of diabetes mellitus consists not alone of freeing the urine from sugar and keeping it free, but of controlling the acidosis which may at any time develop.

Diabetic Cures.—Numberless so-called diabetic cures have been brought forward and more or less tested for years, but whether they have really accomplished cures has not been satisfactorily proved. Not until Dr. Allen instituted what is known as the Allen’s Starvation Treatment has the disease been so universally treated, at least by one method or modification of one method. Dr. Joslin, who has used this treatment most successfully, does not claim to have accomplished a cure, but states that he is watching the results of the treatment in his patients with interest.

Starvation Treatment.—The Allen Starvation Treatment consists of first a period of about forty-eight hours in which the patient is given an ordinary diet, during which time the daily weight is taken and the urine examined and recorded.

Acidosis.—It has been found in some cases, such as with elderly patients or those in whom there is an evident acidosis, advisable to precede the period of starvation by a preliminary treatment.

Method of Treatment.—Joslin[138] suggests the following method of procedure:

“Without otherwise changing the diet omit fat. After two days, omit protein, then halve the carbohydrates daily until the patient is taking only ten grams, then fast.”

In the Michael Reese Hospital, the following series of test diets are given to determine the severity of the diabetes:

Diabetic Test Diets[139]

Diet in Mild Cases.—This diet contains approximately 70 grams of protein, 100 grams of fat, and 70 grams of carbohydrates, and the patient is kept on it for at least two days; then the carbohydrates are cut down by taking away 25 grams of bread every day.

Diabetic Diets[140]

If the case is a mild one, this may be sufficient to free the urine from sugar, but the diet is given primarily to enable the physician to find out by means of urinalysis just how great is the functional impairment.

In some cases, which are mild in character, the urine is made free of both sugar and acetone without further dietetic measures. However, when a severe diabetes is manifested and a high percentage of glucose and in some cases acetone bodies are found in the urine a more rigid treatment will be found necessary.

Preliminary Diet.—Many physicians find it advisable, as has already been stated, to cut down the food allowance before stopping it entirely. In the Michael Reese Hospital this is done by first giving a practically fat-free diet, followed by one or two days in which three or four eggs, 250 to 300 grams (8 or 10 ounces) of 5% vegetables are given, after which it is found safe to institute the starvation treatment.

Sample Menus.—The following menus are given to illustrate the dietetic treatment which it is deemed advisable to institute in cases where the starvation treatment cannot be given at once:

After the test diet of forty-eight hours, the following régime is instituted:

Third Day

Fourth Day