Dietetics for Nurses

by Fairfax T. Proudfit

PREOPERATIVE FEEDING

The dietetic treatment which is essential before and after operations is deserving of attention here, since it constitutes one of the points so frequently overlooked or slighted. As a rule the treatment depends (1) upon the character of the disease for which surgical intervention is necessary, and (2) upon the general health and physical condition of the patient in question.

Preparatory Treatment.—In many cases it is found to be advisable to build up the patient before subjecting her to the shock of an operation, and the more serious the operation the more necessary this “building-up” process.

The character of the disease also has much to do with the preliminary diet. In certain pathological conditions involving the gastro-intestinal tract, for example, the patient comes to the surgeon after medical treatment has failed to give relief and surgical intervention is necessary to save life. The body is found to be in a condition bordering on starvation, anemic and exhausted from insufficient nourishment. The functions of the blood-making organs have become out of gear, as it were, and the blood consequently is deficient in one or more of its essential elements. For such patients it is wise to attempt to reënforce and strengthen their bodies before operation, that they may have more endurance to withstand the shock which is more or less unavoidable.

Adjusting the Diet.—In any case where preliminary diet is prescribed the condition for which the operation is necessary determines the nature of the diet; for example, if the operation is to be upon the kidney, the diet beforehand would naturally be in the nature of a nephritic one to save the diseased organ unnecessary work. If the stomach or intestinal tract required surgical care, the diet would necessarily be formulated to meet the particular needs of the organ in question, an analysis of the stomach content furnishing the keynote of the diet. In any case the food must be simple in character and well prepared. All food in any way liable to bring about indigestion should be studiously avoided.

Habits.—The habits of the patient must be regulated so that she may not “overdo”; at the same time, gentle exercise may be the very thing needed to give an impetus to the appetite and thus assist in the adding of strength for the approaching ordeal. Many patients respond readily to a change of air and scene and frequent small meals instead of a few large ones,—a lunch in the mid-morning and mid-afternoon hours, consisting of a glass of milk and a cracker or malted milk chocolate or reënforced fruit juices. A cup of warm milk before retiring induces the much-needed sleep, hence is advisable under the circumstances.

The Bowels.—The bowels must be kept open. Coarse bread such as that made from bran or graham flour is advisable. Prunes and figs cooked with senna leaves are likewise simple laxatives which are both palatable and effective. For stubborn cases of constipation it is often found that a teaspoonful of a conserve made with a third of a pound each of raisins, prunes, and figs ground fine, with an ounce of senna leaves added, taken at bedtime and before breakfast, will overcome the condition and make the patient more comfortable and the general health better.

Preliminary Light Diet.—The day before the operation the diet must be light; the intestinal tract must not be filled with a food mass which is difficult to get rid of. On the morning of the operation the patient is given no food if the operation is to be performed at an early hour, otherwise a cup of tea, coffee, weak cocoa, or broth with a cracker is given. Some physicians give a glass of milk at this time, while others do not. It is the physician who must decide the question if there is any doubt about it. The stomach must be empty before administering the anesthetic.

In certain emergency operations when it has been impossible to prepare the patient ahead, the difficulties attending the administering of the ether are sometimes greatly increased. The cleansing of the stomach and intestinal tract oftentimes eliminates or materially decreases the nausea and vomiting which so often forms one of the most dreaded sequences of the operation. For this reason many surgeons require the patient to be given lavage before leaving the operating room.

Total Abstinence.—No food is given for twenty-four hours following the operation (1) on account of the nausea and vomiting which so often follows the giving of an anesthetic—ether particularly—and (2) because the entire organism is better for a complete rest.

Routine Treatment.—The routine treatment in uncomplicated cases is rest, then water, very hot or iced, or carbonated, or vichy in spoonful doses, then albumen water, broth, etc., then milk, buttermilk, koumiss, etc., after which the semi-solids, etc., until a normal diet is reached. After a week or more the character of the operation certainly determines the dietetic treatment. To quote Dr. Thomas S. Brown,[106] “To give the same diet after pyloroplasty, gastro-enterostomy, gall bladder operation, or gastric resection as we would after operations for fracture of the thigh or cancer of the breast shows a basic ignorance of the pathologic physiology of the former group of cases.” “We should remember that hyperacidity remains long after the underlying cause has been removed and it is tempting providence, to say the least, to ply these patients with tomato soup, salad dressing, and coarse food in the early stages of their convalescence.”

Character of Diet.—It must be kept in mind that the character of the diet is of vital importance, especially in the after-treatment of operations upon the stomach. In gastro-enterostomy, for example, the food mass passes from the stomach directly into the upper part of the small intestine through the new opening. Thus the semi-liquid food highly acid in character comes in direct contact with the delicate intestinal walls which are accustomed, not to the acid, but to a neutral or alkaline medium.

Adjusting Diet to Disease.—Thus it is demonstrated that unless care is used in selecting the diet this portion of the intestinal tract will be injured; hence the nurse must understand which foods are liable to stimulate an excess flow of acid in the stomach and avoid them. She must also keep in mind that the foods given must be in a semi-liquid or very finely divided condition, since the mechanical efforts made by the musculature of the gastric organ act as a direct stimulant to the secretory cells of that organ.

Much of the responsibility thus rests upon the nurse whose business it is to administer the diet. The efforts of the best surgeon in the world may be entirely overcome by a careless, thoughtless, or ignorant nurse.

Rectal Feeding.—In some cases it is found necessary to nourish the patient more than is possible by mouth. This is especially so with emaciated and very weak patients and for those who have undergone operations upon the mouth or throat and in some of the above-mentioned stomach cases when the passage of any food over the newly-operated-upon surfaces is inadvisable. In these cases rectal feeding is resorted to and from two to three nutrient enemas[107] alternated with saline enemas are given daily.

Under ordinary conditions when the patient has not been operated upon for gastro-intestinal disorders, gall bladder or kidney diseases, the dietetic régime is as follows:

Postoperative Feeding.—First day: starvation, a little hot or cold water or carbonated water may be given if there is no nausea or vomiting. If nausea or vomiting persists, a few spoonfuls of champagne or clam broth or juice will often check or relieve it entirely. Fluids alone must be given during the first forty-eight hours after the operation. When stimulation is necessary, albumen water or coffee containing a spoonful of brandy[108] will be found useful. When nausea entirely disappears, well-skimmed broth milk, clam or oyster broth, buttermilk, koumiss, malted milk, may be given. A gradual return to the normal diet is made, adding soft toast, soft-cooked eggs, junket, ice cream, meat, wine, or fruit jellies before solid food is introduced into the dietary.

After-care in Feeding.—Care must be observed to prevent indigestion after almost any operation, but especially after abdominal operations there is a great tendency to form gas, hence anything which in any way increases the tendency may bring about a condition of extreme discomfort and even acute pain to the patient. For this reason it is unwise to follow too closely the desires of the patient as to the food to be eaten; for example, corned beef and cabbage may be the thing of all others desired by the patient, but it would be the height of folly to risk such a meal until all danger of digestional disturbances is at an end. It is wiser to avoid such disturbances than to trust to relieving them after they occur. The digestion of even a perfectly normal individual is at a disadvantage when that individual is deprived of outdoor exercise. How much more so will it be when the entire organism is taxed by the ordeal through which it has just passed. Convalescence is never hastened by imprudent eating, and a condition as bad as the original may be brought on by lack of care on the part of the one whose business it is to feed the patient.