Chapter 24

FEEDING THE SICK

Substances used for food are generally grouped into three classes, called the three nutrients. The nutrients are: first, the proteids or nitrogenous substances, which are found in meat, fish, eggs, milk, cheese, peas, beans, etc.; second, the carbohydrates, which include sugars and starch; and third, the fats, which are found in butter, oil, the fat of meat, etc. In addition to the nutrients, water and certain mineral salts are essential to life, while some indigestible material like the fibre of vegetables is needed to give bulk and to stimulate the action of the intestines.

The nutrients furnish the body with materials for growth, and for repair of tissues worn out by use; they also furnish fuel substances from which the body obtains its heat and its energy. All three nutrients can serve as fuel, but the proteids alone can furnish materials for growth and repair of tissues. In order to be used by the body for any purpose, nutrients must first go through a series of complicated changes known as digestion, which renders them soluble so that they can soak through the walls of the intestine.

THE DIGESTIVE PROCESS

Digestion begins in the mouth. There the food is crushed and its fibres separated by the teeth, it is moistened by the saliva, and substances in the saliva begin a chemical action upon the starch. Chewing should be sufficient to reduce the food to a soft mass well moistened with saliva. Slow eating is desirable, but the emphasis should be placed on thorough chewing. For instance, long intervals between bites are of no special benefit if mouthfuls of food are washed down by swallows of water.

After it has been swallowed, the food passes into the stomach and remains there for a variable length of time, while it undergoes further preparation for absorption. It is moved about by the contraction of the muscular walls of the stomach, so that it becomes mixed with the stomach juices and more thoroughly softened. Some digestion of proteids goes on in the stomach, and a little absorption through the walls.

Little by little the food is discharged from the stomach into the small intestine, and the most important part of digestion then begins. It is acted upon chemically by a fluid flowing into the intestine from an organ called the pancreas; this pancreatic juice acts upon all three nutrients and is of great importance in the digestive process. The bile and other juices that flow into the intestine perform important functions also.

The food masses are moved along by rhythmic contractions of the intestine, and absorption goes on when the food has been so changed that it can soak through the intestinal walls into the blood and lymph vessels. The small intestine is about 20 feet long, and consequently affords a large surface for absorption, as does also the large intestine, into which the small intestine opens. The blood and lymph carry the digested food substances to all parts of the body, and thus the different tissues are provided with the materials they need for growth, repair, and energy. Excess of food substances may be stored as fat or expelled from the body.

As the blood and lymph go through the tissues they take from the tissues the refuse, or the part that remains after the fuel substances have been consumed. This refuse from the tissues may be likened to the ashes from a furnace; it is finally eliminated from the body through the kidneys and lungs, and to some extent through the skin and bowels. The part of the food that is not digested of course never soaks through the intestinal walls; it merely passes through the small and large intestines and is finally expelled as feces or bowel movements. The characteristic odor of fecal matter results from the action of bacteria upon it while in the large intestine.

It must be remembered that the body is not nourished merely by swallowing food: in order to nourish the body food must also be digested, absorbed, and made use of by the tissues. Many factors may operate both in health and in sickness to render food indigestible. It may be originally unsuited to the human digestive apparatus, or spoiled, or poor in quality, or badly cooked. But even when wholesome in itself it may be ill-adapted to a particular person at a particular time; thus it may be too great in amount, or eaten at improper hours. Moreover a person's own idiosyncrasy or manner of living or fatigue or illness may render it especially indigestible for him.

Experiments have shown that pain, fear, worry, and other unpleasant emotions actually stop the action of the digestive juices and check muscular contractions of the small intestine. Furthermore, even the absence of pleasant anticipation of food has been shown to delay digestion for hours. Thus scientific knowledge confirms our common experience that such mental states seriously interfere with digestion. The converse is also true. Agreeable taste and odor of food, or even pleasurable thought of it, start the secretion of digestive fluids. It is a common saying that the mouth waters at the prospect of inviting food, but it is less well known that appetizing food does actually start the stomach juices also. A person who understands the physiological effect that the emotions have upon digestion is in a far better frame of mind to cope successfully with the difficulties of feeding the sick than one who considers sick persons' likes and dislikes entirely irrational.

FEEDING THE SICK

Nourishing the sick is not always an easy problem, but its importance can hardly be overestimated. Indeed, proper feeding in many illnesses makes the difference between life and death. The actual amount of nourishment needed in sickness is often less than in health, but it may be just as great, or even greater if the illness causes increased tissue waste. Yet the digestive process of a sick person must be rendered as little laborious as possible, all foods ordinarily difficult to digest must be eliminated, certain others must be withheld or restricted according to the nature of the sickness, and in addition one may have to deal with an appetite that is capricious, diminished, or totally absent.

Diet for the sick is often a part of medical treatment; in such cases the doctor will prescribe special diets and his orders must be carefully carried out. Except for special diets, food for the sick is generally divided into four classes: first, liquid or fluid diet; second, semi-solid diet; third, light or convalescent diet; and lastly, full diet. These diets are not very sharply distinguished.

LIQUID DIET generally includes milk, eggnog, albumen water, broths, soup, beef juice, thin gruel, and beverages. Liquid diet makes least demand upon the digestive powers, because it consists of food already dissolved and therefore nearer the condition in which it can be absorbed. Moreover, it is less likely than other foods to contain excess of fat, improperly cooked starches, and other indigestible material. Liquids must be given at regular intervals and at shorter intervals than solid foods; 6 to 8 ounces every two or three hours is not too much if the patient can take it. The doctor usually specifies the amount and the interval. Some patients will take more nourishment at one time if the interval is slightly increased.

SEMI-SOLID DIET includes all fluids and in addition soft milk toast, soft cooked eggs, well cooked cereal, custards, ice cream and ices, junket, and gelatine jellies. Liquid or semi-solid diet is commonly given in acute fevers because digestive juices and other fluids of the body are then diminished, and also because their digestion places a minimum of work upon a system already burdened with bacterial poisons.

LIGHT OR CONVALESCENT DIET generally means a simple mixed diet. In addition to the articles in the two preceding diets it includes oysters, chicken, baked potatoes, most fruits except bananas, simple desserts, white fish, and other meats and vegetables added judiciously until full diet is reached. Fried foods should not be included.

FULL DIET means an unrestricted menu, but even from full diets especially indigestible foods should be excluded. The principles of feeding sedentary persons as described in manuals of dietetics apply to patients who are obliged to be inactive although not really ill, as for example, a patient suffering from a broken leg. Ordinarily in such cases, as in other kinds of illness, the appetite is greatly diminished, but a word of warning should be given against overfeeding patients whose meals are their chief interest. Such patients are only too likely to interpret full diet as anything they desire in any quantity at any time of day or night, and then to attribute their discomfort and irritability to their illness rather than to overeating.

Constipation is especially stubborn in sickness, since the patient is deprived of his usual exercise and variety of food. So far as possible the bowels should be regulated by diet. Laxative foods include most vegetables with a large amount of fibre, coarse cereals and flour, oils and fats, and most fruits and fruit juices. Unfortunately many laxative foods are difficult for sick persons to digest and must therefore be used with caution. A glass of hot or cold water or orange juice an hour before breakfast may be helpful, and at bed time hot lemonade, oranges, prunes, figs, or other fruit if allowed.

It is essential for patients to drink water freely, and it should be given between meals and also between liquid nourishments. Persons inexperienced in the care of the sick frequently make the mistake of bringing water only when a patient asks for it.

Many acute illnesses begin with fever, headache, sore throat, and especially among children with vomiting, diarrhœa, and other digestive disturbances. In such cases all food should be withheld until the doctor comes, but boiled water, hot or cold, should be given freely. Efforts to tempt the appetite are then mistaken; few people are injured and many are benefited by omitting food even for 24 hours at the beginning of an acute illness, and with few exceptions a doctor can be found in a shorter time.

SERVING FOOD FOR THE SICK.--Food for the sick should always be most carefully prepared and of the best quality, and in addition it should be as inviting, as varied, and as well served as possible. Neglect in these respects is inexcusable. Even slight carelessness in preparing or serving food may arouse disgust and thus banish permanently some valuable article from the dietary.

Trays, dishes, tray cloths, and napkins for the patient must be absolutely clean and as attractive as possible. Cracked or chipped dishes should not be used. Individual sets of dishes for the sick may be purchased, and their convenience makes them well worth their price. Paper napkins may be used in many cases to save laundry work; clean white paper is always superior to soiled linen.

Before the tray is brought to the bedside, everything should be arranged so that the patient can eat in comfort. It is bad management to let the soup cool while the patient's pillows and table are being adjusted. In setting the tray great care should be devoted to placing the articles conveniently, and to the appearance and garnishing of the food. Careful serving requires more thought, but little if any more actual time than slovenly serving. Dishes should not be so full that food is spilled in transit; hot dishes should be covered; hot dishes should reach the patient hot, and cold dishes cold. Liquid nourishment in a glass or cup should be served on a small tray or plate covered with a doily. Neither glass nor cup should be held by the rim.

It is not uncommon to overload trays and to serve everything at once in order to save steps, but a patient is ordinarily more interested in a meal that is served in courses unless very long intervals elapse between. Moreover, if the meal is served in courses he is not tempted to eat dessert first and then to refuse the rest of the meal. If food is given sufficiently often it is safer to err on the side of serving too little at a time rather than too much, since the sight of large amounts of food is often disgusting.

The patient's likes and dislikes should be considered as far as possible, but most patients should not be consulted about their menus beforehand. Great variety in one meal is not necessary; it should be introduced by varying successive meals. An article that has been especially disliked should not be served a second time, unless it can be disguised beyond a possibility of detection. An article of food to which a patient objects should be removed at once; one may appear disappointed if it seems wise, but should never argue. When patients persistently refuse necessary nourishment a difficult situation is presented; persuasion and every form of ingenuity must be used, and the doctor's coöperation enlisted. When, for example, a strict milk diet is ordered for a patient who announces that he never takes milk in any circumstances the situation may seem hopeless but it is not necessarily so.

TO FEED A HELPLESS PATIENT.--Helpless and weak patients must be assisted to eat or drink. A napkin should first be placed under the patient's chin. The attendant should place her hand under the pillow, raise the head slightly, and hold the glass to his lips with her other hand. An ordinary tumbler can be used by a patient lying down if it is not more than a quarter full, or a special feeding cup may be purchased. Bent glass tubes may be used for cool liquids; they should be washed immediately after use. A child who can sit up sometimes takes more nourishment if it is given through a soda water straw.

If the patient must be fed with a spoon care should be taken that the liquid is not too hot, but the attendant should not blow upon it to cool it. It should be given from the point of a spoon placed at right angles to the lips, and plenty of time between mouthfuls should be allowed. A swallow should not be given at the moment when the patient is drawing the breath in. Great patience is required if a helpless person is to be fed acceptably. The attendant should sit by the bedside rather than stand, should present at least the appearance of having unlimited time, and should endeavor not to deprive the patient in any way of the satisfaction he may derive from his nourishment.

EXERCISES

1. What needs of the body do food substances supply?

2. Give an outline of the digestive process.

3. Describe the effect of different mental states upon digestion, and give examples of the ways by which a knowledge of these effects may be utilized in feeding patients.

4. Why is the problem of nourishing the body of especial importance in sickness?

5. Name the four ordinary classes of diet for the sick, and mention all the articles you can belonging to each class.

6. Why is constipation a common ailment among patients confined to bed, and what attempts should be made to overcome it by the diet?

7. Why is it necessary for sick persons to drink water freely, and what efforts should the attendant make to encourage them to do so?

8. Describe the proper serving of a patient's tray.

9. How should helpless patients be assisted to eat?

FOR FURTHER READING

Health and Disease--Roger I. Lee, Chapter II.

The Human Mechanism--Hough and Sedgwick, Chapters VIII, XIII, XIX.

Notes on Nursing--Florence Nightingale, Pages 63-79.

How to Live--Fisher and Fisk, Chapter II.

Bodily Changes in Pain, Hunger, Fear and Rage--Cannon, Chapter I.

Food for the Invalid and the Convalescent--Winifred S. Gibbs.

Practical Dietetics--Pattee, Chapters IV, V.

Feeding the Family--Rose.

Diet in Health and Disease--Friedenwald and Ruhrah.

Feeding Children from Two to Seven Years Old--New York City Department of Health.

American Red Cross Text Book on Home Dietetics--Ada Z. Fish.

Emergency Cooking--Pamphlet 708, American Red Cross.

War Diet in the Home--Pamphlet 706, American Red Cross.

Red Cross Conservation Food Course for Children and Special Classes--Pamphlet 705, American Red Cross.