DISEASES OF THE HEART
The dietetic treatment in diseases of the heart has been the subject
of much study, especially during the past few years.
~The Diet.~--In this pathological condition, as in many other diseases
in which one or more of the functions of the body have become
impaired, there can be no hard and fast rule covering the treatment or
diet for all cases, but, as in nephritis, the condition of the
individual, his symptoms, and the progress and extent of the disease
must be taken into consideration in order to formulate a diet
calculated to adequately nourish the body, while at the same time
imposing the smallest amount of work with the least expenditure of
labor upon the part of the diseased organ.
~Division of Treatment.~--The treatment of the disease then may be
said to be divided into three stages: first, the stage of
compensation; second, that of moderate compensation; third, that of
decompensation. The diet is directed, first, toward relieving as far
as possible the strain which is imposed more or less by all the food
eaten; and second, keeping up the general nutrition of the body.
~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 regime.
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
(a) Write a diet order for an elderly patient with severe cardiac
disturbance.
(b) Outline the method of administering the Karell diet.
FOOTNOTES:
[134] See Karell Cure, p. 342.
[135] "Food for the Sick," p. 150, by Strouse and Perry.
[136] See Salt-poor Diets, p. 341.