Diet in Chronic Renal Failure (CRF) - Under Haemodialysis

Your diet will be very important in helping you to feel better and achieve successful treatment. The following dietary nutrients are especially important to regulate in the person receiving dialysis treatment; protein, sodium (salt), potassium, calories and fluids. A dietitian can tell you specifically which foods you should avoid and which foods would benefit you, according to their sodium, potassium and protein content. In general, there are less dietary restrictions after kidney transplant.

It is important that you follow these guidelines that have been suggested specially for you.

(A) Fluid intake

It is extremely important that you strictly adhere to the fluid intake allowance prescribed by your doctor. If you take more fluids than allowed, water will accumulate in your body, leading to serious complications such as a pulmonary edema and hypertension. Generally your fluid intake should be such that the weight gain is restricted to 1.5-2 kg between two haemodialysis sessions.

(B) Sodium (salt) intake

Your doctor will prescribed you a specific amount of salt to be taken per day. Please make sure that you consume the prescribed amount of salt (and not more) every day. Too much of salt intake will result in hypertension, increased thirst etc. Too little salt also will lead to problems such as weakness, and hypotension during dialysis; therefore it is important to take the prescribed amount of salt every day.

Salt substitutes (Lona salt) contain high potassium, hence avoid such preparations.

(C) Potassium intake

Reduce potassium intake

Increase in the potassium level of your blood will have very serious consequences and therefore, it is important that your potassium intake is restricted to the minimum possible. Following food items are rich in potassium and all of them should be avoided or taken in very restricted quantities.

(1) Fruits

Please obtain specific instructions from your dietitian regarding the restriction of these in your diet. The dietitian will help you to choose a low potassium diet which will best suit your particular requirements. Only one fruit (100 gms) can be taken per day (pineapple, apple, papaya or guava).

(2) Vegetables

All vegetables contain potassium. Wash, peel and cut vegetables into small pieces, soak in warm water for 2-3hrs, discard water and add large volume of fresh water, cook and discard water.

(3) Others

Tamarind, spices, condiments and coconut are to be used in very small quantities. They contain very high amount of potassium.

(4) Avoid

Avoid nuts, jaggery, instant coffee, chocolate, cocoa powder and salt substitutes (Lona salt)

(D) Protein intake

In the pre dialysis phase of Chronic Renal Failure(CRF) all the patients are advised to restrict protein intake. Once the patient is on regular dialysis he/she should take high protein diet (fish, chicken without fat, egg white for non-vegetarians and soya protein for vegetarians)

(E) Calorie intake

It is important that your calorie intake is adequate while you are on maintenance dialysis. Inadequate calorie intake will result in loss of weight, generalized weakness, reduced resistance to infections etc. Therefore, please check with your doctor regarding your daily calorie allowance and adhere to the recommendations given by the doctor.

(F) Dietary intake during the dialysis procedure

You are allowed to take anything you like, during the dialysis, but it must be consumed within the first hour of you dialysis. Even food items rich in potassium may be taken during this time. If you wish to take such items, please make sure that you inform the dialysis technician or nurse who is taking care of your dialysis. When you inform them, they will be able to ensure adequate removal of the excess potassium consumed during the first hour of dialysis.

CROSS INFECTION

The following are the methods of transmission of cross infection :

Direct contact : The organisms can be transmitted directly from person to person through kissing, sexual contact, droplet infection and infected hands.

Indirect contact : Contact with the secretions and excretions of the infected persons.

Through fomites : Eg., instruments, utensils etc.

Through contaminated food and water.

Through insects.

Through dust.

Through carriers.

PREVENTION OF CROSS INFECTION IN THE HOSPITALS

1. The hospital should be well ventilated.
2. Maintain the general cleanliness of the hospital. Sweeping and mopping of the floor should be done daily with antiseptic lotions and damp dusting should be done to keep the articles free from dust. All the articles are kept clean and dry. Once in a week, roof is swept to remove the cobwebs. Beds, lockers, stools etc should wash and cleaned. The mattress, pillows and other unwashable articles are exposed to sunlight and aired. Periodical white washing of the walls, painting of the doors and windows etc., should be done.
3. Safe food and water supply : Many diseases are transmitted through food and water. Kitchen and pantry are protected from flies. There must be provision for safe water supply.
4. Safe disposal of excreta : Urine, stool, sputum etc., should be disposed safely. The bedpans, urinals, sputum cups etc., are cleaned and disinfected before it is used for the next patient.
5. Safe disposal of refuse : Discarded dressings, garbage etc., are collected daily and burnt to prevent the spread of infections.
6. Destruction of rodents and insects : Rodents and insects play a great role in the spreading of diseases, so, they should be destroyed.

PREVENTION OF DIRECT CONTACT WITH INFECTED PERSON (BARRIER NURSING)

Barrier nursing or isolation technique is intended to confined the micro-organisms within a given and recognized area. There are a number of isolation techniques and precautions used to prevent the spread of infections.

Respiratory isolation : Respiratory isolation is indicated in the situations where the pathogens are spread on droplets from the respiratory tract. In this type of isolation, masks are generally worn by the nurses. Gowns are also worn when caring for the small infants because of the possibility of drooling by the infants. When possible the patients are taught to cover their noses and mouths with several layers tissue paper or handkerchief. If tissue paper is used they should be disposed properly. Handkerchiefs are cleaned and disinfected before it is used again. Restrict the number of visitors. Precautions must be taken when collecting sputum specimens from the patients. When attending to a patient with respiratory infection, the nurses should keep a reasonable distance to prevent the droplet infection and to prevent breathing contaminated air. If the nurse suffering from respiratory diseases should not attend to the patients.

Enteric isolation : Enteric isolation is indicated when the pathogens are transmitted in faeces. For this type of isolation it is not necessary to wear a mask, but it is recommended that gloves and gowns be worn when handling soiled articles.

Thorough hand-washing should be emphasized both by the patients and the nurses. The excreta may be disinfected by adding lime to it before the disposal. The soiled articles such as linen should be disinfected before it is sent for washing.

Wound and Skin isolation : This type of isolation is for pathogens which are found in wounds and can be transmitted by the contact with the wounds or by contact with the articles contaminated with the wound discharges. Usually gowns and gloves are worn in this type of isolation. Important point to remember is the safe disposal of dressings and discharges from the wounds and the disinfection of the articles. Strict isolation techniques should be followed when caring for the patients with abscesses, boils, infected burns, gas-gangrene, anthrax, rabies, tetanus, venereal diseases, scabies etc. All the articles used for these patients should be kept separate.

Great care should be taken by the nurses to prevent cuts or abrasions on their hands. Frequent and thorough hand washing reduces the chances of infection.

Blood isolation : This type of isolation is intended to prevent transmission of pathogens that are found in blood. Therefore any equipment that comes in contact with the patient's blood should be carefully disinfected before touching another object or person. Use of mosquito nets are also emphasized to prevent this type of infection.

What about Carbs?

A lot of people believed that one of the main drawbacks of common Indian diet is the excess consumption of carbohydrate. In India, rice or wheat are using for preparing most of the dishes. Along with that vegetables, legumes, meat, poultry, fish or eggs are used in smaller portions as side dishes. The main role of these side dishes are to add spice and taste to the main dish. But now the concepts have being changing.

Now experts saying that foods which are rich in carbohydrate are essential for a good nutrition in diabetes.

HOW IS IT EFFECT?

The carbohydrate present in the foods is the only nutrient that make a higher impact on the blood glucose level. Insulin plays the main role in controlling our blood glucose level. The balance between carbohydrate that we taken and insulin produced by our body or taken as medication impacts blood glucose level and diabetes control.

What type of foods contain carbohydrate?

All the foods that we have taken won't give us the adequate nutrients, which are essential for our body. The amount of nutrients varies in different foods. The three essential nutrients that we need are carbohydrate, fat and protein. Most of the calories in foods shown, are from carbohydrate. Some of these foods contain good or healthful carbs, and other containing less-healthful carbs.

A food containing Good/Healthful carbohydrate

Carbohydrate containing foods which are rich in vitamins, minerals and fiber, helps us to avoid empty calories from added sugars. These are comes under the line of healthful carbohydrate foods. Similar servings of related foods may surprise you nutrition wise. For example, 1/2 cup of orange juice with pulp (fiber) and enhanced with calcium offers more nutrition than 1/2 cup of orange drink, which gets most of its calories from corn syrup. Taking fiber is a healthy way to lose weight and at the same time to keep maintaining a good digestion. Having a healthful carbohydrate instead of less-healthful carbohydrate is considered as smart eating.

Carbohydrate rich foods

Samples of foods with Healthful Carbohydrate (little or no added sugar)

• Bran cereal.
• Beans.
• Popcorn.
• Berries.
• Pear.
• Whole grain pasta.

How much carbohydrate do you need to get your essential vitamins, minerals and fiber?

Most of the experts suggest that you get 45-65 percent of your calories from carbohydrate sources. If you eat less carbohydrate, especially if you take lesser than 1,500 calories daily, won't gives you the needed nutrients. Eat unrefined, nutrient-rich foods containing carbohydrate - whole grain, unprocessed and fiber-filled foods rather than refined starches and sugar-added foods and drinks, which contains few nutrients and lots of calories. "Even while eating out, you have to be smart and work around what you get. Increase your intake of vegetables, for instance".

LIFE IS SWEET

You can have your cake and eat it too. Now a days sweeteners offer great options for reducing carbohydrate, lowering calories and yielding such delicious results that you simply do not miss real sugar. You will be spoilt for choice with this list..

Some of the popular Sugar substitutes / Sweeteners and their brand names :

Sugar substitutes

• Sucralose  - Splenda, Zero, Sugar Free Natura approved by FDA.
• Aspartame - Equal, Sweetex, Sugar Free, Sugar Free Gold.
• Stevia - Stevi0cal, Gwiser, Dr Shugar, So Sweet.
• Acesul - Sweet One.
• Saccharin - Sweet 'N' Low, Sweet Twin, Necta Sweet, Sweetex.
• Other sugar alcohols - Sorbitol, Xylitol, Mannitol, Malitol etc.

ADVANTAGES OF USING SUGAR SUBSTITUTES:

There are many advantages of using artificial / reduced calorie sweeteners. some of them are :

• Weight loss. Overweight / Obese individuals often choose to have artificial sweeteners in their foods so that they can reduce the total calorie intake in their diet, which in turn leads to weight loss by creating a negative energy balance. By doing so, they do not have to totally avoid or sacrifice the foods they love to eat.
• Diabetes Mellitus. With the increasing prevalence of diabetes in the world, especially type 2 diabetes, people have started using artificial sweeteners to limit their total calorie intake as well as maintain their sugar levels by avoiding simple sugars, and enjoying most of the foods they like.
• Dental problems. Sugar substitutes are not fermented by the micro flora of the dental plaque, and therefore they are tooth friendly.

Q. Is it advisable for people without any serious health-weight problems to be using sugar substitutes? Should it be used in moderation? Why?

A. Artificial sweeteners should still not play an important role in a healthy and balanced diet. In spite of the green signal given to most of the sweeteners, they are no substitute for good nutrition. They do not contain calories.

Insuring a Healthy Future

Diabetes can prove to be quite expensive. Glucometers, medications, insulin shots, and the risk of diabetes-triggered health complications...... Opting for the right kind of insurance can keep you hassle-free, but knowledge is key.

After spoke to an insurance professional, here are some Questions and relevant Answers which can help an insurance user to find the right facts.

Q.What are the IRDA (Insurance Regulatory Development Agency) guideline for medical insurance for diabetic people?

A.There are no specific guideline for diabetic people. There are general guidelines for medical insurance and diabetes comes under that like any other disease.

Q.Is daily medication, which is very important in diabetes and goes on for years, covered under insurance?

A.No, day to day medication and regular tests are not covered. Testing devices such as glucometers are also not covered. To get insurance benefits, a person has to get admitted for at least 24 hours.

Q.Then why should a diabetic person take medical insurance,knowing that most of his expenses will not be covered?

A.While it is true that you normally don't get admitted to hospital due to diabetes, there are other complications which may arise due to diabetes and need to be treated in the hospital. In that case medical insurance helps.

Q.What are the compensation structures and processes?

A.Again there is nothing specific for diabetes. There are two ways of getting claim under medical insurance. One is to pay all the expenses at the time of treatment and then get them reimbursed from the insurance company according to your policy. The other option is to use cashless cards issued under the Preferred Provider Petwork (PPN). Here all a person needs to do is to provide his cashless card to the hospital which is under PPN. Then the insurance company regarding the payments. You don't need to pay anything in cash.

Q.Tell us more about cashless treatment and PPN?

A.A card issued after taking a policy from a Third party Administrator. the card contains all the required details about you and the policy you have taken and it can be used anywhere in India with hospitals who are registered under PPN. It applies when a person gets admitted to a hospital for a minimum period of 24 hours for the treatment  of a disease which comes under the policy insurance you have taken. It covers the cost of hospitalization and other charges and cost of tests and medicines 30 days prior and 60 days after admission to the hospital for treatment. This hospitalization for minimum 24 hours clause applies to both cashless and pay-now-get-reimbursed-later cases.

Q.What are the problems with cashless facilities?

A.IRDA has prescribed a room cap for policies. It says that if a person has taken a policy of say 5 lakhs then charges for room in hospital which he can take for treatment should exceed Rs 5000/- day. This was done to control the exorbitant money some hospitals were charging once they came to know that the patient is under medical insurance.

But now, some of the leading high-end hospitals have withdrawn from the PPN facility, arguing that they cannot lower their charges and thus their quality of treatment, considering the room cap.

Q.How much time does it normally take for a person to get reimbursed?

A.After the documents are submitted to the insurance company it normally takes 1-1.5 months. Sometimes though not often, the insurance company might investigate a claim if the document provided is not sufficient or during filling the form for taking a policy the policyholder intentionally did not reveal the fats.

Q.Your views on Mediclaim facilities provided by companies for their employees?

A.Its a good thing. It covers pre-existing disease from which an employee may be suffering, including diabetes. Also regular medical expenses can be reimbursed like tests and medicines.

Some essential requirements that should be checked before and after any medical procedures.

Are you sure that's the right patient?

Identification band with Bar Code

Use at least two of these methods to identify your patient when provide care, treatment, or services.

• Patient's name
• An assigned identification number.
• Patient's birth date.
• Patient's phone number.
• Bar coding that includes two or more patient's specific identifiers.
• Do not use the patient's room number as proof of identification.

Hand off with care

Hand Off

Hand off your patient to the next care giver with accurate and relevant information about the patients care, treatment and services.

Tips for conducting an effective hand off :

• Include up to date patient information.
• Use "read back" or "repeat back" techniques.
• Limit or minimize interruptions.
• Use clear language which he/she can understand.
• Allow time for questions and answers.

TIME OUT  (For eliminating surgical mistakes)

Are you operating on the Right patient? Right site? Right procedure?

Verify the correct person, site and procedure.

• At admission
• At the time of surgery procedures is scheduled.
• Any time a patient is transferred from one care giver to another.
• While the patient is awake.
• Before the patient leaves pre-operative area.

Review the following :

• Documentation such as patient history and consent.
• Relevant test result or x-rays.
• Required implants and special equipment.

Surgical Site Marking

Always mark the Operative site, be sure to :

• Make the mark at or near the incision site.
• Use the word "YES" or your initials instead of an X be consistent.
• Involve the patient in the site marking.

Conduct a " Time out " with the surgical team or operative. Check for :

• Correct patient.
• Correct side and site.
• Agreement on the procedure to be done.
• Documentation of the time out.

Setup Your Meal

Skipping your meals is not at all an easy way for weight loss or blood sugar control. Instead of that, go through this tips and find it's working.
1. Get your morning blood sugar reduced.

While we're sleeping, our cells use up the glucose from our last meal and the liver sends more glucose into the blood. In type 2 diabetes, the liver can't able to find, there is already more than enough glucose present. "Our fasting blood sugars have much more to do with your liver and hormonal functions, that what you ate for dinner last night." Taking a breakfast which is rich in carbohydrate, tells the liver to stop releasing glucose. And that helps you to make a lower fasting sugar level.

Plan for three meals daily, which contains at least three food groups (like the protein, starch, and vegetables)


2. Make your levels steady.

Eating foods irregularly can have you "ups and down's between normal blood sugars and high blood sugars". A regular meal can give you a fixed rise in your blood glucose. If you're taking any kind of blood glucose-lowering medications, skipping meals or eating too little can cause a severe decline in your blood glucose level. Foods, especially carbohydrate rich foods, over three meals a day (and snacks if you want them) helps you to maintain steady blood glucose levels.

Feel tired or thirsty? A glass of water and a bit of exercise may help you to beat fatigue.

3. Quit fatigue and boost up your energy.

If you love to have a snack, recommends that you enjoy a small amount of carbohydrate to keep energy levels up and enough protein to help you feel full. "A healthy snack might not give you instant energy,"but it can makes a big difference - you no longer feels fatigue as you used to."

4.  Find the patterns in your blood glucose results.

It find's little hard to sort out the causes of high and low blood glucose and to determine your best eating, exercise,and medication strategies. If your blood glucose levels are unpredictable, eating similar amounts of foods at particular times a day and keeping accurate records of the results will help you and your health care provider to identify the type and guide adjustments to your treatment plan. Eating randomly makes it hard to find the type and to control blood sugar levels.

You can control diabetes

Hooked to butter chicken but hate the gym? Identify what's stopping you from taking the path to self-care. That is the first step towards making lasting changes.


STOP DIABETES IN ITS TRACKS

If your fasting blood glucose is 100-125 mg/dl, it is likely that you have pre-diabetes. Your blood glucose is higher than the normal but not high enough to diagnose diabetes. But don't panic yet. Research shows that if you follow a healthful eating plan (especially limiting how much fat you eat and getting plenty of fiber), be active about 30 minutes five days a week, and lose just 5-7 percent of your starting body weight, you can hope to delay or prevent the onset of type-2 diabetes without going on medication.

Fruits and Vegetables

Here's how to take the first step.

Completing a small change for the better - something as simple as choosing fresh vegetable juice over soda - encourages the good behaviours.

Barriers for your diabetic care.

Three main three things that stands as barriers to diabetes self care are: depression, misconceptions and a sense of deprivation.

Depression: This condition can get in the way of taking care of your diabetes. Depression leads to some other factors which can affect blood glucose, such as overeating, failing to get adequate sleep, or e inability to coax yourself to do some exercise, even for a walk. Get  a way out from depression and you will be able to take care of diabetes.

Misconceptions: If you think that you need not worry about your diabetes until you get older, you're likely to wait too long to take control. This will make you difficult to gain healthful blood glucose, blood pressure and blood lipids levels, and putting yourself at  a risk for complications. Likewise, if you think there's nothing you can do to control your glucose level, then you're likely to do nothing at all. Diabetes is a complex condition which can take into control by small changes in your lifestyle, can improve your health and how you feel.

Deprivation: It founds that, everyone has their own strong opinions about what you can and cannot eat with diabetes. If you've been told too often what not to eat, you may constantly feel deprived. Understand the  facts - talk to a registered dietitian or diabetes educator and learn how you can add your favorite foods into a nutritious meal plan.

Can insulin cause weight gain?

Some people may experience weight gain when they are taking insulin at first few weeks.

• When there is an increase in blood glucose levels, your body  will gradually wasting the calories you eat because there's no insulin to help the body to convert the food into glucose. When your blood glucose gets into better control with insulin, your body makes better use of calories from the food you eat.
• Due to high increase in blood glucose levels, you may be get a  chance to dehydrated. This may seems varying your kilo's.
• The most important, insulin can make your blood glucose too low if it's not adjusted correctly. If you're repeatedly trying to treat hypoglycemia with food, can result in excess calories and weight gain.

What should you do? Work with your physician to adjust your insulin doses to reduce hypoglycemia. Learn how to treat occasional decrease in blood glucose levels with glucose tablets rather than food; it's much easier to control the amount of calories you eat. If your weight gain is out of control, get in touch with a registered dietitian to get an ideal diet plan.

Did you know?

Green Tea

Unlike other teas, Green tea is not fermented; the tea leaves are lightly steamed before being dried. Steaming inactives the enzymes (polyphenol oxidase and peroxidase) thus preventing the polyphenols, the active constituents in the herb.

One of the main antioxidant found in Green tea, Epigallocatechin-3-gallate(EGCG) has been found to be 100 times more effective than vitamin C and 25 times than vitamin E. EGCG is also twice as powerful as resveratrol, a polyphenol that limit the negative effects of smoking and fatty foods.

Green Tea & The Heart

Green tea plays a role in reducing the nagative effects of bad cholesterol. It lowers triglyceride levels and increases the production of 'good' cholesterol, improving the LDL-HDL cholesterol ratio.

Green Tea & Obesity

Green tea could help weight loss by increasing the metabolic rate. It speeds up fat oxidation and slows the digestion of carbohydrate.

Green Tea & Cancer

Green tea polyphenols strongly inhibit tumor cells 'DNA' synthesis and peroxide radical generation. Besides inhibiting the growth of cancer cells without harming healthy tissues.

Green Tea & Arthritis

Green Tea protects joints against cartilage breakdown and reduces inflammation, thereby preventing arthritis.

Green Tea & Aging

Green tea may delay aging by preventing the accumilation of free radicals and the resultant damage caused to the DNA. it also enhances immunity.

Green Tea & Teeth

Green tea with its fluoride content helps to prevent tooth decay and fights cavities by inhibiting the growth of oral bacteria.

Green Tea as Beauty Aid

On topical application, Green tea may protect the skin against the damage caused by ultraviolet rays. it also acts as a skin rejuvenant.

7 Action Steps For Protect Your ' HEART '

Yes, you can prevent or minimize heart disease (and other diabetes complications, too)

1. Shed a few kilos. Losing just 5-7 percent of your weight (that's 5-7 for a 100-kilo person) can decrease the harmful inflammation and insulin resistance that characterize type 2 diabetes. This is especially effective early on, before type 2 diabetes is diagnosed or detected.

2. Take healthy food and be active-- always. Choosing the healthful foods, controlling portions, and being physically active will serve you well your entire life.

3. Reach and maintain your ABC targets. If you're not meeting the targets for blood glucose, blood pressure, and cholesterol, ask your health care provider to setup your treatment. "When it comes to reach some great efforts on lipids and helps to reduce heart diseases, research shows targeting LDL is important."

4. Have your medicine. You may be taking a group of medications to control your blood glucose,blood pressure and cholesterol-no one enjoys that cost or to do so. But some research shows that  patient's with diabetes are likely to need more medications over time to manage the progression of diabetes and heart disease. Talk to your health care provider if you have any difficulty in taking or affording your medications.

5. Includes an aspirin a day. Daily intake of aspirin in low dose is recommended for many people at risk for or with heart disease and diabetes. But ask before your doctor before taking aspirin.

6. If you smoke. If you do smoke, ask to your health care provider about how to quit smoking.

7. Go for health tests you need. Your doctor can refer diabetes medical tests for you that can detect any immediate or hidden problems and help you identify the symptoms. This will help you to spot problems early and initiate a treatment quickly.

DIET IN SICKNESS

Diet is as important in the treatment of diseases. A modification in the diet with more nutrients can cure certain diseases. eg; A patient suffering from peptic ulcer needs a bland diet for his recovery; a salt free diet can reduce the blood pressure in a patient with hypertension.

For every one, eating is an enjoyment. When the person is ill, the food intakes become a problem. The nurse's responsibility in the care of a sick in regard to nutrition, can be analysed into four major areas:

1. Assisting patients to obtain needed nourishment either through feeding or assisting with eating. eg., tube feeding, feeding a helpless patient to eat his food etc.
2. Motivating patient to eat.
3. Assisting patients to obtain needed nourishment by proper planning of the diet.
4. Assisting patients with special problems about therapeutic diets eg., helping a patient to accept a salt free diet.

Principles involved in the diet therapy

1. The diet must be planned in relation to changes in metabolic occurring as a result of disease.
2. The diet must be planned according to the food habits of the patient based on culture, religion, socio-economic status, personal references (likes and dislikes), physiological and psychological conditions, huger, appetite and satiety.
3. As far as possible, changes in the diet should be brought gradually and adequate explanations are given with the changes made, if any.
4. In short and acute illness, the food should not be forced, because his appetite is very poor but he may soon recover the normal appetite. But in prolonged illness it is essential to provide adequate amount of food to prevent wasting of tissues.
5. Whatever the diet prescribed, there should be variety of foods for selection.
6. Small and frequent feeds are preferred to the usual three meals.
7. Hot foods should be served hot and cold foods should be served cold.

Modification of nutrients in therapeutic diet

Carbohydrate are well tolerated and are necessary to maintain the stores of liver glycogen. It is particularly important in patients with high fevers, liver diseases, hyperthyroidism etc. In the absence of carbohydrate, the body fat may be used for energy which may result in the formation of ketone bodies and they accumulate in the blood - a condition known as ketosis. Adequate amount of carbohydrate intake can prevent ketosis. Carbohydrates are given in easily digested forms such as glucose, sugars, gruels etc.

The fat is often not tolerated in illness especially if nausea and vomiting are present. Adequate amount of carbohydrate can replace the requirement of the body for fat.

In illness, especially when there is infection, the protein metabolism is usually greatly increased because of the increased destruction of protein. If an adequate amount of protein is not given, the body will use up the tissue proteins and the patient will loose weight. In illness there is kidney and liver damages the protein intake should be high.

The requirements of minerals should be maintained in illness especially that of calcium and iron. Sodium and potassium may sometimes need to be restricted especially when there is hypertension, oedema, ascites etc.

NUTRITION

TERMINOLOGY

1. Anorexia: Loss of appetite.
2. Dyspepsia: Indigestion. A feeling of fullness, discomfort, nausea and anorexia.
3. Dysphagia: Difficulty in swallowing.
4. Food: Any substance which can be used by the body for its growth, development and repair.
5. Nausea: A sensation of sickness with inclination to vomit.
6. Nutrients: Constituents of food.eg., carbohydrate, protein, fat, minerals, vitamins, water.
7. Regurgitation: Back flow. eg., back flow of partly digested food into the mouth from the stomach.
8. Vomiting: Expulsion of stomach contents via the oesophagus and the mouth.

FACTORS AFFECTING APPETITE

The appetite is increased by:

• Sight and smell of food (attractive serving).
• Food preference (likes and dislikes if the individual).
• Physical and mental relaxation (freedom from hurry, worry, pain, stress and fatigue).
• Regularity in eating (spacing of meals).
• Pleasant environment (attractive and cheerful atmosphere).
• Exercise.

The appetite is decreased by:

• Physical and mental fatigue.
• Hurry, worry and fear.
• Unpleasant environment and experiences.
• Lack of exercises.
• Irregular meals.
• Long spacing of meals timings.

COMPLICATIONS OF PROLONGED REST

On the Cardio-vascular system

• Cardiac output is increased 25 to 30%.
• Patient develops orthostatic hypo tension - a feeling of weakness and dizziness when they first get up after a period of rest.
• Formation of venous thrombosis and pulmonary embolism.

On the Respiratory system

• Decreased chest expansion and decreased chest movements resulting in the decreased ventilation of the lungs.
• Stasis and pooling of secretions leads to hypostatic pneumonia.
• When a patients respiratory movements are decreased, the exchange of oxygen and carbon dioxide in the lungs is severely affected and this leads to tissue hypoxia.

On the Gastro-intestinal tract

• Development of anorexia due to general weakness, worry and boredom accompanying immobility.
• Development of constipation due to change in the diet, changes in the daily routine, decrease in the level of activity, strange experiences such as use of a bedpan, unnatural position used for defecation, etc.

On the Renal function

• Difficulty in urination due to lack of privacy, use of bedpans, unnatural positions. This leads to bladder distension.
• Urinary stasis and formation of renal calculi.

On the Metabolism

• Decreased muscle tone.
• Muscle atrophy.

On the Musculo-skeletal system

• Demineralization of the bones.
• Contractures of the muscle.
• Stiffness and pain in the joints.
• Muscle cramps.
• Foot drop.

On the Mental activity

• Lethargy, loneliness and depression.
• Anxiety and insomnia.
• Emotional disturbances leading to hostility.
• Mental disturbances leading to neurosis and psychosis.

On the Skin

• Bed sore

REST, SLEEP AND PAIN RELIEF

Rest and sleep are basic concepts in nursing. While they are interrelated, they are neither interchangeable nor identical. Sleep is necessary for the subjective feelings of being rested.

The term rest means not only the feeling of peace, relief and relaxation, but it implies from anything that tries, disturbs or worries. Therefore rest is defined as a state of relatively decreased bodily work, either physical, mental or both, which leaves the individual feeling refreshed and revived. During illness bed rest is limiting the physical activity by keeping the patient in bed does not guarantee the state of rest.

When a patient is hospitalized, he/she is vulnerable to rest disorders. Already anxious due to illness, he/she is subjected to a new environment, new faces, loss of privacy, strange noises and experiences, frequent disturbances and to painful procedures.

Beneficial effects of rest in illness.

• Relives pain due to surgical procedures, trauma, fractures and wounds. Rest by decreasing movements prevents excessive irritation of the injured tissues.
• Promotes healing and repair of injured tissues(anabolism) by reducing the metabolic need of tissues.
• It reduces oxygen demand of such vital organs as heart muscles, there by reduce the discomfort and pain in the coronary heart diseases.
• Haste the recovery of the weak, exhausted, febrile and debilitated patients.
• It relives oedema and venous congestion (varicose veins).
• A period of rest will provide relaxation not only to the body but also the mind.
• A period of rest improves the functioning of the different organs such as kidney, liver, etc.

PEDICULOSIS AND ITS TREATMENT

Prior areas for pediculus infection

The term pediculosis is defined as the state of being infected with lice. Lice or pediculi are small wingless blood sucking insects which are parasitic on warm blooded animals. They are found on head (pediculus capitis), the body (pediculus corporis) and the perineal area, eye brows, eye lashes and beard (pediculus pubis). Pediculosis is associated with poor hygiene, crowded living conditions and exposure to other individuals with pediculosis.

Lice can be transferred from one person to other through direct contact or indirect contact. It gets easily transmitted from person to person, perhaps sleeping together, sitting together etc. They can also be transmitted through clothing, bedding, combs etc.

Lice 

Dangers of pediculosis

• The patient complaints of severe itching of the scalp and scratches the head continuously giving rise to abscess formation.
• In severe infestations, the hair may appear to be heavily sprinkled with dandruff.
• The itching of the scalp is a source of discomfort to the patient causing restlessness and insomnia.
• The lice are blood suckers and cause anaemia.
• They spread the diseases eg; typhus fever, relapsing fever, trench fever.
• Itching of the scalp result in the scalp injury and the injured area is subjected to infection which leads to infected glands.

Prevention of pediculosis

Pediculus capitus

Pediculus pubis

Pediculus corporis

Prevention is easier than controlling. For this, proper personal hygiene concept should be practiced by their life. Combing the hair daily, washing it frequently, keeping the skin and clothes clean will solve the problem. Any patient complaining about itching or scratches the head, needs thorough examination of their hair and scalp, body and linen to discover lice. If lice are found on the patients head or body, follow the prescribed treatment.

Parasiticides use in the treatment of pediculosis

1. D.D.T 5% or 10% (add talcum powder to dilute it)
2. Carbolic lotion 1:40 (it is an irritant to the skin)
3. Equal parts of kerosene oil and coconut oil.
4. Preparations containing gamma benzene hexachloride available in the market.

Application of parasiticides

The parasiticide are applied thoroughly on the scalp (to the body if necessary) and is left for overnight. On the next day a thorough bath is given and the linen is changed. The linen should be thoroughly disinfected to remove the lice from the clothes.

Since the parasiticides are not effective against the nits(eggs) the procedure is repeated after a week.

EXERCISES

Exercises

Exercise is the performance of physical exertion for improvement of the health or the correction of physical deformity.

The beneficial effects of exercise

On the musculo-skeletal system

• Maintains the muscle tone.
• Maintains the joint mobility.(prevent stiff joint)
• Prevents and corrects deformities like foot drop, ankylosis etc.
• Maintains the bone density and prevents osteoporosis.

On the cardio-vascular system

• Stimulates the blood circulation and prevents venous stasis.
• Assists in the exchange of oxygen and nutrients into the tissues and waste products from the tissues.
• Prevents varicose veins.
• Helps to reduce oedema.
• Reduce the work load on the heart.
• Prevents venous thrombosis and pulmonary embolism.

On metabolism

• Prevents obesity.
• Regulates body temperature.
• Oxygen consumption and metabolic rate are increased thus providing good lung expansion to meet the additional requirement of the body.

On the gastro-intestinal system

• Improves appetite and digestion.
• Prevents constipation.
• Prevents flatulence.

On the excretory system

• Promotes urinary functions by stimulating the blood circulation through the kidneys and helps in the elimination of waste products.
• Prevents stagnation of urine and formation of renal calculi.
• Promotes elimination from the skin.

On the respiratory system

• Improves the lung ventilation.
• Prevents atelectasis.(collapse of lung)
• Prevents collection of secretions in the lungs.(hypo static pneumonia)

On the mental process

• Promotes the physical and mental well being.
• Prevents depression and boredom.
• Restore a sense of relaxation and equilibrium.
• Improves the memory.
• Provides an outlet for emotional tension.

Others

• Prevents bed sore.
• Adds to the beauty.

ACTIVE EXERCISE

Active exercises

Active exercise is the type of physical activity accomplished by the patient without assistance. These exercises help he patient to attain the normal physiological functions of the body. Some of the active form of exercises that can be done by the patients on the bed are: deep breathing and coughing exercise for the complete lung expansion usually employed for the post-operative patients.

Exercise of the limbs through full ranges of motion which includes flexion, extension, adduction, abduction and rotation.

• Moving in bed to change the position.
• Foot exercise to prevent foot drop and toe deformities.
• Abdominal and gluteal contraction exercise.
• Exercise to prepare the patient for ambulation eg; patient after amputation of legs needs a variety of exercise before he starts crutch walking.

The ambulatory patients can have both indoor and outdoor exercise. Some of the points to be kept in mind during the exercise are:

• The exercise should be planned according to the age , sex and physical condition of the patient.
• Check for the doctor's orders for any specific precautions taken regarding the movements of the patients.
• The room should be well ventilated.
• Exercise should not be done immediately after a meal.
• Avoid over fatigue.
• Avoid chills and draughts.
• Have loose garments to put on.
• Exercise are to be repeated daily at the same time if possible.

PASSIVE EXERCISE

Passive exercises

In passive exercise, the movements or activity is carried out by another person and the patient makes no voluntary effort to assist or resist the action. The passive exercise are usually carried out by the physiotherapist or the nurse. The performance of certain nursing procedures such as bathing the patient, giving back care and changing the position etc; provide some passive exercise for the patient. Passive exercise are useful for the patients with restricted movements, deformities and unconsciousness.

FOOT DROP

Patients with prolonged rest and restricted movements develop a deformity called foot drop in which the foot is plantar flexed (the ankle bends in the direction of the sole of the foot). If the condition continues without correction, the patient will walk on his toes without touching the ground with the heel of the foot.

The deformity is caused by the contraction of both gastrocnemius ans soleus muscles. Prolonged bed rest, lack of exercise, incorrect positioning in bed and the weight of the bed clothes forcing the toes in the plantar flexion are some of the factors that contribute to this crippling deformity.

The foot drop can be prevented by the use of foot board(foot rest) to maintain the position of the feet at right angles to the legs, flexion and extension exercise to the feet and toes.

SIGNS AND SYMPTOMS OF PRESSURE SORES

The early symptoms of pressure sores are redness, tenderness, discomfort and smarting.The area becomes cold to touch and insensitive. There is local oedema. Later the area becomes blue, purple or mottled. Due to continued pressure, the circulation is cut off, the gangrene develops and the affected area is sloughed off.

PREVENTION OF PRESSURE SORES

1. Identification of patients those who are particularly prone to the development of decubitus ulcer.
2. Daily examination of the decubitus- prone patients for redness, discolouration or blister on the pressure points and they should be reported and treated immediately.
3. Keep the patients clean and dry.
4. Change the position of the patient every 2 hours so that another body surface bears the weight.
5. Use a bed cradle to take off the weight of the bed linen of the patient, so as to enable him to move in the bed.
6. Keep the patients skin well lubricated to prevent cracking by using powder.
7. Protect the damaged skin, damaged skin can be further irritated and macerated by urine, faeces, sweat etc.
8. Provide the patient with adequate fluid and with a nourishing diet that is high in protein and vitamins.
9. Use special mattress and beds to reduce the pressure on the body parts.
10. Use adequate amount of cotton under splints and plaster to reduce friction.
11. Encourage the patient to move in the bed as far it is allowed.
12. Teach the patients and the relatives about the hygienic care of the skin.

DECUBITUS ULCER / PRESSURE / BED SORE

Decubitus ulcer is also known as pressure sore or decubiti, are ulcerated or sloughed area of tissue subjected to pressure from lying on mattress or sitting on a chair for a prolonged period of time resulting in the slowing of circulation and finally death (necrosis) of tissues.

Common sites

Pressure points are those that bear weight, so that the skin over them is subjected to pressure.This may happen more frequently over the bony prominences of the body where there is no rich blood supply or nourishment and also there is a thin layer of skin.The common sites depend upon the position of the patient in the bed.

The pressure points in the supine position are back of the head (occiput), scapula, sacral region, elbows and heels.In a side lying position the pressure points are the ears, acromion process of the shoulder, ribs, greater trochanter of the hip, medial and lateral condyles of the knee and malleolus of the ankle joint.

In a prone position, the pressure points are ears , cheek, acromion process, breast (in the females), genitalia (in males), knees and toes.

CAUSES OF PRESSURE SORE

Direct or immediate causes-

Pressure

Pressure is considered to the primary cause of the pressure sore.In a sick person, the areas of tissue resting against the mattress are vulnerable areas.The pressure in these areas causes depletion of blood supply with the failure of circulation to the weight bearing area resulting in the tissue damage.The pressure over these areas are increased in the following conditions:

• When there is lumps and creases on the bed.
• Incorrect positioning of the body.
• Infrequent change of position.

Friction

Friction of the skin with a rough or hard surface can cause tissue damage. Contact with the rough surface of the bed, wrinkles on the bed clothes, hard surfaces of the plaster casts and splints, presence of foreign bodies on the bed (eg. bread crumbs, orange peelings) careless handling of bed pan, pulling sheets under the patient etc, are frequent cause of friction which cause tissue damage. Friction is also caused due to the rough sponge clothes and prolonged massage without lubricant.

Moisture

The skin contact with moisture for a period of time can lead to maceration of the skin. Patients who are sweating profusely; with incontinence of urine and stools are liable to pressure sores.

Presence of pathogenic organism

Lack of cleanliness harbours pathogenic organisms and infection settles on the skin.

DIFFERENT STAGES OF PRESSURE SORES

Stage 1

Stage 2

Stage 3

Stage 4

Deep injury

Unstageable

Predisposing causes

• Impaired circulation.
• Lowered vitality.
• Emaciation.
• Oedema.
• Obesity.

Patients susceptible to pressure sores

• Acutely ill patients, whose general condition is rapidly deteriorating.
• Elderly bed ridden patients, who make very little movements in bed.
• Obese patients.
• Very thin and emaciated patients, having very little subcutaneous tissue to pad the bony prominences.
• Sedated patients who are not moving readily.
• Paralysed patients, who have suffered spinal coed injuries eg., patients with paraplegia, hemiplegia, and quadriplegia. These patients are not able to make movements in the bed and very often they have incontinence of urine.
• Neurologic patients with lack of sensation that they cannot feel any irritation of the skin.
• Oedematous patient especially those with oedema of the sacrum and buttocks.
• Mal-nourished patients with protein and vitamin deficiencies.
• Agitated patients in restraints.
• Patients on complete bed rest or with limited movements.
• Surgical patients with limited movements.
• Patients with hyper pyrexia who sweat profusely.
• Patients with incontinence of urine and stool.
• Patients with excessive bodily discharges or drainage from the wounds.
• Diabetic patients.