Food- Nightingale Minisode #6

Michelle: Welcome to the Florence Nightingale miniseries. This is minisode number six. This episode is all about food. In it, Florence gives us a taste, no pun intended, of what hospital food was like in the 19th century and how she instructed nurses to encourage patients to eat it. Are there lessons we can learn for our practice today? We'll find out. You're listening to the Conversing Nurse podcast. I'm Michelle, your host, and this is where together,  we explore the nursing profession, one conversation at a time.
To start, Florence gives us many details about the best time for a patient to eat, how much to eat, and the types of food that will be attractive to and actually consumed by your patient. Now, I'm being fully transparent here. I have never had to try to feed adults. I can imagine that sick adults would have difficulty eating not just mechanical issues like stroke patients, but chemical issues such as patients undergoing chemotherapy. You might remember in minisode number three, which was Petty Management, I shared with you my breast cancer experience and that I had had five and a half months of chemo. So I can certainly understand from a personal viewpoint the difficulty eating when you're under the effects of those medications. There is a condition called taste perversion. Yeah, I didn't make it up, but it accurately describes how I and many others felt on chemo. Everything I ate tasted nothing like it's supposed to. For example, things that are sweet don't taste sweet. Things that are salty don't taste salty. Textures are altered, and certain foods, suddenly they're just inedible. If I liked rice pudding before chemo, which I didn't, there is no way I'm going to tolerate it while I'm on chemo. I worked with a nurse some years ago, a friend who also had breast cancer, and she was told by her oncologist to, "eat anything you want, anything that tastes good."  And the only thing that tasted good was Nacho Cheese Doritos. So she spent several months on a diet of snack chips. I don't think that's very good advice for people fighting cancer. I mean, that's a time in your life when you absolutely need the best nutrition possible, and a diet of Nacho Cheese Doritos, it doesn't fulfill the nutritional requirement. But on the other hand, I understand that eating something is better than eating nothing. And personally, I would have chosen Cool Ranch Doritos. So, other than my own experience, I don't know what it's like to have to encourage adults to eat. But because of my pediatric and neonatal background, I know for certain that sick kids and infants do need a lot of encouragement. And this is especially true for the premature infant. I mean, their brains are not yet fully grown. To be able to recognize hunger and have the oral musculature, to be able to latch on to a bottle nipple or a breast, have energy to drink and have the maturity to enable that suck-swallow-breathe sequence. So we as caregivers must be able to recognize these deficiencies and then use the tools we have to help them feed better, like observation of feeding cues, external pacing, chin and cheek support, frequent burping, and most of all, patience. As a PEDS nurse, we used a strategy for kids with gastroenteritis, which Florence describes here.  "A nurse is ordered to give a patient a teacup full of some article of food every 3 hours, and the patient's stomach rejects it. If so, try a tablespoon every hour. If this will not do, a teaspoon every quarter of an hour. " And this absolutely worked. Sometimes we could rehydrate a patient within eight to 12 hours and they would even be discharged the next day. The secret to its success is you have to give literally like a half to 1oz every hour. And if the patient vomits, then they go NPO again for 4 hours. And of course, they have IV fluids running during this time, but then you try it again, a teaspoon every hour. If they vomit, stop and start all over again. I mean, oral hydration, it's used in other countries that don't always have access to IV hydration. The problem is the responsibility to carry it out lies with the caregivers. And the parents would always be amazed at this trick, but it's just something they couldn't do at home. Because who can resist a crying child asking for more? More milk, more chips, more of all the wrong foods? Florence says only to provide the freshest food possible. And this might be difficult in a hospital setting, but she says bring it fresh. And if it's supposed to be hot, make sure it's hot. If it's supposed to be cold, make sure it's cold. She also says that food should never be left at the patient's bedside because it's not good for their appetite. And I second that. I really don't like walking in on patients that have food sitting there that's been there for a few hours. It's just gross. I used to work with an OB/GYN who was an avid runner, and he was always starving. But on the postpartum unit, he would peruse the patient's food trays after their meals and frequently be seen taking a bread roll, an unopened carton of milk, a cookie. And we tried to dissuade him from this because it's a little bit risky, but it was not to be. Florence says "never distract a patient while eating. Don't talk to them, especially about food. Don't talk about business or about interesting topics."  This advice, I feel like it could go either way because, you know, eating is a social activity. And while we're eating, whether it's at home or in the break room, provided we get a break, we're talking, we're laughing, we're listening to podcasts, watching YouTube videos. So I guess you could say we're very distracted. But then again, we're not ill. Florence says a nurse should never put before a patient, "milk that is sour, meat or soup that has turned,  an egg that is bad, or vegetables under done. Yet I often see these things brought into the sick."  Really? Nurses serve the patient's spoiled food, she says. "A good nurse will just whip up something else in a few minutes."  And of course, we have no part, nor should we, in the cooking of food for our patients today. That's up to the kitchen. The most we can do is just ask for food and snacks. And luckily, many hospital units are stocked with milk and juice and so forth so that we can get our patients something to eat if they need it. Florence goes on to tell us what we should feed the sick, and she mentioned something called beef tea. It sounds from her description like it's a bone broth. She says, "now, just try and boil down a pound of beef into beef tea, evaporate your beef tea and see what is left of your beef. You will find that there is barely a teaspoonful of solid, nourishment to half pint of water. Nevertheless, there is a certain reparative quality in it. We do not know what as there is in tea, but it may safely be given in almost any inflammatory disease."  Well, we know bone broth is full of collagen, which is great for the gut, the immune system, and as an antiinflammatory, and it tastes great, too. Same thing goes with tea. It's a potent antiinflammatory. She says eggs are usually not tolerated by the sick, except for what she describes as an "egg whipped up with wine." No, this sounds disgusting, but I was able to find several articles about eggs poached in red wine being a thing. Not a thing for me, but a thing.  And I absolutely love what she says about butter. "Butter is the lightest kind of animal fat, and though it wants the sugar and some of the other elements which there are in milk, it is most valuable in enabling the patient to eat more bread."  Florence, you are a woman after my own heart, because sick or not, I can always eat bread with butter. She talks about the patient's chemistry, and she says that sometimes certain patients will tolerate milk and others won't, while some will tolerate beef tea and others won't. And then she talks about a thing called baker's bread. And what I can liken it too is like a commercial bread, because she said patients that are on that for a long period of time can get sick and then they refuse to eat it, whereas homemade bread or brown bread can actually heal them. Again, there's more talk on tea and coffee and how a little bit goes a long way in terms of stimulants. Like they can really help your patients, but if they're given in excess or poorly timed, as in after 5:00 p.m., they will cause insomnia.  I can relate to that. Florence makes some interesting observations. She says,  "sugar is one of the most nutritive of all articles, being pure carbon, and is particularly recommended in some books. But the vast majority of all patients in England, young and old, male and female, rich and poor, hospital and private, dislikes sweet things."  And this surprised me because I had read it wrong. She said most sick patients. And what I was thinking was that most people in England didn't like sweet things. But then I remembered back to the Victorian days of the English trifle and all the different sponge cakes and puddings, and they definitely like their sugar. Then she talks more of sugar in the form of jelly. She said, "It is now known that jelly does not nourish,  that it has a tendency to produce diarrhea. If 100 spoonfuls of jelly were given in the course of the day, you would have given only one spoonful of gelatin. She adds that gelatin contains large quantities of nitrogen, which is one of the most powerful elements in nutrition. And I'm paraphrasing here when she says it's better to consume the gelatin in the beef tea rather than in jelly. And I'm thinking that's because of the sugar content. And then she said the reason why jelly should be in nutritious and beef tea. "Nutrition is a secret yet undiscovered, but it clearly shows that careful observation of the sick is the only clue to the best dietary."  Amen, Florence, way to bring the power of observation home. I'm sure you guys have heard this saying, a picture is worth 1000 words, right? Well, years ago, in the late 1980s, I worked with a nurse who had a gift for translating her observational skills into basically beautiful artwork. You'll see what I mean in a second. Remember, this is the late 1980s when pediatric hospitalists were not yet born, literally. At least not in small rural hospitals like the one I worked in. The pediatricians worked in their offices. That was their bread and butter. So on this day, my colleague and I admitted a three year old in status asmaticus, a direct admit from the pediatrician's office. We're not sure what happened between the office visit and arrival to our unit, but this kid wasn't looking good. We also didn't have pulse oxymmetry yet, so we got really good, really fast at making observations. This patient had blue nail beds, ashen color, barely perceptible breath sounds, a short inspiratory phase and a long expiratory phase. He was in bad shape, retractions everywhere. We did all the things. Started an IV, administered oxygen, gave a nebulizer treatment, started an aminophilin drip. Do you guys remember those? Horrible. But they worked, and no improvement. My colleague called the doctor's office and had to first get through the what I call, defensive line, the front office staff. And then once the doctor came on the phone, he proceeded to argue with her. "Well, I'm seeing patients. Is he really blue? He didn't look that bad in my office. What are his vital signs?" et cetera? This nurse could just not get through to him the critical nature of the situation until she said, "he looks like my hamster right before it died."  Well, that did it, the physician arrived a few minutes later, arranged for intubation, and transferred to a higher level of care. I'm glad that we now practice in the 21st century, where we have 24/7 pediatric hospitalists because they have elevated the care of kids everywhere. Thanks for listening. Join me next time for another Nightingale minisode where Florence tells us all about beds. This should be fun, because, you know, nurses are pretty vocal when it comes to our patient's beds. Thank you and I will see you soon.