considered wise to submit the patient to the shock of so
serious an operation.
Adjusting the Diet according to the character of the
disease for which the operation is to be performed is most
important. It is not always possible to build up the body
beforehand, but in many cases it is necessary to make the
eflfort. At times the reenforcing of the diet and a certain
amount of gentle massage will enable the patient to pass
through the trying ordeal more comfortably than would
otherwise be possible.
Selecting the Diet to conform to the character of the
disease is as important a factor in the recovery of the patient
as food itself. This selection is left largely to the nurse,
consequently it is necessary that she should understand
just which foods are indicated or contraindicated under the
circumstances, and adjust the diet after the abstinence
period accordingly. For example, the diet fulfilling all the
needs of a patient who has just undergone an operation for
a broken leg might be highly injurious for a patient just
operated upon for some disturbance of the liver or kidneys.
The diet given after must be essentially like that given just
before the operation, in order that the affected organ may
have an opportunity to heal and return to its normal func-
tioning power.
Gastro-intestinal Disturbances must be avoided, both
before and after the operation. In the preliminary treat-
ment, when every effort is being made to increase the
strength and endurance of the patient, such disturbances do
away with any gain brought about by judicious dieting.
After the operation, attacks of indigestion not only cause
pain and discomfort as a result of the gas formation, but
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320 DIETETICS FOR NURSES
may cause symptoms far-reaching and even dangerous in
their effects. The diet, then, must be composed of the sim-
plest food and prepared in the most careful manner, the
amount of food given at a time must be small — it is wiser
to feed the patient oftener than to run the risk of indiges-
tion by giving more than can be readily handled by the
already taxed digestive apparatus.
The Bowels must be kept open in the majority of cases.
Peristalsis is stimulated by the giving of water and fruit
beverages as soon as it is advisable to give anything by
mouth.
Reenforcing the Diet is at times necessary in order that
the patient's strength may be kept up. In such cases lac-
tose, eggs and some of the predigested casein or beef prep-
arations are found to be valuable.
Before the Operation the patient must be made ready
to take the anesthetic. This is done by preventing an
accumulation of food in the intestinal tract. The day before
the operation, then, it is necessary to limit the diet
materially by giving food in small amounts. The light diets
prescribed in acute conditions are as a rule suitable, unless
otherwise indicated.
The Day of the Operation a cup of tea, coffee, or broth
may usually be given, with a cracker, unless the operation
is to be performed early in the morning, in which case the
patient is given no food at all. Some physicians allow a
glass of milk on the day of the operation, but this is left
entirely to the physician in charge.
After Operation a period of total abstinence from both
food and water is necessary in order not to increase or in-
duce nausea and vomiting. As soon as these symptoms
subside, unless otherwise indicated, a certain amount of hot,
cold, or carbonated water may be given. After this,
albumen water may form the first nutrient administered.
Milk, broth and fruit beverages follow the giving of albu-
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TREATMENT BEFORE AND AFTER OPERATION 321
men water, after which the semi-solids, such as soft eggs,
gelatin and milk soups, constitute the convalescent diet.
The Character of the Diet after the operation depends
wholly upon the nature of the disease for which the operar
tion was deemed necessary.
Diet After Gastro-enterostomy must be adjusted in
order not to increase the acid content of the gastric organ,
otherwise the delicate mucous linings of the intestines would
be subjected to direct contact with materials which are
irritating in character, owing to the fact that the mass
passes through the new opening and has thus been deprived
of the neutralizing agents found in the upper part of the
intestinal tract. Under the circumstances milk, albumen
water and fine cereal gruels are the best foods from which
to formulate the diet after the necessary period of absti-
nence and fluid diet.
After Appendicitis, as a rule, no food is given for five
days in cases where there has been a pus formation and the
appendix gangrenous. Otherwise the routine treatment diet
is given — water, then albumen water, followed by broth,
milk and fruit beverages, fine cereal gruels, etc.
After Liver and Gall-bladder Operations the character
of the food must be considered. The fats are not well
handled in such conditions and must be avoided as far as
possible. Broths must be well skimmed and the milk fat
free. Buttermilk and koumiss are probably the most suit-
able forms in which to give milk in these cases.
After Kidney Operations the work of elimination
through kidney must be limited as far as possible in such
cases. While it is impossible to rest the organ entirely, the
giving of a proper diet under the circumstances will do much
toward relieving the strain placed upon it. The protein
foods, with the exception of milk, must be excluded from
the diet. The regime practiced in acute nephritis gives the
most satisfactory results.
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322 DIETETICS FOR NURSES
PROBLEMS
(a) Write a diet order for patient operated upon for gastric
ulcer.
(b) Formulate diet to be used after a gall bladder opera-
tion.
(c) Outline diet used after operation upon the kidney.
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CHAPTER XVII
URINALYSIS
The importance of the kidney functions haB been clearly
demonstrated. Urine, which is the fluid secreted by these
organs, is one of the most important sources of information,
not only as to the manner in which the body utilizes food
in health, but as an index to certain pathological conditions,
the processes of which are more or less indicated by the
products excreted in the urine.
Function of the Kidneys. — The kidneys, as has already
been stated, furnish a means by which the greater part of
the waste products of the body are eliminated and in addi-
tion to this function they adjust the salts in the body. In
an early chapter the function of the salts in food was
explained. A certain amount of these substances, we know,
is absolutely necessary to carry on the work in the body,
but harm comes when a surplus is retained in excess of that
which can be used in performing the various processes.
Consequently the function of the kidneys to adjust the
salts balance is by no means their least important one.
Elimination of the Toxins. — The toxic substances man-
ufactured in the body and those resulting from bacterial
action upon unabsorbed proteins are likewise eliminated in
the urine. Thus it can be readily understood how necessary
it is to keep these organs in good repair, that they may con-
tinue their work in an efficient manner.
It is necessary from a pathological standpoint for the
nurse to understand the making of some of the simpler
tests, that she may simplify her own work and that of the
physician.
323
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324 DIETETICS FOR NURSES
Excretion of Carbon Dioxide and Water. — We have
already spoken of the combinations of carbon and hydrogen
compounds. These substances being oxidized, the carbon
dioxide produced is eliminated by way of the lungs and the
water is excreted partly by way of the lungs and skin, but
chiefly by way of the kidneys.
Oxidation and Excretion of Nitrogenous Substances.
— When the nitrogenous substances are oxidized, the
used-up oxygen products are eliminated by the kidneys in
the form of urea and more or less highly oxidized sub-
stances, such as ammonia and other salts, purin bases, and
creatinin.
Uric Acid, the chief of the oxidation products of nucleo-
proteins, is produced in the body and from food, and is
always in the urine, being one of its normal constituents.
It is only when this substance is in excess in the urine that
a pathological condition is indicated.
Examination of the Urine, then, is made for several
different purposes: (1) to ascertain whether the kidneys are
doing their work properly; (2) to find if the kidneys, or any
part of the urinary tract, are either temporarily or per-
manently diseased; (3) to be able to judge from the various
substances in the urine whether there is any abnormal
process taking place in the body.
Tests. — In the examination of the urine for the above
purposes, certain definite tests are made. These tests dif-
ferentiate between the abnormal and the normal.
(1) Color.
(2) Amount in twenty-four hours.
(3) Odor.
(4) Specific gravity.
(5) Reaction, acid or alkaline.
(6) Albumen, indican, acetone bodies.
(7) Sugar.
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URINALYSIS 325
(8) Microscopic examination for casts, cells, bacteria,
etc.
The Color of normal urine varies, especially with the
amount voided.
The variations in color range from the pale straw color
of individuals who are voiding large quantities to the deep
lemon or amber of those who void much less.
Pathological conditions are indicated to a certain extent
by the color of the urine. Fevers heighten the color, small
quantities of blood cause a smoky appearance, while bile
changes the color of the urine to a greenish yellow.
Precipitates in the Urine. — When the urine has been
allowed to stand for a time there is sometimes a brick-red
deposit due to the precipitate of urates. This disappears
upon heating and is not an evidence of any diseased condi-
tion.
Turbidity of Urine. — The turbidity of fresh urine then
is the only kind which need be considered, since standing
in the cold often brings about this condition, due to the
growth of bacteria and deposits of both phosphates and
urates.
Requirements in Testing Urine. — Urine to be tested
should be fresh, and when it is not possible to make the
examination at once it should be preserved with chloroform,
or some other harmless preservative, until ready to use.
Bacteria in Urine. — The changes due to bacterial
growth in the urine are manifested not only by the turbid
character of the urine but also by the odor of ammonia.
The Amount of Urine. — The amount of urine voided
in twenty-four hours varies with the individual in health
as well as in disease. Many individuals void a great quan-
tity during the twenty-four hours, chiefly because they
drink a great quantity of water and other beverages. The
average amount of urine passed in twenty-four hours by an
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326 DIETETICS FOR NURSES
adult, or a chOd over eight years, is from 1000 to 2000 c.c.
It represents from 60% to 70% of the amount of water
ingested.
Collecting the Urine for Testing. — In measuring the
urine it is necessary to begin collecting it after the bladder
has been emptied the first thing in the morning. The patient
should void just before the end of the twenty-four-hour
period to be sure that the amount formed by the kidneys
during this time is accounted for.
Diseases in Which Urine Is Diminished. — In certain
diseases the amount of urine passed is diminished. This is
found to be true in diarrhea and dysentery, when water is
lost in the feces, in hemorrhage from any part of the body
and from vomiting. It is likewise at times the case after
abdominal operations and in nervous conditions, such as
hysteria. The urine is diminished when there is an organic
obstruction in the urinary tract and certain obstructive dis-
eases of the heart, the lungs and the liver. In these latt€r
cases, there is seen to be a retention or suppression of
urine. In both acute and chronic nephritis and in certain
fevers, the bladder at times must be emptied by means of
a catheter. At other times, the condition is relieved as far
as possible by limiting certain articles of food in the diet-
At any rate, these points must be kept in mind when ex-
amining the urine.
E£Fect of Food upon the Urine. — The odor of normal
urine is changed after eating certain foods, such as onions
and asparagus. In disease, the odor of urine has a distinct
value as a means of diagnosis; cystitis gives a foul odor,
certain bacteria bringing about a decomposition in the urine
and giving rise to an odor of putrefaction. In cases where
there is a fistula connecting the bladder and rectum, the
urine has a fecal odor.
Specific Gravity of Normal Urine. — The density or
specific gravity of urine means the weight of any volume of
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URINALYSIS 327
urine as compared with that of equal volume of distilled
water. The specific gravity of normal urine varies from
1012 to 1024, that is, in a thousand cubic centimeters of
urine there are found from 11 to 18 grams of solid material.
In health it is necessary to know the amount of urine
passed in twenty-four hours, to be able to judge whether the
amount of solids is too high or too low.
Specific Gravity of Diabetic Urine. — In conditions like
diabetes mellitus, where there is a wastage of sugar taking
place in the body — that is, instead of being oxidized to car-
bon dioxide and water and glucose, the sugar is passing
into the urine without completing its oxidation — the
specific gravity rises in these cases to 1030 and over, show-
ing distinctly that a greater amount of solid material is
in the urine than is present normally. In chronic Bright's
disease and diabetes insipidus, the specific gravity is low.
Method of Determining Specific Gravity. — The spe-
cific gravity is determined by the use of an instrument
known as a urinometer. The urine is poured into a tube
and the urinometer is dropped into it. The different figures
are marked upon the stem of the instrument and it is a
simple matter to read off the figures of the level to which
the stem sinks.
Reaction to Litmus. — In a former chapter it was stated
that normal urine was, as a rule, acid, that is, it turns blue
litmus red. Certain diseases render the urine alkaline. A
like result is brought about upon the ingestion of sodium
citrate or bicarbonate of soda. Urine which stands and be-
comes decomposed is alkaline in reaction, due to the bac-
terial action, with the production of ammonia.
Albumen in the Urine. — The presence of albumen in
the urine is important, since normal urine does not contain
this material in quantities suflScient to be recognized by
ordinary tests. Hence in disease its presence is an indica-
tion of pathological processes taking place either in the
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328 DIETETICS FOR NURSES
kidney or the urinary passages. The chief abnormal condi-
tion indicated by the presence of albumen in the urine is
nephritis. Traces of albumen may occur in patients with
fever or a heart weakness. Blood and pus in the urine like-
wise indicate albumen. When the nephritic condition is
chronic, the kidneys themselves are diseased and the pres-
ence of albumen may be in traces only, while during the
acute attack large quantities may be passed, but the urine
will clear up after a time.
Benedict's Qualitative Sugar Test. — Boil 5 c.c. of
Benedict's solution; add 8 drops of urine to be examined;
hold the tube over the flame and allow to boil vigorously
for 3 minutes and set aside to cool of itself. In the presence
of sugar the entire solution will be filled with a precipitate
which may be greenish, yellow, or red, according to the
amount of sugar present. When the percentage of sugar
is low (under 0.37c ) the precipitate will form only upon
the cooling of the solution. If there is no sugar present,
the solution will either remain clear or show a slight tur-
bidity, due to the precipitation of urates. The nurse must
remember that to be useful the test must be made accu-
rately. There must never be more than 10 drops of urine
and 8 drops is the usual quantity. The boiling must be
vigorous and the solution allowed to cool spontaneously.
Fehling's Test for Sugar. — Fehling's alkaline solution
and Fehling's copper solution must be kept in separate bot-
tles until ready for use. Then about 2 c.c. of Fehling's
alkaline solution is poured into a test tube and 2 c.c. of
Fehling's copper solution is added. This is diluted with
hydrant water to 8 c.c. Half of this quantity is sufficient
for the test. The upper half of the solution is boiled over
flame (gently agitated while heating), and while still boiling
a few drops of urine are added. If no change appears, it is
boiled again and a few drops more of urine are added. If a
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URINALYSIS 329
reddish precipitate appears, sugar is present. The chemical
reaction taking place is the reduction of copper sulphate to
cuprous oxide. Sometimes a partial reduction occurs when
urates are in excess, but once having seen the real reduction,
a partial one cannot mislead the examiner.
Haines's Test. — Pour 1 teaspoonful of Haines's solu-
tion into a test tube and boil gently over a Bunsen burner;
add 6 or 8 drops of urine and again heat to boiling. A yel-
low or red precipitate will indicate the presence of glucose.
QUANTITATIVE TEST FOR SUGAR
Benedict's Test.^ — The simple quantitative test for
sugar is the one devised by Benedict. This is simpler than
the polariscopic examination and better suited for ordinary
use.
Place 5 c.c. of Benedict's quantitative solution in a
small dish, add a little less than one-fourth of a teaspoonful
of sodium carbonate and one-eighth of a teaspoonful of
talcum and add 10 c.c. of water. Dilute urine (1 part
urine to 9 parts water) except where the qualitative test
showed a low percentage of sugar, that is, when the precipi-
tate turns green instead of yellow, in which case it will be
unnecessary to dilute the urine. Place dish over burner
and bring the contents to a boil. Pour the urine into a
graduated pipette. Now add the urine drop by drop to
the contents in the dish until the blue color entirely disap-
pears. This test should be done over several times to
assure an accurate calculation. The calculation is made as
follows: 5 c.c. of Benedict's quantitative copper solution are
reduced by 0.01 gram of glucose, consequently the quantity
of undiluted urine required to reduce 5 c.c. Benedict's solu-
tion contains 0.01 gram of glucose.
*"Treatpient of Diabetes Mellitus," pp. 182-183, by Joslin.
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330 DIETETICS FOR NURSES
0.01
X 100 = per cent, x = c.c. of undiluted urine.
X
Example; 1500 c.c. urine in 24 hours.
5 c.c. used to reduce (decolorized) Benedict's solution.
0.01
X 100 = 0.2 per cent.
5
1500 X 0.002 (0.2 per cent.) = 3 grams of sugar in 24
hours.
Example: If the urine had been diluted with 9 parts
water, in other words, 10 times, the calculation would be
5 c.c. diluted urine = 0.5 c.c. actual urine.
-^ X 100 = 2 per cent.
1500 X 0.02 (2 per cent.) = 30 grams of sugar in 24
hours.
Hill and Eckman perform the Benedict's quantitative
test as follows: ^
Measure with a pipette 25 c.c. Benedict's solution into
a porcelain dish, add 5 or 10 grams approximately of solid
sodic carbonate, heat to boiling, and while boiling, run in
urine until a white precipitate forms, then add urine more
slowly until the last trace of blue disappears. The urine
should be diluted so that not less than 10 c.c. will be re-
quired to amount of sugar which 25 c.c. of reagent is
capable of oxidizing.
Calculation: 5 divided by number of cubic centimeters
of urine run in equals per cent, of sugar.
Fermentation Test for Quantity of Sugar in Urine. —
If the urine is 70° F. (room) temperature when the specific
gravity is taken at both the beginning and end of the test,
it will assure accuracy.
* "Starvation (Allen) Treatment for Diabetes MellituB," by Hill and
Eckman.
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URINALYSIS 331
To 100 c.c. of urine of known specific gravity, add one-
fourth of fresh yeast cake thoroughly broken up. Mix thor-
oughly and set aside at a temperature between 85° and
95° F. for twenty-four hours, after which time test with
Benedict's or Fehling's solutions. If reduction is obtained,
it will be necessary to allow the fermentation to continue
until it is complete. When no further reduction is obtained,
the specific gravity is taken after the urine has reached a
temperature of 76°. The difference in the specific gravity
at the beginning and end of the test multiplied by 0.23
gives the percentage of sugar in the urine.
The following formulas represent the various solutions
used in the above test:
Benedict's Qualitative Solution
Om, or cx»
Copper sulphate (pure crystals) 17.3
Sodium or potassium citrate 173.0
Sodium carbonate (anhydrous) 100.0
Distilled water to make 1000.0
Pehling's Solution
(1) Copper Sulphate Solution:
34.65 grams copper sulphate dissolved in water
and sufficient water added to make 500 c.c.
(2) Alkaline Solution:
125 grams potassium hydroxide.
173 grams Rochelle salts dissolved in water q.s. to
make 500 c.c.
Keep solution in separate bottles and mix in equal quan-
tities when ready to use.
Haines's Solution
Copper sulphate (pure) 30 grams
(dissolved in % oz. (15 c.c.) distilled water)
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332 DIETETICS FOR NURSES
Add % oz. pure glycerin, mix thoroughly, and add 5 oz.
liquor potassse.
Benedict's (Quantitative) Solution
Copper sulphate (pure crystals) 18 grains
Sodium carbonate (crystallized) (or 100 grams
of anhydrous salt) 200 grams
Sodium or potassium citrate 200 grams
Potassium sulphocyanide 125 grams
5% solution of potassium ferrocyanide .... 5 c.c.
Distilled water to make total volume of 1000 c.c.
Dissolve the carbonate, citrate, and sulphocyanide with
the aid of heat and enough water to make 800 c.c. of mix-
ture. (Filter, if necessary.) Weigh exactly the copper sul-
phate crystals and dissolve in 100 c.c. of water, now add it
to the first solution; stirring constantly. Add the ferro-
cyanide solution ; cool and dilute to exactly 1 liter.
50 mg. (0.050 gm.) of sugar will reduce 25 c.c. of the
above solution.
Gerhardt's Ferric Chloride Reaction for Diacetic Acid.
— To 10 c.c. of fresh urine, add carefully a few drops at a
time of undiluted aqueous solution of ferric chloride U. S. P.
A precipitate of ferric phosphates first forms, but upon the
addition of a few more drops of the same solution it is dis-
solved. A Burgundy red (red wine) color is obtained in the
presence of diacetic acid. The depth of this color is indic-
ative of the quantity of acid present. Joslin ^ records the
intensity of the reaction as follows, +, ++, +++, or
According to Joslin, it must be remembered that similar
reaction is obtained in the urine of individuals taking sali-
cylates, antipyrin, cyanates, or acetates, but it is a simple
process to differentiate between the color produced as a
•"Treatment of Diabetes Mellitus," p. 186, by Joslin.
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URINALYSIS 333
result of diacetic acid and that produced by the above-men-
tioned drugs. If the solution is boiled for two minutes, the
color from diacetic acid will disappear, owing to the unsta-
bleness of that substance, while that from the drugs will
remain unchanged.
Test for Acetone. — Pour 5 c.c. of urine to be tested
into a test tube, add a crystal of sodium nitroprusside,
acidify with glacial acetic acid, shake well, and then make
alkaline with ammonium hydrate. The presence of acetone
is indicated by a purple color.
TESTS FOR ALBUMEN
The heat test * is the simplest. This consists of first
filtering the urine through filter paper, then pouring some
of the clear urine into a test tube, holding the test tube in a
flame so that only the upper layer boils, then adding a few
drops of 2% solution of acetic acid and boiling again. If
there is albumen present, a very faint, or a heavy cloudiness
(precipitate of coagulated albumen) forms on boiling and
persists or becomes heavier on the addition of a few drops
of dilute acetic acid (2%) and boiling again. If a precipi-
tate occurs at the first boiling, but clears up again entirely
on adding acetic acid, it is not albumen but harmless phos-
phates or carbonates.
heller's test for albumen
Into a test tube pour a few drops of nitric acid, filter the
urine and allow a small quantity of it to trickle from a