Happy National Nutrition Month! We’ve officially been in the new office (trailer) for just over a week. It’s still inconvenient to travel a lot further to get to the hospital and our patients, but we’re adjusting. To catch up with my previous clinical experience, check out:
DI: Week 18 – Clinicals and a Seminar
DI: Week 19 – All the Clinicals + Diabetes Education
DI: Week 20 – More Clinicals + Finally Official
DI: Week 21 – Clinicals + Site Visit + Another Seminar
DI: Week 22 – Clinicals + Moving Into a Trailer
In order to maintain patient confidentiality and privacy, I’m being deliberately vague when blogging about where my rotation is and the patients I’m seeing. You can find a more detailed explanation of this in my Week 18 post.
Here’s what my week looked like:
Monday:
I started a new unit in my clinical rotation: telemetry. The telemetry unit, or cardiac unit (we call it tele) is where the patients with heart attack, failure, etc. are. We ended up only having one patient to see in tele, so I picked up some patients from acute care. Overall, it was a relatively slow day (surprising for a Monday). I did a low sodium diet education, heart failure follow up, malnutrition follow up, diabetes diet education, and a difficulty swallowing assessment. I realize I’ve never explained the difference between an assessment, follow up, education, screen, etc. so let’s do that now! An assessment is a longer visit with the patient. I have to completely review their chart and know their past medical history, labs, and medications. During my time visiting with the patient, I ask them more about their weight history and dietary patterns. Assessments also involve making a nutrition diagnosis. The most common ones I’ve had to use are malnutrition, inadequate oral intake, and increased nutrient needs. Once we assess a patient, we continue to follow them until they leave the hospital. A follow up is generally pretty quick. I review any new labs or weights associated with the patient before seeing them. Then I go to their room and have a quick conversation with them about changes in their appetite or eating. If they’ve been getting a nutrition supplement (like Ensure or Boost), I ask them about this as well. For an education, I gather a brief history of the patient from their medical record. I spend most of my time, however, talking with the patient and educating. For example, if I’m doing a diabetes education I look at their recent blood glucose values and Hemoglobin A1C (indicator of how well their diabetes is controlled). Educations use a lot of motivational interviewing and feel more like an outpatient visit. Screens can either be really brief, or can turn into a full-blown assessment depending on the results. For example, a screen could be ordered if a patient says they’ve lost weight in the last 6 months. Sometimes, a patient may have lost only a little bit of weight, or they tried to lose that weight and then we would screen them out and no longer have to follow them. Basically, we chart that they don’t have a nutrition problem and then move on. If during our visit, we find out that they’ve lost a lot of weight, or also have eating issues, etc. we complete a full assessment on the patient. All patients are initially screened by their nurse when they’re admitted, but we also get consulted to complete screens, and have to complete screens if a patient has been in the hospital for 7 days or longer or if they are on an NPO (no food) diet for 5 days or longer.
Tuesday:
Just like yesterday, we didn’t have very many patients to see in tele today, so I picked up some patients from acute care again. I did a vitamin K/coumadin education, a pressure ulcer follow up, 3 length of stay screens, a malnutrition follow up, a poor oral intake/cancer assessment, and a renal weight loss assessment. My renal weight loss assessment was complicated because this gentleman has an extensive medical history and a lot of comorbidities. My patient had end stage renal disease, meaning that his kidneys are barely working and he needs dialysis to filter his blood and stay alive. At this point, he’s had kidney disease for a long time (there are 5 stages to kidney disease that people progress through). He also had recent abdominal surgery, and his surgical wound wasn’t healing. He was losing weight and was obviously malnourished. Kidney disease can be very confusing for patients because it’s relatively complicated from a dietary perspective. When a patient’s kidneys start failing, but they don’t need dialysis yet, they are often put on a protein restriction. Healthy kidneys can easily handle protein, but unhealthy kidneys can’t and too much protein puts more strain on them which causes them to continue to decline. However, once a patient’s kidneys are in such bad shape that they need dialysis, their protein needs go up. This man had only recently started on dialysis, and with a surgical wound his protein needs are very high. He was still following the protein restriction he was on pre-dialysis, and consequently lost a ton of weight. Dialysis patients often don’t have much of an appetite either, which makes it even more difficult for them to get enough protein. In any case, I spent some time talking to him about how his protein needs are higher now and offered him a kidney-friendly nutritional supplement to help him get more protein.
Wednesday:
Another day spent all over the place! Once again, we only had 4 follow ups to do on tele, so I picked up some acute care patients. I did another new diabetes diet education which went really well–these have all gone suspiciously well for me… I also did an assessment and education for a woman with cancer. We talked about strategies to increase protein and calorie intake since she was losing weight. She also had open mouth sores which made eating challenging, in addition to side effects from chemotherapy. Luckily, she seemed to be tolerating liquids well, so she’ll get a nutritional supplement while in the hospital and I gave her protein shake recipes she can use when she’s at home. I also had to write up parenteral nutrition recommendations for a patient with a mass in his stomach. Parenteral nutrition is administered directly through a vein. We use this for patients who can’t digest food properly (like this man who has a giant mass blocking his stomach). I had to calculate how much protein, fat, and carbohydrate his parenteral solution needs to have to meet his nutrient needs.
Thursday:
Today was pretty slow; I only had one patient to see in tele. He was a pretty uncomplicated patient, so it didn’t take long to chat with him and write his note. Then, I did a department training with the nutrition manager at the hospital. Our whole department is changing and moving to a new location (hence us moving to the trailer). I also sat in on ICU rounds since so many of the patients are on tube feedings. ICU rounds are a lot harder to be in than acute care because they have more complicated and sicker patients. It’s just tough to have to hear about a patient who has a very poor prognosis. We also go to all the rooms in the ICU for rounds, so you get to physically see each patient.
In the afternoon, I saw a post-gastric bypass patient admitted with iron and vitamin B12 deficiency. She got gastric bypass almost 30 years ago and hadn’t been keeping up with her supplements lately. I explained the importance of these supplements for her since she’s had bypass and checked in with how she’s been eating. She’s been able to maintain her weight loss since getting bypass, and was eating normally which is good. Her only problem is that she wasn’t taking her supplements and became severely anemic. Now that she knows more about why these supplements are so important, I’m hopeful that she’ll keep up with them better.
Friday:
Today, I did a couple of heart failure diet educations on tele, saw a couple of malnourished patients in acute care/oncology, and did a diabetes diet education in the ICU. We see all patients admitted to the telemetry unit with heart failure to make sure they know about the heart failure diet. We talk about restricting sodium, choosing healthier fats, and discuss fluid restrictions if they have one. One of the patients I saw for a heart failure diet education was doing well with the diet. The other one, however, was in the hospital for a heart failure exacerbation and didn’t care about a heart healthy diet at all. It’s always interesting to see the people who work hard to manage their chronic illness versus those who do nothing to manage it and end up in the hospital with an exacerbation of their illness. Today was also the last day of business as usual–next week we’ll be using a new electronic medical record and charting system!
Weekend:
Spencer came to visit! We watched “Game Night” in theaters, which was hilarious! After that, we went bowling for the first time together. It was a lot of fun, even though I’m terrible at bowling. :P
Next week I’ll be at the hospital Monday-Thursday, at a seminar at Loyola on Friday, and at another seminar for the North Suburban Academy of Nutrition and Dietetics on Saturday. Until then!