Sunday, May 31, 2009
End of Week 3
The rest of last week went well. I got to go on rounds in the NICU, which was a very different kind of experience. The babies are really teeny and many are amazingly young--one of the babies was 0.55 kg and was born at 25 weeks. It's a little heartbreaking to see them with all the tubes and everything attached to them. I also got to talk to patients for the first time last week-- I did two quick followups and I did part of a diabetes education. I had to correct myself a couple of times and say "blood sugar" instead of "glucose." After a year of discussing glucose, it's a little tough to remember to use the more colloquial term. We also had a couple of TPN cases at the end of last week. My dietitian has this really helpful cheat sheet to figure out the TPN formulation and the max glucose rate. I definitely copied that one into my pocket guide...
Week 3 - Gaston Memorial
Nothing too exciting to report. I'm basically just amazed that 3 weeks have passed already. I've been doing more educations on my own which is great so I can attempt to avoid the "food police" vibe coming from all the other RD educations that I've seen. It has definitely made me appreciate the value of anyone who is a good counselor, along with the value of enough time to actually listen and help someone. I suppose I always valued quality over quantity but if it doesn't pay your bills...
Monday I'm headed to the Cardiac Rehab outpatient facility, and I'm really looking forward to it.
Oh, and if anyone wondered, you can thicken pretty much anything with those packets of liquid thickener, including SunDrop.
Monday I'm headed to the Cardiac Rehab outpatient facility, and I'm really looking forward to it.
Oh, and if anyone wondered, you can thicken pretty much anything with those packets of liquid thickener, including SunDrop.
Wakemed 2nd week—cardiac rotation
I have seen lot patients this week in Cardiac floor. It was much different from Rehab Hospital even they belong to same health system. I need to do both paper and electronic chart for each patient, and even the paper chart is different. I have to learn it again from beginning.
I did several educations on diabetic (consistent CHO and calorie counting), low sodium diet as well as heart healthy diet. It was challenging at the first time, since I don’t know how detailed I need to explain to patients. It is hard to explain everything in 20 minutes, especially for patients don’t know anything about the disease, or even don’t care. I tried to follow the handout, then I found that patient only care about whether he can have fried chicken, French fries etc, not about how to control his blood sugar. I was frustrated at that time and felt nutritional education was useless to change pts lifestyle even they are medically needed. The dietitian told me sometimes it happened, just learn how to deal with patients with different need, it always helps them.
The other thing, I have interviewed one patient who were depressed after his diagnosed with CHF, and carry a lot of fluid in body. I talked to him about nearly 30 minutes. He was very open to me and told me how he struggle of his disease and life. I was proud of myself, since I did help him to feel better, not only for his food choice, and also, he has better understanding of his diagnosis and fights it. Patients felt terrible when they are at hospital, they always complain hospital food. The most important thing is not to restrict patients’ diet (for example, renal diet). The more they eat, the sooner they will recover from their illness. It is the most valuable experience I haven’t learned from classes!
Right now, I am familiar with hospital environment, and start to enjoy my internship, and ready to learn more.
I did several educations on diabetic (consistent CHO and calorie counting), low sodium diet as well as heart healthy diet. It was challenging at the first time, since I don’t know how detailed I need to explain to patients. It is hard to explain everything in 20 minutes, especially for patients don’t know anything about the disease, or even don’t care. I tried to follow the handout, then I found that patient only care about whether he can have fried chicken, French fries etc, not about how to control his blood sugar. I was frustrated at that time and felt nutritional education was useless to change pts lifestyle even they are medically needed. The dietitian told me sometimes it happened, just learn how to deal with patients with different need, it always helps them.
The other thing, I have interviewed one patient who were depressed after his diagnosed with CHF, and carry a lot of fluid in body. I talked to him about nearly 30 minutes. He was very open to me and told me how he struggle of his disease and life. I was proud of myself, since I did help him to feel better, not only for his food choice, and also, he has better understanding of his diagnosis and fights it. Patients felt terrible when they are at hospital, they always complain hospital food. The most important thing is not to restrict patients’ diet (for example, renal diet). The more they eat, the sooner they will recover from their illness. It is the most valuable experience I haven’t learned from classes!
Right now, I am familiar with hospital environment, and start to enjoy my internship, and ready to learn more.
Saturday, May 30, 2009
HONK
My most memorable patient this week came in with a HONK! That is, hyperosmolar non ketotic coma.
Direct from Wikipedia: "Nonketotic coma is usually precipitated by an infection,[2] myocardial infarction, stroke or another acute illness. A relative insulin deficiency leads to a serum glucose that is usually higher than 33 mmol/l (600 mg/dl), and a resulting serum osmolarity that is greater than 350 mOsm. This leads to polyuria (an osmotic diuresis), which, in turn, leads to volume depletion and hemoconcentration that causes a further increase in blood glucose level. Ketosis is absent because the presence of some insulin inhibits lipolysis, unlike diabetic ketoacidosis."
This gentleman had a blood glucose reading on admission in the 600s, and a Ha1c of 17. We all thought that was a mistake at first! He admits that he has not been paying attention to his diabetes, does not check his blood sugar much, and doesn't always take his Actos because he believes it makes him gain weight.
He also had a history or ESRD because of congenital kidney malformation and had a kidney transplant in 2001 after many years of dialysis. Since then he has been struggling with nephrotic syndrome which means he is leaking protein in to his urine and battling edema. I'm starting to see why he wasn't paying attention to his diabetes.
His HONK was probably precipitated by a large abcess on his back. I didn't see it, but read that they made a 3cm incision to drain it so it must have been quite large. When I saw the patient he was in quite a lot of pain from his wound, but insisted it was a good time to talk. I did a diet education on carbohydrate counting which he said he had heard of but wasn't using. I tried to emphasize that counting carbs would leave him lots of choices and prevent him from ending up with such high blood sugar again. Of course I forgot to mention the one thing I had written down ahead of time: that eating better will help his wound heal and get him out of here, but luckily my RD was there to back me up. As with many of the diet educations reported, I don't know that I did any good. Pts this week overall were pretty challenging because they all had multiple things going on. I worry about this patient's future kidney function which seems to be going downhill, but we didn't even address that because that blood sugar in the 600s was our first priority.
Direct from Wikipedia: "Nonketotic coma is usually precipitated by an infection,[2] myocardial infarction, stroke or another acute illness. A relative insulin deficiency leads to a serum glucose that is usually higher than 33 mmol/l (600 mg/dl), and a resulting serum osmolarity that is greater than 350 mOsm. This leads to polyuria (an osmotic diuresis), which, in turn, leads to volume depletion and hemoconcentration that causes a further increase in blood glucose level. Ketosis is absent because the presence of some insulin inhibits lipolysis, unlike diabetic ketoacidosis."
This gentleman had a blood glucose reading on admission in the 600s, and a Ha1c of 17. We all thought that was a mistake at first! He admits that he has not been paying attention to his diabetes, does not check his blood sugar much, and doesn't always take his Actos because he believes it makes him gain weight.
He also had a history or ESRD because of congenital kidney malformation and had a kidney transplant in 2001 after many years of dialysis. Since then he has been struggling with nephrotic syndrome which means he is leaking protein in to his urine and battling edema. I'm starting to see why he wasn't paying attention to his diabetes.
His HONK was probably precipitated by a large abcess on his back. I didn't see it, but read that they made a 3cm incision to drain it so it must have been quite large. When I saw the patient he was in quite a lot of pain from his wound, but insisted it was a good time to talk. I did a diet education on carbohydrate counting which he said he had heard of but wasn't using. I tried to emphasize that counting carbs would leave him lots of choices and prevent him from ending up with such high blood sugar again. Of course I forgot to mention the one thing I had written down ahead of time: that eating better will help his wound heal and get him out of here, but luckily my RD was there to back me up. As with many of the diet educations reported, I don't know that I did any good. Pts this week overall were pretty challenging because they all had multiple things going on. I worry about this patient's future kidney function which seems to be going downhill, but we didn't even address that because that blood sugar in the 600s was our first priority.
Friday, May 29, 2009
Durham
So it seems like I'm the last to start my rotations. Yep, that's right, I'll be starting on Monday. There were a few glitches, but now everything seems to be ok so I'll be jumping right in by teaching 2 carb counting/DM classes. But so far, I think I've actually had a great opportunity to see how the "other side" works. My supervisor is fantastic, and I honestly wish I could just keep working with her. I've learned a ton about management and basically how everything works from the moment a diet is ordered up until the food going into the patient's mouth. I really have a new respect for everyone that works to feed all of the patients correctly. It's quite amazing.
I won't go into all the details because I don't think anyone is going into food service but honestly, if any of you have a chance to basically follow a Mr. Mojica in your hospitals, I would recommend giving it a try. Anyways, I've been getting a lot of stuff done that they've been trying to do for the past few months, and it's nice to see it actually being used.
We'll see what happens Monday. Have a nice weekend!
I won't go into all the details because I don't think anyone is going into food service but honestly, if any of you have a chance to basically follow a Mr. Mojica in your hospitals, I would recommend giving it a try. Anyways, I've been getting a lot of stuff done that they've been trying to do for the past few months, and it's nice to see it actually being used.
We'll see what happens Monday. Have a nice weekend!
Touring the upper GI tract
There was no way my super cheerful RD was going to let us cry this week! We got to observe a bedside PEG placement yesterday and it was awesome to watch the scope go through the esophagus, into the stomach, and then into the duodenum, just to check things out. I felt like I was on Ms. Frizzle’s Magic School Bus. The people placing the PEG were doing so for the first time, so the head physician explained each step of the process, which was helpful to my understanding of the procedure. The most memorable part was seeing one end of the thread coming out of the abdomen and the other end coming out of the patient’s mouth, almost like they were flossing her GI tract. They hooked the mouth end of the thread around the tube, pulled it gently into the stomach, and then yanked it through the abdominal opening (the lady had 5.5 inches of subcutaneous abdominal fat, so it took some force to get it through).
I saw the nicest gentleman this week, who unfortunately has a very poor prognosis. He has kidney failure and had had head and neck cancer and radiation treatment left him with a trach and barely able to talk. He is being fed through a J tube and came to the hospital from a skilled nursing facility because the tube became infected. Because of the infected J tube, the patient received no fluids and was severely dehydrated (Na was 177 when he was admitted and his other electrolytes were out of wack). Two days ago, my RD had developed a combination TF regimen for him of a 1:1 ratio of RenalCal and Standard Isotonic formulas to meet his challenging protein and electrolyte needs. Today, I assessed the changes in his labs after he started the formula and it was really exciting to see them trending towards normal! It is the first patient where I’ve been able to really observe the benefits of a nutrition intervention, and it was very rewarding.
I saw the nicest gentleman this week, who unfortunately has a very poor prognosis. He has kidney failure and had had head and neck cancer and radiation treatment left him with a trach and barely able to talk. He is being fed through a J tube and came to the hospital from a skilled nursing facility because the tube became infected. Because of the infected J tube, the patient received no fluids and was severely dehydrated (Na was 177 when he was admitted and his other electrolytes were out of wack). Two days ago, my RD had developed a combination TF regimen for him of a 1:1 ratio of RenalCal and Standard Isotonic formulas to meet his challenging protein and electrolyte needs. Today, I assessed the changes in his labs after he started the formula and it was really exciting to see them trending towards normal! It is the first patient where I’ve been able to really observe the benefits of a nutrition intervention, and it was very rewarding.
More adventures
Hello once again,
This week flew by. I cannot believe we are already finished with week three of our internship. Wow! Over the past four days I rotated with two dietitians on the trauma, general medicine, rehabilitation, psychiatric, geriatric, and joint replacement floors. A lot to take in at once! However, I feel like I learned so much and thoroughly enjoyed the busyness. As Amaris previously mentioned, it has been interesting performing rotations with different dietitians. Each dietitian has his or her own way of charting and talking with the patients. For example, one of the dietitians I worked with this week was very thorough in charting and during patient consults. In contrast, the other dietitian saw about 20+ patients a day and quickly talked with each person and charted briefly. I feel like I am adjusting my "ways" with each RD I follow and think that has been one of the most challenging aspects of the internship thus far. Just as I start to chart the way one dietitian likes to take notes, I change rotations and have to learn other aspects of charting. I spoke with another dietitian about this challenge today, and she said that I should see it as an advantage to have the opportunity to observe 26 different RDs. From each I can learn something and develop my own style! Very true.
On Tuesday and this morning I attended the geriatric and trauma rounds, respectively. Both were extremely interesting. MDs, nurses, social workers, case managers, and dietitians were all present. I felt like attending the rounds was advantageous in fully understanding each patient's case. Afterward, I felt as though my expanded knowledge helped me better relate to the patients once I talked with them and also helped me in providing interventions. If you have the opportunity to sit in during rounds, I would highly recommend it. Plus, it provides a neat perspective on the workings of interdisciplinary relationships.
Hope all is well. Enjoy your weekend!
Rachael
This week flew by. I cannot believe we are already finished with week three of our internship. Wow! Over the past four days I rotated with two dietitians on the trauma, general medicine, rehabilitation, psychiatric, geriatric, and joint replacement floors. A lot to take in at once! However, I feel like I learned so much and thoroughly enjoyed the busyness. As Amaris previously mentioned, it has been interesting performing rotations with different dietitians. Each dietitian has his or her own way of charting and talking with the patients. For example, one of the dietitians I worked with this week was very thorough in charting and during patient consults. In contrast, the other dietitian saw about 20+ patients a day and quickly talked with each person and charted briefly. I feel like I am adjusting my "ways" with each RD I follow and think that has been one of the most challenging aspects of the internship thus far. Just as I start to chart the way one dietitian likes to take notes, I change rotations and have to learn other aspects of charting. I spoke with another dietitian about this challenge today, and she said that I should see it as an advantage to have the opportunity to observe 26 different RDs. From each I can learn something and develop my own style! Very true.
On Tuesday and this morning I attended the geriatric and trauma rounds, respectively. Both were extremely interesting. MDs, nurses, social workers, case managers, and dietitians were all present. I felt like attending the rounds was advantageous in fully understanding each patient's case. Afterward, I felt as though my expanded knowledge helped me better relate to the patients once I talked with them and also helped me in providing interventions. If you have the opportunity to sit in during rounds, I would highly recommend it. Plus, it provides a neat perspective on the workings of interdisciplinary relationships.
Hope all is well. Enjoy your weekend!
Rachael
moving along quite nicely...
I start rotating with a different R.D. today. It’s always kind of interesting switching R.D.’s because I learn a great deal about their work ethic, productivity, the way they interact with patients and the other medical staff, how they organize themselves, their method of in-patient education, etc. So we’ll see how it goes. This particular R.D. is 66 years old, got her MPH from the University of Hawaii and worked at the health department there for a number of years when she was my age. Can’t say I’d mind going that route with my career :). Anyway, she went back to school at age 50 or so to get her R.D. and thus is relatively new to the field. This makes her Moore Regional Hospital’s newest (most recent), AND oldest (age-wise) R.D. on staff.
Anyway, I think one of my greatest challenges at this point is reading pt charts accurately! Believe it or not, half the time I can’t tell what the individual has written down, nonetheless WHO that individual is! (Many times, their initials aren’t even written down, but the R.D. will be able to tell just by their signature who it is). It’s definitely made me value clean, handwritten notes. This skill can never be overlooked. :) After this weekend, I get to observe another surgery on Monday: Gastric Bypass! I’m pretty excited, turns out surgery has been one of my favorite rotations/modules/what have you. I’ll let you guys know how it goes! (Apparently, this surgeon’s quite a character and thoroughly enjoys having an audience). Until next time…
Anyway, I think one of my greatest challenges at this point is reading pt charts accurately! Believe it or not, half the time I can’t tell what the individual has written down, nonetheless WHO that individual is! (Many times, their initials aren’t even written down, but the R.D. will be able to tell just by their signature who it is). It’s definitely made me value clean, handwritten notes. This skill can never be overlooked. :) After this weekend, I get to observe another surgery on Monday: Gastric Bypass! I’m pretty excited, turns out surgery has been one of my favorite rotations/modules/what have you. I’ll let you guys know how it goes! (Apparently, this surgeon’s quite a character and thoroughly enjoys having an audience). Until next time…
End of Week 3 with no crying yay!
Today I did a taste test tray, the dietitians have to do them once a month. My tray was mac and cheese (it was SO good, sorry mr. mojica but it wins for me), turkey salad (which ended up being some strips of turkey on some lettuce, quite odd), a roll, milk and zucchini. This was the low sodium menu so that zucchini was incredibly tasteless. All of the stuff was at the right temp so that was good. I suggested better presentation for the turkey salad and seasoning on the zucchini.
Yesterday I worked through a tube feeding patient which was quite interesting and fun I thought. He was about to go on CRRT (continuous renal replacement therapy, akin to dialysis) for a little while so he was going to be needed increased protein. He also had MAJOR pitting edema, which I got to see, it took many seconds for his skin to come back up when pressed. He was taken off diprivan so those calories needed to be replaced by adjusting his tube feeding rate. so we raised that and decided to add promod. It was like a puzzle to figure out what works. I've also been picking up some pointers about what to do when people are diabetic and they need supplements. the only diabetic supplement we can order from the kitchen is HealthShakes but the hospital only has vanilla which gets super boring for people. So we figured out that it was a little less carbs to give 1/2 can of ensure plus four times a day and that comes in a variety of flavors, so over time hopefully I will pick up more tricks like that and start being able to think more creatively.
Yesterday I worked through a tube feeding patient which was quite interesting and fun I thought. He was about to go on CRRT (continuous renal replacement therapy, akin to dialysis) for a little while so he was going to be needed increased protein. He also had MAJOR pitting edema, which I got to see, it took many seconds for his skin to come back up when pressed. He was taken off diprivan so those calories needed to be replaced by adjusting his tube feeding rate. so we raised that and decided to add promod. It was like a puzzle to figure out what works. I've also been picking up some pointers about what to do when people are diabetic and they need supplements. the only diabetic supplement we can order from the kitchen is HealthShakes but the hospital only has vanilla which gets super boring for people. So we figured out that it was a little less carbs to give 1/2 can of ensure plus four times a day and that comes in a variety of flavors, so over time hopefully I will pick up more tricks like that and start being able to think more creatively.
I saw a patient today with the worst control of diabetes ever. He got an ant bite on his foot and it is now being amputated. He admitted he does not do a thing but drink regular soda and eat at buffets. It's a shame it takes losing a foot for someone to realize they should pay attention to controlling their diabetes.
Have a good weekend!
Have a good weekend!
Thursday, May 28, 2009
OB Rotation
Today I started working with the RD who has the OB floor as one of her responsibilities. The two main tasks on the OB floor are to provide education about breastfeeding to women who are interested in it and to talk to patients who have been admitted for hyperemesis gravidarum. She basically just speaks to them about making sure they are getting enough calories, staying hydrated and still taking their prenatal vitamins. Most of the women we saw today had breastfed with previous children, so they just sort of smiled and nodded as we repeated information that they already knew.
We also saw two hyperemesis gravidarum patients. The first patient seemed to be doing better and was tolerating clear liquids after about 12 hours and was hoping to be moved to solid foods within the next day. The next patient was a lot more challenging. We read her chart and it stated her pre pregnancy weight was only about 100# and that she had a previous history of depression and suicidal thoughts. Her current weight was only 81# and she was about 10 weeks pregnant! After talking to the nurse it seemed like the patient had been in before and the doctor was now suspecting an eating disorder rather than hyperemesis. We went it to see her and tried to help as much as possible, but there was really nothing we could do. She was stating that she was hungry and wanted to eat, but the doctor had made her NPO and hadn't been by to advance her diet. We asked the nurse about giving her some juice, but since she was NPO that wasn't a possibility. I felt like we really missed an opportunity to get her to eat, since any calories would be good for her. It was frustrating that since the doctor hadn't been by to advance her diet, she wasn't able to eat. I am hoping that when we check up on her tomorrow that her diet has been advanced.
We also saw two hyperemesis gravidarum patients. The first patient seemed to be doing better and was tolerating clear liquids after about 12 hours and was hoping to be moved to solid foods within the next day. The next patient was a lot more challenging. We read her chart and it stated her pre pregnancy weight was only about 100# and that she had a previous history of depression and suicidal thoughts. Her current weight was only 81# and she was about 10 weeks pregnant! After talking to the nurse it seemed like the patient had been in before and the doctor was now suspecting an eating disorder rather than hyperemesis. We went it to see her and tried to help as much as possible, but there was really nothing we could do. She was stating that she was hungry and wanted to eat, but the doctor had made her NPO and hadn't been by to advance her diet. We asked the nurse about giving her some juice, but since she was NPO that wasn't a possibility. I felt like we really missed an opportunity to get her to eat, since any calories would be good for her. It was frustrating that since the doctor hadn't been by to advance her diet, she wasn't able to eat. I am hoping that when we check up on her tomorrow that her diet has been advanced.
Rex policies and politics
I didn't do as much dietetics the past few days, but I did get to observe a bedside swallowing evaluation, 2 pulmonary function tests, and three meetings about hospital policies (one RD meeting, where the focus was on pressure ulcers, a renal/pulmonary interdisciplinary meetings, and an interdisciplinary stroke meeting).
The swallowing eval was interesting just because the RD's the MD's order them all the time, and because my father is a speech therapist. I didn't get to observe aspiration like Kayla did, though...unfortunate for me, but good for the patient.
The pulmonary function tests were surprisingly interesting, and they really brought the definitions from the module to life. The respiratory therapist was a great educator. She made me realize that you really have to over-simply the anatomy/physiology when talking to patients, but you can still talk about why you're doing what you're doing. In fact, both patients I observed were really appreciative of the mini-lesson she gave and seemed more likely to follow her recommendations because they understood their importance.
The meetings made me realize that protocols are really important at hospitals, and that they're always changing. Basically, lots of people sit in a room and talk about the latest research and professional recommendations, cases at Rex, and what other hospitals are doing. Rex is always trying to be as good as - or better than - UNC and WakeMed, so policies at those hospitals were frequently referenced. It's definitely interesting to see people from so many different areas all working together.
I also spent a good chunk of today hunting down patients with diabetes to make sure they're getting their HS snacks and that the nurses are recording them. Only about 2/30 were recorded. I had an awkward moment when I walked into a hospice room (only I didn't know it was the hospice wing), and there were ~5 family members there who could care less about the snack at that point.
Another awkward moment this week: I went to interview a 92 year old man, and I walked into his room with a quick knock since the door and curtain were wide open. I realized 2 minutes into my questions that he was on the commode with his gown hitched up. Whoops.
The swallowing eval was interesting just because the RD's the MD's order them all the time, and because my father is a speech therapist. I didn't get to observe aspiration like Kayla did, though...unfortunate for me, but good for the patient.
The pulmonary function tests were surprisingly interesting, and they really brought the definitions from the module to life. The respiratory therapist was a great educator. She made me realize that you really have to over-simply the anatomy/physiology when talking to patients, but you can still talk about why you're doing what you're doing. In fact, both patients I observed were really appreciative of the mini-lesson she gave and seemed more likely to follow her recommendations because they understood their importance.
The meetings made me realize that protocols are really important at hospitals, and that they're always changing. Basically, lots of people sit in a room and talk about the latest research and professional recommendations, cases at Rex, and what other hospitals are doing. Rex is always trying to be as good as - or better than - UNC and WakeMed, so policies at those hospitals were frequently referenced. It's definitely interesting to see people from so many different areas all working together.
I also spent a good chunk of today hunting down patients with diabetes to make sure they're getting their HS snacks and that the nurses are recording them. Only about 2/30 were recorded. I had an awkward moment when I walked into a hospice room (only I didn't know it was the hospice wing), and there were ~5 family members there who could care less about the snack at that point.
Another awkward moment this week: I went to interview a 92 year old man, and I walked into his room with a quick knock since the door and curtain were wide open. I realized 2 minutes into my questions that he was on the commode with his gown hitched up. Whoops.
WMH - ICU stories
Yesterday I saw a patient in ICU who had returned from surgery for placement of a PD cath and perma-cath. When we entered the room he was on dialysis. The nurse in the room took ~30 minutes explaining how everything is connected. She also stated that to receive a PD cath you have to "be approved" because you have to have a sterile room in your home specifically for dialysis. She also stated that patients can now actually do hemodialysis at home! They have their own HD machine and water purifying machine. The pt (or family member, friend, etc) draws their own blood for labs, monthly. Their diets are not as strict because they can do HD everyday. The pt & support person have to attend a training and again, the home has to be "approved" by a social worker.
There was another pt in ICU who overdosed on Goody's BC powder (for those of you who may be unfamiliar - it is basically aspirin in powder form with a lot of caffeine). He is a former meth addict who weaned himself from meth by becoming addicted to Goody's.
This week 2 pts codes were changed to CMO (Comfort Measures Only). One pt is 90 and had a MI while shopping in Wal-Mart (the pt had driven herself there and had the MI while paying for her items). The other pt has been in ICU for a while but had a state appointed social worker as guardian. He was found unresponsive in his wheel chair at a nursing home. Doctors had to track down the SW to get approval to change the code.
A happy ending ICU story: One pt had been in ICU since March. Doctors said the pt would not make it. I first saw the pt 2 wks ago & he was nonresponsive. Monday he was no longer in ICU and when the RD I was shadowing starting asking him questions, he was very responsive. Today he was walking down the hall with aid of walker and they are waiting to secure a room for him at a nursing home to release him sometime next week.
There was another pt in ICU who overdosed on Goody's BC powder (for those of you who may be unfamiliar - it is basically aspirin in powder form with a lot of caffeine). He is a former meth addict who weaned himself from meth by becoming addicted to Goody's.
This week 2 pts codes were changed to CMO (Comfort Measures Only). One pt is 90 and had a MI while shopping in Wal-Mart (the pt had driven herself there and had the MI while paying for her items). The other pt has been in ICU for a while but had a state appointed social worker as guardian. He was found unresponsive in his wheel chair at a nursing home. Doctors had to track down the SW to get approval to change the code.
A happy ending ICU story: One pt had been in ICU since March. Doctors said the pt would not make it. I first saw the pt 2 wks ago & he was nonresponsive. Monday he was no longer in ICU and when the RD I was shadowing starting asking him questions, he was very responsive. Today he was walking down the hall with aid of walker and they are waiting to secure a room for him at a nursing home to release him sometime next week.
5/28
Today I met with a 43 year-old woman who is 5'2", 75 pounds. She has a history of anorexia nervosa, along with a host of other problems. I spent about 40 minutes with her, listening to her and trying to offer helpful advice when I could get a word in. The first thing she said to me when I entered the room was that her recent 20 pound weight loss had nothing to do with a relapse- she blamed it on her gallbladder removal 1 year ago, persistent nausea from migraines, and the 13 pills she takes daily (for legitimate medical conditions). It was both a sad and frustrating experience. She said everything right- she's seen two dietitians, she eats 3000 calories per day, she cross-referenced her medications to make sure none of them cause weight loss, etc. Plus, she knows her stuff (counts calories, understands nutrition). She really made me feel like she honestly WANTED to gain weight, and she was doing all that she thought she could do. At the same time, it was hard not to doubt her. Scientifically, it's VERY hard to believe that if she was truly eating 3000 calories per day, and not exercising as she claims, that she can't get above 75#. I wanted to help her- refer her to a dietitian who specializes in eating disorders or at least give her some new suggestion she hadn't heard before. But to some extent I realize it may not matter how much she knows- she won't change her behavior. The problem is likely outside the realm of dietetics. So that's my naive and wide-eyed inexperienced dietetic intern story of the day...
This week I have seen alot of TPN and TF patients. The doctors tend to over use TPN which is unfortunate but it sure is giving me alot of practice. I also sat in on the Diabetes education class this week which is taught in two parts. The first part is taught by a nurse who teaches them about the insulin pumps, meds etc. and the second part is taught by the dietitian. They have an hour break in between for lunch and we dont tell them that we are going to ask what they had for lunch when they get back. I was shocked at the number of patients who just had diet education go out and eat Bojangles (apparently a huge favorite around here). Its doubtful that they will be doing any carbohydrate counting when they leave.
Last week I got to see a barium swallow on a patient who had surgery on his spine but they entered through the front of the neck. As a result he has had trouble swallowing since he recovered. It was unreal the amount of liquids just sat in the back of his throat or that he aspirated. But the speech therapist had him turn his head all different directions and try to swallow and sure enough when he turned his head to the right he swallowed just fine. It was a pretty neat thing to see.
Hope everyone is doing well!
Last week I got to see a barium swallow on a patient who had surgery on his spine but they entered through the front of the neck. As a result he has had trouble swallowing since he recovered. It was unreal the amount of liquids just sat in the back of his throat or that he aspirated. But the speech therapist had him turn his head all different directions and try to swallow and sure enough when he turned his head to the right he swallowed just fine. It was a pretty neat thing to see.
Hope everyone is doing well!
Wednesday, May 27, 2009
I don't have anything very interesting to report so far this week, as I'm wrapping up with my cardio/DM rounds and I feel like things are starting to get more routine. I did talk to a lovely drug addict today, who I believe chooses meth as his poison of choice. 31 year old guy with a wife and kids, already has CHF and had a pacemaker placed a few years ago. Now has cholecystitis and his liver seems to be angry with him as well. I'm finding it difficult to put so much effort into thorough assessments and diet educations when I know the person doesn't want to hear it and likely won't follow our advice. But I'm trying to put a positive spin on it and think that maybe something that we say will click with them later and potentially keep them from returning to the hospital. Wishful thinking perhaps but you never know!
Another busy day at the VA
I would like to start off today by praising all of the people I have had the good fortune to work with at the VA. Their patience and generosity in giving me so much of their valuable time has far exceeded my expectations. I only hope that everyone else is surrounded by such willing teachers.
The past two days have been crazy! There were a lot of new admits over the weekend and many of them were classified as moderate, and therefore must be assessed by the RD. I think the RD I was working with had about 16 patients to see and assess on Tuesday. Luckily only 2-3 new ones came in today. She also had to cover for someone else this morning, and both of us had meetings yesterday.
The RD I am with remained calm and cool through it all, but I must admit I was a little stressed out about getting everything done. On Tuesday she gave me 5-6 patients, and we didn’t really get working on them until 2pm. I knew I couldn’t finish by the end of the day. Neither of us finished, but we kept plugging away today, and hopefully we will get caught up tomorrow. The RD helped me through each assessment. We sat side by side at two computers so she would be right there to answer my questions while we both worked. It was a brilliant set-up in my opinion.
I had a tube feeder, and tomorrow I may have to work on a very complicated TPN patient, unless he is able to go home. We visited the pharmacist today and she talked to us about the case, which was a great learning experience! I was surprised to learn that he gets TPN at home. I have also been surprised by the number of EN patients that are seen by the out patient dietitian at the VA. The EN patient I assessed was interesting. He was already being tube fed when I started on him yesterday, but I wasn’t able to finish until today. When the RD and I looked at the order we were both surprised by the amount of fluid he was being given. This morning the doctor who ordered the tube feeding called the RD, and said he thought he might be over-hydrating the man due to some of his signs, symptoms and lab values, we agreed. I assessed the patient’s needs and adjusted his fluid. The doctor also decided to switch to a denser formula because the patient was not tolerating the formula well and had recently lost weight. So I calculated the amount and the rate of infusion with the new formula. I was excited that the RD agreed with what I suggested.
Yesterday when the RD and I visited patients I was a little overwhelmed by the number of patients and the fact that her visits were slightly different than the Diet Tech’s visits that I had become accustomed to. Today when we visited I felt like I got to know my patients a little more, and it was incredibly valuable to have a face and body to attach to the medical chart when I was evaluating them. There were a few I was concerned about after reading their medical file, but I couldn’t remember what they looked like or how they had acted. When we visited today I was pleased that some patients had improved, and others appeared healthier than I had expected after reading about their conditions. I found this very reassuring.
The past two days have been crazy! There were a lot of new admits over the weekend and many of them were classified as moderate, and therefore must be assessed by the RD. I think the RD I was working with had about 16 patients to see and assess on Tuesday. Luckily only 2-3 new ones came in today. She also had to cover for someone else this morning, and both of us had meetings yesterday.
The RD I am with remained calm and cool through it all, but I must admit I was a little stressed out about getting everything done. On Tuesday she gave me 5-6 patients, and we didn’t really get working on them until 2pm. I knew I couldn’t finish by the end of the day. Neither of us finished, but we kept plugging away today, and hopefully we will get caught up tomorrow. The RD helped me through each assessment. We sat side by side at two computers so she would be right there to answer my questions while we both worked. It was a brilliant set-up in my opinion.
I had a tube feeder, and tomorrow I may have to work on a very complicated TPN patient, unless he is able to go home. We visited the pharmacist today and she talked to us about the case, which was a great learning experience! I was surprised to learn that he gets TPN at home. I have also been surprised by the number of EN patients that are seen by the out patient dietitian at the VA. The EN patient I assessed was interesting. He was already being tube fed when I started on him yesterday, but I wasn’t able to finish until today. When the RD and I looked at the order we were both surprised by the amount of fluid he was being given. This morning the doctor who ordered the tube feeding called the RD, and said he thought he might be over-hydrating the man due to some of his signs, symptoms and lab values, we agreed. I assessed the patient’s needs and adjusted his fluid. The doctor also decided to switch to a denser formula because the patient was not tolerating the formula well and had recently lost weight. So I calculated the amount and the rate of infusion with the new formula. I was excited that the RD agreed with what I suggested.
Yesterday when the RD and I visited patients I was a little overwhelmed by the number of patients and the fact that her visits were slightly different than the Diet Tech’s visits that I had become accustomed to. Today when we visited I felt like I got to know my patients a little more, and it was incredibly valuable to have a face and body to attach to the medical chart when I was evaluating them. There were a few I was concerned about after reading their medical file, but I couldn’t remember what they looked like or how they had acted. When we visited today I was pleased that some patients had improved, and others appeared healthier than I had expected after reading about their conditions. I found this very reassuring.
Patient Satisfaction?
I got my first taste of a "sour" patient this rotation. Or, depending on your patient care philosophy, a not-so-great counseling experience :) The R.D. I was rotating with was consulted for a patient with a recurrent PICC line infection. After I completed her chart review and EER, IBW, etc. to prep us for our conversation with her, we ventured into her room. Since the patient was also Diabetic, we were explaining our concern about her elevated Glu levels, as they would affect her healing, and then how she could help improve her labs in that sense. Well, the patient would have none of it. The second we mentioned "blood sugar," she got defensive on us. She adamantly stated that there was no way she was going to eat her french toast without syrup. After getting more (negative) feedback from her (mainly about how our expectations for her diet changes were outrageous), and then kindly accommodating our recommendations for her, her room phone started ringing. The patient heard the ring and said "Oh, is that my phone?...thank God!" as she stared us down. My rotating R.D. stopped talking as the patient answered the phone and proceeded to tell the relative on the other side of the line how "these dietitians" were in her room talking to her about fiber (which we hadn’t mentioned to any degree) and that she didn't want to hear any of it, as -again- she stared us down. My rotating R.D. wouldn't back down though, so the patient waved her hand in dismissal, as if to say “I’m through with you, you can leave.” My rotating R.D. was nice and said we’d come back later, and after we left the room I looked at her with my jaw dropped. She just laughed at me and said, “Oh honey, I’ve seen worse!” I couldn’t help but laugh at this point, too! To a certain, definite point, as well-intentioned as we may be, we are only as effective as our patient is accepting and compliant. Lesson learned.
Georgetown Week 3
This week I'm in the ICU focusing on nutrition support and critical care. It has been very different from GenMed/Endo because most of these pts are intubated, so you can't really speak to or education them. I've been writing TF recommendations, which has been pretty straightforward for me, as well as TPN recs, which are a bit more complicated. The TPNs are not calculated the way we learned in class; we have to specify the % concentration (they are not given to us) and the total volume of each nutrient. The RDs use trial and error, kind of weird. I'm trying to figure out if there is a methodical way to do this. What is everyone else doing for TPN?
As far as emotional experiences, again, the ICU is very different. A lot of people are passing :( Actually, I was following and interacted with one pt, Mr. B, while I was in the GenMed unit. He had jaundice with excessive bile drainage, and was off and on NPO for an antipated procedure that kept getting postponed. Earlier this week, I was told to assess the pt in room 9, based on our see within 72hrs of ICU admission protocol. I happened to look over and notice no one was in that room. I looked asked the RN what happened, she said he passed away. Then, I went to our "pts to see" list to check it off and noticed it was Mr. B! It was sad because I had just talked to him the previous week and I thought he was stable. I have yet to find out what brought him to the ICU.
As a f/u to my favorite pt, Mrs. G from last week (she's the one who wouldn't eat because she didn't like the food, and was therefore under consideration for a PEG), I just found out she's was put on TPN. Unbelievable! I know she didn't want TF's, so she probably refused. Her calorie counts over 6-7 days averaged ~44% intake. I think this is a great example of when TPN is not appropriate; the gut is working. The RD following this pt was pretty annoyed about this as well. On the other hand, her low PO intake was probably affecting her progress.
We also have journal club here, and one of the RD's presented a case study this week. In general, I've noticed the dietitians reference studies and research for various topics and issues such as feeding obese pts. I think it's great that they are keeping up with the literature!
Sarah O - I also learned the same thing today about Propofol. A lot of pts are on it in the ICU.
As far as emotional experiences, again, the ICU is very different. A lot of people are passing :( Actually, I was following and interacted with one pt, Mr. B, while I was in the GenMed unit. He had jaundice with excessive bile drainage, and was off and on NPO for an antipated procedure that kept getting postponed. Earlier this week, I was told to assess the pt in room 9, based on our see within 72hrs of ICU admission protocol. I happened to look over and notice no one was in that room. I looked asked the RN what happened, she said he passed away. Then, I went to our "pts to see" list to check it off and noticed it was Mr. B! It was sad because I had just talked to him the previous week and I thought he was stable. I have yet to find out what brought him to the ICU.
As a f/u to my favorite pt, Mrs. G from last week (she's the one who wouldn't eat because she didn't like the food, and was therefore under consideration for a PEG), I just found out she's was put on TPN. Unbelievable! I know she didn't want TF's, so she probably refused. Her calorie counts over 6-7 days averaged ~44% intake. I think this is a great example of when TPN is not appropriate; the gut is working. The RD following this pt was pretty annoyed about this as well. On the other hand, her low PO intake was probably affecting her progress.
We also have journal club here, and one of the RD's presented a case study this week. In general, I've noticed the dietitians reference studies and research for various topics and issues such as feeding obese pts. I think it's great that they are keeping up with the literature!
Sarah O - I also learned the same thing today about Propofol. A lot of pts are on it in the ICU.
Babies
Today I sat in on NICU rounds which proved to be quite interesting. My preceptor this week is 30 weeks pregnant and there were a couple of babies in there who were born earlier, so she said she was having a kind of odd feeling about that. I can't even imagine. The smallest one in NICU right now was born at 28 3/7 to a mom who reports not knowing she was pregnant. She went to the bathroom, had a BM, and delivered 2 feet, then proceeded to call an ambulance. Anyhow, so we were calculating the infant's current intake and thought that we were doing something wrong when we were going form absolute numbers (total kcal/day) to relative (kcal/kg/day), because the numbers went up from 71 kcal/d to 74kcal/kg/d. Until we realized the math was correct - she didn't even weigh 1kg! It's amazing how little the feedings are for these teeny-tiny ones. I'm hoping to follow up with this baby over time (even after I'm done with this rotation), since she'll probably be here until the end of July, too.
Guesstimates and TF recs
My patients are getting really complicated. The first lady I saw this week had nonalcoholic steatohepatitis, hypertension and serious fluid excess (the first hospital she had been to had pulled 7 liters out of her via paracentesis!), diabetes, and failing kidneys, but she was actually admitted for a pulmonary infection. When my RD asked me about my plan for assessing her, I think I looked at her blankly. We ended up asking her about recent weight change (she reported about a 47% weight loss over the last 6 months), any diet that she follows at home, and her current appetite. We switched her to 6 small meals each day to try and increase her intake, and we are following up with her on Friday to see how her labs have changed.
The renal service has been a little slow this week, so we’ve spent a bit of time working on TF recommendations for neuro trauma patients. Many of them come in from the ER and we often don’t have good heights for the patients, so we estimate based on how much of the bed they are taking up. It makes me a little nervous to be using such a crude metric…however, we usually we all come up with the same guess. A couple of lessons from this experience:
-Propofol is an IV sedative that many trauma patients receive. Each mL of propofol provides 1.1 kcal from fat, which needs to be calculated into a TF regimen. My patient this afternoon was receiving 36 mL/hr, for a total of 950 kcal from the medication alone (about 42% of his overall calorie requirements!) We ended up switching him from the CHO control formula he was on to a high protein formula in order to meet his protein needs without exceeding his energy needs. Since his glucose had been high (probably due to the prednisone he was receiving), we had to justify the change in the note. I am looking forward to following up and seeing if they take our recommendation.
-My RD tells me that the literature has shown that it is ok to underfeed head trauma patients, as long as their protein needs are being met. Outcomes are not worse in patients who receive only 70% of their estimated nutrition needs (except protein).
I’m bracing to watch a PEG placement tomorrow – my RD is going to sit this one out because she said she nearly fainted the last time she watched one. Oy.
The renal service has been a little slow this week, so we’ve spent a bit of time working on TF recommendations for neuro trauma patients. Many of them come in from the ER and we often don’t have good heights for the patients, so we estimate based on how much of the bed they are taking up. It makes me a little nervous to be using such a crude metric…however, we usually we all come up with the same guess. A couple of lessons from this experience:
-Propofol is an IV sedative that many trauma patients receive. Each mL of propofol provides 1.1 kcal from fat, which needs to be calculated into a TF regimen. My patient this afternoon was receiving 36 mL/hr, for a total of 950 kcal from the medication alone (about 42% of his overall calorie requirements!) We ended up switching him from the CHO control formula he was on to a high protein formula in order to meet his protein needs without exceeding his energy needs. Since his glucose had been high (probably due to the prednisone he was receiving), we had to justify the change in the note. I am looking forward to following up and seeing if they take our recommendation.
-My RD tells me that the literature has shown that it is ok to underfeed head trauma patients, as long as their protein needs are being met. Outcomes are not worse in patients who receive only 70% of their estimated nutrition needs (except protein).
I’m bracing to watch a PEG placement tomorrow – my RD is going to sit this one out because she said she nearly fainted the last time she watched one. Oy.
CMC Union week 3
This week has been a pretty big change from the first two weeks. I've been seeing more patients on my own and writing some of my own notes. I've mostly been educating patients on what to do when taking coumadin, but I've also talked to a few patients about their recent weight loss. I talked to one woman today about carbohydrate counting for her husband. He was in the hospital for blood sugars in the 500s last week, but last night he came in with hypoglycemia. Hopefully the carbohydrate counting will help a little.
I read that a lot of you have had really emotional or graphic experiences. I can't say that I've seen anything too graphic or difficult yet (the dietitians are very protective of me still). Today I was about to go see a patient in critcal care, but then he started yelling out wierd noises, so the dietitian went with me and helped me. I did have my first experiences with code blue though. The first day I was in the critical care unit, code blue (heart/breathing stopped) was called 4 times on a patient, who unfortunately died the fourth time. The CCU (critical care unit) turned into a whirl of activity each time. Luckily I had not yet visited the patient or else this probably would have been much harder on me. It was very difficult to get back to work after it happened though, and knowing what was going on made me start to sweat. Today I was in the CCU for the second time, and a nurse yelled out to bring the crash cart. Somebody else yelled "no he's DNR," and then I got very worried. Luckily he was okay though.
Tomorrow I'm going to a meeting in Charlotte with my preceptor for a discussion on how to help standardize the PES statements in the online charting system at the hospital, so that should be interesting. She's been having me write down the different PES statements that different dietitians are using. See some of you soon!
I read that a lot of you have had really emotional or graphic experiences. I can't say that I've seen anything too graphic or difficult yet (the dietitians are very protective of me still). Today I was about to go see a patient in critcal care, but then he started yelling out wierd noises, so the dietitian went with me and helped me. I did have my first experiences with code blue though. The first day I was in the critical care unit, code blue (heart/breathing stopped) was called 4 times on a patient, who unfortunately died the fourth time. The CCU (critical care unit) turned into a whirl of activity each time. Luckily I had not yet visited the patient or else this probably would have been much harder on me. It was very difficult to get back to work after it happened though, and knowing what was going on made me start to sweat. Today I was in the CCU for the second time, and a nurse yelled out to bring the crash cart. Somebody else yelled "no he's DNR," and then I got very worried. Luckily he was okay though.
Tomorrow I'm going to a meeting in Charlotte with my preceptor for a discussion on how to help standardize the PES statements in the online charting system at the hospital, so that should be interesting. She's been having me write down the different PES statements that different dietitians are using. See some of you soon!
Wound Center
Today I spent the morning at a Wound Healing Clinic that the hospital owns. This is the first time the hospital has ever sent a dietetic intern over to the clinic, so they weren't really sure what to expect. I have to say it's not for people who get queasy. The first patient I saw had a Stage 1, maybe Stage 2 ulcer that was probably the size of a quarter. I thought I would be fine, so I decided to sit in while the doctor examined her. He started debriding the wound, and if I hadn't left the room I am pretty sure I would have fainted. Basically debriding is just a fancy way of saying they take some instruments and dig into the wound to get out all of the "bad stuff" so that the tissue can start growing. That was definitely an experience I only needed to have once. I left the room when I started to sweat and get a little bit dizzy, but the nurse came out and basically laughed at me because that wound was nothing compared to what they see on a daily basis. Clearly, wound healing won't be something I pursue as a profession.
For the rest of the morning I just went into the rooms as the nurse was doing the intake interview and I tried to stay on the opposite side of the person that the wound was on. There aren't a lot of nutrition screening questions that are asked in the clinic. They basically ask if the patient is eating well. They also recommend that all of their patients take a protein powder, Vitamin C and Zinc, and possibly a multivitamin. This is the basic protocol for all wounds, even in the main hospital. If the wound is not healing well then they recommend Arginaid, which is a protein powder with Arginine in it, since studies have shown that arginine is important for healing.
All of the cases I saw were pretty interesting, but one just stood out. A man came in for follow up on a wound he has had on his heal for quite some time. The nurse started to examine his wound and noticed new wounds on his hands. This wasn't something she was expecting, since his heel wound had been healing nicely, so she started to probe and ask questions about the wounds. After a few minutes he finally told her that he poured Clorox on his foot wound, and the wounds on his hands were as a result of touching the Clorox. A friend had told him that Clorox would kill the infection on his foot and so he tried it. It was really sad to see, because he was clearly in pain. The Clorox had burned his hands so bad that he couldn't even straighten out his fingers. The doctor told me that this isn't the first time he has seen patients try home remedies like this, and he is often fighting with patients who won't comply with his recommendations. Because wound healing is so slow, patients will often try anything anyone tells them in hopes of speeding things up. He says a lot of patients won't even take the supplements prescribed, and as a result it takes a lot longer for them to heal.
For the rest of the morning I just went into the rooms as the nurse was doing the intake interview and I tried to stay on the opposite side of the person that the wound was on. There aren't a lot of nutrition screening questions that are asked in the clinic. They basically ask if the patient is eating well. They also recommend that all of their patients take a protein powder, Vitamin C and Zinc, and possibly a multivitamin. This is the basic protocol for all wounds, even in the main hospital. If the wound is not healing well then they recommend Arginaid, which is a protein powder with Arginine in it, since studies have shown that arginine is important for healing.
All of the cases I saw were pretty interesting, but one just stood out. A man came in for follow up on a wound he has had on his heal for quite some time. The nurse started to examine his wound and noticed new wounds on his hands. This wasn't something she was expecting, since his heel wound had been healing nicely, so she started to probe and ask questions about the wounds. After a few minutes he finally told her that he poured Clorox on his foot wound, and the wounds on his hands were as a result of touching the Clorox. A friend had told him that Clorox would kill the infection on his foot and so he tried it. It was really sad to see, because he was clearly in pain. The Clorox had burned his hands so bad that he couldn't even straighten out his fingers. The doctor told me that this isn't the first time he has seen patients try home remedies like this, and he is often fighting with patients who won't comply with his recommendations. Because wound healing is so slow, patients will often try anything anyone tells them in hopes of speeding things up. He says a lot of patients won't even take the supplements prescribed, and as a result it takes a lot longer for them to heal.
Outpatient Counseling Today
Today I got to sit in on an outpatient counseling session with one of the dietitians that I haven't really had a chance to work with yet. She was seeing a man who just recently had part of his tongue removed due to cancer and is now getting nutrition via a PEG. Over the last month he has lost almost 25 pounds and has been getting really bad reflux. On top of all of that he can barely speak. I was really impressed with Kathy's ability to interact with him and get the information she needed with the help of his daughter who was also there. In just a few minutes she worked up a new plan for him and gave him a few options as to how to obtain the TF formulas for the cheapest price. She suggested first trying a more concentrated formula and also more frequent smaller feedings. We are going to follow up with him in a few weeks so hopefully he shows some improvement. It was definitely a very interesting session to have the opportunity to see.
Fire drills and MBSS
Yesterday was an action-packed day for me. In the morning, while I was in the Rehab hospital working with my dietitian, a hospital Safety Officer pulled me out of the room and had me pull the fire alarm. Then, as the fire doors closed and the alarm started going off , she asked me what I would do if it were a real fire and how I would exit. (During all of this the other staff members were mostly either standing around or going about their business. Fire drills have apparently become quite commonplace over the last few months). Then she quizzed me on the acronyms RAFT and PASS. My dietitian helpfully pointed out that I could check the back of my ID for the letters I was unsure about. In the end, I passed. I was glad I did not bring dishonor to my department.
I also got to see an MBSS yesterday, which was really cool. The patient did very well and will now be able to stop TFs and switch to a regular diet. He was very pleased. Today, we did the consult to switch him to the regular diet. So it was nice to see things have a happy ending, especially since we had to switch another patient on that floor from a po diet to full tube feedings. We'd been tracking him last week, adding supplements and doing a calorie count in order to get him off of the nighttime supplemental TFs he was getting. He did really well, so we switched him to a full po diet, but today they did an MBSS (because they wanted to upgrade him from nectar-thick to thin liquids) and it turns out he was (silently) aspirating everything--fluids of all thicknesses, solids, you name it. So now they have to switch him to a completely npo diet. That was sad.
Tomorrow I start my next rotation-- women's health and cardiology. The women's hospital is really nice and the bathrooms are much nicer than the ones in the rest of the hospital (esp. the one in the basement where the diet office and kitchen are) so I'm looking forward to that.
I also got to see an MBSS yesterday, which was really cool. The patient did very well and will now be able to stop TFs and switch to a regular diet. He was very pleased. Today, we did the consult to switch him to the regular diet. So it was nice to see things have a happy ending, especially since we had to switch another patient on that floor from a po diet to full tube feedings. We'd been tracking him last week, adding supplements and doing a calorie count in order to get him off of the nighttime supplemental TFs he was getting. He did really well, so we switched him to a full po diet, but today they did an MBSS (because they wanted to upgrade him from nectar-thick to thin liquids) and it turns out he was (silently) aspirating everything--fluids of all thicknesses, solids, you name it. So now they have to switch him to a completely npo diet. That was sad.
Tomorrow I start my next rotation-- women's health and cardiology. The women's hospital is really nice and the bathrooms are much nicer than the ones in the rest of the hospital (esp. the one in the basement where the diet office and kitchen are) so I'm looking forward to that.
Craven Week 3
Incredible thing for the day: patient comes into ICU unconcious, with a blood glucose of 1273, patient drinks 1/2 gallon of vodka per day. Enough said. We aren't sure if we will be seeing them tomorrow.
I had an emotional experience with a patient today. I screened an 85 year old man due to low albumin (he had pneumonia) and when I went into talk to him, he was so talkative but as it turns out his wife had died suddenly two weeks ago from CHF and he was completely torn up. He started to tell me about his usual diet and that he hadn't felt like eating, and he felt he needed to force his food down. He started to mention his wife and how they cooked together and he just broke down and cried so much in the bed. I wanted to cry too, as I do now while writing this. I was really glad the nurse was in there with me and we were both trying to console him. She was apparently glad I was in there too because she had been trying many times to stick a needle into him and he was refusing to let it happen but he was too busy talking to me to even notice that she was doing it. It was all very sad but I think that he will get through this. I saw a note in his chart that he had expressed interest in the local senior center Senior Companion program. So I have faith that he will be OK.
Oh and my preceptor told me that they have only had one intern ever who hasn't cried. So I'm really hoping that I can make two. Fingers crossed
I had an emotional experience with a patient today. I screened an 85 year old man due to low albumin (he had pneumonia) and when I went into talk to him, he was so talkative but as it turns out his wife had died suddenly two weeks ago from CHF and he was completely torn up. He started to tell me about his usual diet and that he hadn't felt like eating, and he felt he needed to force his food down. He started to mention his wife and how they cooked together and he just broke down and cried so much in the bed. I wanted to cry too, as I do now while writing this. I was really glad the nurse was in there with me and we were both trying to console him. She was apparently glad I was in there too because she had been trying many times to stick a needle into him and he was refusing to let it happen but he was too busy talking to me to even notice that she was doing it. It was all very sad but I think that he will get through this. I saw a note in his chart that he had expressed interest in the local senior center Senior Companion program. So I have faith that he will be OK.
Oh and my preceptor told me that they have only had one intern ever who hasn't cried. So I'm really hoping that I can make two. Fingers crossed
Diabetology
And I discovered that really is a word (I think it was Carolyn I was talking to about that, but anyways...). So, for the past two days I've been at an outpatient diabetes clinic with John, a 69yo MPH-RD. Quite a rare person. He has a massive depth of knowledge about diabetes and a true passion for what he does. However, every single one of his 12 patients that had appointments for the past two days were no shows. So I have yet to see a patient with him. He did however have me create a potential meal plan for this one patient that we are supposed to see maybe tomorrow. I tell you what, John is all about fiber and eating tons of vegetables. That meal plan was packed full. John himself has an immaculate diet. No sweets or white flour for him. Or Cook-Out milkshakes for that matter. Ever. I would fall apart if that were me. But he definitely practices what he tells patients to do! He says they can't respect you if you don't follow your own guidance. So he really tries to set a perfect example for them.
John had me check my HbA1c on Monday (5.4, so no diabetes here thank you) and had me give myself a shot of saline so I would know how it felt to give myself insulin. I am also currently on a continuous glucose monitoring device, which is supposed to monitor my BG for a full 24 hours. Getting set up for that device was no fun, no fun at all. First, I stuck the needle (which is about 1 1/2 inches long, so not too terrible) into the subcutaneous fat on my stomach. It stung quite a bit, and I got a little dizzy and had to sit down. Then I felt nauseated, and John ran to get a glass of water and the trashcan for me. I didn't end up vomiting, but I was nearly there. Then John tells me that the device isn't communicating with the computer correctly, so we have to stick the needle in a different spot. Dreadful. We decided to insert it into my side since there was more fat there, and thank goodness it worked better and I didn't pass out or anything. So now I have the little monitoring system in my side, and I have to check my blood sugar 4 times before tomorrow so we can calibrate the device. I'll let you know how I do!
An interesting fact I learned today: Red yeast rice can be used to lower cholesterol if patients can't tolerate cholesterol-lowering medications. It has natural statins in it (and is basically where they got the idea for statins from!). Also, John told me about the Novo Nordisk plant in Clayton, NC where they make synthetic insulin, so if anyone wants to go visit, I'm in!
John had me check my HbA1c on Monday (5.4, so no diabetes here thank you) and had me give myself a shot of saline so I would know how it felt to give myself insulin. I am also currently on a continuous glucose monitoring device, which is supposed to monitor my BG for a full 24 hours. Getting set up for that device was no fun, no fun at all. First, I stuck the needle (which is about 1 1/2 inches long, so not too terrible) into the subcutaneous fat on my stomach. It stung quite a bit, and I got a little dizzy and had to sit down. Then I felt nauseated, and John ran to get a glass of water and the trashcan for me. I didn't end up vomiting, but I was nearly there. Then John tells me that the device isn't communicating with the computer correctly, so we have to stick the needle in a different spot. Dreadful. We decided to insert it into my side since there was more fat there, and thank goodness it worked better and I didn't pass out or anything. So now I have the little monitoring system in my side, and I have to check my blood sugar 4 times before tomorrow so we can calibrate the device. I'll let you know how I do!
An interesting fact I learned today: Red yeast rice can be used to lower cholesterol if patients can't tolerate cholesterol-lowering medications. It has natural statins in it (and is basically where they got the idea for statins from!). Also, John told me about the Novo Nordisk plant in Clayton, NC where they make synthetic insulin, so if anyone wants to go visit, I'm in!
SF VA: Renal module
Like Carolyn, I'm currently at the hemodialysis unit. I've been working with HD patients for the last 3 days, giving them their lab values for the month. I am really enjoying the diversity of people that come to the VA, especially in this part of the country. I've had to see patients with all kinds of ethnicity, and food habits. Although sometimes I don't know what they're talking about, when they're talking about specific dishes, I like it.
Something that I see often with HD patients is that they get thirsty, and compensate with drinking water, but they end up going over their fluid limit (usually 4cups of fluid/day depending on uop). So, a tip for them would be to freeze grapes or other low-potassium fruit, and pop some frozen fruits into their mouth instead of drinking water when they get thirsty.
Most of the HD patients have been receptive and grateful for the dietitian, except this one guy who was in a bad mood and did not want to hear anything from me. I've also been covering the acute care floor. That has been more unpredictable than HDU, because you never know what you're gonna get. Diseases present themselves together. That's it from me for now. On to note-writing for the rest of the day.
Something that I see often with HD patients is that they get thirsty, and compensate with drinking water, but they end up going over their fluid limit (usually 4cups of fluid/day depending on uop). So, a tip for them would be to freeze grapes or other low-potassium fruit, and pop some frozen fruits into their mouth instead of drinking water when they get thirsty.
Most of the HD patients have been receptive and grateful for the dietitian, except this one guy who was in a bad mood and did not want to hear anything from me. I've also been covering the acute care floor. That has been more unpredictable than HDU, because you never know what you're gonna get. Diseases present themselves together. That's it from me for now. On to note-writing for the rest of the day.
Tuesday, May 26, 2009
Rex: Comedy and Tragedy
I observed a hemodialysis session today. Watching the patient get hooked up to the dialysis machine was straightforward enough, but the case was really interesting. As you might expect, the pt has T2DM and CKD, but his kidneys weren't quite bad enough to require dialysis...until he had a MI. He underwent cardiac cath, and they injected him with contrast dye as part of an imaging procedure. The dye caused his kidneys to fail. I always thought that the "risks" section in each Medline entry for a procedure was a little overblown, but such complications really do happen. As a dialysis newbie, he was confused as to my I was there as a dietetic intern. I got to explain some of the nutritional concerns of dialysis patients and how RD's play an important role. I think he'll meet one soon since he'll be starting at an outpatient dialysis center after he's discharged. He's hopeful that it's just short term, though, since kidney function sometimes returns after dye-induced failure. (After all, he said, his crea has already returned to his usual ~4-5 mg/dl!) He doesn't seem willing to change his diet to prevent the progression of his CKD - he actually said during our hilarious and discursive conversation, "You know what I wish I had? A spray can of trans fat. Then I could spray it on all of the foods that used to taste good before they took it out of everything. I used to live on hamburgers and fries, but they just don't taste the same anymore." Whoa. Can you say, "precontemplation"?
In contrast to that experience, I was deeply touched by a woman caring for her partner of 49 years who has rapidly worsening dementia. I stood in the room while she stroked his forehead to calm him, and then we stepped out into the hall to talk about how he was eating. She said he doesn't seem to like the pureed diet we put him on (d/t dysphagia), but she acknowledged that he probably won't go back to solid foods. I had no idea what to say at that moment as she grappled with the long, slow loss of a loved one. I hope she appreciated my attempts at empathy in a professional role.
In contrast to that experience, I was deeply touched by a woman caring for her partner of 49 years who has rapidly worsening dementia. I stood in the room while she stroked his forehead to calm him, and then we stepped out into the hall to talk about how he was eating. She said he doesn't seem to like the pureed diet we put him on (d/t dysphagia), but she acknowledged that he probably won't go back to solid foods. I had no idea what to say at that moment as she grappled with the long, slow loss of a loved one. I hope she appreciated my attempts at empathy in a professional role.
Monday, May 25, 2009
Making some progress
I had something that I meant to share about last week. The dietitian that I have been working often takes the patients in the ICU at CRMC because she really enjoys working with tube feedings and TPN's. Anyways, we had a women admitted who was NPO for 5 days. Her physician ordered a nutrition consult for tube feeding recommendations. The tube feeding she had been on at the nursing home normally was not a formula that CRMC carries. I was asked to figure out an alternative formula taking into account her estimated needs in the hospital and what she was getting while at the nursing home. Anyways, the dietitian let me put my recommendations in the chart and everything. I found out the next day that the physician used my recommendations :) I just thought it was kind of neat to see the important role that we play in nutrition support and to be able to do everything mostly on my own. Hope everyone gets through week 3 ok!
Outpatient
Happy Memorial Day everyone! I had my internship today, but I went to an outpatient clinic that is part of CMC rather than the main hospital. It was a nice change of pace, and I really liked seeing the outpatient world! The population that goes to that clinic is mostly Medicare/Medicaid, and the dietitian sees the patients from the internal medicine clinic there. Mostly they are obese and have conditions such as diabetes, HTN, and dyslipidemia.
The dietitian was great, and she had a creative strategy that I wanted to share. She said that most of the patients were not able to grasp carb counting or even really detailed portion size, so she simplifies it for them. She makes a bunch of paper plates with a line down the middle and a line separating one of the halves, and on the big segment she writes "Vegetables" and then has a list of nonstarchy vegetables that she tapes on there. Then, in one of the smaller segments she writes "Proteins" and then has a list of healthy protein choices. In the last smaller segment, she writes "Starches" and has a list of carbs and starchy vegetables that she tapes on there. She keeps a stack of these plates and hands them out to every patient that she sees. Its something easy that they can visualize, and it doesnt require measuring or understanding portions. Its also a really inexpensive take-home for the patients.
Back to the inpatient world tomorrow!
Elizabeth
The dietitian was great, and she had a creative strategy that I wanted to share. She said that most of the patients were not able to grasp carb counting or even really detailed portion size, so she simplifies it for them. She makes a bunch of paper plates with a line down the middle and a line separating one of the halves, and on the big segment she writes "Vegetables" and then has a list of nonstarchy vegetables that she tapes on there. Then, in one of the smaller segments she writes "Proteins" and then has a list of healthy protein choices. In the last smaller segment, she writes "Starches" and has a list of carbs and starchy vegetables that she tapes on there. She keeps a stack of these plates and hands them out to every patient that she sees. Its something easy that they can visualize, and it doesnt require measuring or understanding portions. Its also a really inexpensive take-home for the patients.
Back to the inpatient world tomorrow!
Elizabeth
Weekend Day at the VA
I worked on Sunday with a Dietetic Tech. I had been warned that weekends are busy, but I hadn’t realized how busy! I guess it makes sense, because normally there are 3 Diet Techs and 2 or 3 dietitians, but on the weekend there is just one Tech and no RD’s. The Tech works on Sunday and must see the new admits from Friday night, all day Saturday, and maybe even the ones that come in Sunday morning. I have a lot of respect for the Techs at the VA.
I was not able to help as much as I would have liked because I am still fairly new, but it was a very good learning experience. I spoke with three patients and wrote up drafts of their assessments. The Tech and I discussed the cases and revised the notes together before they were submitted.
I assessed two people in the main hospital and one from the psych ward. I had a difficult time with all of them. Two of them were classified as moderate, so the RD will see them next week. I believe they both had a history of Crohn’s Disease and they both mentioned swallowing difficulties, which was an interesting coincidence. The third I classified as mild, but he was just barely mild. I found the assessments stressful because I was afraid of making a mistake, or missing something critical. The conditions of the patients on Sunday seemed more serious than the ones from Friday; also, on Friday the Tech stood next to me as I was talking with the patients. I talked with two patients alone on Sunday. However, it is reassuring that the RD will see two of the three, and I wrote a note to the Tech who will be in charge of the person I did not refer to the RD, and I know that she sees her patients almost daily for meal rounds.
Knowing where to look in the patient’s file for the pertinent information is one of the hardest things. The Tech showed me some very useful sources, for example, the note written about the patient’s admission to the ER. I hadn’t even realized that they had come in through the ER! So I have a lot to learn about the patient files. I appreciated the fact that some of the questions in my assessment overlap with questions asked of the patient upon admission. I had one patient for whom I questioned what I had recorded, but when I checked the admission note it matched mine, which made me feel better.
Another interesting thing was that I was able to get current weights on 2 of the patients I had assessed on Friday. The new weights changed their nutrition status, but unfortunately the Tech was very busy and so I will have to talk to people on Tuesday to find out how to change a patient’s status. Neither of the changes indicated a need for immediate action.
All in all it was a good day, but I was exhausted by the end.
I was not able to help as much as I would have liked because I am still fairly new, but it was a very good learning experience. I spoke with three patients and wrote up drafts of their assessments. The Tech and I discussed the cases and revised the notes together before they were submitted.
I assessed two people in the main hospital and one from the psych ward. I had a difficult time with all of them. Two of them were classified as moderate, so the RD will see them next week. I believe they both had a history of Crohn’s Disease and they both mentioned swallowing difficulties, which was an interesting coincidence. The third I classified as mild, but he was just barely mild. I found the assessments stressful because I was afraid of making a mistake, or missing something critical. The conditions of the patients on Sunday seemed more serious than the ones from Friday; also, on Friday the Tech stood next to me as I was talking with the patients. I talked with two patients alone on Sunday. However, it is reassuring that the RD will see two of the three, and I wrote a note to the Tech who will be in charge of the person I did not refer to the RD, and I know that she sees her patients almost daily for meal rounds.
Knowing where to look in the patient’s file for the pertinent information is one of the hardest things. The Tech showed me some very useful sources, for example, the note written about the patient’s admission to the ER. I hadn’t even realized that they had come in through the ER! So I have a lot to learn about the patient files. I appreciated the fact that some of the questions in my assessment overlap with questions asked of the patient upon admission. I had one patient for whom I questioned what I had recorded, but when I checked the admission note it matched mine, which made me feel better.
Another interesting thing was that I was able to get current weights on 2 of the patients I had assessed on Friday. The new weights changed their nutrition status, but unfortunately the Tech was very busy and so I will have to talk to people on Tuesday to find out how to change a patient’s status. Neither of the changes indicated a need for immediate action.
All in all it was a good day, but I was exhausted by the end.
Georgetown Week 2
During my second week, I continued my GenMed/Endo rotation. I think I met my favorite patient last Monday, Mrs. G! She is a 98 yo renal patient, who doesn't eat. She is so cute, she was wearing purple satin pj's, and reading a gossip magazine with a magnifying glass! And, she speaks with an accent.
So, the renal team requested calorie counts, which we completed at the end of week 1, because they were strongly encouraging (actually threatening) to put in a PEG if she doesn't increase her intake. However, the pt doesn't want TFs. The nurse said she doesn't have much of an appetite, but when I spoke with her (on my own!) she said that she doesn't eat because she doesn't like the food, so we recommended to D/C the megace. She's been in the hospital for about a month, and Georgetown is only on a 1 week menu cycle, so I can understand that Mrs. G is "just sick of it!"
Previously, the dietitians recommended that she try Glucerna to increase energy intake, but she doesn't like it and it gives her diarrhea. So, my preceptor and I recommended Resource Breeze, which is the clear liquid juice-like supplement in berry flavor.
Mrs. G has been on a Medium Consistent Carb (MCC) diet because she also has DM. We decided not to give her a low-sodium diet because she doesn't want it, and she barely eats as it is; so we would rather get her to have a little bit of the MCC diet, rather than none of the LS diet.
Since I was familiar with this simple case, I did the follow-up with Mrs. G, who said that Breeze is also giving her diarrhea. I even went through a lot of the menu options with her, but she doesn't like anything; she orders out once in a while. Hoping that we could find something to please the pt, so that she doesn't have to get a PEG and tube feedings, I put in a request to have the clinical nutrition manager speak to her about her food preferences. I hope we can find something she will eat!
So, the renal team requested calorie counts, which we completed at the end of week 1, because they were strongly encouraging (actually threatening) to put in a PEG if she doesn't increase her intake. However, the pt doesn't want TFs. The nurse said she doesn't have much of an appetite, but when I spoke with her (on my own!) she said that she doesn't eat because she doesn't like the food, so we recommended to D/C the megace. She's been in the hospital for about a month, and Georgetown is only on a 1 week menu cycle, so I can understand that Mrs. G is "just sick of it!"
Previously, the dietitians recommended that she try Glucerna to increase energy intake, but she doesn't like it and it gives her diarrhea. So, my preceptor and I recommended Resource Breeze, which is the clear liquid juice-like supplement in berry flavor.
Mrs. G has been on a Medium Consistent Carb (MCC) diet because she also has DM. We decided not to give her a low-sodium diet because she doesn't want it, and she barely eats as it is; so we would rather get her to have a little bit of the MCC diet, rather than none of the LS diet.
Since I was familiar with this simple case, I did the follow-up with Mrs. G, who said that Breeze is also giving her diarrhea. I even went through a lot of the menu options with her, but she doesn't like anything; she orders out once in a while. Hoping that we could find something to please the pt, so that she doesn't have to get a PEG and tube feedings, I put in a request to have the clinical nutrition manager speak to her about her food preferences. I hope we can find something she will eat!
Saturday, May 23, 2009
What if you know your patient?
Hi guys,
Sarah is doing a great job of keeping you up to date about UNC, and it is really nice to have a "buddy" going through the internship with me. Thanks Sarah! One interesting thing that happened to me this week is that I walked in to the room of someone I knew. Actually I know the son, and it was his mom who was the patient, but he was in the room when we arrived. I felt completely freaked out, even though I knew that this was a possibility since I am at a local site. I imagine my acquaintance was pretty freaked out also, but we both kept it together and said hello. He introduced me to his mom and brother, told them we went "way back", and then our preceptor did an initial assessment on her. Alas we did oncology last week so the poor woman does not have a good prognosis. And her son is someone I know through my kids' school, so I probably won't see him until the fall (given that I am getting in early and leaving late, I won't be at school the rest of the year) when, I worry, it seems likely his mom will have passed away :(
General question for those who end up seeing cancer patients: does your hospital follow a neutropenic diet for patients with low neutrophil counts? UNC does, it restricts fresh fruits and vegetables and black pepper added after cooking, even though the RD we were working with said there was no research showing the benefit of a neutropenic diet.
Overall, oncology was sad because cancer is so random and unfair, but the patients we saw all had remarkably good attitudes and were much easier to talk to than the cardiac patients the first week, who were pretty grumpy and did not want to hear about heart healthy and low sodium diets! On to renal next week, we've heard renal patients are grumpy too! Hope you all have a day off on Monday. Enjoy.
Sarah is doing a great job of keeping you up to date about UNC, and it is really nice to have a "buddy" going through the internship with me. Thanks Sarah! One interesting thing that happened to me this week is that I walked in to the room of someone I knew. Actually I know the son, and it was his mom who was the patient, but he was in the room when we arrived. I felt completely freaked out, even though I knew that this was a possibility since I am at a local site. I imagine my acquaintance was pretty freaked out also, but we both kept it together and said hello. He introduced me to his mom and brother, told them we went "way back", and then our preceptor did an initial assessment on her. Alas we did oncology last week so the poor woman does not have a good prognosis. And her son is someone I know through my kids' school, so I probably won't see him until the fall (given that I am getting in early and leaving late, I won't be at school the rest of the year) when, I worry, it seems likely his mom will have passed away :(
General question for those who end up seeing cancer patients: does your hospital follow a neutropenic diet for patients with low neutrophil counts? UNC does, it restricts fresh fruits and vegetables and black pepper added after cooking, even though the RD we were working with said there was no research showing the benefit of a neutropenic diet.
Overall, oncology was sad because cancer is so random and unfair, but the patients we saw all had remarkably good attitudes and were much easier to talk to than the cardiac patients the first week, who were pretty grumpy and did not want to hear about heart healthy and low sodium diets! On to renal next week, we've heard renal patients are grumpy too! Hope you all have a day off on Monday. Enjoy.
Unintentional physical comedy
My first week on the floor went well. By the end of it, I'd gotten to take a stab at doing electronic chart notes for two patients, which was thrilling. Working on the general surgery/diabetes floor (in addition to the Rehab wing) has given me a chance to see a wide variety of patients. There was the former Bronx firefighter who'd had a Whipple and has Celiac Sprue (he complies with the diet "93% of the time, because anyone who tells you they are 100% compliant is lying") who drank a gallon of milk a day because he didn't have much of an appetite, wasn't able to afford Boost, and wanted to try to get some nourishment. He lifted up the sheet to show us his belly in order to describe the terrible gas pains he got (because of the Whipple) and show how he could actually see and push around gas bubbles. He mentioned that he used to drink a case of beer a day till he lost his taste for it--at which point his tastes turned to whiskey. My dietitian steered us out of there before he could really get going, though. He could have kept us in there for hours with his stories.
There was also the man who was in the hospital again due to altered mental status following a bout of meningitis a month ago. He had a BMI of 16 and was pretty out of it while we were talking with him and his wife. That is, until the end, when I was throwing away my gown and gloves and smacked my forehead on a shelf. He immediately burst into laughter, as did the rest of us. (Luckily for me, it sounded much worse than it actually was). I was pleased that I was able to bring some joy to his day. As Boden would say: "laughter is the best medicine." Later that day, I almost slammed my head into another shelf, to the amusement of my dietitian. Note to self: avoid wearing heels because they make you just tall enough to bump your forehead on the shelves in patients' rooms.
There was also the man who was in the hospital again due to altered mental status following a bout of meningitis a month ago. He had a BMI of 16 and was pretty out of it while we were talking with him and his wife. That is, until the end, when I was throwing away my gown and gloves and smacked my forehead on a shelf. He immediately burst into laughter, as did the rest of us. (Luckily for me, it sounded much worse than it actually was). I was pleased that I was able to bring some joy to his day. As Boden would say: "laughter is the best medicine." Later that day, I almost slammed my head into another shelf, to the amusement of my dietitian. Note to self: avoid wearing heels because they make you just tall enough to bump your forehead on the shelves in patients' rooms.
I got to post my first notes today in the electronic medical records! Of course I had some help and they were co-signed, but it felt like an accomplishment. The notes were Initial Nutritional Assessments and I had a normal, a mildly compromised, and a moderately compromised patient. There is a template for almost every note that we write at the hospital, which is extremely helpful, especially since the VA does not use the NCP. They use a different template for patients who are moderately compromised because the RD is required to see moderate and severely compromised patients for a Comprehensive Nutritional Assessment. The diet techs do the initial assessments.
In the morning I went on the floor with the diet tech and we talked with each of the new patients, I got to talk with the three for whom I wrote the notes. Then we went back to the office and assessed them based on the information they provided and the notes from the other health professionals in the electronic medical record. I have been impressed by how quickly the health professionals post their notes in the computer system. After doing most of the assessments we went on meal rounds.
I love meal rounds in the psych ward. I am getting to know the patients and I enjoy their questions, complaints, and food requests. I am really amazed by how much time and energy the VA puts into making sure patients receive the food they want. I don’t know if every hospital is this way or if it is a unique characteristic of VA hospitals, or just of the Salisbury VA. I even ended up cutting a man’s salad and unwrapping his muffins because he asked for assistance, and I couldn’t say no. Another patient helped him open his soup, and another is often seen pushing him in his wheel chair. There are little communities in the psych wards and I have enjoyed being part of them for the past week. Very few of the patients are at high nutritional risk, so unfortunately I do not expect to see them much after Sunday.
On Tuesday I will leave the diet techs and I will be with the RD full time. The RD does not do meal rounds in the communal dinning areas in the psych ward. She visits people individually in their rooms.
I learned more about the computer systems. I entered my own “Event Captures” for the first time, which is how we document the time we spend with patients. I couldn’t do it previously because there was some process that had to be completed before hand. I also learned more about menu planning and how to substitute different items to better meet patient’s desires; I learned how to utilize the fact that we are on a 21-day menu cycle to accommodate patient’s dietary preferences.
In the morning I went on the floor with the diet tech and we talked with each of the new patients, I got to talk with the three for whom I wrote the notes. Then we went back to the office and assessed them based on the information they provided and the notes from the other health professionals in the electronic medical record. I have been impressed by how quickly the health professionals post their notes in the computer system. After doing most of the assessments we went on meal rounds.
I love meal rounds in the psych ward. I am getting to know the patients and I enjoy their questions, complaints, and food requests. I am really amazed by how much time and energy the VA puts into making sure patients receive the food they want. I don’t know if every hospital is this way or if it is a unique characteristic of VA hospitals, or just of the Salisbury VA. I even ended up cutting a man’s salad and unwrapping his muffins because he asked for assistance, and I couldn’t say no. Another patient helped him open his soup, and another is often seen pushing him in his wheel chair. There are little communities in the psych wards and I have enjoyed being part of them for the past week. Very few of the patients are at high nutritional risk, so unfortunately I do not expect to see them much after Sunday.
On Tuesday I will leave the diet techs and I will be with the RD full time. The RD does not do meal rounds in the communal dinning areas in the psych ward. She visits people individually in their rooms.
I learned more about the computer systems. I entered my own “Event Captures” for the first time, which is how we document the time we spend with patients. I couldn’t do it previously because there was some process that had to be completed before hand. I also learned more about menu planning and how to substitute different items to better meet patient’s desires; I learned how to utilize the fact that we are on a 21-day menu cycle to accommodate patient’s dietary preferences.
Working with Rex patients (or should say "pts"?)
Hi everyone!
I finally got to talk to pts on Thursday and Friday. My preceptor even stood outside the door and let me do some follow-ups and initial assessments entirely on my own! Some funny stories from the experience:
1. My first pt ever was REALLY chatty. The conversation ranged from an upcoming wedding she wanted to get out of the hospital to attend to her daily enemas to relieve constipation. She asked all sorts of crazy questions about foods that would be easy on her stomach - she was even thinking about trying baby food. She then lifted up her hospital gown to show me all of the water wt she's been gaining. Lesson learned: leave your pager on so that your preceptor can rescue you after 30 minutes.
2. My preceptor and I did a diabetes instruct with a woman who expressed interest in meal planning during a follow-up. She's had a stroke and a heart attack, but no one's ever taught her how to manage her diabetes! The idea of CHO counting was totally new to her. She was pretty interested, but she was distracted by trying to plan her discharge. She took ~5 phone calls while we were in there. Frustrating. Lesson learned: refer pt to an outpatient RD if they can't focus and have a lot to learn.
3. I observed an instruct with a woman who was back in the hospital after gaining 10 lbs of fluid wt (ascites) in the week following her discharge. She had been on a liquid diet in the hospital for testing, and the MD never told her to go back to solid foods once she went home! She hadn't been in the hospital long enough to have a follow-up assessment before discharge, so the RD didn't see her before she went home, either. She was supposed to be on fluid restriction no less! The MD ordered a nutrition consult this time, and we made sure to instruct her on fluid and salt restriction. Lesson learned: good discharge planning and pt education save time and money.
Next week, I'm looking forward to observing some procedures finally.
Enjoy the weekend!
I finally got to talk to pts on Thursday and Friday. My preceptor even stood outside the door and let me do some follow-ups and initial assessments entirely on my own! Some funny stories from the experience:
1. My first pt ever was REALLY chatty. The conversation ranged from an upcoming wedding she wanted to get out of the hospital to attend to her daily enemas to relieve constipation. She asked all sorts of crazy questions about foods that would be easy on her stomach - she was even thinking about trying baby food. She then lifted up her hospital gown to show me all of the water wt she's been gaining. Lesson learned: leave your pager on so that your preceptor can rescue you after 30 minutes.
2. My preceptor and I did a diabetes instruct with a woman who expressed interest in meal planning during a follow-up. She's had a stroke and a heart attack, but no one's ever taught her how to manage her diabetes! The idea of CHO counting was totally new to her. She was pretty interested, but she was distracted by trying to plan her discharge. She took ~5 phone calls while we were in there. Frustrating. Lesson learned: refer pt to an outpatient RD if they can't focus and have a lot to learn.
3. I observed an instruct with a woman who was back in the hospital after gaining 10 lbs of fluid wt (ascites) in the week following her discharge. She had been on a liquid diet in the hospital for testing, and the MD never told her to go back to solid foods once she went home! She hadn't been in the hospital long enough to have a follow-up assessment before discharge, so the RD didn't see her before she went home, either. She was supposed to be on fluid restriction no less! The MD ordered a nutrition consult this time, and we made sure to instruct her on fluid and salt restriction. Lesson learned: good discharge planning and pt education save time and money.
Next week, I'm looking forward to observing some procedures finally.
Enjoy the weekend!
Friday, May 22, 2009
End of week 2...
I'm feeling pretty good and more confident at the end of this week... and I'm hoping to avoid crying during the dreaded "week three" that Mrs. Holliday warned us about. I will apparently experience a breakdown during my ICU rotation, as I have been warned by several people that the trauma RD makes everyone cry when they train with her. Awesome.
I'm still on the cardio/diabetes rotation, so needless to say I'm seeing a lot of older folks. Of particular note was a patient I went to do a followup check on, and walked into the room just a few minutes after the family found out she wasn't going to make it through the afternoon. That was awkward to say the least. Lesson learned: will check with nurse before talking to patient if I see the word "hospice" in chart.
Other than that things are going pretty well. My preceptor observed me do a diabetes education and gave me some good feedback. Apparently I use nutrition jargon when I don't even know it. Ah the perils of only hanging out with you people for the last year.
Have a great weekend everyone! I'm heading down to the city by the bay to enjoy some crisp foggy air and a Carnival parade.
I'm still on the cardio/diabetes rotation, so needless to say I'm seeing a lot of older folks. Of particular note was a patient I went to do a followup check on, and walked into the room just a few minutes after the family found out she wasn't going to make it through the afternoon. That was awkward to say the least. Lesson learned: will check with nurse before talking to patient if I see the word "hospice" in chart.
Other than that things are going pretty well. My preceptor observed me do a diabetes education and gave me some good feedback. Apparently I use nutrition jargon when I don't even know it. Ah the perils of only hanging out with you people for the last year.
Have a great weekend everyone! I'm heading down to the city by the bay to enjoy some crisp foggy air and a Carnival parade.
1/6 of the summer done! So my "GI" module was more of a random mix of whatever the RD I'm following had to do that day. She works by herself at a smaller hospital and helps out at Cape Fear on Fridays. We went on 3rd floor rounds yesterday and visited the 19yo patient I mentioned in my last blog. He was ready for a much-needed skin graft for one of his sacral pressure ulcers, but no one in the area does simple plastic surgeries like that. The doctor said that many plastic surgeons in the area don't want to perform menial skin grafts because they can get so much more money doing cosmetic surgeries for wealthy people. So sad. I'm changing my mind and am now going to be a plastic surgeon to help those people! (just kidding for that one...)
Also, a tip for diet educations in the hospital. Obviously all people have different education levels and willingness to listen to you. So, before you go to visit a patient, have several different pointers in mind that you can use with people of various education levels and interests. I went to educate this lovely lady about a diabetic diet, who apparently had no idea what diabetes was ("somethin' is in my blood" she said) and had a limited vocabulary as evidenced by her choice language describing the bowel movement she had just experienced in bed while we were talking with her. Lovely lady. I was a little scattered in my education session and kind of overloaded her with info that she didn't care about. So if you experience a patient like that, just tell her to eat three meals a day and to stay away from high sugar food and drink, and get out of there.
Happy Memorial Day weekend!
Also, a tip for diet educations in the hospital. Obviously all people have different education levels and willingness to listen to you. So, before you go to visit a patient, have several different pointers in mind that you can use with people of various education levels and interests. I went to educate this lovely lady about a diabetic diet, who apparently had no idea what diabetes was ("somethin' is in my blood" she said) and had a limited vocabulary as evidenced by her choice language describing the bowel movement she had just experienced in bed while we were talking with her. Lovely lady. I was a little scattered in my education session and kind of overloaded her with info that she didn't care about. So if you experience a patient like that, just tell her to eat three meals a day and to stay away from high sugar food and drink, and get out of there.
Happy Memorial Day weekend!
An afternoon in the OR
It's been a sad, but interesting case. Yesterday I was able to complete the initial nutrition assessment on a patient who had colon cancer. She's 49 years old, and this is the first time she's ever stepped foot in a hospital; she has no PMHx. Today my rotating R.D. and I checked in with her and her sweet family again to explain the TPN formula we calculated for her that she'll be on post-op. Hours later, I was able to observe her colon resection surgery in the OR. The surgeon and nurses were so helpful during the surgery, explaining to me what they were doing, and their observations. The tools they had in the OR fascinated me. Gone are the days of regular scalpels, now there are ultra high-heat scalpels that cut by burning! It's brilliant. Everything remains sterile. Anyway, at first, the surgeon began laproscopically, but he ended up having to cut the pt open because the carcinoma had spread so extensively. They even let me touch the cancerous mass after they had removed it all! It was a little smaller than a racquetball (just harder), with smaller cancerous clusters engulfing the tissue.
It's been really neat to be able to see her from Day 1 and be able to monitor and follow up on her throughout her recovery. We'll see how things progress.
Have a great Memorial Day weekend, guys! :)
It's been really neat to be able to see her from Day 1 and be able to monitor and follow up on her throughout her recovery. We'll see how things progress.
Have a great Memorial Day weekend, guys! :)
Quiet week at SF VA
Hi ladies, hope you're doing well. San Francisco's been all about foggy mornings and 60-degree weather lately. It's beautiful!
It's been a quiet week here at SF VA. There are 2 other interns with me for the next 10 weeks (can you believe we're done with 2 weeks?) - one is a foodservice intern, the other is a dietetic intern. They're my lunch buddies and they've been a great resource. One advice I got from them this week is to ask for more work if you feel like you're not getting enough. Because it's been a quiet week, and because it's only the second week, I didn't expect to be given a lot and I feel that what I've been doing is adequate. But in the end, you're in charge of your own experience and whether you get enough or not. So next week, better step my game up and ask to see more patients. I'll be eating my own words before I know it.
I've been doing initial assessments for the past week and a half. Writing notes is becoming easier now. This week, I started with the renal module. I saw a few patients on hemodialysis and did some nutrition education on the renal diet. It was easier than I thought it would be. At the same time, it's definitely been more unpredictable than I thought it would be.
It's been a quiet week here at SF VA. There are 2 other interns with me for the next 10 weeks (can you believe we're done with 2 weeks?) - one is a foodservice intern, the other is a dietetic intern. They're my lunch buddies and they've been a great resource. One advice I got from them this week is to ask for more work if you feel like you're not getting enough. Because it's been a quiet week, and because it's only the second week, I didn't expect to be given a lot and I feel that what I've been doing is adequate. But in the end, you're in charge of your own experience and whether you get enough or not. So next week, better step my game up and ask to see more patients. I'll be eating my own words before I know it.
I've been doing initial assessments for the past week and a half. Writing notes is becoming easier now. This week, I started with the renal module. I saw a few patients on hemodialysis and did some nutrition education on the renal diet. It was easier than I thought it would be. At the same time, it's definitely been more unpredictable than I thought it would be.
Thursday, May 21, 2009
Gen Med at WFUBMC
Hello All!
Hope all is well. I have spent the last two days completing my general medicine rotation. Lots of interesting patients despite the rather "ordinary" reputation of general medicine. I saw a very interesting case earlier this week regarding a young woman who was "prescribed" Fen-Phen (phentermine) by her doctor to help with weight loss. Well, she ended up in the ER with cardiac problems at ~30 yo. Read about Fen-Phen -- a drug taken off the market by the FDA in 1997 due to its negative impact on the heart. (Well, after doing a little research, I found out you can actually purchase the drug on the Internet without a prescription! Crazy!) Thought I would share so you can keep your eyes peeled for Fen-Phen users...
Today I had the opportunity to educate two patients with wired jaws. These people normally have to eat a completely liquid diet for 6-8 weeks. Thus, it is important that we teach them appropriate ways to consume adequate calories and nutrients. Some tips that I learned: recommended adding milk, vegetable soup or apple juice to foods to liquify them instead of water (improves flavor as well as increases calories), advise them to put a lid over their blended food in case the appearance leads to dislike, make sure that they take precautions to prevent food poisoning (washing blender after each use, washing hands, not adding raw eggs, not consuming chunks of food), and advise patients to limit their consumption of junk drinks such as Kool Aid, Sunny D, sodas, etc. so they have an appetite later for more nutrient dense foods.
Well, those are just a few thoughts from today. Enjoy your weekend.
Rachael
Hope all is well. I have spent the last two days completing my general medicine rotation. Lots of interesting patients despite the rather "ordinary" reputation of general medicine. I saw a very interesting case earlier this week regarding a young woman who was "prescribed" Fen-Phen (phentermine) by her doctor to help with weight loss. Well, she ended up in the ER with cardiac problems at ~30 yo. Read about Fen-Phen -- a drug taken off the market by the FDA in 1997 due to its negative impact on the heart. (Well, after doing a little research, I found out you can actually purchase the drug on the Internet without a prescription! Crazy!) Thought I would share so you can keep your eyes peeled for Fen-Phen users...
Today I had the opportunity to educate two patients with wired jaws. These people normally have to eat a completely liquid diet for 6-8 weeks. Thus, it is important that we teach them appropriate ways to consume adequate calories and nutrients. Some tips that I learned: recommended adding milk, vegetable soup or apple juice to foods to liquify them instead of water (improves flavor as well as increases calories), advise them to put a lid over their blended food in case the appearance leads to dislike, make sure that they take precautions to prevent food poisoning (washing blender after each use, washing hands, not adding raw eggs, not consuming chunks of food), and advise patients to limit their consumption of junk drinks such as Kool Aid, Sunny D, sodas, etc. so they have an appetite later for more nutrient dense foods.
Well, those are just a few thoughts from today. Enjoy your weekend.
Rachael
Tips from Oncology
I just posted yesterday, but I learned some neat things today about oncology which I wanted to share.
1. Bone marrow transplant patients aren't allowed to brush their teeth. Their gums become really weak and prone to bleeding, which means they are vulnerable to infection and even worse mucositis than normal. They are allows to use a disposable, mint-flavored sponge on a stick (called a toothette) to clean out their mouth and to swish with rinses. My RD stresses the importance of good oral care with all of her patients.
2. Patients can rinse their mouths with baking soda to neutralize the weird tastes they may have in their mouth.
3. Scott Hamilton has website with a really comprehensive list of chemotherapy agents, their use and mechanisms, side effects, etc. that my RD uses regularly as a reference: www.chemocare.com
1. Bone marrow transplant patients aren't allowed to brush their teeth. Their gums become really weak and prone to bleeding, which means they are vulnerable to infection and even worse mucositis than normal. They are allows to use a disposable, mint-flavored sponge on a stick (called a toothette) to clean out their mouth and to swish with rinses. My RD stresses the importance of good oral care with all of her patients.
2. Patients can rinse their mouths with baking soda to neutralize the weird tastes they may have in their mouth.
3. Scott Hamilton has website with a really comprehensive list of chemotherapy agents, their use and mechanisms, side effects, etc. that my RD uses regularly as a reference: www.chemocare.com
medical records times 70
So after doing a lot of shadowing last week, my preceptor gave me some interesting tasks this week. Yesterday I created a pocket guide for their version of the host/hostess to use when taking patient menu choices. Lots of patients are on coumadin, so the dietitian wanted me to create something for the hosts/hostess to use to help the patients select a diet that is consistent in vitamin K. I also went through the first part of the menu cycle to see how often foods high in vitamin K are offered on each of the different diets. Today I went with the dietitian to go through every medical record at the long term care facility (about 70 ppl) to verify that the diet order in the chart was the same as what was entered in the computer. They have a surprising amount of problems with that, which I discovered today. After that I went with the dietitian to inspect the kitchen; we made a list of a bunch of things that need cleaning...I felt like I was back in food service :) I also went to cardiac rehab for one morning this week and got to see how that worked. Patients come for exercise and then get a short nutrition lesson. I asked if I might be able to teach the lesson at some point.
Aside from these tasks, I wrote my first note in the computer with help from one of the dietitians, so that was exciting. I also saw a patient on my own to ask about recent weight loss. I'm guessing that I'll work more with the patients again tomorrow. Unfortunately I can't get access to the computer charting system until the manager gets back from vacation, but hopefully that won't hinder my progress!
Aside from these tasks, I wrote my first note in the computer with help from one of the dietitians, so that was exciting. I also saw a patient on my own to ask about recent weight loss. I'm guessing that I'll work more with the patients again tomorrow. Unfortunately I can't get access to the computer charting system until the manager gets back from vacation, but hopefully that won't hinder my progress!
Make the DASH
Two new things happened today: one, I taught a class on the DASH diet. Secondly, I worked up a patient with hepatic encephalopathy and learned interesting things about liver disease and how to encourage doctors to listen to you.
1. DASH Class: I taught a class today to stroke patients about the DASH diet. One man left after the recreational therapist talked before me, but I had been in an education with him earlier during the week and he was not interested. One lady left because she said she wasn't going to cook, but her daughter stayed and was very interested and eager to change. After my short power point, we talked about each others diets (there was only 3 people in the class, and one of them comes every time to ask random questions the dietitian with me said), so then I had a work sheet for them to write down some change goals. I also gave out some great recipes from Mayo Clinic (they look AMAZING), a DASH shopping list and a handout on 30 ways to sneak fruits and veggies into your diet. So I feel like that was a success.
2. Hepatic Encephalopathy: this patient had a BMI of 50 (apparently pretty common around here) and cirrhosis. I looked at his current diet order: 1800 kcal diabetic diet, no salt added and 40 grams of protein. So I figured out how many g/kg of actual body weight that is: 0.25!!! My RD looked at it and was shocked, because even though we used ideal body weight to calculate protein needs in obese, she checks it against what they actually weight to see if it is appropriate. So she proceeded to print me out a really great article from this really great journal (UVA's Nutrition Issues in Gastroenterology series) about calories and protein for hepatic failure. Studies have apparently shown that protein restriction is not necessary in these patients and protein of around 1.5 g/kg proves to be beneficial for treatment. The current evidence suggests that lactulose should be prescribed alongside normal to elevated protein depending on the mental status of the patient. So my patient was mentally fine now so we relaxed his diet. Lastly, the RD had me highlight the important points in the article and attach the article to the chart and reference the doctor to it in the order because she says doctors really appreciate evidence like that when they go to sign off on our orders. Have a great weekend!
1. DASH Class: I taught a class today to stroke patients about the DASH diet. One man left after the recreational therapist talked before me, but I had been in an education with him earlier during the week and he was not interested. One lady left because she said she wasn't going to cook, but her daughter stayed and was very interested and eager to change. After my short power point, we talked about each others diets (there was only 3 people in the class, and one of them comes every time to ask random questions the dietitian with me said), so then I had a work sheet for them to write down some change goals. I also gave out some great recipes from Mayo Clinic (they look AMAZING), a DASH shopping list and a handout on 30 ways to sneak fruits and veggies into your diet. So I feel like that was a success.
2. Hepatic Encephalopathy: this patient had a BMI of 50 (apparently pretty common around here) and cirrhosis. I looked at his current diet order: 1800 kcal diabetic diet, no salt added and 40 grams of protein. So I figured out how many g/kg of actual body weight that is: 0.25!!! My RD looked at it and was shocked, because even though we used ideal body weight to calculate protein needs in obese, she checks it against what they actually weight to see if it is appropriate. So she proceeded to print me out a really great article from this really great journal (UVA's Nutrition Issues in Gastroenterology series) about calories and protein for hepatic failure. Studies have apparently shown that protein restriction is not necessary in these patients and protein of around 1.5 g/kg proves to be beneficial for treatment. The current evidence suggests that lactulose should be prescribed alongside normal to elevated protein depending on the mental status of the patient. So my patient was mentally fine now so we relaxed his diet. Lastly, the RD had me highlight the important points in the article and attach the article to the chart and reference the doctor to it in the order because she says doctors really appreciate evidence like that when they go to sign off on our orders. Have a great weekend!
CABG
I ate cabbage for dinner last night in preparation, and it seemed to help me out because I was kind of nervous going into the surgery after all the warnings from the nurses to "sit down before I fall down" but I felt great the whole time! Watching the CABG was a really incredible experience. Some of the coolest parts were standing in there while they were doing all of the prep work on the body, watching them cut open the man, being able to peer into the body and watch the beating heart and working lungs, watching the perfusionist work to use the machine to take over for the heart and lungs, watching them shut off the heart from a basically just K injections and by dumping ice water into the cavity (!!! they literally dumped ice water- they called it "margarita cold"!!!), and then watching the surgeon's hand meticulously work to use the vein that they had basically noninvasively (another incredible technology) removed from the leg and stitching it to the heart. If any of you have a chance to see it, definitely do it...even if you have some reservations! Just be warned that there are some interesting smells, and try your hardest to breathe through your mouth rather than your nose! and be sure to "sit down before you fall down"
Another thing that I wanted to share was that I worked up a young (27 yr old) CF patient yesterday, and the dietitian that I am rotating with this week told me to use the formula from Krause. So if you ever have a CF patient, try the formula on p. 914 of our handy textbook. She wasnt eating very well becaues the hospital food wasn't matching her preferences, so I went in and talked to her about the kinds of things that she would be willing to eat and then I went in and added some of the foods to her meals, some of the supplements as snacks, and then some of the foods as snacks. It was really interesting because with her, I was just like "tell me ANYTHING that you will eat and we will get it to you!"...kind of different for her than for most patients.
And lastly, I went to a group diet session for women with breast cancer yesterday and I have the handouts and everything, so if any of you are interested in the kind of information that they gave to these women then let me know! I'm in oncology next week, and I found that the class was hard for me to sit through- its a very emotional experience for these women (and Rachael knows that I tear up just watching the Today show many mornings) so just prepare yourself if you are going to have an experience in something that you may find sensitive! I definitely think that comfortability comes with time, so I am looking forward to having the experience of oncology next week!
Elizabeth
Another thing that I wanted to share was that I worked up a young (27 yr old) CF patient yesterday, and the dietitian that I am rotating with this week told me to use the formula from Krause. So if you ever have a CF patient, try the formula on p. 914 of our handy textbook. She wasnt eating very well becaues the hospital food wasn't matching her preferences, so I went in and talked to her about the kinds of things that she would be willing to eat and then I went in and added some of the foods to her meals, some of the supplements as snacks, and then some of the foods as snacks. It was really interesting because with her, I was just like "tell me ANYTHING that you will eat and we will get it to you!"...kind of different for her than for most patients.
And lastly, I went to a group diet session for women with breast cancer yesterday and I have the handouts and everything, so if any of you are interested in the kind of information that they gave to these women then let me know! I'm in oncology next week, and I found that the class was hard for me to sit through- its a very emotional experience for these women (and Rachael knows that I tear up just watching the Today show many mornings) so just prepare yourself if you are going to have an experience in something that you may find sensitive! I definitely think that comfortability comes with time, so I am looking forward to having the experience of oncology next week!
Elizabeth
They must be able to read this blog....
I spoke with two patients today! SUCCESS!
I believe there is a Cherokee Indian Reservation somewhere in the mountains west of Asheville. There are a number of Native American patients in the Heart Tower right now, and its been interesting to hear their food preferences and their eagerness to go home to a more familiar life. I would imagine my impatience to get out of the hospital as it is, but to add a different lifestyle to the experience? It must be a difficult stay when they are transferred from their regional hospital to big, bad Mission. I saw two Cherokee patients these past two days, and they seemed sad, complained of the food, and spoke of strong wishes to go home. It also broke my heart to see their diabetes med list, blood glu, and GFRs. I tried to negotiate with an older woman this morning saying that if she ate the protein on the dishes full of the "crazy" food we serve her, she'd heal her ab wound faster and be able to go home.
Nothing else cool happened today. I didn't faint, however, next week, I'm doing the Oncology and Psych floors, so my preceptor and I have agreed to ease me into the eating disorder patients.
I'm so bummed that I'm missing the Memorial Day weekend cookout with our crazy neighbor, Bret! We got the invite yesterday. I'm sure it'd be an interesting experience in itself, however, I'm REALLY curious to go inside his condo and get an accurate cat count. Asheville sure is chock full of individuals. People watching is entertaining.
Patient Education
By now I have been able to perform a number of diet educations to patients, with mixed results and responses. Last week, I counseled a man in his late 60s with a BMI over 40 about the "cardiac diet". To say he was resistant is an understatement. As we talked about lower-fat meat options, low-fat dairy, avoiding processed meats and snacks, and other aspects of the heart-healthy diet, he repeated "it's too late for me to change", and "I can't live without my spare ribs." I was with my preceptor who was observing my education session, and we were both feeling frustrated. At one point he even commented that both of us were "no small things", and we had to look the way we did from eating spare ribs once in a while... Needless to say it wasn't my favorite experience. He started to listen to us a little bit when we spoke about hypertension, but overall we left the room feeling like we wasted our time. Situations like this seem to be one of the frustrating sides of clinical dietetics. What I've enjoyed is utilizing my clinical skills (tube feeds, TPN formulas, and writing notes/evaluations). Some of the patient eds are hard to feel good about, especially (I imagine) for an experienced dietitian who's been doing this for a number of years.
On the other hand, Tuesday I counseled a patient (and his family) about the cardiac diet. This time, the family was concerned about the patient's health and interested in making changes in their lifestyles. They asked me questions, suggested food alternatives, and enthusastically listened to my advice and suggestions. When I left this room, I felt great- like I did actually help to make a difference in the health of that patient. And that my nutrition skills were being put to good use. I can see how many dietitians look forward to starting their own practices. To counsel patients or clients that actually want your advice and are interested in making the effort to improve their health seems like a rewarding experience.
On the other hand, Tuesday I counseled a patient (and his family) about the cardiac diet. This time, the family was concerned about the patient's health and interested in making changes in their lifestyles. They asked me questions, suggested food alternatives, and enthusastically listened to my advice and suggestions. When I left this room, I felt great- like I did actually help to make a difference in the health of that patient. And that my nutrition skills were being put to good use. I can see how many dietitians look forward to starting their own practices. To counsel patients or clients that actually want your advice and are interested in making the effort to improve their health seems like a rewarding experience.
Wednesday, May 20, 2009
Wayne Memorial
My first few days at Wayne have been interesting. They have made the transition to electronic records but still look in the charts just in case new orders have not been entered yet. It is a small hospital so I will not have rotations. Of course, this means that completing one particular module is not necessarily helpful.
Today I got to calculate how much protein a patient with nephrotic syndrome needed. The patient was losing ~17500mg protein in urine/24hr.
Today I got to calculate how much protein a patient with nephrotic syndrome needed. The patient was losing ~17500mg protein in urine/24hr.
3 days with diet techs in the psych ward
I have been working with the diet techs this week. They do all of the initial assessments at the VA, and so this is a good way to begin learning their system. After they complete the initial nutrition assessment they pass on any patients who are classified as being moderately or severely compromised to the RD. They handle all of the patients who are normal or who are mildly compromised.
This morning I got to do the initial assessment of two patients in the psych ward while the diet tech watched and stepped in when necessary. I really enjoy working with the patients, and it was fun to do it myself after having watched her during the past 2 days. After talking with the patients we went back to the office and evaluated them based on the information they gave us and the other information we obtained from their medical file in the computer. It is pretty neat to be able to access all of the nursing notes, the doctor notes, their lab values, etc. After determining their status we wrote up modified SOAP notes on them, entered their food preferences, and then entered what we had done and our time. There is a lot of documenting that must be done in several different computer systems. One neat thing about their system is that they use electronic signatures. When someone writes a note that they want someone else to see they can select that person’s name and the note will show up on that person’s computer, indicating that it is awaiting their signature. For example, when the diet tech writes a note she often sends it to the PA to sign.
I also taught a 30 minute class today to a group of 17 men in the psych unit. I was told it could be on anything, so I modified a class I taught with Melissa on the food guide pyramid. Some members in the audience were active participants, but it was also interesting how many were asleep by the end. I enjoyed teaching the class. After the class we had to document in each patient’s file (in 2 places for most patients) that they had attended. It was quite a process! We got to write a generic template describing the lesson, but then for each patient we had to make a note about how they participated in the class. I recognized over half of them, but knew the names of less than 20% of them. Luckily the diet tech was familiar with these patients. We had to document the specific questions that each patient asked to the best of our abilities.
Many of the psych wards are locked and I have been warned to be careful. When leaving the ward we have to make sure that a patient isn’t right behind us who might try to escape. Despite this, I actually really like working with these patients. They eat in groups and I enjoy going on meal rounds and finding out how they like their meals and what they would like changed for next time. The diet tech I was with tries to do meal rounds almost every day. I did meal rounds with the RD once last week, but she sees sicker patients in their rooms individually, and the experience was very different.
I attended a nutrition meeting/celebration today, and so I got to meet the dietitians I hadn’t met earlier. It was also interesting to see how they conduct their meetings.
I will be working with the techs for the rest of the week. They are the only ones who cover weekends, so I will have my weekend experience on Sunday. I have spent the last three days with psych patients, but staring tomorrow I will be seeing everyone.
This morning I got to do the initial assessment of two patients in the psych ward while the diet tech watched and stepped in when necessary. I really enjoy working with the patients, and it was fun to do it myself after having watched her during the past 2 days. After talking with the patients we went back to the office and evaluated them based on the information they gave us and the other information we obtained from their medical file in the computer. It is pretty neat to be able to access all of the nursing notes, the doctor notes, their lab values, etc. After determining their status we wrote up modified SOAP notes on them, entered their food preferences, and then entered what we had done and our time. There is a lot of documenting that must be done in several different computer systems. One neat thing about their system is that they use electronic signatures. When someone writes a note that they want someone else to see they can select that person’s name and the note will show up on that person’s computer, indicating that it is awaiting their signature. For example, when the diet tech writes a note she often sends it to the PA to sign.
I also taught a 30 minute class today to a group of 17 men in the psych unit. I was told it could be on anything, so I modified a class I taught with Melissa on the food guide pyramid. Some members in the audience were active participants, but it was also interesting how many were asleep by the end. I enjoyed teaching the class. After the class we had to document in each patient’s file (in 2 places for most patients) that they had attended. It was quite a process! We got to write a generic template describing the lesson, but then for each patient we had to make a note about how they participated in the class. I recognized over half of them, but knew the names of less than 20% of them. Luckily the diet tech was familiar with these patients. We had to document the specific questions that each patient asked to the best of our abilities.
Many of the psych wards are locked and I have been warned to be careful. When leaving the ward we have to make sure that a patient isn’t right behind us who might try to escape. Despite this, I actually really like working with these patients. They eat in groups and I enjoy going on meal rounds and finding out how they like their meals and what they would like changed for next time. The diet tech I was with tries to do meal rounds almost every day. I did meal rounds with the RD once last week, but she sees sicker patients in their rooms individually, and the experience was very different.
I attended a nutrition meeting/celebration today, and so I got to meet the dietitians I hadn’t met earlier. It was also interesting to see how they conduct their meetings.
I will be working with the techs for the rest of the week. They are the only ones who cover weekends, so I will have my weekend experience on Sunday. I have spent the last three days with psych patients, but staring tomorrow I will be seeing everyone.
First week @ WakeMed
First week @ WakeMed
I will finish my first rotation by tomorrow! What an amazing week!
First, when I got my rotation schedule from my preceptor a week before my starting day, I was shocked at that time since I will spend most of my summer time @ intensive care units. It is good because it fits my interest very well.
My first rotation is rehab, which uses totally different system from acute sites. There are several unexpected things/good experience:
1. There are a lot elderly patients, I have to learn how to communicate with them—speaks clear, loudly and slowly, make sure they understand what you are saying. I felt awful at first time when I talked to a 91-year-old lady for her food preference, I tried to make myself clearly, loudly, and she still thought I was the person from nursing home. She got pretty upset since she thought she would be kicked off from Hospital. After several tries, we finally worked out and got a good communication. Lessons learned: makes clear points, speaks in short sentence and slowly, and pays attention to what they say as well as their emotions.
2. There will never be the same chart/assessment form with what you learned from classroom. Every hospital has its own format; the best learning way is from your practices. I have already written several charts for initial assessment and done several calorie counts. When I am getting familiar with format and working environment, it is about time I will leave. I have to learn everything when I start my next rotation!
3. I learned how to calculate IBW and EEE for patients with Amputations (AKA, BKA or both, or whole leg) it is more complicated than I ever thought. It is good experience!
4. Culture competency—not easy to do, especially for foods. The hospital diets are very limited for choices. If you are on special diet (diabetic, dysphagia or renal), you wouldn’t have any choice for your menu (even we can enter what you like or dislike)--patients always complained their diets. For patients from different counties, it makes harder to satisfy patients.
That’s all for my first rotation, I expect I will learn more later on …
I will finish my first rotation by tomorrow! What an amazing week!
First, when I got my rotation schedule from my preceptor a week before my starting day, I was shocked at that time since I will spend most of my summer time @ intensive care units. It is good because it fits my interest very well.
My first rotation is rehab, which uses totally different system from acute sites. There are several unexpected things/good experience:
1. There are a lot elderly patients, I have to learn how to communicate with them—speaks clear, loudly and slowly, make sure they understand what you are saying. I felt awful at first time when I talked to a 91-year-old lady for her food preference, I tried to make myself clearly, loudly, and she still thought I was the person from nursing home. She got pretty upset since she thought she would be kicked off from Hospital. After several tries, we finally worked out and got a good communication. Lessons learned: makes clear points, speaks in short sentence and slowly, and pays attention to what they say as well as their emotions.
2. There will never be the same chart/assessment form with what you learned from classroom. Every hospital has its own format; the best learning way is from your practices. I have already written several charts for initial assessment and done several calorie counts. When I am getting familiar with format and working environment, it is about time I will leave. I have to learn everything when I start my next rotation!
3. I learned how to calculate IBW and EEE for patients with Amputations (AKA, BKA or both, or whole leg) it is more complicated than I ever thought. It is good experience!
4. Culture competency—not easy to do, especially for foods. The hospital diets are very limited for choices. If you are on special diet (diabetic, dysphagia or renal), you wouldn’t have any choice for your menu (even we can enter what you like or dislike)--patients always complained their diets. For patients from different counties, it makes harder to satisfy patients.
That’s all for my first rotation, I expect I will learn more later on …
The Nutrition Room
I spent the morning in the Nutrition Room, watching and then helping the two techs fortify human milk and mix up formulas for the neonates. It is really well organized to prevent anyone from accidentally giving a mother’s milk to the wrong baby (which, per JHACO, is a sentinel event, eg, an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.)
The techs get orders from the MDs or RDs and then check their recipe lists to add in extra protein and calories. Human milk is about 22 kcal/oz. Neonates may not be able to consume enough volume to meet their energy needs, so they add human milk fortifier to give them more bang for the ounce. I mixed up a bottle of 30 kcal/oz for one baby. The techs dispense the milk to the nurses, and everyone checks the medical records on the source and the dispensed milk to be sure that they have the right milk. Some of the babies get as little as 3 mL! (But some of the babies only weigh 500 grams. One in there right now was born at 23 weeks’ gestation. She’s hanging in, but she sure is small.) The nurse brought by one of the babies who is doing really well – it was such a delight to see him, given the sickness of the babies on the floor and the fact that I have spent the week seeing oncology patients.
When it got a little slow in the Nutrition Room, I joined Pat for rounds and listened in to a short talk the attending gave about complications seen in infants of diabetic mothers (google Mermaid Syndrome if you want to see one really rare, serious complication).
We had journal club in the afternoon, during which on of the RDs reviewed dermatological changes associated with micronutrient deficiencies common in patients with alcoholism.
Finally, I ended the day by working up and visiting a couple of oncology patients. I practiced calculating and writing TF recommendations and discussing the pros/cons of different formulations with my preceptor. Among those who can eat, most are on a neutropenic diet (no fresh fruits or vegetables, no uncooked black pepper), which seems like common sense given their compromised immune systems. However, my preceptor told me that this is based mostly on tradition, there isn’t any evidence that a neutropenic diet is any more protective against infection than regular diet. Much of what my RD does with her patients is try to encourage them to eat as much as possible, and it is a shame that they have to avoid foods that they might want (eg, pimento cheese—which has peppers—or chicken salad with celery) because of their neutropenic diet.
The techs get orders from the MDs or RDs and then check their recipe lists to add in extra protein and calories. Human milk is about 22 kcal/oz. Neonates may not be able to consume enough volume to meet their energy needs, so they add human milk fortifier to give them more bang for the ounce. I mixed up a bottle of 30 kcal/oz for one baby. The techs dispense the milk to the nurses, and everyone checks the medical records on the source and the dispensed milk to be sure that they have the right milk. Some of the babies get as little as 3 mL! (But some of the babies only weigh 500 grams. One in there right now was born at 23 weeks’ gestation. She’s hanging in, but she sure is small.) The nurse brought by one of the babies who is doing really well – it was such a delight to see him, given the sickness of the babies on the floor and the fact that I have spent the week seeing oncology patients.
When it got a little slow in the Nutrition Room, I joined Pat for rounds and listened in to a short talk the attending gave about complications seen in infants of diabetic mothers (google Mermaid Syndrome if you want to see one really rare, serious complication).
We had journal club in the afternoon, during which on of the RDs reviewed dermatological changes associated with micronutrient deficiencies common in patients with alcoholism.
Finally, I ended the day by working up and visiting a couple of oncology patients. I practiced calculating and writing TF recommendations and discussing the pros/cons of different formulations with my preceptor. Among those who can eat, most are on a neutropenic diet (no fresh fruits or vegetables, no uncooked black pepper), which seems like common sense given their compromised immune systems. However, my preceptor told me that this is based mostly on tradition, there isn’t any evidence that a neutropenic diet is any more protective against infection than regular diet. Much of what my RD does with her patients is try to encourage them to eat as much as possible, and it is a shame that they have to avoid foods that they might want (eg, pimento cheese—which has peppers—or chicken salad with celery) because of their neutropenic diet.
Holy high blood sugar
I'm doing a combo cardio/diabetes round for these next two weeks, and I finally started talking with the patients yesterday. I did one assessment interview with the RD observing me, and apparently that was enough because I'm on my own now. I'm not complaining, because I get nervous when people watch me but it seems a little quick.
Anyhoo, I got my first solo patient (I'm likening this to the first solo surgery in Grey's Anatomy) and I logged into the EMR to check out his admission notes from the doctor. Everything's looking kind of normal, history of CHF, HTN, and DM etc etc-- until I saw his admit blood glucose-- 631! My god! I had no idea that was even possible. Upon further investigation during my inteview it turns out it's gotten in the 700s before. Craaaaaaazyyyyyy!
Just thought I'd share my shock with all of you in case you hadn't come across numbers like that.
Anyhoo, I got my first solo patient (I'm likening this to the first solo surgery in Grey's Anatomy) and I logged into the EMR to check out his admission notes from the doctor. Everything's looking kind of normal, history of CHF, HTN, and DM etc etc-- until I saw his admit blood glucose-- 631! My god! I had no idea that was even possible. Upon further investigation during my inteview it turns out it's gotten in the 700s before. Craaaaaaazyyyyyy!
Just thought I'd share my shock with all of you in case you hadn't come across numbers like that.
Freedom!
It is all relative.
Today, I got to write my notes without someone looking over my shoulder and making me nervous. It was a big day for Laura. Afterwards, they didn't have to make any corrections. Maybe, tomorrow, I'll be allowed to speak with the patients.
Admittedly, Cardio is boring and repetitive. Mission has a special, separate "Heart Path" team which provides a thorough explanation of the Heart Healthy diet to lucid patients in the ICU and those about ready to go home. It was interesting to spend the afternoon with one of those ladies, however, I wouldn't want to do it for more than a week. When I was back with the Clinical team today, there was only 1 cardio patient who was not already picked up by this Heart Path team, so I got to hang out on the Neuro Trauma floors to fill up my day instead. Lots of tube feedings, so I brushed up my arithmetic skills and learned a few new adult formulas.
And, if any of you were wondering.... yes, my neighbor (Bret) is currently playing the Abba CD again. He started it significantly later in the day than usual. He MIGHT have a "lady friend" named Helen. We identified another cat, so the count is AT LEAST seven right now. Jack, one of his grey cats, has an extra "thumb" on both paws, so he's a fantastic tree climber. More to come....
Fatback
I was unaware until yesterday that people actually ate fatback by itself- I thought you just cooked with it. Beware, it's apparently a favorite snack of truck drivers...
Gaston Memorial Hospital has been great in the past week, I'm finally getting to the point where I can do things on my own, just in time to switch to another unit and preceptor on Monday. But, I have been learning a lot about neuro, rehab, and psych AND I got to see these incredible pictures of a man with a megacolon pre/post surgery (and the colon itself, after removal). This guy didn't have a BM for 3 weeks (!!!!!) but kept eating and the colon had stretched so much it was almost 5 feet long and over 4" in diameter in some sections. They took out his colon but left a long rectal stump so he probably won't have to have his ileostomy for more than a year! Moral of the story is: if you/your patients don't poop for a while, you should probably get that checked out by a doctor stat. (Actually, it apparently is more common in the elderly or those with chronic constipation. This guy was only 47, though.)
And in other news, from the so-sad-it's-kind-of-funny section, I visited a husband and wife pair today in ortho. The wife was in for a knee replacement and while the husband was visiting her, he tripped over a telephone wire in her room, fell, broke his hip, and had to get hip replacement surgery.
Hope everyone's having a great week!
Gaston Memorial Hospital has been great in the past week, I'm finally getting to the point where I can do things on my own, just in time to switch to another unit and preceptor on Monday. But, I have been learning a lot about neuro, rehab, and psych AND I got to see these incredible pictures of a man with a megacolon pre/post surgery (and the colon itself, after removal). This guy didn't have a BM for 3 weeks (!!!!!) but kept eating and the colon had stretched so much it was almost 5 feet long and over 4" in diameter in some sections. They took out his colon but left a long rectal stump so he probably won't have to have his ileostomy for more than a year! Moral of the story is: if you/your patients don't poop for a while, you should probably get that checked out by a doctor stat. (Actually, it apparently is more common in the elderly or those with chronic constipation. This guy was only 47, though.)
And in other news, from the so-sad-it's-kind-of-funny section, I visited a husband and wife pair today in ortho. The wife was in for a knee replacement and while the husband was visiting her, he tripped over a telephone wire in her room, fell, broke his hip, and had to get hip replacement surgery.
Hope everyone's having a great week!
Charting at Rex
After all of the posts last week about SOAP notes vs. PES statements, I was interested to see how things worked at Rex. I was not prepared for the chaotic system they use. They transitioned to writing PES statements almost a year ago, and they're getting ready to fully transition to using the NCP (ADIME). However, the electronic medical record (called RCare) is actually getting in the way. Each pt's RCare file is huge: there are ~15 tabs, each packed with info and sometimes even sub-categories. I had to take notes on how to find notes! It's pretty handy after you figure it out since things are arranged by date AND by topic, but it's only as good as the info put into it. Some docs (esp. visiting specialists) don't use RCare, so you still have to sift through the paper record to get everything. And the real problem is that there's no place for RD notes. The PES statement is usually entered in a text box at the very end, and no one looks at it except the RD's. There's definitely no space for the other aspects of ADIME. They're fighting with IT now to get their own tab and drop-down menus.
Another interesting issue at Rex: pts don't always get snacks or supplements, mainly due to the computer system. Protein supplements are especially important for pts with decubs (i.e. bed sores...took me a while to figure out that one), and even though the RD orders them, the nurses don't know to give them because they don't look in the section of RCare that we use. The order is also in the food service computer system, but nurses don't see that.
Like Laurie, I'm a little disappointed by the time RD's spend with pts. I'm shadowing the RD on the renal/pulmonary floors, and we spend ~20 min looking at the pt's chart (checking for wt change, alb levels, decubs, etc.), then maybe 5 min with the pt (or their family), and then another 10 min charting. Sitting in on pt rounds and just listening to the other RDs' stories has been really interesting though.
I had a "project day" today, which meant that I spent ~7 hours menially copying and formatting nutrition info for the cafeteria. Thank goodness the weekly RD meeting and a retirement party broke up the afternoon. I got to try Angelo's famous mac and cheese and the party...pretty good.
Oh, and I got called a "little girl" by a pt. I'm going to have to do something to look at little older when I start counseling pts.
Another interesting issue at Rex: pts don't always get snacks or supplements, mainly due to the computer system. Protein supplements are especially important for pts with decubs (i.e. bed sores...took me a while to figure out that one), and even though the RD orders them, the nurses don't know to give them because they don't look in the section of RCare that we use. The order is also in the food service computer system, but nurses don't see that.
Like Laurie, I'm a little disappointed by the time RD's spend with pts. I'm shadowing the RD on the renal/pulmonary floors, and we spend ~20 min looking at the pt's chart (checking for wt change, alb levels, decubs, etc.), then maybe 5 min with the pt (or their family), and then another 10 min charting. Sitting in on pt rounds and just listening to the other RDs' stories has been really interesting though.
I had a "project day" today, which meant that I spent ~7 hours menially copying and formatting nutrition info for the cafeteria. Thank goodness the weekly RD meeting and a retirement party broke up the afternoon. I got to try Angelo's famous mac and cheese and the party...pretty good.
Oh, and I got called a "little girl" by a pt. I'm going to have to do something to look at little older when I start counseling pts.
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