Wrapping up in cardio (UNCH)

Tomorrow (!) is my last day in my cardiology rotation. My preceptor is very patient and systematic, and we’ve gotten into a rhythm for our days. First thing in the morning, we review the consults that came in over night. Next we scan the list of patients on our services for nutrition prioritization according to hospital criteria and follow-ups. Then we go to work on the consults, reviewing the patient’s electronic medical records, including history and physical, labs, in patient progress notes, diet order, and past diet education (all of which are in different programs). Based on the data we’ve collected, we draft a nutrition care plan.

I was really surprised at how much is done before we even talk to a patient! If it is an assessment, we determine what we need to ask the patient. If it is an education, we prioritize what we think is the highest educational need and plan what to say. We go and talk to the patient, then return and write up a note.

My preceptor is definitely taking it slow since we are starting out and we don’t have a crazy patient load right now, but the whole process takes quite a long time. She produces amazing notes: she only includes data that are going to be useful to her assessment, her assessments are carefully written to address every piece of information she included and to set up her goals, which lead directly to her interventions. It is like writing a short mystery novel every time – every piece gets tied up. I can’t tell if I’m getting the hang of it yet, but she has me and Diane take a stab at each one, and then we go through our versions together to create a final note.

Cardiology has frustrated me, because I feel like the patients we see require far more than we can give them. Many of them don’t really seem in a shape to talk with us, and with only one or two visits, there is no way to really help them with long-term behavior change. Many of them are so sick with so many nutrition-related problems (combinations of heart failure, hypertension, diabetes, renal insufficiency, and morbid obesity, or all of these things together!) that I think it would take several sessions to even convince them that dietary change could help, and then several more to work on education, problem solving, and behavior change. Plus, everything we learned in Counseling about a quiet environment, sitting at the same level as the patient, minimizing interruptions seems impossible in the hospital.

It was interesting to read Sierra’s post about her RD’s approach to hospital diet education. I had already been thinking earlier today that it would be a much better use of our time with a patient to figure out how they can start seeing an outpatient dietitian after they leave then to attempt education.

Besides doing Heart Healthy/2gNa educations, we came up with a tube feeding recommendation for a difficult patient who had had a stroke and suffered frontal lobe damage that left him totally disinhibited. He was actually violent, so we didn’t go in to see him before making our recommendation and then helping to write a beautifully crafted note.

The other highlight of this week was the unveiling of Larry’s Beans in place of Starbucks at the Corner Café. The switch was a good call: Larry's coffee is far superior.