Last week was pretty overwhelming, but this week has been much mellower. Yesterday I spent most of the day getting a bunch of on-line mandatory training completed that all hospital employees are required to complete. Some of it was interesting, some of it wasn’t so interesting, but it was nice to get most of it done.
Today I was back in Long Term Care. Many of the patients are the same ones I saw when I was there for a few days several weeks ago. Also, I met some of the patients who are now in LTC when I was working in acute care. I was excited to see one gentleman looking so much better than when I had seen him in acute care.
I went to a very interesting Interdisciplinary Treatment Team meeting today. Not only was it interesting to hear the professionals talk about the different angles of the patient’s treatment, but for two of the cases being discussed they invited the patient in to talk with everyone. The first patient was very complimentary of the treatment he had received, and I believe he is going to be discharged soon, though I can’t remember for sure. The second gentleman who came in had a bunch of health problems he was dealing with, and the poor man just wanted to make a short visit home. Unfortunately, coordinating such an event was going to be quite an undertaking due to the fact that he has a catheter, and is in a wheelchair, so transportation must be arranged, and there may have been other complications as well. It was neat how the patient was the center of everything and he was able to express his needs and desires and the team talked to him about the obstacles and what needed to be done to fulfill his wishes.
The other shocking thing about the case just mentioned is that the man is only a few years older then my parents, who just spent the last few days camping and windsurfing. It just amazes me how old people seem when they are sick, and how debilitating some of these conditions are.
Tuesday, June 30, 2009
wound care
Last week I was given the pleasure of witnessing a wound change. It was really quite strange. The patient is a frequent visitor to the hospital - she has been on home TPN and has a very large abdominal wound. The wound care nurse was so excited about the improvement in this woman's wound - it was 7-8 inches in length and about 3-4 inches wide and 1/2 inch deep into the abdomen (yikes!). I'm still somewhat confused as to how she acquired this wound. It looked to be really painful, but the patient said that she doesn't really notice it. It seems to have come from a GI surgery that she had a few months back, but I still can't imagine how it could have gotten so large. Anyway, I have never seen a wound vac before, but the collection of deposits were pretty grotesque after 2-3 days of suction - blood and some other brownish liquids. The patient couldn't tell that the wound vac had been turned on after the nurse had finished up, so it sounds like it wasn't a terrible inconvenience at least!
ICU Life
This week I have been "rotating" in the ICU. It is quite a change from all other rotations I have completed. The "patient-RD contact" is very minimal. Most of our ICU patients are sedated and/or on a vent. Very few are alert and oriented. Thus, we primarily review the ICU charts and talk with the nurses in order to establish our nutrition care plan. I must admit that I miss the patient contact. I think I like talking with the patients because I feel like, at least to some capacity, I can help them. I know writing tubefeeding orders assists the ICU patient, but it feels so different. Definitely no diet educations in the ICU!
Yesterday one of the patients I was following died. It was a sad story. Consequently, I spent part of the day talking with the RD about staying detached from patients' lives, yet trying to care for them the best we can. Anyhow, the patient had been taken off all nutrition support yesterday when I saw him. I felt useless (and really was useless as far as nutrition care is concerned). Of course I know patients die daily in a hospital. I guess as a health care worker, it is best to emotionally distance myself from patients' personal lives and simple focus on treating them best. Still learning about this. It's a process. Opinions?
Nothing else too exciting. I will be rotating in the ICU the remainder of this week and all of next week. I'll keep you posted on the going ons...
Rachael
Yesterday one of the patients I was following died. It was a sad story. Consequently, I spent part of the day talking with the RD about staying detached from patients' lives, yet trying to care for them the best we can. Anyhow, the patient had been taken off all nutrition support yesterday when I saw him. I felt useless (and really was useless as far as nutrition care is concerned). Of course I know patients die daily in a hospital. I guess as a health care worker, it is best to emotionally distance myself from patients' personal lives and simple focus on treating them best. Still learning about this. It's a process. Opinions?
Nothing else too exciting. I will be rotating in the ICU the remainder of this week and all of next week. I'll keep you posted on the going ons...
Rachael
tube feedings and TPN
For the past week at CMC Union I've been practicing more tube feedings and TPN's. I got to practice writing the TPN's for my case study, an alcoholic patient with acute pancreatitis who had his gallbladder removed and then had a hemorrhage in his abdominal cavity and went into respiratory failure. I got to transition him to TF and then see him progress to solid foods. It was a very fast progression! For me the hardest part of TPN is knowing what to do with all the electrolytes. It's also hard to figure out exactly how many grams of macronutrients to give when the patient has multiple conditions to consider. I enjoy working on the TPNs though. For tube feedings, the hardest part is again figuring the needs if multiple conditions are present and determining which formula off of the formulary is the most appropriate.
Two other exciting things have happened recently. First, Amanda came to visit last week, and we had a good visit. I enjoyed getting to share everything I've learned :) Second, we were short staffed yesterday, so I got to do third floor medical (excluding the progressive care unit) by myself. Somebody came by to check on me about once an hour and answer any questions I had, but it made me realize how far I had come to be able to take care of my patients without much help. I felt pretty comfortable with everything that was on my list, including two patients that we got a consult on because they were admitted on a tube feed. I definitely ran everything I did by the dietitian for the tube feed patients, but it gave me confidence when she approved of what I did!
Today I gave a "chat session," or mini-lecture on safety to the nutrition and food service department. It went pretty well, except I had an extremely hard time talking loud enough. We held it in the kitchen with all the ovens and fans running, so if you've heard me talk before (which you all have), you know it was a challenge for me!
Two other exciting things have happened recently. First, Amanda came to visit last week, and we had a good visit. I enjoyed getting to share everything I've learned :) Second, we were short staffed yesterday, so I got to do third floor medical (excluding the progressive care unit) by myself. Somebody came by to check on me about once an hour and answer any questions I had, but it made me realize how far I had come to be able to take care of my patients without much help. I felt pretty comfortable with everything that was on my list, including two patients that we got a consult on because they were admitted on a tube feed. I definitely ran everything I did by the dietitian for the tube feed patients, but it gave me confidence when she approved of what I did!
Today I gave a "chat session," or mini-lecture on safety to the nutrition and food service department. It went pretty well, except I had an extremely hard time talking loud enough. We held it in the kitchen with all the ovens and fans running, so if you've heard me talk before (which you all have), you know it was a challenge for me!
The Wild, Uncharted Territory of the Morbidly Obese, critically ill, Renal Failure Patient
Does anybody know of any good articles about dosing protein for very obese patients with renal failure? It appears to be a very unknown area. It is confusing because if they are obese we dose them really high with protein here (like 1.7-2!) but then if they are undialyzed with CRF their creatinines (like say, 22.6!!!) and BUNs (250!!) are crazy high. But then their albumin is low! AH! So any knowledge ya'll have would be much appreciated....
Procedures
Today I finished my rotation on Peds/Medical ICU. I got to see several procedures this past week-- a FEES, a PEG placement, and TPN compounding. For the TPN compounding, we had to change into scrubs and put on shoe booties and hair bonnets before going into that part of the pharmacy. Watching the TPN bags being prepared was really neat, especially because I've seen a lot of TPN orders being written this past week, since my current preceptor just passed the CNSC exam and is working with another RD to practice writing the full TPN orders and doing the daily followups to adjust electrolytes and macros. We also got a visit from Amanda on Friday, which was quite enjoyable, as you might imagine. No one died on my watch that day, thank goodness.
I might finally have found a case study patient-- we saw a woman today who is in the hospital following a parathyroidectomy and has an extensive PMH: ESRD due to lupus nephritis, lupus, rejected renal transplant, renal osteodystrophy, restless leg syndrome, hypothyroidism, diabetes, and HTN, among others. And this poor woman is only 41. Life's just not fair sometimes..
I might finally have found a case study patient-- we saw a woman today who is in the hospital following a parathyroidectomy and has an extensive PMH: ESRD due to lupus nephritis, lupus, rejected renal transplant, renal osteodystrophy, restless leg syndrome, hypothyroidism, diabetes, and HTN, among others. And this poor woman is only 41. Life's just not fair sometimes..
Monday, June 29, 2009
NICU@WakeMed
It's second week of ICU. Not much different compared to last week, however, we spent quite a lot time on TPN. My preceptor is very organized, pays attention to every detail information about patients, careful about making any change of TPN. She shared general information of IV nutrition support to patients w/families, respected their input, which is the most impressive thing for me and totally different to what I thought before.
I finally found my case study, it is very complicated and very interesting. I start digging into details, doing literature search, since there are different aspects for this one, I need to pick one most valuable...
I can't believe it is already week 7, time runs so fast, I still think I need more time to learn... I will spend my next 4 weeks on NICU,SICU, CTSU, the last week will be my Peds rotation. I really appreciate that my preceptors arrange my rotations based on my interests!
(I really like nutrition supports)
GI and TPN
We rotated with the GI surgery RD last week, which was a good way to set us up for the TPN rotation we started today. Last week was pretty slow, actually, but I liked the GI surgery patients I did get to see. I am pretty amazed by how adaptable the GI tract is and how relatively quickly people can get back to (mostly regular) po intake after their surgery.
Like other people have mentioned, the post-bariatric surgery educations made me a little nervous for the patients because they seemed so unprepared. The 2 I spoke with both had to have 6 visits with an RD prior to the surgery, but those visits were a year before the surgery. They couldn't tell me anything about the diet they needed to be following after their surgery. One lady, who appeared to have no family/friends helping her, didn't have any of the nutritional supplements (sugar-free Carnation Instant Breakfast, etc) that they are supposed to drink for extra protein. I'm not sure how soon she will be feeling up to going shopping for food, and it make me a little worried that she hadn't stocked up on these foods before she went in for surgery.
The new medical interns started last week, and it has been fun to educate them about what we do and need. I explained why we ask for metabolic cart studies to one intern today. Diane helped another intern who didn't know which were the fat soluble vitamins.
TPN is not common among UNC patients. There are about 25 adult patients on TPN at any time in the hospital, and there is a special adult TPN team made up of a pharmacist, RN, 2 MDs and 2 RDs. Each member of the team follows patients, and they swap if a patient has needs that are someone else's area of expertise. During rounds today, I was pretty surprised to hear the stories behind the patients - including people who can eat but want to stay on TPN instead. If I have a patient like that, I have already decided that my intervention will be baking cookies and bread outside their room until they caved. :)
Like other people have mentioned, the post-bariatric surgery educations made me a little nervous for the patients because they seemed so unprepared. The 2 I spoke with both had to have 6 visits with an RD prior to the surgery, but those visits were a year before the surgery. They couldn't tell me anything about the diet they needed to be following after their surgery. One lady, who appeared to have no family/friends helping her, didn't have any of the nutritional supplements (sugar-free Carnation Instant Breakfast, etc) that they are supposed to drink for extra protein. I'm not sure how soon she will be feeling up to going shopping for food, and it make me a little worried that she hadn't stocked up on these foods before she went in for surgery.
The new medical interns started last week, and it has been fun to educate them about what we do and need. I explained why we ask for metabolic cart studies to one intern today. Diane helped another intern who didn't know which were the fat soluble vitamins.
TPN is not common among UNC patients. There are about 25 adult patients on TPN at any time in the hospital, and there is a special adult TPN team made up of a pharmacist, RN, 2 MDs and 2 RDs. Each member of the team follows patients, and they swap if a patient has needs that are someone else's area of expertise. During rounds today, I was pretty surprised to hear the stories behind the patients - including people who can eat but want to stay on TPN instead. If I have a patient like that, I have already decided that my intervention will be baking cookies and bread outside their room until they caved. :)
Chronic Renal Failure
There was a patient in the hospital today that I had seen many times before, and always came in and almost immediately went to get dialysis. The patient was NPO because they forgot to order a diet for him after he completed his testing, so needless to say, when I went in to speak to him, he was already in a pretty bad mood and starving from his 24 hour NPO status. The diet hadn't been ordered yet, so I just went off the fact that he was probably on a renal diet. I had looked at his chart it said he was no longer on dialysis, but it was pretty ambiguous, because it also said he was on dialysis in another place in the chart. I asked the RN and she wasnt' sure either. The patient informed me that he was no longer on dialysis. His kidney function labs were WNL. His chart noted that he has chronic renal failure, so I'm not entirely sure what happened. As far as I know, there is no way to regain normal kidney function if there is chronic renal failure? Has anyone else heard differently? The only idea I have is that his chart may have noted chronic renal failure when it was supposed to say acute. He has a history of crack cocaine use, so maybe that triggered his renal failure? I was confused, because the MD didn't order any type of renal diet for the patient, and based on his labs being WNL, I wasn't going to argue it. The patient was not complying with a renal diet at home anyway, or his diabetic diet for that matter, so a day or so in the hospital won't really change anything.
I haven't been able to post for awhile, but it's been a little hectic this past week I'm back in home territory! It was actually quite comforting to see familiar faces and the ground floor of our hospital again. Anyways, I've been trying to transition from elderly, vent-dependent LTAC patients to teeny tiny premature babies. It's been quite fun on peds, to my surprise. I'm still trying to get used to the different charting and computer systems though...
Anyways, I've been getting quite a bit of practice with TPN which is actually quite interesting. It's funny how the new MD interns have no idea how to write TPN, yet they are the ones who have to place the orders. On a different note, I had a psych consult for a 4 yo today. Yep. A 4 yo psych consult for "restricting his intake." (someone tell me if they know a 4 yo that hasn't refused some kind of food..) He was admitted for aggressive behavior, but all I saw was a very calm and typical 4 yo. Of course, there was not much we could do. Encourage him to eat, offer foods he likes... Surprisingly, this was the hardest note I've had to write. How do you explain that a 4 yo may actually do this from time to time and that since his BMI was way above the 97%ile, it might not be a bad idea for him to cut down on his eating??
(on a side note, if you don't already have it, the Texas Children's Hospital's pediatric guide is a must if you're thinking about doing peds. I think you have to order it from them though. It's a little pink book.)
Anyways, I've been getting quite a bit of practice with TPN which is actually quite interesting. It's funny how the new MD interns have no idea how to write TPN, yet they are the ones who have to place the orders. On a different note, I had a psych consult for a 4 yo today. Yep. A 4 yo psych consult for "restricting his intake." (someone tell me if they know a 4 yo that hasn't refused some kind of food..) He was admitted for aggressive behavior, but all I saw was a very calm and typical 4 yo. Of course, there was not much we could do. Encourage him to eat, offer foods he likes... Surprisingly, this was the hardest note I've had to write. How do you explain that a 4 yo may actually do this from time to time and that since his BMI was way above the 97%ile, it might not be a bad idea for him to cut down on his eating??
(on a side note, if you don't already have it, the Texas Children's Hospital's pediatric guide is a must if you're thinking about doing peds. I think you have to order it from them though. It's a little pink book.)
So now that you failed at diabetes...you get a diet that's even harder to follow!
Today I experienced a few interesting educations. The first was on a low fat diet for a youngish man with really high triglycerides. Right in the middle of the education he proceeded to tell me that he though he was bulimic. I was like wha? I was just confused and the RD was outside listening and she told me she was gonna come in and say something but decided that she wouldn't know what to say either so I just continued on with education. I'm not sure he was bulimic, he said something about how he eats too much at dinner sometimes and feels too full and throws up. So I'm a little confused about whether he actually had an eating disorder. But we both felt bad later for not probing more into the topic but he was about to be discharged anyways. There was nothing in his history about it and the nurse hadn't heard him say anything.
The second education was a renal diabetic education. The man had had diabetes for a while but now was in renal failure with a BUN of 250! His wife appeared to be a great hindrance to the learning process. She was flipping out about having to make changes and how she just couldn't cook. The RD was doing this since it is the first renal education that has come up the whole summer, amazingly, and she mentioned something about using garlic. And the wife just freaked and said she would never know what to do with the garlic and was just super negative about everything. She then started telling her husband this might cause them to get divorced. And then at one point she looked like she was feigning sleep while the dietitian was talking. The patient seemed actually interested but she was overtaking the whole conversation with her negativity. Needless to say I don't see them making changes at this point. It was stressful to watch.
The second education was a renal diabetic education. The man had had diabetes for a while but now was in renal failure with a BUN of 250! His wife appeared to be a great hindrance to the learning process. She was flipping out about having to make changes and how she just couldn't cook. The RD was doing this since it is the first renal education that has come up the whole summer, amazingly, and she mentioned something about using garlic. And the wife just freaked and said she would never know what to do with the garlic and was just super negative about everything. She then started telling her husband this might cause them to get divorced. And then at one point she looked like she was feigning sleep while the dietitian was talking. The patient seemed actually interested but she was overtaking the whole conversation with her negativity. Needless to say I don't see them making changes at this point. It was stressful to watch.
Doctors Vs. Dietitians
For the past month or so I have been collecting data for my QI about how often the doctors actually follow the recommendations of the dietitians. Overall, I wouldn't say the outcome has proved to be favorable towards the dietitians. To make things worse this past weekend a doctor actually told a dietitian that all we do is carry around our calculators and are essentially useless because we don't look at the big picture we only see nutrition as a science. I find it increasingly frustrating that very few of the doctors here actually follow the orders but just arbitrarily write TPN/TF orders that rarely meet the nutritional needs and as a result patients suffer. Ego is a big issue here to the point where the dietitians actually have to write please and thank you notes at times in the progress notes for a doctor to even consider their orders. As a follow up to the QI I am going to hand out a RD perception survey to doctors, nurses, speech and pharmacists to get an idea how they all feel about our role in the hospital. Ill keep everyone posted on what I find out although I have a feeling it wont be reassuring.
5 weeks left!
Hi ladies. Hope you all had a lovely weekend.
With just 5 weeks to go, I'm officially done with my modules and am now doing staff relief working on a combination of disease states. Since this hospital is not very large, this is actually more realistic work experience now because there aren't enough patients for each RD to specialize in any one particular area.
Last week I finished up the renal module, and found that I could relate to these patients more so than on the other floors. As many of you know, my father was on dialysis for several years before finally receiving a kidney transplant a few years ago so I have an insight that I found very helpful last week. Basically I just felt a little more confident when talking to these folks, especially those who were going home to face maintenance HD for the first time. I also happened to talk to post-transplant patient who's history looked eerily similar to my dad's, down to the exact same complications they are both experiencing right now as a result of their AV fistulas still being implanted. So that was weird. I'm spending the day at a dialysis unit this Wednesday, and I've already been told that I'm being put to work immediately, so that should be an interesting day and hopefully a nice change of pace from the hospital.
With just 5 weeks to go, I'm officially done with my modules and am now doing staff relief working on a combination of disease states. Since this hospital is not very large, this is actually more realistic work experience now because there aren't enough patients for each RD to specialize in any one particular area.
Last week I finished up the renal module, and found that I could relate to these patients more so than on the other floors. As many of you know, my father was on dialysis for several years before finally receiving a kidney transplant a few years ago so I have an insight that I found very helpful last week. Basically I just felt a little more confident when talking to these folks, especially those who were going home to face maintenance HD for the first time. I also happened to talk to post-transplant patient who's history looked eerily similar to my dad's, down to the exact same complications they are both experiencing right now as a result of their AV fistulas still being implanted. So that was weird. I'm spending the day at a dialysis unit this Wednesday, and I've already been told that I'm being put to work immediately, so that should be an interesting day and hopefully a nice change of pace from the hospital.
Sunday, June 28, 2009
Albumin
1. I was working on my renal module and noticed that in the Nutrition and Diagnosis –Related Care book one of the Intervention Objectives for CKD and renal failure patients is an albumin of 4.0 g/dL. When I went to a dialysis center for Nutr 630 that was their goal too. However, in thinking about the albumin levels I have been seeing in the hospital that seems like a high standard to set. I have been seeing a lot of low albumin, in general, not necessarily in renal patients. One or 2 patients were even below 2.0 g/dL, and many seem to be in the 2 range. I guess that is to be expected, since often one of the reasons a patient is referred to the dietitians is because they have a low albumin. My hospital relies on albumin instead of prealbumin, though they did order a prealbumin for one of my patients. I am curious what the other hospitals use.
2. I just discovered the appendices in the Nutrition and Diagnosis Related Care book, and recommend taking a look if you haven’t already.
2. I just discovered the appendices in the Nutrition and Diagnosis Related Care book, and recommend taking a look if you haven’t already.
Peg tube
On Friday I saw a PEG tube placement which was really fascinating. It took a while for the procedure to get started because the patient refused the NG tube for about an hour. The nurse kept trying to put it in and he kept swatting her hand and freaking out. It was really hard to watch. Finally she used something called Hurricane Spray to numb his throat and gel to numb his nose and it went in really fast and he barely knew what happened. She checked the placement by pulling up secretions from the stomach. She told me that she has had nurses put them into lungs before, one time someones lung even got perforated. She said it is scary sometimes b/c some people won't even cough when it goes into their lungs which is amazing. The surgery was so minimally invasive, it was fascinating! There was barely any blood and it was a pretty quick procedure.
Recently I've been doing a lot of nutrition support. I'm getting good with the tube feedings but TPN is still taking me quite a while to do, which my preceptor said is completely normal so whew. I have learned that diprivan is a bitch! One time a patient on the vent was getting over 50% of their calories from diprivan and it was pretty much impossible to meet his protein needs without over feeding him so I just didn't meet them. He was obese and critically ill so it was really hard to feel him adequately. I left a note in the chart for the doc asking if maybe they could try a combo of multiple sedatives, like diprivan +ativan or versed b/c those don't have calories from fat. Nutrition support is fun, like a puzzle, but there is just so much to learn about it, I don't know if I will feel completely prepared even after doing all of these patients, to be doing this on my own completely within the next three weeks before I leave New Bern, but we'll see! I was told by the RDs that my first few jobs will have really steep learning curves, I will be learning much still on the job when I have a real job, so that was helpful to know.
Recently I've been doing a lot of nutrition support. I'm getting good with the tube feedings but TPN is still taking me quite a while to do, which my preceptor said is completely normal so whew. I have learned that diprivan is a bitch! One time a patient on the vent was getting over 50% of their calories from diprivan and it was pretty much impossible to meet his protein needs without over feeding him so I just didn't meet them. He was obese and critically ill so it was really hard to feel him adequately. I left a note in the chart for the doc asking if maybe they could try a combo of multiple sedatives, like diprivan +ativan or versed b/c those don't have calories from fat. Nutrition support is fun, like a puzzle, but there is just so much to learn about it, I don't know if I will feel completely prepared even after doing all of these patients, to be doing this on my own completely within the next three weeks before I leave New Bern, but we'll see! I was told by the RDs that my first few jobs will have really steep learning curves, I will be learning much still on the job when I have a real job, so that was helpful to know.
Saturday, June 27, 2009
Laryngectomy
Hi everyone! I haven't been updating because I've been having internet issues for a few weeks, I felt so out of touch with the world with no internet. All resolved now.
I went to a Laryngectomy conference yesterday with the RD that I was working with for 3 weeks (I'm working with a different RD now). The conference was for professionals (mainly MDs and RNs), and individuals who are training to be caregivers of laryngectomees. The RD from the VA that I went with was one of the presenters. She spoke on the role of dietitians and nutrition-related issues with laryngectomy.
It was great! I have never looked at laryngectomy so closely. I met a lot a lot of people who have undergone the procedure, and I heard about how they're living their lives now, with the change in the way they eat (no smell, some have their epiglottis removed as well), and the way they speak (they have all kinds of instruments that facilitate laryngectomees in their regular jobs, like a microphone and speakers for teachers, etc.), they can even swim and some even still become bodybuilders, which was a little funny. I also got a chance to hear about the area of Speech Pathology a little bit more. It was neat, since we work with them so closely sometimes to monitor patients' tolerance to his/her diet consistency.
The RD and I were pretty much the only dietitian/future dietitian in the entire conference, so I felt that we were representing our field. She spoke on the basics of nutrition, what we do as dietitians, and some issues relating to laryngectomy and esophageal cancer specifically. I thought she represented us well. I even helped her make a few of her slides for her presentation. Yay.
Anyway, that was a one-day break from clinical. I'm off to the nursing home next week, I'm excited to see the differences between long-term care and acute care.
I went to a Laryngectomy conference yesterday with the RD that I was working with for 3 weeks (I'm working with a different RD now). The conference was for professionals (mainly MDs and RNs), and individuals who are training to be caregivers of laryngectomees. The RD from the VA that I went with was one of the presenters. She spoke on the role of dietitians and nutrition-related issues with laryngectomy.
It was great! I have never looked at laryngectomy so closely. I met a lot a lot of people who have undergone the procedure, and I heard about how they're living their lives now, with the change in the way they eat (no smell, some have their epiglottis removed as well), and the way they speak (they have all kinds of instruments that facilitate laryngectomees in their regular jobs, like a microphone and speakers for teachers, etc.), they can even swim and some even still become bodybuilders, which was a little funny. I also got a chance to hear about the area of Speech Pathology a little bit more. It was neat, since we work with them so closely sometimes to monitor patients' tolerance to his/her diet consistency.
The RD and I were pretty much the only dietitian/future dietitian in the entire conference, so I felt that we were representing our field. She spoke on the basics of nutrition, what we do as dietitians, and some issues relating to laryngectomy and esophageal cancer specifically. I thought she represented us well. I even helped her make a few of her slides for her presentation. Yay.
Anyway, that was a one-day break from clinical. I'm off to the nursing home next week, I'm excited to see the differences between long-term care and acute care.
Friday, June 26, 2009
Georgetown End of Week 7
I started my Neuro/Rehab rotation on Thursday. I've been working in the Neuro ICU, so I'm seeing pts with head bleeds, stroke, dementia, etc. So far, all of my pts have been intubated, so I've been writing a lot of TF recs.
I did a f/u for one pt who was started on Promote at 55ml/hr via DHT per the RDs inital recs. I was expecting to just check on how he was tolerating the TF. I noticed that the TFs were being held, and the pt was NPO. I was confused because I didn't see any residuals noted, and the pt was doing fine with the TF for 1.5 days before it was held.
So, I talked to the RN who said that while they were suctioning the endotracheal tube, some secretions came out that smelled like TF. Then, she lowered the rate to 10ml and tried again, but the same thing happened. So she thought the pt wasn't tolerating it and told the MD and they decided to hold TFs. They did an abdomen Xray to r/o ileus, which came back fine.
I'm not sure I was convinced that the pt was not tolerating/aspirating TF, but we must be cautious nonetheless. So I tried to figure out what was going on. First, I noted that the pt was on Phenobarbital (which can decrease gut motility), which was d/c'ed 2 days ago, but they were still checking levels in the blood, which showed a small amount was still present. I thought maybe this could be the issue, so I noted that in my assessment. Also, the HOB was only at 30 degrees and the pt had an NG Dobhoff. The pt also hadn't stooled for 4 days. He was on colace, and peri-colace. I was going to recommend adding senna, but from the chart I noted that the MD was already aware of this issue and an enema was ordered.
My interventions were:
1) Place DHT past the Ligament of Treitz (into the jejunum), then consider re-starting feeds.
2) If unable to place DHT post-pyloric, consider placing HOB >/= 45 degrees, adding Reglan (to keep things moving through the GI tract, and prevent TF from coming up), and try again with trickle feeds of 10mL/hr of Promote.
3) If pt still NPO/not tolerating TF within 24-48 hours, recommend PPN (we have a standard 4% A, 10% D solution), I suggested 2000ml with no IVL because pt was on 19 mL/hr of propofol.
A couple hours later, I find out that they are going to hold all feeds until the pt stools and that he will probably be extubated today! However, since it's Friday, I had to make sure to cover everything just incase things don't go as planned.
I did a f/u for one pt who was started on Promote at 55ml/hr via DHT per the RDs inital recs. I was expecting to just check on how he was tolerating the TF. I noticed that the TFs were being held, and the pt was NPO. I was confused because I didn't see any residuals noted, and the pt was doing fine with the TF for 1.5 days before it was held.
So, I talked to the RN who said that while they were suctioning the endotracheal tube, some secretions came out that smelled like TF. Then, she lowered the rate to 10ml and tried again, but the same thing happened. So she thought the pt wasn't tolerating it and told the MD and they decided to hold TFs. They did an abdomen Xray to r/o ileus, which came back fine.
I'm not sure I was convinced that the pt was not tolerating/aspirating TF, but we must be cautious nonetheless. So I tried to figure out what was going on. First, I noted that the pt was on Phenobarbital (which can decrease gut motility), which was d/c'ed 2 days ago, but they were still checking levels in the blood, which showed a small amount was still present. I thought maybe this could be the issue, so I noted that in my assessment. Also, the HOB was only at 30 degrees and the pt had an NG Dobhoff. The pt also hadn't stooled for 4 days. He was on colace, and peri-colace. I was going to recommend adding senna, but from the chart I noted that the MD was already aware of this issue and an enema was ordered.
My interventions were:
1) Place DHT past the Ligament of Treitz (into the jejunum), then consider re-starting feeds.
2) If unable to place DHT post-pyloric, consider placing HOB >/= 45 degrees, adding Reglan (to keep things moving through the GI tract, and prevent TF from coming up), and try again with trickle feeds of 10mL/hr of Promote.
3) If pt still NPO/not tolerating TF within 24-48 hours, recommend PPN (we have a standard 4% A, 10% D solution), I suggested 2000ml with no IVL because pt was on 19 mL/hr of propofol.
A couple hours later, I find out that they are going to hold all feeds until the pt stools and that he will probably be extubated today! However, since it's Friday, I had to make sure to cover everything just incase things don't go as planned.
Renal!!!!
The world of renal dietetics: Today was full of lots of diet educations. Actually, I ended up doing two diabetic diet educations and (yet another) renal transplant diet education. I must admit... I really enjoy giving the renal transplant diet instructions because the patients are SO happy. Not only did they just receive a new kidney, but their new diet is much more liberal than their previous renal diet. It is neat to see their faces light up when you say, "You can eat foods with phosphorus and magnesium, and you may not have to restrict your potassium intake!"
My diabetic diet educations, although a somewhat routine instruction, were (nonetheless) interesting. Both patients today were excited to learn how to count carbs. I was grateful for their receptive and enthusiastic attitudes.
Nothing else too exciting. Just a typical day. Next we I start ICU so I imagine there will be a little excitement. Hope everyone enjoyed their seventh (or so) week.
Rachael
My diabetic diet educations, although a somewhat routine instruction, were (nonetheless) interesting. Both patients today were excited to learn how to count carbs. I was grateful for their receptive and enthusiastic attitudes.
Nothing else too exciting. Just a typical day. Next we I start ICU so I imagine there will be a little excitement. Hope everyone enjoyed their seventh (or so) week.
Rachael
Thursday, June 25, 2009
Case Study
Mrs. Holliday visited me yesterday. It was wonderful to see her!! I also gave my case study presentation. The discussion that followed was a fabulous learning experience. I have been following the patient for over a month. I saw some of my errors while looking back over the patient’s treatment in preparation for my presentation, but there were still quite a few things I over-looked, even after spending all that time looking through his medical record. The questions from the audience and the conversation I had with Mrs. Holliday on another case made me realize how important it is to step back and look at the big picture. Though with so many notes in the medical file and so many details that are important to consider that is easier said than done.
On another note, I went in to talk to a patient this afternoon, and when I first looked at him the whites of his eyes looked a little yellow, and then I realized his skin was a little yellow. He has liver cirrhosis and so I believe I was seeing evidence of jaundice!
On another note, I went in to talk to a patient this afternoon, and when I first looked at him the whites of his eyes looked a little yellow, and then I realized his skin was a little yellow. He has liver cirrhosis and so I believe I was seeing evidence of jaundice!
hot dogs, baseball games and your cholesterol.
I spent the day yesterday with an R.D. in Cardiac rehab. Moore's Cardiac Rehab program shares a building with the hospital's fitness center, which is actually a very nice facility. I showed up with the rest of the Cardiac Rehab team: a nurse, an exercise physiologist, an M.D. and the R.D. early in the a.m. to get ready for the first shift of participants to show up at 8am. When these referred clients show up, their blood pressures are taken, BS's are taken if they're diabetic, and they hook themselves up to a portable heart monitor if their level requires them too. Then group warm up time takes place, followed by closely supervised aerobic exercise tailored to each individual. During this exercise period, the second group of participants will show up, and the R.D. I was with will do some one-on-one counseling with pts. It was neat to see the med team interact with the clients by name and know their stories. It was definitely a different dynamic than what you see in the hospital, for sure. At one point during of the overlaps with one group leaving and another showing up, the R.D. told me not to mind the chaos. I thought to myself, wow, this is actually pretty tame compared to how I feel in the hospital sometimes! On another note though, I had the opportunity to talk with one of the program participants, and he was such a fan of the program. In fact, for each of the classes taught by the R.D., the man's wife would come in too and join him and they would sit next to each other and ask the R.D. questions. In general, this program has a really high retention rate, and it really does get results. Most clients finish the program having met their goals of losing/maintaining/gaining wt, exercising 3x week, improving their eating habits, etc. The program lasts 12 wks, and meets 3x/wk, so the participants really get to know their group's members. It almost seemed like a social club at some points. While one group was getting their BP's checked, one of the men was pointing and laughing at a group of three men sitting side by side making jokes at each other...he was calling them the three stooges, and I'm not gonna lie, they could have been!
Anyway, midday the R.D. gave a class on Cholesterol & Dietary Fats. There was a really great turnout, and the participants would ask questions throughout the presentation/talk. Near the end of the presentation one of the men speaks up and says he used to be the poster child for junk food since apparently he ate really poorly before his cardio event. He shared that he had only eaten 3 hot dogs within the past 2 months, and he was so proud. He then said that his doctor told him he could eat hot dogs when he was at the baseball game (I don't know what kind of advice that is) and he continued without skipping a beat: "so I'm going to buy season tickets!" The room erupted in laughter. He was kidding, really, but it was cute to see all these old folks having a good laugh about their new food habits and such. I was impressed with the degree of self-motivation present in these people, I guess because I have gotten mixed reviews about outpt rehab experiences.
I'll be spending one more day in cardiac rehab, so we'll see how things go.
Anyway, midday the R.D. gave a class on Cholesterol & Dietary Fats. There was a really great turnout, and the participants would ask questions throughout the presentation/talk. Near the end of the presentation one of the men speaks up and says he used to be the poster child for junk food since apparently he ate really poorly before his cardio event. He shared that he had only eaten 3 hot dogs within the past 2 months, and he was so proud. He then said that his doctor told him he could eat hot dogs when he was at the baseball game (I don't know what kind of advice that is) and he continued without skipping a beat: "so I'm going to buy season tickets!" The room erupted in laughter. He was kidding, really, but it was cute to see all these old folks having a good laugh about their new food habits and such. I was impressed with the degree of self-motivation present in these people, I guess because I have gotten mixed reviews about outpt rehab experiences.
I'll be spending one more day in cardiac rehab, so we'll see how things go.
Bone Marrow Biospy
So, today I got to see a lovely bone marrow biopsy. Let's just say it did not go over as smoothly as I anticipated.
I was randomly paged by the PA to come observe the procedure. I got to the room and surprisingly knew the patient because I had worked with him last week. She started to explain everything to me. The procedure lasted about 30 minutes. It began with her numbing the patient. This was followed by her inserting a long needle into the bone marrow. She extracted a sample of marrow, which was quickly handed over to a lab tech who smeared at least 20 slides with the marrow. Then, a LARGE hollow needle was pushed in the patient's hip to extract a piece of bone. This is when the room suddenly became dark, hot, and... well, I was watching as the PA put her body weight on the needle as she screwed it into the bone. I saw her bring the bone specimen out of the patient. Then, yes, I had to excuse myself. I thought I would be perfectly fine considering the fact that I have seen multiple hip replacement surgeries, worked in the ER, etc. Something about the procedure was disturbing though. Maybe because the patient was awake the entire time. Anyhow, it was a good experience, and I am glad I got to observe it.
Other than that, this week has been fairly relaxing. I have been doing renal the past two days and before that I rotated in the MICU -- the "intermediate" critical care unit. Both have been intriguing. I did a Renal Transplant Diet education today and talked with a few hemodialysis patients. Still loving the excitement of the hospital.
Hope all is well,
Rachael
I was randomly paged by the PA to come observe the procedure. I got to the room and surprisingly knew the patient because I had worked with him last week. She started to explain everything to me. The procedure lasted about 30 minutes. It began with her numbing the patient. This was followed by her inserting a long needle into the bone marrow. She extracted a sample of marrow, which was quickly handed over to a lab tech who smeared at least 20 slides with the marrow. Then, a LARGE hollow needle was pushed in the patient's hip to extract a piece of bone. This is when the room suddenly became dark, hot, and... well, I was watching as the PA put her body weight on the needle as she screwed it into the bone. I saw her bring the bone specimen out of the patient. Then, yes, I had to excuse myself. I thought I would be perfectly fine considering the fact that I have seen multiple hip replacement surgeries, worked in the ER, etc. Something about the procedure was disturbing though. Maybe because the patient was awake the entire time. Anyhow, it was a good experience, and I am glad I got to observe it.
Other than that, this week has been fairly relaxing. I have been doing renal the past two days and before that I rotated in the MICU -- the "intermediate" critical care unit. Both have been intriguing. I did a Renal Transplant Diet education today and talked with a few hemodialysis patients. Still loving the excitement of the hospital.
Hope all is well,
Rachael
A teachable moment found!
This morning I walked into a patient's room on the cardiac floor, expecting the usual quick assessment with little intervention needed. Much to my surprise, the patient asked me to help explain to her the diabetic diet, exchanges, how to work with exchanges for the 1500kcal diet her doctor recommended, and for a list of high iron foods. Not expecting this at all, I told her I needed to go get some handouts for her and that I would be right back. It was a slow day, so I was able to spend quite a bit of time with her. We sat next to one another on her bed and worked through all of her diet questions and more. When we finally finished, she gave me a big hug and seemed genuinely thrilled to finally understand how to go about following this diet that no one had yet taken the time to explain to her (she apparently had not seen any of the dietitians on previous visits). This encounter totally made my day!
Dialysis Center
I spent some time this week at the dialysis center. One of the first thing that the RD really stressed to me is that dialysis is really a lifestyle. The patients have to arrange their whole lives around their dialysis. She compared it to having a part time job. The patients have to come in three times a week, for at least about 4 hours each time. All of the patients bring a bag of stuff with them, including blankets and pillows, and make themselves as comfortable as possible during the treatment. The whole staff knows each patient by name, and really try to make the environment as pleasant as possible. The RD said that they have one patient who has been getting dialysis for over 20 years! A lot of the patients are trying to get on the transplant list, but to even be able to get on to the transplant list at all, the patient's BMI must be below 30. There are very few patients that are currently meeting this criteria, so the RD works with the patients not only to control their labs, but also to help them lose weight so they can get on the transplant list.
One of the things that I had never thought about in dialysis that was really interesting is the treatment of the water used. The dialysis center has a really complex filtering system for the city water that is pumped in. There are at least 4-5 giant tanks in which different things happen to the water, removing different ions from the city water. Somebody tests the water 4 times every day, and if the tests are out of range the complete system gets shut down and they go to a back up system. If the backup system fails they actually have to stop dialyzing patients until the filtering system is fixed. It was just one of those things I had never thought about, but is really important to helping these patients get their treatment.
One of the things that I had never thought about in dialysis that was really interesting is the treatment of the water used. The dialysis center has a really complex filtering system for the city water that is pumped in. There are at least 4-5 giant tanks in which different things happen to the water, removing different ions from the city water. Somebody tests the water 4 times every day, and if the tests are out of range the complete system gets shut down and they go to a back up system. If the backup system fails they actually have to stop dialyzing patients until the filtering system is fixed. It was just one of those things I had never thought about, but is really important to helping these patients get their treatment.
Wednesday, June 24, 2009
NICU and the phantom illness
I got to see the NICU for the first time today. The peds/oncology RD only goes to NICU 3x per week since it's isolated from the other units and requires a special access code, fingerprint ID and lots of hand washing. The neonatologists and pharmacists actually take care of calculating TPN's and determining EN needs, so my preceptor is basically just another set of eyes on the calculations. Kind of disappointing, but that's just the division of labor at Rex. My preceptor is certified for peds and she really prefers oncology, so I guess it works out for everyone. The babies were so cute though! And I got to see one get prepped for photo-therapy to treat hyperbili.
I assessed a 78 yo pt with a frustrating phantom illness today. He lost his appetite ~1 month ago due to severe abdominal pain and a hacking cough, and he and has lost ~30 lbs. He says he was pretty active and healthy up until then. He's undergone a slew of tests in the past two days, but they haven't been able to explain his illness. I could really sympathize with him, having experienced less severe recurring bouts of seemingly inexplicable abdominal pain myself. He was on clear liquids preparing for yet another test, but I assured him that I would work with him to help keep him strong even if I couldn't diagnose him. So I'll be following up with sooner than I normally would.
Oh, and I had a small confrontation with the wound care nurse today. Apparently she was disappointed that my patient "suffering from vapors" didn't understand the importance of protein in treating her pressure ulcer. I admit, I could have done more to educate everyone involved in her care about the importance of drinking the Boost. However, it's really hard to round up an entire family that's coming and going, and the patient is not always feeling well enough to talk. Moreover, she had more issues than just protein (poor appetite, thrush, out-of-control blood glucose levels, concerns about weight gain). Like I said yesterday, it's really hard to balance all of these problems, especially in already-overwhelmed cancer patients!
I assessed a 78 yo pt with a frustrating phantom illness today. He lost his appetite ~1 month ago due to severe abdominal pain and a hacking cough, and he and has lost ~30 lbs. He says he was pretty active and healthy up until then. He's undergone a slew of tests in the past two days, but they haven't been able to explain his illness. I could really sympathize with him, having experienced less severe recurring bouts of seemingly inexplicable abdominal pain myself. He was on clear liquids preparing for yet another test, but I assured him that I would work with him to help keep him strong even if I couldn't diagnose him. So I'll be following up with sooner than I normally would.
Oh, and I had a small confrontation with the wound care nurse today. Apparently she was disappointed that my patient "suffering from vapors" didn't understand the importance of protein in treating her pressure ulcer. I admit, I could have done more to educate everyone involved in her care about the importance of drinking the Boost. However, it's really hard to round up an entire family that's coming and going, and the patient is not always feeling well enough to talk. Moreover, she had more issues than just protein (poor appetite, thrush, out-of-control blood glucose levels, concerns about weight gain). Like I said yesterday, it's really hard to balance all of these problems, especially in already-overwhelmed cancer patients!
Trying times at Cape Fear
So this week at Cape Fear has been a little hectic for FNS. First of all, JCAHO is here all week. My clinical manager says they are on the lookout for students to talk to, so I'm a little wary of that interaction. Second, on the local news this morning there was a report about a man and his son being murdered in their apartment in Fayetteville. It turns out that the man was a cook in our kitchen at the hospital, and the shooting occurred about a 5 minute drive from where I live. A bit scary to say the least. The nutrition service workers set up a little memorial to him today in the cafeteria. So sad.
Also, I started work on my case study today. She's been at the hospital for a month and a half, so I've been looking through a ton of paperwork on her. Apparently she had a bowel resection due to severe ischemia possibly caused by a drug overdose (suspected suicide attempt), was somewhat fine for a couple days, then experienced severe abdominal pain due to a possible ischemic stricture and SBO. She's had several surgeries and has been on TPN and PPN for a while. She has been trying to drink clear liquids, but throws up immediately after she drinks anything. She almost had a PEJ placed today, but the family doesn't want it done. Complicated lady to say the least. Her poor bowels have about had it.
Anyways, I hope you guys are having a great week! Over half-way there!
Also, I started work on my case study today. She's been at the hospital for a month and a half, so I've been looking through a ton of paperwork on her. Apparently she had a bowel resection due to severe ischemia possibly caused by a drug overdose (suspected suicide attempt), was somewhat fine for a couple days, then experienced severe abdominal pain due to a possible ischemic stricture and SBO. She's had several surgeries and has been on TPN and PPN for a while. She has been trying to drink clear liquids, but throws up immediately after she drinks anything. She almost had a PEJ placed today, but the family doesn't want it done. Complicated lady to say the least. Her poor bowels have about had it.
Anyways, I hope you guys are having a great week! Over half-way there!
Week 7
I worked this past Saturday, which was pretty hectic. But I got to see several patients on my own, which was great. I also got to see a bedside swallow study for the first time because when I arrived to see one of my assigned patients, the SLP was preparing to see her as well.
I got to play with one of the babies we were following in Peds yesterday, which was definitely the highlight of the day. He was born 4 months ago at 28 weeks so his adjusted age is only about one month. At 2.86 kg, however, he's still underweight. This is mostly due to his poor sucking ability. We put a paci in his mouth for awhile to help soothe him (he'd been yelling his head off for quite a while beforehand) and to let him practice sucking. He's not so good at it-- if you took your hand off the pacifier, he'd only be able to suck it a few times before it popped out. Poor thing. They may transfer him to Chapel Hill to see if he has some kind of genetic condition that's contributing to his FTT. So be on the lookout, Sarah and Diane!
I also learned that I won't be able to follow a member of the wound care team around-- apparently, no one on the team is certified to allow students to follow them around. I will just have to content myself with all the other bloody and crusty wounds I've seen and smelled. Such a pity...
I got to play with one of the babies we were following in Peds yesterday, which was definitely the highlight of the day. He was born 4 months ago at 28 weeks so his adjusted age is only about one month. At 2.86 kg, however, he's still underweight. This is mostly due to his poor sucking ability. We put a paci in his mouth for awhile to help soothe him (he'd been yelling his head off for quite a while beforehand) and to let him practice sucking. He's not so good at it-- if you took your hand off the pacifier, he'd only be able to suck it a few times before it popped out. Poor thing. They may transfer him to Chapel Hill to see if he has some kind of genetic condition that's contributing to his FTT. So be on the lookout, Sarah and Diane!
I also learned that I won't be able to follow a member of the wound care team around-- apparently, no one on the team is certified to allow students to follow them around. I will just have to content myself with all the other bloody and crusty wounds I've seen and smelled. Such a pity...
Room Service Chaos
So Craven is just starting a bunch of different things while I've been here. First we started using a NCP form. Now we have just started a room service format where patients can call down to room service operators and tell them what they want food wise. It is creating a huge amount of havoc. Nurses are confused, as are patients and we in the dietitian's office are too. Nurses on floors with less phones are upset b/c they are now expected to be using them alot more to call in food. Today in the morning we all were expected to put in our time in the kitchen answering phones. I ended up having to put in more time, due to being the intern. I hand folded up silverware into napkins for a few hours with a youth volunteer for the entire hospital! I'm a little skeptical that this hand folding will continue to take place, it's really time consuming. I delivered menus and used the language line to confirm whether or not the clear liquid tray sent to a hispanic patient was ok. She was too out of it to really care anyways. The clinical manager is super stressed. They are also closing the cafeteria here for 3 months for renovations! So lots of changes going on around here causing tons of chaos.
Wounds
I have been following a patient recently and the doctors suddenly took him off TF and put him on TPN and we could not figure out why they were doing this. There is no mention of gastric residuals and his labs seemed fine so all in all he seemed to be tolerating it well. We had known he has an open surgical wound on his stomach but they didn't really discuss it much in the notes. Well I got my answer today. PT went in to change his wound sponge and this was the largest gaping hole I have ever seen. It was probably 8-10 in in length and 5-6 inches in width. On the inside it wasnt actually the wound bed but some sort of gauze or netting to protect his organs. They then shoved a huge black sponge into the open wound, covered it with tape and vacuumed it to seal everything. All the while they are doing this on a man who keeps swinging his arm around and trying to swat them away but his hand keeps going in the wound. So i got in there and held his arm while they finished. Definitely not for the faint of heart!
Hope everyone is doing well.
Hope everyone is doing well.
Tuesday, June 23, 2009
Bring on the consults.
Yesterday was my first day back at Moore after our fabulous Diabetes camp all of last week. I was expecting a rough transition from cabins and mountains to sterile walls and lab coats, but I was most pleasantly surprised to find that my shift flew by yesterday. The fact that the day was sprinkled with quite a few very interesting patients likely contributed to this. Allow me to share my favorite:
Mrs. X was a 70 year old admitted for SOB and a productive cough. The M.D. was trying to rule out COPD, the alternate diagnosis being bronchitis with CHF exacerbation. Anyway, we actually got consulted to give the pt diabetes education. So I thought this was a perfect opportunity for my rotating R.D. to observe me doing a diet education. Yeah. After reviewing her labs and chart, I find out she doesn’t have teeth, so she might have problems chewing and swallowing. No problem. She also turns out to be a longtime smoker. Ok, so we walk into her room. We’re immediately greeted with the strongest scent of smoke. Three of the pts daughters are at bedside. I introduce myself and -per protocol- ask the pt to verify her name and DOB….this skinny pt looks at me and says in the most chipper voice, “lady, I’m crazy!”…and she smiles with her big, toothless grin. I’m taken aback for a second, because I can’t even tell if she’s kidding or really nuts. Briskly, one of the daughters takes me aside and says, “I’m going to be honest with you, I let her eat whatever she wants. She doesn’t eat much. I take good care of her.” So I proceed to ask her questions about her DM care and if she’s ever gotten any DM diet ed in the past, etc, etc. when to my periphery, I realize that the pt is sitting up in bed with a wad of something in her right hand, and a clear plastic cup in another, the contents of which look black and slimy. I then see the patient half spit, half drool this black substance down into the cup, and it hits me: this woman is chewing tobacco in her hospital bed. Except, she’s not really chewing, because she has no teeth, she’s basically just gumming the stuff! In fact, that’s probably exactly why she doesn’t have any teeth in the first place!!! (and it also might explain why this lady is having some pulmonary complications!) I managed to not react to the situation, but I realized DM education was not really going to go down in this room right now. Cool. Glad my rotating R.D. got to see me in my shining moment. We made a joke about it in the nurses station, both of us appalled at how the consult unfolded. Another instruction opportunity will present itself, I’m sure. This just goes to show one of my favorite elements about working in a hospital: you never, ever, know what the heck to expect when you walk into a pts room.
Mrs. X was a 70 year old admitted for SOB and a productive cough. The M.D. was trying to rule out COPD, the alternate diagnosis being bronchitis with CHF exacerbation. Anyway, we actually got consulted to give the pt diabetes education. So I thought this was a perfect opportunity for my rotating R.D. to observe me doing a diet education. Yeah. After reviewing her labs and chart, I find out she doesn’t have teeth, so she might have problems chewing and swallowing. No problem. She also turns out to be a longtime smoker. Ok, so we walk into her room. We’re immediately greeted with the strongest scent of smoke. Three of the pts daughters are at bedside. I introduce myself and -per protocol- ask the pt to verify her name and DOB….this skinny pt looks at me and says in the most chipper voice, “lady, I’m crazy!”…and she smiles with her big, toothless grin. I’m taken aback for a second, because I can’t even tell if she’s kidding or really nuts. Briskly, one of the daughters takes me aside and says, “I’m going to be honest with you, I let her eat whatever she wants. She doesn’t eat much. I take good care of her.” So I proceed to ask her questions about her DM care and if she’s ever gotten any DM diet ed in the past, etc, etc. when to my periphery, I realize that the pt is sitting up in bed with a wad of something in her right hand, and a clear plastic cup in another, the contents of which look black and slimy. I then see the patient half spit, half drool this black substance down into the cup, and it hits me: this woman is chewing tobacco in her hospital bed. Except, she’s not really chewing, because she has no teeth, she’s basically just gumming the stuff! In fact, that’s probably exactly why she doesn’t have any teeth in the first place!!! (and it also might explain why this lady is having some pulmonary complications!) I managed to not react to the situation, but I realized DM education was not really going to go down in this room right now. Cool. Glad my rotating R.D. got to see me in my shining moment. We made a joke about it in the nurses station, both of us appalled at how the consult unfolded. Another instruction opportunity will present itself, I’m sure. This just goes to show one of my favorite elements about working in a hospital: you never, ever, know what the heck to expect when you walk into a pts room.
Frequent Flyers
I've seen quite a few patients this week that I had seen already at some point in the previous 6 weeks, leading me to realize that quite a few of the individuals are here on and off, sometimes for years! This can be somewhat frustrating for two reasons, 1. if the patient is noncompliant and that is the main reason they are returning, or 2. in assessing the pt or ordering a diet or nutrition support, something from the patient's previous visit was ignored by the MD/RN/RD, so then you have to go back and fix it- doing work you've already done before.
I saw two patients today who have each had >5 admits in 2009. The older lady has had DM ed 4 times this year, but it was still ordered by the MD and since it was ordered, I had to do it. The older gentleman was in the hospital in March with diabetic gastroparesis resulting in a PEG for drainage, and in his new admit H&P there was no mention of diabetes. So, he was receiving a regular diet and regular Ensure supplements with his BG consistently >240.
I had thought that I was being kind of lazy when I was looking up the previous charts and documentation about the patients in our computer system to see if I was assessing the individual appropriately or if there were any major changes, but now I've decided that it's more like double checking than anything else.
OH and I have to share this disgusting and ridiculous and slightly terrifying story! The other intern at GMH was working with this patient who had a planned C-section & hysterectomy last week and had a sepsis-like reaction following the operation, causing her to be put on TPN. This weekend they did an exploratory lap to see if they had perforated her bowels to cause this problem. They didn't find a perf. They found a surgical towel that had been left inside her abdomen...
I saw two patients today who have each had >5 admits in 2009. The older lady has had DM ed 4 times this year, but it was still ordered by the MD and since it was ordered, I had to do it. The older gentleman was in the hospital in March with diabetic gastroparesis resulting in a PEG for drainage, and in his new admit H&P there was no mention of diabetes. So, he was receiving a regular diet and regular Ensure supplements with his BG consistently >240.
I had thought that I was being kind of lazy when I was looking up the previous charts and documentation about the patients in our computer system to see if I was assessing the individual appropriately or if there were any major changes, but now I've decided that it's more like double checking than anything else.
OH and I have to share this disgusting and ridiculous and slightly terrifying story! The other intern at GMH was working with this patient who had a planned C-section & hysterectomy last week and had a sepsis-like reaction following the operation, causing her to be put on TPN. This weekend they did an exploratory lap to see if they had perforated her bowels to cause this problem. They didn't find a perf. They found a surgical towel that had been left inside her abdomen...
Georgetown Week 7
This week I'm covering Peds and the stepdown NICU. I started peds on Friday, and I immediately disliked it.
My first pt, a 10 yo with a lupus flair wouldn't talk to us. We got consulted because of his decreased PO intake. When we walked into the room, he was playing video games with a young male volunteer. We asked him if he ate anything today, and he ignored us. We asked again, and he said "No" as he was taking a bite of a pop-tart! How frustrating. So, the kid was being a brat. After we talked to the RN, we all decided that he was eating, but just saying he wasn't. Weird. Our intervention was just to continue to encourage PO intake, record intake, and monitor wt.
My second pt was a MRCP pt who came in for some surgery. He has a very involved and knowledgeable mother! I had to sit with her as she discussed his home regimen, and the various supplements and meds he was on. She thought it was imperative that he return to his home regimen ASAP so he can gain back the wt he lost since admission and be strong for his surgery. So, we had to make a list in our note with TF recs, probiotic doses, and carnitine. She also likes to add baby food to his TFs at home, so we had to talk about that too. It just went on and on.
On the bright side, not all pts are difficult. This week has been okay so far. Peds is really a different world. The kids are constantly growing, so their needs are always changing. We have to plot on growth charts, and constantly monitor ht, wt, and BMI. There's a lot going on with these kids, so it's definitely a challenge!
My first pt, a 10 yo with a lupus flair wouldn't talk to us. We got consulted because of his decreased PO intake. When we walked into the room, he was playing video games with a young male volunteer. We asked him if he ate anything today, and he ignored us. We asked again, and he said "No" as he was taking a bite of a pop-tart! How frustrating. So, the kid was being a brat. After we talked to the RN, we all decided that he was eating, but just saying he wasn't. Weird. Our intervention was just to continue to encourage PO intake, record intake, and monitor wt.
My second pt was a MRCP pt who came in for some surgery. He has a very involved and knowledgeable mother! I had to sit with her as she discussed his home regimen, and the various supplements and meds he was on. She thought it was imperative that he return to his home regimen ASAP so he can gain back the wt he lost since admission and be strong for his surgery. So, we had to make a list in our note with TF recs, probiotic doses, and carnitine. She also likes to add baby food to his TFs at home, so we had to talk about that too. It just went on and on.
On the bright side, not all pts are difficult. This week has been okay so far. Peds is really a different world. The kids are constantly growing, so their needs are always changing. We have to plot on growth charts, and constantly monitor ht, wt, and BMI. There's a lot going on with these kids, so it's definitely a challenge!
Where have all the teachable moments gone?
I am primarily working in the Cardiac Care Unit this week. Today, I had a 50-something year old, male patient whose cardiac issues were mostly, if not solely, related to his diet and obese status. My initial assessment of his nutritional status and diet history pretty much consisted of him and his wife complaining about the fact that he was only allowed to order from the cardiac diet menu. They both proceeded to tell me how he ate whatever he wanted before coming into the hospital and that there was absolutely nothing he could eat off the cardiac menu. The food off that menu was simply terrible and he could not eat a thing from it. Mind you, according to his nurse and the tray sitting next to him, he was eating 100% of each of his meals.
I informed him that his physician ordered that diet and that he would have to discuss changing the diet order with him. I attempted to politely hint at the idea that his doctor may have ordered that diet for a reason: Ahem (thinking, but not saying aloud)...the fact that he is now in the hospital, and not for the first time, due to heart-related problems that are directly linked to his diet and obese status. I also crumbled under the pressure and offered to send him Ensures if he was unable to eat any of the kitchen's food, as he needed to eat in order to heal his wound, get better, and leave the hospital.
If this man's current status did not create a teachable moment, what will? And what, as a dietitian, can I do to help him given his current "stage of change?"
I informed him that his physician ordered that diet and that he would have to discuss changing the diet order with him. I attempted to politely hint at the idea that his doctor may have ordered that diet for a reason: Ahem (thinking, but not saying aloud)...the fact that he is now in the hospital, and not for the first time, due to heart-related problems that are directly linked to his diet and obese status. I also crumbled under the pressure and offered to send him Ensures if he was unable to eat any of the kitchen's food, as he needed to eat in order to heal his wound, get better, and leave the hospital.
If this man's current status did not create a teachable moment, what will? And what, as a dietitian, can I do to help him given his current "stage of change?"
Rex patient "suffering from vapors"
I've had a rather high-maintenance but otherwise pleasant oncology pt since last week. She's a sixty-something newlywed, and as my preceptor says, she "suffers from vapors." If her drawl were any more pronounced, she'd be a true Southern belle. She asked me very seriously whether I thought it was safe for her to have her acrylic nails removed. Her Boost Glucose Control makes her feel too full. She worries that the cream soups (which are easy to eat while she has thrush) will make her gain even more than 30 lbs she's put on since being admitted. (It's mainly fluid, but it could have also been her husband bringing her ice cream instead of the Boost last week when she was feeling really sick, despite her blood glucose readings in the 400's.) She can't get settled on her side, so she continues to sit on a pressure ulcer. My favorite: "I think I have...what is it called...a urinary tract infection? yeast infection? Whatever it is, there's a burning around my vagina!" As if I could do anything about that...but at least this has afforded me the opportunity to talk with the oncologist and the wound care nurse as part of the team. She's also taught me about the difficulties that cancer pts face with eating and managing side effects. As the oncology RD says, you have to pick your battles and just be there to support the patient any way you can.
I also saw my first peds pt today - a 16 yo male who was thought to have a ruptured appendix, but it turned out that he had a grapefruit-sized mass in his abdomen, so he required an immediate ileocecectomy. His bowel sounds are just now returning after 5 days, and I'm hoping to see him progress to eating again soon. They suspect he has Crohn's, so I may get to do some education, too.
Tomorrow, I get to go to the NICU for the first time!
I also saw my first peds pt today - a 16 yo male who was thought to have a ruptured appendix, but it turned out that he had a grapefruit-sized mass in his abdomen, so he required an immediate ileocecectomy. His bowel sounds are just now returning after 5 days, and I'm hoping to see him progress to eating again soon. They suspect he has Crohn's, so I may get to do some education, too.
Tomorrow, I get to go to the NICU for the first time!
Oxepa
Hello everyone!
I learned a little bit yesterday and today about the controversy surrounding Oxepa, which is the formula used in respiratory stressed patients at CMC as it is low CHO. I learned about calculating the PO2/%FIO2 (from the vent settings) and then if this ratio is <200 then the person is in ARDS and if it is <300 then the patient is considered in acute lung injury. Traditionally, the dietitians in trauma would use Oxepa if the ratio was <200. However, some new studies apparently came out which demonstrated that there is a higher mortality rate and a higher amount of time on the vent with this formula. They believe that it is due to the Omega 3 fatty acids found in Oxepa. They are in there because of their benefit with inflammation, but they seem to possibly do more harm than good. The dietitians and doctors in the STICU are now unsure of what to do in ARDS patients because of these studies, because as I recall from MNT, using a high CHO formula makes it harder for the pt to "breathe off" the CO2 and could make the resipiratory distress worse. Oxepa only has 105 Gm CHO/liter (as opposed to around 200 in standard formulas) so it seems like if the Omega 3 fatty acids are the problem then they should be removed from the formula and then studies should demonstrate whether or not the low CHO formula plays a beneficial role in ARDS. I was just curious as to whether or not any of you have come across any studies, or if you know what your hospital's policy is. It seems as though CMC is at a recent crossroads with this! Email me or post if you have any insight!
In other news, I'm in GI/Surgery this week mostly and so I've gotten to do a crazy amount of PPNs/TPNs and am loving the practice. Between the dietitian that Im rotating with and myself, we did 11 today! I recently learned that if Bilirubin is >10 then the policy at CMC is to alter the trace elements in the TPN since liver function is down, so just something ya'll might want to note in case your hospitals have similar policies.
Elizabeth
I learned a little bit yesterday and today about the controversy surrounding Oxepa, which is the formula used in respiratory stressed patients at CMC as it is low CHO. I learned about calculating the PO2/%FIO2 (from the vent settings) and then if this ratio is <200 then the person is in ARDS and if it is <300 then the patient is considered in acute lung injury. Traditionally, the dietitians in trauma would use Oxepa if the ratio was <200. However, some new studies apparently came out which demonstrated that there is a higher mortality rate and a higher amount of time on the vent with this formula. They believe that it is due to the Omega 3 fatty acids found in Oxepa. They are in there because of their benefit with inflammation, but they seem to possibly do more harm than good. The dietitians and doctors in the STICU are now unsure of what to do in ARDS patients because of these studies, because as I recall from MNT, using a high CHO formula makes it harder for the pt to "breathe off" the CO2 and could make the resipiratory distress worse. Oxepa only has 105 Gm CHO/liter (as opposed to around 200 in standard formulas) so it seems like if the Omega 3 fatty acids are the problem then they should be removed from the formula and then studies should demonstrate whether or not the low CHO formula plays a beneficial role in ARDS. I was just curious as to whether or not any of you have come across any studies, or if you know what your hospital's policy is. It seems as though CMC is at a recent crossroads with this! Email me or post if you have any insight!
In other news, I'm in GI/Surgery this week mostly and so I've gotten to do a crazy amount of PPNs/TPNs and am loving the practice. Between the dietitian that Im rotating with and myself, we did 11 today! I recently learned that if Bilirubin is >10 then the policy at CMC is to alter the trace elements in the TPN since liver function is down, so just something ya'll might want to note in case your hospitals have similar policies.
Elizabeth
cardiac cath
Yesterday I had the opportunity to observe a cardiac catheterization. I've never been (awake) in an OR so it was really neat to see the set-up and how things are prepped prior to the procedure. It was also fun to have to wear the whole get-up - scrubs, booties, and the leaded vest and skirt. After all the time spent setting up the room, the procedure itself was fairly quick. The cardiologist gave me a short de-briefing afterwards, while we looked at the X-Rays and compared them to another patient in a very different situation. It really helped my understanding of what the MDs are looking for with this procedure.
I was also supposed to observe a PEG placement in the ICU today but they decided to do it an hour earlier than it was scheduled for and I didn't get to see it :( We don't seem to have them done all that often - maybe 1 every 3 weeks? So, hopefully I will have another opportunity before I have to leave!
I was also supposed to observe a PEG placement in the ICU today but they decided to do it an hour earlier than it was scheduled for and I didn't get to see it :( We don't seem to have them done all that often - maybe 1 every 3 weeks? So, hopefully I will have another opportunity before I have to leave!
Monday, June 22, 2009
Wakemed week 6--Introduction to Critical Care
I started my ICU rotation last week, I was frustrated at first because I had trouble time to figure out pt's Calorie and Protein needs. There are too many factors should be considered before choosing the right range, such as age, stress factor, other medical conditions, body weight (IDW, Admission, Average, Adjusted). It is hard for me to pick up all information from beginning, and Doctors' handwriting are horrible, weird abbreviations... Only for weight, every person did kind of different way to assess for protein/Kcal needs. I have been told several ways: such as always use IBW for protein, use Average/Adjusted weight (>135% IBW-- However, I was told by other dietitian in Rehab, use Adjusted weight when >145%, some people just used Average weight). I was confused, and busy to follow different people's style/format...
There is other thing I wanted to mention: I assessing one pt in MICU, with admission weight at 160 kg, (some CHF, CKD issues), however, after 2 days, Pt's weight changed to 106 kg for continuously two days. I was confused and had hard time to choose weight I should believe. Sometimes, it is useful to enter pt's room and assess pt's actual weight by your eyes. The data in medical record may not always be right. (they may not take off bed's weight when measuring pt weight)
It has been challenging last week, there are a lot of stuff I need to learn for critical ill patient, I am getting there...
I will have neurosurgical ICU for two weeks!
Psych Floor
Today I went up to the Psych Floor by myself for the first time. I've been up there a couple times with the RD who normally works up there, but today she let me brave it alone. Mostly what is done is just to screen patients, since they have no electronic medical records, so we have to go to the floor to screen, and to see patients who have been there >7 days. There is one patient who is on the floor fairly frequently who is known for not only requesting to see an RD, but also for making his own referrals. He often comes up to the RD, asks to speak with her, and then when she starts talking to him, he starts telling her she has to see all these other patients because they need her advice too. He also apparently gives weight loss advice throughout the day to various other patients. When I looked at my patient list this morning, I was worried because he was on my list to see, since he has been in the hospital more than 7 days. The nurses have gotten so accustomed to him breaking the rules they don't even try to stop him anymore, so I knew they wouldn't come bail me out if he started referring other patients to me. The last time I had seen him was my 3rd day at the hospital, and he started instructing the RD on how to teach me. Needless to say, I wasn't looking forward to meeting with him. Luckily today he wasn't in a chatty mood, and all of the other patients were in a group session when I spoke to him, so he didn't have a chance to refer anyone to me. The RD was worried that he would be upset, since he denies having diabetes, even though he does, and the MD had changed his diet order to a diabetic diet. Luckily I don't think he noticed the change, and didn't hassle me at all about it.
I also found my case study late last week and started to do some work on it today. The man is 52yo alcoholic who has cirrhosis, had most of his stomach removed due to severe GI bleeding and has chronic pancreatitis, among other issues. Needless to say, he eats A LOT. He is on TPN at home, and eats pretty much anything he can get his hands on. He is in the hospital this time for altered mental status due to increased ammonia levels, but according to the other RDs he is in all the time, so there is a long chart history for me to look through. Tomorrow I am going to try and go in and talk to him about a diet appropriate for pancreatitis, since his wife reports that he follows no diet and eats whatever he wants. He is 69" 110#, so he could use any weight gain. The wife also doesn't know his TPN rate, so I'm hoping she can find that information out and see if he is getting enough calories that way.
I also found my case study late last week and started to do some work on it today. The man is 52yo alcoholic who has cirrhosis, had most of his stomach removed due to severe GI bleeding and has chronic pancreatitis, among other issues. Needless to say, he eats A LOT. He is on TPN at home, and eats pretty much anything he can get his hands on. He is in the hospital this time for altered mental status due to increased ammonia levels, but according to the other RDs he is in all the time, so there is a long chart history for me to look through. Tomorrow I am going to try and go in and talk to him about a diet appropriate for pancreatitis, since his wife reports that he follows no diet and eats whatever he wants. He is 69" 110#, so he could use any weight gain. The wife also doesn't know his TPN rate, so I'm hoping she can find that information out and see if he is getting enough calories that way.
Sunday, June 21, 2009
Georgetown Week 6
This past week I was in the NICU. I didn't think I was going to like it, but the babies were so cute! The NICU here is a level 2. I think there are 4 levels, 1 being the most critical cases? I'm not sure.
When I was going over the module on Monday with the RD, she mentioned that she hadn't seen many cases of gastroschisis (a congenital malformation in which the abdomen remains open to the exterior; organs, usually the small intestine or part of the stomach is exposed and protruding outside of the body). But, one of the new babies had it! the abdomen was repaired immediately after birth, and the baby was doing fine. I also saw cases of meconium aspiration, PPHN, trisomy 21, and PDA.
I had a lot of practice with TPNs, even though most of it is calculated on the computer, as well as calculating feeds. Nutrition is very important in the NICU, and I realized that the MDs really rely on the dietitian for her expertise. We attended medical rounds most days and there were many cases when the RD had to suggest changes to the TPN - addition of acetate, lowering Na, K, etc. I felt like we focused on labs in the NICU a lot more than I did in other units. I was surprised by how much the MDs missed on the TPNs, some of the residents even forgot to review the TPN during rounds!
Overall, I enjoyed the NICU. I'm starting Peds tomorrow!
When I was going over the module on Monday with the RD, she mentioned that she hadn't seen many cases of gastroschisis (a congenital malformation in which the abdomen remains open to the exterior; organs, usually the small intestine or part of the stomach is exposed and protruding outside of the body). But, one of the new babies had it! the abdomen was repaired immediately after birth, and the baby was doing fine. I also saw cases of meconium aspiration, PPHN, trisomy 21, and PDA.
I had a lot of practice with TPNs, even though most of it is calculated on the computer, as well as calculating feeds. Nutrition is very important in the NICU, and I realized that the MDs really rely on the dietitian for her expertise. We attended medical rounds most days and there were many cases when the RD had to suggest changes to the TPN - addition of acetate, lowering Na, K, etc. I felt like we focused on labs in the NICU a lot more than I did in other units. I was surprised by how much the MDs missed on the TPNs, some of the residents even forgot to review the TPN during rounds!
Overall, I enjoyed the NICU. I'm starting Peds tomorrow!
My two cents on Diabetes Camp
To piggyback on Laurie and Cassie (I'll keep it brief!) we had a great week at Diabetes Camp! I learned a whole lot about Diabetes, and also got the opportunity to learn a lot about Celiac's disease and the Gluten free diet (THANK YOU DIANE!!!!!). 11 campers/counselors had Celiac's on top of Diabetes and there are some thoughts about why this correlation may be- it could be that they are both considered autoimmune diseases, or some clinicians believe that persons with Celiac's are more likely to develop diabetes, its just that the celiac's diagnosis comes after the diabetes diagnosis. I think that I like to believe the third theory, which explains why it is important that it is really important that it is properly managed- this theory is that children/adults with diabetes and Celiac's dont actually often have intestinal problems, but more so it is difficult for them to manage their diabetes (they eat a 15 gram CHO slice of wheat bread, but because of Celiac's they dont digest all of the 15 Gm, so they bolus for it and then their BG gets all out of whack). So the kids with it that I talked to seemed to tell me that for the most part they dont have intestinal problems, they were diagnosed with Celiac's because of blood glucose irregularities. Except one girl who told me she gets a pain in her foot when she eats gluten (apparently this is not completely random...)
I really enjoyed the time that I just got to spend with the campers. My age group was middle schoolers, and I tried to mostly stick with them so I could establish some relationships. I hung out mostly with this one group who was going into 8th grade, and I spent some time in their cabin at night and at rest time and so I got to listen in on their conversations. It was really cool to hear them share with one another their struggles with diabetes, with their friends, with boys... and just watch them be middle school girls. One girl explained to me that when she eats pizza she boluses insulin on her pump in a "four square bolus" which means that the insulin is released over an hour rather than immediately because pizza "hits her later" so we talked about why that might be (ie cheese/fat slowing digestion) and what other foods might do that. I appreciated just being around to get to have the chance to have those kinds of discussions.
I expected to leave thinking "kids with diabetes are just normal kids" and while I still think they're normal, I have a newfound respect for these kids and its amazing all that they have to deal with and to watch them manage their diabetes. We should all be so grateful for our working pancreases! I also hope to go back next year, and I would love to stay in a cabin with kids to have more of the opportunity to watch them interact and learn from them teaching one another!
Happy Week 7 everybody!
Elizabeth
I really enjoyed the time that I just got to spend with the campers. My age group was middle schoolers, and I tried to mostly stick with them so I could establish some relationships. I hung out mostly with this one group who was going into 8th grade, and I spent some time in their cabin at night and at rest time and so I got to listen in on their conversations. It was really cool to hear them share with one another their struggles with diabetes, with their friends, with boys... and just watch them be middle school girls. One girl explained to me that when she eats pizza she boluses insulin on her pump in a "four square bolus" which means that the insulin is released over an hour rather than immediately because pizza "hits her later" so we talked about why that might be (ie cheese/fat slowing digestion) and what other foods might do that. I appreciated just being around to get to have the chance to have those kinds of discussions.
I expected to leave thinking "kids with diabetes are just normal kids" and while I still think they're normal, I have a newfound respect for these kids and its amazing all that they have to deal with and to watch them manage their diabetes. We should all be so grateful for our working pancreases! I also hope to go back next year, and I would love to stay in a cabin with kids to have more of the opportunity to watch them interact and learn from them teaching one another!
Happy Week 7 everybody!
Elizabeth
Camp Carolina Trails
Hey everyone! Laurie did a good job of describing camp. It was definitely a unique atmosphere, as most of the people we've been surrounded by for the last week had diabetes. I learned a lot about insulin pumps and technology available is truly amazing! Many of the pumps that the children used were also equipped with glucose meters that beam over blood glucose readings. This reading is taken into account as well as the amount of carbs eaten when insulin is bolused from the pump. Some of the pumps even have an entire library of foods and the grams of carbohydrates per serving programmed into them to make the information easily accessible. I was surprised at how few children used glucose injections, although pumps have shown to better control BG levels.
Throughout the week we were able to put together snack baskets and like Laurie said, we all learned quite a bit about gluten free foods. I thought it was a good opportunity to brush up on some of our food service skills. In addition to that, the medical staff was wonderful and very willing to answer all of our questions about diabetes control. It was really nice to work with younger people and to see the different knowledge levels in each age group.
Also, I have to agree with Laurie that the overnight camping trip that we went on with the rising ninth graders was the best part of the entire week. Being with the same group for a full 24 hours during physical activity and meals was very beneficial for learning strategies of disease management, prevention of low blood sugars, etc. Overall, it was a great week and the rest of the staff seemed to really appreciate our nutrition staff. Camp was great, definitely something I will try to do again next year!
The campers return!
Hello all! Well we returned yesterday from Camp Carolina Trails, a bit damp and smelly to say the least, but with a greater knowledge of diabetes and a lot of fun experiences behind us! There were about 10 nutrition staffers there during the week to help prepare snacks for the kids and gluten-free meals for those with celiac (that was Biz's area of expertise) and help kids count the number of carbs they had during meals.
Cassie and I worked with high school freshmen and sophomores, which was a lot of fun. We went on a hike and an overnight campout with them one day/night, which was probably my favorite experience (though it rained the entire time, and we had to deal with complaining teenage girls... fun). It was really interesting to see how physical activity affected the kids (and counselors') blood sugar levels. On the hike, we had to stop literally every 10 minutes for someone to check their BG and get a snack if they were low. Exercise really does dramatically affect BG. The med staff did a lot of basal insulin adjustments to try to prevent lows, but I felt that they could have decreased the insulin even more so that the kids wouldn't have to eat so many carbs and calories to keep up their BG which could potentially cause unnecessary weight gain. But I loved watching the kids and how they managed their diabetes. They were all very willing to share their knowledge with us, as were the medical staff and the other counselors. Most of the counselors had type 1 diabetes, so they were very good at helping the kids and encouraging them to keep positive attitudes and to use their diabetes as a way to become stronger people.
I'll let the rest of the girls talk about other experiences at camp so I'm not taking up a bunch of space. I really enjoyed everything (yes, even getting stuck in a ditch with Amaris one rainy afternoon, and yes, even parts of the awkward Friday night camp dance). Upon leaving camp, however, I was happy to be entering a clean environment once again and looking forward to doing my laundry. However, as it turns out, the water at my AHEC is turned off for some reason, so I have a huge pile of nasty clothes sitting in my washing machine. Ew. Welcome back Laurie.
I hope everyone had a great week! Get ready for the last half of the summer!
Cassie and I worked with high school freshmen and sophomores, which was a lot of fun. We went on a hike and an overnight campout with them one day/night, which was probably my favorite experience (though it rained the entire time, and we had to deal with complaining teenage girls... fun). It was really interesting to see how physical activity affected the kids (and counselors') blood sugar levels. On the hike, we had to stop literally every 10 minutes for someone to check their BG and get a snack if they were low. Exercise really does dramatically affect BG. The med staff did a lot of basal insulin adjustments to try to prevent lows, but I felt that they could have decreased the insulin even more so that the kids wouldn't have to eat so many carbs and calories to keep up their BG which could potentially cause unnecessary weight gain. But I loved watching the kids and how they managed their diabetes. They were all very willing to share their knowledge with us, as were the medical staff and the other counselors. Most of the counselors had type 1 diabetes, so they were very good at helping the kids and encouraging them to keep positive attitudes and to use their diabetes as a way to become stronger people.
I'll let the rest of the girls talk about other experiences at camp so I'm not taking up a bunch of space. I really enjoyed everything (yes, even getting stuck in a ditch with Amaris one rainy afternoon, and yes, even parts of the awkward Friday night camp dance). Upon leaving camp, however, I was happy to be entering a clean environment once again and looking forward to doing my laundry. However, as it turns out, the water at my AHEC is turned off for some reason, so I have a huge pile of nasty clothes sitting in my washing machine. Ew. Welcome back Laurie.
I hope everyone had a great week! Get ready for the last half of the summer!
Saturday, June 20, 2009
This week was pretty uneventful at Craven. I attended Rehab rounds earlier during the week. They talked about each patient and how they were doing and what to focus on with them for the day. I have been doing a fair number of diabetes educations and heart healthy ones, but not any other kinds yet. Other kinds just don't come up too much (renal, low residue, etc.) I educated a 18 y/o male who came in with severe DKA on diabetes, new onset. He was very brooding and wouldn't talk to anyone, even the nurses. So I just mostly talked to his family, they were nice and seemed very interested. Turns out he hadn't been eating lunch ever, even though his mom gives him money every day so I think there might be some family drama there.
I've started following my own patients now, which is exciting. It's nice to be able to see the same patients over and over and get to know them more. I'm still working on finding a case study though..time is running out! I have a few in mind at least.
I've started following my own patients now, which is exciting. It's nice to be able to see the same patients over and over and get to know them more. I'm still working on finding a case study though..time is running out! I have a few in mind at least.
Another busy week at Cayuga Med - although the patient load is especially low at the moment. I've been keeping occupied with various other activities - including a really great lecture from a Cornell nutrition professor on the use of DHA in hospitalized patients. We've had some interesting cases this week - flesh-eating bacteria, Fitz-Curtis-Hugh Syndrome in a patient with chlamydia (bacteria from the pelvic cavity translocate to the liver causing inflammation). I've also narrowed down who I will be doing my case study on - a 35 yo male with type 1 diabetes who is experiencing nearly every complication imaginable. For my QI I will be looking at gastric residuals in TF patients and how this affected their feedings. Next week I will be viewing a cardiac cath and visiting with the pharmacy department to watch preparation of a TPN solution. I'm exciting to get started on all of these activities!
Wonderful Site Coordinator!
My site coordinator was fabulous today. We had a very good talk at our normal meeting and she really inspired me to try and think outside the box and to be more creative when treating patients. It was very refreshing as I feel that sometimes I am following a generic treatment plan with very little individualization. I spend most of my time looking through the medical records to make sure I am not missing something, and carefully writing my chart notes to make sure the information is accurate, the treatment is appropriate, and the wording is acceptable. As a result, I don’t have time to spend dreaming up creative treatments as much as I would like because I am usually running behind.
After our conversation I spoke with a patient, due to a physician’s request, and I felt like I was able to be more creative. The physician had stopped me in the hall and asked me to do anything I could to provide the patient with more calories and nutrients on his full liquid diet; he had previously been on clear liquids. I spoke with the dietitian before visiting the patient to learn more about what I could offer. Then when I spoke with him we came up with snacks and meals to better meet his needs and preferences. I still feel like I struggle a bit due to my lack of familiarity with what can be offered when, and what can be substituted for what beyond the very basic substitutions.
I met with my site coordinator again in the afternoon and we set up the very rough draft of my Case Study Powerpoint presentation, which I present on Wednesday. She had a ton of Powerpoint presentation tips. It was not what I was expecting to learn from my site coordinator, but it was MUCH appreciated!
After our conversation I spoke with a patient, due to a physician’s request, and I felt like I was able to be more creative. The physician had stopped me in the hall and asked me to do anything I could to provide the patient with more calories and nutrients on his full liquid diet; he had previously been on clear liquids. I spoke with the dietitian before visiting the patient to learn more about what I could offer. Then when I spoke with him we came up with snacks and meals to better meet his needs and preferences. I still feel like I struggle a bit due to my lack of familiarity with what can be offered when, and what can be substituted for what beyond the very basic substitutions.
I met with my site coordinator again in the afternoon and we set up the very rough draft of my Case Study Powerpoint presentation, which I present on Wednesday. She had a ton of Powerpoint presentation tips. It was not what I was expecting to learn from my site coordinator, but it was MUCH appreciated!
IC is not infallible
This week was my medical ICU rotation, ie, the very sick and dying. I got to see a metabolic cart study for a lady who was about 45 kg and 77 years old. I didn't assess the patient, but I think she was at then end stages of cancer with multiple complications and was immobilized in bed. The first study they did on her showed an REE of 6100. We told the MD about the results, who responded "Well, load her up!" My RD explained that it would not be possible to give this little old lady so many calories and that there was almost no way this was correct. So the MD agreed to order a second study, which showed an REE of 1900. Although I was surprised by the MD's response, I also felt like it validated the need for RDs and the unique clinical expertise that dietitians have.
We also ran across a patient we saw three weeks ago when we were on our renal rotation. She is now in the MICU waiting for a liver transplant. Her case is particularly sad because she is a 40 year old teacher who has just had really bad luck with her health. Right now she has serious jaundice, and I have never seen a person that shade of yellow. They think she has developed hepatorenal syndrome, so she is also on CVVHD. There was a chance for a liver transplant on Thursday night, but the liver wasn't good, so it fell through. I'm keeping my fingers crossed.
The big news for this week, though, is that I got a dog! She is a 2-year-old terrier mix with a great personality. I'm looking forward to introducing you all to her when you get back to CH!
We also ran across a patient we saw three weeks ago when we were on our renal rotation. She is now in the MICU waiting for a liver transplant. Her case is particularly sad because she is a 40 year old teacher who has just had really bad luck with her health. Right now she has serious jaundice, and I have never seen a person that shade of yellow. They think she has developed hepatorenal syndrome, so she is also on CVVHD. There was a chance for a liver transplant on Thursday night, but the liver wasn't good, so it fell through. I'm keeping my fingers crossed.
The big news for this week, though, is that I got a dog! She is a 2-year-old terrier mix with a great personality. I'm looking forward to introducing you all to her when you get back to CH!
Friday, June 19, 2009
GMH
Nothing too crazy towards the end of this week- I saw a non-compliant 19 year-old with Type 1 DM whose A1c was 14.9 (!) and about 30 of the typical individuals with past medical histories = HTN/DM/COPD/CAD. I changed a couple of MD-ordered tube feeds to a formula other than Nepro because the pts all had diarrhea and our RDs hate giving formulas with sugar alcohols (Nepro, Glucerna) to pts with diarrhea. The MDs will probably just change them back. That's about all...I can't believe I'm halfway done... and I think it's PEG-placement time next week!
Code Grey--RD down
My preceptor and I (along with another dietitian) had a meeting this afternoon in the NICU with a nurse and a couple of doctors to discuss implementing new feeding protocols for the behbehs. Near the end, my preceptor left the room rather quickly, and I assumed she was going to go potty. Well, a few minutes later, I hear a call over the intercom--Code Gray on the NICU hall. I got a sinking feeling (since my preceptor had been sick earlier this week) but let it go. Well, a few minutes after that, one of the physicians we were meeting with got a call on his cell phone and told us that there was a problem with my preceptor. We go down the hall, and there she is on the floor surrounded by a bunch of people. She was sitting propped up against the wall looking absolutely green. Long story short, they wheeled her to the Emergency Department and they ran tests, and she was told that everything was fine. So that's a relief. I'm hoping she takes a little vacation next week to get some R/R.
In less exciting news (although it was exciting at the time, way back during the morning), I got to see a metabolic cart study (indirect calorimetry) done on a patient. It was a good thing my preceptor had ordered it done, because it showed that he only needed 2100 kcal/day, whereas we had been feeding him about 3100. So that was neat to see.
Oh, in small-world kind of happening-- in the ED, I saw a chemo patient who'd I'd talked with in the cancer outpatient center the other week. She was there for a blood clot in her leg. I'm not sure how that one turned out, but she certainly seemed perky enough, so fingers crossed...
In less exciting news (although it was exciting at the time, way back during the morning), I got to see a metabolic cart study (indirect calorimetry) done on a patient. It was a good thing my preceptor had ordered it done, because it showed that he only needed 2100 kcal/day, whereas we had been feeding him about 3100. So that was neat to see.
Oh, in small-world kind of happening-- in the ED, I saw a chemo patient who'd I'd talked with in the cancer outpatient center the other week. She was there for a blood clot in her leg. I'm not sure how that one turned out, but she certainly seemed perky enough, so fingers crossed...
Leukemia and Bone Marrow Transplants
I was hoping to see a bone marrow transplant today, but none are scheduled for the day. The RD said she can arrange for me to see one next week, which I think will be pretty exciting. I have absolutely loved working with the Heme/Onc dietitian this week. We have a high volume of patients (20-30/day), and spend most of the day addressing nutrition-related issues caused by various treatments and medications. The vast majority of our patients experience nausea and vomiting on a regular basis as well as constipation, diarrhea, taste changes, and xerostoma/mucositis. I did a diet education on a Low Tyramine diet yesterday because one of my patients was on Zyvox (a medication that should not be consumed with foods containing tyramine). I have also spent a lot of time discussing the Neutropenic and the Oncology Select (basically foods that produce minimal odors to reduce nausea) diets.
Two particular challenges about this rotation: medications/chemo and the patients. First, there are such a large number of medications, chemotherapy and radiation therapies that create nutrition-impact symptoms. It is nearly impossible to memorize them all in a week, but I have learned a lot -- Noxafil, Zyvox, Sando, etc. I feel like we spend half of our time addressing issues caused by the patient's therapies. Secondly, I find the patient load difficult because so many patients are young. I think it hits home when you seen a 20 year old dying of a disease they were just diagnosed with a month ago. As a dietitian, you maintain a sense of professionalism to minimize the emotional attachment to patients. However, all of these patients are people, and I never want to become desensitized to their situations. I guess it is a balance.
Overall, I have learned a lot this week. Looking forward to renal next week.
Rachael
Two particular challenges about this rotation: medications/chemo and the patients. First, there are such a large number of medications, chemotherapy and radiation therapies that create nutrition-impact symptoms. It is nearly impossible to memorize them all in a week, but I have learned a lot -- Noxafil, Zyvox, Sando, etc. I feel like we spend half of our time addressing issues caused by the patient's therapies. Secondly, I find the patient load difficult because so many patients are young. I think it hits home when you seen a 20 year old dying of a disease they were just diagnosed with a month ago. As a dietitian, you maintain a sense of professionalism to minimize the emotional attachment to patients. However, all of these patients are people, and I never want to become desensitized to their situations. I guess it is a balance.
Overall, I have learned a lot this week. Looking forward to renal next week.
Rachael
Thursday, June 18, 2009
Ever heard of Haw River Syndrome?
Because High Point is a smaller hospital, I am not on specific rotations. However, each of the four dietitians generally focuses on several specific disease states, simply because of which floors they work on. The past two weeks I have been with the dietitian who mainly sees renal patients, diabetic patients, pregnant patients, and the elderly. Today, interestingly and sadly, we had a patient who has Haw River Syndrome. Never heard of it? That is probably because it affects 1 family in North Carolina. I cannot find any other documented cases in the U.S. Some research says it also known as DRPLA and is found in Japan. Yet other research says that even though the genetic mutations are similar between DRPLA and Haw River, the diseases are not the same nor are the symptoms. In brief, it is a genetic disease that has struck 5 generations of one family in NC (there is a PubMed article about this family and the disease as well as a few other news-related articles). It is a degenerative disease that has characteristics similar to Huntington's but with many more complications. In many of the family members the symptoms did not begin until the individual was in his/her 20s or 30s and by then had children and passed on the mutation. My patient is only in his 50s yet has spent the greater part of this adult life in a nursing home, having lost most of his ability to control his muscles. He is tube fed, has a trach, and is 54% his body weight. He responded to me, very slowly and simply. No one is sure how long that will last for him. Needless to say, this patient and the family have an interesting and difficult road ahead of them in addition to their difficult past.
Team Meeting
I am back in intensive care this week, and things have been going pretty well. This week has been a bit slower than the last, and it is a relief to have the normal dietitian back who knows all of the routines! Though I really enjoyed working with the other one too.
Twice a week the dietitian goes to a treatment team meeting. It is rather interesting how it works, and it illustrates the fact that doctors are the most respected figure on the team of healthcare providers. The pharmacist, the dietitian, several social workers, sometimes the Chaplain, and I think a head nurse, or coordinating nurse of some kind, congregate in the ICU. Then as a group we go around to each of the doctors, or wait in a room for them to come and talk to us about each of their patients. On Monday the ICU doctor did bedside rounds which was a new experience for me. When they update us on the status of the patients other group members can share what is happening in terms of the patient’s care from their angle of treatment. The dietitian I go with usually just listens.
The dietitian had conflicting meetings this week at both of the meeting times, and so she sent me alone, and then I filled her in on what I learned. I always find the meetings very interesting. I enjoy learning about the patients; now that I am more familiar with them the meetings are more meaningful and they are helpful when I write my assessments. I also enjoy seeing the different presentation styles of the different doctors. Each one is unique. I also really like the other members of the team and feel comfortable asking them to help clarify when I do not understand what a doctor has said.
Twice a week the dietitian goes to a treatment team meeting. It is rather interesting how it works, and it illustrates the fact that doctors are the most respected figure on the team of healthcare providers. The pharmacist, the dietitian, several social workers, sometimes the Chaplain, and I think a head nurse, or coordinating nurse of some kind, congregate in the ICU. Then as a group we go around to each of the doctors, or wait in a room for them to come and talk to us about each of their patients. On Monday the ICU doctor did bedside rounds which was a new experience for me. When they update us on the status of the patients other group members can share what is happening in terms of the patient’s care from their angle of treatment. The dietitian I go with usually just listens.
The dietitian had conflicting meetings this week at both of the meeting times, and so she sent me alone, and then I filled her in on what I learned. I always find the meetings very interesting. I enjoy learning about the patients; now that I am more familiar with them the meetings are more meaningful and they are helpful when I write my assessments. I also enjoy seeing the different presentation styles of the different doctors. Each one is unique. I also really like the other members of the team and feel comfortable asking them to help clarify when I do not understand what a doctor has said.
Nothing too exciting to report this week. I continue to do a lot of screening, charting and some diet instruction. This week I talked with a few type 1 diabetics, but both of them had had the disease for a few decades and had very similar situations. There wasn't any diet instruction to be done in these instances. We have yet to have a new type 1 diabetic for me to instruct as of yet. Both of these cases were somewhat "typical" type 1 diabetics as far as complications go. Both had legal blindness in 1 eye and were admitted due to non-healing foot ulcers. Both already had toe amputations in the past and required the use of a cane. I was kind of surprised about the seriousness of their complications (and their young ages - <45 yoa) given how well it appears that they control their diabetes. Perhaps they don't control their blood sugars as well as it seems, or else these complications are more common than I realized?
Wednesday, June 17, 2009
The downside of the late shift
So my 9 am - 5:30 pm schedule this week seems pretty nice, until you consider that I'm with the RD who is on duty for an hour past when the other RD's leave for the day. That means any order or consult that comes in late has to be addressed by her (or me, as the case may be). Today, as we were finishing up some charting, we got a call from a nurse to do an instruct for a pt about to be discharged. The nurse assured us that it was just a refresher about T2DM, so I ran up with a few handouts to take care of it. Well, the pt was knocked out on Ativan. The instruct was actually for the 3 family members who will now be caring for her, and they had never learned anything about DM before. So I gave a brief lesson with what I had, let them look over it while I ran down to the office for more materials and printed off a meal plan, then finished up the basic intro lesson. Then, they asked for additional copies (more running involved) and started asking tons of questions about a heart healthy diet and salt restriction. I walked out of the hospital an hour late today. At least the family was really nice and grateful for my help.
SRMC
The last few days have been pretty uneventful here at SRMC. I am sort of just in a routine with screening, assessing and seeing patients. The hardest patient I have seen so far this week was a 60yo schizophrenic patient on dialysis. The doctor requested that he be placed on a fluid restrictions, so another RD and I were seeing him to explain the fluid restriction and get his preferences for the fluids he would recieve. The last RD that had seen him left a note that pt screams from room, so we knew it was going to be a challenge. The pt found us before we found him, since he was wandering the halls looking for his doctor. The nurses had dealt with him all morning, and found it easier to let him wander back and forth, than to try and keep him in bed. When we got him back to his room and tried to explain the fluid restriction he burst into tears. It was really sad to see. He was in so much pain and the nurses were not paying enough attention to him. We tried to calm him down and get him to rest, and left without explaining the fluid restriction, because he didn't really have any mental capacity to understand it. All in all it was pretty sad to see that nurses get so busy and so used to unruly patients that somebody who really needs some help falls through the cracks.
ER
This morning was follow the Respiratory Therapist time for me, which started out as boring as possible watching her give individuals their inhalers. The second half of the morning was the complete opposite as she got called to the ER for a CPR new admit and then got calls for 3 more new admits from an MVA. I watched a few intubations and everything else that happens in the ER when they get trauma admissions. I think I've seen enough of the ER for the rest of my life... but if you haven't spent any time in the ER, it is a totally different world than the rest of the hospital, and probably worth it just to see. Supposedly, Gaston Memorial Hospital used to be the 2nd busiest ER in the state. Probably because it seems the people in Gastonia are always doing something dumb like smoking while on oxygen, shooting themselves in the foot, or crushing up their pain medicine and snorting it.
PICA
Today we had a 19y/o female come in with abdominal pain, D/V/N. They took an x-ray of her stomach and saw a blockage and come to find out that the girl has been eating cotton balls. Not only that she has a history of it and eats any kind of soft fluffy materials i.e. pillows. This seemed particularly weird to me because I cant understand what she could possibly be getting from cotton. The only thing we could do was to talk to her about eating high iron foods and giving her suggestions of foods to replace nonfood items. Although it seems like she does a pretty good job eating meats, beans and nuts so I can't seem to figure out the cravings. I wanted to read more into it because my knowledge of it is minimal. Turns out this group of people eat some pretty disgusting things other than the usual clay, rocks, ice etc such as feces, mucus, body parts, etc. It typically is seen in children and developmentally challenged individuals of which this patient was neither. The etiology of PICA points to nutrition deficiency but that has not been proven by research and can be any number of factors including low SES to stress. Just thought I would share because I dont think this sort of thing comes up alot. Have a good week!
"Obstetrics" at Rex
As I thought, the most obstetrics experience I'll probably get this week is a tour of the birth center. Oh well - the other cases this RD sees are all over the map, which has made things interesting.
One interesting case: 60-70 yo woman who is bed-bound end-stage MS. She was doing alright at home with family taking care of her, but she came to the hospital last week with pneumonia and severe nausea. During a chest x-ray, the doctors discovered a hiatal hernia - 75% of her stomach was in her chest. She was put on clear liquids, but she wasn't eating anything. She hadn't been eating at home for a while, either, so her alb was already low upon admission. We didn't get a consult to see her until she had been on clear liquids for 5 days, at which point they were still debating what to do. They were leaning towards surgery to repair the hernia the next day. I felt pretty powerless at the time, but I think I may have helped: they actually took my recommendation (or maybe the MD thought of it himself, but I'll pretend it was me) to measure her alb or PAB. The the MD saw that her PAB was 5, so he postponed the surgery to start TPN and make sure she's strong enough for the surgery.
End-of-life issues continue to be important. We also got a consult for a severely demented 84 yo woman who can no longer eat anything without aspirating. ST had to suction the food out of her mouth during the swallow eval after they realized she didn't know what to do with it. Basically, she either needs a PEG or to be placed on comfort care/DNR, but the family can't decide what to do.
Apparently Rex has quite the international clientele: I did an instruct last week with a hilarious German man and an instruct this week with the most adorable British couple. They were in their late 70's but full of life and love.
One interesting case: 60-70 yo woman who is bed-bound end-stage MS. She was doing alright at home with family taking care of her, but she came to the hospital last week with pneumonia and severe nausea. During a chest x-ray, the doctors discovered a hiatal hernia - 75% of her stomach was in her chest. She was put on clear liquids, but she wasn't eating anything. She hadn't been eating at home for a while, either, so her alb was already low upon admission. We didn't get a consult to see her until she had been on clear liquids for 5 days, at which point they were still debating what to do. They were leaning towards surgery to repair the hernia the next day. I felt pretty powerless at the time, but I think I may have helped: they actually took my recommendation (or maybe the MD thought of it himself, but I'll pretend it was me) to measure her alb or PAB. The the MD saw that her PAB was 5, so he postponed the surgery to start TPN and make sure she's strong enough for the surgery.
End-of-life issues continue to be important. We also got a consult for a severely demented 84 yo woman who can no longer eat anything without aspirating. ST had to suction the food out of her mouth during the swallow eval after they realized she didn't know what to do with it. Basically, she either needs a PEG or to be placed on comfort care/DNR, but the family can't decide what to do.
Apparently Rex has quite the international clientele: I did an instruct last week with a hilarious German man and an instruct this week with the most adorable British couple. They were in their late 70's but full of life and love.
Tuesday, June 16, 2009
Yesterday was eventful. The COO of the hospital has a father who is in the hospital and we got a consult for a new peg placement for him. When we went up there she started asking why her father hadn't received his tray because they had advanced him to clear liquids and he was thirsty. Turns out someone put the order in wrong but we got the blame for it. Kind of frustrating that anytime there is a food issue the dietitians take the fall. But the situation ended up getting figured out. I guess it was a good lesson that communication is key to keep the patient from suffering. Otherwise, this week has been pretty average nothing else new to report. Hope all is well!
Code Red
After a long weekend in Yosemite, I was fortunate enough not to die like 2 other hikers did so I could start my oncology rotation today. Apparently you shouldn't try your luck at climbing Half Dome during a rain/hail storm. Mental note.
Back to oncology. Much like I've seen in a lot of other posts, we're still promoting neutropenic diets for those with low immunity even though the research does not support the practice. Fortunately, I've been given the go-ahead to tell patients they do not have to be as strict at home, and to just make sure they wash their fresh produce and avoid raw fish and meats. Yay.
While I was looking up some info on a patient this afternoon, I heard some people yell "Code Red! Code Red!" There was an electrical fire in a patient's room, and they had to be evacuated safely while those the other rooms were protected. The fire was quickly contained, and I helped by closing doors. The 2 patients were fine, just a little shook up and required extra anxiety meds. I also did not sustain any injuries as a result of my heroic acts.
I have had quite a death-defying few days.
Back to oncology. Much like I've seen in a lot of other posts, we're still promoting neutropenic diets for those with low immunity even though the research does not support the practice. Fortunately, I've been given the go-ahead to tell patients they do not have to be as strict at home, and to just make sure they wash their fresh produce and avoid raw fish and meats. Yay.
While I was looking up some info on a patient this afternoon, I heard some people yell "Code Red! Code Red!" There was an electrical fire in a patient's room, and they had to be evacuated safely while those the other rooms were protected. The fire was quickly contained, and I helped by closing doors. The 2 patients were fine, just a little shook up and required extra anxiety meds. I also did not sustain any injuries as a result of my heroic acts.
I have had quite a death-defying few days.
Georgetown End of Week 5
To finish up my transplant module, I watched a real life kidney transplant!
The NP who arranged this joked that we won't be on an elevated balcony, sitting in chairs behind glass, eating chips and looking down on the surgery like on TV. I was actually in the room, wearing scrubs, and right there with the MDs! I was really nervous because everyone was telling me I might get sick or pass out. Actually, it was very interesting and I found out that kidney transplant are the least bloody.
The NP timed it so that we only saw the donated kidney (from the receipient's mother) being attached. The old kidneys were not removed. The donated kidney comes with the artery and vein, the kidney, and the ureter all attached. They have to work very fast as soon as the kidney is removed from the ice bath; at one point they even had to throw some ice into the open abdomen (over the donated kidney) to keep it cold because the surgery was taking a bit longer than anticipated.
First, they clamp and sew the artery and vein onto the existing blood supply. Then, as soon as the sewing is complete, they unclamp and the blood begins to flow through the kidney, bringing it back to life - it got bigger and went from gray to red, very cool! Then, they look for any bleeds/leaks. They sew up any leaks, and burn off some small capillaries which may have bursted and are bleeding. They keep checking with gauze, until it shows clean with no more bleeds. Then, before attaching the ureter (from the donated kidney) to the bladder, they want to test that the kidney is making urine. This part was very fun - the attending squeezed the new kidney, and sure enough urine was squirting out the ureter! Then, they make a small incision in the bladder where the new ureter will connect, and sew it together. Finally, they stitch up the wound.
It was a great experience. I got to see a lot of anatomy and all of the skin and fat layers!
The NP who arranged this joked that we won't be on an elevated balcony, sitting in chairs behind glass, eating chips and looking down on the surgery like on TV. I was actually in the room, wearing scrubs, and right there with the MDs! I was really nervous because everyone was telling me I might get sick or pass out. Actually, it was very interesting and I found out that kidney transplant are the least bloody.
The NP timed it so that we only saw the donated kidney (from the receipient's mother) being attached. The old kidneys were not removed. The donated kidney comes with the artery and vein, the kidney, and the ureter all attached. They have to work very fast as soon as the kidney is removed from the ice bath; at one point they even had to throw some ice into the open abdomen (over the donated kidney) to keep it cold because the surgery was taking a bit longer than anticipated.
First, they clamp and sew the artery and vein onto the existing blood supply. Then, as soon as the sewing is complete, they unclamp and the blood begins to flow through the kidney, bringing it back to life - it got bigger and went from gray to red, very cool! Then, they look for any bleeds/leaks. They sew up any leaks, and burn off some small capillaries which may have bursted and are bleeding. They keep checking with gauze, until it shows clean with no more bleeds. Then, before attaching the ureter (from the donated kidney) to the bladder, they want to test that the kidney is making urine. This part was very fun - the attending squeezed the new kidney, and sure enough urine was squirting out the ureter! Then, they make a small incision in the bladder where the new ureter will connect, and sew it together. Finally, they stitch up the wound.
It was a great experience. I got to see a lot of anatomy and all of the skin and fat layers!
Working the ICUs
On my current rotation, I'm working the Surgery and Trauma ICU, Critical Care Unit, Cardiovascular ICU, and Renal floor. Lots of tube feedings and TPNs. I also saw my first Code Blue in the CCU-- a couple dozen people poured into the woman's room to be there if needed. People from outside the unit also came in, just in case, as did a chaplain, who told me that they always respond to a Code Blue just in case they are needed. Luckily, she was not needed--they got the woman resuscitated.
On my first day in the CCU, I saw a man I'd seen over at the cancer center a week before--the man who had really bad mucositis. Turned out, he'd been admitted the day after I saw him with thrombocytopenia. At one point, he'd also been projectile vomiting bile. But by the time we saw him, he was doing "much better." He still looked rough, and he's only at 64% of IBW, with a BMI of 14.8, but he was able to talk and request lemonade. We put him on tube feedings, which will hopefully help him gain some weight and get better.
Today I shadowed the dietitian who does Peds b/c my current preceptor was out sick. As it turns out, there's this equation for calculating REE needs for kids (Schofield) that is written 3 different ways in 4 different resources that the dietitian has. I found a journal article with the correct equation and it turns out that the equation in ADA's pocket guide for Peds is wrong. Of course, I kind of figured that ahead of time since if you follow theirs, you'll feed a 7 year old 11,000 kcal...
On my first day in the CCU, I saw a man I'd seen over at the cancer center a week before--the man who had really bad mucositis. Turned out, he'd been admitted the day after I saw him with thrombocytopenia. At one point, he'd also been projectile vomiting bile. But by the time we saw him, he was doing "much better." He still looked rough, and he's only at 64% of IBW, with a BMI of 14.8, but he was able to talk and request lemonade. We put him on tube feedings, which will hopefully help him gain some weight and get better.
Today I shadowed the dietitian who does Peds b/c my current preceptor was out sick. As it turns out, there's this equation for calculating REE needs for kids (Schofield) that is written 3 different ways in 4 different resources that the dietitian has. I found a journal article with the correct equation and it turns out that the equation in ADA's pocket guide for Peds is wrong. Of course, I kind of figured that ahead of time since if you follow theirs, you'll feed a 7 year old 11,000 kcal...
Day in the Life of a Wound Care Nurse
Today I shadowed the two WOCNs (Wound, Ostomy and Continence Nurse..mmm fun...). It was really fascinating. I only had to go out of a room once, and it was the room of the man with the massive sacral ulcer I mentioned in an earlier blog. I left due to an overwhelmingly noxious odor coming from his sacral wound area due to some GI issues that were occurring...I felt like vomiting. But other than that, the other patients were fascinating. The thing I saw the most of was venous skin ulcers due to venous insufficiency. They are shallow wounds that develops when the leg veins do not move blood back toward the heart well enough. The slowed circulation causes fluid to seep out of the overfilled veins into surrounding tissues, causing tissue breakdown and ulcers. They usually occur on the calves, which is where I saw them on a few patients.
In the afternoon I attended the wound care clinic in the Rehab facility. This is an outpatient clinic and people in the community can schedule appointments to get their wounds cleaned and re-dressed. It is not free however, but there is a free clinic nearby. There I saw 3 patients with venous ulcers, a young girl with a hand burn, and a lady who had stood up too fast at her massage therapist and sliced a huge chunk of calf off on the glass coffee table there. One of the most used wound dressing techniques is a Unna's Boot. It is a gauze covered with zinc oxide and calamine that is usually used for venous ulcer treatment. You wrap in around the lower leg a few times and then cover it with another wrap that creates more pressure on the leg and squeezes out fluid. I will admit that it was incredibly satisfying to watch wound dressings being put on because they were so good at it, making it line up perfectly! I could totally see myself doing this if I was a nurse except that I couldn't stand the funky odors. Yes, I'm a weirdo...
In the afternoon I attended the wound care clinic in the Rehab facility. This is an outpatient clinic and people in the community can schedule appointments to get their wounds cleaned and re-dressed. It is not free however, but there is a free clinic nearby. There I saw 3 patients with venous ulcers, a young girl with a hand burn, and a lady who had stood up too fast at her massage therapist and sliced a huge chunk of calf off on the glass coffee table there. One of the most used wound dressing techniques is a Unna's Boot. It is a gauze covered with zinc oxide and calamine that is usually used for venous ulcer treatment. You wrap in around the lower leg a few times and then cover it with another wrap that creates more pressure on the leg and squeezes out fluid. I will admit that it was incredibly satisfying to watch wound dressings being put on because they were so good at it, making it line up perfectly! I could totally see myself doing this if I was a nurse except that I couldn't stand the funky odors. Yes, I'm a weirdo...
We have an interesting couple of patients in the hospital right now that have been giving every staff member involved in their care a run for their money. The two women are life partners, and both currently inpatients. One has throat and neck cancer, and is being treated with regular radiation/chemotherapy. She refuses food, is extremely anxious, and plenty of people on the care team would describe her as mean (she made a social worker cry the other day). Her partner has severe COPD, is currently intubated with a PEG tube and is actively dying. The two women have pulled G tubes and trach tubes out of themselves, requiring restraints and sitters to be present in the rooms. Despite all of this, we keep receiving consults to educate the woman with cancer about carbohydrate counting and diabetic meal planning. She has refused our education multiple times, so we keep having to return and convince her about the importance of the information we're trying to give her. She is obese and at risk for a number of diabetic complications if she doesn't start to change her diet. However, with her partner now in the dying process, we're not sure she if she will be able to manage on her own. A PEG tube was placed for this patient yesterday, but we're concerned about sending her home with it/trusting her to feed herself correct and not physically remove the feeding tube. It has been a complicated case. With no definine discharge in place for the cancer patient, we're still strategizing about how best to treat her/get through to her. We are also trying to anticipate how her needs may change when her partner does die (expected to happen today sometime).
In other news, I witnessed a patient die in ICU last week. I'm not sure what his code protocol was, but about 10 hospital workers crowded into the room. It was a calmer scene than I would have expected. One nurse was documenting. Two doctors were present but mostly observing/providing advice and input. Three other nurses were rotating- each would take a turn climbing atop a stepstool to provide manual CPR for a few minutes at a time. The entire episode lasted 15-20 minutes, until the patient was pronounced dead. Thankfully, no family members were present during the event, so the staff managed to keep everything under control and relatively un-dramatic. Something else I didn't really expect is how isolated deaths have been at my hospital. I spend about 1-2 hours in ICU every morning, and this was the first patient to die since I have been interning.
In other news, I witnessed a patient die in ICU last week. I'm not sure what his code protocol was, but about 10 hospital workers crowded into the room. It was a calmer scene than I would have expected. One nurse was documenting. Two doctors were present but mostly observing/providing advice and input. Three other nurses were rotating- each would take a turn climbing atop a stepstool to provide manual CPR for a few minutes at a time. The entire episode lasted 15-20 minutes, until the patient was pronounced dead. Thankfully, no family members were present during the event, so the staff managed to keep everything under control and relatively un-dramatic. Something else I didn't really expect is how isolated deaths have been at my hospital. I spend about 1-2 hours in ICU every morning, and this was the first patient to die since I have been interning.
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