Georgetown Week 4

This week I'm still in the ICU, completing the pulmonary module. I met with a respitory therapist who took me to the equipment room and showed me how the ventilator and bipap machines work, explained the various masks, and went through related terms. It was very helpful to speak with him. He even turned the machines on and showed me the various settings. Even though most of this is not directly related to nutrition, it is helpful to know this background info to get a better overall picture of the pts status.

I've seen quite a few intubated pts over the past two weeks. I also saw someone being intubated, which was kind of intense, but cool!

I am following the pt from last week who had the thoracentesis (fluid drain from pleural space). He was recently extubated, but wasn't eating very well so I made recs for him to receive ensure pudding and shakes. But, I went in to check on him yesterday and found out that he was put on 100% bipap because he was fluid overloaded again which caused pressure on his lungs and therefore difficulty breathing. I was bummed because I was excited to ask if he received and liked the strawberry flavored Ensure that we ordered for him :( I guess he remembered me because as soon as I walked in he said please get me something to eat! I quickly learned that it's best to check the charts/find out the pts status before walking into the room, especially in the ICU where pts status can change so quickly. He's currently NPO because he doesn't have any EN access, so he was probably wondering why I was there. If he doesn't get off of the bipap soon, I'll have to put in TF recs. Also, usually Dobhoffs can be used with bipap masks. However, since this pt is on 100% support, they may not allow us to do the Dobhoff which causes a small leak in the mask.

My other pt - the one who received the FEES test last week - was due for a f/u today. His blood sugars were very high, and the intern MD immediately asked me if we could put him on Glucerna. Well, the pt was already on Osmolite 1.0, which is not too high in CHO, and he has been on it for a while with no problems. I did the calculations anyway to compare Glucerna with Osmolite, and the CHO difference was not very significant in this case. I told the intern that Mr. L has been doing fine with Osmo for a couple weeks, and that it's probably not the TF which is causing the high blood sugar. I went through the med list and noticed that the pt was on Novolog SSI at a low dose, I suggested that they could perhaps try going up to medium dose. I also checked to see if the pt was on any steroids, which he was not. Then, the intern says, "Oh yea, I did give him (some drug/supplement, I can't remember the name), which has a lot of dextrose in it for the past three days." Ha, are you serious? I told him we were going to keep our TF recs the same, and continue to monitor. So, today I learned that MDs can overlook things sometimes too, and that it's okay to question and don't forget to check meds!

So, I've been following Mrs. G still (the renal pt who doesn't eat by choice). Well, it turns out she was not on TPN, rather she was suppose to be on PPN, which was never started. Good! The RD and I attended medical rounds on her earlier this week, and we said we don't want her on TPN or PPN. Luckily, the attending agreed that it was not appropriate to start PN on this pt just because she refuses to eat. We were willing to start TFs, but she refused. The RD I was working with said in this case, "the pt either wants nutrition support or she doesn't; she doesn't get to choose the method (EN vs PN), that's our job!" I agree.