I have been working with the diet techs this week. They do all of the initial assessments at the VA, and so this is a good way to begin learning their system. After they complete the initial nutrition assessment they pass on any patients who are classified as being moderately or severely compromised to the RD. They handle all of the patients who are normal or who are mildly compromised.
This morning I got to do the initial assessment of two patients in the psych ward while the diet tech watched and stepped in when necessary. I really enjoy working with the patients, and it was fun to do it myself after having watched her during the past 2 days. After talking with the patients we went back to the office and evaluated them based on the information they gave us and the other information we obtained from their medical file in the computer. It is pretty neat to be able to access all of the nursing notes, the doctor notes, their lab values, etc. After determining their status we wrote up modified SOAP notes on them, entered their food preferences, and then entered what we had done and our time. There is a lot of documenting that must be done in several different computer systems. One neat thing about their system is that they use electronic signatures. When someone writes a note that they want someone else to see they can select that person’s name and the note will show up on that person’s computer, indicating that it is awaiting their signature. For example, when the diet tech writes a note she often sends it to the PA to sign.
I also taught a 30 minute class today to a group of 17 men in the psych unit. I was told it could be on anything, so I modified a class I taught with Melissa on the food guide pyramid. Some members in the audience were active participants, but it was also interesting how many were asleep by the end. I enjoyed teaching the class. After the class we had to document in each patient’s file (in 2 places for most patients) that they had attended. It was quite a process! We got to write a generic template describing the lesson, but then for each patient we had to make a note about how they participated in the class. I recognized over half of them, but knew the names of less than 20% of them. Luckily the diet tech was familiar with these patients. We had to document the specific questions that each patient asked to the best of our abilities.
Many of the psych wards are locked and I have been warned to be careful. When leaving the ward we have to make sure that a patient isn’t right behind us who might try to escape. Despite this, I actually really like working with these patients. They eat in groups and I enjoy going on meal rounds and finding out how they like their meals and what they would like changed for next time. The diet tech I was with tries to do meal rounds almost every day. I did meal rounds with the RD once last week, but she sees sicker patients in their rooms individually, and the experience was very different.
I attended a nutrition meeting/celebration today, and so I got to meet the dietitians I hadn’t met earlier. It was also interesting to see how they conduct their meetings.
I will be working with the techs for the rest of the week. They are the only ones who cover weekends, so I will have my weekend experience on Sunday. I have spent the last three days with psych patients, but staring tomorrow I will be seeing everyone.
Wednesday, May 20, 2009
First week @ WakeMed
First week @ WakeMed
I will finish my first rotation by tomorrow! What an amazing week!
First, when I got my rotation schedule from my preceptor a week before my starting day, I was shocked at that time since I will spend most of my summer time @ intensive care units. It is good because it fits my interest very well.
My first rotation is rehab, which uses totally different system from acute sites. There are several unexpected things/good experience:
1. There are a lot elderly patients, I have to learn how to communicate with them—speaks clear, loudly and slowly, make sure they understand what you are saying. I felt awful at first time when I talked to a 91-year-old lady for her food preference, I tried to make myself clearly, loudly, and she still thought I was the person from nursing home. She got pretty upset since she thought she would be kicked off from Hospital. After several tries, we finally worked out and got a good communication. Lessons learned: makes clear points, speaks in short sentence and slowly, and pays attention to what they say as well as their emotions.
2. There will never be the same chart/assessment form with what you learned from classroom. Every hospital has its own format; the best learning way is from your practices. I have already written several charts for initial assessment and done several calorie counts. When I am getting familiar with format and working environment, it is about time I will leave. I have to learn everything when I start my next rotation!
3. I learned how to calculate IBW and EEE for patients with Amputations (AKA, BKA or both, or whole leg) it is more complicated than I ever thought. It is good experience!
4. Culture competency—not easy to do, especially for foods. The hospital diets are very limited for choices. If you are on special diet (diabetic, dysphagia or renal), you wouldn’t have any choice for your menu (even we can enter what you like or dislike)--patients always complained their diets. For patients from different counties, it makes harder to satisfy patients.
That’s all for my first rotation, I expect I will learn more later on …
I will finish my first rotation by tomorrow! What an amazing week!
First, when I got my rotation schedule from my preceptor a week before my starting day, I was shocked at that time since I will spend most of my summer time @ intensive care units. It is good because it fits my interest very well.
My first rotation is rehab, which uses totally different system from acute sites. There are several unexpected things/good experience:
1. There are a lot elderly patients, I have to learn how to communicate with them—speaks clear, loudly and slowly, make sure they understand what you are saying. I felt awful at first time when I talked to a 91-year-old lady for her food preference, I tried to make myself clearly, loudly, and she still thought I was the person from nursing home. She got pretty upset since she thought she would be kicked off from Hospital. After several tries, we finally worked out and got a good communication. Lessons learned: makes clear points, speaks in short sentence and slowly, and pays attention to what they say as well as their emotions.
2. There will never be the same chart/assessment form with what you learned from classroom. Every hospital has its own format; the best learning way is from your practices. I have already written several charts for initial assessment and done several calorie counts. When I am getting familiar with format and working environment, it is about time I will leave. I have to learn everything when I start my next rotation!
3. I learned how to calculate IBW and EEE for patients with Amputations (AKA, BKA or both, or whole leg) it is more complicated than I ever thought. It is good experience!
4. Culture competency—not easy to do, especially for foods. The hospital diets are very limited for choices. If you are on special diet (diabetic, dysphagia or renal), you wouldn’t have any choice for your menu (even we can enter what you like or dislike)--patients always complained their diets. For patients from different counties, it makes harder to satisfy patients.
That’s all for my first rotation, I expect I will learn more later on …
The Nutrition Room
I spent the morning in the Nutrition Room, watching and then helping the two techs fortify human milk and mix up formulas for the neonates. It is really well organized to prevent anyone from accidentally giving a mother’s milk to the wrong baby (which, per JHACO, is a sentinel event, eg, an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.)
The techs get orders from the MDs or RDs and then check their recipe lists to add in extra protein and calories. Human milk is about 22 kcal/oz. Neonates may not be able to consume enough volume to meet their energy needs, so they add human milk fortifier to give them more bang for the ounce. I mixed up a bottle of 30 kcal/oz for one baby. The techs dispense the milk to the nurses, and everyone checks the medical records on the source and the dispensed milk to be sure that they have the right milk. Some of the babies get as little as 3 mL! (But some of the babies only weigh 500 grams. One in there right now was born at 23 weeks’ gestation. She’s hanging in, but she sure is small.) The nurse brought by one of the babies who is doing really well – it was such a delight to see him, given the sickness of the babies on the floor and the fact that I have spent the week seeing oncology patients.
When it got a little slow in the Nutrition Room, I joined Pat for rounds and listened in to a short talk the attending gave about complications seen in infants of diabetic mothers (google Mermaid Syndrome if you want to see one really rare, serious complication).
We had journal club in the afternoon, during which on of the RDs reviewed dermatological changes associated with micronutrient deficiencies common in patients with alcoholism.
Finally, I ended the day by working up and visiting a couple of oncology patients. I practiced calculating and writing TF recommendations and discussing the pros/cons of different formulations with my preceptor. Among those who can eat, most are on a neutropenic diet (no fresh fruits or vegetables, no uncooked black pepper), which seems like common sense given their compromised immune systems. However, my preceptor told me that this is based mostly on tradition, there isn’t any evidence that a neutropenic diet is any more protective against infection than regular diet. Much of what my RD does with her patients is try to encourage them to eat as much as possible, and it is a shame that they have to avoid foods that they might want (eg, pimento cheese—which has peppers—or chicken salad with celery) because of their neutropenic diet.
The techs get orders from the MDs or RDs and then check their recipe lists to add in extra protein and calories. Human milk is about 22 kcal/oz. Neonates may not be able to consume enough volume to meet their energy needs, so they add human milk fortifier to give them more bang for the ounce. I mixed up a bottle of 30 kcal/oz for one baby. The techs dispense the milk to the nurses, and everyone checks the medical records on the source and the dispensed milk to be sure that they have the right milk. Some of the babies get as little as 3 mL! (But some of the babies only weigh 500 grams. One in there right now was born at 23 weeks’ gestation. She’s hanging in, but she sure is small.) The nurse brought by one of the babies who is doing really well – it was such a delight to see him, given the sickness of the babies on the floor and the fact that I have spent the week seeing oncology patients.
When it got a little slow in the Nutrition Room, I joined Pat for rounds and listened in to a short talk the attending gave about complications seen in infants of diabetic mothers (google Mermaid Syndrome if you want to see one really rare, serious complication).
We had journal club in the afternoon, during which on of the RDs reviewed dermatological changes associated with micronutrient deficiencies common in patients with alcoholism.
Finally, I ended the day by working up and visiting a couple of oncology patients. I practiced calculating and writing TF recommendations and discussing the pros/cons of different formulations with my preceptor. Among those who can eat, most are on a neutropenic diet (no fresh fruits or vegetables, no uncooked black pepper), which seems like common sense given their compromised immune systems. However, my preceptor told me that this is based mostly on tradition, there isn’t any evidence that a neutropenic diet is any more protective against infection than regular diet. Much of what my RD does with her patients is try to encourage them to eat as much as possible, and it is a shame that they have to avoid foods that they might want (eg, pimento cheese—which has peppers—or chicken salad with celery) because of their neutropenic diet.
Holy high blood sugar
I'm doing a combo cardio/diabetes round for these next two weeks, and I finally started talking with the patients yesterday. I did one assessment interview with the RD observing me, and apparently that was enough because I'm on my own now. I'm not complaining, because I get nervous when people watch me but it seems a little quick.
Anyhoo, I got my first solo patient (I'm likening this to the first solo surgery in Grey's Anatomy) and I logged into the EMR to check out his admission notes from the doctor. Everything's looking kind of normal, history of CHF, HTN, and DM etc etc-- until I saw his admit blood glucose-- 631! My god! I had no idea that was even possible. Upon further investigation during my inteview it turns out it's gotten in the 700s before. Craaaaaaazyyyyyy!
Just thought I'd share my shock with all of you in case you hadn't come across numbers like that.
Anyhoo, I got my first solo patient (I'm likening this to the first solo surgery in Grey's Anatomy) and I logged into the EMR to check out his admission notes from the doctor. Everything's looking kind of normal, history of CHF, HTN, and DM etc etc-- until I saw his admit blood glucose-- 631! My god! I had no idea that was even possible. Upon further investigation during my inteview it turns out it's gotten in the 700s before. Craaaaaaazyyyyyy!
Just thought I'd share my shock with all of you in case you hadn't come across numbers like that.
Freedom!
It is all relative.
Today, I got to write my notes without someone looking over my shoulder and making me nervous. It was a big day for Laura. Afterwards, they didn't have to make any corrections. Maybe, tomorrow, I'll be allowed to speak with the patients.
Admittedly, Cardio is boring and repetitive. Mission has a special, separate "Heart Path" team which provides a thorough explanation of the Heart Healthy diet to lucid patients in the ICU and those about ready to go home. It was interesting to spend the afternoon with one of those ladies, however, I wouldn't want to do it for more than a week. When I was back with the Clinical team today, there was only 1 cardio patient who was not already picked up by this Heart Path team, so I got to hang out on the Neuro Trauma floors to fill up my day instead. Lots of tube feedings, so I brushed up my arithmetic skills and learned a few new adult formulas.
And, if any of you were wondering.... yes, my neighbor (Bret) is currently playing the Abba CD again. He started it significantly later in the day than usual. He MIGHT have a "lady friend" named Helen. We identified another cat, so the count is AT LEAST seven right now. Jack, one of his grey cats, has an extra "thumb" on both paws, so he's a fantastic tree climber. More to come....
Fatback
I was unaware until yesterday that people actually ate fatback by itself- I thought you just cooked with it. Beware, it's apparently a favorite snack of truck drivers...
Gaston Memorial Hospital has been great in the past week, I'm finally getting to the point where I can do things on my own, just in time to switch to another unit and preceptor on Monday. But, I have been learning a lot about neuro, rehab, and psych AND I got to see these incredible pictures of a man with a megacolon pre/post surgery (and the colon itself, after removal). This guy didn't have a BM for 3 weeks (!!!!!) but kept eating and the colon had stretched so much it was almost 5 feet long and over 4" in diameter in some sections. They took out his colon but left a long rectal stump so he probably won't have to have his ileostomy for more than a year! Moral of the story is: if you/your patients don't poop for a while, you should probably get that checked out by a doctor stat. (Actually, it apparently is more common in the elderly or those with chronic constipation. This guy was only 47, though.)
And in other news, from the so-sad-it's-kind-of-funny section, I visited a husband and wife pair today in ortho. The wife was in for a knee replacement and while the husband was visiting her, he tripped over a telephone wire in her room, fell, broke his hip, and had to get hip replacement surgery.
Hope everyone's having a great week!
Gaston Memorial Hospital has been great in the past week, I'm finally getting to the point where I can do things on my own, just in time to switch to another unit and preceptor on Monday. But, I have been learning a lot about neuro, rehab, and psych AND I got to see these incredible pictures of a man with a megacolon pre/post surgery (and the colon itself, after removal). This guy didn't have a BM for 3 weeks (!!!!!) but kept eating and the colon had stretched so much it was almost 5 feet long and over 4" in diameter in some sections. They took out his colon but left a long rectal stump so he probably won't have to have his ileostomy for more than a year! Moral of the story is: if you/your patients don't poop for a while, you should probably get that checked out by a doctor stat. (Actually, it apparently is more common in the elderly or those with chronic constipation. This guy was only 47, though.)
And in other news, from the so-sad-it's-kind-of-funny section, I visited a husband and wife pair today in ortho. The wife was in for a knee replacement and while the husband was visiting her, he tripped over a telephone wire in her room, fell, broke his hip, and had to get hip replacement surgery.
Hope everyone's having a great week!
Charting at Rex
After all of the posts last week about SOAP notes vs. PES statements, I was interested to see how things worked at Rex. I was not prepared for the chaotic system they use. They transitioned to writing PES statements almost a year ago, and they're getting ready to fully transition to using the NCP (ADIME). However, the electronic medical record (called RCare) is actually getting in the way. Each pt's RCare file is huge: there are ~15 tabs, each packed with info and sometimes even sub-categories. I had to take notes on how to find notes! It's pretty handy after you figure it out since things are arranged by date AND by topic, but it's only as good as the info put into it. Some docs (esp. visiting specialists) don't use RCare, so you still have to sift through the paper record to get everything. And the real problem is that there's no place for RD notes. The PES statement is usually entered in a text box at the very end, and no one looks at it except the RD's. There's definitely no space for the other aspects of ADIME. They're fighting with IT now to get their own tab and drop-down menus.
Another interesting issue at Rex: pts don't always get snacks or supplements, mainly due to the computer system. Protein supplements are especially important for pts with decubs (i.e. bed sores...took me a while to figure out that one), and even though the RD orders them, the nurses don't know to give them because they don't look in the section of RCare that we use. The order is also in the food service computer system, but nurses don't see that.
Like Laurie, I'm a little disappointed by the time RD's spend with pts. I'm shadowing the RD on the renal/pulmonary floors, and we spend ~20 min looking at the pt's chart (checking for wt change, alb levels, decubs, etc.), then maybe 5 min with the pt (or their family), and then another 10 min charting. Sitting in on pt rounds and just listening to the other RDs' stories has been really interesting though.
I had a "project day" today, which meant that I spent ~7 hours menially copying and formatting nutrition info for the cafeteria. Thank goodness the weekly RD meeting and a retirement party broke up the afternoon. I got to try Angelo's famous mac and cheese and the party...pretty good.
Oh, and I got called a "little girl" by a pt. I'm going to have to do something to look at little older when I start counseling pts.
Another interesting issue at Rex: pts don't always get snacks or supplements, mainly due to the computer system. Protein supplements are especially important for pts with decubs (i.e. bed sores...took me a while to figure out that one), and even though the RD orders them, the nurses don't know to give them because they don't look in the section of RCare that we use. The order is also in the food service computer system, but nurses don't see that.
Like Laurie, I'm a little disappointed by the time RD's spend with pts. I'm shadowing the RD on the renal/pulmonary floors, and we spend ~20 min looking at the pt's chart (checking for wt change, alb levels, decubs, etc.), then maybe 5 min with the pt (or their family), and then another 10 min charting. Sitting in on pt rounds and just listening to the other RDs' stories has been really interesting though.
I had a "project day" today, which meant that I spent ~7 hours menially copying and formatting nutrition info for the cafeteria. Thank goodness the weekly RD meeting and a retirement party broke up the afternoon. I got to try Angelo's famous mac and cheese and the party...pretty good.
Oh, and I got called a "little girl" by a pt. I'm going to have to do something to look at little older when I start counseling pts.
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