I just posted yesterday, but I learned some neat things today about oncology which I wanted to share.
1. Bone marrow transplant patients aren't allowed to brush their teeth. Their gums become really weak and prone to bleeding, which means they are vulnerable to infection and even worse mucositis than normal. They are allows to use a disposable, mint-flavored sponge on a stick (called a toothette) to clean out their mouth and to swish with rinses. My RD stresses the importance of good oral care with all of her patients.
2. Patients can rinse their mouths with baking soda to neutralize the weird tastes they may have in their mouth.
3. Scott Hamilton has website with a really comprehensive list of chemotherapy agents, their use and mechanisms, side effects, etc. that my RD uses regularly as a reference: www.chemocare.com
Thursday, May 21, 2009
medical records times 70
So after doing a lot of shadowing last week, my preceptor gave me some interesting tasks this week. Yesterday I created a pocket guide for their version of the host/hostess to use when taking patient menu choices. Lots of patients are on coumadin, so the dietitian wanted me to create something for the hosts/hostess to use to help the patients select a diet that is consistent in vitamin K. I also went through the first part of the menu cycle to see how often foods high in vitamin K are offered on each of the different diets. Today I went with the dietitian to go through every medical record at the long term care facility (about 70 ppl) to verify that the diet order in the chart was the same as what was entered in the computer. They have a surprising amount of problems with that, which I discovered today. After that I went with the dietitian to inspect the kitchen; we made a list of a bunch of things that need cleaning...I felt like I was back in food service :) I also went to cardiac rehab for one morning this week and got to see how that worked. Patients come for exercise and then get a short nutrition lesson. I asked if I might be able to teach the lesson at some point.
Aside from these tasks, I wrote my first note in the computer with help from one of the dietitians, so that was exciting. I also saw a patient on my own to ask about recent weight loss. I'm guessing that I'll work more with the patients again tomorrow. Unfortunately I can't get access to the computer charting system until the manager gets back from vacation, but hopefully that won't hinder my progress!
Aside from these tasks, I wrote my first note in the computer with help from one of the dietitians, so that was exciting. I also saw a patient on my own to ask about recent weight loss. I'm guessing that I'll work more with the patients again tomorrow. Unfortunately I can't get access to the computer charting system until the manager gets back from vacation, but hopefully that won't hinder my progress!
Make the DASH
Two new things happened today: one, I taught a class on the DASH diet. Secondly, I worked up a patient with hepatic encephalopathy and learned interesting things about liver disease and how to encourage doctors to listen to you.
1. DASH Class: I taught a class today to stroke patients about the DASH diet. One man left after the recreational therapist talked before me, but I had been in an education with him earlier during the week and he was not interested. One lady left because she said she wasn't going to cook, but her daughter stayed and was very interested and eager to change. After my short power point, we talked about each others diets (there was only 3 people in the class, and one of them comes every time to ask random questions the dietitian with me said), so then I had a work sheet for them to write down some change goals. I also gave out some great recipes from Mayo Clinic (they look AMAZING), a DASH shopping list and a handout on 30 ways to sneak fruits and veggies into your diet. So I feel like that was a success.
2. Hepatic Encephalopathy: this patient had a BMI of 50 (apparently pretty common around here) and cirrhosis. I looked at his current diet order: 1800 kcal diabetic diet, no salt added and 40 grams of protein. So I figured out how many g/kg of actual body weight that is: 0.25!!! My RD looked at it and was shocked, because even though we used ideal body weight to calculate protein needs in obese, she checks it against what they actually weight to see if it is appropriate. So she proceeded to print me out a really great article from this really great journal (UVA's Nutrition Issues in Gastroenterology series) about calories and protein for hepatic failure. Studies have apparently shown that protein restriction is not necessary in these patients and protein of around 1.5 g/kg proves to be beneficial for treatment. The current evidence suggests that lactulose should be prescribed alongside normal to elevated protein depending on the mental status of the patient. So my patient was mentally fine now so we relaxed his diet. Lastly, the RD had me highlight the important points in the article and attach the article to the chart and reference the doctor to it in the order because she says doctors really appreciate evidence like that when they go to sign off on our orders. Have a great weekend!
1. DASH Class: I taught a class today to stroke patients about the DASH diet. One man left after the recreational therapist talked before me, but I had been in an education with him earlier during the week and he was not interested. One lady left because she said she wasn't going to cook, but her daughter stayed and was very interested and eager to change. After my short power point, we talked about each others diets (there was only 3 people in the class, and one of them comes every time to ask random questions the dietitian with me said), so then I had a work sheet for them to write down some change goals. I also gave out some great recipes from Mayo Clinic (they look AMAZING), a DASH shopping list and a handout on 30 ways to sneak fruits and veggies into your diet. So I feel like that was a success.
2. Hepatic Encephalopathy: this patient had a BMI of 50 (apparently pretty common around here) and cirrhosis. I looked at his current diet order: 1800 kcal diabetic diet, no salt added and 40 grams of protein. So I figured out how many g/kg of actual body weight that is: 0.25!!! My RD looked at it and was shocked, because even though we used ideal body weight to calculate protein needs in obese, she checks it against what they actually weight to see if it is appropriate. So she proceeded to print me out a really great article from this really great journal (UVA's Nutrition Issues in Gastroenterology series) about calories and protein for hepatic failure. Studies have apparently shown that protein restriction is not necessary in these patients and protein of around 1.5 g/kg proves to be beneficial for treatment. The current evidence suggests that lactulose should be prescribed alongside normal to elevated protein depending on the mental status of the patient. So my patient was mentally fine now so we relaxed his diet. Lastly, the RD had me highlight the important points in the article and attach the article to the chart and reference the doctor to it in the order because she says doctors really appreciate evidence like that when they go to sign off on our orders. Have a great weekend!
CABG
I ate cabbage for dinner last night in preparation, and it seemed to help me out because I was kind of nervous going into the surgery after all the warnings from the nurses to "sit down before I fall down" but I felt great the whole time! Watching the CABG was a really incredible experience. Some of the coolest parts were standing in there while they were doing all of the prep work on the body, watching them cut open the man, being able to peer into the body and watch the beating heart and working lungs, watching the perfusionist work to use the machine to take over for the heart and lungs, watching them shut off the heart from a basically just K injections and by dumping ice water into the cavity (!!! they literally dumped ice water- they called it "margarita cold"!!!), and then watching the surgeon's hand meticulously work to use the vein that they had basically noninvasively (another incredible technology) removed from the leg and stitching it to the heart. If any of you have a chance to see it, definitely do it...even if you have some reservations! Just be warned that there are some interesting smells, and try your hardest to breathe through your mouth rather than your nose! and be sure to "sit down before you fall down"
Another thing that I wanted to share was that I worked up a young (27 yr old) CF patient yesterday, and the dietitian that I am rotating with this week told me to use the formula from Krause. So if you ever have a CF patient, try the formula on p. 914 of our handy textbook. She wasnt eating very well becaues the hospital food wasn't matching her preferences, so I went in and talked to her about the kinds of things that she would be willing to eat and then I went in and added some of the foods to her meals, some of the supplements as snacks, and then some of the foods as snacks. It was really interesting because with her, I was just like "tell me ANYTHING that you will eat and we will get it to you!"...kind of different for her than for most patients.
And lastly, I went to a group diet session for women with breast cancer yesterday and I have the handouts and everything, so if any of you are interested in the kind of information that they gave to these women then let me know! I'm in oncology next week, and I found that the class was hard for me to sit through- its a very emotional experience for these women (and Rachael knows that I tear up just watching the Today show many mornings) so just prepare yourself if you are going to have an experience in something that you may find sensitive! I definitely think that comfortability comes with time, so I am looking forward to having the experience of oncology next week!
Elizabeth
Another thing that I wanted to share was that I worked up a young (27 yr old) CF patient yesterday, and the dietitian that I am rotating with this week told me to use the formula from Krause. So if you ever have a CF patient, try the formula on p. 914 of our handy textbook. She wasnt eating very well becaues the hospital food wasn't matching her preferences, so I went in and talked to her about the kinds of things that she would be willing to eat and then I went in and added some of the foods to her meals, some of the supplements as snacks, and then some of the foods as snacks. It was really interesting because with her, I was just like "tell me ANYTHING that you will eat and we will get it to you!"...kind of different for her than for most patients.
And lastly, I went to a group diet session for women with breast cancer yesterday and I have the handouts and everything, so if any of you are interested in the kind of information that they gave to these women then let me know! I'm in oncology next week, and I found that the class was hard for me to sit through- its a very emotional experience for these women (and Rachael knows that I tear up just watching the Today show many mornings) so just prepare yourself if you are going to have an experience in something that you may find sensitive! I definitely think that comfortability comes with time, so I am looking forward to having the experience of oncology next week!
Elizabeth
They must be able to read this blog....
I spoke with two patients today! SUCCESS!
I believe there is a Cherokee Indian Reservation somewhere in the mountains west of Asheville. There are a number of Native American patients in the Heart Tower right now, and its been interesting to hear their food preferences and their eagerness to go home to a more familiar life. I would imagine my impatience to get out of the hospital as it is, but to add a different lifestyle to the experience? It must be a difficult stay when they are transferred from their regional hospital to big, bad Mission. I saw two Cherokee patients these past two days, and they seemed sad, complained of the food, and spoke of strong wishes to go home. It also broke my heart to see their diabetes med list, blood glu, and GFRs. I tried to negotiate with an older woman this morning saying that if she ate the protein on the dishes full of the "crazy" food we serve her, she'd heal her ab wound faster and be able to go home.
Nothing else cool happened today. I didn't faint, however, next week, I'm doing the Oncology and Psych floors, so my preceptor and I have agreed to ease me into the eating disorder patients.
I'm so bummed that I'm missing the Memorial Day weekend cookout with our crazy neighbor, Bret! We got the invite yesterday. I'm sure it'd be an interesting experience in itself, however, I'm REALLY curious to go inside his condo and get an accurate cat count. Asheville sure is chock full of individuals. People watching is entertaining.
Patient Education
By now I have been able to perform a number of diet educations to patients, with mixed results and responses. Last week, I counseled a man in his late 60s with a BMI over 40 about the "cardiac diet". To say he was resistant is an understatement. As we talked about lower-fat meat options, low-fat dairy, avoiding processed meats and snacks, and other aspects of the heart-healthy diet, he repeated "it's too late for me to change", and "I can't live without my spare ribs." I was with my preceptor who was observing my education session, and we were both feeling frustrated. At one point he even commented that both of us were "no small things", and we had to look the way we did from eating spare ribs once in a while... Needless to say it wasn't my favorite experience. He started to listen to us a little bit when we spoke about hypertension, but overall we left the room feeling like we wasted our time. Situations like this seem to be one of the frustrating sides of clinical dietetics. What I've enjoyed is utilizing my clinical skills (tube feeds, TPN formulas, and writing notes/evaluations). Some of the patient eds are hard to feel good about, especially (I imagine) for an experienced dietitian who's been doing this for a number of years.
On the other hand, Tuesday I counseled a patient (and his family) about the cardiac diet. This time, the family was concerned about the patient's health and interested in making changes in their lifestyles. They asked me questions, suggested food alternatives, and enthusastically listened to my advice and suggestions. When I left this room, I felt great- like I did actually help to make a difference in the health of that patient. And that my nutrition skills were being put to good use. I can see how many dietitians look forward to starting their own practices. To counsel patients or clients that actually want your advice and are interested in making the effort to improve their health seems like a rewarding experience.
On the other hand, Tuesday I counseled a patient (and his family) about the cardiac diet. This time, the family was concerned about the patient's health and interested in making changes in their lifestyles. They asked me questions, suggested food alternatives, and enthusastically listened to my advice and suggestions. When I left this room, I felt great- like I did actually help to make a difference in the health of that patient. And that my nutrition skills were being put to good use. I can see how many dietitians look forward to starting their own practices. To counsel patients or clients that actually want your advice and are interested in making the effort to improve their health seems like a rewarding experience.
Wednesday, May 20, 2009
Wayne Memorial
My first few days at Wayne have been interesting. They have made the transition to electronic records but still look in the charts just in case new orders have not been entered yet. It is a small hospital so I will not have rotations. Of course, this means that completing one particular module is not necessarily helpful.
Today I got to calculate how much protein a patient with nephrotic syndrome needed. The patient was losing ~17500mg protein in urine/24hr.
Today I got to calculate how much protein a patient with nephrotic syndrome needed. The patient was losing ~17500mg protein in urine/24hr.
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