week three…

another great week under my belt. three down, nine to go!

last week i rotated to a new pediatric dietitian, who covers gastrointestinal (G.I.), pulmonary, neurology, and hemotology/oncology (blood disorders/cancer) pediatric services.

by the end of the week, my preceptor (MP) was giving me my own patients, which i was able to see from start to finish!

what this means: MP gets “assigned” patients based on what services she covers. so, for example, when an MD orders a “nutrition consult” in one of MP’s services (i.e. a kid is admitted with a GI, pulmo, neuro, or heme/onc problem and has a nutritional need), she researches the pt (past medical history, current medicines, reason for hospitalization, reason for nutrition consult), visits the patient, makes adjustment to the patient’s diet (or tube feed or TPN feed) as needed, and writes a note in the pt’s chart using the nutrition care process (NCP).

the NCP is the A-DIME process i spoke about before. the NCP is the method of charting that includes an (A) assessment, (D) nutrition diagnosis, (I) nutrition intervention (what you plan to do for the patient), and (ME) plans for monitoring and evaluating the patient.

so, again, after a week of learning how to assess the needs of MP’s patients, by friday, i was able to see two of my own patients from start to finish! granted, i had MANY questions for MP to answer along the way. MP also accompanied me into patients’ rooms during my visits, and she gave a final edit to all of my chart notes, but… it felt pretty wonderful to start to be independent.

some notable cases: i provided an initial assessment of a 19 yo male with cystic fibrosis (CF). FYI: CF is a heritable disease characterized by abnormal secretions (by the pancreas, lungs, GI tract, etc). this leads to abnormal digestion, decreased lung function (among other systemic problems), which can lead to increased nutrient needs (it takes a LOT of energy/calories to breathe when your lungs are filled with thick mucus, and it’s nearly impossible to digest lipids, protein, and carbohydrates when your pancreas isn’t producing enough enzymes).

thus, the medical nutrition therapy (MNT) for CF patients is a high-protein, high-fat diet with supplemental enzymes and fat-soluble vitamins. anything we can do to increase intake, absorption, and subsequent weight gain is a good thing.

a second case: a heartbreaking 7 yo girl with acute lymphocyte leukemia (ALL), or a type of blood cancer. the nutrition consult was to help the patient find foods that taste good while she undergoes chemotherapies. (FYI: chemotherapy can lead to dysguesia, or a change in taste, and sometimes aguesia, the absence of taste, and it can also suppress appetite).

the best part: this little girl wanted to talk to me. i love it when the kids will talk while the parents patiently listen. the girl’s problem seemed to be a mixture of dysguesia (meat didn’t taste good to her; chocolate chip cookies did!) and simply a dislike for the hospital food.

since she had been steadily losing weight, i educated her on tips for combating dysguesia and appetite changes, i encouraged her to focus on ordering/eating the foods that she knew tasted good, and i added supplements (calorically-dense chocolate milkshakes, puddings, etc.) to her daily meals.

i’ll be checking up on both patients next week to see if the supplements/tips have helped their weight and appetite.

i also got my first bit of experience calculating TPN this week. TPN (total parenteral nutrition) is formula/nutrition delivered through the veins and requires careful planning and calculation.

more to come!

busy week…

two weeks down, 10 to go…

last week was incredibly busy due to an increased patient load for my preceptor (MP). it’s hard to tell whether MP had an increased load or if i was simply slowing her down.

i also attended the Nutrition and Food Service (NFS) Department meeting as well as the pediatric RD meeting.

overall, the NFS department seems to have high employee satisfaction scores, except among the dietitians. chief complaint: they want more help. the good news: the hospital bigwigs have just approved a new budget that includes monies toward the hiring of new registered dietitians (RDs). this made everyone happy.

last week I worked on two calorie counts. a calorie count is simply a tally of a patient’s intake (usually kept by the nurse or the patient’s caregiver for 2-3 days). it’s the RD’s job to calculate the total calories and protein consumed and make recommendations regarding whether or not the patient is meeting or exceeding her needs.

i was surprised by how much estimation the RDs use. for example, the calorie count might list “four waffle fries” without any indication of whether the fries came from inside the hospital or if they were smuggled in by a family member. because the nutrient density of a french fry can change depending on what oil it was fried in, how thick the potato was cut, etc., estimation can lead to a less precise nutrient analysis.

MP mainly used Calorie King to estimate the kcal and protein in items that may have varying nutrient contents (like french fries); however, she used the exchange system to analyze items that have standardized contents (e.g. 8 oz. of whole milk has 150 kcal and 8 grams of protein. period.).

one has to assume there is a better way to calculate total intake, especially at a hospital that uses computrition. i assume the hospital’s computrition system knows exactly how many calories and grams of protein are in the waffle fries the kitchen pumps out. perhaps this would be a better way to handle calorie counts for foods produced within the hospital?

more to come!

day in the PICU…

today i spent most of the day in the PICU (pediatric intensive care unit) with a different preceptor, while my preceptor was out for the day.

two interesting cases: a 17-year old girl had burns covering 55% of her body while another boy had multiple tumors in his meninges, which are thin layers of tissue that cover the brain and spinal cord. we spent the day analyzing their tube feeds and determining whether or not what they’re receiving meets their needs and making recommendations for changes.

we also saw an interesting FTT (failure-to-thrive) kid in general peds who was having a hard time swallowing. we visited the patient and the parents to obtain a diet history, which is basically collecting what, how much and how often they usually feed the patient at home.

this is an interesting case because there are a few etiologies (causes) for his FTT. for one, the child is super active (burns a lot of calories) and resists eating (the parents said that it takes ~1 hour to feed him one scrambled egg). that immediately sent up a red flag — any parent who allows a full hour for one egg is a) probably not using the best feeding strategies (i.e. not in a high chair, not face to face, not very responsive or interactive) and b) is probably allowing the child to immediately burn off whatever is being put in.

the best part: by chance, we were able to witness a feeding during our consult. the parents’ feeding style was, in fact, not very responsive. (FYI: “responsive” refers to an infant feeding style where the parent and child are making eye contact, the parent is talking to the child and maybe reinforcing that the food is yummy, and it also involves some modelling, or literally showing the baby how to chew, swallow, etc.)

the patient was holding food in his mouth for extremely long amounts of time (which made us think there was some sort of physiological swallowing issue). this is also called “pocketing” food in his cheeks. also, because his mouth was full of food for so long, he sort of forgot it was there and at one point he tried to cry out and actually aspirated (breathed in) the food, which caused him to choke and vomit. his parents were also sort of mindlessly spooning in more food, even though his cheeks were distended and full. i’m not sure if this is because we were in the room and they were preoccupied, or if this is par for the course for the type of feeding style they use.

also, it’s interesting to note that the patient was sitting on his dad’s lap facing outward as dad was reaching around and spooning food in. there was absolutely no interaction between them and the baby repeatedly pushed food away.

not surprising that i was thoroughly interested in this case. (FYI: i’m 99.9% sure that i’m going to become a lactation consultant after graduation, but now i’m also wondering if i can, in some way, specialize in infant/pediatric feeding/education as a whole).

i’m a bit confused about whose job it is to make sure these parents are educated on proper feeding techniques once poor habits are identified (in the hospital or anywhere else). is it the WIC dietitian’s job? my preceptor said no. is it our job in the clinical setting? again, my preceptor said no. is it their family general practitioner or occupational therapy or a speech language therapy’s job?  still wondering…

back to general peds tomorrow. i’m going to need to put in a good hour or two one night this week to create some cheat sheets to help me through all of the calculations that many of these dietitians can quickly rattle off.

i’m starting to wish that my clinical experience was going to be longer than 12 weeks, which i never thought i’d say.

more to come!