where did june go?

failing to blog in over a month is not evidence of an event-free six weeks. there is a lot to report, many interesting patient-stories to tell. i’ll try to hit the highlights over a few separate posts…

right now i’m scanning over past patient lists and chart notes to jog my memory of who i’ve seen over the past few weeks.

a “patient list” is just as it sounds — a list of patients that my preceptor (MP) is following. MP and i use the list to plan out our day and to prioritize what patients we’ll see based on any new consultations receieved (from the docs) or based on each patient’s risk level (i.e. their level of nutritional need/acute illness).

a “chart note” is a written record of the care provided to a patient. please forgive me if this is tedious. at our hospital, all of the charting is done online, which is extremely convenient. laptops are scattered throughout the building, allowing us to look up past notes, lab values, medication lists, past medical histories from anywhere, anytime. computerized charting also allows us to write our assessments in a clearer way (read: full sentences with no need to decipher horrible handwriting). the ability to cut and paste information is also priceless — we don’t have to spend time rewriting past medical histories or quotes from other practitioners — we can simply ctrl+v it into our notes. awesome.

most hospitals are still charting by hand, which tends to be messy and time consuming. i’ve absolutely learned that if clinical dietetics is in my future, e-charting may be a necessity.

finally, a GI patient…

today i saw my first gastrointestinal (GI) pediatric patient: a 15 yo boy who had just been diagnosed with ulcerative colitis.

ulcerative colitis (UC) is no fun. UC is a type of inflammatory bowel disease (IBD) characterized by a colon (large intestine) that is covered with ulcers. there are a number of etiologies: environmental, genetic, autoimmune, some think infectious (from a virus/bacteria/etc).

ulcers in one’s colon often leads to intense pain, diarrhea, bloody stools w/ mucus, and sometimes anorexia (loss of appetite) due to the eventual aversion to foods that trigger the symptoms.

the main medical nutrition therapy (MNT) for this type of patient in the acute hospital setting is first and foremost to stop the pain and inflammation (in this case with pain meds and steroids). once the symptoms are under control and the flare up has subsided, the second step is to get the patient on a low-residue (low fiber), low-fat diet with lots of fluids and fat-soluble vitamin supplements to allow the bowel to heal and replenish lost electrolytes and vitamins.

my job was to educate the 15 yo about his GI and his new condition. my main goals were to make a diet plan for him and his family to fall back on during the next flare-up, or teach him how to manage the condition through diet (e.g. lay off high-fiber, high-fat, high-caffeine foods during flare ups).

it was a major bonus that both mom and dad were in the room for the entire visit. they learned a lot as well.

we also talked about how the patient will slowly figure out his own individual “triggers,” or foods that bring on an acute flare-up. his triggers may be caffeine and stress, while his mom says she reacts to alfredo sauce (she also suffers from UC).

before i visited the patient, i really had to think about how i was going to educate a 15 yo boy about his bowels. not an easy sell. i had to figure out a way to make the patient care about his condition and take a bit of interest in the plan of care.

my idea: i would focus on his height. my thinking was that 15 yo boys (and girls) are really still thinking about linear growth, which at 15 is absolutely still happening and absolutely tied to nutrition. as a child becomes malnourished, the first thing to go by the wayside is weight, then height, then brain growth (in pediatrics, brain growth is measured by head circumference).

so, my plan with this kid was to start the conversation with my goals to continue to see nice, normal weight gain (only possible through good eating/bowel health), so we could protect his linear growth (height).

i think i got through.

more to come!

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!