Organize Me: Clinical Edition

My acute care clinical rotation flew by and although it was tough, I grew to love every single minute of it at the Baltimore VA Hospital. With my preceptors, and staff helping me whenever I needed pertinent information about a patient, I found myself appreciating them for every single thing they did. I created relationships there and this was essential for my success. Another thing that made me successful was my reference sheets. These became tools for me to make me more efficient at what I did.

When I was in clinical, my mind was going a mile a minute. Clinical is tough and it never slows down but I gave myself peace. This was done by making my own reference sheets for medications, supplements, formulas, PES phrasing, and more. These were essential for my success at clinical and I think it is useful to have on hand. As a current intern giving a future intern advice, try and prepare a quick reference sheet before you go to your clinical rotation. It shows initiative to your preceptors and can be your saving grace if you get in a tough spot.
Things to consider having on a reference sheet:

• Common medications (brand name, generic name, use)
• Common supplements: Nestle, Hormel, Abbott (kcal/pro)
• Types of Insulin Chart
• BMI chart
• % Significant weight loss over time
• Common PES statement 
• Energy requirements (kcal/kg, Penn State, Mifflin St. Jeor, etc...)
• Adjusted weight for amputation
• Fluid adjustments for dialysis

You may receive a form with your hospital's assessment standards on it but it may not be organized in a useful way for you. I love making tables so this is the route I took when organizing my resources. As long as you reorganize it, make it colorful, and bold so that you use it effectively then you'll do great.  Not every technique you try will be effective the first time you use it. I made a list of over 100 common medications alphabetized before I went to my clinical rotation. Once in my rotation however I found that it was difficult to read and it took forever to find medications on it. After a few days of struggling with it, I went back and condensed it down by category of medications. This helped immensely. Your clinical rotation is a learning process, you learn what works and what doesn't. 

Another thing I made for myself was nutrition assessment sheet. It included everything I needed for a nutrition note at my hospital. I printed it out everyday and used this to organize the information I needed so I only had to look at this while I typed my notes. My notes were much more cohesive when I used my assessment sheets. You can create and adjust it for your clinical rotation and you may find yourself not needing as much information as you go through your rotation.

Things to consider having on a nutrition assessment sheet:

• Name
• Height/Weight
• Room #
• Labs
• Meds
• Diagnoses/Medical Hx: 
• Skin
• Intake from kitchen data or RN
• Subjective Pt. Appetite/Intake
• Nausea/Vomiting/Chewing/Swallowing/Diarrhea/Constipation
• Energy requirements 

These are just suggestions of tools to make in order to have clinical success. Once I utilized these tools, my clinical rotation went much smoothly and I saw myself working more efficiently. I hope that this helps future interns because it helped me. Try new things and be a success. 

Cassie Burr
UMD Dietetic Intern 2015-2016
www.casandraburr.com
Twitter: @cassie_burr

Indirect Calorimetry for Nutrition Assessment

By: Angela Farris, MA

I've spent 12 weeks of my dietetic internship in my clinical rotation. I was lucky enough to spend a few hours of my last day at the hospital in the Pulmonary Function Lab learning about indirect calorimetry. By definition, indirect calorimetry is the amount of heat generated in an oxidation reaction by determining the intake of oxygen consumed (breathing in) and the amount of carbon dioxide out (breathing out). Using the correct equipment and computer program, a range of calculations will be formed revealing useful information for dietitians.

I entered the room and was told to sit down in a chair and relax; any movement can alter the results. I answered provided simple questions like my age, height, weight, and sex. Next I was fitted with a mask and my nose was plugged. The machine was turned on and for the next 5-7 minutes I took normal breaths. This simple test revealed some interesting information!

Here are the results from my indirect calorimetry:

REE (Kcal/day): 1672 *REE=Resting Energy Expenditure, or predicted amount of calories my body burns each day.

RQ: 1.35 *RQ=Respiratory Quotient, or the ratio of carbon dioxide I released to the oxygen I consumed. Goal should be between 0.85-1. (I was told my 1.35 could be related to my carb-loaded breakfast of cream of wheat & fruit)

VCO2 (mL/min): 289 *VCo2=average rate of elimination of carbon dioxide

VO2 (mL/min): 213 *VO2=average rate of elimination of oxygen

Dietitians can utilize indirect calorimetry to get an educated estimate of their patient's exact caloric needs using REE. In Critical Care it is a golden rule to not 'overfeed' the patient. Using indirect calorimetry in conjunction with professional judgement can possibly lower the time a patient is critically ill. Just another reason nutrition matters! :)

Modified Barium Swallow: a Dietetic Intern's Perspective

By: Angela Farris, MA

During the 6th week of my clinical rotation I was able to participate in a Modified Barium Swallow (MBS) evaluation performed by a Speech Language Pathologist (SLP). In order for a patient to have a MBS performed they must have some sort of dysphagia, aka difficulty swallowing. The first step to determine if a patient has dysphagia is for a SLP to perform a bedside swallow evaluation. During this evaluation the SLP feeds the patient a number of liquids and foods to determine if the patient is at risk for aspiration. Have you ever had a drink or a piece of food "go down the wrong pipe"? If you have, you've aspirated. The problem is that if enough foreign body gets down into the lungs via aspiration bacteria can grown and an infection can spread making a patient very ill.

Below is a video showing a MBS with aspiration:

(aspiration occurs at 0:05 seconds; notice the dark liquid on the left)

The patient I followed failed their bedside swallow evaluation so the next step was to perform a Modified Barium Swallow. A MBS is a definitive way to check for any aspiration risk and determine the appropriate diet modification (i.e. mechanical soft, pureed, regular).

The SLP prepared 5 different test food/drinks for the patient to swallow; a graham cracker, applesauce, water, nectar-thick iced tea, and honey-thick juice. Each item received a barium-powder additive so that it would be easily viewed during the X-ray. Yes, the SLP encouraged me to try the powder -- and I did. Let's just say it makes everything taste like berry-flavored chalk!

I stood behind a protective wall and watched the MBS in real-time. It was amazing to visually see how our bodies have a natural rhythm while swallowing -- more muscles are involved than I could have imagined. It was a great experience and I'd like to see another before my clinical rotation comes to a close.

Here is a further description of modified textured liquids:

• Thin liquids: any regular beverage, ie water, juice, iced tea
• Nectar-thick liquids: easily pourable & are comparable to apricot nectar or thicker cream soups
• Honey-thick liquids: slightly thicker, less pourable, & drizzle from a cup or bowl
• Pudding-thick liquids: hold their own shape; are not pourable & are usually eaten with a spoon

The next time I take a drink or chew a piece of food, I will surely appreciate my ability to swallow!!

Clinical Rotation Milestone #1: Mini Case Study

By: Angela Farris, MA - UMD dietetic intern

Five weeks ago I started my clinical rotation, a rotation that I was both excited and nervous to begin. The clinical rotation requires an intern to learn an endless amount of medical terminology, abbreviations, and drug/nutrient interactions on top of mastering electronic medical record systems and assessing/counseling patients in a critical care environment. This is by no means a small fete!

Before I started I knew I had a databank of medical nutrition therapy knowledge stored up in my cortex; it was retrieving this info that took effort. Homework assignments and intern class day lectures restored my confidence and enabled me to complete my first clinical nutrition screen, assessment, and patient education. I’m proud to say I've achieved many personal milestones since I began the rotation. I've performed a chronic heart failure (CHF) diet education, taught carbohydrate counting to a diabetic patient and charted a complete nutrition assessment for an enteral nutrition patient.

During the fourth week of my rotation I was scheduled to present my mini case study. The mini case study is one of the ‘official’ milestones every intern must complete during the first half of their clinical rotation. This mini case study profiles a specific patient and provides a suggested plan of care including any interventions. Additional information found in the case study includes a patient’s background, past medical history, medications, anthropometrics, lab values and estimated nutritional needs.

I’m happy to report I successfully presented my mini case study to four clinical preceptors. As an intern I realize there is always room for improvement. Below I've provided a few tips for my fellow interns that have not yet presented their mini case studies:

1. Know your patient’s medications - review the drug's purpose, specific action, & any drug/nutrient interactions.
2. Bold face lab values that are high or low. This will make it easier for your audience to detect abnormalities.
3. Include references! Document where you found your information.
4. Be prepared for questions.
5. Use feedback & constructive criticism to empower yourself. Couldn’t answer every question? Don’t feel frustrated – that’s why we’re interns :)

I’m excited to begin the second half of my clinical rotation. Next ‘official’ milestone? Major case study!