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

Looking Forward to Elective Week Rotation!

By Joyce L. Hornick, Dietetic Intern

I can’t believe I am almost at the end of my internship and that means elective week is just around the corner! The elective week is an opportunity for interns to explore any realm of dietetics they want. Some interns explore a new opportunity they didn’t get to experience during the internship, such as private practice. Since some rotations are only a week long, some interns return for a more in-depth experience. Some interns choose an elective where they may have a direct connection for a job opening or to expand their networking. The possibilities to explore are vast. 

I decided that I wanted to return to where I first started the internship, Moveable Feast, a nonprofit organization that provides meals and groceries to people with HIV/AIDS, breast cancer, and blood cancers. Even though it was a 3 week rotation, I wanted to go back to learn more. When I was there in September, I got the opportunity to counsel patients via telephone interviews. I was very uneasy at this since I had only done “counseling” in the classroom in role play simulations. Most interns go to Moveable Feast after they’ve done their clinical rotation, so they’ve been able to hone their assessment skills over 10-12 weeks. I hope to do some phone interviews again to see how I’ve grown in my ability to perform assessments. I know I will be more confident, will be able to take what the client tells me to quickly make suggestions for change, and help set goals to help maintain or improve their nutrition status. 

I am also looking forward to new learning opportunities available at Moveable Feast. Back in September, due to funding constraints, Moveable Feast wasn’t doing home visits. Going back now will give me the opportunity to perform this valuable nutrition evaluation for their clients. Grocery deliveries were also very limited in September, so I will also get the opportunity to assist drivers on home grocery and meal deliveries this time. Other plans are to visit patients while they are making their HIV/AIDS outpatient visits at Park West Clinic, helping AIRS clients with a grocery store tour, and hopefully, getting to work in the Moveable Feast community garden!

Comparing Adult with Pediatric Nutritional Assessment

By Joyce L. Hornick

In the fall, I worked at a community hospital as a clinical dietitian helping adult patients. In January, I got the opportunity to work as a clinical dietitian at a children’s hospital helping pediatric patients. Even though we’re all humans, the nutritional care of these two populations is completely different.

Estimating energy and protein needs of an adult follows systematic scientific equations. The energy and protein needs of most adults do not vary widely, from person to person or from day to day. The primary goal of calculating energy needs is typically to maintain current nutritional status if well-nourished, and to prevent loss of lean body mass. Even with chronic illness, needs estimation is relatively easy to achieve. Specific dietary and food recommendations are made depending on the diseases a patient may have and how they can use food to help improve their condition or prevent further progression of the illness.

In infants, the estimation process is much more complex, especially if the infant has a chronic illness or was born with a congenital or genetic defect. In older children and adolescents, the estimation process is still complex, though the rate of growth is typically at a slower pace. The primary goal of energy and protein estimation is to continue with a consistent upward growth pattern. It is very important to prevent trends toward a negative growth curve which could lead to Failure to Thrive. Depending on the type of illness a child has, their energy needs could be double what a healthy infant needs.

The energy needs of pediatric patients are based on their physical body weight. For a newborn, whose weight should be increasing typically by 25-30 grams per day, their energy needs will need to be evaluated every month to month and a half. If the chronic condition they have increases their metabolism, they may need twice as many calories to have optimal weight gains and their energy needs may need to be evaluated more often. Specific dietary and food recommendations are made much the same way they are made with adults. Though, since children tend to be pickier eaters than adults, there is a higher risk of malnutrition.

I was quite naïve upon starting my clinical pediatric rotation. I thought to myself, how hard could it be? Children are smaller than adults, but how much different can their nutritional needs be? In reality, their needs are much different than an adult. It was eye opening to see how detailed some pediatric patients needed their nutritional needs planned out. Children with special dietary needs due to illnesses need individualized care plans, just like adults, but the risk of malnutrition is much greater, making the care plan that much more important and even more detailed.

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! :)