Clinical: doing it well

As I dive deeper into my clinical rotation, I’d like to take this opportunity to reflect on what I’ve learned about being a clinical dietitian. Aside from the clinical experience itself, I had the benefit of working with a variety of clinical dietitians to pull techniques, shortcuts and tricks from. I’ve learned that there is not one right way to be a clinical dietitian – there may not even be a best way. Throughout my journey I was impressed by a clinical dietitian with a compassionate bedside manner, and equally impressed by a dietitian who was rarely able to speak with her intubated patients, but knew their whole medical plan of care as well as the most current, evidence-based approach to their nutritional treatment. I was amazed by the speedy, efficient work of one dietitian while admiring another’s greatly detailed and thorough reports.

It has been a relief to discover that a variety of personality types make good clinical dietitians. The important factors in becoming “good” are to know your strengths, practice to your strengths, and stay passionate about your work!

The shortcuts and tricks I learned from the clinical dietitians I’ve worked with thus far are as follows:

• Start the day by organizing your patients – color code
• As you’re jotting down patient information, plan for the patient interview by highlighting areas you need to ask about
• I repeat: use a highlighter
• Create your own shorthand
• Use the fishbone to record lab work – it doesn’t take long to learn
• Talk to the nurse! They can tell you key info faster than you can look it up

And feel free to add your own.

Renal Nutrition for BBQ Season

By: Sasha B. Bard, MS, Dietetic Intern

A few posts back one of my fellow UMD dietetic interns, Joyce Hornick, wrote a blog about her experience with renal nutrition.

Unlike Joyce, I had been in a dialysis center prior to my renal rotation. My mother is a social worker in a dialysis center in Richmond, Virginia and during graduate school I would go to work with her when I was in town and spend time shadowing her dietitians. From my experiences in both Virginia and Maryland, I completely agree with Joyce- renal dietitians are impressive! They have to wear many hats. One minute an educator, the next a clinician. And at times a cheerleader, a chef, or a counselor.

One of our projects during the renal rotation was to go to the grocery store and compare the nutrient content of various condiments. With barbecue season right around the corner, we wanted to see how much sodium, phosphorus, and potassium there was in some of the popular condiments. My partner, Erika Wincheski, and I looked through bottles and bottles of ketchup, mustard, hot sauce, worcestershire, and BBQ sauces.
Not surprisingly, we discovered that many of the sauces have a high sodium content. Especially barbecue sauces! It varied from brand to brand, but we found some BBQ sauces with 175 mg of sodium per serving and others with over 500 mg of sodium per serving. And keep in mind that a serving of sauce is only 2 Tb! I bet there are a lot of people who use more than 2 Tb on their chicken.

After the investigation we put together a handout for the dialysis patients that included a dialysis-friendly recipe for homemade pulled pork barbecue. The DaVita recipe had dialysis-friendly ingredient modifications, such as salt-free ketchup and Sunny Delight in place of orange juice. (Did you know that 1 cup of orange juice has 430 mg potassium, whereas 1 cup of Sunny Delight only has 23 mg potassium?!?) And it's always best to convince people to try a new recipe with a taste test, so we passed out samples during the patients' treatment. Luckily, it was a hit!

Adventures in Pediatrics

By: Rachel Coury

This week marks the end of my 2-week clinical pediatric rotation at Children's National Medical Center (CNMC) in DC. Children's is world-renowned for the innovative and extensive services they provide in treating kids who are sick. During my rotation, I had the opportunity to gain insight into a variety of unique specialities that their dietitians take part in. My first week was spent with an RD covering general pediatric medicine, neurosurgery, burns, and trauma units. I was able to learn about the ketogenic diet and how it is used as a treatment method for children with epilepsy. This diet is high in fat and very low in carbohydrates with a modest amount of protein. It is designed to keep the body in a prolonged state of ketosis, which has been shown to have a therapeutic effect in preventing seizures in this population, although the exact mechanism of its effect is still unknown.

I was able to see a young girl with Pica (a disease I thought only existed in textbooks) who preferred eating her hospital bracelet to an actual meal of food and performed an initial and follow-up assessment on an adolescent female with a redundant colon. This patient had been suffering from chronic constipation since age 4 prior to the discovery that she had extra loops of bowel in her large intestine making it more difficult for waste to pass through. She came to CNMC to get a colectomy and is hopeful that post-op her constipation issues will be a thing of the past.

My second week at Children's provided just as many interesting experiences. My preceptor covered the intestinal rehab, bowel/liver transplant, and home TPN services. I was impressed by her ability to whip out a TPN faster than I could whip out my calculator. She was part of a unique team who work with children who have short gut. Some of the kids have as little as 10 cm of their bowel remaining (compared to a normal bowel length of ~400 cm), which puts them at severe risk for malabsorption, dehydration, and poor growth. The intestinal rehab team works to ween these kids off TPN as they slowly advance their enteral feeds (we're talking 1 ml per week here if they're lucky). Their goal is to get the kids' short gut to function as closely as possible to a bowel of regular length and maintain adequate hydration as these kids' can suffer from extensive intestinal losses.

As you can see, my experience at Children's was very enriching and exciting. I'm sad to call tomorrow my last day here but am excited to move on to my next site and continue my progression towards becoming an RD.

Until next time!

Can Reading a Story Actually Teach Nutrition Behavior Change?

“Read For Health” a new Maryland SNAP-Ed curriculum focuses on Interactive reading and activities to encourage healthy eating.  At Baybrook Elementary School’s After School Program - Maryland SNAP-Ed Educators (including UMCP dietetic interns) participate in reading nutrition related books like – “WHO NEEDS TO EAT RIGHT”. Some of the children have reading roles…….

 

……..while others read along and help if we might miss a word or two.

 

In “WHO NEEDS TO EAT RIGHT” – there are really two stories.  On the purple side – Tony gets little sleep, eats unhealthy foods and just does not have energy or a lot of fun. When you turn the book over to the green side– Tony gets enough sleep, eats healthy foods, has lots of energy and fun.  During the story children share their ideas on different parts of the book. E.g. What can Tony and his mother do to be better prepared to start the day listing some healthy breakfast foods.  Later they share their favorite activities when you play outside; what are some of the ways you help your families prepare meals.  Every one learns from every one else.

After the story is read – the activity (“the real fun”) begins.  With this story the children make a healthy snack that they can eat a little during the program, but also get to take them home or share later with friends.

The excitement and the interactions this creates are amazing and simply fun to be part of. Nutrition Education can also be fun!

What's the Risk?

During clinical rotation, interns spend eight weeks learning the ropes of a clinical dietitian and two more weeks putting their new skills to the test in staff relief. I am excited to announce that I am heading into my second week of staff relief, and it is flying by too quickly! I am finally getting comfortable on my unit, which includes patients from Med Surg and Critical Care. The biggest challenge with these patients is assessing their nutritional risk. When considering if a patient is at a high or low risk, it is important to look at the bigger clinical picture.

Here are some quick tips for determining the patient's nutritional risk:

• Was the patient well nourished or malnourished prior to admission?
• Does the patient's diagnosis increase calorie and protein needs?
• What type of diet is the patient tolerating: clear liquids, full liquids, or general?
• If the patient is not tolerating the diet, how many days of inadequate intake?
• Do the patient's medications affect appetite or cause nausea, vomiting, or constipation?
• Are there any swallowing or aspiration concerns?
• Last but not least, does the gut work?

Coming to these conclusions is not always an easy task because it involves communication between many disciplines of the medical team. However, collecting this information is imperative to assess the whole clinical picture of the patient. With this information, I can make an accurate assessment of the patient's nutritional risk and develop a plan of care that best meets his or her prescribed nutritional needs.   

'Sailing The Chesapeake' - A Theme Meal

By: Angela A. Farris, MA

As a University of Maryland Dietetic Intern I was able to spend my 6 week food service rotation at Riderwood, an Erickson Living Community in Silver Spring, MD. My internship Partner Joyce and I's main mission was to create, plan, and execute a theme meal fit for Riderwood residents. We chose the theme 'Sailing the Chesapeake' - a traditional, classic menu with flavors of the Bay.

Here I am prepping for our theme meal day

As interns we spent most of our time researching recipes, analyzing recipe costs, performing kitchen sanitation audits, meeting with various Riderwood staff and prepping for theme meal day.

The week of our event we were found mostly in the kitchen, prepping all of our recipes so that on theme meal day we’d have little to worry about. The chefs and cooks at Riderwood were so very helpful in answering all of our questions. Jumping right in the kitchen and not being hesitant to get dirty or try new techniques worked in our benefit. I’d like to think that we gained the staff’s respect for actively participating in every step of our theme meal’s preparation and execution.

Did everything turn out exactly how we planned? No (Re: our 'Tangier Sound' strawberry rhubarb cobbler). Did we serve residents a tasty, authentic meal? Yes! Mission accomplished. It was a GREAT food service experience!!

For more information and documents on our theme meal, check out my ePortfolio site!

Is Being a Renal Dietitian Right For You?

By Joyce L. Hornick

My first thoughts about being an RD who works in a dialysis center are completely wrong. I thought that specializing in renal nutrition would be pretty much the same as any RD working in the clinical setting of a hospital. The only difference would be that you only deal with people who have End Stage Renal Disease (ESRD) and not many other issues. There would be the occasional help with diabetes and blood sugar control, but not much else.

Four days of working with an RD at a dialysis center with approximately 140 patients showed me how wrong I was. Renal dietitians work in a very clinical atmosphere and are very clinically oriented. Patients with ESRD are on many medications. Most of these medications are directly related to their nutritional status, especially with their phosphorus, potassium, sodium, calcium, and vitamin D levels. They need to take phosphate binders to prevent phosphorus from building up in their tissues and blood. If a patient takes them incorrectly, they may not work efficiently. They can also cause upset stomach, vomiting, and constipation. All of their medications depend on their diet and the dosing of other medications. Dosing needs to be fine tuned on a regular basis. The RD is in charge of these dosing recommendations.

The renal dietitian works very closely with their patients. They know who is good at following their diet and who is not. They know who likes a lot of technical information about food and who doesn’t. One question by a patient about hidden phosphates in salad dressings created an investigative and educational project for all of the patients in the center, complete with a handout, a brief education, and a taste test of ranch dressings with pretzels.

If you think being a dietitian at a dialysis center would be too technical or clinical for you, think again. Even though it does involve these aspects, it involves so much more. You get a lot of personal interaction with patients and get the opportunity to help them over a long period of time.