The week of Sept. 15-19 was my first full week of being a dietetic intern. During this rotation, I am paired with another intern, and both of us started our week by following our preceptor in all that she did.
First thing in the morning, our preceptor would start by printing out a list of all the patients who are on her wards. She would then review the previous work day’s notes about the patients who did not get discharged (which would be the majority), and transfer any planned follow-up dates/ details about these patients to the new list. She would then check the physical & admitting report of new patients admitted to the ward using the electronic medical record system to decide if they should receive further screening. There are usually a few patients who get referred to her through nurses, doctors, or other allied healthcare workers. She makes a list of patients to see, which includes the patients she wanted to follow up with, referrals, and new patients. From what I’ve seen, this list is 12-15 patients long, and we need to prioritize the patients we want to see. The patients we prioritize include: anyone who is starting/ transitioning to a new feeding regime, referred patients, those with severe unintended weight loss, and those with nutritionally-relevant diagnosis.
I learned this week that “seeing” a patient may not always involve talking to a patient. Much of a patient’s information relevant to dietetics can be obtained from the patient’s chart notes. For example: the amount of hospital food eaten, bowel movement type and frequency, IV infusion rate, patient’s self-feeding ability, dysphagia status, and the medications a patient is on. Sometimes a patient isn’t the best source of information, especially when there are neurological impairments that limit their speech or cognition. In this case, talking to family or previous care facilities can be incredibly helpful in gathering information. Some information which feels like it should be easy to obtain, like a patient’s weight and height, can actually be somewhat challenging. Some patients are unable to provide this information themselves, some patients are unable to sit or stand safely to be weighed, and a few require a bed lift to move them from the bed. I asked a pharmacy resident how she deals with not knowing a patient’s weight. Her response was to ask them to step on a scale, and to ask nursing for help if needed. I guess I could do that too.
Another difference between being in hospital versus learning from a book is the amount of information that need to be sifted through in order to gain a complete picture of a patient’s nutritional needs. In case studies, we’re presented with all the relevant information about a patient in 2-3 pages. In real life, someone may have 20-30 pages worth of information on the electronic record system documenting their recent hospitalizations in the Fraser Health Authority. A part of our learning this week is picking out nutritionally relevant information to include as part of our assessment of a patient.
Another aspect of patient care we got to practice was asking for the patient’s consent. I think we talked about consent in our professional practice courses, but somehow saying the words to a person in real life feels so different. One of my favourite parts of the orientation training was learning to use the Subjective Global Assessment (SGA) to assess a patient’s nutritional status. We then practiced the SGA on a couple of patients. Looking back, I realized we practiced on particularly lucid and willing patients who were able to give informed consent. In actual patient interactions, I still feel awkward about asking patients whether it would be alright for me to touch their arms, and if I can take a peek at their collarbone; especially when they look so weak lying on a hospital bed with an IV attached to the very arm I wanted to examine. So I need to practice talking to patients and being confident when asking questions. It’s really strange to embody the role of both a healthcare worker and a student at the same time.
After the information gathering is complete, the next step is deciding what/ if anything should be changed in a patient’s nutrition plan. For oral diets, this could involve changing a meal’s texture, type, or components (such as adding nutritional supplements, or adding fruit at all meals). If a patient is on nutrition support (enterally or parenterally), the rate and type of feed could be adjusted. Sometimes, the follow up is continuous monitoring of the patient, which is different from “discharge from active nutrition care”. Discharge education is another possibility as well.
So after gathering information and implementing the nutrition intervention, we get to document, or chart, what we did. This involves recording nutritionally relevant medical, social, anthropometric, diet information, as well as writing a Problem-Etiology-Symptom (PES) statement about the patient and and recording our implementation and follow up plans. At the end of the day, we assign a Nutrition Acuity Score (NAS) to the patients we’ve seen for statistical purposes.
That’s pretty much the gist of what I’ve been observing for the first few days of internship. By the end of the week, my fellow intern and I have screened the wards’ new patients, assessed a patient’s nutrition status, made diet order changes to cater to patient’s preferences, and charted on patients. We’ve still got a long way to go: becoming more knowledgeable about drug-nutrient interactions, developing better clinical judgement about patients, and just being… better and faster at everything.
Personally, I’m trying to to adopt to the next three weeks’ 7:30 am – 3:30 pm schedule. I don’t remember a time when I had to wake up at 6 am almost every day of the week. I guess I’ve been pretty spoiled. The awesome part of this is that we get off work during daylight hours (yes, even during the overcast days!), and I have time for other pursuits afterwards. I’ve been trying to workout three times a week for at least 30 min. It’s been somewhat successful so far: I managed to hit the gym, go for a run, and do a hike in the last 7 days. Here’s to keeping up good habits.
One of my goals for this current week: be more articulate when speaking and thoroughly consider all information before coming to a conclusion about a patient’s nutrition care plan.