Dietetic Internship Week 3: Nutrition Care I

Internship is starting to feel a bit more settled after the initial weeks of orientation and getting adjusted to being in a hospital environment. A routine is becoming apparent from the things we do from day to day, and that is no longer a shock to me. Now that the outline of this internship period is more defined, I’m turning my attention to the finer points of patient care as a dietitian.

This week, my internship buddy and I started by seeing a couple of patients each day and charting on them. I’m refining my understanding of what medical information to include and what not to include. For example, background about a patient’s medical status should be included in their initial nutrition assessment, whereas in a follow-up report, only changes need to be noted. My internship buddy mentioned that she asks herself “if another dietitian had to take over this patient’s care, would they have all the information they need from my chart note?” as a way to make sure she’s got all the relevant details. Another important tidbit is to make sure the PES statement, goals, implementation & follow up all relate with one another. This sounds intuitive, but when I review my chart note, I am often surprised how frequently this does not happen, so it’s a good yardstick to keep in mind when charting.

Vancouver Public Library Entrance
Vancouver Public Library Entrance

We talked about transitioning a patient from a continuous to an intermittent feeding schedule. My preceptor transitions most patients over 2 days, and the goal rate can vary depending on the end site of the feeding tube. In a jejunal feeding tube, the max rate is 175 mL/ h, as any more would likely lead to bloating and discomfort. In a gastric feeding tube, the max rate can be much higher, since the stomach is designed to be a holding place for food. Some patients who are on bolus tube feeds often inject ~300 mL of feed into themselves in a few minutes, which isn’t so different from downing a milkshake. Some strategies our preceptor mentioned when designing the transition included: stopping the continuous feed the night before so the patient will be hungry in the morning when the intermittent feedings begin, leaving a 2-3 hour gap between each feeding when starting the transition, paying attention to open versus closed systems (closed is more convenient and less likely to be contaminated), and being mindful of nursing shift changes: make sure to schedule the beginning of tube feeds an hour before/ after the change of shift, otherwise it’s more likely that the tube feed may be forgotten during the switch.

The most valuable learning experience is seeing patients on my own and getting timely feedback from my preceptor. One area (among many) I need to improve is my patient interviewing skills. As part of our nutrition care I requirements, we developed a custom nutrition assessment and progress form to assist with patient data collection and synthesis. I find it a helpful prompt and it definitely reminds me to ask some less comfortable questions, like “can I take a look at your upper arm to assess your nutrition status?” However, it’s impossible to fit all the questions that I may need to ask to clarify and gain a more detailed understanding of a patient’s intakes and weight history. Even very simple follow-up questions that seem intuitive, like asking a patient who mentioned difficulties chewing which food items they had difficulties with, or digging a bit deeper to find out when and why a patient’s diet order was changed from general regular to pureed thick if there were no clear indications from a person’s medical records. A lot of this comes from being exposed to different patients and situations. Right now, I feel pretty rigid when speaking with a patient, and I think this prevents me from picking up some of the more individualized nuances of a person’s eating abilities, dietary preferences, and nutritional needs. I’ve noticed being relaxed and curious about a patient can make the information gathering process feel less intrusive. Another aspect of successful patient interviewing is having enough confidence and self-assurance to ask questions. Because ultimately, having the right information helps healthcare providers recommend better options for patient care, and that’s the end I’m trying to keep in mind throughout my learning process.

View from St. Mark's Summit on Cypress Mountain
View from St. Mark’s Summit on Cypress Mountain

We’re also starting our research projects in earnest now. My group is assessing 4th year dietetics students’ perceptions of their upcoming integrated internships. There’ll be semi-structured focus groups conducted in March, and together with UBC researchers and our research module preceptors, we’ll be compiling this research, presenting our findings at the intern research symposium in June, and hopefully sending it for publication in the Canadian Journal of Dietetic Practice & Research.

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