Dietetic Internship Week 7: Nutrition Care I

The second placement of my Nutrition Care I module takes place at Royal Columbian Hospital in New Westminster, BC, and I just finished my first week as on the neurosurgery and acute care for elders (ACE) wards.

Being on new wards, I was initially bombarded by new terminology: morbidities, drugs, medical devices, and anatomy terms to name a few. I’m constantly searching up new words on Google when reading a patient’s chart notes and my preceptor has been pointing out some of the more common and nutritionally relevant ones to me, which has been helpful for my learning process.

One disease state that I’ve been wanting to learn more about is chronic obstructive pulmonary disease (COPD), and I was lucky enough to assess a patient with COPD exacerbation this week. COPD is caused by damage to the lung air sacs (alveoli), can result in coughing, difficulties breathing, shortness of breath, and excessive phlegm production. Nutritionally, COPD patients have a higher energy requirement due to the increased effort needed to breath. Unfortunately, eating can be challenging for this patient population. The act of meal-preparation, self-feeding, and chewing can be difficult due to shortness of breath. Swallowing requires holding one’s breath for the duration of the swallow in order to protect the airway, and this can be uncomfortable for someone who has poor lung function and decreased oxygen exchange to begin with.

From a nutrition standpoint, a few things to consider for patients with COPD:

  • Can they benefit from an easy to chew or minced diet?
  • Do they need additional energy or protein?
  • Are they on any long-term medications (such as corticosteroids) which interfere with nutrient metabolism?

I also got to practice my first tube feed start at RCH! The patient who is receiving tube feeds has a low BMI, been eating poorly for about 4 weeks, and the patient’s illness is associated with increased energy needs. As a result of malnutrition and the disease state, their estimated energy requirements were a bit higher than what I had initially assessed. But that’s part of the learning process. One more piece about this patient we had to consider was the fact that they were at risk for refeeding syndrome (more information here) due to their low BMI and prolonged inadequate energy intakes. Part of the refeeding protocol includes lab orders for Mg, Phos, K. It’s important to wait for the lab results to come in before starting the tube feeds. If the lab values are normal, tube feeding can begin. If Mg, Phos, or K is low, repletion of the deficient micronutrient(s) should begin before starting to feed the patient. Patients with refeeding syndrome risk are also started at a lower rate and the tube feed is advanced to goal rate more slowly (3-7 days vs. 1-2 days). Other measures to reduce the risk of refeeding include: administering thiamine, a multi-vitamin and mineral, and more frequent lab tests for Mg, Phos, and K, all of which are a part of standard procedure for patients at refeeding risk in Fraser Health. After discussion with my preceptor and the patient, we decided to provide all of their estimated energy and protein needs through the tube feed, but still provide them with a full fluid tray (minus high carbohydrate items) during mealtimes so they can choose to have some of the items (such as soup) if they wished to.

One thing I’ve been concerned about is that I’m very slow at assessing and following up with patients. Everything from reviewing a patient’s chart, to interviewing a patient, seems to take me forever. I brought this up with my preceptor today and she mentioned to not worry about it, because I’m still learning, and it’s more important that I take time to understand the concepts behind what I’m doing. Over time, it will get faster, she reassured me.

Goals for next week:

  • Write complete and logical PES statements. Make sure it’s well supported by the information included in the rest of the chart note and the nutrition problem identified is the most relevant one to the patient.
  • Conduct patient interviews based on their specific condition and concerns.
    • I created a new patient assessment form to use, hopefully this will help!
    • I’ll develop a habit of thinking about which questions I want to ask the patient before talking to them to make sure I get the key information I need.
  • Practice big picture thinking supported by details
    • Understand which parts of the patients’ condition is influenced by nutrition and judging if that influence is clinically significant, and if dietitians need to address it. .
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