Dietetic Internship Week 8: Nutrition Care I

Divisions of patient care responsibilities amongst healthcare providers can change depending on the patient’s needs. A patient’s fluid status is one area where the role of the dietitian overlaps with other disciplines. For patients who experience dangerous changes in their blood pressures, doctors play a large role in managing their fluid status (which impacts blood pressure) through prescribing IV fluids, medications, and probably other measures as well. These patients tend to be in higher acuity units for close monitoring of their bloodwork, fluid intakes/outputs, and vital signs. If such a patient is also tube fed, the dietitian is responsible for suggesting the rate and type of formula used. However, flushes are often minimized (25-30 mL Q4H) in order to simplify fluid management as much as possible. In the hospital where I’m currently interning, the dietitian in the High Acuity Unit (HAU) only recommends minimal flushes, which would be insufficient to meet the patient’s fluid needs without additional IV fluids. This works well in the HAU, where a patient’s fluid balance is closely controlled through IV fluids. When a patient becomes more medically stable and gets transfers to a ward unit, the ward dietitian needs to assess the patient in a timely manner (within the same day) to make sure that their tube feed formula, rate, and flushes are still appropriate for their needs. With regards to fluid status, it’s important to recommend increased tube flushes in the event that IV fluids are discontinued so the patient can remain adequately hydrated.

The big picture of being a clinical dietitian is becoming more clear as I encounter more patients. For most patients, it boils down to matching their estimated nutritional needs to what they’re receiving in hospital– except in cases where it would be unethical to do so– not appropriate for plans for care, patient does not consent, etc. I think the clinical dietetics courses I took did a good job of covering the nutritional requirements of various disease states (how much information I retained afterwards is a different question). However, I don’t think I learned how to deal with factors that impact a patient’s intake within a hospital setting in class. So I’ve listed a few of the issues I’ve encountered (underlined in red) as well as some potential solutions to these problems.

A mind map of factors that influence a patient's estimated nutrient requirements and a patient's intakes.
A mind map of factors that influence a patient’s estimated nutrient requirements and a patient’s intakes. Please alert me about any wrong information and forgive my mistakes.

One skill that I would like to focus on improving is effective communication with the healthcare team, patients, and their families. My preceptor’s motto is: the more you communicate, the better your chances of success. Having the right information and giving information appropriately are important for coming up with a good nutrition care plan and having that plan implemented. What this means for me would be:

  • Talk to nursing as part of my nutrition assessment– ask about a patient’s oral intakes, tube feed tolerance, and physical signs and symptoms related to nutrition such as nausea, vomiting, and abdomen distention.
  • Talk to the patient and family about potential implementation plans, and assess if the plans will be accepted. Encourage patient/ family to follow with nutrition plan when appropriate. Education can be one way for patients to get on board.
  • Talk to nursing about any changes to a patient’s diet (new supplements, etc), tube feeds or flushes, or special instructions related to nutrition.

I have one more week in Nutrition Care I to soak up all that I can before my Management rotation. I’m excitedly optimistic.

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