Dietetic Internship Week 9: Nutrition Care I

Early this week, I assessed a patient who was put on a dysphagia thick diet after showing signs of intolerance with thin fluids (such as water or juice). All fluids on the dysphagia thick diet are thickened to a honey-like consistency (thickened juice, blended, thickened soup), and there are no mixed textures (cereal with milk, stew, fruit cup). For some patients with difficulties swallowing (dysphagia), having thickened fluids can help prevent fluids going down the trachea. For this particular patient, I noticed the nursing notes described them coughing and pocketing food in their cheeks when eating. They were also being suctioned for lots of lung secretions, as well as bits of food. Based on the signs and symptoms this patient was exhibiting, my preceptor alerted me that they should not have been allowed to eat due to the high risks of aspiration and aspiration pneumonia. As the patient had a DAT (diet as tolerated) order from the MD upon admission, the role of the RD in this situation is to change the diet order to one that is safe for the patient until they can be seen by an SLP. In this case, the safest diet for the patient was NPO (nothing by mouth). This patient was already awaiting an SLP assessment for swallowing, and since their diet was changed to NPO, this automatically bumps them up to a high priority for the SLPs. The SLP saw them later that day and kept them NPO as well. Soon, a tube feed was started on this patient and they are followed by SLP for progression with their swallowing and potential diet upgrades. This was a pretty neat experience in applying what I have learned about dysphagia to a real life case. Being able to identify signs and symptoms of dysphagia as a dietitian is important for the timely management of this syndrome in patients, especially in circumstances where SLP may not be able to assess a patient right away. In this case, the doctor, nurse, dietitian, and SLP/OT all could’ve picked up on the dysphagia symptoms and made the patient NPO. But having overlapping areas of expertise helps ensure that the patient is less likely to fall between the cracks.

Later this week, when I was observing a bedside swallow screen with an SLP for the same patient, I learned a few more symptoms of dysphagia to watch for:

  • inability to keep food/ saliva in mouth
  • easily distracted when eating and forgetting to swallow
  • multiple swallows  per bolus of food
  • grimaces when swallowing
  • coughing during or after (could be up to 10-15 minutes) a meal

When an SLP assesses a patient for swallowing difficulties, whether they get put a diet depends on more than just their ability to chew and swallow food. Big picture criteria include: patient’s alertness, ability to manage their saliva, oxygen status, and shortness of breath. These are particularly important in an inpatient setting where dysphagia could be the result of a recent, acute injury.

Another patient I assessed this week came to hospital with abdominal pain secondary to constipation. Constipation is a common issue for elderly patients. This condition is commonly assessed by: frequency of bowel movements, abdominal exams, and abdominal X-rays. It’s important to note that a patient may still be constipated even after a bowel movement, as there could be more stool remaining in the colon. Nutritional management of constipation includes increasing fibre (particularly insoluble fibre), and fluid intake. Part of my intervention for this patient included patient education regarding dietary strategies to prevent constipation. Counselling the general public for dietary change is challenging enough, for patients in hospital, there are often other barriers to making positive changes in one’s eating habits post-discharge:

  • mobility: limits frequency of grocery trips, patients may not be able to prepare their own meals, may depend on meal delivery service or family members to bring food
  • cognitive changes: short-term memory loss can impact ability to recall information, dementia can impact appetite and food intakes, there is often decreased ability to perform instrumental activities of daily living (driving, cooking, etc), which can also be a challenge.
  • co-morbidities: often leads to complicated nutrition therapies that may be challenging to comply with
  • lack of food choices: especially if a patient depends on others for food preparation (long-term care facility, family members, meal delivery service, food bank, soup kitchen)

In addition, dietitians who provide education in an inpatient setting have limited time with a patient, and there are very few opportunities for follow up. I believe follow up is crucial for most people to make and sustain lifestyle changes, so I question the efficacy of talking to patients for 10-20 minutes while they’re in hospital about how to best manage their chronic constipation or diabetes or renal failure. But I think it’s probably better than nothing, and focusing on one concrete goal may increase the likelihood of adherence.

This week was the last week in my Nutrition Care I placement at Royal Columbian Hospital. I got to see a variety of interesting patients here and I’m really grateful for this opportunity. I cannot believe that internship is ~25% over. Next week, I begin the Management Module at Eagle Ridge Hospital, where the start time is 9:30 am… a full 2 hours later than my first placement! Although to be honest I kind of like going to bed around 10 pm and waking up at 6 am. So I may keep that schedule for now and just do more things in the early morning.

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