Dietetic Internship Weeks 19 + 20: Nutrition Care II (Medicine)

These past two weeks in the medicine ward, I came into contact with a wide variety of patients, and managed to put into practice a few of the principles I’ve learned about in theory.

I find the medical patient population tend to be older. Consequently, there were a lot of patients with dementia as a co-morbidity. Dysphagia is more common — partially due to age (I suspect) and partially due to the nature of the illness (stroke patients, for example). Tube feeds are used to feed patients who are severely dysphagic, and I’m hoping to get my first home tube patient soon. Many patients are frail and elderly, and inadequate oral intakes / malnutrition are prevalent issues regardless of the illness(es) which brought the patient to hospital. With multiple co-morbidities and often a long past medical history, there are more factors to consider when deciding an appropriate nutritional intervention for patients.

Fluid Balance

  • Especially important for patients who have renal failure (chronic or acute), are on dialysis, have liver damage (ascites), and chronic heart failure. Want to ensure adequate hydration but not fluid overload.
  • Assess the amount of fluids in vs. out: check nursing notes to find out the amount of fluid the patient is receiving via IV and medications, if possible.
  • Assess edema — check feet, legs, hands, and arms.
  • Assess ascites.

Alcohol / Drug and Micronutrient Interactions

  • Recommend vitamin D (1000 IU OD) and calcium carbonate (1250 mg BID) for patients receiving long-term epilepsy (dilantin) or corticosteriod (prednisone) treatments.
  • Folic acid may interfere with the effectiveness of dilantin in a small percentage of patients. Patients on dilantin are more susceptible to becoming deficient in folic acid. Recommend supplementing folic acid and monitoring dilantin levels in consultation with pharmacy.
  • Alcohol abuse: supplementing folic acid, thiamine, B6 and B12 are not unreasonable, especially if a patient has cirrhosis. Probably easier to take a B-complex vitamin.
  • Bile acid sequestrants (for example: Questran), may lead to fat-soluble vitamin deficiency in the long-term. Consider supplementing with a multivitamin daily.

I think I’m improving with regards to designing appropriate nutrition care plans– however, one area I would like to improve is anticipating and planning for upcoming changes, such as patient discharges. This is important especially for patients who need diet-related information prior to discharge. To learn about patient discharges, I could attend rounds more regularly, speak with the patient care coordinator, and of course, just ask the patient. If a patient is needing diet education prior to discharge, I need to find out to where they’re getting discharged (back home, to a residential facility, or to a different hospital/ ward), and provide information accordingly. Another unexpected thing to plan for– patients who are scheduled a swallow assessment may not get them on that day (barriers to assessing swallow: level of consciousness, inability to manage secretions), should come up with a plan in case this happens (?EN, or dextrose containing IV), especially if patient has been receiving inadequate nutrition for a few days. Talk about this plan with other members of the healthcare team (nurse, doctor, SLP/OT, etc).

So I have one more week in nutrition care II before starting relief, it’ll be a short one with Monday being Family Day and a pediatric symposium in the afternoon of the Thursday, but I’m really happy about the progress I’ve made in the past weeks ad am looking forward to the new patients I’ll get to see next week!

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