Dietetic Internship Week 23: Nutrition Care IV (Relief)

I’ve made it through my first week and a bit of relief, wohoo! Can I say I’m genuinely relieved?

Today, I was able to follow up with a good number of patients, and my preceptor agreed with most of my nutrition care plans. But the patients I had weren’t complex, so while a good confidence booster, I’m not sure if it’s a true indication of my progress.

My self-evaluation seem to fluctuate up and down quite frequently. At the end of last week, I felt quite inadequate. I didn’t meet my own expectations in terms of patient load, and I still felt uncertain about some of my nutrition care plans. Over the weekend, I thought about the areas which I needed to work on the most, and came up with a few actions that I want to practice this week. I emailed this to my preceptor and asked for 5-10 minutes to discuss my progress on Monday. My preceptor agreed with the areas I wanted to work on, and assured me that I was actually doing fine. That was a huge relief to hear and I’m really grateful for the feedback.

This rotation has taught me a lot about managing tube feeds, here are some of my experiences.

Transition from Tube Feed to Oral Diet:

  • Do a calorie count to get a more accurate idea of what and how much patients are eating.
  • When patients aren’t eating enough, figure out why this is happening, and whether you can do something about it.
    • Liberalize diet
      • If patient is on a dysphagia diet and followed by SLP/ OT, ask when they anticipate a patient will be upgraded.
      • Remove dietary restrictions if possible: sodium, potassium, fat, sugar, etc.
    • Manage GI / medical symptoms: nausea, constipation, pain, drowsiness, depression.
    • Customize diet.
    • Some patients will not eat “well” orally and we have to accept that.
  • Nocturnal feeds are okay to use when transitioning, but patients should be followed closely to ensure they are eating adequately orally.
  • Top-up feeds are an option: if patients eat less than __% of their breakfast, lunch, or dinner, provide ___ mL of tube feed. This gives patients an opportunity to eat while ensuring they meet their estimated needs.

Insertion of Long-Term Feeding Tube

  • It’s a surgical procedure with associated risks, and the risk/ benefits should be carefully weighed before recommending to insert a long-term feeding tube.
  • Discuss with SLP/ OT how long the patient is anticipated to be NPO.
  • If patient is pending swallowing assessment in the next few days, then should wait until the swallow assessment is complete before recommending long-term feeding tube insertion. A few extra days with a nasogastric entube is probably worth avoiding a GJ or PEG insertion if the patient is able to start on a diet after the swallow assessment.
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