New Rotation – What Does a Clinical Dietitian Do?

This past week I started a new rotation.  This rotation will include the majority of my objectives from Medical Nutrition Therapy II and the Clinical Concentration.  I will be here for about six weeks and am excited to take on a new challenge and get more experience in the clinical setting.

There are a variety of hospitals in the area and many dietitians that I will get to work with over the next few months so that I can experience the greatest diversity in patients and conditions. This first week I primarily spent my time with surgical and neuro patients on the floors and in the intensive care unit (ICU).  Due to the severity of these patients’ conditions, many of these patients required tube feedings, which is also known as enteral nutrition – stay tuned for a post specifically about enteral nutrition! In the weeks to come I will have a chance to work with trauma, pediatrics, rehab, cardiac, behavioral medicine, weight loss, cystic fibrosis, diabetes, transplant, and even the wound clinic!

So before I get too far into this rotation I wanted to provide a little background so you can start to understand what exactly it is that a clinical dietitian does!  A clinical registered dietitian (RD) will typically have following responsibilities:

• Identify patients at nutritional risk
• Provide nutrition care using the Nutrition Care Process (see below)
• Determines the nutritional needs and diet restrictions for patients
• Plans therapeutic diets and implements preparation and service of meals for patients, which includes tube feedings, parenteral nutrition, and modified texture diets.
• Instructs patients and their families on healthy eating and/or special diets
• Participates in interdisciplinary discussions and meetings with other health care providers

What is the Nutrition Care Process?

The NCP is a systematic approach to providing quality nutrition-related care.  It is divided into four separated, but interrelated steps: assessment, diagnosis, intervention, monitoring/evaluation.

• Nutrition Assessments – obtain, verify, and interpret data to identify nutrition-related problems, their causes, and their significance. Five main domains:
  • Food/Nutrition Related History:
    • Examples include:
      • Allergies, intolerance, special diets
      • How has the patient been eating?
      • Access to food
    • Anthropometric Measurements:
      • Examples include:
        • Height and Weight
        • Calculate BMI, Ideal Body Weight, Adjusted/Feeding Body Weight
        • Any weight changes?
        • NOTE: use this information to calculate calorie, protein, and fluid needs
    • Biochemical Data, Medical Tests, and Procedures:
      • Examples include:
        • Lab values, test results, surgeries
    • Nutrition-Focused Physical Findings:
      • Examples include:
        • Edema, skin breakdown, hair loss
    • Client History:
      • Examples include:
        • Previous health conditions

• Nutrition Diagnosis – describe nutrition related problem using standardized language
  • Commonly referred to as a PES statements
    • Problem, Etiology, Signs and Symptoms

• Nutrition Intervention – actions used to remedy a nutrition diagnosis/problem
  • Calculate tube feeding prescriptions
  • Calculate parenteral nutrition prescriptions
  • Recommend nutrition supplements to meet calorie/protein needs
  • Modify diet consistency or texture
  • Provide nutrition education or counseling

• Nutrition Monitoring and Evaluation:
  • Follow the progress of nutrition goals by monitoring weight, labs, intake and/or diet tolerance.

 

Nutrition Care Process

 

What patients are seen by the dietitian?

Patients of nutrition risk are seen by the RD – This can be determined by:

• Admitting diagnosis, condition, or chief complaints.  Common examples include:
  • Bowel Obstruction/Ileus
  • Burns
  • Cancer
  • Celiac Disease
  • Cirrhosis
  • Chronic Kidney Disease
  • Cystic Fibrosis
  • Diabetes, new onset
  • Dysphasia
  • Hepatic Encephalopathy
  • Malnutrition
  • Pancreatitis
  • Renal Failure
  • Renal Transplant
  • Spinal Cord or Traumatic Brain Injury
  • And many more…
• NPO/Clear Liquid greater than 3 consecutive days
• New tube feeding (enteral nutrition) orders
• New parenteral nutrition orders
• Specific lab values:
  • Low albumin (<2.5 mg/dL)
  • Low prealbumin (<16 mg/dL)
  • High blood glucose (≥200 mg/dL X 3 consecutive results)
  • NICU: Phosphorus (>600 U/L)
  • NICU: Bilirubin (<4.5 mg/dL)
  • NICU: Alkaline phosphatase (> 2 mg/dL)
• Consults made by MD, RN, Pharm D, ancillary or patient’s family.
  • May include a request for: an assessment, visit, calorie count, tube feeing, parenteral nutrition, or education.

 

References:

http://www.eatright.org/HealthProfessionals/content.aspx?id=7077

http://andevidencelibrary.com/ncp/inc/circle.gif

My First Immersion into Clinical Nutrition!

I just finished up my first week of my clinical nutrition rotations! I have just one more week left at Monongalia General Hospital before I move on to my next set of rotations. I have learned so much this week on the overall role of clinical dietitians and how it is to really utilize the Nutrition Care Process on real patients.

 

Monongalia General Hospital is one of two major hospitals in the Morgantown area – in fact they are practically right next to each other! These two hospitals serve very different needs in the community. Ruby Memorial Hospital is a large teaching hospital that is over 500 beds and is fully equipped with a cancer center, children’s hospital, and a level I trauma unit. Monongalia General Hospital is only 189 beds equipped with a level IV trauma unit. It is definitely more a community hospital with less high-risk patients, which makes it an ideal location to start for my clinical journey.

 

So, what exactly does a clinical dietitian do? This is a very common question that, unfortunately, not many know the answer to! While I knew the basics of what a clinical dietitian was responsible for, this week gave me a much deeper understanding what a typical day was like as a clinical RD. Each day there are two clinical dietitians that are available to assess and treat patients. The day begins by looking at the list of patients that have been given “consults.” These consults can be sent to the RD’s for multiple reasons. First, nursing staff always conducts a basic nutrition risk assessment on all newly admitted patients. If the patients are considered high risk, then a consult is sent to the dietitians. Physicians can also order consults on patients who they feel will benefit from a nutrition intervention, education, or that require monitoring. The final way that a consult can be sent to the RD’s is by what is called a “system consult.” System consults are triggered by the electronic medical database for patients with a length of stay greater than seven days, a stage II or greater pressure ulcer, recent cardiac surgery or diagnosis, or a variety of other scenarios. Once the dietitian receives the list of patients for the day, the assessment process beings.

 

The assessment process involves a very comprehensive reading of all the lab values, and medical notes from physicians, mid-levels, nurses, and other allied health fields. Even though dietitians deal with nutrition interventions, they are still required to understand all the lab values, medical terminology for the conditions, surgical procedures, medications, and the abbreviations that other medical professionals are required to know. Before any patient is seen there is an extensive review so that the patients’ condition can be fully understood. After preparing a preliminary chart note for the patient with the information from the electronic medical records the patient is then visited. During the visits with the patients the dietitian assesses current intake and collects any information to determine if the patient requires any education or additional nutritional intervention (i.e. Ensure, tube feeding, parenteral nutrition (IV feedings), supplements, etc.). After finishing up with the patient, chart notes must be written and entered into the electronic medical record system. In addition to visiting patients that have consults, dietitians also participate in interdisciplinary care meetings and grand rounds with the physicians, case managers, and nursing staff.

 

I always had imagined that I would end up in clinical nutrition and being able to actually assess patients, deliver nutrition education and interventions, and write chart notes on patients throughout this rotation has confirmed my desire to become a clinical dietitian! This past week I was able to assess and deliver nutrition education to a variety of cancer and cardiac patients and write the chart note! I am looking forward to this next week with Monongalia General Hospital to focus on more nutrition interventions!