22nd Annual Antonio Palladino Memorial Lecture & Resident Research Symposium

WVUH

Today I had the opportunity to present a 15-minute oral presentation at the 22nd Annual Antonio Palladino Memorial Lecture & Resident Research Symposium that was put on by West Virginia University’s Department of Obstetrics and Gynecology.  The other presenters at this event were all physicians who were in the process of completing their residencies.  This event was held in the Health Science Center in the Fukishima Auditorium and approximately 50 physicians, residents, and other health care providers attended this event .

Below is the brief brochure for the event or you can to download the PDF – 2014 Department of Obstetrics and Gynecology Brochure but the full program for this event that includes the abstracts is available to view at the end of this post.

 OBGYN Palladino Series - Page 1Palladino Research Day

Here is the presentation that I presented! Please excuse some of the formatting errors – they were not in the actual presentation but just happened with the conversion in SlideShare.

To view the full program with abstracts for this event, click here: 2014 Palladino Program

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Nutrition Case Study Presentation

It is crazy to think that my rotation is already wrapping up!  I have learned so much information and practical information that will help me to succeed as a dietitian and a health professional.  As a final evaluation of my performance as a dietetic intern I was responsible for identifying a patient to follow for a case study.  After conducting multiple nutrition assessments on my patient for the past few weeks I complied the information I learned into a presentation that I presented to all of the registered dietitians – about 10 of them.

<div style=”margin-bottom:5px”> <strong> <a href=”https://www.slideshare.net/wmthompson/nutrition-case-study&#8221; title=”Nutrition case study” target=”_blank”>Nutrition case study</a> </strong> from <strong><a href=”http://www.slideshare.net/wmthompson&#8221; target=”_blank”>Wendy Thompson</a></strong> </div>

Nutrition Topic of the Week: Parenteral Nutrition

What is Parenteral Nutrition (or TPN)?

As you all know – everyone needs food/nourishment to live!  So… what happens when a person is unable to eat normally or tolerate a tube feeding or cannot get enough intake? That is were parenteral nutrition comes in.  Parenteral nutrition refers to feeding through the vein, or intravenous nutrition.  This is very different from enteral nutrition because it does not enter the digestion pathway.  Parenteral nutrition (PN) bypasses the normal digestion process (ingested food is broken down in the stomach and the intestines, absorbed in the bowel, and carried by the blood throughout the body).  PN in inserted directly into the blood stream via an IV catheter to the vein bypassing the digestive tract.  This is a sterile formula that is mixed in the pharmacy that contains water, amino acids, glucose, *lipids, vitamins and minerals and requires very close monitoring.  Note: it is very common for their to be a lipid (fat) shortage (or a different drug shortage) so at many facilities lipids are only give lipids on Monday, Wednesday, and Friday and in limited quantities.  Since parenteral nutrition may be someone’s only source of intake it is important that all essential nutrients are provided if PN will be used for a long duration. In addition to macronutrients, PN may also include electrolytes (sodium, potassium, chloride, phosphate, calcium, and magnesium) and trace elements (since, copper, manganese, and chromium).  There is currently a shortage on trace elements so they are typically not included unless the patients has been on PN for over 30 days.

Who May Need Parenteral Nutrition?

People of all ages may receive parenteral nutrition and the time may be relatively short or for as long as needed.  Patients may require PN for conditions or diseases that impair food intake, nutrition digestion or absorption. Common examples include: short bowel syndrome, GI fistulas, bowel obstruction, critically ill patients, severe acute pancreatitis, ulcerative colitis, or severe Crohn’s Disease.

How is Parenteral Nutrition Supplied?

An IV catheter (needle) is placed a large vein in either the arm, chest or neck. Common names for these catheters include: PICC, triple lumen, double lumen, single lumen catheter, and ports.  Parenteral nutrition can be supplied continuously over 24 hours or cyclically down to about 12 hours a day.  An infusion pump will control the rate at which the solution is supplied.  Total parenteral nutrition (TPN) will need to be administered through a central access vein such as the chest or the neck and can be supplied in higher concentration to meet the needs of a patient who is relying solely on TPN for nutrition.  Peripheral parenteral nutrition (PPN) is administered in lower concentrations and can be given through a peripheral vein such as through the arm and is mostly used for patients who are also consuming food through another source.  TPN lines will go through a major vein and end at the superior vena cava.

What are the Potential Complications of Parenteral Nutrition?

  • Infection – can be a common complication because of the chronic IV access point. If the infection is severe enough septic shock and death could ultimately occur.
  • Blood Clots – if a blood clot forms in the IV lines but breaks off and enters the lung then death can result from a pulmonary embolism. Patients on long term tube feeds typically receive a Heparin flush periodically to dissolve clots.
  • Liver Damage and Liver Failure – may appear as jaundice
  • Cholecystitis – inflammation of the gallbladder
  • Osteoporosis – bone disease
  • Refeeding Syndrome – characterized by hypokalemia, hypophosphatemia and hypomagnesemia (or low serum potassium, phosphate, and magnesium levels)
  • Hyperglycemia – high glucose levels, can be controlled with insulin

How is Parenteral Nutrition Monitored?

Depending on the facility, TPN will usually be monitored by a nutrition support care team that may include a physician, dietitian, pharmacist, and nursing staff. It is crucial to the patient’s safety that labs be monitored frequently in addition to monitoring weight status. The following labs should be closely monitored so that the order can change as needed:

  • CBC – Complete Blood Count
  • Electrolytes (Sodium, Potassium, Calcium, Phosphorus, Magnesium, Chloride, Bicarbonate)
  • BUN – Blood Urea Nitrogen
  • Glucose Levels
  • Albumin/Pre-Albumin
  • Triglycerides

 

TPN Formula - No Lipids

TPN Formula – No Lipids

TPN Formula with Lipids

TPN Formula with Lipids

PN Routes

PN Routes

References:

http://www.nutritioncare.org/wcontent.aspx?id=270

http://transplants.ucla.edu/body.cfm?id=70

http://www.merckmanuals.com/professional/nutritional_disorders/nutritional_support/total_parenteral_nutrition_tpn.html

Weight Loss Surgery and Lifestyle Changes

This past week I had the opportunity to spend time at a weight loss center, wound clinic, and also in medical telemetry and ICU. I am sure you all have heard of weight loss surgeries (more appropriately called bariatric surgeries) by now and while it may seem like a quick and easy fix… it is far from that.  Even though the majority of these surgeries are preformed laparoscopically, no surgery comes without some risk.  At this particular center the surgeons performed three different bariatric surgeries: Laparoscopic Adjustable Gastric Banding (LABG), Laparoscopic Sleeve Gastrectomy, and Roux-en-Y Gastric Bypass (RYGB).

Bariatric Infograph

 

What is the role of an RD when it comes to bariatric surgeries?

Bariatric surgeries all require a dramatic lifestyle change. Dietitians are responsible for conducting an initial nutritional screening to ensure that the client is suitable for surgery. If the patient is not willing to change their diet then they will not be allowed to undergo surgery due to the danger it could  cause. Dietitians are also used to explain and educate the patient on the bariatric diet prior to surgery and participate in follow-up appointments with patients as needed. Here is just a brief overview of some of the dietary changes one must undergo after surgery.

  • Advance diet as tolerated from clear liquids to puree/soft foods to solids post surgery – this typically takes at least one month.
  • Eat slowly – it should take 20-30 minutes to finish a meal!
  • Always sip liquids, NEVER chug! You should drink about 1 oz. every 15 minutes.
  • Chew slowly and thoroughly before swallowing
  • Avoid sugary foods to prevent “Dumping Syndrome”
  • Limit fat intake – fats slow the digestion process which can lead to nausea
  • REMEMBER the stomach can only hold a few tablespoons immediately after surgery and will eventually hold up to 0.5-1 cup so you will need to eat less
  • Drink at least 64 oz. fluid to prevent dehydration
  • Do not drink fluid with meals – stop drinking 30 minutes before eating and wait until 30 minutes after to drink again
  • Always eat your protein food first to make sure your protein intake is adequate
  • Tolerance of dairy (lactose) may be altered so substitute a lactose-free dairy if needed

What does a typical menu look like for the first month after surgery once you are discharged?

Breakfast – 8:00AM:

  • ¼ cup unsweetened applesauce
  • ¼ – ½ cup non fat cottage cheese

Supplement – 10:00AM:

  • ½ cup skim plus with 1 scoop of protein powder

Lunch – 12:00PM:

  • ¼ – ½ cup blended soup
  • ¼ cup tuna fish with low fat mayo

Snack – 2:00PM:

  • ½ cup sugar free yogurt
  • 1 sugar free popsicle

Dinner – 6:00PM:

  • 1-2 oz. flaked fish
  • ¼ cup puree vegetable

 

References:

http://www.nordbariatric.com/en/articles/infographics/different-wls-compared

http://www.mayoclinic.com/health/gastric-bypass-diet/my00827

Final Reflections on WVU Dining Services Rotation

After spending 5 weeks rotating with WVU dining services, working with the dietitian and food service staff, I have a much more complete view of the role of a food service dietitian and a greater appreciation for the work they do.  Over the past five weeks I have been able to: work with food service administration to design staff in-services, wellness programs, and plan employee schedules; work with production staff in multiple dining facilities to learn about cash operations, assist with food preparation, design production schedules, and assist with catering events; conduct temperature, quality, and waste studies; assist with the farmer’s market and hold a student forum to promote local foods; design new meals and put together week-long menus, conduct recipe and cost analysis; and design and conduct a process improvement project on portion control.  In addition to food service activities, I have managed to attend and conduct nutrition counseling sessions, assess body composition, create meal plans, lead and assist with grocery store and dining hall tours, speak with athletic teams, and observe the interactions between the strength and condition staff, athletic coaches and the sports dietitian.  These past five weeks have been busy with a wide variety of activities to ensure that I walk away from this experience fully prepared to tackle the food service industry as a registered dietitian.

My favorite part of the rotation was the week I spent with the sports dietitian.  I had never imagined that I would end up liking sports nutrition as much as I did.  I found it fascinating and very enjoyable to work closely with student athletes.  This was also my first experience with outpatient nutrition counseling and I enjoyed that very much and was surprised how naturally it flowed.  I learned a great deal from the dietitian and listening to her converse with athletes and from her feedback on my counseling skills. (See my previous blog post about this section here!)

I learned so much from each of these activities and how the entire process works together to seamlessly serve thousands of students each day.  I learned the importance of knowing job descriptions in order to be able to contact the correct individual with concerns or consultations. In such a large institution it can seem overwhelming to determine who does what but after my time spent here I realize that that aspect just takes time.  I feel confident in my abilities and my understanding of the role of a dietitian in a food service organization and I can see the need to refill the open position with WVU Dining Services as soon as possible.

I find it very interesting when you think about how many different allergies and diets the staff must accommodate here at Café Evansdale.  This is definitely a skill I need to refine prior to working in a food service establishment.  It is difficult to know exactly which items contain some of the not-so-common allergens.  Part of learning this would come with time and dealing with this on a regular basis and becoming familiar with the food that is served.  I am thankful for having this opportunity to complete this rotation and have learned a tremendous amount of information that has helped me understand food service on a larger scale.

It’s Pumpkin Time!

This past week I have been completing various projects with multiple people at WVU Dining Services.  I assisted with a safety and sanitation audit in the dining facility and helped with a catering event at the WVU President’s house and so much more.  The project I decided to share with you all this week is a brief topic I covered for a series called “Nutrition Nuggets” that dining serves puts out for WVU students and staff a few times a month.

 

Nutrition Nuggets - It's Pumpkin TimeAlso, in favor of fall traditions I have been searching for a HEALTHY pumpkin flavored drink to make and I think I finally found one! Now, I have yet to have a chance to get to the store to purchase pumpkin puree (or milk…) so I have yet to try it. Once I do, I will be sure to share my thoughts but if you beat me to it please share your comments (good or bad!). Original recipe can be found here.

Pumpkin Spice Smoothie

1/2 cup pumpkin puree

1 banana

2 scoops vanilla chai protein powder

(or try 1 scoop chai tea mix and 1 scoop vanilla protein powder instead!)

1 cup of milk

Ice

Directions: Blend all ingredients together until desired consistency is reached!

iCook Session #1

After months of planning, recruiting, and conducting assessments it finally came time to teach session one! We ended up filling about five of our six classes with at least four parent/child groups (also referred to as dyads). Currently, there are three interns who will be teaching the first four sessions and then the other two interns will teach the last two. Remi, Erin, and I alternated teaching the lessons by serving as either Chef, Sous Chef, or an extra helper. We were also lucky enough to have the assistance of three undergraduate students who assisted with note taking, technology, set-up, and cleaning all the dishes.

This first session was entitled “Tools of the Trade.” We covered knife safety skills, physical activity, camera/website use, and an introduction to iCook. The classes had anywhere from four to eight dyads present. This was a great learning experience for the children, parents, and even us! The kids knife skills improved greatly just from the beginning of the class to the end and the parents’ confidence in their kids abilities also greatly improved. While allowing kids (age 8-11) to use a sharp chef knife may seem like an unsafe thing to do, with the right support and monitoring from the parents the kids can accomplish cutting bananas, strawberries, apples, and even kiwi safely! We made it through the entire weekend without any cuts! You can tell which kids had prior experience and which had never even held a knife before. It was fun to work with these kids and I can’t wait to watch their skills improve over the next few months as we move through the sessions!

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