A little bit of this, a little bit of that....

This past week at FRMC provided a medley of events. Medical nutrition therapy is proving to be a wonderful mixture of both predictability and surprise. There was a little bit of this, and a little bit of that....

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The week began and ended with nothing out of the ordinary. Your typical to-dos with patient follow-ups, assessments, education sessions, and IDR rounds. That's right, I am not misspoken, you heard me correctly. I was privileged to try my hand at a couple of initial assessments, and from what I gathered I did a fair job of it. One aspect of my MNT rotation that I am feeling particularly confident about is my knowledge of the Meditech software. I can navigate my way around a patient's chart within seconds, making me more efficient at charting than ever.

Competencies:
CRD 2.1 Practice in compliance with current federal regulations and state statutes and rules, as applicable and in accordance with accreditation standards and the Scope of Dietetics Practice and Code of Ethics for the Profession of Dietetics.
CRD 2.6 Assign patient care activities to DTRs and/or support personnel as appropriate.
CRD 2.7 Refer clients and patients to other professionals and services when needs are beyond individual scope of practice.
CRD 2.10 Establish collaborative relationships with other health professionals and support personnel to deliver effective nutrition services.
CRD 2.11 Demonstrate professional attributes within various organizational cultures.
CRD 2.13 Demonstrate negotiation skills.
CRD 3.1 Perform the Nutrition Care Process (a through e below) and use standardized nutrition language for individuals, groups and populations of differing ages and health status, in a variety of settings.
CRD 3.2 Demonstrate effective communications skills for clinical and customer services in a variety of formats.
CRD 3.4 Deliver respectful, science-based answers to consumer questions concerning emerging trends.
CRD 4.5 Use current informatics technology to develop, store, retrieve and disseminate information and data.

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It was the middle of the week where things started shaking up a bit. Here are the highlights:

Tumor Board

On Tuesday we participated in the FRMC Tumor Board over a working lunch. During this meeting we collaborated with healthcare professionals to discuss the status and treatment plan of oncology patients. This meeting was particularly interesting by testing my MNT knowledge of cancer staging, using the TNM system.

The TNM system is based on the size of the primary tumor (T), the amount of spread to nearby lymph nodes (N), and the presence of metastasis (M). A number is added to indicate the extent of the tumor and the degree of cancer spread. 

Primary Tumor (T)
TX: Primary tumor cannot be evaluated
T0: No evidence of primary tumor
T1-4: Size and/or extent of primary tumor

Lymph Nodes (N)
NX: Regional lymph nodes cannot be evaluated
N0: No lymph node involvement
N1-3: Degree of lymph node involvement (number and location of lymph node)

Metastasis (M)
MX: Metastasis cannot be evaluated
M0: No distant metastasis
M1: Metastasis present

For example, cancer classified as T3N2M0 refers to a large tumor that has spread to nearby lymph nodes but no other parts of the body. TNM combinations correspond to one of five stages, and differ for different types of cancers. 

References:
National Cancer Institute. (2015). Cancer Staging Fact Sheet. Retrieved from http://www.cancer.gov/about-cancer/diagnosis-staging/staging/staging-fact-sheet

Competencies:
CRD 2.1 Practice in compliance with current federal regulations and state statutes and rules, as applicable and in accordance with accreditation standards and the Scope of Dietetics Practice and Code of Ethics for the Profession of Dietetics.
CRD 2.10 Establish collaborative relationships with other health professionals and support personnel to deliver effective nutrition services.
CRD 2.11 Demonstrate professional attributes within various organizational cultures. 

Meal Rounds

In between our daily doings we have been sprinkling in the occasional Meal Supplement Round. For many of our patients we order oral supplements as a means for providing them with extra protein and calories to facilitate healing. We have been making meal rounds to patients' rooms who are receiving supplements to inquire about their satisfaction. 

Many patients have requests beyond the preference of their supplement flavor, so the meal rounds have been really useful in providing customer service. In addition, it is very beneficial to set aside time to meet the patients we are serving face-to-face to assess not only their preferences, but also their capabilities. You can only learn so much about a patient from a chart, and spending even just 30 seconds with a person can give you an idea of how well they are able to feed themselves, their ability to communicate, etc. 

Competencies:
CRD 1.3 Justify programs, products, services and care using appropriate evidence or data.
CRD 2.2 Demonstrate professional writing skills in preparing professional communications. (Tip:  Examples include research manuscripts, project proposals, education materials, policies and procedures.)
CRD 3.6 Develop and evaluate recipes, formulas and menus for acceptability and affordability that accommodate the cultural diversity and health needs of various populations, groups and individuals.
CRD 4.6 Prepare and analyze quality, financial or productivity data and develops a plan for intervention.
CRD 4.8 Conduct feasibility studies for products, programs or services with consideration of costs and benefits.

In-Service Lesson Plan

While we're on the topic of oral supplements, I will take a quick second to explain our idea for an in-service at FRMC. Oftentimes it is difficult for the RD to evaluate if a patient is meeting their energy needs due to inconsistent charting of supplement intake. For example: 

• Supplement intake being included in meal intake data
• Supplement intake being included in fluid intake data
• “Oral supplement” space in chart left blank

​Consistent charting of supplement intakes is essential for the RD to assess the patients’ nutritional progress. More specifically, charting of oral supplements separately from meal and oral fluid intake is necessary for proper nutritional re-assessment.

It would be extremely helpful and beneficial to the RDs if the RN staff were willing to collaborate on this effort. RDs would be able to more successfully assess the nutritional status of each patient if oral supplement intake was consistently documented. 

Encouraging nutritional supplements as a team will not only help RDs perform duties with more efficiency, but will also help patients heal faster and could potentially decrease patients’ length of stay. It would also be beneficial to document if a patient is refusing oral supplements that are being delivered with their meals, in order to cut back on waste and improve cost effectiveness for Food and Nutrition Services Director.

Here is a quick reference guide of oral supplements that I created to be posted at each nurse's station:

Competencies:
CRD 1.1 Select indicators of program quality and/or customer service and measure achievement of objectives. (Tip:  Outcomes may include clinical, programmatic, quality, productivity, economic or other outcomes in wellness, management, sports, clinical settings, etc.)
CRD 1.2 Apply evidence-based guidelines, systematic reviews and scientific literature (such as the Academy’s Evidence Analysis Library and Evidence-based Nutrition Practice Guidelines, the Cochrane Database of Systematic Reviews and the U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, National Guideline Clearinghouse Web sites) in the nutrition care process and model and other areas of dietetics practice.
CRD 1.3 Justify programs, products, services and care using appropriate evidence or data.
CRD 1.4 Evaluate emerging research for application in dietetics practice.
CRD 2.2 Demonstrate professional writing skills in preparing professional communications. (Tip:  Examples include research manuscripts, project proposals, education materials, policies and procedures.)
CRD 2.3 Design, implement and evaluate presentations to a target audience. (Tip:  A quality presentation considers life experiences, cultural diversity and educational background of the target audience.)
CRD 2.8 Apply leadership principles to achieve desired outcomes. 

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Long story short, there is never a dull moment at Franklin Regional Medical Center.