Here, There and Everywhere

 Last week was a whirlwind of experiences!

It was not uncommon to find me bustling about the floors. In addition to my typical responsibilities of assisting the registered dietitians, I was also fortunate to assist the Wound Ostomy & Continence Nurse (WOCN). Not to mention, I had the opportunity to observe some outpatient counseling and to perform one-on-one education exercises with patients.

And that's just the tip of the iceberg lettuce, folks.

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Before jumping into the juicy details of the week, I want to give a quick update on the daily doings of the dietetic life. I have become the go-to girl for follow up assessments. Essentially, I monitor and evaluate patients by utilizing the Registered Dietitian's initial assessment notes alongside the most recent reports charted by the healthcare team.

Here are a few tools that I find absolutely essential for re-assessing a patient and their nutritional status.

These resources have proven to be invaluable in my training experience as a rookie clinical dietitian. Although Google is always available to fill in the gaps, it is nice to have a hard copy that I can add my own notes to for further reference. 

Competencies:
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.

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Unless you have hours to spare over a cup of coffee or a seven-course meal, there is essentially no way for me to be able to deliver all of the details of my experiences this past week. Even then, something will be left out. I was literally here, there and everywhere in this hospital! 

Here's a neatly organize re-cap of the week, for your viewing pleasure:

Patient Education

I have become a self-proclaimed pro at educating patients in regards to their Warfarin prescription. This week I had the chance to educate four different patients about their drug-nutrient interactions related to Warfarin, also known as Coumadin. 
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This medication works as an anticoagulant to prevent strokes, heart attacks, and blood clots. There are many foods that may affect how Warfarin works, especially foods that are high in vitamin K.

Vitamin K is known as the "clotting vitamin." You guessed it, this vitamin helps to clot the blood. Therefore, if a patient is prescribed Warfarin/Coumadin and consumes these foods, the efficacy of their medication could be altered.

It is important to note that the patient does not have to eliminate foods high in vitamin K from their diet. The key is to maintain consistency, as the medication works best if the same amount of vitamin K is consumed each day.

​Therefore, when counseling patients it is important to emphasize that they should eat these foods regularly or avoid them altogether. Provide the patient with a list of foods high in vitamin K for their reference after being discharged. 

Competencies:
CRD 2.4: Use effective education and counseling skills to facilitate behavior change.
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 3.2: Demonstrate effective communications skills for clinical and customer services in a variety of formats.
CRD 3.3: Develop and deliver products, programs or services that promote consumer health, wellness and lifestyle management.
CRD 3.4: Deliver respectful, science-based answers to consumer questions concerning emerging trends.

Diabetes Outpatient Counseling

I am fortunate enough to be working in a facility that employs a Registered Dietitian who is also a Certified Diabetes Educator (CDE). She is an expert in all things insulin-related, and has provided fantastic resources to help me learn the ins-and-outs of diabetes management. 

This past week she invited me to observe a couple of her counseling sessions, including a one-on-one session and a group of ten individuals. This experience was valuable because I got to see those counseling skills in action!

It was very interesting to note the differences between the one-on-one session and the group session. In the one-on-one session, rapport had already been built throughout past visits, therefore the greeting was much more relaxed. However, in the group setting the RD took time to give a bit of her background before diving into the topic.

Both sessions involved motivational interviewing skills of different fashions. The one-on-one session included a lot of specific goal setting, and the RD used phrases such as, "What would be a realistic goal for now? What do you feel comfortable changing?" While the group setting used motivational interviewing as a means of encouraging participation, including asking participants to call out answers to questions such as, "What foods are high in cholesterol?"

In each session the clients were very eager to learn and asked questions. Many asked questions about specific foods or brands that they had heard would be "healthy" via the news or other media source. One woman asked for an opinion on the supplements a specialist had encouraged her to take. 

It was very interesting to observe the counseling sessions. Now that I have seen them in action, the next step is to participate in teaching!

​Competencies:
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. ​​

Neonatal Intensive Care Unit

The Neonatal Intensive Care Unit at FRMC is a Level II unit affiliated with Korsair Children's Hospital in Louisville. Level II facilities care for newborns with a corrected gestational age of 32 weeks or greater, who are moderately ill with problems that are expected to resolve quickly.

I finally had the chance to visit the NICU with my preceptor and it has so far been my favorite experience. The NICU is an entity all its own. At FRMC the NICU keeps most of their charts on paper instead of electronically, so in order to assess the patients you must visit them directly.

It was incredibly interesting to see their wing, and to learn the tiniest bit about their procedures. It is only a four bed unit at FRMC, but that does not keep them from being busy. The day I visited the NICU they were fully occupied. It was interesting to hear about the different formulas available and their indications for use. The nurses in this unit are very experienced and generous with their knowledge.

​Plus, extremely cute babies made it that much more fun. :-)

Competencies:
CRD 2.10: Establish collaborative relationships with other health professionals and support personnel to deliver effective nutrition services.

Wound Ostomy & Continence Nurse

Alright, if you're still reading then you are in luck. I saved the best for last. I began last week by following the Wound, Ostomy & Continence Nurse around for roughly 4 hours.

Let me preface with two things:
1. She is a superhero.
2. I could never do her job.

Within these four hours we saw four different patients, presenting with various different stages of wounds, from pre-stage - unstageable. I'm not going to bore you with the stages of wounds, but if you're curious you can check it out here. 

I cannot reiterate enough how hard the WOCN works. Not only is she responsible for identifying and staging, but she also dresses and monitors wounds on every patient presenting with them. Many of the patients who suffer from pressure ulcers are elderly and unable to move around very well. Therefore, she must move and roll patients who would otherwise never be able to/want to move in order to perform her duties. 

From that day, there were a few specific instances that stuck out. Firstly, ostomy appliances were present on every patient we evaluated. Ostomy appliances are prosthetic medical devices that provide a means for collecting waste from the body, including the colon, ileum, and bladder. 

Second, I had the chance to assist in the changing of a wound bed dressing that required a wound vacuum. Essentially, the pressure ulcer was on the posterior side and required intensive dressings. After packing the wound with a sterile sponge-like material, the wound was sealed air-tight and a vacuum was attached to facilitate drainage and healing. 

Thirdly, and most disturbingly, a patient presented with severe unstageable wounds to his sacrum. Gangrene had developed and the wounds were wet and emitted a foul odor. Most surprisingly was the patient's noncompliance with treatment, despite the severity of his condition. This will more than likely be my case study to be presented this May. 

Once again, this has by far been the most eye-opening experience thus far. It is interesting to see first hand the conditions that we are treating. These patients are high risk nutritionally, and require additional calories and protein in order to promote proper healing. 

Competencies:
CRD 2.5: Demonstrate active participation, teamwork and contributions in group settings.
CRD 2.10: Establish collaborative relationships with other health professionals and support personnel to deliver effective nutrition services.
CRD 3.2: Demonstrate effective communications skills for clinical and customer services in a variety of formats.

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Believe it or not, this blog merely skims the surface of the experiences that I have been having at FRMC. There are so many more things to be discussed and shared, but time just does not permit.

Stay tuned for the next round of wild events!​

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.