Another week of the traditional duties! I won't bore you with the same old stories.
However, there were a couple of fun things beyond the ordinary.
Enteral Nutrition (EN)
Alright, back to business. The most notable accomplishment from my last week in MNT was my shining moment of recommending Enteral Nutrition for a patient. Throughout my time as an intern at FRMC I have had my fair share of experience calculating tube feeds and monitoring the progress of patients receiving EN/PPN/TPN. However, this moment was my big break in being the first person "on-the-scene" for recommending Enteral Nutrition for a patient.
For a little background, our patient had a history of alcohol abuse, which was only just discovered upon initial discharge. Patient X had been initially admitted due to increased dizziness and fatigue, status post squamous cell carcinoma to the neck/throat with former tracheotomy, chemotherapy and radiation. Upon initial discharge our patient became exceedingly confused with severe tremors, and was readmitted after reports from family confirmed alcohol abuse.
By the time the case came to me our patient had already been NPO for five days, with a history of a clear liquid diet only one day out of a total eight days of admission. Speech Language Pathologists (SLP) had been consulted for PO diet recommendations related to throat cancer history, but were unable to perform a Modified Barium Swallow (MBS) due to the patient's inability to tolerate sitting up.
According to ASPEN Guidelines, if the gastrointestinal tract is functioning then Enteral Nutrition is indicated for administering nutrition support. Our concern with EN was the possible inability to insert a NG tube for feedings due to the patient's history of tracheotomy related to throat cancer, which could present complications. Therefore, we left the decision for EN or PPN up to the MD based on what they deemed medically achievable/realistic. However, we continued to assess the patient for EN recommendations.
Estimated energy needs:
1400-1680 kcal (25-30 kcal/kg ABW), 56-67 g protein (1.0-1.2 g/kg ABW), 1400 mL FW.
Enteral Nutrition Recommendation:
Jevity 1.2 at goal rate 55 mL/hr will provide 1584 kcal, 73 g protein, 1065 mL FW, providing 100% RDIs.
Additional FW flushes of 520 mL.
Inadequate energy intake R/T alcohol withdrawal procedures AEB NPO >5 days.
Enteral or Peripheral Parenteral Nutrition support to meet minimal estimated energy requirements.
Continue NPO per SLP recs
If able, recommend EN - Jevity 1.2 at goal rate 55 mL/hr; FW flushes 520 mL/day per MD discretion.
If EN not an option, recommend initiate standard PPN at 50 mL/hr.
MONITORING & EVALUATION:
No s/s aspiration - pending SLP MBS eval
Initiate EN or standard PPN support
RD will FU in 1-3 days
Follow Up on Patient X
Four days after my assessment of patient X and recommending EN/PPN for nutrition support, the patient is still NPO. Due to a rapid decline in function, patient has been transitioned into hospice care, with a code status of DNR/DNI. Supportive measures are being taken, but due to a terminal prognosis EN/PPN are no longer indicated for patient care. RD signs off care, but remains available for further consult if needed.
Overall, I have learned an incredible amount in just ten short weeks of working at FRMC. Every day I learn something new. I feel much more confident in my acute care capabilities, and have enjoyed the opportunity to advance my skills in MNT. While I still have a lot to learn, I feel assured that I would do well as an entry-level clinical dietitian.
Cheers to MNT, and here's to the next chapter of my Dietetic Internship!!
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 2.1 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 2.2 Demonstrate professional writing skills in preparing professional communications. (Tip: Examples include research manuscripts, project proposals, education materials, policies and procedures.)
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 2.12 Perform self-assessment, develop goals and objectives and prepare a draft portfolio for professional development as defined by the Commission on Dietetic Registration.
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.