Midpoint of MNT

It is hard to believe that I am already on the back nine (so to speak) of my Medical Nutrition Therapy rotation. I guess that really goes to show how time flies when you're having fun.

The workplace community at FRMC is unbeatable, and I am really starting to feel like I have found my niche in the office. 

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Over the last 5 weeks at Franklin Regional Medical Center I have been growing and learning at a break neck speed. It wasn't until our midpoint evaluation rolled around that I really took time to stop  and meditate on my progress as an entry-level dietitian in training. 

The most notable change, from my perspective, is my level of comfort when interacting with patients. During the first couple of weeks at FRMC I was very hesitant to approach patients for fear of disturbing their peace. After gaining experience through patient education and meal rounds, I have learned the boundaries and social graces which facilitate such interactions, and it is now much less intimidating. Meal rounds are actually the most beneficial part of my day, where I truly get to know the status of the patient through my own observation versus those recorded in a medical chart.

I also feel very confident in my understanding and utilization of the Nutrition Care Process. I have been more involved in initial assessments, and actively request a larger load of patients to help with staff relief.

Although I am not quite there yet, I am slowly approaching independence in daily tasks. I enjoy being a team player and want to help share the case load. I look forward to the day when my superiors have enough confidence to let me utilize my leadership skills.

There are still a great many things that I can and will improve upon, but I feel as though there will always be room for improvement, no matter how much experience is acquired.

Here are the highlights of the week....

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NICU

Every time I assess a patient I learn a little bit more. When I read a medical chart and come across a disease state that is less common, I always take a minute to do a little research to familiarize myself with the terminology. The Neonatal Intensive Care Unit is my absolute favorite specialty to study.

​The way we assess NICU babies is a tiny bit different from the way we assess our other patients. While the ADIME format and Nutrition Care Process remains the same, the method about which we obtain our information is much more hands on. 

​For starters, relatively none of the babies' information is accessible via the Meditech charting system. Therefore, in order to gather our data we have to make a visit to the NICU to review the nurses' paper charts. Oftentimes, information such as rate, volume and method of feedings cannot be found in the chart, and must be verbally confirmed by the NICU nurses. 

This week I was put in charge of initial assessment and follow-up of all NICU babies at FRMC. It was so very exciting for me to be involved with an area that I find so fascinating. After all, my favorite classes during my lengthy undergraduate career included Maternal and Child Nutrition, Nutrition in the Life Cycle, and Childhood Development. 

Here are a few things I have picked up so far:

• Gravida (G) - number of pregnancies
• Para (P) - number of deliveries
  • (Example: G2P1)
• Oligohydramnios - deficiency of amniotic fluid
• SVD - spontaneous vaginal delivery, no forceps or vacuum required
• Meconium - baby's first bowel movement
• Vernix - waxy substance that protects fetus' skin during last trimester of pregnancy

• Neonatal Abstinence Syndrome (NAS) - exposure to addictive opiate drugs in the womb
• Apgar score - quick assessment of overall newborn well-being at 1 minute and 5 minutes after birth.
  • 1 min - indicates toleration of birth
  • 5 min - indicates toleration outside womb
  • Scale 1-10 
    • 7, 8, 9 is "normal"

Outpatient Counseling

This past week I discovered that a mentor of mine is not only a Certified Diabetes Educator, but is also level 2 certified by the Commission on Dietetic Registration (CDR) in Adult Weight Management. Her outpatient counseling at FRMC has been slowly gaining momentum, and last Thursday was the gauntlet of sessions.

​We counseled two clients for weight loss related to obesity, one pediatric client with their parent present, and one diabetes client. ​We were also scheduled for a gestational diabetes client who did not show up for their appointment. In addition, we prepared for a free diabetes education session for 5 clients who were referred by physicians, but not a soul showed up!  

Outpatient counseling is quite different than inpatient, as you may have been able to guess. The amount of time allotted for outpatient clients is increased 10 fold, but is also dependent upon insurance or payment ability. From what I have gathered, certain insurance policies will pay for X amount of time with a dietitian. Therefore, clients can split up their allotted time into several visits or use it all at once. After insurance coverage is maxed out then it is up to the client whether they want to continue seeing the dietitian by paying out of pocket.

​Outpatients and inpatients are similar in how their knowledge and interest in nutrition education varies widely. Some people who come in for counseling are openly disgruntled with having to participate, and view us as the "food police." On the other hand, some people are eager to learn and are shocked by some things they learn, particularly serving sizes! Additionally, some people walk into a session having already formed their own opinions and are simply looking for validation from an expert. 

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Pediatric Counseling

My favorite outpatient counseling session this week was with our pediatric client. Personally, my work is most rewarding when I feel like I am benefiting the "big picture." While I enjoy each client individually, I like to think that I am somehow helping on a larger scale as well. 

For example, while it is important for people with type 2 diabetes to receive education to help them manage their symptoms, I would prefer to work towards preventing people from developing type 2 diabetes in the first place. And that's my tiny soapbox moment.

But....where better to start than with the youth of our communities? For the most part, this population is energetic and eager to learn. By educating our youth about healthy lifestyle choices we can potentially change the fate of the next generation. The picture doesn't get much bigger than that. 

Our client is having a follow-up appointment towards the end of my rotation at FRMC, and we have made a deal to make a healthy snack together. I hope to play a game and be able to encourage our client to try two new foods. I am really looking forward to it.

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Meal Rounds and Trayline

Meal rounds are still going strong, and this week we added another step to our routine - the trayline. After IDR and patient rounds we passed through the kitchen on our way back to the office. Patient trays were being assembled and loaded into carts to deliver up to the floors.

As someone with much experience in the restaurant industry, it was interesting to see the same type of service in the context of a hospital. Meal orders were being filled in much the same way, but the orders are based on the health of the patient in addition to their preferences.

While we watched the process that the staff has nearly perfected I was also poking around in the drinks bin, reading labels and comparing the supplements. 

My preceptor saw me checking out the different beverages and allowed me to try one. I chose the apple juice that has been thickened to a honey-like consistency, used for dysphagia patients. There was also thickened sweet tea, but I stuck with the apple juice for my first attempt.

I have to admit, it was actually really good. Imagine apple sauce with a smooth texture, and that is honey-thick apple juice. However, I'm not quite sure I'm ready for the sweet tea just yet.

I really cannot believe my first rotation is half past. I have been waiting for this for so long, and now that it is here the time is flying. It feels really good to gain professional experience, and to meet such great people.

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Competencies:
CRD 1.3 Justify programs, products, services and care using appropriate evidence or data.
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 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.