Tuesday, October 26, 2010

A day in the life of a clinical dietitian...

Ok, maybe this isn't that interesting, but I have had SEVERAL people ask me the question, "So what exactly do you DO?" I usually don't have a very good answer for them, so I decided to post it on here.

At St. Luke's we see ALL the patients (medical floor, surgical floor, pediatrics, inpatient rehabilitation, ICU, Cancer Center, labor and delivery, NICU, and even Canyon View patients.) Each dietitian is assigned certain floors and units they cover, but I'm kind of the fill in person. I help whoever is really busy, and cover for whoever takes a day off, so I get a little dose of everything.

There is a process that we go through when we see patients. First, we have Diet Techs who screen all the new patients that come into the hospital. They see every patient and ask them a slew of questions that helps determine if they are at nutrition risk. (Do you have any food allergies, how's your appetite, have you lost/gained weight lately, have you had nausea, vomiting, or diarrhea, do you have problems chewing or swallowing, etc, etc.) Then depending on their answers, they get a certain score. Other things are also taken into consideration like their age, diagnosis, and albumin level. If they score 6-10, they are of "moderate" nutrition risk, anything over 10 is "high" nutrition risk, anything below 6 is "low" risk. We (the dietitians) see all the moderate and high risk patients.

So when I get a patient there are several things I do. First I go through their records on the computer and write down any pertinent, helpful information. I read their history and physical that is dictated by the doctor, where I can find out what brought them into the hospital, their past medical history, if they're married, if they came from a nursing home, what the plan for their treatment is, etc. Then I look at their labs and write down abnormal nutrition related ones (Sodium, Potassium, BUN, Creatinine, Glucose, etc, etc.) I look at their medications and do the same. Some medications have food interactions so they are good to know (for example Coumadin and Vitamin K, Cipro affecting calcium absorption, etc.) Others (like antibiotics) can cause diarrhea, so they are good to write down so that if your patient who's on tube feeding comes down with diarrhea (sorry I'm using that word so much :) and the nurse comes to you and says that you need to change the formula or slow down the rate, you can say, well they're also on 5 antibiotics, that's probably causing the problem. (Not that I like to argue with nurses). I can also look at weights, in's and out's (to see their fluid balance) what diet they're on, and how much of their meals their eating. I also look at the Diet Tech's screen and see what they screened out for so that I can address those things with the patient (for example if it says they have problems chewing, I can ask them if they want a mechanical soft diet.) I also look at previous dietitian's notes if they have already been seen this hospital stay.

Once I have all my information I go down to talk to the patient. I always flip through their chart and look at the doctor's orders first. Sometimes I can find updated information in there about meds or diet, or even find a consult for us that we havn't received yet. I then talk to them about their appetite. If it's not good I might try to come up with something that sounds good to them. I will offer them snacks, supplements (like Carnation Instant Breakfast or Ensure), or sometimes even offer them the cafeteria menu (depending on their diet) to peak their interest. If I'm really worried about a patient I can start a calorie count, which is where every single thing they eat is recorded for 3 days and then we know exactly how many calories and how much protein they are eating. From there I can determine if maybe I need to add more calories to their diet, like adding extra protein to every meal, extra butter and gravy, whole milk, etc, or I can see that they are actually doing ok. We also educate patients on different diets. I always ask my diabetic patients what they do to control their diabetes (count carbs, watch portion sizes, etc.) and how often they check their blood sugars, etc. If they have any questions I answer them. Sometimes we get consults from the doctor to educate a patient (could be on anything-diabetes, weight loss, etc,) or to add more calories to a diet, write a tube feeding order, etc. Sometimes I will talk to the nurse to get any information. Especially if the patient is obviously confused and cannot answer my questions appropriately.

Once I've talked to the patient, I write my note. I document what we talked about, their labs, medications, and anything else I find pertinent. I estimate their calorie and protein needs. I identify a nutrition related problem (there's a standardized list to pick from that the whole dietetics community is supposed to be using, for example: Inadequate oral intake) and write a specific goal to overcome this problem (for example: Patient will consume 75% of most meals and snacks x length of stay.) Then I list any interventions I did ( for example if I sent them snacks or a supplement, gave any education or handouts, and the things I'm going to monitor like labs, weights, and appetite. Then I make any recommendations to the doctor (if any). A recommendation I might make would be to start a multivitamin, or liberalize the diet (say from a low sodium to just a no added salt diet to increase the patient's intake), or this is where I would write my tube feeding recommendations. We also see patient's with a low or high BMI and offer information on gaining or losing weight, and must get the doctor's signature agreeing with us that they have a low or high BMI (for billing purposes I think.) Once my note's done I stick it in the chart, and write any orders in the chart that I want to do (downgrade the texture of the diet, send supplements, or start a calorie count.) If I write any orders I fax it to the nurse's station so it gets put in the computer.

At the end of my note I put a follow up date. Moderate risk patients must be followed up with in 5-7 days and high risk patients must be followed up with in 3-5 days. If we see a low risk patient for any reason (i.e. high BMI) it can be 7 days. It can be sooner too, if you think it needs to be sooner. Most of the patients go home before they have to be followed up on, but if not, we go see them again...and again, and so on until they go home. Sometimes you might have to change your nutrition problem(s), or change your interventions (for example, if they get really tired of being sent Ensure three times a day, you might want to change it to something else.) Every now and again you might get a patient that doesn't really have a nutrition problem. (For example, they told the Diet Tech that they don't have a good appetite, but by the time you see them, they are eating really well, their labs are good, etc, then you can say that no nutrition problems are identified at this time.)

So basically that's what I do. I think people think I write menus all day or something, but a clinical dietitian doesn't really deal with that very much. Our job can actually be very complicated. Tube feeding and TPN patients are serious business, and there are some pretty malnurished patients that come into the hospital. Studies show that the better nourished a person is, the better and faster they will heal. We have all kinds of formulas and references to help us when we get stuck on something, and when all else fails, we "use our clinical judgement."

I am also going to be doing some outpatient counseling. These patients are usually referred to us by their doctor and need counseling on weight loss, or even things like ulcerative colitis or celiac disease. These patients just come to the hospital and meet with us. It also looks like I'm going to start doing some home health. I will go into patient's homes and visit them. Both of these things will give me more hours, so I'm excited!

So that's what I do in a nutshell, let me know if you have anymore questions. :)


Lorraine said...

Very interesting to read what you do!

Lorraine said...

That very episode of Psych is what reminded Seth that he loved Thunder Cats as a kid. Now are kids love it too.