Tag Archives: inspired

The Interdisciplinary Team: How an RD Fits

One of the things that drew me to become a Registered Dietitian was working directly with other people and helping patients live healthier lives.  Clinical nutrition wasn’t my dream career while I was still in college; I always thought clinical dietitians worked independently on their patients, who they only saw for a few minutes for assessment anyways.

After completing my clinical rotation, however, I quickly saw that I could still enjoy face-to-face contact with not only my patients, but also my co-workers.  I loved being part of the interdisciplinary medical team, going on rounds and discussing the patients’ plan of care.  It feels really good to contribute to someone’s recovery, especially in such a specialized field as nutrition.

Here are a few members of the medical team that I work with on a daily basis:

Nurses & CNAs: These individuals are my number one allies.  They are the ones that spend the most time with the patient.  They can see how well the patient is eating, if they have GI issues, or if they have wounds that require extra nutrition to heal.  They are also the ones administering tube feeds and checking residuals.  Additionally, they are much easier to get in touch with than the doctors, and can be a valuable advocate for my recommendations when the doctor does come around!  Every time I respond to a consult, finish an education, or drop off tube feed orders, I let the nurse of that patient know.  He or she starts to recognize and trust me.  In fact, I seem to get more consults and calls now that I have established professional relationships with the nurses on my floors, which is great!  (Plus it’s always nice to have people smiling and saying hello to you, instead of “who are you?”)  The only thing I’ve had to really push for them is at what residual level you need to stop a tube feed (ie please do not stop a 65 ml/hr tube feed when you get a residual of 40 ml! Check the nursing manual! This person needs their calories & protein to heal!) However I have the utmost respect for nurses and everything they do.  My own mother was a nurse!

Speech: Speech Language Pathologists aka Speech Therapists do not always teach people how to speak; they assess everything in the vicinity of the throat.  They are a dietitian’s best friend when it comes to determining patients’ ability to swallow.  This is mainly for older adults, those with a stroke, or certain other medical issues.  Sometimes I have to delay my nutritional assessment until Speech comes through with their recommendations; I can’t recommend extra protein or a particular diet order if the patient can’t even swallow! (And in that case, they’d probably need a tube feed.)  Also, they are the ones that recommend modified textured diets; for example, it is easier for people to swallow pureed foods and thickened liquids than dry foods and watery liquids.

PT/OT: Physical and Occupational Therapists are vital for anyone needing any sort of rehabilitation after an operation, trauma, stroke, etc.  Learning from PT that my patient on a continuous tube feed is ambulating in the hallways and doing exercise regularly tells me perhaps I should switch them to bolus feeds.  Learning from OT that my stroke patient can feed themselves with utensils tells me to monitor their meal intake closely now that they are eating without assistance.

Social Workers & Case Managers: When a patient cannot afford the food they need to keep them healthy after discharge, social workers can recommend food assistance programs, community meals, and other resources.  They can also coordinate home care, nursing home referrals, home tube feeds/TPN care, transportation for follow-up appointments, etc.  I’ve had to work with these individuals on several occasions to make sure the patients have a smooth transfer out of the facility in regards to supplements, education, and tube feed orders.

Doctors: In my experiences, the doctor has always needed to sign off my orders, so they have the ultimate say in what happens.  For the most part, they take the dietitian into consideration.  I especially enjoyed clinical rotations in teaching hospitals – students and interns were quick to listen and go with what the dietitian had to say.  On the other hand, some doctors are less receptive to the input of a dietitian, which any RD will tell you.   Also some doctors have crazy schedules that have them visit patients at 6 am or 8 pm, making them hard to get a hold of.

Throughout my internship and beyond, I’ve had to push my way through in a few patients – namely ones on total parenteral nutrition (TPN, which is basically a nutrition IV) – to give them optimal nutritional status (ie- if the gut works, use it!)*  What the doctor says goes, but I’ve had a few instances where I had to be pretty convincing in my charting, as well as verbally defend my recommendations.

*Going with this example, some people (nurses, patients/families, and doctors alike) think TPN is an easy fix if someone cannot eat by mouth.  However, it can be detrimental to use TPN if the person has sepsis (you’re pumping sugar straight into infected blood, feeding the bacteria!) or diabetes (you’re pumping sugar straight into diabetic blood, making it difficult to control blood sugars!).  Also the intestines actually function as part of the immune system, so by eliminating use of the gut, you may be decreasing their immunity.  Not to mention potential overgrowth of intestinal bacteria, sky-high healthcare costs associated with TPN, risks associated with placing a central line, etc.  Ok, enough with my TPN rant….

What I’m getting at is this: RDs are the nutrition experts, and we are a valuable asset to the medical team.  Working with these other professionals is extremely rewarding, and you can learn so much from everyone else.  At times you have to stand up for yourself, but you also have to step back and see the big picture.  Nutrition may not be as important as say, SURGERY.  Nutrition alone CANNOT FIX EVERYTHING.  And very importantly: you can’t make it personal if a doctor decides to ignore your advice.  That’s when the issue becomes about YOU and not the interest of the PATIENT.

The medical team, not to mention the patients, rely on us to convey cutting-edge, research-based nutritional interventions.  Contributing patient care recommendations in the specialized field of nutrition is interesting and rewarding.  It’s so gratifying when you can work together with the other disciplines for the patient’s benefit!

RD Web Presence – A Valuable Thing

I have always had a passion for social media and information technology, which is no surprise if you have followed my blog or know my background!  Communicating with the public online is something I really enjoy.

Having a website, blog, Twitter, LinkedIn, etc can be a lot of work to maintain (especially when you have a full-time job, too!)  however it can really pay off.  For example, I was contacted by a company called AD Medical, or America’s Dietitians, which is in Chicago.  One of their employees in the communications department stumbled upon my website and blog, and took the time to contact me directly.  He asked if I would be interested in writing a guest blog for his company’s brand new website.

Just some background – AD Medical works primarily with those on Medicare and with diabetes.  Their new website provides information for both clients and health care providers.  Their new blog, BlogAbetic, offers a more interactive feature for clients to learn tips on healthy living.

I was really excited to be featured as the first blogger featured on BlogAbetic after they debuted their brand-new website.  I definitely hope to work with them more in the future!

Check out my entry – Color Your Plate, Improve Your Health!

Having a website, blog, and various social media platforms have given me many other opportunities as well, such as career advice, notification of available jobs/volunteer work, and even an offer for free RD exam study materials!  Plus, when you apply to a job, all you have to do is refer them to your portfolio to find all the information they’d ever want.

It may seem like a lot of work to maintain a web presence, but don’t give up.  For example, my blog had very few views when I first started, but now I get more than I ever initially expected!

How has social media and web presence helped you in your career/education?

Community Experience: Moveable Feast

Moveable FeastJust finished up 2 weeks with Moveable Feast, and let me tell you: I learned a lot more than just about community nutrition!  This non-profit organization (funded by grants) cooks, packages, and delivers food to people in Maryland with HIV/AIDS, breast cancer, and in certain cases, blood cancers.  Not only that, but there are three registered dietitians on staff to provide nutrition assessments, home visits, phone counseling, and educations to the clients.  The dietitians on staff were so passionate about their jobs- it was really inspiring.

Packing moveable feast meals

Packing meals for Moveable Feast clients

I was able to participate in duties normally done by the RDs such as risk screens, counseling, etc.  Plus I taught volunteers about food safety, designed handouts/seminar materials, and even helped pack a few meals!  Some parts of this dietetic internship rotation definitely took me out of my comfort zone, however.  I was going into areas of Baltimore City I might not normally find myself in, and counseling clients in their homes is A LOT different from counseling them in a hospital or clinic.  But with patient preceptors and friendly, grateful, inspiring clients,  the experience was one that I will never forget.  I’m so glad I could be a part of Moveable Feast and help out members of the community!

If you live near Baltimore, learn about participating restaurants that will donate part of the check to Moveable Feast on Sept 22, 2011.  And if you enjoy cycling, definitely check this out!

CNPP, in Photos

Moving on Up: In Age, at Least!

The past two days I’ve been working with younger children from preschool to first grade.  Yesterday we also talked to some parents about the importance of family meals- for nutrition, social support, and other reasons.

Today, still in Baltimore, I was presented a new challenge: middle schoolers.  Fortunately it went very well, although I was wiped out at the end of the day, it was fun!  It is so interesting to see the big differences with each grade, even just between 6th and 7th graders, developmentally and behaviorally.

fat in a super size fry from McDonalds

The amount of fat in a McDonald's Super Size Fry. Gross, right?

We did 3 classes: 8th grade, 7th grade, and then 6th grade.  Each lesson started out with calculating the teaspoon equivalents of fat in fast food items (represented by shortening), and teaspoon equivalents of sugar in beverages (represented by salt).  We said that 4 grams=1 tsp, so they could figure out the grams of fat/sugar in each item and go from there.  It was pretty effective in terms of shock value. One girl was looking through the booklet with all the nutrition info for fast food restaurants, and said, “Wow, I want to show my mom,” which prompted the nutrition educator and I to find her a booklet to take home!  If that’s the only impact we made today- to spark that girl to start thinking about nutrition in a way she hadn’t before- then our work was worth it. Definitely.

Helping 8th graders

Helping the 8th graders coat veggies in oil and spices before grilling.

After that activity, we made a healthier fast food option: chicken fajitas on whole grain tortillas with TONS of veggies: onions, mushrooms, peppers, zucchini, squash, and tomato.  We got out the portable grill and made it right there in the classroom, with everyone helping out by chopping veggies, stirring, flipping, or setting up plates.

So sad that this was my last day for FSNE!  I’ll never forget it- I learned so much about teaching for different audiences, and it will definitely help me in my future career.  The nutrition educators I got to work with were fantastic and really inspiring!  It reminded me of why I love community nutrition.

Students as chefs

Students cutting up their veggies for fajitas.

Critically Progressive

It is my last week in clinical!  I cannot believe it.  Next week we have two class days and are off for 3 days for Thanksgiving.  Then I will start my other various dietetic internship rotations, which are in MUCH quicker succession.  Hopefully my blog will get a lot more interesting 🙂

Calculator for tube feeds

Glued to my calculator figuring out tube feeding orders.

Staff relief has been wonderful.  It’s been my favorite part of the internship so far- I’m basically a dietitian at the hospital.  The independence is great!  Last week I was mostly covering the critical care unit as well as a few med/surg patients.  I ended up doing so many tube feedings that I’ve become really comfortable with ordering them.  This week, however, my preceptor has put me on a different floor; I saw oncology and progressive care patients (with many different diagnoses).  The variety is refreshing…as well as the ability to actually speak to my patients, which is my favorite part!

On to the 5th Week

Well, this upcoming week is the 5th week of my clinical rotation.  I have to do 8 weeks at my current hospital, 2 more weeks at a different hospital (just to get another perspective from how another place runs things), and then come back to do 2 weeks of staff relief at my original hospital.  12 weeks total clinical, technically.  It’s a long time, but I don’t mind- I am really enjoying what I’m doing just because it’s so interesting!

Because the 8-week period is halfway over, I had an evaluation  with my preceptor.  He said I’m doing very well so far, which was great to hear!  He even observed me while I educated a patient on dietary interactions with the drug Coumadin.  (Coumadin prevents blood clots by thinning the blood, and you have to watch Vitamin K intake because K promotes blood clotting mechanisms.)  One thing I do need to work on is my “authority”- aka my confidence and portraying myself as an expert (although I don’t feel like one just yet!)  I’m sure that will come as time goes on, however, as I become more and more comfortable.

Friday was an exciting day.  I finished up my mini case study report on a patient I had been following for a few days.  He had not only diabetes…but hypertension…congestive heart failure…and worsening chronic kidney disease!  He was definitely more complex that originally anticipated, but I got to learn a lot about how all these conditions affect each other.  Plus he was the nicest guy who was great to work with.

Friday I also did FOUR patients, which is the most I’ve ever done.  I followed up with my case study, did a diabetes and low-sodium diet education, assessed a patient with severe nausea/vomiting from chemotherapy, and worked with a patient to find soft foods he could eat since he didn’t have a lot of teeth.

This week’s homework topic is enteral and parenteral feeding, which is nutrition support in the form of tube feeding and IV administration.  Speaking of homework…I have to get back to doing it!  I’ll try to update again later this week, hopefully after getting the chance to write some nutrition support orders!