Tag Archives: tube feeding

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!

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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!

Tube-ular!

This week has been very busy.  My focus has shifted more to critically ill patients and those needing enteral feedings, which are formula feedings through the nose or through a tube connecting to the stomach/small intestine.  I’ve had to pick out which formula to use, their daily needs for calories and protein, and how much they need to be given per hour.  Its using a few algebra skills as well as clinical judgement.

One lady I wrote an order for has a jejunostomy tube, which is a tube that connects from the skin to the jejunum, a part of the small bowel.  She is on enteral feedings at home, and uses a particular formula that is pumped into her during the night.  However, she is post-op from surgery, which automatically  increases her nutrition needs- mainly protein!  Extra protein will help her body to heal better.  I went in to speak to her about starting her tube feeding and she was worried about switching formula; sometimes with different formula compositions, some side effects such as diarrhea could occur.  I assured her that we would be following her very closely to make sure she was tolerating it ok, and that her body needed the high-protein formula.  She and her husband were glad I took the time to speak to them, and I was too!

A lot of the other enteral feedings I ordered were for people who were unable to speak to me- and visiting with patients is one of my favorite parts of dietetics- so I was glad to have this interaction.

Having the ability to order tube feedings is pretty awesome, if I do say so myself.  It’s nice to have a definite impact on a patient’s plan of care.  With interviews and recommendations, you never know if the patient is really going to be impacted by what you say or if the doctors are actually going to listen to you.  Tube feedings are another story- once the doctor gives the word, it’s all up to me!

The Reality of It

I, for one, have never had to stay in the hospital more than maybe a night in the emergency room. No one close to me has had to be hospitalized for a lengthy amount of time that I have been old enough to remember. (Both things i am extremely grateful for!) Therefore, working at the hospital does give me a big dose of reality- that there are REALLY sick people out there. People who led healthy lives that suddenly are dying of cancer. People who will end up with diabetes and renal failure. Others with devastating strokes.

Today I spent some time on patients in the Critical Care Unit, the  ICU if you will. That’s where the sickest of the sick end up. I had to recommend tube feedings to two patients. One of the patients was probably going to end up in a long term care facility, never being the same after a terrible cerebrovascular event. The other was being considered for hospice, which of course means that he is getting ready to die. Today I left with a different perspective. Instead of happily bopping into patients rooms and teaching them how to order off the menu, recommending supplement shakes, or teaching about nutrition with whatever new disease they acquired, I had to sit at the computer and think about the severity of their conditions. It didn’t help to run into a family that was crying for another patient further down in the ICU.

It kind of makes you appreciate life, you know?

My mom, a former ICU nurse, made a comment a week or two ago about how patients love students in the hospital. Probably because we’re not used to being in this environment, we almost care too much! One of my patients dying or being close to dying affects me quite a bit. I know in time it will impact me in a lesser way, but it’s definitely something that takes getting used to.

I don’t mean to complain; I know doctors deal with this stuff all the time. But it’s almost reinforcing my original plan to get into public health- prevention!