Learning Outcome 5
Based on the efficacy and strength of scientific evidence, collect data, assess nutrition status, determine nutrient requirements, develop and implement interventions for individuals and groups in a variety of practice-based settings, and document in appropriate records.
Artifacts:
Artifact 1 – NUTR6007 – Grady Acute Care Supervised Practice – Evaluation and Case Study
Reflection:
In contrast to my experience at the Georgia State University Counseling Center, I genuinely had mixed feelings concerning my clinical rotation at Grady Memorial Hospital. To be honest, part of me wondered, why Grady? After all, I had heard some worrisome stories about the type of patients at the hospital: homeless, incarcerated, altered mental status, etc. Essentially, their patient profiles were the exact opposite of my clients at the Counseling Center. I have to admit, a part of me was excited to put the medical nutrition therapy (MNT) I had spent several semesters learning to work and interact with real, live, patients – not just case study patients on paper. While I had thought I would utilize my MNT knowledge at the Counseling Center, the clients were students with less needs and complexities and the type of relationships differed. Students visited the Center frequently, which allowed me to build strong relationships and help support lifestyle changes more so than in a hospital setting where patients often are quite ill and unable to fully grasp the important aspects of nutrition education. This made the Counseling Center a great place to build a foundation of practice – but it was not nearly as challenging. After making it to this point in the program, I now understand the progression and, therefore, look forward to acquiring more knowledge and experience as I continue in my rotations.
Despite having my Counseling Center rotation completed, a wonderful professor for MNT that taught us all the ins and outs of every disease state imaginable, and a short shadowing and training period at Grady, I still did not feel ready to see patients on my own. Most of the patients at Grady had multiple health conditions and diseases, and I was concerned that I would not be able to provide the level of care these people deserved. I was afraid that I may not be able to retrieve all of the research-based knowledge I had learned in school and provide valuable recommendations to patients. However, I did my best to push that fear into the back of my head and provide the most effective care possible.
I arrived at Grady early each day, logged into the medical charting system, EPIC, and printed out my patient list. Fortunately, my time at the Counseling Center familiarized me with electronic charting systems, which made the transition to EPIC an easy one. Next, I prioritized which patients needed to be seen based on the protocol the Grady nutrition department uses. Most patients did not need to be seen for the first time until the fifth day after admission; however, I was not at the hospital every day, and usually I needed to see them before the five days were up. Follow-up visits and second follow-up visits had different protocol as well. I found that preparing for initial assessments took the most time. I had to review notes from all disciplines: residents, physicians, nurses, respiratory therapists, physical therapists, social workers and case managers and research the information I found in the patient charts. This research allowed me to come up with a list of questions to ask each patient and assisted me in writing evidence-based nutrition diagnoses and interventions.
Over the course of this rotation, I met with many patients. Some of them I saw multiple times before they were discharged and others I only saw once. Several of them taught me not to judge a book by its cover. However, there was one particular patient with whom I really made an impact, leading me to use him as my case study focus.
JJ was a 27-year-old male with HIV/AIDS, AIDS-related dementia, bipolar disorder, hypertension and a history of polysubstance abuse. He was admitted to the hospital for aggressive behavior and confusion. The initial assessment with JJ revealed a confused patient with visible AIDS-related wasting. He was extremely thin and had a body mass index (BMI) of 15.21kg/m2, which is well under the underweight mark. JJ was dissatisfied with the amount of food he was receiving in the hospital. Moreover, he had multiple dietary preferences. He had no complaints of typical AIDS nutrition-related symptoms such as decreased appetite, mouth sores, taste changes or bloating. After meeting with JJ, the following nutrition diagnosis was written: Malnutrition NI-5.2 related to increased needs as evidenced by HIV/AIDS and low BMI. The intervention was general/healthful diet ND-1.1 and Commercial beverage ND 3.1.1. Research shows AIDS patients have an increased resting energy expenditure (REE), which requires a higher energy intake than a healthy person. Therefore, JJ’s needs were calculated using 30 – 35kcal/kg based on his recommended body weight (RBW). Protein needs were also higher for JJ due to his wasted state. JJ was placed on a general diet with double portions and Boost Breeze supplements to help him gain weight and increase his BMI.
Nutrition follow-ups with JJ uncovered a strong desire to gain weight. His appetite remained strong, and he was consuming all of the food and supplements provided, but his weight was not increasing very much. JUVEN was introduced to the patient to help slow muscle breakdown and improve immune function. JJ increased his weight from 102.5lb to 106.5lb over a three-day timespan and as a result, his BMI increased to 16.2kg/m2. This weight increase may not be directly associated with JUVEN, but it seemed to give the patient hope that he would be able to continue to gain weight. Even though JJ’s case was very sad, I was grateful for the opportunity to work with him, and with any luck, improve his quality of life. The case study assignment allowed me to reflect on the impact I had made, dive deeper into the literature and examine the strengths and weaknesses of the intervention I chose.
I cannot believe how much I learned and grew as a person in my acute care rotation at Grady. This experience allowed me to build on the knowledge and communication skills I had gained at the Counseling Center, forcing me to become a better practitioner and a more empathetic future dietitian. While both experiences proved vital for my education, Grady acted as the cornerstone, giving me the ability to react appropriately in any nutritional setting. But it also tested me emotionally, by opening my eyes to the sad realities that can often be a symptom of social and economic issues, lack of insurance and poor lifestyle choices. My time at Grady allowed me to see the important role a dietitian plays in a hospital setting and I am confident that I am well equipped to practice in this environment in the future.
Artifacts:
Artifact 1 – NUTR6007 – Grady Acute Care Supervised Practice – Evaluation and Case Study
Reflection:
In contrast to my experience at the Georgia State University Counseling Center, I genuinely had mixed feelings concerning my clinical rotation at Grady Memorial Hospital. To be honest, part of me wondered, why Grady? After all, I had heard some worrisome stories about the type of patients at the hospital: homeless, incarcerated, altered mental status, etc. Essentially, their patient profiles were the exact opposite of my clients at the Counseling Center. I have to admit, a part of me was excited to put the medical nutrition therapy (MNT) I had spent several semesters learning to work and interact with real, live, patients – not just case study patients on paper. While I had thought I would utilize my MNT knowledge at the Counseling Center, the clients were students with less needs and complexities and the type of relationships differed. Students visited the Center frequently, which allowed me to build strong relationships and help support lifestyle changes more so than in a hospital setting where patients often are quite ill and unable to fully grasp the important aspects of nutrition education. This made the Counseling Center a great place to build a foundation of practice – but it was not nearly as challenging. After making it to this point in the program, I now understand the progression and, therefore, look forward to acquiring more knowledge and experience as I continue in my rotations.
Despite having my Counseling Center rotation completed, a wonderful professor for MNT that taught us all the ins and outs of every disease state imaginable, and a short shadowing and training period at Grady, I still did not feel ready to see patients on my own. Most of the patients at Grady had multiple health conditions and diseases, and I was concerned that I would not be able to provide the level of care these people deserved. I was afraid that I may not be able to retrieve all of the research-based knowledge I had learned in school and provide valuable recommendations to patients. However, I did my best to push that fear into the back of my head and provide the most effective care possible.
I arrived at Grady early each day, logged into the medical charting system, EPIC, and printed out my patient list. Fortunately, my time at the Counseling Center familiarized me with electronic charting systems, which made the transition to EPIC an easy one. Next, I prioritized which patients needed to be seen based on the protocol the Grady nutrition department uses. Most patients did not need to be seen for the first time until the fifth day after admission; however, I was not at the hospital every day, and usually I needed to see them before the five days were up. Follow-up visits and second follow-up visits had different protocol as well. I found that preparing for initial assessments took the most time. I had to review notes from all disciplines: residents, physicians, nurses, respiratory therapists, physical therapists, social workers and case managers and research the information I found in the patient charts. This research allowed me to come up with a list of questions to ask each patient and assisted me in writing evidence-based nutrition diagnoses and interventions.
Over the course of this rotation, I met with many patients. Some of them I saw multiple times before they were discharged and others I only saw once. Several of them taught me not to judge a book by its cover. However, there was one particular patient with whom I really made an impact, leading me to use him as my case study focus.
JJ was a 27-year-old male with HIV/AIDS, AIDS-related dementia, bipolar disorder, hypertension and a history of polysubstance abuse. He was admitted to the hospital for aggressive behavior and confusion. The initial assessment with JJ revealed a confused patient with visible AIDS-related wasting. He was extremely thin and had a body mass index (BMI) of 15.21kg/m2, which is well under the underweight mark. JJ was dissatisfied with the amount of food he was receiving in the hospital. Moreover, he had multiple dietary preferences. He had no complaints of typical AIDS nutrition-related symptoms such as decreased appetite, mouth sores, taste changes or bloating. After meeting with JJ, the following nutrition diagnosis was written: Malnutrition NI-5.2 related to increased needs as evidenced by HIV/AIDS and low BMI. The intervention was general/healthful diet ND-1.1 and Commercial beverage ND 3.1.1. Research shows AIDS patients have an increased resting energy expenditure (REE), which requires a higher energy intake than a healthy person. Therefore, JJ’s needs were calculated using 30 – 35kcal/kg based on his recommended body weight (RBW). Protein needs were also higher for JJ due to his wasted state. JJ was placed on a general diet with double portions and Boost Breeze supplements to help him gain weight and increase his BMI.
Nutrition follow-ups with JJ uncovered a strong desire to gain weight. His appetite remained strong, and he was consuming all of the food and supplements provided, but his weight was not increasing very much. JUVEN was introduced to the patient to help slow muscle breakdown and improve immune function. JJ increased his weight from 102.5lb to 106.5lb over a three-day timespan and as a result, his BMI increased to 16.2kg/m2. This weight increase may not be directly associated with JUVEN, but it seemed to give the patient hope that he would be able to continue to gain weight. Even though JJ’s case was very sad, I was grateful for the opportunity to work with him, and with any luck, improve his quality of life. The case study assignment allowed me to reflect on the impact I had made, dive deeper into the literature and examine the strengths and weaknesses of the intervention I chose.
I cannot believe how much I learned and grew as a person in my acute care rotation at Grady. This experience allowed me to build on the knowledge and communication skills I had gained at the Counseling Center, forcing me to become a better practitioner and a more empathetic future dietitian. While both experiences proved vital for my education, Grady acted as the cornerstone, giving me the ability to react appropriately in any nutritional setting. But it also tested me emotionally, by opening my eyes to the sad realities that can often be a symptom of social and economic issues, lack of insurance and poor lifestyle choices. My time at Grady allowed me to see the important role a dietitian plays in a hospital setting and I am confident that I am well equipped to practice in this environment in the future.