Bonnie Buckingham Summer 2010 EXSS 406

Transcription

1 Bonnie Buckingham Summer 2010 EXSS 406

2 Overview and summary of intern experience. My goals for this internship were to intimately learn what a Registered Dietician s job entails in a hospital setting as well as gain experience in the field of nutrition. Due to the fact that I am not a Dietician I understood that I would be unable to perform many tasks and would mainly be observing. A typical day began in Janice Wolk s office where we would review patient charts to check lab values and look for any nutritional risks, nutritionally pertinent medications, and the doctor s and/or nursing assessments of the patient. After reading the charts Janice and I would visit newly admitted patients and ask them if whether they had any food allergies, difficulty chewing or swallowing, if their weight had been stable or fluctuating, and about their appetite. While asking them these questions we would assess whether the patient looked well nourished and if we could detect any abnormalities (dentures, missing teeth). When all the new patients had been assessed we would talk with the other patients and ask how they were eating. Janice and I made the rounds together so I could learn what types of questions to ask the patients. After a few weeks she felt I was ready and allowed me to make the rounds without her. When we finished making the patient rounds we would chart our initial assessment. Janice initially did the charting while she explained how it done and then under her supervision began letting me chart. Charting on a patient includes inputting weight, height, verifying BMI, making notes on any of the aforementioned assessments we made, determining if they were at nutritional risk, writing a clinical nutrition note, confirming the patients diet as order by their physician, determining their caloric, protein, and fluid needs, and noting who we had talked to (the patient, spouse, family).

3 A few times a month Janice and I worked in the Kidney Dialysis Clinic. Before seeing the clients we reviewed their lab values for the month and identified any areas that needed to be modified in their diet. We met with each client to go over their lab values and explain what they meant. The lab values we discussed were their albumin, blood urea nitrogen, phosphorus, calcium, sodium, potassium, and fluid levels. After going over the lab values, Janice would ask them about the foods they were eating and make dietary changes to correct for any problems with their lab values. Every month Janice also gave each of the clients a different educational packet about how to manage kidney disease and deal with dialysis. She would briefly explain what the packet was about and tell them to read it. After we had talked with all the clients we would chart on their nutrition assessment and what education they recieved. Once a week Janice and I attended the clinical management meeting. This meeting consisted of the RN s in charge of each department, the dietary manager (Janice), and the vice president of patient services. The topics of the meetings would vary, but they mainly consisted of developing ways to enhance quality of patient care and improve department efficiency. Occasionally I had the opportunity to sit in on a meeting with a sales representative from a food distribution company. In these meetings Janice and the chef would talk to the representatives about how to meet the supply demands of the hospital kitchen for the best prices. They also discussed new food products for people who were on mechanical soft or pureed diets to help them meet specific nutritional demands. During the month of July we held a diabetic class once a week for 3 hours. The diabetic class is available to provide in depth education on the different components of diabetes for those who wish to have better control their disease. A variety of topics are covered throughout the course of the class as well as some hands on teaching about how to check blood sugars and

4 measure portion sizes. I was allowed to help teach pieces of the diabetic class to gain some teaching experience. The topics I was assigned to give a PowerPoint presentation about were on exercise and how to handle a common illness. At the end of each class we helped each participant develop one action plan for the week that they could accomplish. Types of action plans we helped participants develop were checking blood sugars every day after their largest meal, walking for 30 minutes five days a week, taking ten minutes every day to de-stress, and trying out three new high fiber foods. As part of the class, we had several guest speakers come in including a local optometrist, podiatrist, pharmacist, and physical therapist. Attending and teaching the diabetic classes provided me with valuable knowledge and experience handling a diverse amount of questions pertaining to nutrition and diabetes. I went with Janice on one home health visit to a client who had type 2 diabetes and was morbidly obese. This particular client was mostly immobile due to their weight and was using a hospital bed in their living room to pull themselves upright. The client did not seem to have the motivation or understanding to make any large life changes so we counseled her on portion sizes and set up a feasible meal plan for her. Other than the client s weight, they did not have any health conditions that prevented them from exercising. We also advised the client to do chair exercises for five minutes about three times a day to aide in their weight loss. During my internship Janice hired two new employees for the kitchen. I was able to sit in on their interviews and learn what kind of questions to ask a potential employee as well as review their applications. In addition I was able to be part of a discussion concerning an employee that needed disciplinary action and helped write the disciplinary letter. Another experience I had during this internship was working with the Outpatient Dietician Sue Phillips RD LD. I would meet with Sue in her office and we would review the

5 charts sent over from the physician recommending a nutritional consult and their diagnosis. I learned that only certain diagnoses were covered under insurance and that insurance wouldn t cover a diagnosis of obesity. We had a few clients who chose to pay on their own for a weight loss consult, but the majority of clients we saw were type 2 diabetics, type 1 diabetics, or had another medical condition that was triggered by obesity. When the client arrived Sue and I would meet them in the lobby and bring them up to her office. The beginning of each consult included an initial client assessment of height, weight, medical conditions, medications, physical activity, living situation, occupation, and 24 hour diet recall. For a type 2 diabetic we would start off by teaching the client about what type 2 diabetes was and how it was affecting their body. If they were on any diabetic medications we would explain to them how the medications were affecting their blood sugars. Next we would teach the client about portion control and the basic principles of a diabetic diet. The main tool we used was the Choose Your Foods Diabetic Exchange booklet to teach portion sizes of different types of foods and how it affects blood sugar levels. The typical diet plan we gave a type 2 diabetic was a consistent carbohydrate diet which would keep their blood sugar stable and the client from getting too hungry. One aid we used for teaching portion sizes was a large assortment of plastic foods that had been measured out in exact portion sizes. We would teach meal planning with the plate method. The plate method is a paper plate with lines drawn on it to illustrate how many vegetables, meats, and starches fill the plate. After several weeks of observation, Sue began allowing me to lead the consultations while she helped guide me. An additional consultation I learned about was with a type 1 diabetic. With a type 1 diabetic the counseling premise is nearly identical as the type 2 diabetic, but the majority of the session is focused on the use of insulin. This included teaching clients how to use the sliding

6 scale in order to implement correction factors in their insulin usage and demonstration on how to properly inject insulin. This internship experience exceeded my expectations. My anticipation was that I would only be able to observe since this was a clinical setting that required an Oregon Dietetics License to perform any hands on duties. Janice, however, found out that I could talk to people and give advice as long as there was a Registered Dietician present to supervise.

7 Samples and or description of any work completed by you. In the mornings I would review the patient charts to check for any nutritional risks, nutritionally pertinent medications, and review the doctor s or nurse s assessments. I would do patient rounds and ask new patients if they had any food allergies, difficulty swallowing or chewing, if their weight had been stable or fluctuating, and what their appetite was like. While I was asking them these questions I would assess if the patient looked well nourished and check for any missing teeth or dentures. If a patient had been there more than one day, I would ask how the food tastes and how their appetite was. After I finished the rounds I would chart on the new patients under Janice s supervision. Charting on a patient included inputting weight, height, verifying BMI, making notes on any of the aforementioned assessments I made, determining if they were at nutritional risk, writing a clinical nutrition note, confirming the patients diet as order by their physician, and noting who I had talked to (the patient, spouse, family). When we held diabetic class I would answer any questions I could before class started. I gave PowerPoint presentations about exercise and how to handle an illness when you have diabetes. I also helped the clients develop weekly action plans for a healthier lifestyle. Under the supervision of the outpatient dietician I did an initial outpatient client assessment of height, weight, medical conditions, medications, physical activity, living situation, occupation, and 24 hour diet recall. I explained to the client what type 2 diabetes was and what was going on in their body. If the client was on any diabetic medications I would explain to them how it was affecting their blood sugars and how the medication impacted their eating schedule. Then I would teach the client about food exchanges and portion sizes. To supplement this I used plastic food models, the plate method, and the Choose Your Foods Diabetic Exchange

8 booklet. Occasionally Sue would step in to answer questions I didn t know and add any extra information or advice. She also helped guide me to set up an individualized diet for the client.

9 Brief biography of your supervisor Janice Wolk is a Registered Dietician, Certified Diabetic Educator, and a Licensed Dietician in Oregon. She went to college at La Sierra University and graduated with a bachelor s degree in dietetics. Janice completed her internship at Loma Linda University with a focus in general nutrition. After finishing her internship Janice went on to work her first job at the Shawnee Mission Hospital in Kansas City, Kansas. She worked as a clinical dietician and eventually became the Food Service Director where she redesigned the hospital kitchen. After working there for several years Janice moved to Florida and worked for Florida Hospital as a Clinical Dietician for the Family Practice residents. She then began pursuing a career with Adventist Health and got a job with San Alena Hospital doing clinical dietetics and working as the associate food service director. When she and her husband decided to move to Oregon to be closer to his family, she worked for Portland Rehabilitation doing a wide variety of clinical and food service positions. She soon applied and got a job with Adventist Health Corporate as a traveling consultant. Her family eventually decided to settle in a small community and has been employed with Tillamook County Hospital as the Food Service Manager and Clinical Dietician ever since.

10 Project Summary For my project I helped organize the Nutritional Services booth at the Tillamook County Hospital Health Fair at the Tillamook County Fair. The theme for the Nutritional Services booth was fiber and diabetes. The purpose of the Health Fair is to educate the community about general health practices and promote healthy lifestyles. I was given several tasks and responsibilities for the Health Fair. One project I completed was creating a design for the spinning wheel game and putting it together. The spinning wheel was a healthy snacks/prizes game for people to play when visiting our booth. Prizes included packages of apples, carrots, bouncy balls, and a grand prize of a puppet for children. I was also in charge of making supplementary posters to draw attention to the booth and picking out other visual aids. Another project that I completed for the health fair was developing three educational handouts that pertained to the fiber and diabetes theme. The three topics I chose for the handouts were sleep, alcohol, and fiber. I chose these topics because sleep deprivation can raise blood sugars in diabetics, a large proportion of diabetics in Tillamook County abuse alcohol, and fiber because it provides a variety of health benefits including slowing digestion to prevent blood sugar spikes. I distributed all the handouts at the health fair except the alcohol handout because Adventist Health does not endorse alcohol consumption. However, although I was not allowed to distribute the alcohol handout at the fair, they will be used at diabetic class to help teach clients about alcohol use. Before the county fair opened I helped move over supplies and decide how to set up the nutrition booth. I worked at the booth from open until close and fielded a variety of exercise

11 and nutrition questions from the public. We provided a body weight scale and a BMI chart for people to discretely check if they were in a healthy weight range. I talked with most of the people who checked their BMI and explained the limitations of the BMI chart if I determined that they appeared to be a healthy weight for their activity and body type. I also helped set up a display that showcased different types of foods that were high in fiber. I explained to people as they came about ways to incorporate these high fiber foods into their everyday meals and how to cook unusual foods like quinoa. Other types of questions I answered were about what a calorie is, what constitutes physical activity, how much physical activity or scheduled exercise should a person get, what vitamins and minerals to be taking, what blood sugar levels should be, and about food exchanges. I felt well prepared to answer questions from the public at the health fair due to all the experience I had gathered throughout the summer working with Janice and Sue. A large part of my project was the ability to apply the knowledge I had acquired through inpatient rounds, outpatient consults, and diabetic class to answering questions that public had about nutrition and diabetes. Overall I believe that my contributions to the Health Fair benefited Adventist Health. By creating and distributing relevant health handouts the public was able to receive tangible and useful information they could implement at home. In addition, working at the nutritional care booth provided another person available to answer questions and increase the total number of people who received nutrition information. This project benefited me for a variety of reasons. I was able to apply the knowledge I had learned over the course of the summer in answering questions and teaching the public about diabetes. This was an excellent test for my comprehension about diabetes and nutrition

12 and allowed me to explore my own creativity in teaching these subjects. Most importantly, this project helped me explore my passion for teaching others to live a healthy lifestyle through exercise and nutrition.