A Week of Clinical Nutrition at Teay’s Valley Hospital


I am spending this entire week focusing on clinical nutrition and medical nutrition therapy at Teay’s Valley Hospital.  Teay’s Valley Hospital (TVH) is a small, 70-bed, rural hospital located in Hurricane, WV.  Associated with Charleston Area Medical Center, TVH is located about 25 minutes outside of downtown Charleston, WV.

I have had the opportunity to work with the on-staff registered dietitian. One of the biggest adjustments I have had to make is the transition from electronic charting to PAPER charting!  I have always been used to reading a patient’s medical record electronically, so the process of paper charting was completely Greek to me.  But I think it will be beneficial for me to experience how things are run in different types of  hospitals.  And the paper charting wasn’t as hard as I thought it was going to be…even though it sometimes felt like I was deciphering through hieroglyphics! 🙂

As the weeks of my clinical rotation roll by, I am slowly beginning to become familiar and comfortable with the daily roles and responsibilities of being a clinical dietitian. And thank goodness, because isn’t that the purpose of the dietetic internship?! Like they always say…practice, practice, practice!

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Clinical Nutrition Topic of the Day: Cystic Fibrosis


Cystic Fibrosis (CF) is a debilitating disease that affects secretory cells that produce mucus, sweat, and digestive juices.  CF is genetically inherited as an autosomal-recessive trait that mostly occurs in the Caucasian population, or about 1 in 3,500 births.  The treatment and early detection of the disease has aided in a drastic improvement in the survival rate (the average life expectancy is 37 years), even though some individuals are not diagnosed until the late teens.  A defect in the CF gene, located on chromosome 7q, causes mucus to become thick and sticky, which plugs up many essential ducts and passageways.  CF predominately alters the proper functions of the lungs and pancreas.

Respiratory Symptoms and Complications

  • Wheezing
  • Coughing up sputum and mucus
  • Shortness of breath
  • Decreased ability to exercise
  • Infections with various different strains of bacteria, which causes many hospitalizations and decreases prognosis

Digestive Symptoms and Complications

  • Pancreatic insufficiency – This is due to the production of thick mucus, which blocks the secretion of digestive enzymes from the pancreas into the small intestine. This leads to the inability of the digestive system to metabolize and break down fat consumed though the diet. Also, pancreatic insufficiency can often lead to Cystic Fibrosis-Related Diabetes (CFRD).
  • Bulky, foul-smelling stools
  • Cramping
  • Poor weight gain and/or failure to thrive
  • Intestinal blockage
  • Constipation
  • Steattorhea
  • Gallstones (blocked bile ducts)
  • Rectal prolapse

Medical Treatments of Cystic Fibrosis

  • Many medications – Antibiotics, mucus-thinning drugs, bronchodilators, inhaled medications, and pancreatic enzymes.
  • Chest physical therapy – Such as a clapper or an inflatable vest that shakes the chest cavity to loosen the mucus.
  • Surgical procedures – Nasal polyp removal, oxygen therapy, endoscopy and lavage, lung transplant, feeding tube.
  • Counseling – Nutritional and/or psychological counseling may be recommended for patients and their families.

Nutritional Implication of Cystic Fibrosis

Due to the GI tract’s inability to break down and absorb fats, CF patients are at a high risk for malabsorption and malnutrition.  Because each CF patient manifests the disease differently in terms of the age of the patient, severity of the disease, stage of their treatments, lung function, GI function, and other complications, nutrition interventions are very individualized from patient to patient.

Regardless, the nutrition management of CF patients typically include:

  • Controlling maldigestion and malabsorption with pancreatic enzymes – Digestive enzymes, or enteric-coated enzyme microspheres, are consumed orally and released in the duodenum. The dosage of these enzymes depends on the degree of pancreatic insufficiency and the amount and type of food consumed. The more fat being consumed in a meal will results in a higher dosage of enzymes in order to metabolize the fat.
  • Meeting increased energy needs – Energy needs will vary depending on the patients age, gender, BMR, physical activity, respiratory function, and severity of malabsorption. (Some tips to increase energy and calories are suggested below)
  • Promoting appropriate weight gain – Nutritional supplements are often recommended in order to increase energy intake and promote weight gain.
  • Vitamin/mineral supplementation – Typically, fat-soluble vitamins (vitamins A, D, E, and K) are poorly absorbed in CF patients and may need to be taken as a supplement or a multi-vitamin. Also, osteoporosis is also common because vitamin D aids in the absorption of calcium.  Therefore, CF patients may have increased calcium needs.

Scandishakes are a common nutrition supplement recommended by dietitians for patients with CF who have increased energy needs.
Scandishakes contain ~600 calories when mixed with eight ounces of whole milk. That’s a lot of calories in a small volume of fluid, which is great for CF patients trying to gain weight!

Here are some nutrition tips for individuals with CF:

  • Eat as often as possible
  • Prepare foods with, or top foods with, high calorie-condiments such as extra butter, margarine, dressings, gravies, creamy sauces, heaving whipping cream, peanut butter, and whole milk to foods and recipes whenever possible
  • Add dried skim milk powder to add protein to sauces and beverages
  • Add extra cheese to pizza, baked potatoes, soups, pastas, etc
  • Add extra deli meats to sandwiches
  • Top bacon to burgers
  • Milkshakes, milkshakes, milkshakes
  • Add instant breakfast mixes to milk-based drinks
  • Add nuts to cookies, cakes, pancakes,
  • Add nuts, eggs, meats, and creamy dressings to salads
  • Breaded meats and fish adds calories

Sources:

L. Kathleen Mahan & Sylvia Escott-Stump. Krause’s Food & Nutrition Therapy, 12th Edition

http://www.mayoclinic.com/health/cystic-fibrosis/DS00287

http://kidshealth.org/parent/system/ill/cf_nutrition.html#

Determining the Nutritional Risk of a Patient


As part of the nutrition assessment process, the dietitians at CAMC need to determine the nutritional risk of a patient by using a scoring method. A patient who is scored at a higher nutritional risk is put at a higher priority in terms of follow-up and monitoring. Thus, the higher the risk score, the closer the follow-up time frame.

The nutritional risk and follow-up criteria are shown below:

Determining the Level of Nutritional Risk

Criteria Score
Nutrition Support (enteral/parenteral nutrition) 6
Admitting Diagnosis (this can be a number of different things such as pancreatitis and chronic renal disease) 2
Weight Loss 2
Oral intake <50% OR NPO/Clear liquid > 5 days 2
Dysphagia 2
Albumin <2.5, Pre-albumin <16 2
Vent dependent 2
Skin breakdown/Deep tissue injury 2
BMI <18.5 2

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Time Frame for Follow-Ups Based on Level of Nutritional Risk

Score Level of Risk Follow-Up
< 8 High 5 Days
6-8 High-Moderate 5-7 Days
4-6 Moderate 7 Days
2-4 Moderate-Low 7-10 Days
2 Low 10 Days

Clinical Nutrition Topic of the Day: Small Bowel Resection


As part of a case study for my Mon General clinical rotation, I chose an elderly patient who had recent bowel resection surgery.  The patient had been having abdominal pains for the past two weeks.  The patient was permitted no food by mouth (NPO) until further notice and may need possible nutrition support (enteral/parenteral feeding) if the patient cannot tolerate food orally in the next couple of days.  So what is bowel resection surgery and what causes it? Here is some general information.

The purpose of small bowel resection surgery is to remove an area of the small intestine that is blocked or diseased.  The procedure can be performed lapar0scopically or an open surgery on any of the three sections of the small intestine: the duodenum, jejunum, or ileum. A small bowel resection is commonly used to surgically treat these types of conditions:

  • Crohn’s disease
  • Cancer
  • Ulcers
  • Intestinal obstruction or blockage
  • Bowel injuries or trauma
  • Precancerous polyp removal

The diseased or obstructed portion of the small intestine is removed.
Source: http://health.rush.edu/HealthInformation/cancer%20center/10/000118.aspx

The healthy segments of the small intestine are then reattached.

There are many concerns a dietitian may have after a patient undergoes a bowel resection.  The first concern is for the patient to gradually start eating post-surgery.  Due to the altered functioning of the GI tract, many people may experience discomfort after surgery including bloating, nausea, diarrhea, and even have a general fear of eating.  It is important for the dietitian to be realistic about the patient’s goals to gradually increase food intake depending on the severity of the patients surgery and current condition. Clear liquids can be introduced into the diet once the bowel is functioning again (signalled by the presence of bowel sounds or flatus).  The diet can be advanced based on the individual’s recovery process.  If the patient is not meeting their energy needs by oral intake of foods, enteral support may need to be initiated.  Some individuals may never be able to consume normal volumes of food and complete adaption of the GI tract can take up to one year post-surgery.

The small intestine is the site of much of the body’s nutrient absorption, with the majority of nutrient absorption in the first 100 cm. Thus, the dietitan next needs to address nutritional concerns of the patient.  Five factors need to be taken into account: (1) the length of the small bowel left, (2) the presence of the ileocecal valve, (3) which section of the small bowel is left, (4) age of the patient, and (5) the presence or absence of disease.  For the most part, the small intestine will compensate in terms of nutrient capacity for the section of intestine that was removed.  However, the jejunum is much more adaptive whereas removal of the ileum would most likely render a patient on lifelong parenteral nutrition, supplemental vitamin B12, and cause fat malabsorption.

Sources:

ADA Nutrition Care Manual

Clinical Nutrition Topic of the Day: Cholecystectomy


In the past 3 days of my clinical nutrition rotation at Monongalia General Hospital, I have come across several cholecystectomy patients. I have been doing some reading on the condition and the medical nutrition therapy that is appropriate for after the procedure.  For those who aren’t sur what a cholecystectomy is, here is some general information. Then I will delve into the MNT a dietitian should know relating to a patient post operative.

What is a cholecystectomy?  The surgical removal of the gallbladder. The gallbladder is not essential and can generally be tolerated by humans.

Where is the gallbladder located? It is pear-shaped organ just below the liver in the upper right side of the abdomen.

What is the function of the gallbladder?  The gallbladder collects and stores the bile that is produced by the liver. By storing bile in the gallbladder, the bile becomes more concentrated and thus more potent.  The gallbladder mainly aids in fat digestion.  When food containing fat enters the GI tract, it stimulated the release of cholecystokinin (CCK).  The release of CCK stimulates the relaxation of the Sphincter of Oddi and opens the common bile duct between the gallbladder and the small intestine.  The gallbladder can then release it’s bile contents into the duodenum (or small intestine) where it emulsifies fat and aids in the digestion of food.

What is the function of bile?  Bile consists mainly of cholesterol, bilirubin (from hemoglobin), and bile salts.  Bile has two main functions. (1) Breaks down fats from the diet so it can be utilized by the body.  Without adequate bile, a deficiency can result in the fat-soluble vitamins (A, D, E, & K).  (2) Bile aids in the removal of toxins that have been filtered out by the liver.

What are the causes for a cholecystectomy?  The gallbladder may be removed for a number of reasons, but typically to treat gallstones.  It may also be caused by:

  • Gallstones in the gallbladder (cholelithiasis)
  • Gallstones in the bile duct (choledocholithiasis)
  • Gallbladder inflammation (cholecystitis)
  • Pancreas inflammation (pancreatitis)

Gallstones are hardened deposits of bile that form in your gallbladder. These stones can create an obstruction into the bile ducts causing abdominal pain and cramping.

What are the risk factors for gallstones?

  • Female gender
  • Family history
  • Pregnancy
  • Older age
  • Obesity
  • Truncal body fat distribution
  • Diabetes
  • Inflammatory Bowel Disease
  • Certain drugs (lipid-lowering medications, oral contraceptives, estrogens)
  • Certain ethnicities (Pima Indians, Scandinavians, Mexican-Americans)
  • Rapid weight loss (i.e. after gastric bypass or severe calorie restriction)
  • Chronic low-grade infections
  • High dietary fat intake over a prolonged period of time

What role does the dietitian play in the treatment after a cholecystectomy?

  • Most patients after a cholecystectomy are not hypermetabolic or catabolic, and can be assessed at standard nutritional requirements for their height, age, and weight.
  • A low-fat nutrition prescription (<30% energy as fat) with a modest protein content may assist in controlling symptoms until surgery to remove the gallstones can occur.
  • Consuming a large amount of fat in one meal can overwhelm the bile needed to be produced by the liver. This can cause bloating, gas, and diarrhea due to undigested fat.
  • Cholecystectomy patients can advance to a regular diet as tolerated.
  • Patients should consume small, frequent meals.
  • Foods NOT recommended: high fat foods, fried foods, foods with strong odors, foods that cause gas.

1-Day Menu Fat-Restricted Diet

Breakfast ½ cup oatmeal with 1 cup skim milk
2 slices whole wheat toast with 1 teaspoon margarine and
2 teaspoons jam
½ cup orange juice
Lunch 1 cup chicken noodle soup
Turkey sandwich: 2 slices whole wheat bread, 2 oz turkey, and 1 teaspoon   mayonnaise 8 baby carrots
1 apple
1 cup skim milk
Evening   Meal 3 oz lean roast beef
1 cup potato
½ cup green beans
1 whole wheat dinner roll with 2 teaspoons margarine
1 orange
½ cup pudding made with skim milk
Snack ½ cup pretzels

Approximate Nutrient Analysis

Calories: 1,600
Protein: 85g (21% of calories)
Carbohydrate: 259g (63% of calories)
Fat: 29g (16% of calories)
Cholesterol: 107mg
Sodium: 2,191mg
Fiber: 25g

Sources:

ADA Nutrition Care Manuel

Krause’s Food & Nutrition Therapy 12th Ed.

http://www.mayoclinic.com/health/Cholecystectomy/my00372

Clinical Rotation: Day One


Today was the first day of my clinical nutrition rotation at Monongalia General Hospital in Morgantown, WV. I will be spending the first 2 weeks of this rotation doing clinical work and the second 2 weeks doing food service/patient services.  Mon Genearl is a 189-bed acute-care community hospital and Level IV West Virginia Trauma Center.  The hospital offers a full range of services, including General Surgery, Cardiac Surgery, Cardiology, Orthopedics, Imaging and the Hazel Ruby McQuain Birth Center.   Mon General has consistently been rated in the top 10 percentile in the county for patient satisfaction.

Monongalia General Hospital – Morgantown, WV

Today being my first day at the facility, I was oriented and introduced to the general procedures of the dietetic department.  I shadowed an RD throughout the day as she performed dietetic education and recommendations when consulted by a doctor or staff.  I observed her as she educated four different patients on their specific diets (as well as a spouse or family member if present).  She spoke with two post-heart attack or bypass surgery patients who were placed on a cardiac diet, which consists of low-sodium and low-fat intake.  She also spoke with a newly diagnosed renal disease patient about the importance of limiting protein, sodium, and potassium in the diet.  She always asked each patient their satisfaction with the food the hospital had provided them (taste, temperature, etc). For the most part all of the patients were very pleased with their meals.  She also gave the patients educational handouts to take home with them regarding the diets they should continue while they are home.  This usually included a list of recommended foods, foods to avoid, and a shopping list.  I also learned how to record the dietary consult into the patients electronic record or chart.

Overall, I really liked my first day of clinical and look forward to the next two weeks.  It will be a huge learning process, but I am very excited!