Week 4 is over and I was very lucky to have Labor day off this week! It’s so hard to believe I’ve already been in my internship 1 month and I can cross that month off the list! 9 months left 
(aka: 9 months to paycheck as we’re calling it in my house).
As usual, here’s a recap of this past week’s internship with my usual disclaimer. I have to be VERY confidential about what I talk about regarding my internship. I can’t take any pictures and I can’t provide any patient details.
So this week was really like introduction to clinical, except you are actually on the floors and working with patients. I was with another intern this week, but we both had our own preceptor – so I pretty much just worked with my preceptor/by myself all week. My preceptor was awesome – she’s a past Baylor intern who finished the program 2 years ago, so it was so nice to be with her all week.
The week was focused on getting practice with tube feeding and just general patients that are in the hospital that don’t really fall under any specialty. This means I saw a lot of patients who were admitted for reasons like diabetes (new diagnosis and problems with blood sugar control), pancreatitis, infectious disease (West Nile, HIV/AIDS/or and other patients who are being tested for infectious diseases), some liver/kidney cases and post GI surgery patients who were stable. Of course we also had some random patients as well. You never know what you’re going to get on the general med floors!
With these general patients, I conducted both initial assessments and follow-ups. I also did diet educations with patients throughout the week. I gave three diabetes educations on my own, as well as observed my preceptor giving a few diabetes educations and a Coumadin/Vitamin K diet education – which was super interesting!
The initial assessment process is really just going into the patients room (after reading their entire medical chart!) and getting a good picture of their diet/weight history and figuring out any problems they are having in regards to their GI system or anything that may interfere with them receiving nutrition while in the hospital. We have a lot of questions we ask that target specific areas we need to know for the overall picture of their nutrition and the care process we will provide.
We then chart a nutrition note with their medical diagnoses/past medical history, their labs, their pertinent medications to their nutrition/GI system and all the information we found in our interview. We then write a nutrition diagnosis (or several) for the patient and set up interventions, goals and monitoring criteria we will watch for the patient while under our care. We write our nutrition recommendations – which include interventions with their diet, supplements, nutrition support (if they are on it) and sometimes even recommendations for medications/changing their medications.
We do the same thing in follow-up interviews, except we are just checking on how our interventions from the last time are doing and we update our notes with new medical information, labs, meds, etc and update our diagnoses and goals/interventions/monitoring to reflect how the patient is now doing. Most patients we see every 2-3 days (depending on their diagnosis, some patients we see every day), so that’s when we are writing the follow-up notes.
To help make this clear – I’ll give y’all a VERY basic example of this Nutrition Care Process with a patient. This is like a super super easy case – Say I had a patient who admitted with really high blood sugar levels. Other than all the initial assessment information I need to gather, I would find out if the patient is eating and what is standing in the way of that patient eating. It could be nausea, vomiting, diarrhea, constipation or it could be as simple as food preferences. I would work with the patient to increase their intake of calories and protein, if they are not meeting their needs. I would give the patient a nutrition diagnosis for whatever their problem is (which could even be increased energy needs, or other things). Then I would intervene by possibly recommending the patient ask for nausea medication, giving the patient oral supplements or working with them on food preferences. I would set my goal for where I want the patient to be with their diagnosis, and I would set up monitoring criteria. For this patient, I would want to monitor their diabetic finger sticks and probably things like their food intake and their weight. If I felt the patient needed an education on diabetes, or the patient indicated they wanted one – I could give that as well.
Again, basic example but hopefully that shows some of the scope of work I did this week. However, most patients are WAY more complicated than this and have numerous issues going on at once.
So this was really what I focused on this week. Monday and Tuesday I observed/interviewed while she watched me and wrote notes for my preceptor. By Wednesday, I was seeing a few patients on my own. Thursday and Friday I was completely on my own for the day and met up with my preceptor later to go over my notes/talk about any questions I had for my patients. I was completely in charge of my own time and set my schedule for the day. Friday, I ended up seeing 7 patients on my own!!
I also spent a little time in the cardiac ICU with my preceptor. We practiced some parenteral (vein) nutrition calculations, which was good for me to see in practice before I have those rotations in the future!
As for tube feeding, we really didn’t have TOO many tube feeding patients, but I did get to write one tube feeding order (which was exciting!) and did a lot of practice calculations for patients who are already on tube feeding. We had a tube feeding quiz as well where I learned all the different formulas we use in the hospital and when it’s appropriate/indicated to use those. I also had case studies for tube feeding that I did on my own, as well as research I read over tube feeding indications and complications.
For my cross-training, I spent time with a Care Coordinator and a Discharge Planner. I would go more into what they do, but it’s really really confusing. Basically – they are both RNs. The Care Coordinator spends time ensuring that the medical charts reflect the accurate diagnoses so the hospital can get reimbursed and their ratings are appropriate. The Discharge Planner works with a team of people to make sure the patient leaves the hospital with everything they need for home care or to another facility (like a SNIF or rehab center). The Discharge Planner also is the patient’s advocate and can help the patient if they are having problems with the rest of the medical staff.
I participated in “huddles” with the Discharge Planner, as well as the medical team on my floor. I was able to interject a few notes on nutrition status/diet educations during the general medical huddle for a few of my patients. I also observed rounds one day in the ICU for all the patients present. And I provided a few recommendations for medications to doctors for two different patients, which was awesome! I really hope those medications help both patients and I was proud I was able to advocate for my patients in that way!
Overall, I enjoyed the rotation and learned SO MUCH. I was able to see so many things and utilize knowledge from school for certain diseases. I feel like I understand so much better some of the most general diseases people have. That being said, I don’t know if Gen Med would be my first choice in the long run. I definitely missed the sense of relationship I felt with my patients from the Rehab rotation. There were patients being transferred on and off the floor every day, so I didn’t get to follow-up with all of the patients I saw. I will also say that people on the floors are definitely more sick/not as happy as the people in Rehab were.
I just really loved Rehab, so I’m not sure what it’s going to take for a rotation to top that just yet. However, it’s only been 2 weeks of actual rotations, so obviously there’s a good chance I will find something!
So there you go – General Medicine and Tube Feeding from an intern’s perspective.
