di: intro to clinical

People seemed to like reading my recap post for the first week of my internship, so I’m back to share a recap for the second week!

Again, I’m going to post this disclaimer every time, just to cover myself. 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. I’m sorry if these posts bore you!

My internship program is clinical focused. This means the majority of my rotations will be in the clinical settings and disciplines. I will still round through community, foodservice and management rotations – but the majority of my time, energy and learning will take focus on clinical nutrition and dietetics. For this reason, I just finished a week long orientation for my clinical rotations.

Out of 12 interns, 6 of us were in this rotation this week. We are the 6 that are starting in the clinical rotations first, whereas the other 6 are starting in the foodservice/mgmt/community rotations and will do this same clinical introduction in a few weeks. This was the first year the program offered this orientation. In the past, interns haven’t gotten the full experience of those first few clinical rotations because they were still getting used to being in the hospital/clinical setting. So this orientation was supposed to remove that problem for us so we can focus on the rotation next week rather learning how to chart, perform interviews, etc.

The one BIG theme of the week, which I was not expecting, was the focus on Nutrition Focused Physical Exams. The field of dietetics is starting to move to a more “hands-on” approach and in our hospital, we are starting this push this year with us interns. We went through some really specific training this week on nutrition focused physical exams and we will be doing one physical examination per clinical rotation. We have been tasked with spreading our knowledge and training to the RDs who will precept us. I was really against it at the beginning of the week, but now I’m totally on board and I will talk about that.

Here’s the weekly recap for you:

Monday:

• A lot of practice/coverage of the Nutrition Care Process, which is how we treat patients in the clinical setting. We use a format called ADIME, which is a 4 step process including: Nutrition Assessment, Nutrition Diagnosis, Nutrition Intervention and Monitoring/Evaluation. We learned this in MNT, but spent a lot of time going over it again and practicing with real-life case examples. This theme also was weaved into our sessions throughout the week.
• A session on common laboratory values we will see for our patients and the indications of these values when they are not normal. We also covered common medications we will see given to our patients.
• Videos on the Subjective Global Assessment (SGA) and Nutrition Focused Physical Exams (NFPE). SGA is used to determine malnutrition status from physical examination. NFPE is used to indicate nutrient excess/deficiencies and other problems that may impact a person’s ability to eat/receive nutrition.

Tuesday:

• Started with a presentation on Oral Health and Nutrition. I had this in school, so it was mostly a review, but it was good to hear more about what we will see in our Dental rotation and meet the preceptor. Our preceptor for this rotation is a combined Dental Hygienist/RD!
• Coming straight off that presentation, we had a presentation on Extra-Oral and Intra-Oral physical exams given by a Dental Hygienist who works in Baylor’s cancer dental clinic. We learned how to perform these exams and how to interpret the results of the exam to determine nutrient deficiencies and conditions that will interfere with nutrition intake/nutrient delivery.
• Combined with the physical exams, we learned about the cranial nerves (another review) and then how to determine physically if there is a problem with a cranial nerve through physical examination.
• We then PRACTICED all these physical exams on each other. We each performed/received an extra-oral and cranial nerve physical exam, then gloved up and performed intra-oral exams on each other.
• In the afternoon, we did some more Nutrition Care Process practice, both on our own and in our sessions.
• We had a session on General Oncology, and the types of cancer we will see in our rotations. We discussed the treatments for these cancers, both medically and nutritionally.
• After we had a session on General Pediatrics and tried four different pediatric liquid supplements, which was interesting. We ended that session with practice formula calculations and learning how to calculate single formulas and batch formulas.
• The day ended with a session on clinical productivity, which is a process we will complete once a month showing how we spent our work time for an entire week.

Wednesday:

• We spent the entire day with a Registered Nurse, who was absolutely amazing. The first half of the morning was dedicated to learning the physical examination and analysis of vital signs and heart/lung/abdominal sounds. We then practiced measuring/analyzing these vital signs and sounds on each other. We practiced taking each other’s pulse, blood pressure and listening with a stethoscope to each other’s heart, lung and bowel sounds in the abdomen.
• We also learned how to place NasoGastric (NG) feeding tubes, which are inserted into the nose and run to the stomach. They can be used for feedings, medications, fluid and also used to suction out the stomach. At Baylor, RDs place these tubes (and small bowel tubes as well), so it’s something we will do if we stay on at Baylor.
• We spent the second half of the day practicing listening to abnormal sounds on a Sim Man, which is a medical robot that is used to teach and simulate a patient for medical students/health care providers. We again listened to his heart, lungs and abdomen. We also practiced placing a NG tube on the sim man. We will not be placing NG tubes as interns, but it was good to know how to do it for the future when we may have to do it as a RD. The RN also walked us through what happens during a Code, when someone either stops breathing or their heart stops beating.

  This was really when my eyes turned around to the Nutrition Focused Physical Exams. Hearing from a nurse how important it is for us to learn and how everyone in the hospital welcomes it helped me to realize that it’s a major skill set I will benefit from learning. I really can’t get out of learning it and I’m in a teaching hospital, so it’s a safe environment for me to learn how to examine patients. Plus, if I can help both the patients and the RD preceptors feel more comfortable performing them – that’s a task I want to take on.

• This is what the Sim Man looks like (taken from a random website). He is controlled by a computer and has the ability to have pretty much any disease that would impact the way his heart, lungs and stomach sounds. He breaths, talks, has moving eyelids and can be used in a variety of ways to teach students. He was very nice as we inserted tubes into his nose (except he was “coughing and vomiting” when I inserted my tube)

Thursday:

• We started the day with a webinar on how to access literature/research.
• We then had a class on Enteral nutrition (tube feeding), where we were introduced to the different formulas the hospital uses. We then practiced calculating enteral feedings.
• Next was a session on Parenteral nutrition, which is vein or blood-infused nutrition. Again, we learned about the types used at Baylor and how to calculate the feedings.
• We were introduced to the ICU environment in our next session. We learned about the different types of intubation and ventilators. We were exposed to the different medications ICU patients will be on and how to use these to consider their nutritional needs. We also learned about all the different machines we will see in the ICU rooms and how to access an ICU patient when you see them.
• Next we learned how to conduct patient interviews, and how to deal with different types of situations/patients. We role played interviews as well.
• The day ended with a reception for the interns, where we met many of the RDs in the hospital and some of the management staff in the nutrition department.

Friday:

• We spent the entire day getting oriented to our Electronic Health Records and medical charts. We learned where to find everything/how to interpret what’s in the patient charts. We also learned how to write the nutrition notes for the EHR and how to document our nutrition assessments/re-assessments in the EHR. We ended this session with writing a nutrition note on a recently discharged patient. It took the RD about 20 minutes to write the note, whereas it took us about 2 hours. HA! We have a LOT of practice ahead of us here.

Overall, the week was SO informative. Coming into this orientation week I was still terrified of the thought of starting my rotations and seeing patients. After this week of introduction and classes, I definitely feel ready to be on the patient floors this (now current) week. By the end of this introduction week, I was feeling more than ready to just dig in, get my hands dirty and get over the anxiety of seeing patients for the first time.

And those experiences are definitely something I will share with you next week in my weekly recap! I’m in the Rehab rotation this week, so I’m sure I will have a lot of good experiences to discuss next Tuesday!