Final Weeks at Food, Nutrition, and Wellness (DOA)

The last two weeks of my internship were at our Food, Nutrition, and Wellness. There were some projects to finish and presentations we had to give. The other intern and myself worked on an in-service for our division. We then presented the short power point to the whole department.

We spent a lot of time working and completing our research paper which we presented to the supervisors the last week of the internship. We also worked on the Florida School Breakfast week menu.

This internship was wonderful. It provided me with so many opportunities and I really feel well-rounded coming out of this program. I have learned to make the most of everything given to me and I feel as though I really did.

Thank you to Florida Department of Agriculture and Consumer Services, Division of Food, Nutrition, and Wellness as well as all the preceptors throughout the internship who helped me during this internship!

Florida Department of Health- CCFP Rotation

The last rotation was at the Department of Health's Child Care Food Programs. 

The Child Care Food Program and two related programs, the Afterschool Nutrition Program and the Homeless Children Nutrition Program, are administered by the Bureau of Child Care Food Programs. These programs provide nutritious meals and snacks to children through public-private partnerships with organizations committed to caring for children. All three programs are funded by the U.S. Department of Agriculture Food and Nutrition Service. http://www.doh.state.fl.us/ccfp/

We worked with the Nutrition sections while with this department and created a 4 week cycle menu. We also worked on a food safety online training for CCFP centers. We created three modules for the training and presented our work at the end of the rotation. We met with various staff in the department to learn what they did for the program.

It was a good learning experience and nice change of pace to end the internship.

TMH Diabetes Center Rotation

I worked at TMH's Diabetes center for one week. This was an outpatient setting. http://www.tmh.org/diabetes

The first day I came in and met my preceptor then sat in while she saw clients. I also sat in with the RN when she had clients. While with the RN, I sat in with clients who had Gestational Diabetes. That afternoon my preceptor and I saw a few pediatric patients. One pediatric patient was a new Type 1 patient. That evening I sat in on an Optifast class that the diabetes center offered. http://www.optifast.com/Pages/program.aspx

This center offers three diabetes education classes that are offered for adults who get a referral from their doctor. The second day of this rotation I attended the third diabetes education session then sat in with a dietitian all afternoon and saw clients. Tuesday evening I attended the second diabetes education session.

Wednesday I sat in on classes all day. I attended a Gestational Diabetes class in the morning followed by Diabetes Education Session 2 again. I sat in on class 2 again because I was able to teach part of it. It was a great experience to get up in front of the class and teach about food labels. After I taught the class I was able to sit in with a pediatric client with my preceptor.

Thursday I sat in on the center's case review with the endocrinologist, RN's and RD's. The rest of the morning I then sat with a dietitian and saw a few type 2 diabetes clients. That afternoon I sat with and RD who works for the Bariatric Center and saw a client who was focused on weight loss (no surgery). I stayed that night for another Optifast class that evening followed by a Diabetes Prevention Program class.

This rotation was a great experience and offered a lot of variety. It was really neat to work with so many different dietitians and see how they all council clients.  I also learned a lot from attending all the classes that were offered the week I was there.

Wakulla County Cooperative Extension Service, University of Florida

I was at Wakulla Cooperative Extension Office for two weeks.
Check out their website: http://wakulla.ifas.ufl.edu/

The Cooperative Extension Service is nationwide and was established by the Smith-Lever Act of 1914. It is a partnership between state land grant universities, the United States Department of Agriculture (USDA) and the county governments throughout the nation. All of these groups share in the planning, financing, and operation of extension programs. In Florida, the Cooperative Extension Service is administered by the University of Florida.

Wakulla County Commissioners provide support for local faculty, staff and facilities. The Wakulla County Cooperative Extension Service conducts research-based educational programs in Agriculture, Horticulture, Family & Consumer Sciences, marine interest, and 4-H Youth Development. Locally based advisory committees assure that programs are designed to meet community needs. Volunteer training is strongly emphasized in our programs to enable us to reach more of the county’s population.

These two weeks have been jammed packed with different events. The first day I attended a canning class to learn how to pressure can foods.

The next day I went to EFNEP nutrition lesson in a school. Later that day I went to an after school program where there was a guest speaker talking about electricity.

Wednesday I was not in the office as I had a makeup day for my renal rotation.

Thursday was a work from home day because my preceptor was out of the office.

Friday I attended a School Advisory Committee meeting. I found out that the extension services are now going to be promoting the USDA HealthierUS School Challenge program so we discussed this with the principle for a few minutes http://www.fns.usda.gov/tn/healthierus/.

The second week I worked on my article for a local news paper and also worked on my lesson plan that I would be giving later that week. Shelley and I then met with a farm to school coordinator and spoke about what needs to be done to get some schools into the HealthierUS School Challenge. Tuesday I was at the Tallahassee Children's Day at the Capital (separate post).

Wednesday April 10th, I went to see an EFNEP nutrition lesson in a kindergarten classroom. It was really cute how involved and excited the students were for the nutrition lesson. They learned about vegetables.

The rest of the day I prepped the food for my nutrition lesson. My lesson was given later that afternoon. I taught the nutrition lesson to elementary school students about protein and Florida Agriculture. We made salsa- a bean, tomato, and corn salsa, then a mango salsa.

Thursday I was with Shelley helping her in the kitchen. We prepared different foods for an herb workshop that evening.

Friday morning I finished my newspaper article about dehydration. I then attended an EFNEP quarterly discussion.

I really enjoyed this rotation so I managed to go back for a couple extra days. This might have been my favorite rotation.

Tallahassee Children's Day with the Florida Dairy Council

On Tuesday April 9th I worked with the Florida Dairy Council along with the Florida Dairy Farmers at the Tallahassee Children's Day at the Capital as part of Tallahassee's children's week http://www.childrensweek.org/ 

I arrived at 7:30 am to meet all new faces and just jump in and start serving breakfast bags. These breakfast bags were reusable 'breakfast bag' with a yoplait yogurt, a yogurt covered granola bar, a tangerine,  and a chocolate milk. Breakfast was suppose to be 8-10 am, however, most children did not come until after 10 am. We gave out over 1500 bags!!! Most of the bags were pre-made the day before and held in the dairy truck, but there were bags that needed to be made during the event. There was almost nothing left at the end of the event! 

 At 9 am, there were some students who came and sang, then we had a milk toast. The dairy council had been told the toast was going to be 4 people and six cups were brought, but there ended up being a few more without cups. There was the President of the Florida Dairy Farmers as well as some Legislators present for this milk toast.

 After we gave out all of the breakfast bags we gave out pencils. We all received free lunch- a sandwich from Nuke's. I was able to sit down with the Dairy Council employees and talk to them about working for the Dairy Council. There seems to be a lot of opportunities with them.

I worked mostly with Alyssa Greenstein, RD, LD/N, Senior Manager, Nutrition Affairs for DAIRY COUNCIL OF FLORIDA, a division of Florida Dairy Farmers. 

floridamilk.com

facebook.com/floridamilk 

twitter.com/floridamilk 

youtube.com/floridadairy

pinterest.com/floridamilk

Renal Rotation

Renal rotation was at DaVita, a world wide dialysis center (http://www.davita.com/) This rotation was only Monday, Wednesday, and Friday due to those being the days clinic is open.

The Tallahassee center offers dialysis in three shifts, 6 am, 11 am, and 5 pm. They are the only one around that offers 5 pm dialysis which is great for those persons still working and cannot come during the middle of the day. This center has 24 chairs total.

The first day I met with the RD and learned about the dialysis machine and the 'fake kidney'.

The second day of this rotation I was in Perry, Florida (about an hour drive) at another DaVita dialysis location. It was a much smaller clinic with only 12 chairs and two shifts.

The dietitian talked about the effects of cancer and dialysis and she showed me their charting program. We charted on some patients together. They use a point of care note, not nutrition care process so there's no PES (problem, etiology, signs/symptoms) statements. Their charting covers why the patient was seen, what education was given and what was spoken, as well as if goals were set, met, or not met. It's mostly a lot of box clicking with minimal writing. The RD does suggest putting in comments that will make you remember the patient at a later point in time if needed.

At dialysis, the lab values of concern are Albumin, PO4, K, Ca.

The first Friday was very interesting. I was back at the Tallahassee DaVita clinic, and saw some of the same patients from Monday. I was able to sit down with two of the patients and hear their story about dialysis and how they live with it and what it's like to be in kidney failure. These patients shared their stories and experiences.

It was interesting to know that if any DaVita patients travel, DaVita's are world wide- they can set up appointments while traveling and DaVita sets the appointments. DaVita can even schedule dialysis appointments around the world even if it's not a DaVita clinic.

The following Monday I was back in Perry, FL . It was kind of a crazy morning, the doctor was there for rounds on the patients. The interaction between the patients and the doctor was pretty neat. He checked almost every patient for fluid retention in their legs/abdomen. After rounds we met with the doctor to discuss bone mineral disease and see if the medications are enough or too much for the patients related to their calcium levels.

In Perry I made this lovely bulletin board (below)

Wednesday I was not at the rotation, I was at RD Legislature Day. (I have a separate post about this)

Friday I was back in Tallahassee and gave the patients reminders that 'big labs' were on Monday. Big Labs are when monthly labs are taken. I had to remind them to watch what they ate on Easter and to take extra binders if needed.

I went back to DaVita for my final day on Wednesday April 3rd as a make up day because I missed a day due to the Legislature Day. I went around to the patients and gave them their 'report card' for their monthly labs. Many people had high phosphorus lab values so I had to educate them on proper foods and to take binders.

RD Legislative Workshop Day

March 27th, 2013  was Florida Dietetic Association's  2013 Legislative Workshop held at the Leon County Extension Office, 615 Paul Russell Road, Tallahassee, FL 32301

Lauri Wright, PhD, RD, LD/N, Florida Dietetic Association (FDA) President, started off the legislative workshop by speaking about the legislative process and why it is important for Registered Dietitians to be involved in the process. Public policy is important for the protection of the health of the public as well as for insurance reimbursement and future legislation. FDA has their own Public Policy team consisting of 5 members: Julie Spiker- state policy representative, Jennifer Boutin- public policy coordinator, Sue Stemke- state regulatory specialist, Nadine Pazder- licensure liaison, and Dianne Van Treeck- reimbursement representative. There is no paid lobbyist for Florida Registered Dietitians.

Lauri Wright stressed the importance of dietitian advocacy by identifying and spreading the word about being a Licensed, Registered Dietitian. Lauri also went through specific tips for gaining influence in the legislature. She suggested getting to know your legislators, write, email, and visit them. Planting the seed is the beginning of the process for bills. The most important tip Lauri gave today was to be brief, clear, accurate, persuasive, timely, persistent, grateful, and polite when presenting your position and communicating with your legislators.  

In order to understand legislature, one must understand the basics as to how a bill becomes a law. First there is an idea formed by a citizen, group or legislator. A Representative must then decide that the idea should be a bill. A House Bill is then drafted and referred to a committee or subcommittee meeting and is reviewed for inclusion on an agenda. All bills must be read three times before being voted on.  A bill can ‘die’ in a council or committee, never being heard. It is the Chair of the committee or subcommittee who decided which bills should be heard. Next the bill is placed on a Special Order Calendar and is voted on prior to the house considering those bills on a specific legislative day. Once the bill has been introduced and read on the Special Order Calendar, it is explained, questions are answered about the bill and amendments are considered. This is the bill’s second reading. This process is then repeated for the bill, it is put on the Special Order Calendar and read for a third time, at which point, the bill is then voted on by the members of the House. Any bill not receiving a favorable vote ‘dies’ on the floor. If the bill is passed by the House, it is sent to Senate with a ‘message’. The Senate can vote to pass the bill without amendments and return the bill to the House, refer the bill to a committee for consideration, or defeat the bill on the Senate floor. The Senate may decide to further amend the bill and pass it. If this happens, the bill is returned to the House. At this point, the bill is in an ‘enrolled’ version and is sent to the Governor for consideration. The Governor has a specific time period to respond to the bill and may take one of three actions: Sign the bill into law, allow the bill to become law without his signature, or veto the bill. If the Governor vetoes the bill, the Legislature may override his/her veto by ⅔ vote of the Legislature during the next session.

Julie Harmon, RDN, LD/N, 2012-2013 FDA’s State Policy Representative showed how to find local representatives. Those interested in becoming part of the legislative process must become familiar with their elected officials, which may be done by visiting myfloridahouse.gov and searching for the representative for his/her geographic area. Julie also spoke about the key messages/current bills and leaders that Registered Dietitians and dietetic students are currently focused on within the legislative process.The following are current bills in the process of becoming approved that Registered Dietitians in the state of Florida have a specific interest in.

The Community Health Workers (HB 241 and SB 894) is aimed at improving the health care services of residents living in medically under served communities, including those in geographic areas with a shortage of health care professionals and those individuals without public or private health insurance and are at or below 185 percent of the federal poverty level.  This bill involves Community Health Workers who will serve as liaisons between health care services, social services and the under served community. Community Health Workers are trusted members of the community with an understanding of the community and the residents he or she serves. Their aim is to promote culturally appropriate education, including nutrition education, regarding preventive care and disease management. They also aim provide information regarding available resources, provide social support, assist residents during communication with health care providers and establish referral services and continuation of care. The Community Health Worker Task Force, established under the Department of Health, would provide administrative support and services to the task force. The task force would be established within a state college or university and will include 1 member of the Senate, 1 member of the House, 1 State official, 6 culturally and regionally diverse community health workers, and 3 representatives of the Florida Community Worker Coalition. The inclusion of a Registered/Licensed Dietitians or Dietetic Technician as part of the task force and in the training of Community Health Workers in topics surrounding nutrition education, disease prevention, and disease management is strongly encouraged. This bill has been approved by the house and is currently awaiting approval in the Senate.

The Physical Education in the Public Schools (HB 877 and SB 1144) aim is to revise the criteria to waiver physical education requirements for students in grades 6-8th. Registered Dietitians are in support of this bill because regular physical activity is an important factor in achieving and maintaining a healthy weight. Instilling healthy habits such as physical activity at a young age will positively affect children's health as they grow and develop. The Physical Education in the Public Schools bill will require school district boards to provide 150 minutes of physical education each week for students in grades K-5. This is equal to 30 minutes of physical activity per day during the school week. The bill also will require that 6-8th grade students be provided physical education for the equivalent of one class period per day for one semester each year. This equals 3 semesters of physical education in 3 school years. Exemptions from this requirement for 6-8th grade students are limited to the following criteria: The student is enrolled in a remedial course, the student’s parent has indicated in writing to the school principal or designee and thus been verified that this student is participating in physical activities outside of school that are greater than or equal to the mandated requirement, or a letter is submitted from a licensed physician specifying the health reason to and why the student should not participate in physical education.

The final topic discussed was the Patient Protection and Affordable Care Act (PPACA). This federal law is implemented through state and federal rule making and state legislation. It is referred to as the Acts. The goals of the Acts is to provide coverage for 32 million uninsured Americans, to improve affordability and stability of insurance for those who already have it, and to slow the growth of health care costs to reduce the federal budget deficit. This will be achieved in the hopes of health care’s shift from a current fee-for-service payment model to a preventive care and wellness model, a patient centered approach, and a reformed delivery system that includes more primary providers, medical homes and community based health centers. Registered Dietitians are identified as potential but not required providers. It is the goal of Registered Dietitians to be the required providers for disease prevention and chronic disease management.

After the legislative workshop, Nadine Pazder, FDA’s Licensure Liaison allowed us to shadow her around the Capitol Building. She showed us where to find our specific legislative officials. We followed her to her Senate Representative, Jack Latvala, though unable to set an appointment up with him today, we spoke with his Legislative Assistant, Jennifer Wilson. Nadine explained very briefly who we were and why we were there. There was a quick bullet point summary given to the assistant and explained why the bills are of importance from our perspective. We then went on to another Senator and repeated the process. Again, the Senator was out of office and we spoke with an assistant. Once we were finished we found the Calendar of the House of Representatives and the Calendar of the Senate and looked at the committee meetings occurring at that time.There was one committee meeting we were interested in, however this meeting was not in session at the designated time so we were unable to attend.

Overall, this was a great learning experience and really showed us how important it is to be involved with public policy.     

Hospital Food Service Rotation

I spent two weeks at Tallahassee Memorial Hospital for food service.The first day I was in the kitchen at TMH,  there NSF auditor came for their food service safety inspection. I was able to shadow the inspector.  It was neat to see what he observed, and also allowed me to become familiar with the huge kitchen.

The second day of this rotation, the hospital was implementing a new wellness program incorporating healthy menu options. The launch of this was perfect for my requirements for this rotation. I was able to help set up and plan during this event.

Throughout the two weeks at TMH, I assisted on tray line as well as conducted a tray accuracy and a tray assessment.

My preceptor showed me how scheduling is done. He showed me how each position breaks down into FTEs (Full time equivalents) and how it all works out into positions and the breakdown from there. He then showed me how he figured out manager schedule including weekends. It was interesting seeing the breakdown and how in depth is has to get some times. They are hiring a new manager which made the schedule a little difficult with training's and necessary staffing for this new hire.

Friday I conducted inventory  with the staff in the kitchen. The store room took a while but then I helped out in the cooler. It was freezing! There was three coolers, I made it through the last two- helped out writing the numbers down for the kitchen staff as they called out the product and number.

By the second week of this rotation, I had already finished most of my projects. My preceptor scheduled my in-service at the behavioral health center but Wednesday came and everyone forgot about it and we had to reschedule.

It was a good learning opportunity to see the hospital food service management side of being a dietitian.

Leon County CRE Rotation

Our division, Food, Nutrition, and Wellness through the Florida Department of Agriculture, conducts CRE reviews to all schools. CRE is a Coordinated Review Effort.This review observes the national school lunch program. Our division monitors the school lunch program in schools, reviews/validates their documentation and provides technical assistance. 

The CRE I participated in was for Leon County schools and was an 'additional review'. This just means it wasn't as in depth as a normal CRE. 

The first day we met with the food and nutrition services director for Leon County and other food and nutrition services staff who joined us for the meeting. We then reviewed 10% of the free and reduced priced school lunch applications. 

Part of my job this day was to review civil rights and make sure that  at least one person from each school in the county attended the training on civil rights. I also reviewed 10% of the direct certification list for students and verified them. Student eligibility for free meals is determined by application or by direct certification.
Although direct certification systems vary by State, all such systems substantially reduce the need for household applications. Many States certify eligible children through computer matching of SNAP, TANF, and FDPIR records against student enrollment lists. Those systems require no action by the children’s parents or guardians.

This CRE was used as a training for our division. In two days, collectively we observed 6 schools in two days. Four people went to each school per day (12 of us total as reviewers). 

The second day I went to an elementary school, which the director was helping out at. It was a wonderful school, almost brand new kitchen. The staff was VERY nice and great at their jobs. We had no findings of errors or problems. We had to check their storage areas and ensure their commodity goods were properly stored. We also watched breakfast and lunch for correct, complete meals. 

During this review, I was able to spend some time talking with the director. She use to be the director of food, nutrition, and wellness (my division that I am with through the department of agriculture- but she was head of the division when it was at Department of Education ). This director is also a dietitian, it was nice to hear her story of how she came into the job as director. It was awesome to be able to hear her stories.  After we went to the schools,  we had a meeting back at the office about what we found and saw at the schools.

The third day we were at second school. I was at a special needs school where they have pre-k students through high school ( students through the age of 22 years old). We walked into the kitchen, and found out this kitchen was one of the oldest kitchens in the county. We observed breakfast and started our inspection. 

We had some findings at this school started. We found some shelving was not within standards off the floor and there was some ice from the freezer fan. The staff was so nervous  while we were there that a an employee actually dropped a full pan of collard greens. We told them it was okay and accidents happen. We met back as a team (all 12 reviewers) and discussed our findings with everyone.

It was nice to understand the way a CRE works and how what our division at FDACS does. 

Manatee School Food Service

After working in Sarasota County, the next rotation was at Manatee County Food and Nutrition Services main office. The first day we went to the department's Monday Briefing meeting and learned what we would be doing the rest of that week.

We then sat through a KPI (financial) meeting which looked at the financials of the school food service and action plans were created. In the afternoon we spoke with Sandy Ford, the director of the program and also school nutrition association president.

The next day we went with Melissa to a couple Fresh Fruit and Vegetable Program schools (http://www.fns.usda.gov/cnd/ffvp/). We learned about the program and saw the actual implementation of the program and the difficulties associated with it.

During this rotation we shadowed an area supervisor. We were able to see the kitchens and staff interact at various schools in the district. We learned that the supervisors here in Manatee have 17-18 schools each whereas Sarasota only had 12-13 schools but also had other job requirements. That afternoon we attended a staff meeting and learned about the different projects the staff are working on.

Valentines day was during this rotation and I was able to go to a school and help serve  strawberry shortcake dish to all the students and parents at the school.

I then went with another area supervisor to schools again. I attended a staff meeting discussing ways to lower cost in the schools.

The second week of this rotation, FDACS came to do a summer food service program training- it was nice to see familiar faces!

For our internship we have to do a research project, while in Sarasota I gave surveys to students one day. Then at Manatee I gave surveys to students again.

We shadowed our preceptor who gave a breakfast component training at a high school.

The second to last day I went to an elementary school and gave a nutrition lesson. Our lesson was on fractions and nutrition. We created oatmeal bars and used the process of cutting them to teach fractions. We also used oranges to help teach fractions to 3rd grade students. We created the lesson plan as well as a parent handout which gave the recipe taught about breakfast, and incorporated Florida history into the handout.

Sarasota School Food Service Weeks 3 & 4

Week 3 was the last week actually in the school. I did the grocery list and put the orders in. On the last Friday,I was the "manager".

Throughout the week I learned how to do inventory. I also made a grocery list and then submitted the order online. I received food orders online. I also helped out each day during the service time by restocking items.

On my manager day, the dish machine broke. I do not know much about the dish machine so I had to ask the actual manager ( who was there). We had to call the repair man and get it fixed. We had to use disposable trays for lunch service.

The last week of this rotation I was at the Food and Nutrition Services main office. I shadowed an area supervisor, they supervise the school food service managers. We went around to some schools delivering new thermometers and also looking and correcting any issues in the schools. I got to see how vastly different every school kitchen was in the district. Some were brand new, while another kitchen I saw was very very old and waiting to be fixed (it was on the list to be fixed asap).

While at the main office we had one office day where I was able to finish up projects and print them. We also attended a staff meeting and also sat through a commodity order meeting with Coastal Foods.

One of my favorite parts about this rotation was working with the secondary nutrition educator. It was a wonderful experience. We did about 6 nutrition lessons and I wish we could have done more.

Sarasota School Food Service Week 1 & 2

My school food service rotation was at a middle school in Venice, Florida (about 5 1/2 hours from Tallahassee).

This rotation is actually in part with the Sarasota school food service internship (http://www.sarasotacountyschools.net/departments/fns/default.aspx?id=1628).

As an intern we are working with the kitchen managers to learn how to do their job so we fully understand the kitchen. I learned how to check people out at the register as well as count the money and make the deposits. I learned how to do the grocery orders and how to prep foods. I have a TON of assignments to do for this rotation- including a menu, a work schedule, and job position descriptions.

For this rotation, I had to at the school by 6am,  that means I had to get up absolutely no later than 4:30am to leave my uncle's house to get to the school on time. The first couple days I shadowed the manager. She was absolutely wonderful. She explained everything to me and showed me how to do it myself.

The second week I learned how to do grocery orders and how to receive orders. I attended a manager's meeting at the main office.  The third week of this rotation I will be at this school  again, but the 4th and final week of this rotation I will be at the Sarasota County Food and Nutrition main office.

TMH Case Study

Here is most of my case study... there was a lot more to the written document but I wanted to share most of the clinical part.. 

Introduction:

While working at the Tallahassee Memorial Hospital (TMH) I found many patients very interesting, however, most of these interesting patients had already been seen by the dietitians. After a few days of searching for a case study, I found a patient whose case involved complex digestive problems and a need for the use of total parenteral nutrition (TPN).

Nutrition care process was carried out for this patient per TMH and Sodexho protocol following the Sodexho medical nutrition therapy guidelines. Initial assessment for this patient was carried out by Brittany Pond. Patient was screened to be at risk due to NPO status times three days in the intensive care unit (ICU) using the TMH nutrition screening guidelines. The medical record was reviewed and patient was seen. The assessment was written using the PowerChart system. Once the initial assessment was completed with an RD who signed off on the assessment note. Due to Christmas break, the follow-ups were carried out by the TMH dietitians.

Patient’s History

The patient is an elderly 79 year old Caucasian female who was admitted for sudden abdominal pain with copious episodes of nausea and vomiting. The family was concerned the patient had an abdominal obstruction and brought her to the emergency room. A CT scan showed focal ileus in the right upper quadrant with air fluid levels in the small bowel but no focal transition, suggestive of a small bowel obstruction. Free fluid in the right upper quadrant raised a question of gastroenteritis versus peritonitis. Also present in the patient is diverticulosis without inflammation of the colon. Patient’s last bowel movement was the night prior to admission with no diarrhea.

Patient’s Past Medical History Includes:1. Hypertension2. Transient ischemic attack3. Spontaneous pneumothorax in 20094. Hyperlipidemia5. Partial small bowel obstruction in 20106. Microscopic colitis7. Stage I diastolic dysfunction and minimal aortic sclerosis in 20118. Cholecystectomy9. Multiple bladder surgeries10. Bilateral tubal ligation11. Appendectomy12. A-fibrillation
Past Surgical History:Patient had a partial small bowel obstruction requiring resection in 2010 at Emory University Hospital in Atlanta, Georgia.

Allergies: Atropine, Codeine, Sulfa Drugs.

Physical Exam:General: 79 year old, ill appearing, elderly Caucasian femaleVital Signs: Afebrile, temperature 97.4, heart rate 90, respirations 18, blood pressure 138/77,Neurologic: Alert and orientated to person, place, situation, time


Primary Diagnosis:Necrotic tissue was found in the patient’s small intestine leading to a small bowel resection this admission.

Patient’s course of stay prior to first nutrition visit:· 12/19/12: Patient arrived at TMH emergency room (ER), had contrast scan (CT) of abdomen and pelvis with contrast, admitted to the cardiac intensive care unit (CICU).· 12/20/12: Exploratory laparotomy revealed necrotic tissue in patient’s small bowel with removal of this section of the small bowel.· 12/21/12: Patient initially assessed by nutrition.

Nutrition Care Process: Assessment

In order to begin the nutrition care process for this patient, the patient’s medical charts and past history were reviewed. Initial nutrition assessment was on 12/21/12. Patient was on a clear liquid diet with instructions to sip clear liquid with NG in only.

Anthropometric Data:Height: 60 inches, 152.4 cmWeight: 116 pounds, 52.6 kgBMI: 23 kg/m2 (normal)Ideal Body Weight: 45.5 kg

Subjective Data:Patient assessed due to NPO x3 days. Patient is a small framed, pale, white female seen lying in bed with NG tube connected to suction with dark green/brown output. She had a partial small bowel resection in June 2010, after which, the patient had frequent vomiting and diarrhea resulting in weight loss. Uncertain how many pounds patient actually lost since this time, but patient was able to state her weight was 160 pounds prior to 2010. In 2011 she had a small bowel obstruction. Current admission is for abdominal pain, nausea, and vomiting. Patient had an ex lap 12/20/12 with results that showed an area of necrotic small bowel secondary to adhesions. This area of necrotic small bowel was removed this admission.

Objective Data:Laboratory Data: Sodium, Glucose, CalciumIVF: Amiodarone IV @ 17 mL/hrD5 ½ NS + KCl @150 mL/hr (Providing ~681 kcal/day)Braden Score: 14Urinary: Foley, amber colorBowel Status: hypoactive, last bowel movement was 2-3 days prior+ afebrile+nasal cannula+edema Ankle Bilateral+edema Arm Bilateral

Biochemical Data (Labs):Na 133 (L), Ca 7.3 (L), 97-172 BBGs past 48 hours

Estimated Nutritional Needs for Patient’s Ideal Body Weight of 45 kg:· 1242-1426 kcals based on 27-31 kcal/kg increased for wound healing needs.· 46-55 g protein based on 1.0-1.2 g/kg increased for wound healing needs.· 1150-1380 mL fluid based on 25-30 mL/kg.

Nutrition Care Process: Diagnosis

Moderate malnutrition related to current NPO status x 3 days with poor intake prior to admission as evidenced by review of diet order and patient report.

Increased nutrient needs for energy, protein, fluid, and micronutrients related to recent abdominal surgery as evidenced by review of operative note in medical record.
Inadequate protein-energy intake related to NPO status and no alternate nutrition yet initiated as evidenced by review of current diet order, visual observation, and medications/IVF providing minimal protein-sparing kcals.
Altered GI functions related to small bowel resection versus microscopic colitis as evidence by small bowel resection post-operative day #1, previous small bowel resection in 2010, NG tube output, and hypoactive bowel sounds.

Nutrition Care Process: Interventions

1. If patient has improvement in GI function and patient’s NG tube is discontinued, please add Enlive supplement and advance diet as able.2. If improvement in gut function not anticipated, recommend TPN to allow bowels to rest and heal.· Suggest Clinimix 5/20 with a goal rate of 42 mL/hr, 250 mL 20% lipids daily.i. To provide: 1008 mL total volume, 1385 kcals, 50g protein, 202g CHOii. 2.64 mg/kg/min dextrose infusion rate and 36% kcal from lipidsiii. Please add MVI and MTE, insulin per physician3. Monitor K, Mg, and Phos for signs of refeeding syndrome. If these labs are low, continue TPN at ½ rate of 21 mL/hr until labs normalize.4. Please monitor weights and labs per parenteral nutrition order set.5. Continue to provide anti-nausea medications as needed
6. Bowel Care per MD.

Nutrition Care Process: Monitor and Evaluation

1. Nutrition Goal: Patient to start oral diet or TPB within next 24 hours.2. Weight Goal: Patient to remain within 1-2% of admission weight.3. Bowel Goal: Patient to have evidence of improving function, i/e: decreased NG tube output, + bowel movement.4. Lab Goal: Maintain BBGs >70, <180; electrolytes WNL.

Free Text Nutrition Note: 12/22/12

TPN started per RD recommendations: Clinimix 5/20 @ 42 mL/hr + 200 mL 20% lipids daily + MVI 3x/week + MTE daily. Potassium dropped from 3.9-3.4, may be related to re-feeding syndrome. Check magnesium and phosphorus once-twice daily to appropriately manage possible re-feeding syndrome. If these values are not adequate, may continue TPN at ½ goal rate. Patient continues with clear liquid diet, drinking minimally. Encourage oral intake.

Follow Up Assessment- 12/24/12

Patient is seen in follow up. The patient was lying down in bed at time of visit with family present. Patient is post-operative day number 4 since the small bowel resection. The patient continues to have TPN support. RD spoke with patient who reported no nausea or emesis at this time. Patient indicated they have bouts of diarrhea. No alleviating factors during last bowel resection. RD discussed food preferences and need to advance diet slowly. Patient and family verbalized understanding.

TPN Regimen: Clinimix 5/20 @ 42 mL/hr with 250 mL of 20% lipids daily. Doctor ordered multivitamin on Monday, Wednesday, and Friday schedule and will monitor multi-trace elements.
PO Regimen: Mechanical soft, carbohydrate controlled. Patient was on a full liquid diet prior to interview.

Biochemical Data (Labs): Ca 7.6 (L), Phos 2.2 (L), Mg 1.3 (L), 92-370 BBGs past 48 hrs.
Nutrition Diagnosis:

Moderate malnutrition related to current NPO status x 3 days with poor intake prior to admission as evidenced by review of diet order and patient report. Progress: Continue/unresolved.
Increased nutrient needs for energy, protein, fluid, and micronutrients related to recent abdominal surgery as evidenced by review of operative note in medical record. Progress: Continue/unresolved.
Inadequate protein-energy intake related to previous NPO status x3 days and clear liquid diet as evidenced by review of current diet order, visual observation, and medications/IVF providing minimal protein-sparing kcals. Progress: Improving.
Altered GI functions related to small bowel resection versus microscopic colitis as evidence by small bowel resection post-operative day #4, previous small bowel resection in 2010, NG tube output, and hypoactive bowel sounds. Progress: Continue/unresolved.

Interventions1. Continue with mechanical soft, carbohydrate controlled regimen as medically appropriate/tolerated· Consider GI soft/bland restriction to promote diet tolerance· Consider Boost Glucose Control BID is PO regimen is well tolerated.2. Continue TPN to allow bowels to rest and heal as medically appropriate, wean per physician.3. If signs of refeeding syndrome present (low K, Mg, Phos) continue TPN as ½ rate (21mL/hr) until labs normalize and decrease PO regimen.4. Please monitor weights and labs per parenteral nutrition order set.5. Continue to provide anti-nausea medications as needed.6. Bowel Care per MD.

Final Follow-Up Assessment- 12/27/12

Patient is seen in follow-up. Patient complains of ongoing chronic diarrhea related to microcytic colitis. The Patient reports an okay appetite, she states she feels full quickly and portion sizes sent on meals are too large. RD discussed consuming small frequent meals. The patient drinks Boost at home and would like some sent to her with meals. The patient’s TPN was discontinued today due to lack of parenteral access. Diet: Healthy heart. PO intake: Fair.
Biochemical Data (Labs): Na 135 (L) Ca 7.6 (L, same), 101-121 BBGs
Nutrition Diagnosis:

Moderate malnutrition related to fair intake on current diet as evidenced by review of diet order and patient report. Progress: Improving
Increased nutrient needs for energy, protein, fluid, and micronutrients related to recent abdominal surgery as evidenced by review of operative note in medical record. Progress: Continue/unresolved.
Inadequate protein-energy intake related fair intake on current diet as evidenced by patient report, review of current diet order. Progress: Improving.
Altered GI functions related to small bowel resection versus microscopic colitis as evidence by small bowel resection post-operative day #7, previous small bowel resection in 2010, and ongoing diarrhea. Progress: Continue/unresolved.

Interventions1. Encourage intake of small frequent meals· Send Boost supplement per patient request2. Recommend a multivitamin with minerals to ensure micronutrient needs are met.3. Recommend Lactinex 1 packet BID to promote GI health.

Patient’s Course of Hospital Stay at TMH

· 12/19/12: Patient arrived at TMH ER, had CT of abdomen and pelvis with contrast, admitted to CICU.· 12/20/12: Ex lap revealed necrotic tissue in patient’s small bowel with removal of this section of the small bowel.· 12/21/12: Patient initially assessed by nutrition due to NPO x 3 days.· 12/22/12: Patient moved to 5B- Diabetes Floor. Free text nutrition note.· 12/24/12: Patient seen for nutrition follow up, on full liquid diet then moved to mechanical soft diet. 12/27/12: Patient seen for nutrition follow up, heart healthy diet with fair intake. TPN stopped.· 12/31/12: Patient tolerating small meals, waiting for a rehab bed.

Conclusion:

The patient was treated for 12.6 days at TMH. Initially she was moderately malnourished. Before transferring to TMRH, her nutrition had improved based on her lab values and her ability to eat a heart healthy diet. The RD’s had discussed future nutrition care for the patient by explaining the importance of eating small frequent meals and bland foods with the patient. The patient was transferred to TMRH on December 31st, 2012 for continued care and rehabilitation.

Last week of TMH Clinical

The last week of clinical was 'staff relief' week. I was able to cover one floor by myself and part of another floor. It was awesome to be 'on my own'. The dietitians still signed off on my notes but I really felt like my notes were a lot better from when I first started.

During this week I presented my case study. I was unable to follow this patient through her full course of stay at TMH due to Christmas break. However, I made it work and presented well. I was able to explain in enough detail for a few people who are not dietitian's or nutritionists to be able to follow along and understand what I did for the patient and why.

Overall TMH was a good rotation, I learned a lot and I hope to work in clinical for a few years before finding more of a community based job.

ICU (second week) and Case Study Topic

This week was only a three day week for me due to the holiday break. I worked with the dietitian who works on the MSICU (medical  surgery Intensive Care Unit), CVICU (Cardiovascular ICU), and the IMCU (Intermediate ICU- or step down ICU).

This dietitian really helped me gain full understanding of the ICU and possible interventions for these patients. After working with this dietitian I really feel more confident with the ICU. I learned and now know what to look for when visiting the patient and I also learned that rounds and speaking with the patients nurse are very helpful in gaining information about the patients.

I present on case study in a week! My patient is an elderly Caucasian 79 year old female who was admitted for sudden abdominal pain with copious episodes of nausea and vomiting too numerous to count. The family was concerned the patient had an abdominal obstruction and brought her to the emergency room. A CT scan showed focal ileus in the right upper quadrant with air fluid levels in the small bowel but no focal transition, suggestive of a small bowel obstruction. Free fluid in the right upper quadrant raised a question of gastroenteritis versus peritonitis. Also present in the patient is diverticulitis without inflammation of the colon. Patient’s last bowel movement was the night prior to admission with no diarrhea. The patient was NPO  for 3 day in the ICU, I calculated TPN for the patient, and it was initiated the next day!  It felt awesome to see my recommendations carried out!!

Introduction to ICU

My next TMH week I had an introduction to the Intensive Care Unit. I shadowed my preceptor in the ICU's. He showed me where to find the pertinent information in the medical chart, then he had me chart on a few patients.

I shadowed the RD who works with the cardiac ICU for the next couple days and she helped me to learn  what is important to look for and notice in the ICU. I felt more confident in writing my ICU patient notes after she helped me.

For my case study I chose a patient for my case study. I chose a patient who had multiple small bowel resections. I will check how they are when I get back from the holiday break. However, due to the multiple breaks during my rotation, I will not be able to follow this patient myself the whole time and will have to present some follow ups done by the RD's.

Pediatric Specialty Rotation

I spent two weeks at the University of Florida's Pediatric Pulmonary Division working with Shands hospital. More information about UF PPD can be read at : http://www.peds.ufl.edu/divisions/pulmonary/index.asp

During this rotation, I spent a lot of time learning about Cystic Fibrosis (CF). The first day I watched a few power points which helped to train me on CF and the nutritional needs of these children. CF is a genetic disease in which both parents are carriers of the gene. Basically, CF patients need  ~150% increase in nutritional needs. Many CF patients do not absorb fat which means they must take pancreatic enzymes.

The University of Florida's Pediatric Pulmonary Division sees CF patients on Tuesdays. CF patients must be seen every few months to ensure they are growing properly and are healthy. Because CF children and adults can easily obtain sickness from others, this is the day when CF patients are instructed to be seen.While in the clinic, patients with CF must wear face masks to prevent themselves from obtaining germs and disease. I saw many patients here and learned what their struggles are with this disease.

I was fortunate enough to watch a lung test (a breathing test) on a CF patient. I realized that it takes all their energy to expend all their breath from their lungs. I also learned that these patients have to perform breathing exercises at home every single day, on top of increase energy needs. I learned about the family struggles with having a CF child, for example, the child needs a high fat high calorie diet, but the mom and dad may need decreased fat and calorie needs themselves. Thus meal time may be difficult with greater temptations for those without the increases calorie needs.

Wednesdays at the University of Florida Pediatric Pulmonary Division are the days they go to sleep clinic where children with sleep problems and nutritional needs are seen by the dietitian. Our case study was picked from the sleep center. We (the other intern and myself)  chose a patient with Cerebral Palsy. It was a very interesting case, the patient was spastic quadriplegia cerebral palsy with nutrition solely from a tube feeding pump.

Thursday we worked on our case study and had a power point presentation about family centered care. Friday was a work from home day were we each had to write our own ADIME note to write on our case study patient, as well as some videos to watch related to CF.

The next week we shadowed the in-patient RD for Shands. We followed him around the floors and saw a few patients.

At UF PPD both in-patient and out-patient (clinic) settings, they have their own charting system where the charting is online but the notes are previously formatted and pull some information from the patients chart. It was very different from the charting system at the Tallahassee Memorial Hospital.

The second Tuesday of the rotation we were in CF clinic and saw more CF patients.

 The following Wednesday we were at sleep clinic again. We saw children with obstructive sleep apnea (mostly due to being overweight). The RD allowed the other intern and I to counsel patients ourselves.

The last Thursday we were at UF PPD, we presented our case study to the Pediatric Pulmonary Division personnel. We had a great turnout with social work interns and pharmacy interns there as well!

This was probably my favorite rotation so far. I enjoyed having the chance to work here!