Day 3: Clinical

While the RD was at morning meeting, I went to start a new admission’s nutrition assessment using her chart binder and going over the preadmission paperwork to get more information and add into the nutrition assessment form. We came up with a diagnosis, intervention, and goals to resolve a core nutritional problem the Pt may have. I also inspected a Pt’s breakfast tray and recorded how much of the tray was completed to take note on the electronic medical record. A core meeting took place at ~11:30am in which members of the IDT talked about how to improve each department in the nursing home as a whole. There is a patient readmit on a PEG tube feeding and I got to refresh my memory on doing tube feeding calculations. The RD and I figured out how much of his tube feeding he should be getting to cover his calorie, protein, and fluid needs. For the rest of the day, the RD and I did some follow ups for some patients in order to document their current nutritional status. I learned that if a Pt refuses medication, supplementation, or weight measurements, it is important to document their refusal in order to cover yourself, and you can’t force anyone to do anything they don’t want to. At the end of the day, an IDCP care team meeting took place regarding a Pt anticipating on being discharged. The IDT wanted the Pt to realize that she needs more time to recover in order to get home safely since this woman uses an oxygen tank while having other comorbidities such as CHF, which is a huge risk factor since she is living alone. The IDT needs to monitor her independence as well as her breathing sufficiency. The role of the RD in this meeting is to report the Pt’s nutritional status, and the RD’s concern was how she would get/cook her meals since she is living alone, and the RD recommended some local food assistance programs if Pt is eligible. Overall, this was an informative day and I’m getting the hang of looking through Pt binders to get the pertinent information I need for the nutrition assessment. I need to come up with a list of common medications + labs since I feel that is my weakest at this point.

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