DRAFT: This module has unpublished changes.

Journal for Inpatient Clinical Rotation

 

Date:  10/21/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

My first day at NCBH consisted of reviewing the Policy and Procedures Manual, taking a tour of the kitchen, and introductions to the staff.

 

Comments / Thoughts / What You Learned / Challenges:

The kitchen has a very open setup with a lot of space to maneuver in. This facility operates on an assembly serve system which with the elimination of most of the cooking equipment provides the extra space available in the kitchen. I wasn’t able to observe the kitchen during service but look forward to seeing that process soon.

 

Learning Objectives Met: 2.11          

 

Hours:  6 (10:00AM-4:00PM) – 6     

 

 

 

Date:  10/22/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Today I was given an overview of the diets, enteral supplements, outpatient support information, paging system, resident contact information, and of the QuadraMed medical record system from the clinical nutrition manager and my preceptor Marie Keogh. I assigned screening times to patients based on either their nutritional risk or the last time they had been seen by a dietitian. I also reviewed initial nutrition assessments and follow-ups with the two staff dietitians: Ally and Eugene.

 

Comments / Thoughts / What You Learned / Challenges:

It was very interesting learning about the large number of different diets that the hospital provides depending on a patient’s medical condition as well as their ability to masticate their food. It is unfortunate however that diet orders are placed by the doctors and have to be changed by them in the case of a different diet being recommended by the dietitian. There is a procedure in place to notify the doctors of a change that should be made. QuadraMed seems like a challenging system with many different screens that have to be accessed to gather information on a single patient.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (9:00AM-5:00PM) – 14     

 

 

 

Date:  10/23/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Today Ally had me go into QuadraMed on my own to gather assessment data on patients that she was scheduled to see. I saw four patients with her and observed the questions she asked them and the education she provided. After collecting this information I observed Ally while she charted on the patients that we saw together.

 

Comments / Thoughts / What You Learned / Challenges:

It was a challenge to work through all of the different screens in QuadraMed to find the data needed on the patients I observed today. It took much longer than I expected it to and over my time here I hope to get faster at this process.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (9:00AM-5:00PM) – 22     

 

 

 

Date:  10/24/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

I continued to learn my way around QuadraMed today and observed Ally with three patients.

 

Comments / Thoughts / What You Learned / Challenges:

The charting process here at NCBH follows the ADIME format and would be more straightforward if the fields that needed to be filled out where not as scattered in QuadraMed as they are. I am getting more familiar with QuadraMed however which will allow me to be more efficient when charting myself. The dietitians here do a great job of noting previous assessments and follow ups on a patient when writing their comments on a subsequent visit. This allows for a better level of care to be provided in a more efficient manner by knowing what has been going on with a particular patient each time they encounter them.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (9:00AM-5:00PM) – 30     

 

 

 

Date:  10/25/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

I spent the last day of my first week here at NCBH using QuadraMed on my own more than previous days. I observed four more patients of Ally’s and her charting on them.

 

Comments / Thoughts / What You Learned / Challenges:

Ally cleared up an area of confusion for me today on finger stick blood glucose levels. She explained that for a diabetic a level of <150 is acceptable especially while the person is hospitalized as inflammation could cause an elevated result.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (9:00AM-5:00PM) – 38     

 

 

 

Date:  10/28/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Today was my first day observing patients with Eugene. The floors he covers include the ICU so I had my first experience in the ICU with him today. We screened patients in the morning to determine the workload for the day and then attended ICU Rounds. Eugene had me chart on one patients who was intubated. I also worked on tube feeding calculations.

 

Comments / Thoughts / What You Learned / Challenges:

I learned today that a continuous tube feeding has different meanings depending on the facility you are working at. Here at NCBH a continuous tube feed has a duration of 18 hours. This is done to give the patients time for bowel rest. There is a concern however that within those 18 hours that a feeding may be stopped several times for medication administration, tests, residuals, and other causes. If this occurs and is not rectified with an increase in the feeding rate which is not always medically feasible than the patient will not receive the correct amount of calories and nutrients.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (7:30AM-3:30PM) – 46     

 

 

 

Date:  10/29/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

I saw my first patient on my own today. The patient has a diagnosis of Upper GI Bleed and is currently NPO. The patient is intubated and on mechanical ventilation. The plan is to extubate the patient and start a clear-liquid diet. If the patient remains intubated a tube feeding is recommended.

 

Comments / Thoughts / What You Learned / Challenges:

The patient that I saw today was unable to speak due to intubation. This made the assessment of the patient much more challenging as I had to rely on information obtained from the medical record and the nurses during rounds. I was therefore unable to conduct any nutrition education with the patient. I was however able to assess the patient’s nutritional status, create a PES statement, plan a nutrition intervention with the goal of providing nutrition either by mouth or enterally, and determine the aspects that needed to be monitored for evaluation upon follow up. I then documented this information through charting in QuadraMed for Eugene to review. Eugene and I spent time reviewing my note and made a correction to the formula recommended should tube feeding be required.

 

Learning Objectives Met: 1.2, 2.1, 2.11, 3.1             

 

Hours:  8 (8:00AM-4:00PM) – 54     

 

 

 

Date:  10/30/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

I saw another patient on my own today while observing Eugene with his patients. The patient has diagnosis of Symptomatic Anemia.

 

Comments / Thoughts / What You Learned / Challenges:

I was unable again today to communicate with the patient I saw due to intubation. I have found that going to rounds in the morning is a great way to obtain information on a patient you are unable to communicate with from other members of the healthcare team. In addition to the information found in the medical record, conversations with the doctors and nurses on a patient provides valuable information when assessing a patient.

 

Learning Objectives Met: 2.5, 2.11               

 

Hours:  8 (8:00AM-4:00PM) – 62     

 

 

 

Date:  10/31/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

I saw two patients on my own today. The first patient’s diagnosis is a pulmonary embolism and the second patient has a diagnosis of UTI.

 

Comments / Thoughts / What You Learned / Challenges:

Neither of these patients presented a high nutritional risk. I was able to provide some education to the first patient on iron supplementation and the risk of constipation.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (8:00AM-4:00PM) – 70     

 

 

 

Date:  11/1/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

Today I saw two more patients with Eugene reviewing my notes. The diagnoses were dehydration and social issues.

 

Comments / Thoughts / What You Learned / Challenges:

The patient with the social issues is noted be at a high-risk for readmission. Eugene explained to me that patients with limited resources and no insurance tend to be readmitted into the hospital frequently due to lack of adherence to medications that they cannot afford to take. It seemed apparent that the social workers are doing everything they can for this patient but there’s just not enough resources available to them. This type of patient had to come back to the hospital just to receive the medication they need once their symptoms can no longer be self-managed.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (8:00AM-4:00PM) – 78     

 

 

 

Date:  11/4/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

Four patients today. Diagnoses included: hypertension, hypothermia, new onset CHF, and suicidal ideations.

 

Comments / Thoughts / What You Learned / Challenges:

The first patient I saw today, hypertension diagnosis, also was refusing to speak with anyone and was refusing to eat. I was able to get the patient to open their eyes and nod once. Another patient I saw today expressed concerns about their weight status, BMI is 45. I counseled the patient on the benefits of a 10% weight reduction in relation to their new onset CHF. The patient stated that they have reached the point of wanting to change their health status and will act on the 10% weight loss goal.

 

Learning Objectives Met: 2.4, 2.11               

 

Hours:  8 (8:00AM-4:00PM) – 86     

 

 

 

Date:  11/5/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

Saw three patients today. Diagnoses included: failure to thrive, sickle cell anemia, and CVA.

 

Comments / Thoughts / What You Learned / Challenges:

My second patient today with a diagnosis of sickle cell anemia was very inquisitive about their medical condition and its relation to diet. I informed the patient about the unintended consequences of folic acid supplementation possibly causing a Vitamin B12 deficiency to go undetected. I also informed the patient about the importance of consuming an adequate amount of calories while at home. The patient has a BMI of 18.7. I referred the patient to the outpatient dietitian staff at NCBH for the purpose of developing a meal plan.

 

Learning Objectives Met: 2.7, 2.11, 3.7        

 

Hours:  8 (9:00AM-5:00PM) – 94     

 

 

 

Date:  11/6/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

Three patients today. Diagnoses included: dehydration, pancreatitis, and CHF.

 

Comments / Thoughts / What You Learned / Challenges:

The patient with pancreatitis is currently NPO. It was explained to me by Ally that a dietitian should only recommend that a patient remain NPO if their medical condition is unknown. Otherwise, an appropriate diet should be recommended and started once the patient is able to tolerate it.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (9:00AM-5:00PM) – 102   

 

 

 

Date:  11/7/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

I saw four patients today with the following diagnoses: failure to thrive, two cases of pneumonia, and CVA.

 

Comments / Thoughts / What You Learned / Challenges:

The patient presenting with failure to thrive was noted to have problems swallowing food per the nurse on duty. The patient confirmed this issue and reported having a poor appetite as a result. I made a recommendation that the patient be seen by the Speech-Language Pathologist in my note.

 

Learning Objectives Met: 2.7, 2.11               

 

Hours:  8 (9:00AM-5:00PM) – 110   

 

 

 

Date:  11/8/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

Four patients today with the following diagnoses: abdominal pain/colon cancer, hypertension, pancreatitis, and dyspnea.

 

Comments / Thoughts / What You Learned / Challenges:

Conducted a follow up assessment today on the patient who was refusing to eat. The patient continues to refuse most meals but did however eat some yogurt fed by a doctor providing a lot of encouragement. The nurse on duty will attempt to feed applesauce to the patient as well.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (8:00AM-4:00PM) – 118   

 

 

 

Date:  11/11/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Today I saw five patients with the following diagnoses: acute coronary syndrome, asthma, hypertension, bowel obstruction, and dyspnea. Due to the holiday, rounds on the floor my patients are on were cancelled.

 

Comments / Thoughts / What You Learned / Challenges:

I was surprised that rounds would be cancelled for a minor holiday as was the case today. I am a Veteran myself and I do not understand why this holiday, or any other holiday, would be cause for such an important hospital function to be cancelled. I think that the staff that was present should have still met this morning to discuss the patients.

 

Learning Objectives Met: 2.11          

 

Hours:  7.5 (7:30AM-3:00PM) – 125.5         

 

 

 

Date:  11/12/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

I saw five patients today with the following diagnoses: two cases of pneumonia, new onset renal failure, new onset CHF, and syncope. In addition to seeing patients today all of the nutrition staff attended Nursing Grand Rounds. A presentation was given on geriatric nutrition.

 

Comments / Thoughts / What You Learned / Challenges:

The patient with syncope also reports constipation for the past three days. Eugene assisted me in recommending a fiber supplement and we will be monitoring the patient’s GI motility and bowel movements in an effort to return GI motility to normal. The presentation given this morning was a great refresher on the nutritional issues faced by the elderly. The speaker covered the topics of poor dentition, lack of mobility, lack of appetite, malabsorption, and polypharmacy as potential causes for geriatric patients not receiving the proper nutrition required.

 

Learning Objectives Met: 2.11          

 

Hours:  9.5 (8:00AM-5:30PM) – 135            

 

 

 

Date:  11/13/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Five patients were seen today with the following diagnoses: two cases of ESRD, CHF, CVA, and Type II diabetes. I attended ICU Rounds this morning. The other intern, from Queens College, that is also here at NCBH gave a presentation today on bariatric surgery. Also, on Wednesdays the entire foodservice staff and nutrition staff meet in the kitchen for what is called a Weekly Huddle. I attended my first Weekly Huddle today.

 

Comments / Thoughts / What You Learned / Challenges:

The intern presentation on bariatric surgery was very informative and well-researched. The presentation took place in our office and was conducted on a normal computer screen which made it difficult for everyone to have a clear view of the presentation. Other than that issue, the presentation provided useful information on the types of bariatric surgeries performed and compared their similarities/differences, success rates, and cost. The Weekly Huddle was a short meeting in the kitchen and the issue of tray temperatures was addressed. The foodservice staff were instructed to check the functionality of the cart that they will be using to deliver trays.

 

Learning Objectives Met: 2.11          

 

Hours:  9 (8:00AM-5:00PM) – 144   

 

 

 

Date:  11/14/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Today I saw four patients with the following diagnoses: cardiogenic shock, ARDS, CHF, and alcohol withdrawal. Utilized the phone interpreter service.

 

Comments / Thoughts / What You Learned / Challenges:

I faced the challenge for the first time today of having to do an assessment on a patient who does speak English. I was able to successfully initiate the phone interpreter service process and conducted my assessment through the service. The patient had all of their questions about their diet answered and appeared to be satisfied with the process. I expected this process to not be as simple as it turned out. The interpreter was very helpful in asking the patient to repeat questions that were unclear and ensured that the patient understood everything they were being educated on.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (9:00AM-5:00PM) – 152   

 

 

 

Date:  11/15/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

In addition to seeing patients today I also discussed ideas for my Service Improvement Project (SIP) with Marie. We agreed on the topic of unused oral nutrition supplements being returned from the patient floors. The four patients I saw today had diagnoses of: abdominal pain, partial bowel obstruction, altered mental status, and asthma exacerbation.

 

Comments / Thoughts / What You Learned / Challenges:

I am looking forward to the meeting the challenge of completing my SIP on such an interesting and important topic. Marie provided me with a lot of encouragement to start my SIP process. It will be a great learning experience for me to work with the kitchen staff, nurses, doctors and the other nutrition staff as well as using QuadraMed to determine the cause of the problem with the supplements being returned and to develop solutions.

 

Learning Objectives Met: 2.11          

 

Hours:  9 (8:00AM-5:00PM) – 161   

 

 

 

Date:  11/18/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:
For the first half of the day I attended the Volunteer Hospital-Wide Orientation at Jacobi Medical Center. When I got back to NCB I started the data collection phase of my SIP.

Comments / Thoughts / What You Learned / Challenges:

Orientation provided a lot of good information on NCBH and HHC in general. It would have been more helpful however if I had received the information sooner after I had started here. I do feel more prepared now though to perform my duties at NCBH within their guidelines. I had been informed of the number of supplements that had been returned over the past few months since the kitchen staff had started keeping track but I was still surprised by the information I saw in the logbook. Some patients had six or more unused cans of supplements returned to the kitchen in a day indicating that they did not receive a large portion of their prescribed calories and nutrients for the day.

Learning Objectives Met: 1.5, 2.11               

 

Hours:  8 (9:00AM-5:00PM) – 169   

 

 

 

Date:  11/19/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

I continued to collect data for my SIP today.

 

Comments / Thoughts / What You Learned / Challenges:

I worked on collecting information from QuadraMed today on specific patients for my SIP. I looked into their medical records to determine if there was a reason given to explain why supplements were returned. I have found that a large number of incidents do not have any explanation in QuadraMed. Other cases have been associated with legitimate reasons as to why cans of supplements were returned. Some of the reasons seen include: patient discharged, patient out for test, residuals, GI intolerance, and patient dislike.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (8:00AM-4:00PM) – 177   

 

 

 

Date:  11/20/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Today I had the opportunity to attend the Nursing-Nutrition Meeting with Marie. I was able to discuss my SIP with the head nurses and hear from them on what they think some of the problems are. In the nutrition department we had a Dietitian Meeting in which I was also able to talk about my SIP. There was also a Weekly Huddle meeting.

 

Comments / Thoughts / What You Learned / Challenges:

I gained a lot of valuable insight during the Nursing-Nutrition Meeting today for my SIP. The nurses were very helpful in offering their views on the problem and we discussed possible solutions and their likelihood of success. It was a great experience to be able to participate in an upper-level meeting between these two departments of the hospital.

 

Learning Objectives Met: 2.10, 2.11             

 

Hours:  8 (8:00AM-4:00PM) – 185   

 

 

 

Date:  11/21/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

I saw four patients today with the following diagnoses: COPD exacerbation, ESRD, rapid afib, and failure to thrive. I attended rounds in the morning. I also spent more time on my SIP. I continued to look into specific patients medical records to determine the cause as to why their supplements were not consumed.

 

Comments / Thoughts / What You Learned / Challenges:

The failure to thrive patient with a BMI of 16.3 is currently receiving TwoCal HN and has now been recommended for an appetite stimulant to increase caloric intake. I have now finished the collection of information in QuadraMed for my SIP. I have begun to analyze the data I have collected.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (9:00AM-5:00PM) – 193   

 

 

 

Date:  11/22/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

ICU Rounds in the morning. I saw four patients today with the following diagnoses: syncope, failure to thrive, acute coronary syndrome, and pneumonia.

 

Comments / Thoughts / What You Learned / Challenges:

A lesson I learned today from Eugene taught me that lab values close to the normal range, above or below it by 0.1 or 0.2, do not need to be noted when charting on a patient. Since each facility sets their own normal ranges that vary slightly from one to another it is acceptable if a lab value is just outside of that range.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (8:00AM-4:00PM) – 201   

 

 

 

Date:  11/25/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Four patients today with the following diagnoses: two cases of failure to thrive, colon cancer, and hyperglycemia.

 

Comments / Thoughts / What You Learned / Challenges:

Ally and I had a discussion today about A1c levels and diabetic patients. The patient I had today with hyperglycemia did not have a very high A1c. Ally told me that high levels of serum triglycerides can give a false low A1c result. It is important to always check a diabetic patient’s lipid panel to determine the cause of a lower than expected A1c. Knowing if it is due to high triglycerides or possibly lifestyle is important in developing the nutrition intervention.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (7:30AM-3:30PM) – 209   

 

 

 

Date:  11/26/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

I attended ICU Rounds this morning. I saw three patients today with the following diagnoses: ESRD, rapid afib, and failure to thrive. I also continued work on my SIP by looking into the remainder of the patients selected for the project.

 

Comments / Thoughts / What You Learned / Challenges:

In the medical records that I have looked through at this point, about 50% of the incidents of unused supplements being returned do not have an explanation. This makes the process of developing an intervention difficult when I cannot get a complete picture of the problem I am attempting to correct. This is an indication that better record keeping of oral nutrition supplements needs to take place.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (8:00AM-4:00PM) – 217   

 

 

 

Date:  11/27/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Today I saw four patients with the following diagnoses: failure to thrive, bipolar disorder, psychosis, and major depression. I attended rounds on my patient’s floor. We had a Weekly Huddle with the foodservice staff as well.

 

Comments / Thoughts / What You Learned / Challenges:

The patients I saw today were all on the psychiatric floors. The main psychiatric floor was challenging to work in since you have to go to the nurse’s station which is completely enclosed and talk to the patients through a window with holes in it. This is a necessary safety feature in the hospital but it makes patient education and counseling very difficult especially with patients that require a more personalized level of care. The other psychiatric floor that I saw patients on is the geriatric psychiatric floor. You are allowed to visit the patients in their rooms on this floor which makes the assessments easier to conduct. The patients were mostly cooperative but a one was not able to communicate with me so I had to gather information on them from the nurses.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (8:00AM-4:00PM) – 225   

 

 

 

Date:  11/29/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Five patients today with the following diagnoses: ESRD, rapid afib, failure to thrive, pulmonary artery embolism, and CHF. I attended rounds on my patient’s floor.

 

Comments / Thoughts / What You Learned / Challenges:

I faced a challenge to with the patient diagnosed with ESRD. This patient has been consuming less than 40% of meals due to dislike of the food for the past two weeks. The patient has an order for an oral nutrition supplement, Nepro, but does not always consume that either. The patient complains about their diet which is currently a cardiac, diabetic, renal diet. This diet with all of its restrictions limits the foods that the patient is offered to only a few choices that are repeated frequently. The patient has stated that they have an appetite but have grown tired of the same food being offered. I have made a recommendation to liberalize the patient’s diet due to lack of adequate calorie intake. This will provide the patient with a greater variety of foods that will hopefully get them to eat more. The patient is 76 years old and has a BMI of 21.3.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (8:00AM-4:00PM) – 233   

 

 

 

Date:  12/2/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

Five patients seen today with the following diagnoses: acute renal failure, acute coronary syndrome, hypokalemia, CHF exacerbation, and syncope. I also attended ICU Rounds.

 

Comments / Thoughts / What You Learned / Challenges:

Today I had three patients who were all on either contact or airborne precautions. These patients are in single rooms and you are required to wear a gown, gloves, and a mask (for airborne precautions) to enter the room. I thought that this protective gear would make conducting an assessment more of a challenge but it wasn’t really an issue. The patients realize that you are taking necessary precautions and do not seem to be bothered by my appearance.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (8:00AM-4:00PM) – 241   

 

 

 

Date:  12/3/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

Three patients today with the following diagnoses: dehydration, diverticulitis, UTI, and dyspnea. I also met with Marie today to discuss the progress of my SIP.

 

Comments / Thoughts / What You Learned / Challenges:

My SIP has progressed into the solution phase. In my meeting with Marie we agreed upon changes needed to menu room procedures and the need for a flowchart to be created that will guide the doctors, nurses, and dietitians in deciding if an order for an oral nutrition supplement should be continued or if it should be cancelled or changed. The menu room changes that are being considered are to have the menu room staff complete the supplements orders at mealtimes instead of once per day. This way the supplements that are sent up to the floors are based on the most recent information in QuadraMed and there will be less supplements being returned from the floors that went unused due to changes in orders or if a patient has been discharged.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (9:00AM-5:00PM) – 249   

 

 

 

Date:  12/4/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

Three patients seen today with the following diagnoses: UTI, acute renal failure, and CHF exacerbation. I attended the Weekly Huddle meeting as well.

 

Comments / Thoughts / What You Learned / Challenges:

The Weekly Huddle meeting covered an upcoming NSF inspection. The manager went over the safety regulations of the kitchen and took questions from the foodservice staff and an interesting topic was discussed. The kitchen is kept at a low temperature in order to maintain the quality of the food. The foodservice staff are allowed to wear jackets while in the kitchen but have been informed that they are not allowed to wear them out of the kitchen when delivering meals to the patient floors. The concern is that the jackets may become contaminated on the patient floors and then cross-contaminate surfaces in the kitchen when the foodservice employee returns. This was understood by all employees and the regulation is followed by everyone. There was a question however about why doctors and nurses are allowed to wear their scrubs and lab coats around the hospital, outside, and back inside of the hospital. While they are not coming into contact with food that will be served to all of the patients they still have direct contact with some of them and should also have to maintain a clothing used specifically for that purpose which is also not allowed to leave the space that it is intended for.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (9:00AM-5:00PM) – 257   

 

 

 

Date:  12/5/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

Saw three patients today with the following diagnoses: chest pain, acute cholecystitis, and COPD exacerbation. Conducted research on indications and contraindications for oral nutrition supplementation for my SIP.

 

Comments / Thoughts / What You Learned / Challenges:

In my research on oral nutrition supplementation I found a lot of information on reasons a supplement should be provided and also reasons that would indicate that they are no longer necessary. I am using this information to develop the decision flowchart for my SIP that will help the staff at NCB determine if a supplement needs to be changed or if it should not be given to the patient at all. The issue of supplements given to patients who do not require them or a patient refusing them due to GI intolerance or dislike of the taste/flavor result in unused supplements that are either disposed on once they’ve entered the patient’s room or are returned to the kitchen if not offered to the patient. Understanding when and why a supplement order should be adjusted will result in great acceptance of the supplements and less waste overall.

 

Learning Objectives Met: 1.4, 2.11, 4.6       

 

Hours:  8 (9:00AM-5:00PM) – 265   

 

 

 

Date:  12/6/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

Four patients seen today with the following diagnoses: dehydration, cellulitis, failure to thrive, and CHF.

 

Comments / Thoughts / What You Learned / Challenges:

I have learned today that it is important to not always recommend a diet type based on a patient’s past medical history. The patient I saw today with failure to thrive is also a diabetic. I recommended a high-calorie diabetic diet but their current medical condition contraindicates placing any restrictions on their diet. If a patient presents more pressing symptoms that contraindicate a diet restriction of any type than the diet should be liberalize to meet the current problem. Once medically feasible the diet can then be restricted to meet ongoing nutritional requirements.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (9:00AM-5:00PM) – 273   

 

 

 

Date:  12/9/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

Saw three patients today with the following diagnoses: chest pain, two cases of dehydration, failure to thrive. I also worked on the decision flowchart for my SIP and I talked with the staff in the menu room about possible solutions.

 

Comments / Thoughts / What You Learned / Challenges:

It was important to involve the menu room staff in the solution phase of my SIP. I heard some valuable input from them and have a better understanding of their processes. They are open to the proposed changes and will be briefed further on them soon.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (7:30AM-3:30PM) – 281   

 

 

 

Date:  12/10/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Saw four patients today with the following diagnoses: chest pain, failure to thrive, ESRD, and neutropenia. I also conducted my first drug-nutrient interaction (DNI) patient education today on Coumadin. There was another presentation today similar to last month’s Nursing Grand Rounds on advanced directives.

 

Comments / Thoughts / What You Learned / Challenges:

The DNI education that I provided to a patient today was very fulfilling. The patient had already received education on this medication but did not fully understand everything they had been told. I had the opportunity to clarify their questions and help them understand the steps they need to take to ensure their wellbeing and the effective use of the medication. The patient stated that they were much more comfortable about knowing how to safely plan their diet after our session.

 

Learning Objectives Met: 2.4, 2.11, 3.4        

 

Hours:  8 (8:00AM-4:00PM) – 289   

 

 

 

Date:  12/11/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

I saw five patients today with the following diagnoses: persistent vomiting, visual disturbance, lung cancer, unstable angina, and aspiration pneumonia. I attended ICU Rounds in the morning and we had a Dietitian Meeting and Weekly Huddle in the afternoon.

 

Comments / Thoughts / What You Learned / Challenges:

The Dietitian Meeting today covered various aspects of charting. Marie talked about creating goals for patients that are measurable. This will ensure that the dietitians are better able to evaluate how well or how poorly an intervention is helping a patient. She also instated a new procedure of recommending a diet for the patient to follow upon their discharge from the hospital. This information will be a part of the patient’s discharge summary and will provide them with a direction for their diet at home and a starting point with an outpatient dietitian should they see one.

 

Learning Objectives Met: 2.11          

 

Hours:  9 (8:00AM-5:00PM) – 298   

 

 

 

Date:  12/12/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Saw four patients today with the following diagnoses: bradycardia, tachycardia, failure to thrive, and steroid induced myopathy. I also worked with the menu room staff to come to an agreement on the intervention for my SIP in regards to menu room procedures for preparing oral supplement orders.

 

Comments / Thoughts / What You Learned / Challenges:

The menu room have agreed to the new way of completing supplement orders. They do have some concerns on the new system however but we came to an agreement that they will report on any issues that result from the change and we will address them as they come up.

 

Learning Objectives Met: 2.6, 2.8, 2.11, 2.13, 4.4   

 

Hours:  9 (8:00AM-5:00PM) – 307   

 

 

 

Date:  12/13/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

I saw six patients today with the following diagnoses: seizure, ESRD, two cases of CHF, CVA, and dehydration. I attended ICU Rounds. The nutrition staff all received training on the changes to MSDS.

 

Comments / Thoughts / What You Learned / Challenges:

The changes to MSDS, which will now be known as just SDS, are taking place to bring them in line with the Globally Harmonized System or GHS. This will result in more consistent information available on hazardous chemicals. The changes sound like a good idea and will hopefully have a positive effect on safety.

 

Learning Objectives Met: 2.11          

 

Hours:  9 (8:00AM-5:00PM) – 316   

 

 

 

Date:  12/16/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Five patients today with the following diagnoses: two cases of failure to thrive, ESRD, UTI, pulmonary edema, and a fall related to ETOH abuse. Attended morning ICU Rounds. I continued to work on the flowchart for my SIP.

 

Comments / Thoughts / What You Learned / Challenges:

The decision flowchart has been a challenge to put together because of all of the possible scenarios that it must account. It is important that it addresses all scenarios in order for it to be useful or else it will not be adopted by staff here at the hospital. I have mapped out all of the various scenarios that I can think of and will seek the input of Ally and Eugene to see if they can offer any others.

 

Learning Objectives Met: 2.11          

 

Hours:  8.5 (8:00AM-4:30PM) – 324.5         

 

 

 

Date:  12/17/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Saw five patients today with the following diagnoses: pyelonephritis, pneumonia, chest pain, CHF and right toe and foot cellulitis. I attended rounds on my patient’s floor.

 

Comments / Thoughts / What You Learned / Challenges:

I had a hard time today finishing my charting on time because I spent too much time with two of my patients. One of the patients I saw today was out of their room for a procedure. I was informed that they should be returning very shortly from their nurse. I did see another patient while I was waiting but overall I ended up spending too much time waiting for the patient to return. In the future I plan to return to the office to work on charting and return to the floor later to check on the patient. Another patient I saw today was very talkative. I made every effort to keep the patient on topic but with every new question I received a lengthy story in response. I tried to ask closed-ended questions but that strategy did not help either.

 

Learning Objectives Met: 2.11          

 

Hours:  8.5 (8:00AM-4:30PM) – 333            

 

 

 

Date:  12/18/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Saw six patients today with the following diagnoses: pericardial effusion, polysubstance abuse, pneumonia, CHF, acute renal insufficiency, and ESRD. Attended ICU Rounds and the Weekly Huddle meeting.

 

Comments / Thoughts / What You Learned / Challenges:

I had an informative discussion with Eugene today about my patient diagnosed with ESRD. I originally thought to recommend a renal diet, without a protein restriction, assuming that the patient was receiving dialysis treatments based on their diagnosis. The patient however has not been started on dialysis because their fistula has not matured enough at this time. In this case the patient should be placed on a protein restriction until their dialysis has begun.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (8:00AM-4:00PM) – 341   

 

 

 

Date:  12/19/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

I saw four patients today with the following diagnoses: pulmonary edema, steroid induced myopathy, acute diverticulitis, and UTI. I attended rounds on my patient’s floor. I completed the formatting of the decision flowchart today and submitted it to Marie for approval.

 

Comments / Thoughts / What You Learned / Challenges:

Marie is checking over my decision flowchart for any necessary changes or additions. Once I have her comments to work on the flowchart will be complete and I will be able to present it to the residents next week.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (8:00AM-4:00PM) – 349   

 

 

 

Date:  12/20/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Saw four patients today with the following diagnoses: seizures, acute myocardial infarction, depression, and appendicitis. Made some corrections to the decision flowchart and prepared my remarks for a presentation to the residents that I will give on Monday.

 

Comments / Thoughts / What You Learned / Challenges:

Today I completed the decision flowchart for my SIP. This has been a great learning experience to develop a tool such as this flowchart. It incorporated a lot of collaboration with the staff here at NCB and research on my part. I am looking forward to presenting it to the residents on Monday so that they can begin to utilize it with their patients.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (9:00AM-5:00PM) – 357   

 

 

 

Date:  12/23/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

Saw three patients today with the following diagnoses: two cases of depression and schizoaffective disorder. I submitted a pamphlet that I have been working on at home that will be included on patient trays for the upcoming winter holidays. I also presented the intervention of my SIP to the residents at NCB. I informed them that the decision flowchart that I had developed should be used starting today. I spoke with the menu room staff as well about implementing the changes we had discussed today.

 

Comments / Thoughts / What You Learned / Challenges:

My presentation went well today. The residents were very receptive to the flowchart and its intended purpose. I was able to answer a couple of questions they had concerning its use and feel that I was successful in my goal of introducing this tool to the audience I was presenting to. They are now aware that the tool is to be used and this begins the intervention phase of my SIP. The menu room is also aware of the start of this phase. I will now wait until as much time as possible has passed before the end of my rotation to evaluate the effect my SIP has had on the number of unused supplements being returned. The winter pamphlet that I created included tips on navigating food choices at holiday celebrations, physical activities for the winter season, a healthy sweet potato brownie dessert recipe, and other helpful information on maintaining a healthy outlook during the challenging winter months.

 

Learning Objectives Met: 2.2, 2.3, 2.11       

 

Hours:  6 (9:00AM-3:00PM) – 363   

 

 

 

Date:  12/31/13          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital 

 

Activities / Assignments for the day:

I saw four patients today with the following diagnoses: urosepsis, COPD exacerbation, pyelonephritis, and pneumonia. I also attended ICU Rounds.

 

Comments / Thoughts / What You Learned / Challenges:

The actual number of patients that I saw today was six. However, two of the patients were discharged before the end of the day which meant that their record for this visit was closed and I could not chart on them. It is still important however to see the patient if they are schedule for an initial assessment or follow up regardless of whether or not they are planned for discharge in case they do not actually get discharged. It is better to see them and have them be discharged then to not see them and have the discharge cancelled resulting in a late assessment.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (8:00AM-4:00PM) – 371   

 

 

 

Date:  1/2/14          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital      

 

Activities / Assignments for the day:

Today I saw three patients with the following diagnoses: pneumonia, dehydration, and CHF. I also had the opportunity to shadow the Speech-Language Pathologist at NCB. Marie has each of her interns shadow the SLP as well as the Pharmacy during their rotation.

 

Comments / Thoughts / What You Learned / Challenges:

I felt so fortunate today to have had the opportunity to shadow the SLP and to see the work that she does that is so important to a patient’s nutritional wellbeing. The first patient that we saw together was an outpatient child with delayed developmental status. The child presented with little ability or interest in feeding. The SLP offered recommendations to the caregiver to conduct feedings in an environment without distractions and to establish a feeding schedule to begin to form some structure around mealtimes. I also observed the SLP on the patient floors with two elderly patients. Both of these patients had difficulty swallowing due to their frail condition. A restriction of thin liquids was recommended for each patient to prevent aspiration. After reading many of the SLP’s notes it was very helpful to actually see what her position entails and this process has given me a greater understanding of the relationship between our two fields of practice.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (9:00AM-5:00PM) – 379   

 

 

 

Date:  1/3/14          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital      

 

Activities / Assignments for the day:

I spent the day in the Pharmacy shadowing several different people.

 

Comments / Thoughts / What You Learned / Challenges:

The second department Marie had me shadow was the pharmacy which is very relevant to the field of nutrition. The pharmacy here at NCB performs the calculations necessary to prepare TPN solutions. They are prepared off site and are delivered in the same day to the hospital. The pharmacy will discuss calculations with the dietitians if the case is more complex but overall they handle most of this function. I spent time with the manager reviewing TPN solutions and their components. I also went to the patient floors with technicians and observed their process of delivering and rotating medications.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (9:00AM-5:00PM) – 387   

 

 

 

Date:  1/6/14          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital      

 

Activities / Assignments for the day:

Today I had the opportunity to experience staff relief. Both Ally and Eugene were out of the office and I saw every patient that was due today. The six patients that I saw had the following diagnoses: ESRD, hypernatremia, hypertension, schizoaffective disorder, and two cases of CHF.

 

Comments / Thoughts / What You Learned / Challenges:

I was a little concerned about how today was going to be after finding out at the end of last week that I would be responsible for seeing all of the patients on my own. It was a great learning experience however and I was able to handle the workload. Not having the dietitians available for questions was a challenge but I found the information I needed through other resources and this has helped to strengthen my ability to work independently.

 

Learning Objectives Met: 2.11          

 

Hours:  8.5 (8:00AM-4:30PM) – 395.5         

 

 

 

Date:  1/7/14          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital      

 

Activities / Assignments for the day:

Saw three patients today with the following diagnoses: encephalopathy, COPD exacerbation, and uncontrolled DM. Conducted a DNI patient education on Ciprofloxacin. Attended ICU Rounds.

 

Comments / Thoughts / What You Learned / Challenges:

I was able to provide a successful DNI education with a patient prescribed Ciprofloxacin. The patient stated that they fully understood the negative interaction of this medication and calcium-containing foods and expressed a high level of compliance to this information.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (8:00AM-4:00PM) – 403.5            

 

 

 

Date:  1/8/14          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital      

 

Activities / Assignments for the day:

Today I saw six patients with the following diagnoses: syncope, DM, ESRD, sepsis, hypotension, and CHF. I conducted another DNI with a patient taking Coumadin. I attended rounds on my patient’s floor. I also attended the Weekly Huddle.

 

Comments / Thoughts / What You Learned / Challenges:

The Weekly Huddle this week covered the topic of discrimination. The manager discussed the different sources of discrimination and the fact that there is zero tolerance for any type of discrimination on the part of any employee regardless of their position within the hospital. This training was provided as a required refresher on the subject rather than in response to a particular incident.

 

Learning Objectives Met: 2.11          

 

Hours:  8.5 (8:00AM-4:30PM) – 412            

 

 

 

Date:  1/9/14          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital      

 

Activities / Assignments for the day:

Today I saw five patients with the following diagnoses: seizure, pneumonia, hypernatremia, Etoh withdrawal, and ESRD.

 

Comments / Thoughts / What You Learned / Challenges:

I was able to make a recommendation today to a resident that the patient diagnosed with Etoh withdrawal be supplemented with folic acid and thiamine. This practice is standard care for this condition and the patient had not yet received an order for these supplements. The supplements were ordered for the patient by the end of the day.

 

Learning Objectives Met: 2.10, 2.11             

 

Hours:  8.5 (8:00AM-4:30PM) – 420.5         

 

 

 

Date:  1/10/14          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

Saw five patients today with the following diagnoses: transaminitis, acute coronary syndrome, syncope, pyelonephritis, and pneumonia.

 

Comments / Thoughts / What You Learned / Challenges:

I had the challenge today of responding to a patient who was very dissatisfied with the food served throughout their stay. This patient expressed their opinions of the food very strongly and it took a lot of effort to calm the patient down and explain the options available to them. I informed the patient of the hospital’s complaint process and urged them to submit their complaints in addition to voicing them to me which I passed along to my preceptor.

 

Learning Objectives Met: 2.11          

 

Hours:  8 (9:30AM-5:30PM) – 428.5            

 

 

 

Date:  1/13/14          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

Saw six patients today with the following diagnoses: pneumonia, right food cellulitis, sickle cell crisis, asthma exacerbation, failure to thrive, and CHF. I also spend time on my SIP collecting data on the number of unused supplements that have been returned since the implementation of my interventions.

 

Comments / Thoughts / What You Learned / Challenges:

I had another patient today that was very talkative and would have kept me in their room for too much time if I had let them. Based on what I had learned with my previous experiences with patients like this I was able to obtain the information I needed for my assessment by explaining the importance of the questions I was asking. I also dealt with the patient by informing them that they could have the nurses contact the nutrition office if they had questions that come up at a later time.

 

Learning Objectives Met: 2.11          

 

Hours:  8.5 (8:00AM-4:30PM) – 437            

 

 

 

Date:  1/14/14          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

I saw three patients today with the following diagnoses: small bowel obstruction, new onset diabetes, and GI bleed. I attended another nursing presentation on wound care.

 

Comments / Thoughts / What You Learned / Challenges:

The patient I saw today diagnosed with new onset diabetes with very interested about how they should proceed with their diet. I was able to provide a little more education to the patient on a diabetic diet. I also referred them to the outpatient dietitian staff here at hospital for further counseling on their diet.

 

Learning Objectives Met: 2.7, 2.11               

 

Hours:  8.5 (8:00AM-4:30PM) – 445.5         

 

 

 

Date:  1/15/14          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

Saw four patients today with the following diagnoses: sepsis, pneumonia, asthma, and syncope. I also had the opportunity to shadow the SLP one more time.

 

Comments / Thoughts / What You Learned / Challenges:

The patient that I saw with the SLP was another child that has been diagnosed with failure to thrive. The parent of the child explained that mealtimes in the household are controlled by the child. The child refuses most foods and the SLP made the recommendation that a food that the child will eat always be offered at mealtimes. Small changes to the child’s diet should be made with modeling on the parent’s behalf to demonstrate healthy eating habits.

 

Learning Objectives Met: 2.11          

 

Hours:  8.5 (9:00AM-5:30PM) – 454

 

 

 

Date:  1/16/14          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

Saw five patients today with the following diagnoses: two cases of pneumonia, GI bleed, multiple rib fractures, and sepsis. There was Dietitian Meeting in the office today during which I had the opportunity to present the findings of my SIP which showed that an improvement had been made from the previous dataset.

 

Comments / Thoughts / What You Learned / Challenges:

The dietitians, diet techs, and my preceptor expressed positive reactions to the findings of my SIP. They were encouraged by the reduction of unused supplements returned from the patient floors and will continue the procedures that have been adopted as a result of my SIP. The success of this project and the continuation of it are very gratifying to realize after the work that has been put into seeing it accomplished.

 

Learning Objectives Met: 1.3, 2.11               

 

Hours:  8 (9:30AM-5:30PM) – 462   

 

 

 

Date:  1/17/14          Rotation:  Inpatient Clinical         Location:  North Central Bronx Hospital    

 

Activities / Assignments for the day:

I saw five patients for my final day at NCB. They had diagnoses of: abdominal pain, GI bleed, hypoglycemia, schizophrenia, and schizoaffective disorder.

 

Comments / Thoughts / What You Learned / Challenges:

These past four months at NCB working with the very supportive and highly capable dietitians and diet techs has been an incredible learning experience. I have grown so much in my knowledge of medical nutrition therapy as well as in my ability to educate and counsel patients. The clinical rotation was the rotation that I was least looking forward to coming into the internship but I have a much more positive outlook on clinical dietetics after my experience here.

 

Learning Objectives Met: 2.11          

 

Hours:  7 (10:00AM-5:00PM) – 469  

DRAFT: This module has unpublished changes.