National Nutrition Month Campaign

March is National Nutrition Month and it has been a process in the making at developing a campaign for such an important month to the professional of dietetics! As an intern, I have worked with the entire staff at the facility that I am rotating at currently at, and there are a number of events, activities, and education that we have planned for this month.

MyPlate March Madness:
– Employees register for a month-long MyPlate cornhole tournament and particpate during their lunch hour in the multipurpose room within the facility. The winner at the end of the month will receive a healthy cookbook and cooking tips as well!

West Virginia Ramps:
– Nutritional information, cultural background, cooking use, and growth information will be provided to clients, patients, and employees at the facility. I collaborated with another staff member at developing the content.

NNM 2014 Table Tents:
– I developed these table tents with the NNM 2014 logo as well as “Nutrition 101” questions and answers at the bottom of each side of the table tents. Then I put these on display in the facility’s public eating area for everyone to see! This gives this specific population a boost of nutrition knowledge all throughout the month!

March Mediterranean Lunch ‘n Learn:
– This event will incorporate cooking skills, food culture, and nutritional benefits-like heart health. I assisted in the development and implementation of the event and this will take place at the end of the month, as a 1-hour event in a multipurpose room within the facility as well. Participants will learn how to create easy, affordable, and creative appetizers, dips, and spreads. I’ll even give you a hint- kale chips will have a BIG role in this delicious event as well!

NNM VAMC 2014

Pro-Stat Supplement

Pro-Stat is a nutritional supplement that I recently became familiar with at my MNT rotations. This supplement is used for patients who are having difficulties gaining weight or consuming energy, in general. This supplement delivers the highest concentration of protein and calories in the smallest serving size. It is ideal for patients with an increased need for protein, have a poor appetite, suffer from pressure ulcers, or who could be experiencing protein-energy malnutrition. Pro-Stat is a complete protein and contains all the essential amino acids while being easy to administer. There is no mixing required and I witnessed the supplement being used with a patient who was on a tube feeding. The patient didn’t seem to mind the supplement, which is rare. A large number of patients who are on tube feedings seem to be very particular about what supplements or formula they are consuming. So, it was to my surprise that the patient who we introduced this supplement to, actually seemed like he enjoyed the protein supplement. Plus, I think it helped that I explained to the patient why we were giving him the supplement and how it would help his health status too.

ProStat

Nasogastric Tube Feedings

A nasogastric (NG) tube is a special tube that carries food and medicine to the stomach through the nose. It can be used for all feedings or for giving your patient/client extra calories. It’s important to take good care of the feeding bag and tubing so that they work properly, as well as the skin around the nostrils so that it does not get irritated.NG tube feedings incorporate a procedure where a thin, plastic tube is inserted through the nostril, down the esophagus, and into the stomach. Once the NG tube is in place, healthcare providers can deliver food and medicine directly to the stomach or remove substances from it.

NG tube feeding has four distinct advantages:

·         Short-term (<4 weeks)

·         Most commonly used

·         Easiest to place (with a prior patient assessment)

·         Least expensive to administer

Nasogastric tubes are used mainly for short-term support in patients who do not have problems like vomiting, GERD, poor gastric emptying, ileus or intestinal obstruction. Nasogastric tubes can be used for longer term support where other enteral access is not possible or could potentially carry a risk. NG tubes are potentially dangerous in patients who cannot swallow correctly and those who need to be nursed. A patient assessment should always be carried out prior to placement of an NG tube. NG tubes are placed by appropriately trained staff like nurses or doctors.

There is a small risk that NG tubes can be misplaced on insertion or move out of position at a later stage. Position of NG tubes should be verified on initial placement and before each use. It is recommended that a pH <5.5 is consistent with gastric placement. If aspirate cannot be obtained or the pH is >5.5 feeding should not begin. The NG tube should be left in place, the patient’s position changed and the aspirate re-tested in 1 hour. The feed itself can increase the pH in the stomach, so aspiration should take place at least 1 hour after the feed has been stopped.

NG tube

Parenteral Nutrition

When a patient cannot eat any or enough food because of an illness or health complication, sometimes other forms of nutrition are required to assist the patient towards better health. The stomach or bowel may not be working normally, or a person may have had surgery to remove part or all of these organs. When this occurs, and a patient or client is unable to eat, nutrition must be supplied in a different way. One method that can be applied is Parenteral Nutrition.

Parenteral Nutrition bypasses the normal digestion in the stomach and bowel. It is a special liquid food mixture given into the blood through an intravenous (IV) catheter (needle in the vein). The mixture contains proteins, carbohydrates, lipids, vitamins and minerals. This special mixture may be called Parenteral Nutrition or Total Parenteral Nutrition (TPN).

A special IV catheter will be placed in a large vein in the chest or arm. It can stay in place for as long as needed. Proper care is required to avoid infection and clotting. Different kinds of catheters may be used. Common types of catheters are Peripherally Inserted Central Catheter (PICC), triple lumen, double lumen, or single lumen catheters, and Ports. Nutrition is given through this large vein. Coordinated care, consisting of doctors, nurses, RDs, and pharmacists, will talk with the patient about the different types of catheters prior to administering anything.

Prior to initiating TPN, a nutrition assessment is necessary to determine nutrient needs and to anticipate any metabolic changes that may occur due to the patient’s underlying condition, medications or concurrent therapies, etc. Important factors to consider when assessing a patient for TPN are:

·         Anthropometric Data: CBW, Wt Hx, IBW

·         Lab Values: Mg levels, Phosphorus levels, TG levels

·         Patient Medical History (PMH): Anatomy resections, ostomies, pre-existing conditions like diabetes or renal failure

·         Diet History: Diet prior to admission, Food/Drug Allergies

·         Medications: Current medications and supplements

TPN_All tube feedings

Modified Barium Swallowing Test

A Modified Barium Swallow (MBS) test is an X-ray that is taken to check the swallowing skills of a client or patient. I recently observed an MBS in a patient who has been cancer-free for nearly 10 years but, was aspirating when he swallowed certain foods and beverages. The MBS was carried out by a Speech Language Pathologist (SLP) at the facility that I’m rotating at currently. The SLP had previously worked with this patient and mentioned that he had developed fibrous tissue along his esophagus, caused by his radiation treatment several years earlier. This was her initial assessment of the patient’s swallowing problems.

Throughout the test, the mouth, throat, and esophagus are checked to see if there are any visible problems with a patient’s ability to swallow.  Before we began the test, the SLP and I put on protective lead vests and a thyroid collar. This was done to shield ourselves from the radiation used in the actual test.

Barium is actually a dry, white, chalky powder that is mixed with water to make thick, almost like the consistency of a milkshake. It is an X-ray absorber and appears white on X-ray film. When swallowed, a barium drink coats the inside walls of the pharynx and esophagus so that the swallowing motion, inside wall lining, and size and shape of these organs is visible on X-ray. This process shows differences that might not be seen on standard X-rays. Barium is used only for diagnostic studies of the GI tract. The use of barium with X-rays contributes to the visibility of various characteristics of the pharynx and esophagus. Some abnormalities of the pharynx and/or esophagus that may be detected by a barium swallow include tumors, ulcers, hernias, diverticula (pouches), strictures (narrowing), inflammation, and swallowing difficulties.

The SLP noted that if she were to have assessed this patient bedside, she probably would have missed that he has aspirating when he swallowed. The MBS really caught the problem that the patient was actually having. It was interesting to see how everything looked through the MBS and to see how problems can go unnoticed.

The SLP was really hands-on and pointed out every part of the patient’s anatomy including his epiglottis, esophagus, stomach, tongue, etc. I can honestly say that working with patients who suffer from dysphagia or who are experiencing temporary swallowing problems is really becoming an interest of mine. There’s so many elements that an RD has to take into consideration, for example consistencies of beverages and foods or physiological problems from cancer treatments.

Swallowing_Phases.95151037_std

barium-swallow

What is a SOAP Note?

A SOAP note is a form of documentation used by healthcare professionals to record a patient’s visit or consultation. It is an ongoing system to support the steps of the Nutrition Care Process (NCP) in the capacity of a hospital, long-term care facility, and other similar agencies. Standardized language is part of NCP, which improves both written and oral communication among members of the health care team as well as communication with the patient. A Registered Dietitian at my rotations said to me the first week I was there, “Ninety percent of life is communication.” And when the RD said this to me, it really stuck with me. Life really is based on communication- every aspect of it. So, if healthcare professionals all use the same words, or standardized language, when documenting the progress of a patient, it prevents a barrier of communication or confusion. These SOAP notes are designed to be relevant, accurate, and timely. Yes, there are several other forms of documentation but, the SOAP note seems to be the most commonly used. Here is a brief outline of how a SOAP note should be constructed:

Subjective (S):

This is where the healthcare provider enters all patient information or data collected from the patient or caregiver. This information would also include a diet recall and any food allergies that the patient reports.

Objective (O):

This section is based more on physical evidence about the patient. Information in this section would include height, weight, BMI, weight change over a period of time, labs, PMH, medications currently using, or any other trending values (i.e.: TG levels over the past 6 months).

Assessment (A):

This is where the Nutrition Diagnosis is made. This diagnosis is referred to by healthcare professionals with a nutrition background, as a PES statement. PES stands for problem, etiology, and signs and symptoms. The PES statement is phrased as follows:

Problem related to etiology as evidenced by signs and symptoms

Examples:

·         Altered GI function related to Partial Bowel Obstruction/ileus as evidenced by hypoalbuminemia, parenteral nutrition.

·         Excessive intake of simple sugars related to consumption of regular sodas and juices as evidenced by food and blood glucose logs.

·         Inadequate oral food/beverage intake related to decreased appetite due to cancer and treatment as evidenced by dietary recall and unintentional weight loss.

Plan (P):

This is the section where an outline of interventions is made necessary to treat the nutrition problems(s). Goals are made, short-term and long-term, using the SMART format.

S: Specific

M: Measurable

A: Attainable

R: Realistic/Relevant

T: Timely Manner

This section also includes information as to how the patient plans on monitoring their progress, when their follow-up consultation should take place, and if any multivitamins are being suggested.

oldSOAPnote

soapnote_example

Cancer of the Sigmoid Colon

The sigmoid colon is the terminal section of your large intestines that attaches to the rectum and anus — a sigmoid colectomy is a surgical procedure in which the sigmoid colon is resected. During this procedure, the sigmoid colon is removed and the remaining large intestine is then reattached to the rectum. After the procedure, patients will need to eat certain foods to allow the intestines to heal, as well as to prevent gastrointestinal upset such as diarrhea, constipation and excessive gas.

Patients should follow a low-fiber diet for about six weeks after discharged from the hospital. A low-fiber diet is imperative for post-colectomy patients to decrease the risk of trauma to the intestines and promote healing. After six weeks, slowly introduce fiber back into your diet. Patients can then increase fiber intake by only one serving each day, until they are able to tolerate 20 grams to 35 grams per day, or about five servings. Patients should be sure to drink plenty of water while increasing your fiber. Fiber can be constipating when not complemented with adequate water.

I recently led a follow-up appointment with a patient who was on his third chemotherapy treatment and recovering from a sigmoid colectomy. The patient consistently lost 14 pounds over the last 6 months but gained 10 pounds since his last appointment, which was last month. But, the patient reported that he was slowly gaining his appetite back but could not tolerate smells like he used to. On the SOAP (subjective, objective, assessment, plan) note I developed, I indicated that I educated the patient on the importance of keeping his weight up and maintaining that weight as well. It’s important for patients to maintain their weight after major surgeries like a sigmoid colectomy, in addition to cancer treatment. The stronger the state that the body is in, the more tolerable it will be towards the treatment of cancer. The patient is currently prescribed a vanilla-flavored supplement from the facility and reported that he couldn’t tolerate the taste of it sometimes. So, I educated him on different ways to make his supplement taste better like adding chopped strawberries to his supplement. We talked about what foods he could eat and how we were going to make sure that the patient listens to his body. By listening to his body, I mean if a patient can tolerate a certain food on a Monday- then eat it. But if he can’t tolerate that same food on Tuesday- try something different. The patient reported that he “forces himself to eat”, which is good for patients going through chemotherapy. A number of patients that are going through chemotherapy become easily frustrated. But, RDs are there to remind them that they need to fight through the frustration and aggravation of their senses (taste and smell specifically) changing.

Livestrong

This is an image of a normal colon

This is an image of a normal colon

This is an image before a sigmoid colectomy and highlights the area that will be removed.

This is an image before a sigmoid colectomy and highlights the area that will be removed.

This is an image of how the colon looks after surgery and the shows the section where surgeons re-connected.

This is an image of how the colon looks after surgery and shows the section where surgeons re-connected.

Roux-en-Y Gastric Bypass Surgery and Nutritional Concerns

Bariatric surgery is performed for patients who have chronic problems and difficulties losing weight, in order to be of a healthy body mass index for their individual size and frame. Weight loss surgery is a major surgery, yet it is safe and effective. It is not considered a cosmetic operation. It is considered to be permanent. One particular bariatric surgery, that I have noticed more common compared to other procedures, is the Roux-en-Y Gastric Bypass procedure.

Roux-en-Y gastric bypass is the current gold standard procedure for weight loss surgery. In this procedure, stapling creates a small (15-30cc) stomach pouch. The outlet from this newly formed pouch bypasses most of the stomach and several feet of the small intestine, preventing your body from absorbing all the calories and nutrients from the foods you eat. By combining the smaller stomach and the malabsorption feature, this surgery produces more weight loss than operations that only decrease the intake of food. The malabsorption of nutrients, especially calcium, iron, and Vitamin B12 can be managed through proper diet and vitamin supplements. An excess intake of sugar and fat may trigger a condition known as “dumping syndrome.” The results can be extremely unpleasant and can include nausea, weakness, abdominal cramping, and diarrhea.

Reasons for the procedure

Obesity lowers quality of life. This can result in poor overall health, and contribute to a higher risk for depression. Your doctor may suggest a RYGB surgery if you have a body mass index (BMI) of 40 or more or if you have a BMI of 35 and also suffer from serious obesity-related health problems such as diabetes, coronary heart disease, sleep apnea, high blood pressure, or severe arthritis.

Doctors generally recommend the weight-loss surgery only if you are severely obese. That means about 100 pounds overweight for men and 80 pounds for women. They also usually don’t recommend it unless you haven’t been able to lose a large amount of weight and keep it off through diet, exercise, and changes in lifestyle.

Before the procedure

It’s important that your weight-loss surgery be arranged at a qualified bariatric center, where you will complete an extensive educational and preparatory program before surgery. Your doctor can obtain a referral from the American Society for Metabolic and Bariatric Surgery (ASMBS).

  • Your doctor will typically test you for nutritional deficiencies and prescribe supplements to correct any problems before the operation. Your surgeon may ask you to have tests and visits with other health care providers before surgery such as a dietitian and a psychologist.
  • Because smoking slows recovery and increases risks of surgery, your doctor will suggest you stop smoking for good several weeks before surgery. Tell your doctor or nurse if you need help quitting.
  • You’ll want to check with your health insurance provider to make sure bariatric surgery is covered in your health insurance plan, as many plans will not pay for it.
  • Let your doctor know about any prescription or over-the-counter drugs, vitamins, and herbs you are taking. In the week before surgery you may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), vitamin E, warfarin (Coumadin), and any other blood-thinning drugs. Ask what drugs you can take on the day of your surgery.
  • Let your doctor know if you have had any trouble with anesthesia in the past.

During the Procedure

With either open or laparoscopic RYGB surgery, you will be given general anesthesia for the procedure. Initially your doctors will start an IV and may deliver medications to help you relax. Your anesthesiologist will use a drug or combination of drugs to control pain and make you unaware of the procedure.

When you reach the operating room, your medical team will use routine monitoring equipment throughout the procedure or longer, depending on your health conditions.

The surgery to create the stomach pouch and the bypass usually takes several hours.

After the Procedure

You may stay in the hospital for two to four days after the procedure. You will typically only have liquids or puréed foods for at least three to six weeks after surgery. Rarely, you may have a catheter, or tube, from the larger bypassed part of your stomach that will come out of your side to drain excess fluids from your abdomen for four or more weeks.

Your RD may slowly add soft food and then regular food to your diet about a month after surgery. You will be instructed to chew slowly and completely and not to drink 30 minutes before or after you eat food.

Talk with your doctor, surgeon, and RD about proper wound care, the type of pain-relieving drugs that are safe to take, and when you can resume physical activities. Your surgeon will tell you how often to change the dressing on your incision.

You should inform your doctor immediately if you develop a fever or if your wound becomes painful or hot to the touch or has a foul-smelling drainage. Also look for any coughing or difficulty breathing, vomiting and diarrhea, pain in the abdomen, chest, shoulder, or legs, or any other unusual symptoms.

Your initial weight-loss may occur quickly, so it’s important to get all of the nutrition and vitamins you need as you recover. Your doctor will prescribe certain vitamin and mineral supplements that your body may no longer absorb well from food alone.

Recommendations for the following supplements to prevent nutritional deficiencies after recovery from surgery are:

  • Daily vitamin D and calcium supplements. Vitamin D deficiency is common in people who have had this kind of gastric bypass. Multivitamins containing 1,200 mg of daily calcium citrate and 400 to 800 IU of vitamin D don’t appear to provide enough protection for bone health, studies suggest. Some experts have had success stopping bone loss by increasing vitamin D intake to 1,600 to 2,000 IU daily. Additional calcium supplementation of 1,600 mg daily is also suggested.
  • Multivitamins. You should take a daily multivitamin that contains 200% of the daily values. Wait two hours to take a calcium supplement after your multivitamin.
  • Vitamin B12 supplements. Doctors recommend vitamin B12 supplementation for all weight-loss surgery patients to help prevent bone fractures. You may need to give yourself B12 injections for the rest of your life.
  • Oral vitamin D supplementation if a deficiency is detected. Your doctor may prescribe 50,000 IU of vitamin D2 taken orally once a week for 8 weeks, some people require lifelong vitamin D supplementation.
  • Iron supplements. Research suggests that after RGBY surgery, the amount of iron contained in a standard multivitamin may not be enough to prevent anemia. Teens and menstruating women may require the amount of iron found in two multivitamins, along with 50 to 100 mg of elemental iron a day.

Because nutritional deficiencies are so common after this surgery, RDs recommend that your blood be tested every 6 months for the rest of your life to ensure that you are getting the right amount of vitamins and minerals.

roux

roux en y

What is the Braden Scale?

The Braden Scale for Predicting Pressure Sore Risk was developed during a Robert Wood Johnson Teaching Nursing Home project and while writing an NIH proposal to study pressure ulcer risk factors. The scale is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom and the purpose of the scale is to health help professionals assess a patient’s risk of developing a pressure ulcer.

The Braden Scale is a scale made up of six subscales, which measure elements of risk which contribute to both higher intensity and duration of pressure, or lower tissue tolerance for pressure. These subscales are: sensory perception, moisture, activity, mobility, friction, and shear. Each item is scored between 1 and 4, with each score accompanied by a descriptor. The lower the score, the greater the risk for a pressure ulcer a patient is at-risk for.

braden scale1

Braden

pressure ulcer

pressure ulcer1

The Burlodge Multigen III

Who is Burlodge?

Burlodge is a kitchen equipment company originating from Italy but has companies and factories in the United Kingdom, Italy, France, United States of America, and Canada. The headquarters in the US in based out of Winston-Salem, North Carolina.

What is the Multigen III 105 Series?

This piece of kitchen equipment is a revolutionary dual-oven technology that is used is a variety of patient foodservice systems around the world. The Multigen series allows foodservice professionals to re-thermalize products of different densities and textures to a consistent heat, insuring optimum food quality every time. Another beneficial characteristic of the Multigen series is the adaptability of the oven compartment which can be configured to various sizes to accommodate different meal arrangements. Basically, this piece of equipment is a multi-portion point of service trolley that is intended for cook-serve, cook-chill, and cook-freeze foodservice applications.

I was trained how to use this equipment yesterday at my patient foodservice rotation. The representative who trained the kitchen staff was a Registered Dietitian from Nashville, TN who worked for Burlodge.

The Burlodge equipment is broken down by different categories of major kitchen equipment:

          Tray Systems

          Bulk Systems

          Tray Assembly Systems

          Trayware

          Support Equipment

The Multigen III 105 Series falls in the Bulk Systems category and is a two compartment cart consisting of oven and refrigeration settings. The equipment is used in locations that cook, hold, and deliver food to other parts of the facility that are physically farther away than ideal. For example if a hospital setting had a nursing home attached, foodservice workers would be able to cart their Burlodge Multigen III over to the connecting facility, while the meals for service were cooking. Then, serve these meals without compromising the food safety of the meal.

Features of the equipment include:

          The Multigen III uses convection heat (Competitors use conduction heat)

          Reaches temperature in less time

          Heating time reduced and food re-thermed at a lower temperature

          Distributes heat evenly

          Saves energy

          The cart can be programmed to wake itself up and begin cooking

The daily cleaning procedures include:

1.      Removing racks and shelves from cart

2.      Using a hot soapy solution, wipe compartments, exterior stainless steel panels, shelves, and hot top; then rinse with a separate cloth and plain water. Allow to dry.

3.      Allow heavily soiled surfaces to soak for about 15 minutes.

4.      The hot top should also be sanitized as this surface may come in direct contact with food.

5.      Clean the sneeze screen with a soft cloth and a suitable hard surface/glass cleaner. Do not use abrasive pads or cleaners as these will damage the screen surface.

6.      Clean the control panel with a damp cloth only.

Burlodge USA

Multigen 3multigen 3_