Dietetic Internship - Clinical Rotation




Walking out of the hospital from my clinical nutrition rotation on my last day had me feeling ✨For anyone who follows me on insta (@erika_behrmann) you probably already know I've been completing rotation hours that go toward becoming a registered dietitian.





The clinical nutrition rotation is the core of any didactic internship. Everyone must complete clinical practice hours, which seems like a never-ending marathon. Surprisingly I ended up enjoying it and could really see myself working as a clinical nutrition RD. It was great because it was at a hospital that I used to work at! It was hard but it is important to stay positive and just keep at it! 

There were a couple of things I found surprising, one of them was how much weight could fluctuate day to day due to fluid status, or if patients are on dialysis so weight wasn't always a reliable indicator. Another point was that even though a patient could have 100% intake, that could still mean they are getting suboptimal calories, so it is important to look at their nutrient report to see exactly what they are consuming if it is available. 





In this post, I will discuss a typical day in the life, 5 helpful tips on getting through (including with a kid), and if you are interested, some journal posts on happenings week to week throughout the rotation. 




A Typical day in the Life

5:00-5:30am: Wake up with Addie and get outfit and lunch ready

6:45am: Out the door to drive an hour to internship. Listen to NPR, podcasts, or Jean Inman RD exam test prep in the car.

7:45am: Arrive and run sheets for floor(s) covering for the day and prioritize who needs to be seen

8:00am: Look into patients medical record by priority and gather necessary information pertaining to nutrition for assessments or follow-ups/education

9:00am: Attend rounds where members from the healthcare team like Nurses, Speech Therapists, Social Workers, and Doctors discuss patients needs from each discipline

10:00am: Go up to floors to meet with patients to assess, follow up on progress, or educate and document in the EMR (electronic medical record)

12:00-12:30: Rounds on other floors or Lunch

1:00-4:00: Continue to meet with patients and document care.

4:00: Done for the day. Drive home while listening to podcasts or music.

5:00-5:45: Arrive home and hang out with family and have dinner with Addie

6:00: Bath time for Addie

6:30: Reading books

6:45-7:00: Bedtime for Addie

7:30: Dinnertime

8:00: Work on projects like Journal Article or Case Study

9:30-10:00pm: Bed


It was about every 5-8 days that I would be with a new preceptor and they would have a number of floors that they covered. I spent the most time in the ICU and on a cardiology intense floor where patients went after surgery and bariatric surgery patients as well as a number of other more complicated disease processes.


Listening to Jean Inman on my drive in

---------------------------------------------------------------


5 Helpful Tips for the Clinical Rotation

Here are five helpful tips to help fellow interns who are going to go through/going through their clinical rotations. Keep in mind that this was my individual experience and what happened for me but it may vary depending on your own experience and background. 


1. Listen to Your Preceptors, but Develop Your own Personal style:
As an intern, the preceptor is a guide and will show you how to be an RD so that you can become a competent RD when you are on your own for staff relief and in the real world. Your preceptor will be there to show you how to educate patients and how to document an effective, concise medical note in the EMR but they won't be with you 24/7. Some preceptors will let you fly solo more than others and they say that it is because you learn more on your own. Some preceptors will challenge you more than others after a certain point because they know what you are capable of and want to push you to do your best. I had a preceptor who had a "good, better, best" philosophy when it came to medical notes and I'm sure performance in general. A note can be good and have all the information needed, but it can be better by how it flows, including any additional pertinent information from the notes by other members of the health care team, or by filtering out extraneous information that doesn't really add to the note. 

2. Stay organized:
Throughout the rotation, I had a nutrition assessment tracking sheet that helped me to write all the information I needed to write a good assessment, which included patient diagnosis, problem list, previous medical history, admit date, age, BMI, weight, height, pertinent lab values, nutrition intake and calculations for kcal and protein needs, and room for PES (Problem, Etiology, Symptoms) statements and important info to add to the patient summary. Some hospitals may provide this and some may not. For follow-ups and teachings I folded a blank paper into 9 squares which I would often use two sides if needed. I would also keep any/all educational resources that preceptors provided in a folder and make photo copies to have extra on hand to use them for other patients. This made it really easy to grab anything when I needed something for my case study or if a patient needed something or asked for additional information.

3. Participate as much as you can:
When given the opportunity, be an active member of the healthcare team as much as you can. Provide input at rounds about your patients, especially if they are on TPN or tube feedings. I would usually say if I was following the patient or if teaching was done and if they were on any oral supplements. If there are any in-services, ask questions if you have them. Interact with the nutrition ambassadors/assistants/diet techs. Talk with the MD if you have any question regarding a patients care. I had to speak with a doctor about a patients need for a particular tube feeding and though it can be scary at first, think of it as advocating for your patient and doing what is best for them. Engage as much as you can because you never know if it may be a future job for you, and they may remember you.

4. Use your resources:
In addition to the resources the RD's provide you, it is important to have a book with you to brush up on certain disease processes or look more in depth on what patients need. The internship recommended getting this clinical nutrition pocket guide and I referred to it a number of times throughout and actually kept it in my lab coat. I had to pull it out for someone with liver cirrhosis, gestational diabetes, and I read the whole chapter on bariatrics and it was very useful. You can't remember everything and it is great to have something on hand that is evidence-based to pull information from. The hospital often has a research program that is incredibly helpful as well. The hospital I had my rotation at had UpToDate and it is actually where I pulled my journal article from for the journal article project and info for my case study. They also had a nutrition care manual (NCM) that I pulled, for example, high protein, high calorie foods for a patient with an ostomy with decreased appetite or high potassium foods list for someone with hypokalemia.





5. Stay positive:
It is going to be hard and time-consuming, but take your time and don't be afraid to ask questions. That is what the preceptors are there for. Continue to see your friends and family outside of the internship to help keep your sanity even if all you want to do is sleep - you need it! Listen to music and/or podcasts, play with your kids, do the things you enjoy and cook healthy meals even when you are exhausted because it will help your overall well-being. Batch cook on a Sunday if you need to and bring meals in for lunch. Don't view the rotation as something you just need to get through. Every day and every interaction is a building block to a better RD and a better you.


---------------------------------------------------------------------


Weekly Journal Entries

During the rotation I was tasked to write weekly journal entries to keep track of the happenings throughout the time there. I was at the hospital for a total of 11 weeks. Here are each of the entries below. Feel free to read on or just look at more pictures below!

Week 1


Even though I used to work at my clinical site, I was still heavily anticipating my first week of my clinical rotation like I'm sure many of us interns are. I was able to see a lot of familiar faces and meet new ones. I met with the clinical nutrition manager and we went over paperwork and started getting oriented to how an RD starts the day and prioritizes. We went over the computer system and how to document. It was the same system they used back when I worked there so I just had to re-learn how to use it as a Dietetic Intern.
The first day I shadowed my preceptor and peppered in some recommendations to our patients. The second day my preceptor told me that some of the other preceptors may just let me shadow this week but she was comfortable with me talking with a patient for a follow-up. The rest of the week I was able take on more of the talking with other preceptors and even go up on my own. They knew I had a good amount of experience from my other rotations but it was reassuring. I started to pick out pertinent information on patients more quickly in order to do an assessment and calculate energy/ protein needs and I was able to encounter tube feeding and TPN (nutrition through an IV) calculations. I was also able to take a few cracks at some PES statements (Nutrition Diagnosis statements). I'm still working on this but the pertinent issues are becoming more clear with practice.
Even though I came into this rotation not 100% sure what to expect, I'm finding that I like it much more than I thought I would. I'm looking forward to working on different floors as the weeks go by and experiencing different patient populations.

Week 2
In my second week, I was able to work with a few other preceptors and see their different styles in teaching and documenting. I was able to complete a number of new assessments, and I was able to go up to the floor alone for meal rounds to check in on patients and see how patients who were on oral supplements (protein shakes) were liking them, or if they would like to continue with a particular flavor. 
This week was a lot more education, and our floor had an abnormally high number of admits for stents, MI's (myocardial infarction or heart attacks), and other cardiac issues and surgeries. We had 10 patients to see on one floor on the last day of the week and that didn't even include two other floors we needed to do follow ups and assessments on. Luckily the other floors were a little lighter on the load. It was a great experience to be able to talk to so many patients and really delve deeper into the cardiac (heart healthy) diet. 
Next week I'll be on a different floor with some different types of patients. I'm definitely feeling more confident as the weeks go by!

Week 3
This week I was on a new floor with less cardiac teaching but more assessments and follow ups. I'm understanding a bit more how to write a cohesive note and an accurate assessment. I'm able to follow up with patients I've seen before and see if the interventions I put in place are having an impact. I'm able to identify more of what patients needs are and if they need oral supplements and which ones.
I was able to attend rounds by myself a few times this week and be a part of the medical team. It is interesting to see how different floors perform their rounds, whether they tailor it to the MD's that are present so that they can get back to their caseload, or if they go through the list in order patient by patient and ask each member if they have anything to contribute. Usually Dietitians mention if we are following, or if a patient is on supplements or tube feed, or if we have advanced their TPN order. 
Next week, I focus more on med/surg on a new floor!


Getting ready to head up to the floors

Week 4
I can't believe I've completed 1 month for this rotation!  I have experienced so much so far, and feel like I have a good handle, but I also have so much more to experience. My preceptors have commented on how well I'm doing and offering helpful advice on how I can do certain things better or easier, like how my note can include more medical information like when a patient advances from high flow oxygen to nasal cannula making it easier for intake, or changing the way a note is written for a patient who is on palliative care (end of life care). It's important to see the big picture and not just focus so much on just the nutrition side of it all.
I am finishing up my journal article presentation that I will be presenting in the next week or so, and nailing down deadlines for the other projects. I have practiced with a TPN that we had to increase on our floor after a patients phosphorus level rose above 2 (when phosporus is low it can indicate refeeding syndrome which means that they haven't been getting an adequate amount of nutrients for a long time), and found that I was pretty close to what my preceptor would recommend. She said that my order wouldn't be wrong, but that a lot of the dietitians there go lower on the dextrose (carbohydrates/glucose) than 50% of their needs. 
Next week I will be on the same floor at the beginning of the week and then a "crazy" floor as they call it for the second half. One of the RD's said it was like a step down ICU unit. I'm ready!

Week 5
For the 5th week I finished up on med/surg and then started to work on a cardiac floor for the last two days. I had merely an intro to the new floor this week but I could tell that they were always busy. There are a lot of CABG patients (coronary artery bypass grafts), people coming from the ICU, complex wounds, encephalopathy (brain issues), or other deeper medical issues. I was able to participate in rounds on my own and offer my input on a patient that was questioning changing their TPN order. I'm starting to gain more independence. I've worked with several preceptors now and I've seen a variety of different styles in teaching and gathering information. I'm starting to develop my own style based off of my observations and experience. Next week will be all the crazy cardiac floor, lets see how it goes!

Week 6
This week was all on the cardiac floor. I actually really enjoyed this floor and the week for that matter. This floor has a good balance of teaching and assessments and follow-ups. I learned how to do more CABG (Coronary Artery Bypass Grafts) and AVR (aortic valve replacement) teachings as well as bariatrics phases (surgical measures to lose weight like gastric bypass or sleeve gastrectomy). I also had the chance to go over to the cancer center across the street. It is often sad the prognosis of the patient population, but I think it takes a positive and strong personality to work with this population and my preceptor was just that. I have been working on adding more of the medical side into my note and my flow is getting better. Next week will be a short week starting on the ICU due to Martin Luther King day.


The Noris Cotton Cancer Center



Week 7
This week I was on one of the highest acuity floors, the ICU. The people here are really sick, and often have a lot going on. Many are on ventilators and cannot speak with you. We encountered a person who was on ECMO, a life support machine. I'm not sure if they made it, but we went by on one of the days and the curtain was drawn. I've been a part of more rounds, in the ICU and also including the special care nursery. 
The first couple days this week was really adjusting to the new floor, I started to get the hang of it on the third day. There is definitely a lot more going on and it can sometimes be tough to pick out the most pertinent nutrition problems to focus on. What supplement do you choose when someone has a tube feed and they are both diabetic and on hemodialysis? Nepro or Glucerna? Maybe Osmolite depending on the many other comorbidities. 
I finished up a pre-diabetes handout that I had been working on and I also created an oral supplement rounding sheet that we can use for one of my nutrition competencies. I'm finishing up my journal article that I'll be presenting on February 5th. I can't believe this month is already over and that there's only really a month left! It went by so quick and I don't want it to end. The preceptors here have been amazing teachers and have really helped me become more confident and proficient in becoming an entry level dietitian.

Week 8
I was told that if and RD can work with ICU patients being the highest acuity, then they can work with any population. I went from being on the step down cardiovascular floor the week before but these patients were sick. They had multiple disease processes going on, and it was even more important to zero in on what was the most important thing to focus on nutrition-wise. 
There were a lot more tube feeds (nutrition through a tube that goes into the nose or mouth and into the stomach or into a tube that goes into the intestines) to work with on this floor, which was surprising because I figured there would be more TPNs. 
The rounds were very interesting on this floor as we spent more time talking about each patient so rounds would take about an hour on the ICU. We also attended rounds on the Special Care Nursery which is like a step down NICU. It was interesting to discuss what was going on with a totally different patient population and assess growth via growth charts. 
Next week I'll be on the ICU for a few more days before I'm back on one of the other floors. I'm loving it! I have to say ICU is one of my favorite floors so far. The only thing I miss is being able to provide education to patients a little more.

Week 9
Week 9, I can't believe it's week 9 already. Week 9 I worked on the ICU for a few more days and got a really good handle on it. I also was able to go to the Rehab unit where I used to work as an LNA to do an assessment. 
I gave my journal article presentation in which I scored 4.5-5! I tend to get a little nervous presenting, especially when I'm getting evaluated by professional in the field. It was a little different when I was a Teaching Assistant at the University and I presented every day. Now I'm working on my case study, the final project. I have worked on a few other competencies for the rotation. I created a Pre-diabetes handout, because sometimes the info given in a big booklet can be overwhelming to someone with pre-diabetes. I also created an oral supplement meal rounding sheet that has been actually very helpful and plan to use if I work in clinical. I also did some additional writing in their heart healthy diet booklet discussing eggs and their amounts per day/week. 
I have learned so much over these weeks, and I've even heard from preceptors that I worked with a week or so prior saying how much I've advanced. This rotation is definitely helping to mold me into the dietitian I'll become once I finish the internship and work as an RD.


When a preceptor tells you there's a free book on short bowel syndrome, you sign up.

Week 10

This week I was with preceptors for two final days before going on staff relief! I felt like I was ready and the preceptors are there if I had questions. I feel so much more confident. I can see myself working as a dietitian and I don't want to leave! I can't believe there's only one week after this. I have been working diligently on my case study and submitted the draft about a week ahead to my preceptor to make any notes. She made some notes and I added some material. I'm excited to present on the 19th! The last big project of the rotation. Patients have seemed very appreciative of my education and I have been able to make recommendations on my own on staff relief. I was consulted for a tube feed for a patient who was just admitted and had been on tube feeding at his nursing facility and I had to investigate a tube feeding substitute since we didn't have the one they had at his facility. He was on Peptaman 1.5 and the closest elemental tube feed we had was Vital 1.2. Although it was a question as to why he was on an elemental in the first place since he didn't have a history of inflammatory bowel disease or a need for an easily digestible formula. So I spoke with the MD before putting in the order. He did have a history of congestive heart failure so it made sense to give him a calorically dense formula so that he wasn't getting fluid overloaded. The MD said he didn't know of any reason why he should be on an elemental tube feed so the easiest replacement was a standard calorically dense formula of Osmolite 1.5 which provided the same amount of calories and fluid. He tolerated it well! It was kind of a challenge because he didn't even have a height and weight in the computer yet, and no charts or records on the EMR, so I had to do some investigating and go up to the floor and review his paper chart as well as look into the emergency department record for his height and weight to calculate his needs. Very interesting case and a great start to staff relief.


Week 11

The final week of staff relief! I can't believe we're here! This week I found a good groove and I knew exactly how to go after the day. Teachings first (if possible) and follow ups and assessments toward the end of the day and after rounds when we'd find out who was going home. This worked out well as there were some people that were going home that I would've put an assessment in on. This week was also the case study presentation. I have been working on it every night ensuring that I cover everything. This case study is incredibly fascinating. It has to do with Crohn's disease and ostomy blockages over 30 years of resections and now a development of an enterocutaneous fistula which ended up having significantly more output than her ostomy. She was on TPN and encountered some refeeding (when someone has been getting very low intake over a long period of time and then are suddenly given more nutrients too quickly) initially then switched to cyclic TPN (nutrition on a 12-14 hr cycle usually overnight vs a continuous cycle) later on d/t increased lipase (lab value for increased fat in the blood) and LFTs (liver enzymes) and stayed on that for the remainder of her stay. It was perfect actually because I was able to follow her course pretty early on all the way up to discharge. She had issues with pain medication balance, anxiety and depression, anxiety about diet and getting another ostomy blockage, and fear of going home without all the staff to help. The presentation went as well as it could have. I received a 54.5 out of 55 and that was only because the font could've been bigger on a couple slides. I was much more relaxed this presentation. vs the journal presentation. After the presentation I had a few more days of staff relief which were relatively uneventful. I did get a tube feeding consult on the last day where a patient had tonsillar cancer and was getting a PEG tube (Percutaneous Endoscopic Gastrostomy) placed for feedings since they suspected his dysphagia (difficulty swallowing) would worsen with chemo radiation. I put in for Promote which my preceptor approved and with progression to 80 ml/hr and if needed once tolerance was reached to administer overnight at 12 hours so that he can move about and get more PO intake during the day while he can. I have learned so much from the dietitians here. This experience has really been invaluable. I will look forward to my critical care rotation toward the end of my internship in September to get more clinical experience!



Me and another intern. We survived!

As you can see I encountered so many types of patients and scenarios. I learned so much from this rotation and the preceptors. One more step closer to Erika Behrmann, RD, LD.




Thankful that I am able to have this experience and I can't wait to sit for the RD exam in September/October. Next I will be finishing up my Nutrition Communications and Marketing rotation! Stay tuned and read my other posts on the Dietetic Internship:

5 Tips for Scoring a Dietetic Internship
Dietetic Internship Begins - Orientation
Dietetic Internship - Community Rotation at WIC
Dietetic Internship - Community Rotation with a Diabetes Educator



Comments

Popular Posts