Grady Memorial Hospital and CHOA Employee Wellness Rotations

Objective 5 Based on the efficacy and strength of scientific evidence,

collect data, assess nutrition status, determine nutrient requirements,
develop and implement interventions for individuals and groups in a variety
of practice based settings, and document in appropriate records.
It was a wonderful experience to implement the use of scientific
evidence when making decisions concerning medical nutrition therapy (MNT)
for patients during my acute and critical care rotations at Grady Memorial
Hospital. When diagnosing nutrition problems, creating interventions, and
establishing monitoring and evaluating methods, the American Society of
Enteral and Parenteral Nutrition (A.S.P.E.N) guidelines, the Academy of
Nutrition and Dietetics (AND) Nutrition Care Process (NCP), and
recommendations from organizations such as the American Heart
Association (AHA) were used. My preceptors encouraged me and my other
peers to use evidence based guidelines in our plan of care for each patient.
Based on our plan, they would provide us feedback giving us the opportunity
to research and develop a deeper understanding of MNT.
Developing an intervention for an individual in acute or critical care is a
process that must consider the outcomes for the patient. The first step of the
NCP is to assess the patient. In order to do that, we had to review the
medical record and then visit the patient to complete a full nutrition
assessment if appropriate at that time. We would assess the patients
condition by talking with them, a family member, or their nurse to get as
much needed information as possible. Information such as their current
height and weight, recent weight changes, allergies, food preferences, ability
to self-feed, swallowing ability, appropriateness for oral or alternate feeding
and readiness for certain interventions would dictate the plan of care
implemented. After an assessment of a patients nutrition status, we would
then determine nutrient requirements based on relevant predictive equations
and guidelines related to the disease state. For example, a person with a
severe wound would require a high calorie, high protein diet while a person
with a BMI > 40 who is in the obesity class 3 category might need a low
calorie, high protein diet. Each patient varied, many had multiple
comorbidities requiring clinical judgement, and many patients stayed long
enough to require adjustments to their plan of care.
Data collection in critical and acute care was done for each patient as
we began our day. We reviewed charts, analyzed lab results, current
medications, as well as doctors and nurses progress notes to assess the
nutrition status of our patients, as well as the acuity of care they would need.
If there were any gaps in our proposed care plan, the preceptor would ask us

to research the condition of the patient further and proper nutrition

interventions for that disease. This allowed us the opportunity to develop
the best plan of care for each patient. An example of a patient that required
further research was a patient I had in the ICU. The patient had been
severely injured in a beating at the state penitentiary. He was on total
parenteral nutrition (TPN), and we were beginning to prepare him for enteral
nutrition (EN). After calculating his needs and the appropriate choice of
formula, I was told to read more about the change from TPN to EN for a
smooth transition. As I gathered evidence and read relevant nutrition
guidelines, I was able to decide on the proper actions for this patients care.
The reduction of TPN, while beginning trickle feeding of EN is beneficial when
transitioning to complete EN (which usually takes 24-72 hours). This method
is preferred over a switch to enteral and cut off of TPN because when
beginning enteral, you must advance feedings as the gut tolerates it, and if
this is not achieved quickly your patients nutrition needs are not adequately
met.
All of the nutrition notes including assessment, diagnosis, intervention,
monitoring and evaluation are done by RDNs and Coordinated Program (CP)
students at Grady and documented in EPIC, the electronic medical record
(EMR) for Grady. As CP students, we would complete both initial and follow
up notes in the EMR that followed the NCP. Our preceptors were required to
approve all student notes. Continuity in the care of patients is achieved with
the accuracy of the note. As the patient is seen by different dietitians or
students, the RDN or student must use the past note to refer to and justify
changes made to the nutrition plan of care. Without proper documentation,
patient outcomes may suffer.
My experience at Grady was unparalleled to anything I had learned from any
textbook or case study. Having the opportunity to work one-on-one with
patients was extremely effective in the development of my growth as a
member of the healthcare team.
Grady gave me the opportunity to work with numerous individuals but
did not provide any opportunity to work with groups. I was able to learn
effective methods of group intervention through my rotation at CHOA
Employee Wellness. CHOA offers their employees group sessions that focus
on the theme, Ditch the Diet. Employees are encouraged to come to the
classes in an effort to learn about ways to set attainable goals for improved
nutrition, without dieting. Evidence supports the hypothesis that many
people who try to follow strict diets, specifically ones that eliminate food
groups or severely restrict calories, are less likely to have sustainable results.
Attendance is documented but the use of an EMR is not needed for this type
of setting. Additionally, utilizing the full NCP is not warranted with a group

setting. Each employee chooses whether to come to the class or not, and
whether to set goals or apply what they learn to their lives. The most
important thing about the group intervention is that everyone is given the
support of a dietitian for motivation and assistance to achieve their
individual goals.
Throughout my rotation at Grady and CHOA Employee Wellness, I was
able to use scientific evidence to collect data, assess nutrition status,
determine nutrient requirements, as well as develop and implement
interventions for individuals and groups. These interventions were
documented as appropriate for each rotation, which gave me the opportunity
to learn how to document patient care appropriately. I gained an exponential
amount of experience through Grady and CHOA that I am sure to use
throughout my career in dietetics.