A day in the life of a dietician

Recently for one of my dysphagia competencies i spent the day shadowing a dietician on the stroke and elderly care units. Here's what i found out.......

A Day in the life of a Dietician

Examples of joint working

1. Weaning a patient from PEG feeding to Oral feeding. ·   If the patient is able to manage at least 3 days of good oral intake(>50% of required daily intake) the dieticians may agree to reduce their PEG feed in order to stimulate appetite. ·   A PEG may be used simply for fluids/hydration needs. 1.    Supplements ·   E.g. for a patient who will not tolerate an NG-feed and is not eating enough of a puree diet (with fluids often the doctor will prescribe sub-cut fluids). ·   E.g. supplements which are the right consistency for a patient to swallow. ·   On the stroke unit all patients on a puree diet are referred to the dieticians.

Interpreting Dieticians Clinical Notes

A.     Assessment – e.g. weight etc.

B.     Bloods (e.g. electrolytes, raised CRP/WBC = inflammatory/ infection marker)

C.     Clinical e.g. prescriptions

D.    Dietary – observation chart

E.     Estimated requirements

F.     Family

G.     Goals

H.    Aims/ plan

Body Mass Index

BMI = weight (kg)/ height (m2) <18.5 = underweight (probable poor protein energy status 20 – 25 = desirable weight 25- 30  = overweight

Estimating Nutritional requirements

1.     Calculate the approximate basal metabolic rate (BMR) 2.     Determine the patients metabolic state e.g. higher if metabolically stressed due to infection/ surgery etc… (increased energy requirements due to disease processes). 3.     Add an activity factor i.e. bed bound immobile/ bed bound mobile (sitting)/ mobile on the ward. 4.     Determine the goals of treatment e.g. maintenance/ weight gain.

Re-feeding syndrome

Definition: - a group of clinical symptoms/signs that can occur when nutrition is reintroduced to a malnourished individual. ·   Over-rapid/ unbalanced provision of oral, enteral or parenteral nutrition can lead to biochemical abnormalities (elecrolyte disturbances).

Electrolytes	Respiratory symptoms	Neuro-muscular symptoms
Low Phosphorus (P)	Acute ventilatory failure	Lethargy Weakness/paralysis Confusion Coma Diaphragm weakness
Low Potassium (K)	Respiratory depression	Paralysis Weakness Muscle breakdown
Low Magnesium (Mg)	Respiratory depression	Ataxia Confusion Muscle tremors Tetany
Fluid/glucose	Respiratory depression/ Pulmonary oedema	Coma

Feedback from the dieticians

1.    Refer patients to the dieticians more regularly if you feel they are at risk of malnutrition/ re-feeding syndrome.

2.    Find out patients’ food/drink preferences.

3.    Tea is a diuretic, so if encouraging fluids due to dehydration encourage other drinks as well.

4.    Information to hand over to dieticians: a) Consistencies the patient can manage b) Prognosis for their swallowing function.

5.    Fill out food and fluid charts and encourage the nursing team to as well. Include if the patient has refused food so that the dieticians know that someone hasn’t forgotten to record the data.

6.    SLT’s can prescribe build up soup e.g. the cal shake (made with milk).

7.    There are thickened supplement dinks in grade 1 and 2 however they are slightly thinner than thickened fluids of the same grade.