Formulas & Farewells

And just like that, 10 weeks have passed. One of our directors in the dietetics program, Liz Combs, said that the days may seem slow, but the weeks will fly by; I found this is to be very true so far in the internship. It somehow feels like the first day of my clinical rotation was months and months ago, but also only yesterday. Since this program is unlike anything I have ever experienced before, I have had to manage my time and energy differently. These past 10 weeks have taught me quite a lot.

These past couple weeks, I worked several hours on our written case study assignment and the case study presentations. I felt the need to give it as much time and effort as I could. My case study's focus was on a patient with severe COVID-19 who ended up needing enteral nutrition. Coincidentally, we have had the most tube feed order consults in these past two weeks at T.J. Samson Hospital than I have seen throughout the entire rotation. I calculated and wrote orders for several kinds of tube feed formulas with different routes of enteral access.

According to the American College of Gastroenterology, "Enteral nutrition generally refers to any method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements." Using the GI system through enteral nutrition is the preferred method of feeding, versus parenteral nutrition, which is the intravenous route of feeding. Nasal or oral tubes may be placed in the patient at the bedside for feedings. Gastrostomy and jejunostomy tubes are percutaneously inserted (through the skin) by a small incision on the abdominal wall. The patient I used for my case study assignment had a PEG (Percutaneous Endoscopic Gastrostomy) tube put in during their hospital stay, so I got the chance to study the placement and formula development for that specific tube. A PEG tube is necessary for more long-term use.

I have found that at this hospital, nasogastric and orogastric tubes are the most commonly placed for patients. These two enteral access devices are meant for short-term use and can be generally easier to place, which may be why they are used more often.

The blue card to the left shows all the supplements, along with the tube feed formulas, used here at T.J. Samson. In my current experience, I have found that we use Jevity 1.2, Glucerna 1.2, and Pulmocare 1.5 the most often with patients who need tube feeds, but it is of course case by case and specific to the needs of the patient. This may be a widely used and applicable competency, but I greatly feel that writing the tube feed formula orders fulfills this competency, "CRDN 1.6 Incorporate critical-thinking skills in overall practice." Calculating the nutrition needs for a patient in critical condition in need of enteral nutrition takes critical-thinking.

I took these photos of two therapeutic nutrition supplements that Food Service Staff stores in the kitchen. On my first week here, I remember finding it interesting that the tube feeding formulas were found in the kitchen's dry storage closet instead of in the pharmacy. I must have had a preconceived idea! I have found it fulfilling to take all that I learned from my undergraduate MNT courses about enteral nutrition and finally apply it to real patients. I vividly remember finding it challenging to write tube feed formulas for homework and on exams, but now that I have real patient-centered knowledge on the topic, I find it much easier and even exciting to do.

My preceptor, Carrie, is the full-time dietitian at the hospital, but the part-time dietitian, Cathy, works only 2-3 times per week. When she is not on-site, I get to use her office to chart on patients and assess the consults. I really enjoy the independence that Carrie has given me throughout this rotation; she taught me everything I needed to know in order to do the job correctly, then proceeded to let me figure out my own working groove. I'll miss my daily coffee and fruit in the mornings that I get from the TJ Cafe. It's been great having Pailina here as well while she has been completing her FSSM rotation.

As I approach my next rotation in just a few days, I am feeling excited to begin a fresh start at a new location. Although I'm feeling sad to leave Carrie (she has been so wonderful), I'm thrilled to meet new people to learn from and new peers to get to know. Looking back over these past 10 weeks, I have advanced plans of managing my time better, while trying not to feel guilty for taking time to do some self-care and reflect on myself. I can only imagine the next 10 weeks will fly by as well.

Cheers to the next adventure - Madisonville, KY, here I come!

References:

Kirby, D., MD, & Parisan, K., MD. (2011, September). Enteral and Parenteral Nutrition. Retrieved March 24, 2021, from https://gi.org/topics/enteral-and-parenteral-nutrition/