How to solve the clinical nutrition problems all new RDs stumble into. 7 common issues and 7 simple solutions.
7 common problems in clinical nutrition
Starting out in clinical nutrition is hard. As a new dietitian or a dietetic intern, solving problems that come up in acute care can feel overwhelming. This post will take you through the 7 problems that you’ll likely encounter in clinical nutrition, and how to solve them.
We’ll walk through each one and give you solutions so that you’ll have a clear place to start the next time you find yourself face with one of these challenges.
- Determining a patient’s most acute issue
- Talking to doctors with confidence
- Writing comprehensive diet orders
- Writing PES statements that make sense
- Gathering all necessary information from patients / Talking to patients
- Evaluating lab work
- When to liberalize a diet
So let’s start solving these common clinical problems you’ll likely see again and again.
PROBLEM #1: Determining the most acute issue
One of the hardest parts when starting clinical nutrition is figuring out what to focus on. It’s one of those clinical problems everyone in nutrition struggles with in the beginning.
You’ve got a patient with a massive diagnoses list. Where do you start? What deserves your attention right now? How about in 3 days? Or before they’re discharged from your facility?
The simplest way to think about this is to find the one thing that has the potential to change everything else.
These are some of the questions to ask yourself as you’re thinking this through:
- Where are the doctors focusing their energy?
- What will be solved through medical intervention?
- Identify your patient’s admitting diagnosis.
- What is directly impacting your patient’s ability to meet their nutritional needs?
The Solution:
Here’s a 2 step trick to figuring out the most acute issue your patient is going through.
First, find the reason your patient was admitted to your facility. Whatever brought them in to be seen by the doctor is likely the most acute condition they’re currently dealing with. Let’s use the example of a broken hip.
Next, think about if that admitting diagnosis has nutritional implications. Sometimes a broken hip is just a broken hip. Other times, there are underlying issues.
This might look like an older adult with osteoporosis who ended up with a broken hip that was caused by a fall, after experiencing dizziness brought on by dehydration.
Now, you’ve got the most acute issue (a broken hip) AND the nutrition-related issues (osteoporosis and dehydration) with which to focus your care.
PROBLEM #2: Talking to doctors with confidence
An extremely underrated skill in clinical work is your ability to communicate with doctors. With the confidence to clearly state your recommendations to your patient’s care team, comes an ability to see your patients get faster and more accurate care.
Every dietitian knows the level of training that goes into passing the RD exam.
There should be no doubt that we are the health care professionals with the training to provide accurate medical nutrition therapy recommendations.
Most doctors don’t have this training. Residents who are just starting their medical careers in internal medicine rotations definitely don’t have this training. Dietitians are the ones most equipped to manage the patient problems in clinical nutrition settings.
The Solution:
Learn to justify your decisions. Get comfortable articulating your thought process in a clear and precise way.
Don’t just say your patient needs a cardiac diet.
Say: “because patient X just had a heart attack and is obese with elevated LDL cholesterol and sodium levels, we need to get her on a cardiac diet immediately”.
Be able to state exactly what you’re doing and why you’re doing it. Once you’ve got that down, you’ll have what you need to approach doctors and show them why you’re right.
PROBLEM #3: Create comprehensive diet orders
Before starting in clinical nutrition, our nutrition training is usually pretty simplistic. We learn how to evaluate diet needs on a very basic level.
- Patients with diabetes should get a carbohydrate controlled diet
- A heart condition means receiving a low sodium, low fat / cardiac diet
- Someone diagnosed with chronic kidney disease will get a renal diet order
Once we enter the world of clinical nutrition, it suddenly becomes very clear that we rarely see patients with only one nutrition-relevant diagnosis. Most of the time, we see a patient who was just admitted for a heart attack with additional diagnosis of both diabetes and CKD.
What do you then?
The Solution:
Everything that is nutritionally-relevant to your patient should be included in their diet order. And I mean everything.
Your patient with CKD who was admitted for a heart attack doesn’t just need a cardiac diet. They need a cardiac, CCD, renal diet.
Or more simply: CCD, renal, low fat diet.
Why? Because a renal diet already has the low sodium built in. No need to restate the low sodium from a cardiac diet along with what’s already happening in a renal diet.
PROBLEM #4: Write clear PES statements
Even if you aren’t obligated to write PES statements, being able to write them can go a long way to helping you get very clear on your patient’s needs. Once you know your patient’s most acute issue and you’ve figure out a way to justify that argument, writing your PES statements will become a whole lot easier.
The structure of a PES statement is pretty straight forward:
- What problem are you focusing on (think: the most acute issue)
- What’s the proof that there is, in fact, a problem (think: a diagnosis, reason for admission)
- What are the signs or symptoms of that problem (think: lab work, patient statements or complaints, a need for medical intervention)
It’s the putting it together part that can keep us staring at the computer screen for much longer than we should.
The Solution:
Start by using the IDNT Reference Manual with pre-written suggestions to kick off your PES statements. There’s starters for most medical conditions, and ways to justify each problem. Mix and match items under problem and etiology until you’ve crafted a perfect PES statement.
For something more simple, check out this PES statement cheat sheet here.
After you’ve written a great PES statement for something you see regularly, save it and reuse it.
Take a PES statement that says: “dysphagia as related to recent stroke leading to impaired swallowing ability evidenced by SLP recommendation for purees and nectar thick liquids”. This can be recycled and reused as many times as you see patients with dysphagia.
Don’t reinvent the wheel. When you find one that works, keep it and use it again and again.
PROBLEM #5: Talking to patients
Of all the items on this list, this is the one that will impact your ability to provide comprehensive nutrition support for your patients. It’s also the one that you’ll get better and better at the more you do it.
Dietitians are in a unique position to collect a lot of information on our patients. The simple act of asking your patient about the food they eat can often be the key to opening flood gates of information about their lifestyle and eating habits.
And these 2 things are usually a major part of why your patients have landed in your care in the first place.
Focusing the conversation on a few key questions can help you get some clear answers that can significantly change the way you provide MNT.
The Solution:
Have a go-to set of questions you initiate a conversation with that will get your patients talking.
Great starter questions are:
- Do you do your own cooking or grocery shopping?
- What else do you eat? Do you eat anything after that?
- Is your weight different today than it was 6 months or a year ago?
Patients who are eating out all the time might explain they can’t stand up long enough to cook on their own and could use the support of a home health aide.
If your patient is only giving you a list of the healthy food they eat during their main meals, asking about what they snack on or drink during the day might shed light on their lab results.
Getting your patient to think about their health or weight status a year ago is a great way to understand their reported “sudden” drop or gain of weight.
Ready for more on motivational interviewing in a clinical nutrition setting? Nutrition Quick Chats gives you all the resources, handouts, case studies and videos you need to counsel your patients confidently. Sign up HERE.
PROBLEM #6: Evaluating lab work
Here’s a little-known secret about reviewing lab work: you don’t have to memorize what all the labs mean.
What you do need to be able to do is understand what labs are important. Then be able to figure out what those labs mean for your patient’s nutritional status.
The Solution:
Keep a cheat sheet of the most common lab values used to evaluate the status of chronic medical conditions. Use one that gives you examples of what’s indicated when a lab is above normal and when it’s below normal.
Pin this list up close to the computer you use to write your nutrition notes. Or keep it tucked in your lab coat pocket for quick reference when you’re writing notes on the go.
PROBLEM #7: When to liberalize a diet order
The primary objective we have, as dietitians, is to support our patients in meeting 100% of their estimated nutritional needs. This clinical nutrition problems is one of the most common.
There will be times when the obvious diet order – the one that most closely matches your patient’s diagnoses – does not complement their current state of health.
In these cases, your goal is still the same: find a way to help them meet their estimated nutritional needs.
The Solution:
More often than not, the answer here is to liberalize your patient’s diet order. Give them intake guidelines that are less strict, have more room for pleasure feeds, or accommodates preferences.
Liberalizing a diet order might look like this:
- A malnourished heart patient. Liberalize a cardiac diet by skipping the low fat and only including the low salt part of their diet plan.
- A patient with well controlled diabetes who lost 11% of their body weight in the last 2 week after their wife died. If they only thing they will eat in a day is a small cup of ice cream and a glass of apple juice, it might not be worth their further weight loss to haggle over that ice cream or the juice until their appetite returns.
- A 97 year old elderly patient with HTN who was recently diagnosed with cancer. Eliminating their low Na diet in favor of a regular diet so they can enjoy their favorite salted mixed nuts, might be exactly what they need to enjoy their food during the remainder of their life.
At the end of the day, this will always be your decision.
You’re responsible for their diet order, so you’re also responsible for gauging their ability to meet their estimated nutritional needs with the food you provide them.
As long as you’re able to clearly state why you’re deciding to do what you’re doing, you can be as strict or as liberal with your patient’s diets as you’d like to be.
And That’s It!
These 7 issues are definitely not the only challenges new dietitians or dietetic interns will face when starting out in acute care.
But they are some of the most common clinical nutrition problems you’ll see. Start with these and you’ll have a leg up every time you step out onto the unit and begin working with your patients.
Want even more to help in clinical?
Check out The Nutrition Cheat Sheets Shop for all the nutrition education and clinical resources that will make your life easier.
