5 steps every clinical nutritionist new to dietetics need feel confident. Clinical nutrition was never made this simple.
5 necessary steps for a clinical nutritionist
When I was a new RD, I felt like I was drowning. Every day. Clinical nutrition was a world I knew nothing about, even though I’d finished grad school and was well into my dietetic internship. I didn’t know how to do anything. I could barely explain what a carbohydrate was to a patient with diabetes without sounding like I was giving a dissertation. It was all super embarrassing.
It took me way longer than I’d like to admit to figure out the basics of doing clinical nutrition. Because actually BEING a nutritionist, that was not something I was taught, in my 2 whole years of grad school.
I had to figure it out the slow way through trial and error, which took what felt like forever. But once I was able to make sense of everything, I was able to concentrate on getting better at counseling. I started digging deeper into actual nutrition therapies, and began to really enjoy working with patients.
Instead of having to deal with what I did, you can follow the 5 step system I created for myself. It’s the same exact one I still use every day with my patients.
Here are the exact 5 steps I’ve been using ever since:
- Get to know your patient
- Meet your patient
- Determine their swallowing needs
- Determine their diet order
- Follow up with your patient
Each of these steps will force your attention to a different part of patient care. They’ll also help you with all the information you need to create a therapeutic diet plan that you’ll be able to put into a stellar note or share in rounds.
Let’s take a look at each step and work our way through how to do them well.
Know your patient
This is step one. Basic and almost obvious. But the kind of thing that’s so easy for a new dietitian to forget.
We’re talking about knowing your patient on the level of the health care system. Pull their chart. Review everything you can about the person you’re about to meet. Get a good understanding of who you’re dealing with.
You’re looking for four things:
- Past medical history
- Current diagnosis
- Most recent lab results
- Current diet order
In the beginning, this can take a while. But the more you do it, the faster you’re going to get.
Soon, you’ll get comfortable with the way your facility’s charts are organized. You’ll know which doctors are more, or less, thorough. Finally, you’ll start to know how your facility’s admission process works.
And you’ll find out quickly if there’s even the slightest chance your patient has been fed since they arrived.
Use this list as a reference when you’re checking a new patient’s chart:
- Their most recent labs. If they have any. You’re checking for any glaring abnormalities. An admitting diagnosis is often closely tied to a person’s lab results. This can give you a great starting point for your upcoming diet recommendation.
- Their anthropometrics (height, last available weight, age). A lot of facilities don’t get this information right away (if at all). So, if you can’t find it, make a note that you’ll have to look for it somewhere else, and move on.
- Scan through their diagnoses list. Extra points if you can get a solid timeline on their health progression. Most of the time, this will be in the doctor or nurse’s admission note. If you can find it, you’ll often save yourself some running around later.
- Current diet order. Or anything that indicates how your patient will be fed. Are they NPO or did someone order a diet (either oral or enteral)? Think about if current diet order falls in line with their CURRENT DIAGNOSES.
- Read between the lines. Just a little. If they had a stroke, is there a Speech and Language Pathologist note in the chart? Did they just from the ICU where they intubated? If they’re NPO, was a meal ordered?
Clinical Nutrition Fun Fact:
In my experience, nutritionists are some of the most comprehensive note writers in the health care system. We spend a lot of quality time with our patients and we ask really good questions.
For this reason, I will ALWAYS READ THE LAST RD’s NOTES on a patient. You’ll get invaluable information about your patient that you probably won’t find anywhere else. I promise.
Meet your patient
After you’ve pulled their information, you’ve got to have a face-to-face with them.
Clinical nutrition can be very fast paced. That means, the time you have to actually spend with your patient can feel really rushed. So, it’s easy to want to skip this step.
Don’t.
This is when you’ll get information that won’t show up anywhere else on the chart.
Even a quick pop-in can make a huge difference on how you decide to move forward with a person’s treatment. On average, you’ve got about 5 minutes with your patient. More if you’re lucky. Less if it’s crazy.
It’s up to you to make the best of the time you’ve got.
When you’re with your patient, you’re looking for 4 things:
- How are they being fed? And how are they SUPPOSED to be fed? As a clinical dietitian, this is your chance to determine if what’s in there chart is happening in real life. And, maybe more importantly, do they look like they’re actually eating what they’re getting.
- How do they look? Do a quick visual check (or physical assessment if you’re up for it). You’re looking for any indications of malnutrition like cachexia, temporal or clavicle muscle wasting. Are they looking frail or age appropriate? Is there some obesity that may impact their metabolic health. Check for edema (or verify it’s still there), look for indications of past wounds or cellulitis. Ask the nurse about pressure ulcers that might not have been in the chart. This last one is HUGE.
- Try to clear up any significant weight changes. Ask your patient for any history of edema. Double check for amputations. Missing toes won’t cause changes to weight, and can easily be left off quickly written medical notes. Have a conversation with your patient about their eating habits. Ask about any recent major life changes or stress indicators. Issues like recent deaths, job loss (leading to income changes and insurance changes) and mental health conditions are all fluid parts of people’s lives that can make huge impacts on their over all health.
- Determine what they’re eating at home. Do they follow a special diet at home that reflects their current diagnosis? Even better, has anyone ever explained to them what a healthy diet might even look like? You’ll get less and less surprised by how many people have no idea what healthy means for them.
Talking as a Clinical Nutritionist:
People love to talk. Especially about themselves. And even more when they’re sick and feeling a bit lonely. So take advantage their desire to chat and get a good handle on their intake history.
I’ve found that there are 2 things we can ask about that will get just about anyone to spill their guts: money and food. A person will dump their entire life story on a clinical dietitian who has 5 minutes and a smile. Ask about a patient’s intake, what they normally eat, the foods they’re willing to eat. And then be prepared to hear a dissertation. Be patient. Take it in. Let them talk (if you have the time).
I can guarantee that (almost) no one else they’ve seen in the hospital have really listened to them. Be the one who does. You’ll be rewarded with everything you need to support your patients well.
Remember: Healing doesn’t happen without nutrition. And when we’re in a clinical setting, the medical nutrition therapy we’re providing can be the difference in recovery or re-admission.
Determine speech and swallow needs
We talked a little about this. But this is really, really important. So much that it’s the third key point clinical dietitians should to pay attention.
This part of the conversation should only take a minute.
About 60 seconds worth of chatting with your patient or caregiver and you’ll likely be able to figure out if they need a Speech and Language Pathologist consult.
Usually you’ll use a guided question as a clinical nutritionist.
Something like: “How’s your swallowing?” and “Do you cough when you swallow?”. You’ll get a pretty clear idea what’s going on because most people don’t think to lie about this.
Here’s a reminder of some common indications of swallowing deficiencies.
- Coughing during swallowing
- Pocketing
- Drooling
- Holding food in the mouth for an unusually long amount of time
I ask almost everyone these questions. Mostly because this is the kind of thing people don’t think is important enough to tell us on their own.
But we know better.
These will put a patient at high risk for aspiration:
- Recent history of stroke. Especially if that’s the reason they were admitted.
- Dementia. This can go either way. But it’s not unusual and is not always something family or caregivers think to look for.
- Poor dentition. When dentures don’t fit (or don’t exist), an inability to chew food can significantly change the way it’s swallowed. PRO TIP: this can also cause heart burn, since chewing is our first point of digestion.
- Recent intubation or removal of an NG tube. Think the throat soreness or simply not having used those muscles in a while. Sometimes recovery can be a bit slow.
Don’t Forget: ONLY SLP (speech and language pathologists) are permitted to determine swallowing issues. Not doctors. Only SLP.
RDs are permitted to DOWNGRADE a diet. This means we can assume someone needs softer, easier to swallow food. However, we cannot UPGRADE anything. And that means we cannot assume someone is better or can suddenly receive a regular consistency meal.
Doesn’t matter how much they argue, yell or beg. This is all SLP.
So make your facility’s speech and language pathologist your BFFL and keep them on speed dial. Because you’ll be talking to them a LOT.
Determine their diet order
This is the heart and soul of clinical nutrition. Crafting the appropriate diet order based on medical nutrition therapy is the reason we’re all here.
It’s also the reason clinical dietitians are called dietary by people who don’t realize how specialized MNT can be.
Like everything else here, getting this right in the beginning can be tough. Inevitably, things are left out. But after you do it a few times, you’ll be able to rock it almost without thinking.
Thinking through a diet order takes a few steps. All of them simple. Each of them important.
Here are the basics to start a diet order:
-
When they’re eating a PO diet. Determining their need for a SLP eval takes firm priority. If a SLP is needed, it’s your job to decide what consistency meal your patient will receive. Until that eval comes in. Talk to your patient about what you’re going to do and follow up with SLP to make sure the referral goes in quickly. Make sure to consider any ONS they might need.
- When they’re getting enteral nutrition. First, figure out what medical conditions are nutritionally relevant. This will help you decide what kind of therapeutic diet your patient needs. Next review the formulary available at your facility. Figure out which formula works well for the diet you’ve decided on. Use the calculation found on this handout to make sure you get the final diet order correct, every time.
Once you’ve figured out what your patient how your patient is getting fed, check their current diagnoses to guide your therapeutic diet of choice.
Then write it up and get it in your note.
Follow-up with your patient
Ok! The hard work is over.
You got to know your patient, both medically and personally. Additional consultations they needed were recommended. AND you’ve put their diet order into a solid nutrition note, documenting everything you’ve learned.
Nicely done. Now what?
As a clinical nutritionist working in a hospital (especially a busy or large hospital), there’s a pretty good chance you’ll never a see your patient again. You’ve got new admits coming in ALL the time. This means the opportunities for follow ups can often be slim.
But some people stay. Some people actually stay a while. Others just need more attention and hands on care.
These are the people you’ll follow up with as a clinical nutritionist.
A follow-up review of your patient’s chart, usually goes quickly.
Look for the notes that are particularly relevant to your patient’s medical conditions or reason for being in the hospital. Notes like speech and swallow pathologist, endocrinologist and GI are good ones to read.
If they had surgery, read that follow up note. Then do a quick review of the medical notes and any recently re-drawn labs.
In a nutshell, you’re asking yourself 4 questions:
- Are they eating what’s provided? Or are they tolerating their feeds?
- If they’re receiving enteral nutrition, are their feeds running at goal rate?
- Have any medical conditions changed? And does this change your treatment plan?
- For those scheduled for discharge, what education do they need from you for ongoing care at home?
In a perfect world, you’ll have at least one more opportunity to meet with your patient before they go home.
Use this time (if you get it) to have a quick conversation about the ins and outs of the therapeutic diet that can help them reach their health goals. Help reduce the likelihood of re-hospitalization for the same condition by setting a few goals SMART goals with them.
Lastly, be patient
Ask your patient if they understand your recommendations. Give them a chance to ask questions. If they have a caregiver who’s supporting them at home, make them part of the conversation. Then make sure everyone is on the same page with your patient’s nutritional goals.
Finally, give your patient the handouts that will support everything you’ve just explained, and you’re done!
And That’s It!
Wish your patient well and feel good knowing that they had a kick-ass clinical nutritionist supporting them and their health.
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