Doing clinical nutrition in a hospital means learning to identify the most acute issue. Learn to do that here.
Nutrition in a hospital is complex
Picture this: You’re suddenly dropped into the ICU for a high-risk consult.
You learn that your patient, admitted for a heart condition, has just morphed into a renal condition. You stop by the ICU and the doctor tells you your patient is about to be intubated. Your first thought when you see them is they look way too thin.
After reading their chart, you learn your patient is also diabetic. When you compare the labs taken at their last admission, you notice their A1C is starting to creep up. You do the math on their body weight and find out they lost a significant amount of weight since their previous hospitalized.
This is a lot to absorb.
A severe heart condition and kidney failure in a patient at high risk for malnutrition. Should you worry about the upcoming intubation? How do you fit in managing their blood sugar?
All of that sounds important. So what do you do? Where do you even start?
Start thinking like a clinical dietitian for nutrition in a hospital
Our patient hospitalized with a heart condition is not an exception.
Most “high-risk” patients who need nutrition support while in the hospital are not admitted for just one thing. With 4 out of 10 adults having two or more chronic diseases, we deal with complex patient cases in clinical nutrition all the time.
It’s your job to figure out which of those chronic diseases is most nutritionally relevant and must be dealt with immediately. This can be one of the hardest things to figure out when we’re just getting comfortable in the clinical setting.
School was different.
When we’re in school, we usually learn about clinical nutrition in terms of single conditions.
Kind of like this:
- A person has diabetes. Therefore, we help them manage their blood sugar.
- A patient had a stroke. So, we help them manage their salt intake.
Simple.
But when we start to actually work with real people, it’s different. VERY different. Clinical nutrition in a hospital is a whole other world.
It becomes obvious REALLY fast that no one is the cookie cutter patient we were tested on in school. That means you’ve got to start thinking differently.
You’ve got to start thinking like a clinical dietitian.
How to determine the most acute issue for nutrition in a hospital
Ask yourself these 3 questions to get you thinking about where to begin.
3 questions to narrow down the most acute issue:
First: What is your patient admitted for?
This is likely their most acute MEDICAL issue. And it will be the starting place when deciding on your patient’s most acute issue. Decide if the admitting diagnosis has an accompanying therapeutic diet. If it does, write that down.
Next: Which diagnoses are nutritionally relevant?
Start by looking at their complete past medical history and compare that to their admitting diagnosis. Make a list of all the conditions that require a therapeutic diet and nutrition education for complete management.
Lastly: What nutritional issue can you impact RIGHT NOW?
Ask yourself which of those conditions YOU, as a dietitian, have immediate control over. Another way of thinking about this is by asking yourself what can be directly impacted with a specific diet order.
Here are some examples
Clinical nutrition in hospitals is never one dimensional. Use these examples to start thinking about how one patient can escalate – and change the focus of your care plan, in the process.
Example 1: The Admitting Diagnosis
Let’s say your patient has an admitting diagnosis of a broken ankle and a past medical history of stroke. One of these issues require medical nutrition therapy and a therapeutic diet order. There is no therapeutic diet for the other.
In this case, the broken ankle is a medical issue.
Therefore, the stroke is the most acute nutritional issue. Regardless of if your patient is having symptoms or not. You’ll provide the diet order and nutrition education that will help preventing future stroke-related issues.
Example 2: The Nutritionally Relevant Diagnoses
It turns out your patient with a broken ankle and a PMH of a stroke, also has diabetes and no dentures.
This changes everything. Now there are 3 potential diagnoses that are nutritionally relevant.
Because they’re edentulous, is there a consistency change for the diet you need to consider? Is their blood sugar well controlled at home? What about blood pressure?
Think about which diagnosis will most impact your patient’s diet order. These will take you a step closer to the most acute nutritional issue.
Example 3: The Most Acute Nutritional Issue
Your patient with the broken ankle ends up in the ICU with a renal complication from the anesthesia during surgery. Your edentulous patient now has a history of a stroke, diabetes, AND acute kidney disease. What do you do?
First, determine their most acute medical condition.
What’s directly managed by the medical team, is strictly speaking, a medical condition. Maybe that’s whatever’s happening in the ICU to manage the kidney issues while your patient is NPO.
The most acute nutritional issue is what you manage. The dietitian.
Any PO changes to a diet order or enteral need is the domain of the dietitian. That might be ordering the feed for a new NG tube while they’re in the ICU.
It’s your job to make sure your patient’s blood sugar control and sodium intake is addressed.
And That’s It!
Always consider this: What’s the one thing that will make everything worse if you don’t handle it first? This will always give you a place to start.
Think liberalizing a diet order to manage malnutrition before you worry about a strict renal diet. Sometimes that means watching an NPO diet order while doctors manage DKA with insulin.
No matter where you begin, if you can justify your decision, you’re on the right track.
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