Pinning Ceremony

Georgia Southern University Inaugural Dietetic Internship Class

We had our pinning ceremony which was a chance for the interns to get together one last time (all but a few attended). We got our RDN (registered dietitian nutritionist….however, I won’t add the N part once I finally get it) pins, however, we had to sign a document saying that we would not wear them until we passed our RD exam. This was the longest year of my life, and I’m glad it’s coming to an end! Now there’s lots of studying to do before passing the RD exam!

Pinning Ceremony

Pinning Ceremony – Most of the Dietetic Interns

Pinning Ceremony- Most of the Dietetic Interns with our Professors and Director

With my awesome supportive husband!

With my awesome supportive parents!

School Nutrition Association Conference

I loved the School Nutrition Association Conference in Salt Lake City, Utah! There two parts: the classes and the food expo. Food expos are awesome, but really overwhelming. You feel this need to sample everything and before you know it you’ve eaten an entire days worth of calories in just a couple hours. But, it’s great to sample different foods. This conference was much less overwhelming than FNCE, but it was still so much stuff. Vendors at this conference specifically dealt with school nutrition foodservice (but many of them are also involved in general foodservice, unlike FNCE which is products for the general population, however there are several of the same vendors. At the expo I sampled so.much.food. The food here meets the government guidelines mandated for school nutrition (like being whole grain rich).

I also went to several classes, I will talk more about those later! In the meantime here’s lots of photos from my time in Salt Lake City!

At the entrance of the food expo and what part of the food expo looks like from above

Barilla had lots of wonderful pasta samplings that could be done in schools

After day one of free snacks!

With the Mini Wheat and the Uncrustable!

An awesome yogurt bar

One of the booths was about making lunchrooms more fun. I would have loved to eat lunch in a place like this as a kid!

With some of the interns in a session and at the food expo!

GSU Dis with one of the awesome presenters! She calls herself MGM (her initials) Superstar!

We had one more open afternoon so we went on a little hike!

Loved this view! I will miss Salt Lake City.

Culinary Institute at GSU

My week at the Culinary Institute was great! I had no idea what it was until shortly before hand. Basically, some of the school nutrition managers get chosen by their directors to attend. There is a Culinary Institute 1 and 2, and this week was 2. It counts towards their continuing education. It started with going shopping at the Statesboro Farmers Market the Saturday before. The foods were going to be used throughout the week to prepare recipes, most of which were examples of foods that mangers could serve the school children and had a low sodium content. We started off on Monday grouping into two groups based on what level (elementary, middle, and high) that the managers were part of. I ended up being in the “fruit group” with the elementary and middle school mangers. The biggest focus that morning was the breakfast meal pattern. There were 4 interns working this week and so we each took a part of the presentation to do it. The biggest thing with breakfast is that 1/2 cup of fruit must always be offered and fruit juice can’t account for over 50% of all offered fruit servings. In addition, there must be 2 grains or 1 grain and 1 meat/meat alternative offered. After going through the breakfast, my group then got to work in the kitchen. We worked with the chef and we were each assigned a food to make for the dinner later in the day. After each meal, the recipes were discussed and evaluated to determine if they would be suitable in the schools, and if not, what could be done to make them more appealing to the kids. On Tuesday, we discussed standardized recipes. Then, my group went into the kitchen to prepare lunch. After lunch, the recipes were evaluated and discussed again. Then, it was the interns job to present on Offer vs Serve and then do an activity with the group. Betsy was the other intern in my fruit group so we presented on Offer vs Serve, which is where you allow students choices instead of just serving them all the same items. It helps allow kids to pick what they want and reduce waste. After that we talked with the managers about different or unusual fruits they have offered in their cafeteria and how the kids reacted to them. We showed them a Kids Eat Right site where they have fun ideas for different ways to serve fruits and vegetables. Later that day there was a presentation on marketing. On Wednesday my group came in early to prepare breakfast. Breakfast options were then discussed and evaluated. After that we had a presentation on wellness. Following lunch we had a demo on how to train someone that was coming in to work for you in a school nutrition kitchen. One of my favorite things that we did was a presentation on herbs and spices. Several of each were set out. We took time trying to identify each one. Then, each one was discussed and we talked about the importance of using herbs to flavor food, especially when the government has placed restrictions on sodium in school lunches. On Thursday we started the day with breakfast again and an evaluation of the entrees. There were then presentations on children with special needs, and diabetes as well as food allergies. There was a big discussion among everyone about how they handled those diabetes and allergies in their schools. Friday was pretty much a day of wrapping things up. Then interns help set out posters that each of the managers could take home. We then helped straighten up the room and the kitchen. I really enjoyed my week! One of the biggest things I learned was that there is a lot more to being a school nutrition manager than people realize. They think they are just ladies that work in a lunchroom but it is so much more complex than that and they deserve so much respect!

My group for the week

Fourth week at Memorial on the GI and Surgical Floor

This week I worked with Trish who was on the GI and surgical floor. I was really excited about this week because  I am eager to learn more about GI issues. This week there weren’t too many people that had a huge GI disorder like Crohns or something. However, my case study is on a guy that has Crohns. He was in the middle of a flare up but wasn’t having huge issues, so we signed off on him, but for my case study I will be presenting a lot on different nutritional management strategies of Crohns. I got to do a diet education on FODMAP diet, which is something I was familiar with from my own GI doctor. Basically, FODMAP is an acronym for some different types sugars that are harder for the body to break down. While more research needs to be done, there has been some promising research for using a FODMAP diet with irritable bowel syndrome (IBS) and sometimes doctors ask patients to try it out when they are having other GI issues. I also did another Coumadin diet education, which is basically staying away from foods high in vitamin K (green leafy vegetables).

There was also a patient post-op with a below the knee amputation (BKA), which basically resulted from an infection due to his uncontrolled diabetes. He was still making excuses and having his daughter bring him in extra food in addition to eating everything there and all I could think was….didn’t an amputation teach you anything?! Some people get diagnosed and they really want to make changes, and some would still rather make excuses. The wide range of people is amazing. Calculating the needs to amputees is also a little bit different, because you have to account for their missing limb, which for his specific case was subtracting 6%. I also got to see patients with GI issues that were also in end stage renal disease (ESRD), so I was learning how to recommend different supplements when they have multiple comorbidities. One lady had ESRD but was also diabetic and wasn’t eating, and there are nutritional shakes for diabetics and ones for renal, but not one for both, so that’s when I learned to look at the renal labs to see if the phosphorous and potassium were ok, and if they are then it’s ok for them to have the diabetic shake instead of the renal one (but if their phosphorous isn’t ok they could maybe have vanilla but not chocolate because chocolate has more phos.), so it’s a really interesting balancing act.

One thing Katie and I are doing while we are here is getting some baseline data for a study they are doing. We sat in a meeting with reps for them to go over the product and baseline data. Basically, it is for tube feeds, and what it is is a bag that automatically delivers water flushes. When patients are on tube feeds, flushes are important for two things… helping keep the line clean and make sure it doesn’t get clogged, and to help maintain the hydration status of the patient. Many times these flushes don’t get administered the way they should according to the order, so patients aren’t always getting the fluids they need. With this bag, nurses just type in what the flush should be and how often so it does it automatically, just like the tube feeds. So, the job of me and Katie is to get some baseline data and find patients who have tube feed orders, and see if they are getting the proper amount of flushes. The reason for getting this data is because initially, the bags are more expensive, however, since hydration plays a crucial role in patient care, it could end up saving the hospital money by possibly helping to reduce the length of stay. So the reps taught us what to do and how to look for the information in the chart!

First Clinical Week at Memorial: Pediatrics

Well, minus the commuting I had a great first week in clinical! I had my pediatric rotation this week and got to see kids of all ages, ranging from infant to teenager.

I got to see lots of different types of cases including: a kid with Pierre Robin Syndrome (smaller than lower jaw, facial deformities) as well as agenesis of the corpus collusum (where all or part of the corpus collsum fails to develop normally during pregnancy), Neurogenic bladder, and several others! Peds is so different from the “adult world” as they call it. However, I really enjoyed it, which surprised me since I’m not a kid person.

I think the most interesting case to me was a 21-month-old baby that was diagnosed with type 1 diabetes. I knew anyone could end up with T1DM, but I couldn’t believe that someone so young could end up with it. The baby came in because the mother noticed her acting unusual and when she was admitted her blood sugars were in the 400s. With this patient, lots of diabetes education had to be done with the mother. We went over what to do incase of a hyper/hypo glycemic episode, and the biggest thing we went over was carb counting and portion sizes. We tried really hard to make sure she understood that the baby could still have lots of things, but if it had a carbohydrate that it would have to be counted. Since the mother was still breastfeeding the child, we had to enforce that if she continued to do it, she would need to pump the breast milk out so it could all be measured, otherwise there would be no way to know how many carbohydrates the baby was actually getting. This was a work in progress all week long because we went back to visit her almost every day.

Other interesting cases involved a child who comes back frequently because he was born with his intestines on the outside of his body, so he now has short bowel syndrome. This required him to be on constant tube feeds (which took me forever to get the hang of calculating, and I’m still really slow). It was kind of a reality check this week with seeing multiple kids that rely on these feeds, and they have literally gone months without having a drop of food. It amazes me.

My week at DaVita Dialysis

This is my last rotation before starting my 2 month long clinical rotation at Memorial! I was scheduled to work at DaVita Dialysis in Brunswick, so I got a hotel to avoid the 1 hour 45 minute commute. My week also got cut short this week, so since I was only going through Wednesday I went in super extra early to do work!

Most of Monday was spent working on modules. I knew hardly anything about renal but there is SO MUCH to learn. Geez. We mainly focused on the hemodialysis, which is where a dialyzer acts as a kidney and filters the blood for the patients. There is also something called peritoneal dialysis, which is typically done at home and uses the peritoneal cavity of the lower abdomen. There are pros and cons to each, but hemodialysis is the kind done at DaVita.

Tuesday was a little bit more hands on with the patients. We went around and talked to patients. Their blood is drawn twice per month so labs can be run, then the dietitian (Amy) talks with the patients about things they are doing right and what can be fixed. Here they want to focus more on the good rather than scolding the bad, so if something isn’t right then it’s addressed in a positive way to see what can be done to remedy the solution. The “report cards” of the labs include albumin, hemoglobin, iron saturation, ferritin, corrected calcium, phosphorous, PTH intact, potassium, and spKdt/V dialysis. Today, the most issues were with high phosphorus, PTH, and potassium. Many times phosphorous and potassium are high if the patient’s diet isn’t what it should be. PTH can be altered based on calcium or phosphorous levels. I also learned about the different medications that renal patients take, with the main ones used here as Renvela (is a phosphate binder so it helps lower phosphorous levels) and Sensipar (helps with PTH).

Wednesday I got to do a nutrition assessment on a patient. It was a follow up so it wasn’t super long. I also got to go around while Amy went through and did the “report cards” for the patients. The end of the month is busiest for dietitians here, and when looking at all of the patient labs, most of the values were good, but it was the PTH that was out of range for many patients. Apparently, not a lot of importance is placed on PTH (in comparison to things like phosphorous and potassium levels). She said the overall final score is worth 100 points but PTH is only weighted to get 5 points. There’s apparently no real side effects for having a high PTH, the way there is if you have consistently off calcium or phosphorous levels or something. So not too much attention is given to it. After going around and talking to all the patients I got to watch Amy some as she charted and see how that process works.

One thing I also had to do was come up with patient education materials. Amy wanted a handout made using foods on the traditional southern diet, most of which are not good for patients with CKD to consume due to the high amounts of phosphorous and potassium. Because of this, she wanted a kind of “enlightening” poster to know how many phosphate binders and things they would need if they consumed all these foods on the same days.

 

I wish I could have had longer in the renal setting because there is so much to learn within a week, much less in three days because it got short. But my preceptor was great and I wish I had more time to work with her!

Week at Ethica Health and Rehab

This week I spent the week with Ethica Health and Rehab which is in numerous places around Georgia, but I was in the SE district region including super rural cities. Ethica Health and Rehab is a group of nursing homes around Georgia. The first few days I watched her do assessments on patients and then the last days I got to work on an assessment myself. When watching her doing the charts with the patients we got to go talk with the patients and see how they were feeling when it comes to their diet and eating. It’s interesting how many patients tell little lies and say they eat fine and have a good appetite, then you talk to the nurses and they tell you otherwise. When reading their charts it’s all documented in there. I learned that even though sometimes people should have certain restrictions, there are certain times that the diet should be liberalized so they at least eat something, because them eating nothing does no good. Tracey, the dietitian I worked with, then let me do an assessment of my own in the chart, and then she checked over it. When she does an assessment it includes the trigger, weight, height, BMI, IBW (ideal body weight), %IBW, weight history, pertinent diagnosis, pertinent medications,Braden scale (predicts pressure sore risk), diet, PO intake, estimated needs (calories, protein), nutrition diagnosis (PES statement), goals, and recommendations. I’m not sure I could do a job like this, because working in a nursing home can be kind of sad, but I did learn some interesting things this rotation!

My week at St. Joseph’s Candler Hospital

This week I was at St. Joseph’s Candler Hospital for my rotation in the Diabetes Management Center (DMC). I had a pretty good week here, and I learned a lot about diabetes from the two RDs in the DMC, Aggie and Windsome. On Monday, Meagan and I learned how to take blood sugar. We also did rounds with Windsome, one of the RDs in the DMC (who is also a registered nurse and certified diabetes educator). She taught us how to fill out a card before going up to see the patients and explaining what was relevant to us. We then were assigned to go to the Wellness Center in the afternoon. We learned about a diabetes program and that was really it. There was way too much down time and thankfully we didn’t spend more time down there. However, we did have to go to a class that talked about diabetes in relation to Periodontal Disease. It was taught by dental hygiene students. I didn’t realize how much the mouth could be an indicator of so many diseases, so I thought it was really interesting how high blood sugars could impact the mouth so much.

On Tuesday we spent some time with Aggie learning lots about insulin pumps and how to inject insulin. I had no idea about insulin pumps and only understood the basics of how they worked so it was interesting to learn about them.

We learned how to attach them and how they worked. I can’t imagine having to do that every day, but if you want to manage your diabetes well you have to. There’s so many different pump options it’s crazy!

Learning how to pull insulin into the syringe.

Different needle sizes.

We also got to sit in on a consult of a woman who went into diabetic ketoacidosis (DKA) the week before. She wasn’t really trusting her pump and over the course of this week I have learned that is something that you have to do. DKA is caused by the breakdown of fat for energy (which causes ketones) when the blood sugar gets high and is unable to get into the cells for energy. When that happens your cells think they are starving so they start breaking down fat which leads to ketosis. This is super dangerous and can lead to death. Later, we got to do inpatient rounds with Windsome. We saw two patients, both older males, who were resistant to learning about insulin injections. One guy had had diabetes for years and though he had been giving himself insulin properly. After watching him draw up the insulin he needed in the syringe, we realized that he wasn’t drawing up the right amount, because he had a harder time reading the numbers. Unfortunately, his insurance will not cover the insulin pens (probably more friendly to older patients), so he has to use the insulin syringes. This is apparently a common sad reality among diabetes patients. He thought he was doing fine with the syringes but all this time he may not have been giving himself the proper amount of insulin. The next patient was a man recently diagnosed. He got really frustrated when Windsome told him that he was going to need to have a schedule for administering his insulin. He got defensive and tried to tell her it wasn’t going to happen and his wife was trying to calm him down. Windsome suggested that if administering two different insulins (one rapid acting and one slow release) didn’t work for him then he should try a 70/30 insulin, which is a combo insulin so you only have to stick yourself twice per day instead of four to six times per day. The downfall of that insulin is that it doesn’t give you as much control over amounts, but it is better for people that may not be compliant otherwise.  After the patients we then learned how to document in the computer charting system. We also got to sit in on a diabetes education class. It went over basics and diet. It’s amazing how many of the participants had had diabetes for so many years but never received formal education about diabetes. There are so many misconceptions that people have about diabetes and what is and isn’t good to eat.

On Wednesday I was supposed to have my resting metabolic rate (RMR) measured. This is where you are fasted and are hooked up to a mask and breathe normal. I started mine and then they forgot about me so I never actually got my results, but I now know what it feels like to have one done.

Being hooked up to an RMR mask.

I then got to sit in on an new patient session, which is where patients get a one on one session prior to taking the diabetes classes and their specific concerns are addressed. I was amazed at one woman who has been passed around from doctor to doctor and had a couple ER visits and nobody had done anything to help her. One woman was pregnant and had some diabetes issues going on.  Later in the day we made calls to patients in the program to check on their goals and see if they had been trying to meet  them.

Thursday was a slower day that the others, but we still were able to see patients on the floor. We saw a couple people recently diagnosed with type 2 diabetes. One of the ladies had a big problem with drinking sugar drinks and snacking on hard candies. There was another lady who came into the ER because she ended up with polyurina and polydypsia and when the nurse at her worked checked her sugars they were over 500. Since she was so thirsty she kept drinking more and more tea (not realizing that would keep increasing her sugars). We talked to her about some basic food changes and showed her how to check her blood sugars. She is going to do the diabetes class here where she will learn more information. We also got to see a 22 year old type 1 diabetic (since she was 7!) for uncontrolled sugars. She wasn’t checking her sugars regularly so they got out of control. She also wasn’t eating properly and was skipping meals so we talked about some options for her, which included Boost for diabetics if she wasn’t willing to eat (because she also has gastroparesis).

Overall I got some good exposure to diabetes.

My week at SouthCoast Medical Group

This week was at SouthCoast Medical Group in Savannah. I am so glad to finally be truly learning something! I spent all of Monday observing. It is mostly diabetes counseling, but sometimes there is just an obesity case. On Tuesday I started counseling any new client, while my preceptor still did her followups. I knew that diabetes and obesity were huge in America, but this has really made it even more real in my mind. As I started I was super choppy and all over the place, but it got better as the week went on, though I still have lots of work to do. I’m still trying to learn how to individually tailor a session, but I’m getting better. With diabetes, you typically find out if it’s a new diagnosis, if they are checking their sugars, and if they’ve made any changes. Then, you go through a typical day and find out what they are eating. Then, you’d typically go over what carbohydrates are and go over carb counting with them. It’s always important to find out about physical activity to see what they are doing, because physical activity will help get their blood sugars under control. I’ve also been able to counsel those with obesity. With obesity, you obviously focus more on overall diet (the highest BMI I saw this week was 69 (and a BMI over 25 is overweight)!!. I am really trying to work more on my motivational interviewing. It’s all about guiding with open ended questions. I also got to observe a chronic kidney disease patient. I had one patient with elevated triglycerides (455!! and you want them <150).

I also got to meet another dietitian in Savannah who is a Certified Diabetes Educator (CDE). She also brought me some free education material which was awesome! She also talked to me a little bit about diabetes which was awesome.

These were a coupe of ADIME (Assessment, Diagnosis, Intervention, Monitoring & Evaluation) notes that my preceptor had me do. She took the time to go over each one with my and give me critiques on each one. With an ADIME note it is important to write down their basic anthropometrics, past history, meds, dietary recall, and physical activity. When writing a diagnosis, you do it in the form of a PES statement (Problem AS RELATED TO Etiology AS EVIDENCED BY Signs/Symptoms. My first note had a lot of work to be done on it, but they got better as time went on. With my PES statements I would sometimes be redundant on my symptoms but I think I got it down now.

           

I am also working on a 5-10 presentation about physical activity for Vivian (my preceptor) to give to the staff.

I learned a lot at this rotation. I am so thankful!

Two weeks at the Statesboro Farmers Market

I had two weeks with the Statesboro Farmers Market with fellow intern Betsy. Sadly, the market wasn’t open while my rotation was going on so we weren’t able to actually work the Saturday market. We attended the annual market meeting, where the market earnings and new ideas are discussed for the following year. For our market, they are trying to get a board of directors set up. It was interesting to see that side of things, and I can’t wait for the market to get started again. There’s a lot more that goes into running a market than expected. One thing we also did for the market was doing some recipe ideas with international inspiration. They hand these out, and there had to be at least 2 ingredients in the recipe that can be purchased at the farmers market. It was a pretty fun task to research different dishes for countries and then pair that with what can be purchased at the market.

         

These were the flyers that I did for the international inspiration!

In addition, we were able to go to the Market2Go distribution. This is where people order from the market online  by Tuesday and do then pickup at one of 2 locations on Thursday. We got to see how they sorted stuff out when the farmers dropped it on then have it separated into the Sugar Magnolia pick up for the RAC pickup. A recipe of the week was also done, so this week I did a recipe for a kale and apple salad. Yum!

My flyer for the salad.

We also had to do some kids activities for the Corny Days.

  

The second week was spent finishing up assignments for the market!

Next week I will start my clinical rotations for the rest of the internship!