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Outpatient rotation (120hrs)Outpatient Nutrition Services Reflection Report. During their first day of the “Shadow and Document Nutrition Care to Patients” activity (described previously), students write their observations and reflections of the benefits and long term impact of outpatient nutrition services in their journal. Students then write a report, due on the next supervised-practice day, based on these observations and reflections, identifying and where appropriate, justifying: 1) ?The outpatient nutrition services offered by the facility ?2) ?The outpatient groups and their demographics who currently are and would benefit from nutrition services ?3) ?The benefits provided by the service to patients and the community ?4) ?The short- and long-term impact of outpatient nutrition services ?5) ?Who should be informed of these benefits to recommend the service. ?1-Westchester government senior program, nutrition and wellness division, focuses on the elderly population, who are high risk for adverse medical ailments based secondary to their age, and ability to eat healthy food. The nutrition services delivered by the program provide participants with healthy menu choices through home delivered meals, and 1:1 and group nutrition counseling conducted during congregate meal service. Participants have the ability to participate in various health and wellness events throughout Westchester, which offer nutrition counseling, educational handouts, and evaluation of the need for home delivered meals through the conduction of a nutritional risk score questionnaire. 2-The outpatient demographics targeted were the elderly residents of Westchester who have a high nutritional risk score, and who suffer from some medical issues which prevent them from preparing their own meals, or accessing healthy food. 3-Benefits provided are home delivered meals to help with the prevention of malnutrition in the elderly population, free nutrition counseling sessions aimed at prevention, and nutrition and wellness events that involve nutrition education presentations, and healthy cooking demos to promote independence even in advanced age.4- The short-term impact of these programs is ensuring that participating seniors receive at least 1/3 of their recommended dietary intake daily, through healthy meals provided at congregate meal sites and via home delivered meals. The long-term impact of these programs, is the development of healthy eating habits through continuous nutrition counseling sessions, and nutrition educations presentations, as well as nutritional assistance with managing medical conditions through healthy eating. 5.) The services provided have been well promoted throughout the community centers of Westchester and at farmers markets. Additional marketing strategies could include mailing flyers to residents known to be greater than 65 yrs old.Nutrition Department Outpatient Education Materials Report. Students examine their facility’s patient education materials focusing on the needs of patients in the outpatient setting. The literature may or may not address the needs of patients who provide their own meals, complete with selection, shopping, preparation, and storage. For some patients and their caregivers, methods of appropriate food selection, requiring reading and interpreting labels, and preparation of meals may be new and even overwhelming to apply to their daily lives. ?RDNs may have to use two or more pieces of literature or create their own in order to meet patient and caregiver needs. Therefore, in preparation for providing nutrition education to patients seen in the outpatient setting, students create a four- part report on the usage of the existing education materials. The report should consist of: 1) ?A catalog: Students list and review at least ten of their facility’s outpatient nutrition education materials. For each piece, students list the title, disease state or condition, key components, and implied audience level including age, reading level, and cultural considerations such as ethnicity and customs. ?2) ?An evaluation: Students select three pieces they deem to be effective for outpatients that represent different styles of design and communication. Students explain why they think each piece is effective through the combined use of text, graphics, format, and relevance to disease state or condition. ?3) ?Material combinations: Students describe how these materials can be combined or modified to address the needs of outpatients for the particular disease state or condition, including those dealing with complex disease states or conditions. ?4) ?A library assessment: Students analyze the overall outpatient nutrition education collection, considering the needs of outpatients dealing with uncomplicated to complex disease states and conditions, and write the strengths, limitations, and recommendations to meet the needs of outpatients ?Reviewed 10 outpatient nutrition education materials, that are currently used at the facility, and are given to seniors during the home nutrition counseling visits.Identified the weakness of each nutrition education material and discussed my findings with my preceptor. Identified the most distributed nutrition counseling material for seniors and worked on editing the handouts and including new research finding and easy to read material, taking into consideration seniors’ age group, food preferences and level of difficulty of the recipes. The 10 nutrition education materials included: Hypertension Dash dietEating for diabetes Increase your fiberGERDTips to add more proteinHealthy snacks AnemiaHeart Healthy DietThe weaknesses of the handouts were lack of visual attractiveness of the handouts, repetition of information, excessive provision of information (above grade 5 reading level), lack of bulleted information for ease of use, and not tailored to the needs of the client (i.e discussing glycemic load of a particular food is not the most pressing concern for an 88 year old diabetic). I worked to simplify the material presented, make it more relevant to the population, and added pictures to make the handouts more appealing.I’ve attached the starting version and my revised version for the Shake Your Salt Habit handout as an example.Electronic Medical Record Training. Students receive training on how technology systems are used in rotation activities. If formal sessions are not available, preceptors should arrange informal one-on-one training sessions. CRD 4.5 if informatics technology is used in the facility ?During my rotation hours completed at North Central Bronx Hospital I was shown how to use their EMR system named Quadramed to review patients’ charts, analyze growth charts, document sessions (group and individual), and add in billing codes for reimbursement.Outpatient Facility Procedures for Nutrition Reimbursement Report. In preparation for participating in coding and billing for nutrition reimbursement, students find out how RDN activities are incorporated into the facility’s billable charges and submitted for reimbursement. Since RDN services are billed either as separate professional services or bundled into the hospital fee, the report must include: 1) ?The different reimbursement claim forms used by the facility, including Medicare and Medicaid, with an explanation of the fields on the forms ?2) ?How the services the RDN provides are communicated to the billing office, such as an automatic update from the medical records software ?3) ?How RDN services are submitted to public and private insurers, for example, as either identified professional services requiring diagnosis and services code, or bundled into the facility fees. ?I was exposed to reimbursement protocols during my hours at North Central Bronx Hospital. Within each group or individual counseling note, I observed the dietitian adding ICD-10 codes and CPT codes. The most commonly used ICD 10 codes in her work were (E66.3 – overweight, E66.9 – obesity, and R73.02 – impaired glucose tolerance. Depending on the visit being documented we used as CPT codes 97802 – individual initial assessment, 97803- individual follow-up assessment, and 97804 – group session. Once placed in the note, the billing information automatically transfers to their financial software called Sorian Financials. In order to remain a provider with the various insurance companies taken by the hospital, the dietitian must annually fill out an application with CAQH Proview, which applies the provider to be a provider with multiple insurance carriers.Assignment 2Westchester county senior program report. The facility offers many advantages to the senior residents residing in Westchester county Some of the advantages include residential and health care options such as, retirement housing and assisted living, enriched housing, adult homes, and residential health care facility.Other services benefits includes:Escorted shopping, food stamps, friendly visiting, emergency response system, nutrition sites, managed long term care, and much more.As for the nutrition programs… The nutritional needs of older adults become more critical with advancing age especially if seniors are suffering from acute or chronic illness. Goals for nutrition program is to enable adults, especially those who are in the greatest social and economic need, to remain in their own homes with a high quality of life, for as long as possible through the provision of home and community –based services including supports for caregivers . Some of the activities include: Provide nutrition counseling and medical nutrition therapy to seniors who are at risk nutritionally or suffer from chronic disease.DSPS provides nutrition education through researched materials and informational materials Designs food and nutrition education training sessions to promote safe food preparation and sanitation practices in accordance with NYS department of health and sanitary code.Improve senior accessibility and participation in the SNAP food stamp program. The main purpose for this facility is to monitor and evaluate the 28 sites in order to make sure the food delivered is safe and within temp, and to check on the quality of food.There are 5 dietitians, 3 of them monitor regional kitchens, attend congregate meetings, and offer nutrition counseling for homebound seniors.Several forms are prepared prior to the visit such as:Nutrition health risk score questionnaire obtained from WJCS .Compass Form which includes a comprehensive overview of the participant’s social, financial and medical situation.Medical forms that list the illness(es) the participant suffers from along with lab values and medication taken. NAPIS form (shorter version of the compass from) to evaluate the need for nutritional counseling. 5.) Nutrition assessment form to be filled at the interview time. After completion of the homebound delivery interviews, a report is to be typed and signed by the program administrator the reports should include as follows: Brief description of the activity of the dayDay and dateLocation observedWhere meals are preparedWhat is being served and when ex, hot meal on weekdays Who delivered the meals and how they deliver it Meals and food safety run What the meal that day included How many meals were served The name of the volunteer Temperature of meals and whether it is acceptable or not Comments about the meals from seniors Home Delivery Meal Run: Participant files are reviewed, participants are met in their home, and the data collected becomes part of monthly reports. The report includes: how many HDM were reviewed at the time of visit, which community a HDM belongs to , and how many reports were up to date and how many were not.1-Meal prep2- HDM routs3-Participant files 4- Evaluation of food service system Abbreviations learned:NYSOFA : NY state office of the aging III C2 = OAA older American act provides grants to state agencies on aging to support congregate and HDM for people 60 and upIIIC-1 address dietary inadequacy and social isolation , program provides nutrition education Nutrition risk screening, and nutrition counseling C1&C2 federal funded , WIN state funded WIN= Wellness in nutrition primary funding OAA title C2, C1DSPS = Department of senior program and services COMPASS= Comprehensive Assessment for Aging NetworkAssignment 3Food protection During this rotation I was exposed to temperature control and food holding regulations. Temperatures for potentially hazardous foods were reviewed (i.e. 165 minimum temp for poultry, stuffing and reheating left overs, 160 minimum temp for egg dishes and ground meats, 145 for beef, pork , lamb, veal, etc. Proper food handling processes were also reviewed as I assisted with the food demos at the farmers market.Assignment 41. Shadow and Document Nutrition Care to Patients (2-4 consecutive practice days). While shadowing their preceptor throughout their shifts, students document in their practice journal the facility and NCP procedures and techniques used by their preceptor, including Subjective Global Assessment (SGA), Nutrition Focused Physical Assessment (NFPA), Stages of Change assessment and Motivational Interviewing (MI), effective education and counseling techniques, and professional referrals. Students also write questions to discuss and mock medical notes for each patient in their journal. By the end of each day, students meet and discuss their journal entries with their preceptor. Students work on concurrent activities and assignments throughout this activity. Preceptors continue this activity for a minimum of the established time frame until students fulfill the requirements listed.Nutrition Counseling for Seniors CASE 1:84 years old, BMI 30Diet: Low Sodium, Fluid Restriction of 700 ml Medical Dx: Water Retention PMHx: Colon Ca, HTN, SOB, Suffers from Burping and gas after eating Current Meds: Lasix, Folic acid, Flomax, Eliquis, Losartan, Metorpolol, Gentle Iron 28mgPES: Excessive fluid intake r/t diet non-compliance in the setting of altered cardiac function, as evidenced by reported intake of fluids above designated fluid restriction and pt. presenting with fluids retention.Intervention : Limit intake of salty fish.Limit intake of water while increasing intake of protein-rich foods to assist in reducing edema.Try to increase potassium to lower blood pressure. MedsLasix Diuretics, antihypertensive this med lowers K, Mg, Ca, Na, CL, Ca it is best to recommend Mg or K+ suppl. It can also affect thiamine levels, which when low can increase risk for CHF. Discontinue Na restriction if hyponatremia occurs.Med can raise glucose levels, BUN , Creat, LDL, TG and can cause Anemia.Flomax ( Tamsulosin) Antihypertensive and BPH treatment ? after meal Interact with grapefruit Recommend lowering Cal, and NaMay cause weight gainEliquisAnticoagulant/ factor Xa inhibitor Avoid herbal supplement ( ginger, garlic, ginsing) , caution with grapefruit, vit E Lowers KLosartanAntihypertensive, CHF treatmentType 2 dm nephropathyCaution Ca recommendedMonitor BP, K and renal functionMetoprolol Antihypertensive, diuretic Need Mg, K supplement Lower Na, Ca is advisedCaution with Ca or vit D may cause hypercalcemia Case 260 years old female, BMI 23Diet: Diabetic diet for 15 yearsCurrent dx: Hyperglycemia, and Heart Condition (unspecified)Meds: Atorvastatin, Ca, Metformin, Hydrocodone, Xarlto, Digoxin, Omeprazole, Ramipril, Metoprolol, Glipizide, Cortia PES: Inadequate protein-energy intake r/t limited acceptance of foods secondary to decreased appetite and fear of raising BG levels, AEB dietary recall and wt. loss noted.Unsupported beliefs about food r/t food and nutrition-related knowledge deficit, AEB lack of prior access to nutrition counseling and pt. reporting fear of consuming veggies due to belief that they are high in carb and may raise BG.Intervention: Increase protein and vegetables Meds: Atorvastatin Ca ( Lipitor ) Antihyperlipidemia take with meals Recommend low fat-low cholesterol diet Caution with grapefruitRecommend co q10 May raise glu levels.Metformin Antihyperglycemic- take with mealsLowers B12, folate recommend both May cause anorexia and wt lossHydrocodoneAntitussive, analgesic, narcotic ( treat pain)Take with food to lower GI stressCause anaroxia, delay digestion avoid with alcoholXarelto Anticoagulant/ factor Xa inhibitor Avoid herbal supplement ( ginger, garlic, ginsing) , caution with grapefruit, vit E and fish oil supplements Lowers K DigoxinCardiotonic, Antiarrhythmic CHF Maintain diet high in K, low Na, adequate Mg & Ca supplement Caution with vit D and Ca supplement Monitor K, Ca, MgOmeprazoleAntiulcer, anti GERD30-60min before mealMay reduce abs of Fe, Vit B12, Ca, Zn, Mg and protein. Suppl. Should not be taken within 2 hrs of med.May raise Cholestrol, glucose, Creat RamiprilAntihypertensive, CHF treatment Insure adequate fluid intakeRecommend lowering Na, CalCaution with K and Mg supplement, drug raise K&MgGlipizideOral hypoglycemiaTake 30 min before lunchMay reduce or increase appetiteCan cause N/D/C CartiaAntiangina, antihypertensiveLower cal maybe neededStrict low Na may blunt antihypertensive effect of drug Metoprolol Antihypertensive, diuretic Need Mg, K supplement Lower Na, Ca is advisedCaution with Ca or vit D may cause hypercalcemiaCase 382 years old female, BMI 23Diet: RegularCurrent dx: Cancer multi-melenoma PMHx: Gout, Pacemaker and port CHFCurrent meds : Lexapro, Revilimd, Miralax, amlodipine, acyclovir, Aricept, Olmesartan, metoclopramide PES: Unintended weight loss r/t lack of appetite in the setting of increased nutrient needs, AEB low appetite and reports of 20lb wt loss.Intervention: Increase calorie intake by drinking Ensure 1x per day.LexaproAntidepressant Increase wt and appetiteRevilimdUsed to treat multiple mylenoma, transfusion dependent anemia Amlodipine (Norvasc) Anti hypertensive lower Na, Ca is recommended Acyclovir Antiviral ( herpes, shinglesInsure adequate fluid intake May cause anaroxia ariceptAnti alzheimers , reduce wt ,dehydrationOlmesartanAntihypertensive , CHF treatment Caution with K supplement or salt tableMetoclopramide (Reglan)AntiGerd, diabetic gasteroparasis Case 4 75 years old male, BMI 20 (Underwt. For Age)Diet: Low-sodium Diet24hr oxygenPMHx: COPD, Asthma, Prostate , HTN, Heart condition PES: Unintended weight loss r/t inadequate energy intake AEB diet recall and reports of wt loss. Intervention : Add more protein, to meals such as scrambled eggs. Increase caloric intake through increased addition of fats to meals. Eliminate low-sodium therapeutic diet.ApixabanAnticoagulant/ factor Xa inhibitor Avoid herbal supplement ( ginger, garlic, ginsing) , caution with grapefruit, vit E Lowers K Aclidinium Bromide bronchodilator. It helps open up the airways in your lungs to make it easier to breathe. This medicine is used to treat COPD, including emphysema and chronic bronchitisAlbuterol Anti asthma, bronchodilator Limit caffineIncrease appetiteLower K, Chol, LDL, WBC, HCT and increase GlucoseAtrovastatin Antihyperlipidemia- lipitor take with meals Recommend low fat-low cholesterol diet Caution with grapefruitRecommend co q10, may cause edema Azelastine nasal spray is a histamine blocker. It helps to relieve itching, running and stuffiness in the nose. This medicine is used to treat nasal symptoms from allergies and other irritants.BaclofenSkeletal muscle relaxantCan cause N/V dry mouth and constipationIncrease GLuc, AST/ALT ClopidogrelAcute coronary syndrome treatment AVOID grapefruitCaution with hepatic functionDiltiazem Antiangina, antihypertensiveLower cal maybe neededStrict low Na may blunt antihypertensive effect of drug Docusate NaRecommend high fiber with 1500-2000 ml fluid oz to prevent constipation Increase glucose and K in blood FinasterideBPH treatment ( proscar) treatment for prostate Zoloft Antidepressant Avoid tryptophan supplement Caution with grape fruitLowers Na in blood Can cause anorexia, wt lossDeltasonePrednisone- CorticosteroidsIncrease Na, Glucose, TG, Cholsterol Lowers K, Ca,Zinc, Vit C, Vit ADiet Low in Na, high Ca, VIt D, ProteinMay need K, Vit A, C, P supplement Caution with grape fruitIncrease appetite, and wt Protonix Proton pump inhibitor Antiulcer, anti GERD30-60min before mealMay reduce abs of Fe, Vit B12 and CaRaise Cholestrol, glucose, CreatNitrostatAntiangia – for relief of acute attack Not with severe HTNSingluarAsthma treatment LasixDirutics, antihypertensive this meds lowers K, Mg, Ca, Na, CL, Ca it is best to recommend Mg or K, MG suppl Discontinue Na restriction if hyponatremia occurs Meds raise glucose levels , BUN , Creat, LDL, TG and can cause AnemiaCase 5: 88 years old female Diet : Low-SodiumCurrent medical status : Parkinson’s diseasePMHx: HTN, Kidney problems , open heart surgeryPES: Altered nutrition-related lab values (BUN/ Creat. And Phos) r/t excessive intake of phosphorus AEB labs + pt. on Renvela as a phosphate binder.Intervention : Low-phosphorus diet. Protein separate from LevodopaMeds: Levodopa, stool soften, simvastatin, metoprolol, amlodipine besylate, allopurinol, Renvela, HCTZ, calcitriol, vit DLevodopa Antiparkinsons Take MVI or Fe separate from the drugCaution with Fava beans ( contains high levels of levodopa) Low K, low WBC Not directly with high protein Protein re distribution diet of 5:1To 7:1 CHO to pro with most pro in evening may stabilize drug effects and monitor fluctuationsSimvastatinAntihyperlipidemia – zocor Low fat, low cholesterol, low cal diet if needed Caution with grape fruitLower CoQ10Amlodipine besylateAntihypertensive Recommend low NA, Cal AllopurinolAnti gout Avoid large dose of vit CDrinl 2.5-3 L of fluid to produce 2L urine/24hrAffect hepatic labsRenvlaPhosphate binder use in ESRD Recommend Low P diet Lower Phosphorus , increase Ca.Monitor Ca, Cl, P HCTZAntihypertensive, diuretic May need lower Na, Cal, and K&Mg supplCaution with Vit D& Ca risk hypercalcemiaIncrease glucose, TG, Chol levels Case 6 :92 yearls old female, BMI 23 (underweight for age)aDiet : RegularCurrent dx: HBP, high cholesterolPMHx: HoH, CVAPES: Altered GI function r/t decreased GI motility secondary to age, AEB ned for Colace, and reports of constant constipationIntervention: Prune, bran and apple juice porridge, increase high fiber snacks, whole wheat bread. Increased fluid intake.Case 7 :76 years old male, BMI 26Diet : Whole food, low in salt and fat Current dx: S/p shoulder replacement surgery PMHX: Stage 1 Ca removed from kidney, stentMeds : Amlodipine PES: Unintended wt. loss r/t increased nutrient needs secondary multiple surgeries requiring hospitalization AEB reports of wt loss of 21lb since May 2017.Case 8:74 years old Female, BMI 27Diet : low in salt and fatCurrent dx: HypoglycemiaPMHx: Lyme disease, fibromyalgia , sciaticaPES: Altered nutrition-related lab values (Glu) r/t inadequate protein-energy intake, as evidenced by pt. presenting with hypoglycemia.KombiglyzeAntidiabetic(n combination drug)Increase wt Lower cal if neededLyricaAnalgesic for DM neuropathy, fibromyalagiaRestless leg syndromeIncrease wt and appetiteLevothyroxine Thyroid hormoneTake Fe, Ca, Mg suppl separtly from drugLow abs with high fiber food and soy milkAppetite changes and wt lossIncrease gluc, cholesterol, CA, PCrestore Antihyperlipidemia – zocor Low fat, low cholesterol, low cal diet if needed Caution with grape fruitLower CoQ10Comparative Case study assignment CASE 1:84 years old , BMI 30Diet: Low salt , fluid restriction 700 mlMedical Dx: Water retention PMHx: Colon Ca, HTN, SOB, suffers from burbing and gas after eating PES: Water retention r/t unknown factor AEB edema present on hands and abdominal areaExcessive salt intake r/t HTN AEB need for HTN meds and diet recall Intervention: Limit intake of salty fishLimit intake of water to assist in reducing edemaTry to increase potassium to lower blood pressure CASE 2:75 years old male, BMI 20Diet :Low saltMedical Dx: 24hr oxygenPMHx: COPD, Asthma, Prostate , HTN, Heart condition PES: Wt loss r/t inadequate energy intake AEB diet recall and reports of wt loss Intervention: add more protein , to meals such as scrambled eggs, and limit sodium intake The comparative study will focus on the compliance of low sodium restricted diet between two individuals who suffer from HTN. The two were instructed to stay on a low sodium diet in order to manage their high blood pressure, and avoid any serious complications from high blood pressure such as heart disease.Current research literature indicated that dietary patterns of the individuals affect their blood pressure levels. The strongest evidence for maintaining a low blood pressure and preventing hypertension was through following a dietary intervention such as the DASH diet and the Mediterranean diet, which emphasize on the concept of increasing the amount of fruits and vegetables, and eating less saturated fat and total fat found in red meats. In addition to that it is recommended to increase the amount of potassium rich food in the diet and limit the alcohol consumption. the interview there was a significant difference between the two case studies. Our first case is an 84 years old male , who has a BMI of 30.6 which indicate overweight given age. This pt. however is suffering from Ca as well. He was eager to change his dietary habits, and demonstrated willingness to try out new cooking methods to decrease his sodium intake, and substitute his canned and pre packed convenience food with heart healthy, sodium-free alternatives. Stages of Change Report. Students investigate the established Stages of Change model using their DPD class notes and texts, the Internet, and professional resources. Their reports should include: 1) ?Major researchers of the Stages of Change model ?2) ?The label, definition, and characteristics for each stage of change ?3) ?Approaches that RDNs may find effective in the outpatient setting to meet the possible challenges with each stage of change. ?Registered dietitians can effectively help patients move through the stages of change especially through group interactions using motivational interviewing. ................
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