Guess what? I just reached 500 followers on my Instagram! I think it's so cool that people are interested in my dietitian-to-PA journey. I've also started sharing short videos in my Instagram stories about nutrition topics that I think would be of interest to my followers, and so far they've been well received.
With that in mind, I thought it would be fun to walk through a day in the life of a dietitian, because I think a lot of people don't really understand what we really do all day. Now, dietitians can work in a variety of areas -- food service, outpatient care, bariatric surgery, oncology, school nutrition, dialysis centers, private practice, etc -- and each one of our days would probably look quite different. So, this is my perspective, as a clinical dietitian in a large metro hospital.
Side note #1: this is what life looks like this summer, while I'm not taking any classes. Things are WAY more hectic when I'm also taking classes!
7:45 - Arrive at work, put my lunch in the fridge and say "hi" to my lovely coworkers! Fire up my computer and sign into my floors in Epic so if other people are trying to find out who the dietitian is for their patient that day, they'll see my name in the treatment team.
8:00 - Start making my list of patients for the day. We do a full follow up on patients every 7 days, so I highlight the people who are due for a full follow up. Then I review the consult list. Consults are often for things like enteral and parenteral nutrition and diet education. Next, I'll see which patients have been screened by nursing staff during their admission questionnaire and have nutrition concerns. These questions are along the lines of "have you lost weight recently without trying?" and "do you have a poor appetite that has been affecting your intake?"
Finally, I'll look through reminders I've left for myself about things I want to check in on about a patient, such as how they've been eating recently or lab results. Some of these check ins are quick and easy, so I'll cross them off my list right away. Let's say I have a patient who has end stage liver disease and I checked their vitamin A and E results. Looks like vitamin A came back low, so I'll write a short note, get the supplementation ordered, and send a quick FYI page to the doctor to keep them in the loop. One great thing about my current hospital is that dietitians have order writing privileges for oral supplementation.
9:00 - Time for Care Coordination Rounds (CCRs)! During these meetings, doctors and/or nurses present their patients and discharge planning is discussed. A social worker, case manager, nurse educator, charge nurse, nursing manager, PT/OT, pharmacist and dietitian may be present for these discussions. We talk about how long a patient is expected to be admitted based on their diagnosis, any issues that have come up during the admission, and anything else that needs to be done to get them discharged safely.
As a dietitian, I usually don't have a ton to contribute. Oftentimes, I'm asking about enteral nutrition, because if a patient needs to go to a subacute rehab or nursing facility, they can't go with an NG, and the doctor needs to discuss with the patient their goals and if they want a permanent tube. The sooner the better, because we need a little time after the tube is placed to ensure the patient tolerates the tube feeding regimen (usually we're transitioning from continuous 24-hour feeding to intermittent/bolus feedings a few times a day). It's also helpful for me to hear when patients are leaving, so I can be sure to complete any necessary teaching.
10:00 - After going to CCRs on both of my floors, I head back to my office for a mid-morning snack and to start prepping to see my patients. I'll get started on chart reviews for my new consults and follow-ups and get my notes started. If I have any patients on parenteral nutrition, I'll review their labs for the day and then either call or instant message with the pharmacist to collaborate on any changes. For example, if I notice that the phosphorus is trending up or now above normal, I'll decide with the pharmacist what's an appropriate lower amount of phosphorus to have in the PN bag. At my current hospital, all PNs are custom, which gives a lot of freedom for dosing the correct macronutrients and micronutrients.
11:00 - I head up the floors, armed with my patient lists, any education materials I need, pager, pen, a surgical mask and goggles. Thank goodness scrubs have lots of pockets! My first patient is an education. This person got a new colostomy during this admission, and I want to review the nutrition recommendations for an ostomy. I have printed out education materials from the Academy of Nutrition And Dietetics that overviews why the patient is on this diet, foods that would be good/not-so-good choices, and a "troubleshooting" section as I like to call it, which goes over foods that may cause problems like gas, blockages, discoloration of stool, diarrhea/loose stools. Yes, as a clinical dietitian I talk about poop A LOT!
11:35 - Next patient on my list is a new consult for "nutrition assessment" and from my chart review, it looks like the patient has lost a lot of weight recently. During this visit, I'll ask about their intake history so I can estimate if they've been meeting their needs, discuss any issues with chewing/swallowing/nausea/vomiting/constipation/diarrhea, and then give nutrition recommendations. Let's imagine this is a patient with liver disease and ascites, which is causing the patient to have poor appetite and early satiety. I'll likely discuss small but frequent meals, the use of oral nutrition supplements (like Ensure or Boost) and the importance of adequate protein. I'll review sources of protein as well, since I find that many people don't even have a good idea of which foods count as protein. I'll place an order in Epic for oral supplements PRN so the patient can start drinking Ensure in the hospital.
During this visit, I'll also complete a Nutrition Focused Physical Exam (NFPE) to look for macronutrient and micronutrient deficiencies. This involves feeling numerous areas on the patient's body for muscle and fat loss, and looking at their hair/lips/eyes/gums/tongue/skin/nails for signs of micronutrient deficiencies. I'll take this information (weight loss, estimated intakes, muscle and fat loss) into account if I plan to diagnose this patient with malnutrition. If I do, I write a second note that will get co-signed by the physician.
12:00 - Huddles! This is when all the dietitians have a quick meeting to discuss any updates and evaluate everyone's workload. If someone is really busy, this is the time to ask for help and give patients away to other, less busy dietitians.
12:10 - Time for lunch! While I'm eating, I'll multi-task and finish the notes for any of the patients I saw in the morning and start chart reviewing for my afternoon patients.
12:30 - For the next couple hours, I'll go see the remaining patients on my list. Here's what I might do:
Visit a patient I'd previously diagnosed with malnutrition to discuss how they've been eating and troubleshoot as needed, and complete another NFPE on them.
Discuss a patient's tube feeding tolerance with their nurse, who reports the patient is having frequent loose stools. I'll review the patient's medication list to see if there are meds that might be causing diarrhea and then page the doctor if I see anything that could be changed (like oral solution tylenol that contains sorbital) or discuss starting the patient on banana flakes, a supplement that can provide bulk to stools.
Complete heart failure diet education with a patient who has been readmitted for fluid overload.
See a patient who was admitted three days ago but hasn't been eating due to lethargy. I may page the team about placing an NG tube while the patient is unable to take sufficient oral intake, and create a tube feeding plan for the patient. If the patient is at risk for refeeding syndrome due to poor oral intake prior to admission, I will suggest advancing the feeds slowly, monitoring electrolytes and supplementing them as needed, and maybe even giving thiamine.
3:00 - Receive a page from an RN that a patient's family is available for tube feeding teaching. I'll provide a printed tube feeding plan to the patient and their family member and review the regimen - what formula will be used, how many cartons of formula to give a day, how it will be administered (syringe, gravity bag, or pump), how and when to flush the tube with water, issues to watch out for, and answer any questions they may have. The RN will then do some hands-on teaching with the family as well.
3:30 - Back to my office for another snack and to finish up my charting! Document any education I completed, provide home tube feeding recommendations for the case manager to use, send off any malnutrition notes to be cosigned, and so on. It's unfortunately a lot of time on the computer, but that's healthcare these days!
4:00 - Decide to stay a little late to print off additional articles for a project I'm working on. I'm creating an online education module and "pocket guide" for indirect calorimetry, that way all dietitians are trained on how to complete and interpret results for both indirect calorimetry completed on ventilated patients using a metabolic cart (with the help of a respiratory therapist!) as well as handheld calorimeters for ambulatory patients. This project has been a lot of work, and with my workload recently it has been hard to dedicate much time to it. Every little bit counts!
4:15 - Pack up my stuff, shut down my computer, and call it a day! While not every day is a good day, I love being in a hospital and continuing to see patients and be exposed to a wide variety of patient cases.
Even though I had hoped I would spend more time studying this summer, I can take some comfort in the fact that I'm always working on my patient interviewing skills, expanding my knowledge (even if it's primarily related to nutrition) and getting more and more comfortable advocating for my patients.
I have sincerely enjoyed being a dietitian but I'm obviously very excited about this next step in my career!
Thanks for reading,
Olivia
With that in mind, I thought it would be fun to walk through a day in the life of a dietitian, because I think a lot of people don't really understand what we really do all day. Now, dietitians can work in a variety of areas -- food service, outpatient care, bariatric surgery, oncology, school nutrition, dialysis centers, private practice, etc -- and each one of our days would probably look quite different. So, this is my perspective, as a clinical dietitian in a large metro hospital.
Side note #1: this is what life looks like this summer, while I'm not taking any classes. Things are WAY more hectic when I'm also taking classes!
Side note #2: this day is just an example, and therefore kind of made up to demonstrate the variety of work I do.
8:00 - Start making my list of patients for the day. We do a full follow up on patients every 7 days, so I highlight the people who are due for a full follow up. Then I review the consult list. Consults are often for things like enteral and parenteral nutrition and diet education. Next, I'll see which patients have been screened by nursing staff during their admission questionnaire and have nutrition concerns. These questions are along the lines of "have you lost weight recently without trying?" and "do you have a poor appetite that has been affecting your intake?"
Finally, I'll look through reminders I've left for myself about things I want to check in on about a patient, such as how they've been eating recently or lab results. Some of these check ins are quick and easy, so I'll cross them off my list right away. Let's say I have a patient who has end stage liver disease and I checked their vitamin A and E results. Looks like vitamin A came back low, so I'll write a short note, get the supplementation ordered, and send a quick FYI page to the doctor to keep them in the loop. One great thing about my current hospital is that dietitians have order writing privileges for oral supplementation.
9:00 - Time for Care Coordination Rounds (CCRs)! During these meetings, doctors and/or nurses present their patients and discharge planning is discussed. A social worker, case manager, nurse educator, charge nurse, nursing manager, PT/OT, pharmacist and dietitian may be present for these discussions. We talk about how long a patient is expected to be admitted based on their diagnosis, any issues that have come up during the admission, and anything else that needs to be done to get them discharged safely.
As a dietitian, I usually don't have a ton to contribute. Oftentimes, I'm asking about enteral nutrition, because if a patient needs to go to a subacute rehab or nursing facility, they can't go with an NG, and the doctor needs to discuss with the patient their goals and if they want a permanent tube. The sooner the better, because we need a little time after the tube is placed to ensure the patient tolerates the tube feeding regimen (usually we're transitioning from continuous 24-hour feeding to intermittent/bolus feedings a few times a day). It's also helpful for me to hear when patients are leaving, so I can be sure to complete any necessary teaching.
10:00 - After going to CCRs on both of my floors, I head back to my office for a mid-morning snack and to start prepping to see my patients. I'll get started on chart reviews for my new consults and follow-ups and get my notes started. If I have any patients on parenteral nutrition, I'll review their labs for the day and then either call or instant message with the pharmacist to collaborate on any changes. For example, if I notice that the phosphorus is trending up or now above normal, I'll decide with the pharmacist what's an appropriate lower amount of phosphorus to have in the PN bag. At my current hospital, all PNs are custom, which gives a lot of freedom for dosing the correct macronutrients and micronutrients.
11:00 - I head up the floors, armed with my patient lists, any education materials I need, pager, pen, a surgical mask and goggles. Thank goodness scrubs have lots of pockets! My first patient is an education. This person got a new colostomy during this admission, and I want to review the nutrition recommendations for an ostomy. I have printed out education materials from the Academy of Nutrition And Dietetics that overviews why the patient is on this diet, foods that would be good/not-so-good choices, and a "troubleshooting" section as I like to call it, which goes over foods that may cause problems like gas, blockages, discoloration of stool, diarrhea/loose stools. Yes, as a clinical dietitian I talk about poop A LOT!
11:35 - Next patient on my list is a new consult for "nutrition assessment" and from my chart review, it looks like the patient has lost a lot of weight recently. During this visit, I'll ask about their intake history so I can estimate if they've been meeting their needs, discuss any issues with chewing/swallowing/nausea/vomiting/constipation/diarrhea, and then give nutrition recommendations. Let's imagine this is a patient with liver disease and ascites, which is causing the patient to have poor appetite and early satiety. I'll likely discuss small but frequent meals, the use of oral nutrition supplements (like Ensure or Boost) and the importance of adequate protein. I'll review sources of protein as well, since I find that many people don't even have a good idea of which foods count as protein. I'll place an order in Epic for oral supplements PRN so the patient can start drinking Ensure in the hospital.
During this visit, I'll also complete a Nutrition Focused Physical Exam (NFPE) to look for macronutrient and micronutrient deficiencies. This involves feeling numerous areas on the patient's body for muscle and fat loss, and looking at their hair/lips/eyes/gums/tongue/skin/nails for signs of micronutrient deficiencies. I'll take this information (weight loss, estimated intakes, muscle and fat loss) into account if I plan to diagnose this patient with malnutrition. If I do, I write a second note that will get co-signed by the physician.
12:00 - Huddles! This is when all the dietitians have a quick meeting to discuss any updates and evaluate everyone's workload. If someone is really busy, this is the time to ask for help and give patients away to other, less busy dietitians.
12:10 - Time for lunch! While I'm eating, I'll multi-task and finish the notes for any of the patients I saw in the morning and start chart reviewing for my afternoon patients.
12:30 - For the next couple hours, I'll go see the remaining patients on my list. Here's what I might do:
Visit a patient I'd previously diagnosed with malnutrition to discuss how they've been eating and troubleshoot as needed, and complete another NFPE on them.
Discuss a patient's tube feeding tolerance with their nurse, who reports the patient is having frequent loose stools. I'll review the patient's medication list to see if there are meds that might be causing diarrhea and then page the doctor if I see anything that could be changed (like oral solution tylenol that contains sorbital) or discuss starting the patient on banana flakes, a supplement that can provide bulk to stools.
Complete heart failure diet education with a patient who has been readmitted for fluid overload.
See a patient who was admitted three days ago but hasn't been eating due to lethargy. I may page the team about placing an NG tube while the patient is unable to take sufficient oral intake, and create a tube feeding plan for the patient. If the patient is at risk for refeeding syndrome due to poor oral intake prior to admission, I will suggest advancing the feeds slowly, monitoring electrolytes and supplementing them as needed, and maybe even giving thiamine.
3:00 - Receive a page from an RN that a patient's family is available for tube feeding teaching. I'll provide a printed tube feeding plan to the patient and their family member and review the regimen - what formula will be used, how many cartons of formula to give a day, how it will be administered (syringe, gravity bag, or pump), how and when to flush the tube with water, issues to watch out for, and answer any questions they may have. The RN will then do some hands-on teaching with the family as well.
3:30 - Back to my office for another snack and to finish up my charting! Document any education I completed, provide home tube feeding recommendations for the case manager to use, send off any malnutrition notes to be cosigned, and so on. It's unfortunately a lot of time on the computer, but that's healthcare these days!
4:00 - Decide to stay a little late to print off additional articles for a project I'm working on. I'm creating an online education module and "pocket guide" for indirect calorimetry, that way all dietitians are trained on how to complete and interpret results for both indirect calorimetry completed on ventilated patients using a metabolic cart (with the help of a respiratory therapist!) as well as handheld calorimeters for ambulatory patients. This project has been a lot of work, and with my workload recently it has been hard to dedicate much time to it. Every little bit counts!
It's hard to smile with a handheld calorimeter in your mouth!
4:15 - Pack up my stuff, shut down my computer, and call it a day! While not every day is a good day, I love being in a hospital and continuing to see patients and be exposed to a wide variety of patient cases.
Even though I had hoped I would spend more time studying this summer, I can take some comfort in the fact that I'm always working on my patient interviewing skills, expanding my knowledge (even if it's primarily related to nutrition) and getting more and more comfortable advocating for my patients.
I have sincerely enjoyed being a dietitian but I'm obviously very excited about this next step in my career!
Thanks for reading,
Olivia
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