ROTATION SUPERVISOR

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					LANGARA COLLEGE AND UBC DIETETICS MAJOR PERFORMANCE OBJECTIVES & LEARNING ACTIVITIES CHECKLIST MODULE: CLINICAL III (a) Advanced Practice
INTERN’S NAME: ______________________________________ DATES: _____________________ CLINICAL III PLACEMENT NUMBER: _____________________ OF _________________________ PLACEMENT LOCATION: _____________________________________________________________ PRECEPTOR’S NAME: _______________________________________________________________

Clinical III Module Overview:
This 6-week module is part of a 23-week experience consisting of 3 modules (Clinical I, II and III). Clinical III, is designed to assist interns to gain further exposure to complex clinical care and clinical relief. Clinical Module III (a) is for use in advanced clinical practice settings, such as: critical care, burns, ICU, nutrition support team, renal unit, organ transplant, specialized oncology, tertiary care pediatrics.

Intern Instructions:
1. Use one of these checklists to track your progress in meeting the requirements of each placement within this module. 2. Complete the form in ink. 3. As learning activities are completed, check them off. Use the Notes section to clarify learning activities completed. Note that the learning activities listed are suggestions only and your preceptor may modify the learning activities as needed. 4. To prepare for your evaluation, a few days prior to the end of your placement: a) Assess your achievement of performance objectives, using either the Met or Not Yet Met column. Note: i) “Met” is defined as: “acceptable performance considering the stage of internship”. ii) Although the module is designed for all performance objectives to be achieved, it is expected that interns will progress at different rates and not all performance objectives will be met within a placement. iii) It is possible to meet a performance objective without completing every listed learning activity (learning activities expectations need to be determined in consultation with your preceptor). b) Pass the completed checklist to your preceptor (your preceptor may opt to have a discussion with you when you submit it). You will have an additional opportunity to discuss, and if necessary, revise the assessment during the evaluation meeting. c) Prior to your evaluation session, complete the Performance Evaluation – Intern Component form. d) Once your evaluation meeting with your preceptor has taken place, you will be given a copy of this document and the evaluation forms. If applicable to your next placement/rotation, take this completed document to your next placement/rotation.

Preceptor Instructions:
1. Prior to the placement, plan an area-specific schedule for achieving all of the learning activities at a specific placement location. 2. When planning an intern’s activities, keep in mind that the focus of these modules is to assist interns to achieve entry level practice skills. 3. Focus on clinical practice fundamentals and avoid providing too much information or assigning an excessive workload. Assignments can be given, but interns should be able to complete them within the scheduled placement. 5667e527-a6e5-49b9-98e1-effd4e32e66d.doc Used in collaboration with the University of BC

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4. Note that the learning activities listed are suggestions. You may adjust these as necessary. 5. All interns require RD supervision. During earlier placements within the clinical modules, this supervision typically needs to be more direct. As interns become more proficient, they can move towards independent work with general supervision only. 6. According to the College of Dietitians of British Columbia, all health record documentation completed by an intern must be co-signed by a preceptor. Notes:

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In Clinical Module III a, interns focus on nutritional care for patients/clients in advanced practice areas e.g., critical care, burns, ICU, nutrition support team, renal unit, organ transplant, specialized oncology, tertiary care pediatrics. PERFORMANCE OBJECTIVES Upon completing this module, you must be able to: Met () Not Yet Met () LEARNING ACTIVITIES Done () NOTES

1. Demonstrate the ability to
organize work to achieve all requirements of the placement.



 

Two weeks prior to the placement, contact the preceptor to obtain pre-placement work assignments (e.g., readings, terminology, course work review, study questions). Print off module forms. Working with preceptor, develop and implement a plan to ensure that all required learning activities are achieved in the available timeframe. Revise the plan as needed to reflect issues arising. Assess personal learning goals for this placement. Meet with preceptor to review past Medical Condition and Lifespan Stages Tracking Form (if applicable) and discuss personal learning goals (Pre-Rotation Form). Tour clinical areas Read assigned materials relevant to practice area, e.g., articles, policies and procedures, regulations Review medical terminology Job shadow the RD for assigned time period

2. Demonstrate the ability to
reflect upon past performance and set personal goals.

 

3. Demonstrate familiarity with
Clinical III environments (e.g. resources, tools, routines).

 

4. Demonstrate familiarity with
the clinical dietitian role in Clinical III settings.

 

 Arrange discussion(s) with RD re their approach to practice  Actively participate in discussions Page 3 of 24

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PERFORMANCE OBJECTIVES

Met ()

Not Yet Met ()

LEARNING ACTIVITIES with RD, asking appropriate questions as issues arise

Done ()

NOTES

5. Demonstrate familiarity with
interprofessional roles in Clinical III areas.

6. Demonstrate knowledge of
nutritional management of patients in Clinical III areas, e.g., a) burns b) critical care c) ICU d) nutrition support e) organ transplant f) renal

7. Demonstrate familiarity with
diet modifications used in Clinical III areas.

 Attend pertinent meetings (e.g., ward rounds, care conferences, family meetings)  Meet with various professionals to observe and discuss their roles (e.g., occupational therapist, physical therapist, recreational therapist, nurse, pharmacist, social worker, speech language pathologist, physician)  Review readings related to patients in Clinical III areas  Undertake a self-directed learning process as unfamiliar issues are encountered (e.g., diseases, drugs, terms)  Complete study questions and case studies as assigned (case studies are typically used when appropriate patients are not available)  Work on completing Medical Condition Tracking Form (form for documenting exposure to diseases and conditions throughout clinical modules)  Review diet types, diet textures and process for ordering diets  Observe diet office procedures and menu systems  Review available supplements and diet modifications/substitutions  If applicable, write menus  If applicable to area, conduct meal rounds for an assigned area to observe the types of diets in use

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PERFORMANCE OBJECTIVES

Met ()

Not Yet Met ()

LEARNING ACTIVITIES  Observe RD gathering and interpreting pertinent information from various sources (e.g., the medical record, verbal communication with physicians, nursing staff, allied health staff)  Review medical records to identify and interpret information necessary to develop a care plan under RD supervision  Observe RD conducting a nutrition assessment interview with patient or significant other and developing a nutrition care plan including goals of intervention  Conduct a nutrition assessment interview with RD observation/ supervision and develop a care plan for RD feedback  Calculate nutritional requirements for a minimum of two patients  Under RD supervision, complete a minimum of five to ten nutritional assessments per week  Complete Clinical III study questions related to nutritional assessment. Discuss responses with preceptor. Diet Modifications  Using area-specific procedures, communicate diet changes for assigned patient to appropriate others (food services, team members, family, etc.)  Choose appropriate nutrition support for assigned patients Healthcare Team Communication  Document nutrition care plans for each assigned patient, seeking RD feedback prior to placing in

Done ()

NOTES

8. Demonstrate the skills
necessary to complete nutritional assessments and develop nutritional care plans for Clinical III patients.

9. Demonstrate the ability to
implement care plans, including: a) Diet modifications b) Health care team communication: - Documentation in health record - Oral c) Patient/ family education as needed 5667e527-a6e5-49b9-98e1-effd4e32e66d.doc Used in collaboration with the University of BC

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PERFORMANCE OBJECTIVES

Met ()

Not Yet Met ()

LEARNING ACTIVITIES health record  Identify and communicate with team members necessary to implementation and monitoring of a nutritional care plan Documentation in the Health Record  according to policies and established timelines  using appropriate abbreviations and medical terminology Patient/Family Education (if applicable)  Observe RD providing a nutrition education session for at least one patient, and/or family member  Provide nutrition education for at least one assigned patient, including:  Establish nutrition goals with patient/resident/family  Select appropriate education resources and tools  Lead nutrition education session  Establish follow-up plans  For assigned patients, conduct follow-up visits and health record reviews to assess achievement of nutrition goals  Discuss effectiveness of intervention with RD  Assess patient/resident satisfaction with nutritional care  Screen patients for nutritional risk with RD  For each assigned area, review nutritional risk indicators and priorities for nutritional intervention  For each assigned area, visit patients at meal time, identifying

Done ()

NOTES

10. Demonstrate the ability to
evaluate a nutritional care plan and modify as necessary

11. Demonstrate the skills
necessary to screen populations of Clinical III patients, in order to identify high priority cases

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PERFORMANCE OBJECTIVES

Met ()

Not Yet Met ()

LEARNING ACTIVITIES patients potentially requiring nutrition intervention.

Done ()

NOTES

12. Demonstrate evidence of
progression towards managing a small patient caseload of Clinical III patients, e.g., 9 to 10 patients by the end of a six-week rotation. 13. Demonstrate appropriate professional conduct, including: a) Manage time effectively b) Practice according to the ethics of the profession c) Maintain a professional appearance d) Use appropriate workplace conduct e) Use a collaborative approach f) Demonstrate effective interpersonal skills

 Provide nutritional care for assigned patients.

To be demonstrated throughout the placement, as learning activities are carried out.

g) Communicate
appropriately, both verbally and in writing h) Assess strengths and weaknesses and takes appropriate action i) Seek, recognize, and respond to feedback

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Intern's Signature: _____________________________________________________ Date: __________________________

Preceptor’s Signature: __________________________________________________ Date: __________________________ The above signatures indicate that the Intern and Preceptor have reviewed and discussed this form together, making any necessary edits. This is the final version.

Internship Co-ordinator’s Signature: ______________________________________ Date: __________________________

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Clinical 3a Assignments
Intensive Care
A. Metabolic Stress    Define stress Describe the metabolic response to stress. Determine the levels of metabolic stress and outline the effect of this stress on: a. Energy/protein/fluid requirements b. Blood sugars/carbohydrate metabolism  Calculate the differences in requirements in an acutely stressed individual and one in an adaptive phase

B. Enteral Support      Complete a “Formula Chart” (see appendix) for the Enteral formulae available in the hospital What are the benefits of enteral feeding? What patients, if any, should not be fed enterally? What types of patients or situations would enteral feeding be contraindicated in? When selecting the appropriate formula for a patient, what factors should the RDN consider? What patient type(s) is an appropriate candidate for: a. b. c. d.  A gastrostomy A gastrojejunostomy A PEG A surgical jejunostomy

List and discuss at least two techniques for preventing and treating the following complications: a. b. c. d. e. Pulmonary aspiration Obstruction of the feeding tube lumen Delayed gastric emptying Diarrhea Over-hydration

    

What procedures should a nurse follow when checking a tube-fed patient’s gastric residuals? What is the purpose of a nasogastric (NG) tube? What should be monitored when a patient is receiving enteral support? How would you respond to a physician to insists on waiting for strong bowel sounds before beginning tube feeding? Do nutritional assessments for at least 5 patients who will be receiving enteral support. Include feeding regime, progression and monitoring parameters. a. Calculate the nutritional requirements for patients using the three different types of feedings: hypercaloric, high nitrogen and elemental. Note: Fictitious situations can be used if actual cases are not available during the rotation. Prepare care plans for each, considering possible complications and monitoring tools used.

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C. Parenteral Support          Review the parenteral solutions used at the facility. Include macronutrient content and additives. Does the institution use a TNA (total nutrient admixture) or Piggyback type TPN? What are the pros and cons of each? What are the indications for use of parenteral nutrition? What types of patients or situations would TPN be contraindicated in? What are the limitations of peripheral parenteral nutrition? List 4 possible metabolic complications. List at least 5 things that should be monitored in a patient receiving TPN? Calculate the requirements for 3 patients receiving parenteral support using the guidelines of the facility. Include macro and micronutrients. If you needed to customize a TPN solution, how would you do this? ie. How would you calculate grams of protein, total calories, and calories from dextrose, protein, and fat?

D. Refeeding Syndrome    Describe the refeeding syndrome. Include metabolic parameters and the patient types who may be at risk of developing this. What labs should be monitored and why? What can be done nutritionally to reduce the likelihood of the refeeding syndrome developing? How would you progress the feeding regime of someone at risk of developing the refeeding syndrome?

Solutions    Identify at least 3 IV solutions and how they affect nutritional management. Discuss parenteral support with the Supervising Dietitian, when and how it would be used, possible complications and ethical considerations. Calculate the requirements of 3 patients using the guidelines of the facility.

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Example Case Study
Mrs. K. is a 68 yr. old female, admitted on October 5 th with a bowel obstruction due to colon cancer. PMHx: Crohn’s disease x 46 yrs. Multiple bowel resections – 1986, 1988x2, 1990 – resulting in 200 cm of small bowel remaining. Normally has 5 stools/day. Sx: Oct. 5 – for Hartman’s resection (transverse colectomy and colostomy) Oct 12 – Anastomostic dehiscence repair. Anthropometrics: 155 cm., 45 kg. Usual wt not available. Enteral feeding was tried and failed.     How many days (approx.) has this pt. been NPO? What type of nutrition support would you recommend for now? At this point, what are the pt’s energy, protein, fluid and micronutrient requirements? Mane 3 – 5 nutrients of specific concern.

November 15 – Severe bleeding. To OR for laparotomy, numerous small bowel fistulas found and resected. Output now by ileostomy. Remaining absorptive surface area is approximately 51 cm. The Dr. allows the pt to have a oral full fluid diet December 4, while still on TPN.   What modification would you make to her full fluid diet? What are three concerns you would have with the initiation of an oral diet?

Mrs. K. now states that if she can’t eat normal food, there is no point living.     What would you do? Who would you talk to about this? What changes would you make to her current diet if the Dr. said all the changes were up to you? Suppose her ileostomy output increased to 3 – 5 litres daily. What changes would you make to her diet? What things would you monitor closely? If you found out that her husband was bringing in food at the patient’s request, what would you do?

Mrs. K. goes home on diet and TPN and has adjusted her diet to provide an output she is comfortable with.   How will you assess the adequacy of calories over the long term? What is a reasonable goal for maximum ileostomy output per day?

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Diabetes Assignments
These assignments relate to the functioning of clinical services and may be time sensitive. The completion and scoring of these assignments should be done during the rotation, on dates determined by the Supervising RD 1. Disease conditions  Produce a spread sheet outlining the different types of diabetes against the medications, nutritional interventions and other treatments or considerationsPrepare 2 Patient Profiles (see Appendix) of Clients of the Diabetes center. Meal Planning      Using the format and tools used by the facility complete meal plan calculations and programs for three different individuals Study the “Good Health Eating Guide”. Discuss why it is no longer being used in the majority of cases. Use the Calculation factors (CHO = 4kcal/g etc.) to produce: a realistic 1200 kcal diet for a working woman a realistic 2400 kcal diet for a teenaged male Understand that although these calculations are not used frequently, the concept is important to understand.

2.

3. Patient Education   Attend several sessions of Diabetes Day Care Education. When possible and under the supervision of the RD , teach one section of the program Observe several individual teaching sessions. Under the observation of the RD conduct at least two sessions.

4. Education Tools



Based on the requirements of the Supervising RD, prepare a first draft of an education tool for future use. If more appropriate, revise and update a current tool.

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Sample Diabetes Case Studies
These case studies were written by an RD from the Central Okanagan Diabetes Program. Her assistance has been much appreciated.

Case Study I
JB is a 79 year old widower with Type 2 diabetes. His weight is 92.3 kg and he is 182 cm in height. He is referred to you for review of his diabetes. His doctor has suggested SMBG but JB is uncertain if this is necessary. He lives alone in an apartment building in a large city. His daughter lives nearby and drives him to medical appointments. Although he takes glyburide 5 mg BID, his blood glucose levels are consistently elevated (8.0 – 15.2) when measured at the physician’s office, and his most recent HgbA1C is 8.6%. JB does not report symptoms for high or low blood sugars but is concerned about having to get up during the night to urinate as a result of his “water pill”. Other medical problems that he reports are arthritis (which limits his activity), cataract surgery 4 years ago and a mild heart problem for which he takes digitalis.       What would you tell JB that might make him more willing to do SMBG? What difficulties might JB have doing his blood glucose monitoring? When and how often would you suggest that he test his BG? What might be the causes of his persistent hyperglycemia? How would you pinpoint these? What blood glucose goals would you recommend to JB? What other areas are important to address in your education plan?

Case Study 2
Jane is a 50 year old woman with Type 2 Diabetes. Her height is 5’6” and weight is 195 lbs. She is eager to lose weight by changing her diet. She has just started an exercise program at the local recreation centre. 24 hour recall Breakfast (7:00)  2 eggs  sliced tomato and  cucumber  lettuce  1 tbsp regular salad dressing Lunch (12:00)  Chicken leg (baked with skin)  2 cups salad – mostly lettuce, a little tomato, red pepper and cucumber  ¼ cup Italian salad dressing  1 cup 1% chocolate milk Dinner (5:30)  180 g/6 oz baked fish  2 cups rice  ½ cup mixed peas and carrots  4 tsp margarine  2 cups unsweetened orange juice Evening Snack (9:00)  6 cups of light microwave popcorn

Medications include: Insulin: 30/70 30 units BID Women’s Specific multivitamin/mineral tablet

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Jane’s blood sugar log indicates that she is always 9.0 mmol/L or higher before breakfast but she often has low blood sugars before lunch (less than 3.5 mmol/L). She states she often feels so awful before lunch that she has trouble concentrating at work. Often she has a ½ chocolate bar at that time to bring her blood sugars up. She tells you that she has just read the book “The Carbohydrate Addict” and has been trying to implement the principles at some of her meals since she knows that carbohydrates are very bad for people with diabetes. She is very frustrated with the fact that she has not lost any weight recently even though she feels she is not eating very much.          What part of Jane’s diet is likely contributing to the low blood sugars before lunch? How would you instruct Jane to treat the low blood sugar? What can you tell Jane about the role of carbohydrates in the body? What suggestions would you give to Jane to help prevent a low blood sugar before lunch? What part of Jane’s diet may be contributing to her high fasting blood sugars? What suggestions can you give Jane to help bring down her fasting blood sugars? How does Jane’s diet compare to Canada’s Food Guide? Why might Jane be having trouble losing weight? What diet suggestions would you give to Jane to promote weight loss?

Case Study 3
LB is a 38 year old woman who has just been diagnosed with Gestational Diabetes. She is at 30 weeks gestation and this is her 3 RD pregnancy, but the first time she has had GDM. She is 5’5 and her current weight is 73.7 kg. Her pre-pregnant weight was 60 kg and she had been stable at this weight for the last 3 – 4 years. In her last pregnancy, LB gained 27.5 kg. Other than mild heartburn this pregnancy has been uneventful. She has limited mobility due to a pulled muscle in her back. 24 hour recall Breakfast: 8 am  3 bacon  1 poached egg  2 white toast  2 black coffee Lunch: 12 noon  1 bowl homemade turkey soup  1 ham sandwich with mustard, margarine and mayo  2 chocolate chip cookies  1 glass orange juice PM Snack: 3 pm  1 banana Dinner: 5 pm  3 oz chicken breast  2 cups spaghetti  1 cup tomato sauce  1 cup tossed salad w/ dressing  1 thick slice garlic toast HS Snack: ~ 8 pm  1 pear  1 slice choc chip banana loaf

AM Snack: 10 am  1 apple  1 whole tuna sandwich (with mayo)   

What are the main concerns with LB’s diet in relation to gestational diabetes? How does LB’s diet compare to CFG? What kind of meal plan would you give LB to better meet goals for blood sugars in GDM?

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When LB returns for her follow up visit, these are her blood sugars: Goals: AC <5.3 2 hr PC <6.7 Date June 3 June 4 June 5 June 6 June 7 AC B 4.8 5.1 5.2 6.0 5.5 PC B 7.6 5.5 6.7 4.9 4.9 AC L 4.2 4.5 6.6 5.3 5.5 PC L 5.7 5.2 6.2 4.9 AC D 4.6 4.9 4.2 PC D 5.5 4.9 6.2 7.8

She has gained 0.7 kg over the last week and has not shown any ketones.   What are your main concerns with these blood sugars? Does the meal plan seem to be working for LB?

You find out that for the last 3 days LB has been getting up feeling hungry in the night because she has been missing her HS snack. At 3 am she has been eating honey-nut Cheerios with milk and 1 slice of toast with peanut butter and regular jam.  What are your overall recommendations to LB?

One month later LB returns to the clinic with the following blood sugars: Date July 1 July 2 July 3 July 4 AC B 5.2 4.9 5.0 PC B 4.0 6.3 6.6 AC L PC L 8.0 7.2 6.8 5.5 AC D PC D 7.8 8.5 7.4 5.2

She has lost one kg since the last visit and has been showing ketones regularly.   What questions would you ask her to assess why blood sugars are elevated? What are your main concerns at this point?

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Case Study 4
AK is a single 35 year old female who is referred to you for diabetes education. She first went to the Doctor complaining of excessive thirst. She is a sales representative for women’s clothing and has a hectic schedule. She can only come to education sessions when her schedule permits, which is rarely. She is in town approx 1 week out of every month. She is 5’5” and weighs 165 lbs. Her diet is the following:

Breakfast:  Coffee (cream, no sugar)  6 oz orange juice  2 slices white toast with jam

Lunch:  On the road – Wendy’s or a Sub shop type lunch is preferred. Sometimes she skips lunch because it is not convenient to stop

Dinner:  Out of town – a restaurant – she tries to get a decent meal – burger, salad and no dessert  At home – she often skips dinner or has microwave popcorn to try to lose some weight

She drinks 2 – 5 coffees and 3 diet sodas throughout the day. Her lifestyle is busy and she states there is no reason to exercise as she is always moving and there’s no time anyway. Her fasting blood sugar was 9.0 and 13.2 - 2 hr post 75 g glucose load. Her physician wants to approach this first through diet and then, if not effective in reducing blood glucose levels within 2 months, she will implement medical intervention.    What are all the possible interventions you could suggest to this patient? What difficulties to you anticipate when presenting the education plan? How will you approach this patient and the education plan?

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Case Study 5
TW is a 28 year old man who has had type 1 diabetes since he was 13. He returned to regular follow up at the clinic 1 year ago after 7 years of no follow up. He was switched to a basal bolus intensive insulin management regimen 9 months ago and at that time learned carbohydrate counting with much success. He has returned with his wife as she has many concerns about his eating patterns. His blood sugars have been very well controlled in the last year and his most recent HgbA1C is 7.1%. He is moderately active with a BMI of 25 but he has gained 9 lbs in the last 6 months. A 24 hour recall shows: Breakfast:  5 pancakes with 4 tbsp regular syrup and 2 tbsp butter  8 ounces orange juice Lunch:  3 lg slices meat lovers pizza  1 large diet coke  2 apples and 2 choc chip cookies Dinner:  5 ounce chicken breast  2 potatoes  1 cup broccoli & 1 cup salad  1 pc chocolate cake 9 pm snack  1 large bowl Rolo ice cream

10 am snack:  1 coffee with cream  1 large muffin 

3 pm Snack:  1 package M&Ms

What are your main concerns when you see his food record?

TW’s wife is concerned that he has begun eating very poorly. Before he started this recent insulin regimen he followed a more specific meal plan and limited high sugar/high fat items. She is worried about his health even though his blood sugars are well controlled.   Are TW’s wife’s concerns valid? How is TW doing compared to CFG?

TW complains that he wasn’t able to eat this way for so long he deserves to treat himself a bit especially given that his blood sugars are usually good.   How do you respond to this? How can you assist TW and his wife so they both feel better about the situation?

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Renal Pre-Rotation Questions
Do as many of the questions before the rotation as possible. They will provide needed background information for the rotation. Those that you do not know and cannot find the answer for can be completed during the first part of the rotation. The Case studies can be completed during the rotation, unless specified by the Supervising RD. Using the “Laboratory Values Chart” ( see appendix) complete for the following parameters. If the parameter has been completed for a previous rotation, re-evaluate your answer based on the current rotation.

1.

Random glucose HgA1C sodium potassium chloride carbon dioxide anion gap urea creatinine urate total protein albumin alkaline phosphate calcium ionized calcium phosophorous serum iron TIBC iron saturation ferritin

PTH (parathyroid hormone) TSH/T4 - thyroid hormones magnesium Hepatic Panel - AST - GGT - total bilirubin reticulocyte count CK (creatine kinase) B12 Folate Lipid profile - total cholesterol - LDL cholesterol - HDL cholesterol - Tryglycerides 24 hour urine for - creatinine - urea - protein - sodium - potassium Urine Osmolarity

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1. 2. 3. 4. 5. 6. 7. 8. 9.

What are the 4 main functions of the kidney? Define the following types of renal failure and give an example of each: Pre-renal failure Intra-renal failure Post-renal failure What is rhabdomyolysis? While screening a chart you come across the term “acute on chronic renal failure” explain the meaning of this phrase. What is meant by the terms “wet weight” and “dry weight”? When assessing protein intake what type of weight should it be based on?

10. What are the vitamin requirements of dialysis patients and why? 11. What are the causes of iron deficiency anemia in the renal population? How is it treated? 12. Describe the relationship between PTH, Vitamin D, calcium and phosphorus. 13. List three reasons why a renal patient may have a low serum albumin level. 14. List four reasons why a dialysis patient may have a high potassium level. 15. List four reasons for a renal patient to have a high phosphorus level. 16. List four reasons for a renal patient to have a low phosphorus level. 17. What is the end product of protein metabolism? 18. What is the average Canadian’s intake of sodium? 19. List five common foods to restrict: 20. on a low potassium diet: 21. on a low phosphorus diet: 22. on a low sodium diet: 23. How is fluid allowance determined for hemodialysis patients? 24. How much fluid weight gain is allowed between dialysis runs? What are some of the consequences of high interdialytic fluid weight gains? 25. A new hemodialysis patient is asking about appropriate snacks. Give at least 10 examples.
Module: Clinical III a Advanced Practice Used in collaboration with the University of BC

26. Would these snacks be any different for a diabetic renal patient? What would you recommend? 27. Mr. Jones is anephric. He is on a 1 L/day fluid restriction and is complaining of thirst. List some methods to help deal with thirst. 28. Constipation is a common complaint amongst hemodialysis patients. List some factors that play a role in this. 29. Why should hemodialysis patients avoid starfruit? 30. List at least 7 reason why hemodialysis patients may be malnourished. 31. A patient has recently started on dialysis and the nephrologist has ordered 500mg calcium carbonate TID with meals. Why? 32. What is the purpose of kayexalate? 33. Many renal patients receive a drug called erythropoieten (EPO). What is its purpose? 34. A patient has a potassium level of 2.5 mmol/L and is started on Slow K. Why? 35. Mrs. Jones is new to hemodialysis and has been prescribed a multivitamin called Diavite. She has a big bottle of Centrum Forte at home and is asking if she can take these instead. What do you say and why? 36. What is calcitriol and why is it used? 37. What are the systemic effects of end stage renal failure? 38. What is IDPN (Interdialytic Parenteral Nutrition)? When would this therapy be indicated? 39. What is the etiology of kidney stones? What are the dietary interventions for kidney stones? 40. How does acute renal failure differ from chronic renal failure? 41. What is urea kinetics? What are the benefits? 42. What is nephrotic syndrome? What are nutritional concerns of individuals with this condition? 43. How are the tests for HIV, Hepatitis B and Hepatitis C done? What is being measured?

Module: Clinical III a Advanced Practice Used in collaboration with the University of BC

Sample Renal Case Studies
Case Study 1
Mr. Kim is admitted to hospital with an enlarged prostate. His enlarged prostate is obstructing the flow of urine causing hydronephrosis. On day 1 a catheter is inserted and he begins draining large amounts of urine. Bloodwork: Day 1 Day 2 Day 3 Day 4 Questions: 1. 2. 3. Is this acute or chronic renal failure? Is this type of renal failure categorized as pre, post or intra-renal failure? What diet instruction is required prior to discharge? Potassium 6.5 5.0 4.0 4.1 Urea 45 20 14 10 Creatinine 952 411 320 151

Case Study 2
Mrs. Steele is a 68 year old female with chronic renal insufficiency. She has been followed by a pre-dialysis clinic for the past year. Mrs. Steele was instructed on a low protein, no added salt diet. In the past few weeks intake has decreased significantly as a result of nausea and vomiting. Hemodialysis is set to start tomorrow. Bloodwork: K+ 4.5 Urea 40 Creat 600 PO4 1.3 Alb 29

Example of typical intake over past few days: Breakfast AM snack Lunch Dinner Questions: 1. 2. 3. What are some possible reasons for Mrs. Steel’s nausea and vomiting? List possible reasons for Mrs. Steel’s potassium NOT being elevated. Mrs. Steele is asking about dietary changes now that hemodialysis has started. What do you tell her? Tea with milk Dry toast Tea with milk Broth soup + crackers ½ sandwich + tea with milk or 1 oz meat, ½ cup rice and ½ vegetables + tea with milk

Module: Clinical III a Advanced Practice Used in collaboration with the University of BC

Case Study 3
It is Monday morning. There is a note on your desk to see Mr. Mitchell a 58 year old new hemodialysis patient re: diet. Upon further investigation you collect the following information: Admitted to hospital on Friday night dx: renal failure and hyperkalemia. Renal failure is due to diabetic nephropathy. He has had diabetes for 10 years however it is only in the last few years that he has been watching his diet and monitoring his blood sugars. He had dietary counseling for diabetes but none for renal failure. First dialysis run was on Friday night. He will require hemodialysis today and then there are plans to discharge him home to continue dialysis three times a week as an outpatient. He is eating well, has no complaints of nausea or vomiting. Height Weight on admission Usual body weight Urine output Diet history: Breakfast 1 cup oatmeal (made with milk) 1 slice multigrain bread 2 oz low-fat cheese Small glass of prune juice Coffee and sugar substitute 1 cup cottage cheese & ½ cup fruit Whole wheat roll and margarine 6 Crackers and 1 oz low-fat cheese Tea and sugar substitute 4-6 oz chicken breast 1 cup Mashed potatoes 1 cup Steamed vegetables 1 cup lettuce and salad dressing Lite hot chocolate made with milk ½ peanut butter sandwich 180 cm 78 kg 70 kg ~ 700 mL/24 h

Lunch Afternoon snack Dinner

Evening snack

He is very keen to learn about his diet and is requesting that you provide him with a sample meal plan. Calculate his nutritional requirements for fluid, protein and energy. Create a sample meal plan for Mr. Mitchell.

Module: Clinical III a Advanced Practice Used in collaboration with the University of BC

Case Study 4
Mr. King is a 23 year old male. Over the weekend he was admitted to hospital with sepsis, respiratory failure and ARF due to rhabdomyolysis. Mr. King was given kayexalate, intubated and hemodialysis was initiated over the weekend (additional dialysis is planned). MD ordered a continuous tube feed of Twocal HN at 40 cc/hr. Height Usual weight Urine output Bloodwork: On admission Today Questions: 1. 2. 3. Estimate Mr. King’s protein, energy and fluid requirements. Is this tube feed meeting his nutritional needs? What changes if any would you recommend be made to the tube feed? Potassium 7.1 5.3 Urea 52.5 38 Creat 921 700 Sodium 130 135 183 cm 85 kg ~550 cc in previous 24 hours

Case Study 5
Patient: AC 52 yr old Italian Canadian woman. Has just started dialysis. Is experiencing nausea, vomitting, and anorexia x 2 months. 5’2” 45 kg UBW 50kg Medium frame Lost 5 kg in 2 months PO4 – 1.9 Ca – 2.12 Alb – 30 K – 4.5 Urine output – 1200 ml/day

Anthros:

Biochem:

Medications: Captopril, CaCO3 1250 TID Uses Centrum Forte daily Dialysis: Dialysing on K 1.5 bath Fluid removal 1.5 L BP 190/90

Module: Clinical III a Advanced Practice Used in collaboration with the University of BC

Questions: 1. 2. 3. 4. 5. What are appropriate nutrition goals for this woman? Calculate a renal diet that would help to achieve these goals. What would be the first diet counselling you would provide for this woman? What medications would you recommend? Write a brief chart note for this woman.

Module: Clinical III a Advanced Practice Used in collaboration with the University of BC


				
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