Quinoa Stuffed Acorn Squash

You know those meals that just taste like the season you’re in? Well, I know this dish doesn’t contain the popular kids at the moment (apples or pumpkins), but this Quinoa Stuffed Acorn Squash absolutely oozes autumnal flavors! The cranberries, sage and maple infuses the quinoa mixture that you then stuff the roasted acorn squash with- just heavenly! Did I mention I added cumin spiced ground turkey as a protein? Oh ya! This is optional, of course. I will definitely be making this again before fall is over, and I hope you enjoy it just as much as I do!

Servings: 4

Prep time: 10 minutes

Cook time: 40 minutes

Total time: 50 minutes

Ingredients

• 2 acorn squashes
• 2 Tbsp olive oil
• 1 cup dry quinoa (any color- I used tricolor)
• 1/4 cup sliced yellow onion
• 1 lb ground turkey
• 1/4 cup dried cranberries
• Fresh sage (about 10 leaves)
• Sea salt
• Black pepper
• 1 tsp minced garlic (about 2 cloves)
• 1 Tbsp cumin
• 1 Tbsp vegan chicken-less seasoning from TJs (or a blend of sea salt, onion and garlic powder, turmeric, celery seed, ginger powder, and pepper)
• 1 tsp cinnamon
• 2 tsp maple syrup
• 1/3 cup crumbled feta

Instructions

1. Preheat oven to 425F. Line a baking sheet with aluminum foil and lightly coat with oil.. Cut the very ends of each squash, but not too deep. This is meant to stabilize the squash to sit upright in the oven. Continue by cutting the squash in half, parallel to the cut you just made. Scoop out the middle with seeds- enough to stuff but not too much so you have enough squash to dig into!
2. Brush the squash liberally with olive oil, then season with a few pinches of salt and grinds of black pepper.
3. Roast for 40 minutes, or until a fork easily breaks the meat.
4. While that’s cooking, bring a medium sized pot with 2 3/4 cups water to a boil. Rinse 1 cup quinoa then add to boiling water. Reduce to a simmer and cook for 20 minutes, or whatever the package instructions reads. Once done, drain in colander and transfer to a large bowl.
5. Warm 1 large sauté pan over medium heat. Add 1 Tbsp olive oil. When warmed, add the sliced onions. Cook for 3-4 minute before adding the ground turkey, followed by the cumin, chicken-less seasoning (or alternative), and cinnamon. Sprinkle with sea salt and pepper. Cook for about 7-8 minutes (or when turkey is nearly cooked but not completely), stirring occasionally.
6. Add the sliced (chiffonade) sage, cranberries and garlic. Let cook for 2-3 minutes longer.
7. Add this turkey mixture in the quinoa, along with 2 tsp maple syrup. Mix well.
8. When the acorn squash is done. Remove from the oven. Stuff each squash with quinoa mix. Crumble feta on top of each before serving (I also added a few pieces of fresh sage for an elevated kick!), and you’ve got yourself an amazing fall dish!

*NOTE* Acorn squash vary in size, and the room you have for the quinoa mixture also depends on the hole you scooped. If the well is smaller then you’d like, add some quinoa mixture on the side for more bites! Omgosh it’s soooo good. Bon Appetit!

How I Started My Nutrition Private Practice

Hi there! I’m assuming that if you’re reading this, you are interested in starting your own nutrition private practice. The thought alone is exciting, but the extensive research and preparation that goes into starting your own business (and properly) is no joke, costly, and downright overwhelming. I am not here to sugar coat things, nor will I deter you from taking this route. I am simply providing you with the steps and resources I used to get started in the hopes of helping a fellow peer out. You can take it from here, and you best bet you’ll have my support and encouragement along the way too. 😉 Please keep in mind that I am not a business pro, so all of the information below are things I came across on the interweb.

1.Decide on your business structure: a sole proprietorship vs LLC.

A sole proprietorship is any business where the owner is fully liable for their business. The business does not have to be registered by the state, and you are responsible for all facets (including absorbing business taxes along with personal ones). An LLC stands for Limited Liability Company, which partially protects the owner and their personal assets should bankruptcy occur. In addition, you are officially recognized as a business by your state, and taxes are filed separately from your personal ones. You can learn more about these frameworks here.

2. Reserve a business name or file for your sole proprietorship or LLC.

You can simply reserve a business name through your Secretary of State’s Office or file for a sole proprietorship or LLC here. To be honest, coming up with a business name was the most challenging part for me! Whichever you decide, I recommend doing more research to do determine which business framework is best for you, your business, your goals, and your situation. I personally filed for an LLC because I wanted to be officially recognized as a business from the get go, but this is a bit pricey up front. Filing took 2 1/2 weeks, but it can take up upwards of 4-6 weeks. This waiting period is good to be aware of since you want to wait for filing to be approved before taking on paying clients (for payment tracking and tax purposes).

3. Protect yourself with health professional insurance.

This component is also pricey, especially upfront, but you can also pay monthly with interest. Getting insured was an important and crucial step for me to protect myself as a health professional. After 4 years of working towards my credential, I refuse to put myself in any situation that someone can take it away from me. I’m sure you wouldn’t want to jeopardize your license either. You never know, so be smart and get insurance! I was set up via phone with HPSO.

4. Decide on a HIPPA-compliant platform if you plan on virtually counseling.

After weighing the pro’s and con’s of a few online platforms, I landed on Practice Better as a user friendly portal to communicate with my clients on and store their personal health information (PHI). Video chat is an option on here, so I didn’t have to pay extra for Zoom’s Healthcare Plan.

5. Set up a checking business account to properly track your earnings, expenses, and overall income.

I set my business account up through Bank of America, and then I linked that account to Stripe so I had a payment processor on Practice Better for clients to pay through.

6. Gather legal client forms and contracts (usually provided when you register your business) to have future clients sign before working together.

GovDoc provided these for me, but I also created a contract for clients to sign stating they would be obligated to pay the entire fee they signed up for, and prior to sessions. In addition, I created a 10-page comprehensive new client form on jotform.com.

7. Determine how you will track your finances.

I will be using Quickbooks to properly organize my income and have records for tax purposes. My brother-in-law (who is both an accountant and lawyer) and other business owners I’ve spoken with say this is the go-to service for this- as user-friendly as it gets.

8. Figure out how you are going to gain clients and market yourself.

I was already on Instagram and under the name Feed.Me.Happy on my WordPress blog here. While I was never consistent with posting due to school, my internship, and life in general, I still had a presence and reach to promote to. Figure out how you want to market yourself, and aim at being consistent! Streamlining your messaging and areas of specialties can also help attract your ideal clientele.

Okay, friends. That’s all I have for now. I hope this brief overview on how I started my very new business helped a bit. If you have further questions, I recommend doing your own research or consulting with a business coach or professional, even a lawyer for some parts.

Thank you for your understanding in me providing information this way. My time and energy is precious to me, especially with 3 jobs now, so it was easier to streamline this info here. Take care, and good luck if you choose to pursue this entrepreneurial route! And speaking of, join the Nutrition Entrepreneurs (NE) DPG group through the Academy for more valuable content and resources too!

My First Job as an RD

I am happy to share that I officially took my first job as a Registered Dietitian! And get this- it’s at the hospital I interned at. WHAT?! Ya, I never in a million years thought I would start in clinical, as it’s not what I want to do long-term. However, the position I took is per diem, meaning that I can accept or decline shifts as they are offered. That flexibility alone sold me because I want to start my own business (which will take time), travel, and continue to live my life as I want, not in the conventional M-F 9-5 way. I also plan on staying at my part-time gig at All Access Dietetics for the time being, especially since it only requires 15 hours/week.

More than likely, your first job isn’t going to be your dream job, and that’s okay! You have to start somewhere, and my somewhere is with a fabulous group of clinical dietitians that I adore and can learn A LOT from. If I just started a business isolated at home, I wouldn’t have the consistent expose and influence to learn and push myself. I also snagged a once a week outpatient counseling job within the same hospital that will give me the counseling experience I so desire.

This is a win/win/win situation, and I’m looking forward to what’s to come.

I’m writing this not only to share the good news, but to also inform you as a future dietitian or other professional that it is OKAY if your employment opportunities don’t look exactly like you imagined they would. You have to start somewhere, and you never know where those experiences and connections will lead you.

✌️

The Dreaded RD Exam

Hi peers! I’m assuming that if you’re reading this it’s because you are preparing to study for and take this monstrous exam. So, here’s the deal. During our DPD courses and even our internship, we have an idea in the back of our minds that this “far-off” test is going to be a doozy, but were any of us REALLY prepared to even study for this? My guess is…no. No, we weren’t.

So how can we pivot and prepare to not only pass, but make studying as minimally stressful as possible? I’m going to share a few tips, tricks and resources that worked well for me, and that can possibly translate for you to apply!

1.Create a realistic study schedule and plan.

Most people order their study material and dive right in without hesitation. While I love the enthusiasm, not having a plan can make you feel uncertain, uneasy, and unsure of how studying is going. It’s great to have a gauge on progress in one concrete way or another. I suggest using a planner to write out the study material content to cover and the duration of studying and/or pages to complete for that study session. For example, if you look at domain 1 of your study material and note it contains 150 pages in total, then you can tackle 25 pages/day for 6 days (essentially 1 week with a day off). Just make sure to customize this plan according to how you learn and operate. Write this out for all 4 domains to determine how long it will take you to cover everything at a realistic pace. Then add a week or two for both cumulative review time and for built-in time off or in case something pops up like an illness or emergency.

2. Give yourself breaks!

Yes, we have all been working towards this credential for YEARS, and this is the exam to give us just that! It may seem like powering through and taking the exam as soon as possible is the best option, but is it really? Keep in mind that if you don’t pass on your first try, there is a 45 day waiting period before you can sit for it again. Breaks literally reset our minds, allow us to process and retain information, and provide our body with much needed movement after being sedentary. I typically worked remotely for 3 hours, took my dogs for a long walk while listening to the @rdexampodcast and/or @allaccessdietetics study review sessions, then I studied for 3-4 hours with another 15 minute breather built in there somewhere.

3. Don’t use every and any study material out there.

While I do believe that having different modes of learning (visual, audio, kinesthetic) is important to switch it up, sometimes dabbling in all of them can create confusion and add to being overwhelmed. I’m not gonna lie, I did use 5 different resources, but one was audio, one was audio/visual, one was simply text, and the last two were active practice quizzes/exams. The point is that they provided me with different ways of learning and kept things fresh. I will note that I am also a kinesthetic learner, so it would be beneficial for you to know or figure out what type of learner you are as well. Then you can decide which material is best suited for you.

4. Expect the best, but prepare for the worst.

I think a lot of pressure revolves around this exam, and it’s a shame that we aren’t prepared for both outcomes: passing and failing. While the word fail has a negative connotation to it, many of the greats have failed their way to success because they had to learn from their mistakes and overcome them. This, in retrospect, made them stronger and more resilient. FAILING DOES NOT MEAN THAT YOU FAILED OVERALL. PERIOD. We have to get rid of this toxic positivity BS and stop telling each other “Oh, you’ll pass!”. I get that it seems encouraging, but if that person doesn’t, then what? Does that mean it’s all for shit? Nope. We’re still proud of them for studying their asses off! It’s okay! We have more shots at this guys. It took me two times to pass because I didn’t make the time frame for my first try. I felt like it was the end of the world, but was it? Nope. Did I learn more because of it? Yep.

5. Learn how to manage test anxiety.

While test anxiety can be common and normal to an extent, it’s good to arm yourself with some coping and management strategies to put into practice the day of your exam. Figure out what works for you. Whether that is deep breathing exercises, using aromatherapy, or positive self-talk, start practicing those things now to implement come your big day.

6. Know that this exam is timed and will NOT be graded unless you answer 125 questions in 2 1/2 hours (150 minutes).

I did not process this information correctly before sitting for my first exam. I arrived at question 125 with seconds left, then the screen went blank. My exam was not graded because of it. DO NOT MAKE THIS MISTAKE! Practice with timed exams so you get a feel for how timely you must be. 2 1/2 hours seems like ample time, but I promise you that it goes by quickly, especially if you take your time weighing your options or calculating math equations.

In addition to this advice, my husband seriously helped me the day of my second exam because he told me to be aware of my time left (in the top right hand corner of the screen). He said that halfway through, with 75 minutes left, I should have around 60-65 (if not less) left. Well, that halfway marker arrived, and I had more to go, so I sped up my pace to make sure I made the time cut. Checking in at least halfway through was so helpful for me, but I don’t recommend continuously looking at the time either, as it’s just taking away from your focus.

That’s all I have for today, but I hope that was helpful! What questions do you have for me?

Happy studying!

❤ Danielle

Clinical: Week 7

Whoa. Where did the time go?! It’s 2021, and I just completed my 7th week of my clinical rotation. It was my first week in the IMCU, and I really enjoyed it. Unfortunately, all of the patients but one on the IMCU unit had COVID, so I didn’t have any patient interaction. However, I stayed plenty busy with screening patients, attending rounds with the IMCU lead doc and residents, and writing notes afterwards. I adore the dietitian I’m interning under, just like the previous two. She’s brilliant, both personally and professionally. She is a CNSC (Certified Nutrition Support Clinician), so she orders the parenteral nutrition when needed, which is often on the IMCU, unfortunately.

The week was pretty consistent with what I described above- screening patients, attending rounds, and writing notes, among other things. Those others things included reading up on enteral nutrition on vasopressors, nutrition support for the critically-ill (slowly advancing to goal in order to not overfeed patients), and attending a monthly RD meeting. The dietitian team is going to be trained on how to insert dobhoffs, so that’s exciting and badass of them!

I’m at a point in this rotation where things are just clicking. I feel proficient in the EMR system, my ADIME notes, and patient communication/education. I need to dabble more in enteral and parenteral nutrition calculations, but DAMN am I proud of myself for how far I’ve come in this short amount of time. Actually, I learned the following from my preceptor: She starts renal patients or those with kidney disease/injuries on Vital High Protein instead of Nepro because the potassium and phosphorus are very similar in each; however, Nepro overfeeds critically ill patients at the beginning stages of advancing to goal. She transitions them to Nepro after 10-20mls, or what’s appropriate for that particular patient’s energy requirements. 🤯 So strategic.

I know how to read most labs, recognize proper medication names and their role/interactions with nutrition, and how to engage with the doc and residents during rounds at this point. I’m actually really liking clinical, to the point where I would consider applying for a prn position. 🙂 Who would have thunk?!

This week, my preceptor is giving me the green light to represent the nutrition department in rounds, and then my last two weeks will be staff relief (covering floors as needed). I have my major project left, which I want to complete this week, and one last presentation to the kitchen staff (topics TBD). But I am goddamn doin it, and doin it pretty well! 2 weeks until my birthday, and 3 weeks until we leave for beautiful Big Sky, MT for 1 month. Let’s go! So much to look forward to.

What questions do you have? I don’t have terms and abbreviations for you this week because I’ve learned a lot of them already; however, here are some good pointers I learned from my preceptor!

1. The 4, 3, 2 guideline of where potassium, phos, and mg should be. This is easier to remember.
2. That opioid bowel dysfunction is a thing, causing severe constipation in many patients where a bowel regimen of 1 to up to 3 different laxatives are needed (Senna, Bisacodyl, Miralax, etc.)
3. Levophed can prevent us from safely feeding patients based off the dosage. You can calculate this by taking the patient’s wt in kg and multiplying by 0.3. Whatever that number is, is the amount Levophed should be under in mcg.
4. Propofol is a lipid-based sedative that contributes calories to the overall energy intake. Propofol in mls x 24hrs = total pls x 1.1 the = what kcal propofol is providing

Did this make sense and help? LMK! Have a great start to your week!

Clinicals: Week 6

Happy holidays and New Year, friends! 🎆 I hope you had a lovely couple of weeks and some down time to reset. Since I am interning at the hospital, I chose to stay home with my husband and two dogs to keep my family safe. Although we had COVID back in March, it has not been confirmed that COVID antibodies last long-term (or for what duration), and being on COVID floors makes me uneasy (not for me, but passing it on to others). My 92 year old at-risk grandma lives below my parents, so it’s not worth chancing to me. While I am open to approaching 2021 with hope (my chosen word of the year), I am cautiously optimistic and holding reservations with COVID still in swing. I’m planning 2-3 months out and taking life one day at a time, which is sometimes all we can do. Okay, that was a little intro- onto my clinical recap! 👇🏼

Week 6 of my clinical rotation was just what I needed, an over-the-hill turning point! On Monday I completed my first patient notes with NO CORRECTIONS!!!! AHHHHH!!! 👏🏼 This was such a big deal and win for me since I’m such a type-A perfectionist (not always a good thing), and every correction and edit I received felt like a punch to the gut lol. However, as I mentioned in my previous post, this is part of the learning process and time of growth for us future dietitians. It just also felt good to bask in the glory of my error-free note haha.

Then on Tuesday, I wrote my first tube feed order with no corrections needed! Man, I was on a roll and floating on cloud 9 (at least in the office). Like I said, COVID is still in full swing, and I’m reading too many H&P (History & Physical) notes detailing depression, suicidal ideations, and other mental illnesses exacerbated by COVID and isolation. It’s sad, and I’m so impressed with the medical personnel who see this on a daily basis. I can’t imagine, since I’m just reading about it. The other difficult component is speaking with family members pleading to help their loved one when you’re calling to retrieve wt, ht, and nutrition Hx info. This part challenges your communication skills and evokes empathy and compassion (other crucial components of patient care).

Aside from those two wins of writing correct patient notes and a tube feed Rx, I learned that thiamine is used as MNT intervention for alcoholism, refeeding syndrome, and sepsis in the critically ill. I now order this for any patient who presents with any of those since thiamine is depleted, and subsequently impairs glucose metabolism, which can cause elevated POC glucose levels.

I have come across many patients with trouble swallowing too, so I’ve had practice and open communication with contacting the SLP (speech language pathologist) on staff. My preceptor told me a story of when she was an intern. Her patient reported mild trouble swallowing. The doctor said it was fine, but she ordered the speech consult anyways. The SLP found said patient had cancer in their voice box. Had she not had the bravery to listen to her clinical judgement, the patient might not have been diagnosed as early as they were with cancer. That story spoke to me, so I thought I’d share. The moral of the story is that you should focus on providing your patients with the best care possible. If you suspect something within your scope of practice, follow up, refer out, or place an order. It can’t hurt, only help.

I’m not sure if I mentioned this, but I’ve been shadowing the RD who covers the GI floors and COVID wing. We don’t go on the primary COVID floors, but they’ve overflowed to other floors. On the GI floors, I’ve seen many patients with SBOs (small bowel obstructions), ileuses (lack of movement in the intestines), ischemia (tissue and cell death), etc. Very interesting! If these patient’s issues do not resolve and their bowel isn’t working fully, TPN is initiated 5-7 later. I will be learning more about parenteral nutrition on the IMCU over the next two weeks.

I was surprised that I only had to work half days on Thursday and Friday for NYE and NYD- so exciting and nice! I really have loved and appreciate my experience at Swedish Hospital, made possible by the incredible dietitian team there.

4 weeks left- 2 on the IMCU and 2 as staff relief on floors assigned to me- OMG, so so close! 😆

Terms I learned

• Ogilvie Syndrome: dilation of the colon, which causes a pseudo-obstruction

Abbreviations I learned

• ESBL: “Extended Spectrum Beta-Lactamases” are chemicals or enzymes secreted by harmful bacteria that make them more resistant to antibiotics
• MRDO: “Multi-Drug Resistant Organisms” are bacteria themselves resistant to antiobiotics
• KUB: a kidney, ureter, and bladder (KUB) X-ray
• MAP: mean arterial pressure
• HCV: Hepatitis C
• PCT: procalcitonin (marker for sepsis, and COVID)

Happy to discuss this post further and hear you thoughts. 4 weeks and counting! Happy New Year again, and best wishes in 2021.

Clinicals: Week 5

I’m posting this a little later than I normally would because girlfriend needed a break from thinking about the hospital for a sec. I cried this past week…twice. I’m not sharing this for sympathy, but more of a heads up…You see, I have heard that interns cry at any given point during their clinical rotation. Whether it’s harsh preceptors, the environment, the pressure, stress, or all of the above- it seems to get you at some point. I stayed strong until week 5. I think I held out this long because I love the hospital and dietitian team I work with. What got me to crack was the pressure of trying to execute charting when I’m still learning how to chart certain things. It’s frustrating being a type A, perfectionist who cannot write a note without a correction, but that’s the learning process!

I realize these moments of pressure, stress, and being uncomfortable/unsure are catalysts for growth, so I’m embracing them. I tried my best to suppress my tears, but my sweet preceptor noticed I was being quiet on Wednesday and asked if I was okay. We all know too well that when we’re asked that question when already on the verge of tears, the floodgates open (and that’s just what happened). Luckily and thankfully, she waited until we were alone in the office. She heard me out and listened to what was plaguing me, and I swallowed my pride and moved on with the day, which included presenting RIGHT AFTER balling my eyes out lol.

I presented on this article titled the Association of DHA Concentration in Human Breast Milk with Maternal Diet and Use of Supplements: A Cross-Sectional Analysis of Data from the Japanese Human Milk Study Cohort. Check it out if you’re interested. I plan on presenting my findings in an Instagram Live this upcoming Sunday at 3pm CST. This is the handout I created to showcase the content of breastmilk and how it varies based on time of feed (beginning vs end), etc.

So Wednesday’s cry happened, I presented, and I thought I’d move on with my head held high with 2 more days to go before Christmas break. Nope. Friday I teared up again after I had multiple corrections on my notes. PEERS, repeat after me. “IT IS OKAY IF I MAKE MISTAKES IN MY INTERNSHIP. THIS IS A LEARNING PROCESS AND THIS IS THE TIME TO MISTAKES AND LEARN FROM THEM”. Give yourself grace in knowing that mistakes are how we learn! I will also say that all dietitians have their own charting/note-taking styles, so be patient in knowing that you may have to adjust accordingly without the expectation of being able to mind read how to match your next dietitian’s notes. This can be very annoying, but stay patient with this.

Aside from me crying, things worth mentioning were my cases with hyperemesis gravidarum and my pt who had an ileostomy. My pt with hyperemesis was young female who was newly pregnant (1 month) and was experiencing hypemesis (severe and frequent vomiting). She was dehydrated, depleted in sodium, and could not keep any food or water down, so she was a candidate for TPN. This wasn’t the only interesting part. The addition of cannabis use and suspected cannabis hyperemesis syndrome was also at play and could have been a factor of her chronic emesis.

The ileostomy pt was very interesting. He was a senior with current rectal cancer. He had his colon removed and an ileostomy (stoma, or hole, made through his abdomen into the ileum portion of his small intestine). He showed me his ileostomy bag filled with his excrements, so that was interesting. Surprisingly enough, these things don’t make me squeamish. I educated him on how to proceed with his diet post-op, including avoiding carbonated beverages, focusing on extra water and electrolytes, and slowly increasing fiber starting at 5-10g. These simple guidelines will help reduce stress on his GI tract while adjusting to his new norm of digestion and excretion. His water and electrolyte needs increased because the colon was removed, where most water and electrolytes are normally reabsorbed.

A little less than half my patients were PUIs or COVID+, so that was nice to see less cases for now…Swedish also started vaccinating on Friday! Heres the room set-up for vaccine screenings.

To end the week, the director of our department came by like Santa with gifts for all of us. This was very sweet of her to think of everyone, especially being a single mom with 4 kids! Impressive in my book. The rest of my learnings was first-hand, in-person experience, which I’m sorry, but real life experience cannot be replaced in the clinical context. I highly recommend getting most of your clinical hours done in person if possible. You’ll get way more out of it, even if it is more stressful.

And here are the terms and abbreviations I learned this week.

Terms

• Spondylosis: degenerative and age-related spine osteoporosis
• Capsulotomy: eye surgery with incision made on capsule on lens
• High output ileostomy: fecal matter and excrements exceed >1500ml post-op ileostomy. This makes pt at-risk for dehydration and electrolyte imbalance.
• myeloma: cancerous plasma cells that accumulate in the bone marrow

Abbreviations

• AAA: abdominal aortic aneurysm

*Notice the list getting shorter! 🙂

What questions or comments do you have? 5 weeks left of clinical until I complete my supervised practicum hours and head to Big Sky, MT to study in a winter wonderland!

Clinicals: Week 4

I’m nearly halfway through my clinical rotation, and guys…this setting is growing on me!! I never thought I’d be interested in or enjoy my clinical experience, but here I am…doing just that, and in the middle of a pandemic at that! I attribute my liking to clinical greatly to the amazing dietitian team at Swedish Covenant Hospital. Each one of them is amazing, both personally and professionally. I think patient, kind and guiding mentors make all the difference. I was lucky enough to get connected to them through one of my professors in my DPD program. I simply asked her if she knew any clinical RDs, and come to find out, she works there part time! Never be afraid to ask or network. It’s how I got 3 of the 4 of my rotations (of which I had exceptional experiences at each).

I also think I’m enjoying clinicals more because 1) I’m getting really good at navigating the EMR and charting, and 2) because I have the freedom to see patients by myself. I love that independence. It may seem scary to do this at first, but I suggest embracing the scarier because that’s how you grow! Practice is key. You won’t be perfect from the start. I have forgotten to ask a few questions or dig deeper for clarification with some patients, only to realize this later when I need the info for charting or for assessing malnutrition. That’s okay! Do the best you can. Also know that you can always call the patient’s room or visit them again later on to get this information. Is it ideal? No. But can you do it in a learning environment? Hell yes!

Besides the normal screening, assessing, diagnosing, and charting, here are some other noteworthy things I did this week.

1. Attended rounds with med students on the GI floor. I LOVED listening in on their reports because I learned so much, but also felt like I was on Grey’s. lol
2. I learned more about nephrology and palliative care. Unfortunately, we’re seeing a lot of elderly patients transitioning to palliative care due to COVID.
3. We had a lunch and learn about the latest food insecurity initiative that launched at the hospital last week.
4. I presented my first nutrition education to a patient with diverticulitis and who was post-op from a Hartmann’s procedure (resection of the sigmoid colon). OMG, I got to see a stoma with this patient too- aka hole in the abdomen to a part of the digestive tract (in this case, the colon)! It was literally plugged by gauze. Like what?! That was crazy to see.
5. I also got fitted for an N95 mask (finally). We don’t wear these on the floors, even with COVID patients on them, but they are required for TB+ rooms. It was kind of neat to experience how this is done. You choose a size mask that you think will fit your face well (small, medium, large). You position it with the two straps. Then they put this plastic covering over you and spray a scent into this covering. You’re supposed to count to 20 out loud as if you were normally talking. If you can smell or taste the spray after that, then your mask is too big because the droplets made their way in. If not, you good. I passed on my first try with my small face. haha

Other than that, the week wasn’t as crazy as the last few with learning and increased hospitalizations. I even got to leave early a few days, which was SO nice and makes all the difference in your energy levels and rest of your day. There was a sad COVID story, but I don’t think we need another one of those right now. Reach out if you’re curious.

Let’s cover the terms and abbreviations I learned. Notice, the length of the lists are getting smaller as I’m learning more. 🙂

Terms

• Rhabdomyolysis: muscle injury and breakdown where fibers are released into the bloodstream and negatively impact the kidneys
• Myelodysplastic syndrome: bone marrow disorder that doesn’t produce enough red blood cells
• Esophageal varices: enlarged veins in the lower esophagus
• Pyelonephritis: kidney infection, example is a UTI
• Uremia: elevated urea levels in the blood
• Ischemic bowel: inadequate blood flow to the small intestine
• Necrosis: cell death in tissues or organs
• Edematous: having edema
• MRCP/ERCP: imaging done to get better clarity on the gallbladder, pancreas, and liver

Abbreviations

• LBP: lower back pain

So, that was week 4 friends. What do you think? What questions do you have? I’d love to hear your thoughts. I have 1 more week untilChristmas break! (one week) Then powering through 5 more weeks until I’m completely through with my internship! I’m going to push myself to start studying a little each week to start preparing for the RD exam. The plan is to drive to MT and stay out there all of February when I’m studying, then take it as soon as I return. I hope to be licensed by February 15th, 2021! Eeeek!

Clinicals: Week 3

3 weeks down. 7 weeks to go! This week’s triumphs revolved around still improving with Swedish’s EMR system, further educating myself on refeeding syndrome and nutrition therapy for enteral and parenteral nutrition, and staying calm amid the increase in COVID cases and hospitalizations. I also plan on sharing my inspiration to learn a new language (or at least advance to conversational Spanish), some clinical attire I recommend (with the links to these items), and I’ll wrap up with more terms and abbreviations I picked up this week.

Okay, so EMR systems and charting can be extensive. I learned the basics pretty quickly in the first 2 weeks, but advancing to detailed charting is a little trickier. It takes time, patience, and proper navigation. What I mean by this is that you have to know where to look to retrieve pertinent information to determine the best clinical course of action for that patient. There are probably 15-20 main tabs to choose from, but then those tabs branch into past history and sub-tabs. 🤪 It’s a lot, but the advice I have for you is to be as attentive as possible when being trained. Remain patient, and simply do the best you can when trying to tackle this for the first several times. Give yourself grace. You’re learning, after all, and you won’t know how to execute charting perfectly at first.

As many of you know, knowledge is power. This is especially true in the nutrition and dietetics field. Studies are constantly being published, and this means we need to keep up with the latest evidence-based research. I’m lucky enough to have preceptors that supply me with applicable studies. If you’re interested, here are the ones I read this week.

Nutrition Therapy & Critical Illness: Practical Guidelines for the ICU

ERAS (Enhanced Recovery After Surgery): A Review

I also read 3 articles on enteral nutrition (EN) and watched an inservice webinar on parenteral nutrition (PN), which was very interesting (especially with adaptations for COVID patients). You see, COVID patients usually require BiPap, a pressurized oxygen mask used to force the delivery of oxygen into the lungs. With this positive pressure, comes an increased risk for aspiration. Therefore, EN might not be feasible or recommended when a COVID pt requires continuous Bipap. In addition, COVID pmts have a lower threshold for PN due to increased risk of infection. This puts medical professionals in a tough spot. Intermittent Bipap with EN is the goal, should PO (oral) intake not be an option. Remember, we always want our patients to eat orally first if possible, then continue to use the gut with EN if that’s not possible. TPN is the last resort, but it’s necessary in some patients.

Speaking of COVID, we (hospital staff) were aware that it would probably take about 2 weeks to see the aftermath of Thanksgiving get togethers. The load at the beginning of the week seemed pretty consistent with how it’s been the last 2 weeks, but Wed-Fri started increasing day by day. By Friday, the ICU floor was at capacity and we received an email that other floors would see an overflow of patients and COVID+ cases. This was evident in the workload the dietitian had that even bleed to us interns. The team was stressed, but not nearly as stressed as what we witnessed not he floors among the nurses and doctors all suited up in full-on PPE wear (gowns, gloves, double masks *surgical + N95*, and face shields). The energy was palpable. I teared up once on Thursday and once on Friday.

I’m not sharing this for you to pity me. I’m sharing to be transparent that this is exactly what’s going on in hospitals right now. it’s real, just as they report it and you hear on the news and from medical personnel. I watched Grey’s Anatomy on Thursday. It was the 1st episode of this most recent season about COVID. It depicted EXACTLY how it’s like in the hospital right now, so if you want a visual, watch that episode. I say this not to scare you either. I’m actually not scared, just sad. I’m sad for patients fighting for and losing their lives. I’m sad they have to do this alone. I’m sad for the family members that can’t be with them. I’m sad for the medical staff that are so stressed and overwhelmed but remain dedicated to saving lives and doing the best they can. I hope this wave ends soon.

On a lighter note, I witnessed my preceptor speak conversational Spanish to several patients. This re-inspired me to pick up Spanish as my second language. I would love to utilize this skill in both my professional and personal life, as I find it important to be able to communicate in various ways with others. I got to use the translation service too to communicate with a Japanese patient. That was fun! I received important information from him that I would have otherwise not known to improve his intake for MNT and recovery.

Okay! So I purchased these stretchy yoga-like (but not quite) pants that look like business pants. OMG they are SO comfortable! I’ll link both pair below. Very affordable too.

The grey, patterned pants above can be found here.

And then I purchased black ones with pockets, found here.

I’ve been alternating shoes, between booties, my Sperry boots, and these Sketcher’s glitter sneaks. Love them all, but the last two are the most comfortable for being on your feet.

Last but not least, here are the terms and abbreviations I learned this week that may be helpful for you to learn or add to your vocabulary in preparation for clinicals.

Terminology

• stoma: opening in the abdomen
• ileus: the inability for the intestine to contract (can lead to obstruction)
• midline PN is peripheral, not a central PICC (confusing, right?)
• trophic feed: progressive, incremental increases to ease into feeding and maintenance to avoid referring and overfeeding while achieving tolerance and goal

Abbreviations

• SBO: small bowel obstruction
• PE: pulmonary embolism
• TTP: thrombotic thrombocytopenia purport
• HFpEF: heart failure with preserved ejection fraction
• TIA: transient ischaemic attack
• DVT: deep vein thrombosis
• PCI: percutaneous coronary intervention
• CP: community pneumonia
• NST: nutrition support team
• SVT: supraventricular tachycardia
• BNP: brain natriuretic peptide
• PICS: post-intensive care syndrome
• IMN: immunonutrition
• OA: osteoarthritis
• OSA: obstructive sleep apnea

Did this help? Let me know! Hopefully I can play catch up with my Feed Me Happy and Fuel Her Up content soon. I have a plan for 2021. 🙂 Stay tuned!

Clinicals: Week 2

So I survived another week of clinicals, and guess what? Not only did I survive, but I thrived! I’m finding that approaching a task with positivity and determination usually leads you to success. If you fail, both positive thinking and that gritty determination will push you through to try, try again. This mindset has worked me during this rotation so far. First there was the fear of COVID. Then there was the frustration of realizing I was underprepared in some regards, and thirdly, I was overwhelmed with learning and navigating Swedish Hospital’s EMR system. I didn’t let my emotions get the best of me and just kept trying, and that fear, feeling of incompetence, and uncertainty just melted away.

This week (or 3 day holiday week) mainly consisted of screening, assessing, and charting patients. After only 8 days of practice, I feel MUCH more comfortable working their EMR system, so that was a win! Being trained on anything just takes time, my friends. Be kind to and remind yourself of this. Aside from the EMR, I did a supplement tasting with all of the supplements Swedish carries. I also attended my first journal club discussion with the dietitian team, and I saw patients all by myself for the very first time! 🙂

Let’s start with the tasting. At Swedish Hospital, they carry Ensure Enlive in chocolate and vanilla, Nepro in chocolate and mixed berry, Glucerna in chocolate, rich chocolate, vanilla and strawberry, Ensure Compact in chocolate and vanilla, the Ensure puddings and Magic Cup. In addition, the hospital makes in-house “power pudding” that contains prunes to relieve constipation, “super cereal” that’s a cinnamon oatmeal with 10g of protein, and “super potatoes” that are cheesy potatoes with additional nutrients and protein. Yes, I tried ALL of these! As my preceptor pointed out, it’s good to be able to relate to what your patients are receiving. For this reason, I was happy to do the tasting. None of the supplements were terrible, and in fact, I kind of enjoyed Glucerna’s rich chocolate flavor, the puddings, and all of the made-in-house foods. Magic Cup was a decent flavor, but the gummy texture was weird for me. It’s made that way to be safe for patients with dysphasia.

The journal club discussion I attended was held over lunch. The dietitian team hosts it monthly. This month, an intern presented her findings on calcium supplements in relation to increased cardiovascular risk. Some studies indicate that calcium supplements can potentially increase the risk of CVD, but more evidence is required to determine this and shed light on the pathophysiology. We, of course, joked about how everything is inconclusive initially…so annoying, but I get it. It was very interesting to discuss and get refreshers on calcium, supplements, bioavailability, pairing with vitamin D, etc. I’m sure I will be giving an inservice presentation on a journal article or two in the weeks to come.

The greatest win of my week was assessing my first patients independently. I can’t believe I got to do this in just 7 days, but I did! I also managed to navigate through the hospital wings, which was almost as great of an achievement since I am so pathetically directionally challenged lol. Here is a breakdown of the patients I saw while protecting their HIPAA rights.

1. I saw an elderly man who was A&O x1 (aka he wasn’t there and answered “ya” to everything I asked). Patients in this state are not considered reliable and/or “poor historians”, so I simply conducted an NFPE on him and retrieved more information from his nursing home.
2. Okay, it gets better…my 2nd patient was an elderly woman. She was so cute and sweet at first and seemed to be pretty aware, although, she couldn’t hear me well. I spoke as loud and as clear as possible so she could understand me. She told me she was hungry and that she couldn’t feed herself because she had “mittens” on *she held these up to show me*. For those who don’t know, mittens are put on patients who are either flight risks or pull their IVs out. She does both. She forgets she is 92 y/o, in a hospital, and just tries to take off- poor thing- but also kind of funny. I spoke with her nurse, and her nurse told me she’s been refusing to eat. I conducted an NFPE and recognized signs of malnutrition that I documented. Before I left, this patient asked if something was on the floor, but I couldn’t make out what she was asking about. Her words were mumbled. After 5 times of apologizing that I couldn’t understand her, she spelled M-O-N-E-Y. Money? Was there money on the floor? I told her no, that I didn’t see any money. She looked me dead in the eyes and said, “You’re lyinggggg!”. I was both amused and taken aback. I told her I would never lie to her. This woman went from sweet as can be to accusing me of stealing her imaginary money. Lol experience #2 on flying solo.
3. My last patient started out very alert and oriented. He reported loving the hospital food but having no appetite. We discussed the food, his supplements, etc. when all of a sudden he started to moan. “Sir, are you alright?”, I asked. I wanted to check on him, but also see if I needed to call for a nurse. All of a sudden he seemed out of it and started falling asleep. “Wait a second….is he pretending to fall asleep so Ill go away?”, I thought to myself. “SIR! I need to ask you just a few more questions”. “Uh-huh”, he replied incoherently. Alright, this man was either really good at pretending or his drugs kicked in and he’s a goner. I didn’t gather any other important info I needed, but I did manage to get his consent for an NFPE, which was helpful because he did have some fat and muscle loss present. The moral of the story for this one is to work in a timely and focused manner. You never know when your time will be cut short with a patient and retrieving that really crucial information from them.

What else I learned this week

Terminology

• osteomyelitis: infection in the bone
• edentulous: has no teeth
• myalgia: muscle pain/aches

Abbreviations

• DTI: Deep Tissue Injury
• BPH: Benign Prostatic Hyperplasia
• ADAT: Advance Diet as Tolerated
• ERAS: Enhanced Recovery After Surgery

*I also learned that Juven (a supplement that contains zinc, vitamin C, vitamin E, B12, arginine, and glutamine is contraindicated by severe cases of sepsis. Good to know.

Those were the 3 busy days of this past holiday week and week 2 of my clinical rotation experience at Swedish Covenant Hospital. What questions of comments do you have?

Turkey Enchiladas

Last but not least for my Thanksgiving 2020 meal edition are these turkey enchiladas! Fun and different, right? I mean, most of us love tacos, burritos, and anything wrapped up, so why not combine Turkey foods into an enchilada then bake it!?

Prep time: Varies Cook time: 10 minutes

Serving size: 2 Serves: 3

Ingredients

• Tortilla wraps
• Cooked turkey breast, shredded
• Pumpernickel stuffing OR your stuffing of choice
• Turkey gravy
• Cranberry chutney OR cranberry sauce
• Swiss OR goat cheese (if you like tangy flavors, goat cheese is awesome, but it can be overpowering with the cranberries)
• Thyme

Directions

1. Preheat oven to 350F and line baking pan with tine foil.
2. Ideally, everything will be cooked by the time you’re ready to assemble these. To do so, lay out a tortilla wrap. Drizzle gravy (may 1-2 Tbsp) down the middle. Add 4 oz of turkey, then top with 1/4 cup stuffing and 2 Tbsp cranberry chutney/sauce. Roll up and place fold at the booth to stay secured.
3. Continue doing this for all tortilla wraps. Top with Swiss or goat cheese, fresh thyme, and extra cranberry sauce.
4. Bake at 350F for 10 minutes, or until cheese melts.