Clinical Practicum Reflection

Jenna Godfrey
My clinical rotation consisted of three different facilities, all varying in size and
specialties. Transitioning between facilities was not as challenging as I had originally thought. As
all facilities were managed by one organization, the nutrition departments policies and
procedures were all relatively similar. They all utilized the same electronic medical record with
the same guidelines for prioritizing nutrition assessments based on acuity level. However, the
facilities themselves differed in terms of what services are offered, number of beds and
consequently how lengthy their patient assessment lists were each day. This provided me with
more variation in my clinical experiences as well as a strengthened ability to adapt quickly to
different environments and personalities rather than working with the same individuals in the
same facility for the full 12 weeks or so.
The first facility was very understaffed in the nutrition department, which gave me the
opportunity to jumpstart conducting nutrition assessments independently as my preceptor needed
help shortening the patient lists each day. The first week was spent observing my preceptor
conducting nutrition assessments and reassessments in their entiretyfrom reviewing charts to
interviewing patients to NCP documentation in the EMR. I was able to receive formal training,
the same training that new RD employees receive, on documentation in the EMR very early on
in my rotation at this facility. From this point forward, I began completing nutrition assessments
independently and reporting my work back to my preceptor for review. I was exposed to various
disease states and medical conditions including complex patients who presented with multiple
comorbidities. During my time at this first facility, I was able to complete two case studies using
the NCP form. These cases were for patients presenting with diabetes and cardiovascular disease.
For the diabetes case, I selected a rather complex patient who was admitted due to a recent non-

healing toe amputation (diabetes-related gangrene) which inevitably required a transmetatarsal

amputation. This patient had minimal oral intake with ESRD and was receiving hemodialysis
three days per week, complicating her case even further by increasing her energy and protein
needs. She ended up being in the hospital for several weeks, and I was able to track her case very
closely. This was a great opportunity to see a complex patient for the full duration of her
inpatient medical course. For my second case, I selected a patient presenting with congestive
heart failure and was able to conduct his initial assessment as well as diet education intervention.
Unfortunately, there was minimal exposure to more critical cases in the ICU, those requiring
enteral nutrition, as well as pediatrics during my time at this facility.
My next clinical adventure began at a much smaller facility. Despite this facility having
less beds than the previous, I was exposed to even more disease states and medical conditions.
During my time at this facility, I continued conducting nutrition assessments and reassessments
independently. Additionally, I was able to complete all three diet education requirements with my
preceptors observation at this facility in the fields of diabetes, congestive heart failure, and
warfarin-vitamin K interaction. Another opportunity to follow a patient closely presented itself at
this facility, ultimately leading to the selection of my case for the clinical case study. The patient
chosen was admitted due to acute pancreatitis caused by cholelithiasis. I was able to follow his
case repeatedly as he remained in the hospital for a total of 37 days due to a complicated medical
course involving respiratory failure, enteral nutrition, and acute rehabilitation. I also provided
this patient with pancreatitis nutrition therapy education as my final intervention, which further
strengthened my educational skills and understanding of MNT in different disease states. My
preceptor was able to arrange for me to observe a modified barium swallow study as well, which
was very exciting and beneficial for my understanding of SLP. Similarly to the previous facility,

I did not have significant exposure to cases involving enteral nutrition, critical care, or pediatrics
during my time at this facility.
Lastly, I transitioned to a significantly larger facility during the final three weeks of my
clinical rotation. This facility provided me with more experience and exposure that I was not able
to receive at the previous facilities. I was able to work on most units of the hospital including
general, respiratory care, surgical step-down, neurology, cardiac, renal, oncology, and the ICU. I
had more direct exposure to patients requiring enteral nutrition, as well as patients who were
obtunded and mechanically ventilated. During my time at this facility, I was able to present my
clinical case study on acute pancreatitis and receive helpful feedback from the RD staff. I was
hoping to gain more experience in pediatric MNT at this facility, but no assessments were
triggered while I was scheduled to work with the RD covering that particular unit. Additionally, I
had expected more exposure to cases requiring parenteral nutrition, but was only provided with
case studies and examples by my preceptors as no actual assessments became available. As a
result, I do not feel as comfortable with my skills in pediatric MNT and parenteral nutrition as I
do in cases of diabetes, CVD, renal, cancer, infection, wound healing, etc.
Overall, I feel that I have had a positive experience in clinical nutrition and have a more
narrowed idea of the fields I am interested in pursuing. I feel more confident in my skills in the
nutrition care process, patient interviews, diet educations, and navigating the Nutrition Care
Manual. I have become significantly quicker and more confident in my ability to construct
accurate and evidence-based PES statements as well as appropriate interventions. I still have
some difficulty remembering the right questions to ask during patient interviews if I did not write
them down. I imagine this will continue to improve through practice to the point where it would
come as second nature. There are also some aspects of MNT that I feel are still ambiguous,

specifically in the area of clinical judgement. For instance, I occasionally second guess myself
when estimating energy and protein needs in cases of obese patients who present with acute
illnesses that increase their needs. I question certain calculations for these types of cases because
the results seem too large as well as unrealistic for the hospital to provide. This is also
concerning in cases involving nutrition support as we need to be careful not to overfeed. I
imagine that this will also improve with practice and my clinical judgement will become stronger
overtime.