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Clinical Nutrition Support

Overview

This rotation provides a total of 2 weeks experience in learning the clinical considerations in the formulation of TPN, composition and properties of enteral formulations, and the clinical conditions and responses of patients who require clinical nutrition support.  Two weeks are taken in first year, and again in third year, with the option for longer exposure according to the fellow’s elective choice.

Principal Teaching/Learning Activities

A web based module organizes the didactic activities with links to key articles, curriculum review and video lectures.  Additionally, there is interpersonal didactic instruction in the mechanisms of TPN formulation with the pharmacist director of Nutrition Support Services, and consultations in Nutrition Support under the immediate supervision of a Clinical Nutrition Specialist of the Nutrition Support Team.  Outpatient TPN management is learned under the supervision of Nurse Practitioner Nutrition Support specialists.  Weekly participation in Nutrition Support Inpatient Rounds, and Nutrition Support Clinic is available.

Problem Mix / Patient Characteristics / Types of encounters

Adult inpatients from intensive care units, general medical and surgical floors.  Ambulatory outpatients on chronic TPN.  A wide variety of underlying disease conditions and problems with one common unifying theme – the patient is unable to sustain hydration and nutrition through natural oral intake.

Purpose and Principal Educational Goals by Competency

Patient Care

Principal Educational Goals

  • Learn elements of patient history relevant to malnutrition, enteral intolerance, and tolerance of TPN support.
  • Learn elements of patient exam relevant to malnutrition, enteral intolerance, and tolerance of TPN support.
  • Learn strengths and limitations of laboratory studies in supporting care of patients receiving nutrition support.
  • Clinical knowledge of refeeding syndrome and how to avoid this.

Medical Knowledge

Principal Educational Goals

  • Expand knowledge base of methods of nutrition support, diseases causing malnutrition and malabsorption, eating disorders, nutrient and micronutrient absorption and clinical signs of depletion, short-bowel syndrome.

Practice-Based Learning and Improvement

Principal Educational Goal

  • Identify and correct knowledge deficits in the above issues of nutrition support.

Interpersonal Skills and Communication

Principal Educational Goals

  • Learn to work with varied allied health care personnel, including pharmacists, dietitians, and nurse practitioners, in the management of nutrition support for inpatient and ambulatory patients.

Professionalism

Principal Educational Goals

  • Behave professionally with patients and varied allied health care personnel in the management of nutrition support for inpatients and ambulatory outpatients.

Systems-Based Practice

Principal Educational Goals

  • Learn the complex systems for delivery of home care TPN.
  • Apply evidence-based and cost-conscious strategies in the delivery of nutrition support.
  • Learn to collaborate with other members of a diverse health care team in providing nutrition support to inpatients and outpatients.
  • Learn the third-party reimbursement limitations on the delivery of TPN.

Evaluation

This rotation is observational, and there are no patient care activities under direct faculty supervision.  The fellows competence in clinical nutrition is assessed by faculty as part of their global performance assessment.

Recommended Reading

  1. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, (Nutritional Assessment and Management; Enteral and Parenteral Nutrition; Obesity, Anorexia and Bulimia; Digestion and Absorption of Nutrients and Vitamins; Maldigestion and Malabsorption; Short-bowel Syndrome)
  2. University of Virginia Nutrition Support curriculum.  (program provides)
  3. Practical Gastroenterology series curriculum of nutrition support articles (program provides)
  4. Web based Nutrition support module, developed at URMC