Stephanie Perez, Registered Dietitian at Bacharach
If you think that being a Registered Dietitian at a rehabilitation hospital is easy – think again. RDs are responsible for making sure that patients have adequate nutrition to participate in therapy, so that they can do the physical work involved in rehabilitation.
Stephanie Perez, RD, recently celebrated 18 years at Bacharach. We asked her to tell us about her role in patient care, from preventing medication interactions, to menu planning, to helping patients with communication issues.
How do you make sure that patient medications are in line with nutritional needs?
We keep an eye out,” said Stephanie when asked about patient medications, “for Warfarin (Coumadin), Digoxin, Lithium, and a few others including diuretics in order to advise the patient as to foods that may need to be avoided or increased in the diet for best results.
Lithium is an older drug used for Bipolar disorder. Patients who are on it, and well controlled on it, may be admitted. Patients who take Lithium should not have restricted sodium intake; it is best that they stay as close to their normal intake as possible for the drug to keep working correctly.
It can be challenging that the Renaissance Pavilion and Bacharach’s acute medical hospital unit are run under different regulatory requirements, meaning varied assessments are required between the two hospital units.”
However, this year the NJ Department of Health approved diet order writing privileges for RDs in nursing homes like our Renaissance Pavilion (order writing had already been approved for Acute Care hospitals in prior years). Although we are still awaiting the actual change in the Medical Bylaws, this makes our jobs easier in terms of meeting the patients’ needs as quickly as possible when we can write orders for exactly what we’ve determined to be needed without a waiting period.
We literally monitor everyone’s diet orders and can select the best diet for them– and then order the correct diet for each individual.
How do you ensure that your patients get adequate nutrition?
If a patient appears to be uninterested in food, or states that they have not been eating well (‘no appetite’) this is a trigger for us to intervene immediately. Malnutrition occurs very quickly, especially in the elderly patients.
Since patients’ nutritional needs are different and will vary (generally higher needs for protein and calories) after any type of surgery this might include adding an oral supplement (the famous Ensure®!), which is a frequent and necessary intervention when patients are in the hospital, as they are at increased risk for dehydration and skin breakdown.
Sometimes they refuse to take supplements, in which case we may consider diet liberalization (discontinuation of restrictions they have been placed on) for a while until they are more alert and oriented as well as eating better. We need to rely on nursing observation as well as what the patient says to determine adequacy of intake; then nursing monitors the meal completions and charts them. We also monitor the body weight as well as any abnormal lab values that are taken. We then work with the physician to make the best plan possible for the patient to become well.
What are common problems that you must work around?
When a patient cannot hear, cannot speak (aphasic), and cannot identify their needs to us we investigate by way of discussion with speech and nursing staff and also by calling the next of kin. An example is a 37 year-old man who had a stroke and is unable to speak or feed himself. I was able to reach next of kin to get very specific food preferences. We have a wonderful food service software program that allows food preferences to be imbedded into the profile of each patient. When meals are selected the patient receives what is known to be liked.
When you are planning menus how do you calculate the optimal quantities and calories?
I have developed so very many menus over the years of my work that I can plan a well- balanced menu easily. However, when I first started I utilized huge nutrition textbooks and volumes of ‘Content of Calorie, Protein, and Fluid provided’ printouts in order to look up every individual nutrient for food on the menu. From there, I could determine the calorie, carbohydrate, sodium, and protein content within. All of this used to be handwritten, believe it or not. With the advent of computers, software programs have been developed so that the calculations can be done automatically now. Our software in the kitchen can spit out the nutritional value of any meal patient meal we make. Additionally, we aim to supply a low sugar diet without added salt during the preparation process, based on Dietary Recommendations for Americans provided from the U.S. department of Health and Human Services.
How has COVID affected what you do and how you do it?
We have not been on the floor anywhere near the extent to which we had in the past. We stay off the units as much as we can to decrease the possibility of spread of the virus. So over the past 6 months we have been utilizing the phones in our offices to call patients when we need to contact them. It has been challenging but mostly works! When we do travel to the units, we wear face masks and face shields, wear our lab coats and enter the patients’ rooms only if absolutely needed. Many patients look forward to their daily call from the diet clerk and love to chat for a while.
Do you have any sweet stories about patients who appreciated what you do?
I absolutely love when I am providing diet education to someone who now realizes the huge part that their diet plays in overall health. I can see the lightbulb going off, and it is beautiful. Surprisingly, many patients do not make that connection, including even extremely obese or severe cardiac patients.
I would like to also mention who the “we” is that I mention frequently in the Clinical nutrition department. She is Danielle McDevitt, MS, RD. She has worked here since June 2019.