DTR: Check

Holy cow, I passed the DTR exam.  This post will be me brain dumping any advice I can think of since it is all very fresh in my mind.

1.  Scoring
I still don't understand how this test is scored.  To pass, you must receive at least 25 out of 50 on a scaled score, "scaled scores represent an adjustment to the raw score that compensates for any slight variation in the difficulty of the examination."  I guess this is because each person that takes the test gets different questions.  Who knows! All I know is I got 28 points which means I passed and don't have to take it again!

2.  Cost
The test is made by the Commission on Dietetic Registration and it costs $120 to take the exam.  You can purchase a study guide for about $60.  The study guide is a binder containing an 8 page very detailed outline of topics that can be covered on the exam.  I attempted to go through the detailed outline defining and studying the topics listed but made it halfway through page 2 before I stopped.  The study guide does contain a practice test that is available on paper and online.  You are able to take the online test 3 times. 

Although the paper and online tests have all the same questions, it is helpful.  You are able to see the style of questions asked and also can become comfortable taking the test on a computer since that is what you do for the real exam. It's up to you if this is worth the extra cost.  Personally, I wanted to take the test knowing I had exhausted all resources so purchasing the study guide gave me a better piece of mind.  I think it is worth it though.

3.  Preparation
Again, you can use the CDR study guide.  I also had a study guide made by a student, found here.  I basically used both and was able to pass.  Plus I made about 500 flashcards. I was really concerned I wouldn't remember information I learned in school since I graduated 5 months ago.  However, when you know something well it should be able to stick with you for a long period of time.  You may be asking yourself what to study and the answer I'm afraid is EVERYTHING!

You can be asked everything from a basic accounting question, to the temperature of a beef patty, to what is age appropriate to feed a toddler for lunch, to handling employees, to how to remodel a kitchen.  I found the broadness very frustrating.  I have trained as a diet tech at our hospital where the job is limited to modifying diets, taking temperatures of food, ordering supplements, and communicating with patients, doctors, nurses, and dietitians.  They do not have to calculate FTE's, accept food deliveries, discipline employees, or counsel patients.  However, in the big picture this knowledge will be needed for the RD exam so I decided to grin and bear it. Also, techs at different facilities may have different responsibilities. 

So to summarize; you need some sort of study guide or outline to go off of so you know all of the topics you are responsible for.  You can purchase the CDR study guide.  You can ask me about the student study guide I used.  Or if you search online there are additional resources you can purchase.  Flashcards are helpful!  Practice tests are helpful!

4.  Other Tips
I did notice a couple of patterns with answers for questions.  Don't rely on what I say, it is something I think may be true

-Questions asking you about seeing patients (i.e. they have dentures and aren't eating, they have lost weight and may need to be put on parenteral nutrition) with answers such as place patient on tube feed, give patient pureed food, ask about food preferences, refer to dietitian.  Since techs are not allowed to prescribe diet orders, it would never be to put the patient on a tube feed or pureed diet.  You can ask about food preferences, but usually the patient will get referred to a dietitian.

-Questions about disciplining employees (i.e. the clerk has been leaving early or the cook has been leaving the food out over the heaters for 2 hours when they are only allowed out for 30 minutes) with answers such as report to supervisor, conduct an in service, record the incident, instruct/counsel employee in private/individually.  The answer was always talk to the employee personally about the issue.

-Questions about patients not eating, having low intakes, or losing weight.  The answers varied from monitoring through daily weights, plate wastes, calorie counts, and asking about food preferences.  Honestly, I relied on calorie counts, but this wasn't always the answer.  I wouldn't put daily weights since a tech usually wouldn't weigh a patient everyday, that would be up to a nurse. 

Example of a ridiculous question from my CDR study guide:

"A noon meal at a nutrition site for senior citizens consists of baked chicken, mashed potatoes and gravy, and asparagus with hollandaise sauce.  To improve plate presentation and appeal, the tech should substitute:

A.  Broccoli with cheese sauce for the asparagus with hollandaise sauce
B.  Steamed broccoli for the asparagus with hollandaise sauce
C.  Fried chicken for the baked chicken, and tomato slices for the mashed potatoes and gravy
D.  Fried chicken for the baked chicken, and broccoli with cheese sauce for the asparagus with hollandaise sauce"

The answer? B.  This is because you want varied colors and textures.  There is already gravy on the potatoes, so having a similar colored sauce over the green veggies makes the plate look rather beige.  Subbing in broccoli brings in green to a plate of whites and browns.


ALSO don't worry about memorizing all of the can sizes.  I just memorized the #10 can, and I don't think there was even a question on that.  There were at least 2 scooper questions though.


All in all, don't be intimidated by the broad amount of info you need to study.  Just do it and get through it.  I found a glass of wine and the Mumford and Sons Pandora station to make the studying process a little more enjoyable!  Take the test as many times as you have to to pass.  I trained as a tech before I took the test and it helped me learn food exchanges, renal patterns, and standard food servings really well.  Once you have this certification, when you get a job there won't be much nutrition learning for you to do!  You will be able to focus on how your facility runs (i.e. the computer program, daily routine, staff, etc).  Remember, you can do it!  The feeling of passing has made it all worth it for me! 

Can Confusion

I'm studying for my very upcoming DTR exam and have been avoiding learning about can sizes because I'm scared to memorize the various sizes and how many servings they contain.  So here's me brain dumping all I know about can sizes. 


What I found from Wikipedia, summarized
Different Sizes:
Size 7/8: one serving of 1/2 cup (weighs 4oz)
Size 1 "picnic":  2 or 3 servings totalling 1 1/4 cups (weighs 10 1/2 oz)
Size 303: 4 servings totalling 2 cups (weighs 15½ ounces)
Size 10: most widely used by food services, 25 servings totalling 13 cups (weighing 103½ ounces)
taken from http://en.wikipedia.org/wiki/Tin_can

I wanted to see how much each serving contained in a #10, I divided 25 by 13 and got 1.92 which wasn't helpful. When I converted the 13 c to ounces and divided that by 25 I got 4.16 oz.  So I guess it is safe to assume that each serving from a #10 can is a little over 4 oz or half a cup.  I did the same for a #303 and got a little under 4 oz (3.875 to be exact). 

I think it is also important to know that there are 6 #10 cans per case.  It came up on a practice question on my DTR study guide from the CDR.



Then I found this from fooserviceequipment.com, a very  helpful but scary chart I'm worried I will spend the next 30 hours trying to memorize...until I realized it doesn't tell you how many servings each can contains.  It would appear that most are 4 oz servings, but I don't want to assume that and be wrong.

Can Sizes
8 ounces	8 ounces	1 cup
Picnic	10-1/2 to 12 ounces	1-1/4 cups
12 ounces vacuum	12 ounces	1-1/2 cups
#1	11 ounces	1-1/3 cup
#1 tall	16 ounces	2 cups
#1 square	16 ounces	2 cups
#2	1 pound 4 ounces or 1 pint 2 fluid ounces	2-1/2 cups
#2-1/2	1 pound 13 ounces	3-1/2 cups
#2-1/2 square	31 ounces	scant 4 cups
#3		4 cups
#3 squat		2-3/4 cups
#5		7-1/3 cups
#10		13 cups
#300	14 to 16 ounces	1-3/4 cups
#303	16 to 17 ounces	2 cups
Baby food jar	3-1/2 to 8 ounces	depends on size
Condensed milk	15 ounces	1-1/3 cups
Evaporated milk	6 ounces	2/3 cup
Evaporated milk	14-1/2 ounces	1-2/3 cups
Frozen juice concentrate	6 ounces	3/4 cup

taken from http://www.foodserviceequipment.com/PROLINK-WEB/cookingconversion3.htm#Can Sizes and Equivalents

Then I stumbled upon this beautifully organized rectangle of numbers and measurements on the same website.  I wish I could spend a couple hours in a tattoo parlour getting it inked onto my forearm in about 4 pt Arial font.  I really did.  Until I realized it would be about as attractive as a tramp stamp on my lower back and unless I planned on limiting my dating to fry cooks or dishwashers it would not help my game.  Sigh.  I'll try to mentally ink it into my cranium for now.

Common American Can Sizes
Size Number	Weight	Cups	Servings
1/4	4 oz	1/2	1
3/8	6 oz	3/4	1
1/2	8 oz	1	2
1 picnic	10 1/2 oz	1 1/4	2 - 3
211	12 oz	1 1/2	3 - 4
300	13 1/2 oz	1 3/4-2	3 - 4
303	15 1/2 oz	2	4
2	20 oz	2 1/2	5
2 1/2	28 1/2 oz	3 1/2	7
3	33 1/2 oz	4 1/4	8
3 cylinder	46 oz	5 3/4	10-12
5	56 oz	7	14
10	103 1/2 oz	13	25

taken from http://www.foodserviceequipment.com/PROLINK-WEB/CookingConversion2.htm

I have a hard time getting myself to memorize this, because form my experience at where I work now, the DTR does not deal with cans and measurements.  There is a food service director that does this instead.  However, I will admit that I have seen one of the DTR's do projects analysing current recipes for kcal counts and she has to go through every ingredient and figure out serving sizes.  Still, she would refer to a chart like this and not her memory.  Even at a previous food service job at the Children's Center we were able to refer to a chart just like this attached to the wall above the prep area. 

ANYWAYS instead of whining, I need to spend my time MEMORIZING and STUDYING.  Here's a practice problem I encountered on the practice test from the CDR:


How many cases of #10 cans of green beans are needed to serve 285 1/2 c portions?

First of all, if you don't know how many #10 cans come in a case, you're screwed.  We know that there are 6 per case, so we can move on with our calculations instead of blindly picking answer C.

Secondly, we know that each can contains 13 cups or 104 oz.  We need a total of 1,140 oz.  1,140/104=10.96 or rounded up 11 #10 cans. That means we need 2 cases since each contain 6 cans.  

(The study guide attacked the problem a little differently, they said that since each can has 25 servings, multiply 6 cans by 25 servings to get 150 servings per case.  Since you need 285 servings total, you would need 2 cases.)

So what do we need to memorize after doing this problem?  
There are 6 #10 cans per case
Each #10 can contains 13 cups or 25 1/2 c servings


How many #10 cans of green beans must be bought to make 200 1/2 c servings?

We know that each can has 25 1/2 c servings, 200/25=8.  8 #10 cans


A 2oz portion of beans is needed per servings.  How many #10 cans should be ordered if making 235 burritos and each can weighs 5 lbs?

We need 470 oz or 29.375 lbs total.  Rounding that up to 30 lbs, we would need 6 #10 cans at 5 lbs each.

This question didn't require anything memorized, just basic math.  How nice!

TEASER: Day in the Life of a Diet Tech

Sorry this blog's posting has become about as reliable as a college aged boy calling you back.  Ok that's a bit harsh, who even calls people anyways?  We'll go with texting back, sometimes boys get around to that.  I have been incredibly busy at work, in fact the last two weeks I've worked 7 day stretches in a row with a one day break in between.  (If you're thinking this isn't possible, it is.  It somehow works and although it is painful, it is also legal.  Thanks for caring though!)  Anyways, besides coming up with some interesting hair do's or lacktherof at 5:45 in the morning I learn more and more everyday.  I am still hostessing but have also been training as the tech.  The tech position requires a lot of knowledge that the exam and certification ensure.  However, the position needs a lot of training and experience because it entails a ton of multitasking.  A lot of responsibility too!  The tech corrects orders and is responsible for patients receving their appropriate diet, or getting possible supplements/tube feeds, or making sure their meal doesn't contain anything they are allergic to.  Techs are also responsible for giving patients a birthday dessert if they happen to be hospitalized on their bday.  Allergens, supplements, tube feeds, birthdays, isolation rooms, carb counting, renal diets, patient 1234 needs 7 splendas and doesn't eat lemon or blueberry yogurt, can you cover this computer while I go to the restroom?, time to take food temperatures, beep beep goes the beeper, is it 4:00 yet?????

Can you tell I wrote this at 6:00 in the morning?  Hopefully once I have a day off and rely on a full night's sleep over 5 cups of coffee I will write a full and more detailed post about the tech position before Brad from Bull's texts you back in this lifetime....

A Caramel Apple a Day...Adventures in Mocky Mountain

In honor of Halloween and our dearly beloved friend the apple, I thought it would be "fun" to make caramel apples for Halloween.  I've never made them before, but decided to go all out and do my take on the apples done by the Rocky Mountain Chocolate Factory.  If you've never been to a Rocky Mountain, don't.  You won't know what your missing and you will still be missing the 5 lbs you will gain after visiting.  Just kidding.  Not really.  The store makes fantastic fudges, chocolates, and best of all: the caramel apples.  With flavors like s'mores, apple pie, pecan bar, rocky road, snickers, and cheesecake, you'll forget you're getting a fruit serving!  Needless to say, these are off the charts in Weight Watchers points.  (I was appalled when I found out the kcal count in each apple-do your self a favor and don't look.  That goes against everything I preach about nutrition, but you're more likely to have a heart attack from the shock of discovering the mass amount of calories in each apple than from the amount of fat  clogging your arteries).  Anyways, I decided to make my own "Mocky Mountain" apples.  I pictured artisan apples perfectly coated in homemade caramel, white chocolate, and a spiced graham cracker coat.  I laughed at the thought of paying up to $10 for the same creation at Rocky Mountain.  How hard could dipping apples be?

Let me tell you, this isn't rocket science, but once I was done it left with my kitchen looking like hurricane Sandy had hit it. $10 a pop wasn't sounding too awful.  Here are some tips you should know from my mistakes:

• Use a knife straight down the apple to make it easier to push the lollipop stick through.  I kind of made an X slit if you were looking down where the stem would be.
• I decided to buy caramels and melt them instead of making my own.  Try and get unwrapped caramels if possible.  Also, melt them over a double boiler and add 2Tbsp water to thin it out.  I did not add water at first and only got 3 apples dipped from 1 bag of caramels.  Oops.
• DON'T set dipped apples on wax paper.  It will stick.
• Chill dipped caramel dipped apples before doing the white chocolate coat.  
• I set my apples in cups after doing the crumb coat, stick down.

If that didn't scare you away, here are the steps to a heart attack on a stick.  Don't feel too bad, an apple a day does keep the doctor away...


1.  Remove stems from apples.  Wash well, dry, and chill.  It is important that the apples are washed well so the caramel sticks.  Store- bought apples usually have a wax layer that won't let anything stick.  This goes without saying since you're washing, but take the stickers off too.  No one wants a bite of that.

2.  Use a knife to make a pilot slit for your lollipop stick.  Insert stick.  I guess you can do this before you chill the apples.

3.  Melt the caramels + 2 Tbsp of water together using a microwave or double boiler.  I like the double boiler because it melts slowly and you are less likely to burn them.  If using the microwave, do it in phases.  Melt over the double boiler until it becomes smooth. Remove from heat.

4.  Dip the apples in the caramel.  You can dip the apple in as far as you like.  Try and get the excess off, especially the bottom.  Set down on a plate and chill.

5.  In a food processor, crush 6 graham crackers until  fine and sand-like.  I added in cinnamon (kind of a lot) and brown sugar and pulsed to mix.  Pour into a bowl for dipping.

6.  Melt the white chocolate.  I do this in the microwave in 30 second intervals, stirring each time.  It may sound annoying, but it's not as obnoxious as the smell and sight of burnt white chocolate or driving to the store to get more.  Once the chocolate is smooth, dip the chilled apples in.  Again, dip as far in as you like.



7.  Immediately dip into the crumbs, being careful the chocolate layer doesn't pull off.  I then put the apples in cups, stick down, to set.  This 90% worked because one apple actually stuck to the cup and I ended up having to throw both out (my kitchen was a mess and I was fed up.  I blame Sandy.)

8.  I placed my apples in cute Halloween candy bags and secured them with a tie.  I placed the bags in the refrigerator to chill before I delivered them to my hungry aunts, uncles, and cousins.

Am I Boring You?

Happy Halloween! Yum look at all those vegetable servings!

I was "viewing" my blog and noticed my recent posts have been on the more educational and informative side.  Sorry if that also means boring.  I've been lead to believe my beginning posts were entertaining and even considered quite funny on the hilarity scale.  Now that I'm working it seems the tone has changed.  Due to this contrast you might be lead to believe that joining the working world sucks any sense of fun and humor out of you.  This is not the case.  There are an embarrassing amount of things that happen to me at work that you might find funny (I can already count on two hands and almost one foot how many times I will look at a baby or a picture and say "Your son is adorable!" and get the reply, "She's a girl...").  The thing is that although I find things funny, I value and take my job more seriously than the need to share stories for laughs.  What I do at work is confidential.  You might think a patient's choice between short ribs or chicken picatta shouldn't be kept secret, but it is.  All patients have the right to 100% confidentiality, from their medical records to their dinner entree. 

On a different note, I had someone ask me what I was doing right now professionally.  I told them I would be starting diet technician training next week but I was currently a hostess at the hospital.  The person was kind of snooty to be honest with you.  They asked why I didn't just work in a restaurant and make tips.  I laughed it off, but it also made me think.

First.  When I was offered this job, my boss told me I would be starting at the bottom and that I was overqualified.  The other hosts I work with don't have degrees in nutrition and haven't finished college.  They still know A LOT about diet orders and could even teach some current nutrition students a thing or two from the things they have absorbed working in a hospital.  

Being in a professional environment and absorbing information and experience can apply to any field.  My mom told me a story about her first job in accounting at a CPA firm.  Her boss was holding a meeting and was putting an employee at the very bottom of the totem pole  responsible for making all photocopies.  This employee asked the boss, "I have a college degree, how is this task putting it to use or furthering my career?"  The boss replied, "You can turn any task into a learning experience.  Read the memos and reports, you can pick up language, terms, and policies.  Absorb everything you can and don't take a task for granted and turn it into a thoughtless process."

This totally applies to me.  I could go on robot mode with patient orders.  I don't.  I learn the diet order abbreviations and know what is allowed in each order.  This might be the responsibility of someone else (the tech/RD) but those are positions I will be doing someday.  Being exposed to it now gives me valuable knowledge.  So no, I won't be a host in a restaurant.  The exposure I have now is far more valuable than tips.

Patients love when the dogs visit!

Second.  I like that I'm called a host.  I like to think that I am the one person in the hospital (besides the therapeutic dogs* maybe, they're THE COOLEST!)  that can help the patient think they are somewhere else.  I like to think that maybe, just maybe, giving patients meal choices can help them think for a second they are sitting at a restaurant table instead of laying in their hospital bed.  I know other hospitals get a diet order (i.e. Cardiac, Renal, Mechanical Soft) and have a set menu already in place with a meal for the patient. I work at a spectacular facility that gives patients choices and these choices can only be made with hosts and hostesses.  

Working as a host in a restaurant might be more comfortable, but for me personally what I'm doing now has much value and purpose.  Working in inpatient, patients come and go.  I usually don't see them for more than a couple of days.  However, I do have my "regulars" like a waitress in a diner would have.  Of course, I would never wish it upon anyone to ever be a "regular" at a hospital.  I'd rather people be healthy and get discharged as soon as possible.  Regulars are patients in the hospital for several days that I build relationships with.  I remember their names, their juice of choice, and what college football game they're watching on Saturday.  Sometimes, I even let them order cheeseburgers or let them have ice cream and apple pie (if their diet allows it, of course).  They brighten my day and I like to think I brighten theirs.  

*Your dog can be a therapeutic dog too!  They are the dogs of volunteers that are friendly mellow dogs.  They are groomed appropriately and visit with patients.  All people that come in contact wear gloves.  

Pumpkin photo by Stephen St. John, National Geographic retrieved on 31 Oct 2012 from http://news.nationalgeographic.com/news/2011/10/111028-halloween-facts-costumes-history-nation-science/

Therapeutic dog photo retrieved on 31 Oct 2012 from http://www.petanim.com/6399/jlbenton/pet-therapy-pet/

 

Diet Order Abbrevs.

As you can imagine, there are many different diet orders in the hospital. Techs and clerks use abbreviation/s on tickets for patients' meal orders. The tickets are on the tray with the meal and have the patient name, DOB (date of birth), room number, diet order, and a list of all items on the tray.  Before trays are passed, diet orders are read off the tickets to the charge nurse or secretary in each unit.  This is done because a diet order may change after tickets are printed (i.e. a patient may move from a liquid to puree diet or from a regular diet to no food by mouth).  Keep in mind different staff or hospitals may use different abbreviations.  Do you know some abbreviations? Let's find out!

1. ClLiq
2. FlLiq
3. GBPs
4. LctOv Veg
5. LactI
6. CarbCont
7. LoFt
8. Viet
9. 18Cal
10. 15Fl
11. GERD
12. TF
13. NPO
14. GlutF
15.  MinFib
16. LoFib
17. Microb
18. NAS
19. 2gNA
20. Card
21. Lo Res
22. Veg
23. Kosh
24. Dys 1/2/3
25. HnyThc, NctThc
26. K
27. HiFib
28. Reg
29. RnlStnd

1.  ClLiq: Clear Liquid

taken from be-kind-have-faith.blogspot

Clear liquids include juice, tea, coffee, water, jello, broth, and popsicles (anything clear that melts at room temperature).  May be reserved for patients with digestive issues or prior to medical procedures.  Post-partum patients that have undergone a Cesarean section will be put on this diet post op.  Should be followed short term as it contains minimal energy, fat, and protein. (I had a patient this week on a Cl Liq who kept asking for a pitcher of beer, I mean he kind of has a point...)

taken from sparrowhawkseries.com

2.FlLiq: Full Liquid
Full liquids include cream based soup, pudding, custard, ice cream, milk, milkshake, supplemental shake, and creamer.  Patients usually transition from a clear liquid to a full liquid or may be on this diet prior to or after a procedure.  As you can imagine, a full diet can offer more energy, fat, and protein than a clear diet.






3. GBPs: Gastric Bypass
After a patient undergoes gastric bypass surgery it is absolutely essential that their intake is monitored.  A patient will start with a clear liquid diet, but only when the nurse allows them to begin eating.  In fact, a GBPs patient's first tray will not be delivered but put in the fridge.  A nurse/doctor will decide when the patient is ready.  This is because the body must heal and adjust to eating patterns.  Post op patients will transition from clear liquid, to full, to puree, to mechanical soft, to regular foods.  Straws are NOT allowed for GBPs patients because you don't want them to be in-taking anything too rapidly. 

4. LctOvVeg: Lacto Ovo Vegetarian
Does not eat any meat, including fish.  Does eat dairy and milk products.

5. LactInt: Lactose Intolerant
Does not eat dairy products.  This includes ice cream, milk, cheese, ranch dressing, some shakes, etc.

6. CarbCont: Carbohydrate Control
Usually for patients with diabetes.  Need to make sure patient has protein  with carbohydrates and encourage whole grain sources and fiber.  Limit fruits, juices, and other starches.

7.  LoFt: Low fat
Limit fat.  For example if a patient has had their gallbladder removed.

taken from Stanford School of Medicine: eCampus Gariatrics

 8.  Viet: Vietnamese food
Some hospitals may offer Vietnamese food for patients who are Vietnamese.  A nurse has to request this order.  Items may include a pork based porridge for breakfast, tofu, stir fry, chicken, won ton soup, fish, rice, soy milk, and tea.





9. 18Cal: 1800 calorie diet
May have any number (i.e. 20 for a 2000 kcal diet).  Patient may have to limit calories for weight loss or diabetes.   

10.  15Fl: Fluid Restricted to 1500 mL
A patient may be on a fluid restriction if suffering from edema or swelling.  Fluid may be distributed evenly (i.e. 8 oz at breakfast, 8 oz at lunch, 4 oz at dinner).  This includes soup, broth, beverages, jello, and popsicles.

Taken from gerdremedies.info

11. GERD: Gastroesophageal reflux disease
Want to discourage food from refluxing up from stomach.  No pepper! Avoid spices, caffeine, fat intake, chocolate, mint, carbonation, citrus, and tomato products.  Small frequent meals are encouraged over large meals.  




12.  TF: Tube Feed
Patient is intaking food via enteral or parenteral feeds.  The type and rate is calculated and orders by a doctor or Registered Dietitian. 

13. NPO: Nothing by Mouth
 These patients cannot have a tray of food, not even liquids.  Usually there will be a NPO sticker by their door number to alert food service workers not to bring them a tray if it was ordered.  These patients may be awaiting surgery or a medical test.  They also may be receiving a tube feed.

14.  GlutF: Gluten Free
Patients with gluten allergies cannot have many bread products.  Can consume corn or rice products.

15.  MinFib: Minimal Fiber
Extremely low fiber intake.  Very limited amount of wheat carbs, fruits, and vegetables.

16.  LoFib: Low Fiber
Low fiber intake.  Can intake a little more fiber than MinFib.  Again, limit wheat based carbs, fruits, and vegetables.

17.  Microb: Microbial

taken from http://tripsons.blogspot.com/2012_04_01_archive.html

For patients with compromised immune systems or have undergone intensive cancer therapy that may get sick easily from  microbes found in raw/fresh fruits and vegetables or undercooked meat.  These patients can eat canned products which have had microbes safely eliminated in the canning process.  It is highly likely that these patients will be in isolation rooms, which means visitors must wash hands and put on a gown, gloves, and mask before entering. 


18.  NAS: No Added Salt
No salt on tray; patient may get a no sodium seasoning packet instead.  Also limit processed meats and soups.

19. 2gNA: 2 grams of Sodium (or 2000 mg)
Again, could be 1gNA for 1 gram.  Patient's sodium is being limited, usually for cardiac patients.  Patient will not be allowed meat besides poultry or fish (no ham, sausage, bacon, or beef).

20. Card: Cardiac Diet
Patient will be limiting fat and sodium.  Usually will not be allowed sodas, coffee, tea, some red meats, margarine, butter, regular salad dressings.  May offer diet dressings, sugar free puddings, jellos, custards, and ice cream.

21.  LoRes: Low Residue
Limit fiber and other foods that are harder for your body to digest are restricted.  Usually for patients with Crohn's, Ulcerative Colitis, or Diverticulitis.  

22.  Veg: Vegetarian
Patient doesn't eat meat but does eat fish.

taken from http://www.theyeshivaworld.com/article.php?p=28664

23.  Kosh: Kosher
Follows Jewish guidelines.  Some patients may follow the guidelines stricter than others (i.e. will eat chicken or fish not killed in accordance to law but won't eat any pork).  A Kosher diet allows fruit and vegetables but not pork.  Dairy cannot be eaten with meat (flesh of animals).  Approved animal products must be killed in accordance to Kosher guidelines.  Some Kosher patients may also be concerned of utensils used with non-Kosher food used with Kosher food.  Some hospitals may have pre-prepared Kosher meal packs available that are ready to eat.  

24.  Dys 1/2/3: Dysphagia 1, Dysphagia 2, or Dysphagia 3
Different levels according to patient's ability to swallow.  Patients with dys1 especially will not be allowed any straws due to risk of aspiration which could cause pneumonia (largest concern).  Remember that 1 is pureed foods, 2 is usually mechanical soft foods, and 3 is no sticky or crunchy foods.

Taken from Hormelhealthlabs.com

25. HnyThc, NctThc: Honey Thickness, 
Nectar Thickness
Usually in addition to a liquid diet. Remember that honey thickness is thicker than nectar.  Thickening agents can be added to beverages for patients at risk for aspirating. 




26. K: Potassium
Some patients may need to increase certain minerals such as Potassium, which can be found in bananas, potatoes, orange juice, beets, white beans, yogurt, and tomatoes.  Grapefruit is a good source of potassium, however products such as grapefruit or grapefruit juice are typically not allowed in hospitals because it harmfully interacts with many drugs including Lipitor, Valium, and Xanax to name a few.

27. HiFib: High Fiber
Encourage wheat carbohydrates, fruits, and vegetables. 

28. Reg: Regular
Patient has no restrictions.

39.  RnlStnd: Renal Standard
There are 5 stages of Chronic Kidney Disease (CKD) and are defined by different glomerular filtration rates (GFR).  GFR is basically the rate at which wastes are cleared from the blood plasma by the glomeruli, which are capillaries surrounded by an epithelial membrane in the kidneys.  Patients in stage 5 usually undergo dialysis, which is a procedure that uses a machine (hemodialysis at a medical center or peritoneal dialysis which can be done at home).  Patients in the hospital that have any stage of CKD or undergoing dialysis must follow a very strict diet.  When the kidneys deteriorate, it becomes more difficult for it to remove products from protein, fluid, and minerals such as sodium, potassium, phosphorus, and calcium. 

• Stages 1 and 2: focus therapy on controlling diabetes, hypertension(blood pressure), and hyperlipidemia(cholesterol).  
• Stages 3 and 4: monitor and limit protein intake (as kidney function slows, it becomes harder to excrete protein products).
• Stage 5: differs between hemodialysis and peritoneal dialysis.  Hemodialysis patients have a diet high in protein and must limit foods containing potassium, phosphorous and sodium.  Must also limit fluids.  Peritoneal dialysis patients have a diet higher in protein, sodium, potassium, and fluid than hemodialysis because peritoneal have higher losses during the actual dialysis process.  Peritoneal patients still have to limit phosphorous.  

High sources of Potassium (avoid): bananas,orange juice, melon, spinach, tomatoes, beans, broccoli, bran, milk, nuts, yogurt, salt-free broth, potatoes
Low sources of Potassium (ok): apple, pears, pineapple, asparagus, carrots, corn, peas, squash, rice, noodles,

High Phosphorous sources (avoid): chocolate, coke, dairy, fish, organ meats, beans, bran, caramel, seeds, whole grain

**Post partum patients will not be allowed caffeine due to breast feeding and cardiac patients may also be restricted from caffeine due to heart defects or testing that needs to be done.


Keep in mind that many of these orders will be combined.  For example...

Viet, Veg, MS: Vietnamese, vegetarian, mechanical soft.  This patient could eat tofu, chopped steam vegetables, and possibly fish

MinFib, Veg, K: Minimal fiber, increase Potassium, vegetarian.  This is tricky because the patient needs to decrease sources of fiber (fruits and vegetables) but needs to increase potassium which is found in fruits and vegetables.  Patient will receive potato products (mashed, hashed browns) and orange juice.  Encourage eggs and cottage cheese for protein.

Card, CarbCount, 18Cal: Cardiac, carbohydrate control, 1800 kcal.  Encourage fruits and vegetables.  No red meat, pork, caffeine, butter.  Limited non-fat dairy.  Diet jellos, pudding, custard, and salad dressings.

LctI, GlutF, LoFib: Lactose intolerant, gluten free, low fiber.  No dairy, carbohydrates, fruits, or vegetables.  Encourage rice, corn products, and proteins.  Patient may need to be on a lactose free shake for supplemental calories due to limited choices.  

15Fl: Patient is limited to 1500 mL fluids per day.  Could do 8 oz at breakfast (4 oz juice and 4 oz milk for cereal), 8 oz at lunch (4 oz soup and 4 oz juice), and 4 oz at dinner (4 oz milk).

NPO: sorry Charlie.  No choices can be made because no meal delivered to patient. 

Elevator Etiquette

I wish I could count how many times I go up and down in an elevator each day at work.  If I didn't have 453948 work related things already going through my mind, maybe I would have room in my cerebellum to count.  If I had to guess, I would say I go up and down the elevator 40 times a day.  That's 200 times a week!  Thanks be to Vitamin C that I don't have claustrophobia or issues being inside elevators!  I'm going to keep this short and sweet (instead of doing more food service equations; bet you're thinking you dodged a bullet on that one) and give you some pointers on elevator do's and don'ts in a hospital.

I hate to burst any fantasy Grey's Anatomy based bubble you may have floating above your head containing images of two or more attractive medically licensed individuals steaming it up or oozing sexual tension in between floors.  If you want to keep on believing that doctors have ample free time for shmoozing shenanigans and elevator escapades while patients await care, go ahead.  In reality, hospital staff are far more focused on patients than anything else.  Sorry McSteamy.  You too McDreamy.  Patients are the priority.

DO know what floor you're going to.  This might sound dumb, but there are days so busy you forget where you're headed.
DON'T push every button because it is fun (Elf)
DO make sure if you want to be going up the elevator is in fact going up (again, we all have those days, myself more than others)
DON'T jump up when the elevator is moving down (Elf)
DO step out of the elevator if a patient needs to use it; patient=priority (everyone uses the same elevators; this means people being wheeled to surgery, carts full of food, doctors, nurses, visitors, etc.)
DON'T talk about patients or anyone else for that matter inside the elevator; confidentiality is extremely essential in a hospital.  Always.  In fact, never talk about a patient.  Ever.
DO ask other people in the elevator what number floor they need and push the button for them if you are closest.
DON'T be an elevator hog; move to the back when possible.
DO assist visitors in the elevator if they don't know where they're going.
DON'T stick your arm out when you see the door closing and you need to get in.  If the door goes far enough, your arm might not stop it.  Waiting a couple minutes for the next elevator is in fact more time efficient than losing an arm.
DO introduce yourself to nurses or doctors on the elevator, "Hi, how's your day going?  What department do you work in?"

Maybe most of that was common sense.  I don't know.  Today I realized I spend a large portion of my day in elevators.  I guess in summary, know where you're going, get off to let patients use the elevator, be courteous to everyone in the elevator, and don't do anything you saw in Elf while riding. PS 62 days until Christmas, but who's counting?

Food Service Equations: Portion Costs

I like math.  Correction; I like easy math.  I am eternally grateful the applied nutrition curriculum's highest level of required math was pre-calculus.  I aced my pre-calc classes with A+'s, mostly because it's pretty simple math.  My method of studying when it came to math was to do example problems over and over until the process was brutally ingrained into my brain.  Sometime I understood what I was doing, and other times I didn't understand.  In those circumstances I repeated the example problem over and over until I could automatically and basically thoughtlessly solve the problem.  I think there is a lot more thinking involved with higher level calculus; thank God I dodged that bullet or I would probably have a life sentence at Cal Poly trying to get through math.

Anyways, I was studying for the DTR and hit the math problems: Food Cost Percentages; Edible Cost/Portion and Edible Yield; Cost Factor; Meals/labor hours, min/meal, payroll cost/day, payroll cost/meal, labor cost.  If you remember from my previous post about food service systems, I didn't pay much attention in my food service classes because I seriously underestimated an RD's role within the system itself.  (If you didn't read that one, long story short I assumed RD's lived in Clinical La La Land and had nothing to do with food service.  Some RD's might not be as involved with food service as others in the system, however they still must thoroughly understand food service.)

Anyways-anyways, I decided to take the same approach I did with pre-calc studying for the food service math problems and equations.  I kinda just did the problems and hoped it would stick.  I've been doing that on and off since July and nothing has stuck.  I decided to suck it up and actually learn the equations and why they were being used.  I want this information to stick with me so I can use it.  This requires me to teach myself using my study guide and the Internet since I never really comprehended it during my food service classes (shocking).  If I'm teaching myself, I might as well teach anyone reading this.  They say when you are able to teach someone else a topic it shows you fully comprehend it.  So, here we go!

Standard Portion Cost  (how much an item costs to purchase, prepare, and present)

These methods are used to help determine the total cost of product needed to produce an item on the menu. 

• Cost per unit is basically the cost of one portion from the whole unit.  This mostly has to do with items bought ready made, which is called the edible product in the food service world.  Basically, anything that can be served without altering (i.e. removing bones, cutting off stems).  Examples of edible products would include a cake that just needs to be sliced, a pack of bottled water, skinless/boneless chicken breasts, or pre-cut lettuce for salad.  Basically anything that requires little further prep before service.  

          To determine the standard portion cost, simply divide the cost of the whole unit by the

          number of portions.  For example, a cheesecake was purchased for $18 and can serve 

          12 people.  $18 by 12 servings equals $1.50 standard portion cost. This tells the kitchen

          how much each portion is costing them.  This can help determine how much an item

          should cost to the customer to make adequate profit for the business. 

• Yield calculations are used to determine how much of a product is used and how much it costs.  Most products are bought as purchased.  This is different than the edible product.  Products that are as purchased need further preparation.  This would include whole heads of broccoli (needs to be trimmed) or meat with skin/bones/fat that needs to be removed.  Or think about a bell pepper.  Lots of cutting and trimming.  Items such as these have trim loss or waste.  For example, you might need to buy 24 lbs of carrots.  However you cut 2 lbs worth of stems off (2 lbs of waste or 8.3% waste loss) and are left with 22 lbs edible portion (91.7% edible product).  

          If you take the edible weight and divide it by the as purchased weight and multiply by 100,

          you get the edible yield percentage.  Let's look at the green bean example:

          22 lbs / 24 lbs x 100= 91.7% edible yield

     

         If you flip flop that and take the as purchased and divide it by the edible portion, you can 

         see the percentage of edible cost.

         24 lbs / 22 lbs x 100= 109% edible cost or in decimal form, 1.09, also known as the cost 

         factor.

       

        **It's also important to remember that a buyer might look at the edible portion and compare

           that cost to the cost of a ready made product.  Keeping in mind labor costs, a buyer

           might decide a ready made product could be more cost effective after looking at the 
           edible portion from the as purchased.

Did I lose you?  I hope not.  Let's look at some sample problems and see if we can apply the terms and concepts learned.  (These sample problems are taken from a study guide I am using written by Jonathon Brown)

You need to prepare 374 4 oz portions of broccoli.  You note broccoli has a waste of 19%.  How much broccoli do you need to purchase?
Did you say 1,496 oz or 93.5 lbs?  If you did, you were thinking of the edible portion, not the as purchased amount.  

Did you get 115.5 lbs? Good job!
100%-19% waste=81% edible product
4 oz (portion size) divided by .81=4.938 oz (this is the AP amount per each portion)
4.938 divided by 16= 0.308 lbs
0.308 lbs x 374 servings= 115.5 lbs, round up to 116 lbs

OR make a proportion
81/100 (edible portion over total) cross multiply with 93.5 lbs/X (total edible portion over the variable, the total as purchased)
(81)(X)=(100)(93.5)
81X=9350
X=115.5 lbs


The yield factor on green cabbage is 87%.  Approximately how much cabbage is needed to prepare 175 servings of coleslaw that requires 2.25 oz of cabbage in each serving?
This is similar to the broccoli question.  87% edible portion is given and we are finding the amount in pounds that should be bought.  You could made a proportion again:
87/100 cross multiply with 24.61 lbs/X [24.61 lbs was found by (175)(2.25oz)]
X=28.3 lbs to purchase, round up to 29 lbs


You have purchased 35 lbs of fresh green beans with a 23% waste.  How many 4 oz portions will be prepared?
First let's figure out how many ounces are in 35 lbs.  35 lbs x 16 oz in a lb = 560 oz purchased

Second let's figure out the yield/edible portion (77%) of 560 oz.  560 oz x 0.77 = 431.2 oz

Lastly, divide 431.2 oz by 4 oz portion = 107.8 portions, 107 portions


How many pounds of pork roast (with a 15% shrinkage factor) should be bought to serve 600 portions that each weigh 3 oz?
First let's find out the total edible amount needed for service : 600 x 3 oz=1800 oz or 112.5 lbs

Next make a proportion again since we are trying to figure out how much to purchase
85/100 cross multiply with 112.5 lbs/X
(112.5)(100)=(85)(X)
11,250=85X
=132.35 lbs, round up to 133 lbs


CURVE BALL!  I'm going to throw in a scooper problem at you since I explained the concept in an earlier post (see Buckeyes).  The Standard portion for gravy is served with a No. 8 scoop.  Three gallons of the product should yield how many servings?
Do you remember what the number means?  It is the amount of scoops the scooper can get from 1 quart.  Therefore this scooper can get 8 scoops from 1 quart.  The question is asking how many scoops you could get from 3 gallons.

Since there are 4 quarts in 1 gallon, 3 gallons=12 quarts.  8 scoops x 12 quarts = 96 servings


A 4 oz serving of soy cheese is used in one omelet.  How many 5 lb blocks of cheese do you need to make 400 omelets?
1600 oz or 100 lbs are needed total.  100 lb divided by 5 lb blocks equals 20 blocks




Well that wasn't too bad now was it!  Stay tuned for more math adventures regarding Food Cost Percentages, Meals/Labor hrs, and Payroll Costs!  



 

Food Systems Management & Organization

Last year, I would be sitting in my Food Systems Management class about this time of day.  When I say sitting, I purposely exclude the words "paying attention."  I didn't dislike my food service classes, but I definitely underestimated their usefulness.  I  underestimated it even more as my senioritis kicked into full gear that fourth and final fall quarter. At the time, I agreed a dietitian should be familiar with how a kitchen is run and know  time and temperature control.  However, I was more interested in learning about clinical nutrition and things  such as medical nutrition therapy, counseling, and education.. Needless to say those previous sentences were fluff to cushion this upcoming sentence: I did not pay attention in my food systems management class.  I had already taken a two part series about food service and had learned all I thought I needed to know about the topic.  Food systems management covered topics such food purchasing, HR/employee management, and inventory.  I was not amused.  

An educational film from the 1980's was brought into this class about the Disney Corporation's unique method of employee management.  I was literally banging my head on my desk wondering why I had to watch a movie about this-I was a nutrition major, not a business major.  To me this was something so unnecessary and outdated it needed to be rewound before watching.  I should be learning about the DASH diet* or metabolic syndrome**.  In hindsight and a safe distance away from my brooding senioritis, today I will tell you the film is actually pretty interesting and educational; Disney calls their employees "cast members" and treats them as such.  They must be doing something right because Disney employees are always extremely friendly, happy, and helpful.  The film might have been made in the 80's, but the system Disney uses is so successful it is still implemented today.  However back then I didn't realize the connection of employee management to dietetics. 

Now that I am part of a system, I see that management is essential.  RD's, techs, clerks, hosts, and kitchen staff are all part of a system.  Some of the RD's may never meet our prep cook or dishwasher.  I don't directly work with the a lot of the RD's .  However we are all still connected.  For example, an RD will meet with a patient in surgical who just had jaw surgery and puts them on a temporary clear liquid diet.  (Hosts don't see NPO or liquid patients because their meal is pretty much already selected) The tech will receive the diet order from the RD and create the patient's dinner order.  Kitchen workers on tray line will put this meal together (i.e. jello, juice, popsicle, tea).  The clerk will double check the appropriate items are on the tray.  The host will deliver it to the appropriate patient.  Maybe the RD meets with a patient in telemetry recovering from a heart attack and puts them on a cardiac diet.  The host would see this patient and help them choose a meal with minimal non-fat dairy products, lean meats, diet salad dressing, and no caffeine or margarine.  The tech gets the order in their computer, the tray is made by kitchen staff, clerk verifies tray, and full circle-host delivers the tray.

What I'm trying to get at here is even if you're not the dietitian that supervises the system, you must understand how it works if you are a part of it.  Without a system, the RD would have to meet the patient, make an order, cook the food, make a tray, and deliver it.  A system is much more efficient!  Said RD may not know the cook making the food or the host delivering it, but they are still connected by the system.  If you are the supervisor of the system, you definitely need to understand system management.  This includes managing employees' hours, wages, and work ethic.  It also includes meals made per day and accounting.  To get a better idea of employee organization in a hospital system, here is a possible outline of organization.  

I.  VP Operations: da boss

    A.  Dietary Department Director: usually an RD that is the face of the department.  The 

          director communicates with other vice presidents in the hospital and receives complaints   

          and praise from patients and other departments.  Oversees all activity in the cafeteria 

          and with patients.  The director is held responsible anything dietary/food related.  

          1.  Administrative Assistant: I like to think of this position as the eyes and ears in the 

               kitchen for the director.  While the director may be dealing with a patient complaint or 

               communicating with another department, the admin assistant will be keeping an eye   

               out in the kitchen or going through orientation with a new dietary employee.

          2.  Clinical Dietitian Supervisor: this RD sees patients but is also the supervisor for

                employees in the dietary office.  The supervisor holds meetings and creates the work

                schedule for hosts, techs, and clerks.  They will also make sure daily tasks are 

                completed in a timely manner and employees must inform their supervisor if they are 

                running behind and need to work overtime.

                a.  Registered Dietitians: see patients and gives consultations on diets (don't let that  

                     short description fool you, there's a TON more RD's do with the inpatient world)

                b.  Dietetic Technicians Registered: DTR's work in the dietary office and receive 

                     meal selections and requests from patients from the computer system via the

                     hosts.  They will verify that the selections and requests are appropriate to the

                     patient's diet order and will alter the meal if necessary.  For example, the host may

                     have input an inappropriate amount of carbs for a diabetes order or juice for a 

                     fluid restriction patient.  DTR's must have a certification for this position.

                c.  Host/Hostess: interact with patients to make meal selections and deliver trays.

                d.  Diet Clerk: assist technician with printing and balancing meal selections.  Runs

                      tray line and is the last person on tray line to make sure the tray is correct.

           3.  Kitchen Supervisor/Buyer: oversees cooks and food service workers, manages 

                inventory, and makes food purchases.

                a.  Lead Cook

                     i.  Cook

                     ii. Grill Cook

                     iii.  Floaters

                     iv.  Food Service Workers: assist in kitchen and restock snacks and juices in on

                           floor kitchens in each unit, work in tray line production

                     v.  Storeroom Clerk: organize store room, bring in new products following FIFO 

                          (first in first out), disposing of expired items

          4.  Evening Lead: the kitchen is busiest and has the most people working from 5 am 

               to  3 pm.  This is when orders are taken, food is prepped for the day, and breakfast 

               and lunch is served.  Patients tend to be discharged in the afternoon, so the hours 

               between 5-3 are when the bed count or patient quota is highest.  Therefore there is a 

               distinction for evening staff that don't work during peak hours.

               a.  Vietnamese Chef: depending on the location of the hospital, there may be a 

                     strong need for a specific cultural type of food (i.e. Vietnamese, Kosher, etc).  

                     Vietnamese food may have items such as porridge, won ton soup, tofu, stir fry, etc.

               b.  Food Service Workers: deliver dinner trays since hosts are not working

               c.  Dishwashers

               d.  Cleaners

          5.  Cafe Lead: In charge of cafeteria where hospital employees and visitors may choose 

               to eat their meals.  May also include catering for hospital events or conferences.

               a.  Food Service Workers/Cafe Staff: serve customers and use cash registers

My next post will be related to all of the fun management equations I didn't pay attention to in class last year that will now be on my DTR exam...long story short to all you seniors out there-pay attention in food systems! 

*DASH diet: recommended for stopping hypertension, focuses on eating more fruits and vegetables, whole grains, lean proteins, Mg, K, and Ca.  Eat less saturated fats, red meats, sweets.

**Metabolic Syndrome: three or more of the following symptoms-hyperglycemia (diabetes), abdominal obesity, hypertriglyceridemia (high cholesterol), reduced HDL (the "good"/you want it to be high) cholesterol <40 for men, or hypertension (high blood pressure) above 130/8- mm hg

http://www.theclassroompost.com/2010/03/is-there-cure-for-senioritis.html