Creating a PES statement: the nutrition diagnosis Presented by Victorian ADIME/IDNT Working Party

Content Creating a PES statement IDNT definitions PES examples In Victorian ADIME/IDNT Working Party Version 3: May 2014

The Nutrition Care Process - ADIME Nutrition Assessment A Nutrition Diagnosis D Nutrition Intervention I Nutrition Monitoring M Nutrition Evaluation E Victorian ADIME/IDNT Working Party Version 3: May 2014

The Nutrition Diagnosis (or PES) The purpose is to identify and describe a specific nutrition problem that can be resolved or improved through treatment/nutrition intervention by a food and nutrition professional. A nutrition diagnosis (eg: inconsistent carbohydrate intake) is different from a medical diagnosis (eg: diabetes) Diagnoses/problems are those that dietetic professionals are responsible for treating independently Victorian ADIME/IDNT Working Party Version 3: May 2014

PES = Problem, Etiology, Signs and symptoms Victorian ADIME/IDNT Working Party Version 3: May 2014

Basic Structure of a PES Statement Problem (P) related to etiology (E) as evidenced by signs & symptoms (S) Victorian ADIME/IDNT Working Party Version 3: May 2014

Problem (P) related to etiology (E) as evidenced by signs and symptoms (S) Problem/ nutrition diagnosis label describes alterations in the patients/clients nutritional status. Need to describe actual problem, not potential for or risk of. Related to Etiology is the cause/contributing risk factors and is linked to the nutrition diagnosis label by the words “related to”. Etiology may be social, situational, physical, developmental, cultural, psychological, pathological and/or environmental nature. As evidenced by Signs (objective)/Symptoms (subjective)is data used to determine that the patient/client has the nutrition diagnosis specified and is linked by the words “as evidenced by” Victorian ADIME/IDNT Working Party Version 3: May 2014

IDNT Standardised Terms Terms divided into 3 categories: intake, clinical and behavioural-environmental. Intake: too much or too little of a food or nutrient compared to actual or estimated needs Clinical: nutrition problems that relate to medical or physical conditions Behavioural-environmental: knowledge, attitudes, beliefs, physical environment, access to food, or food safety Victorian ADIME/IDNT Working Party Version 3: May 2014

Nutrition Diagnosis Aetiology Refer to handout “Nutrition Diagnosis Aetiology Matrix” Lists suggested aetiologies Not specific diagnostic terminology so you can choose what you feel appropriate

When to do a PES? Required for: For all NEW patients & For REVIEWS, only when there is a change in the nutritional diagnosis Not required for: Reviews that require no change in nutritional diagnosis Palliative care Cases where nutrition diagnosis not yet confirmed Victorian ADIME/IDNT Working Party Version 3: May 2014

Excessive Energy PES Example 1 Excessive energy intake Related to food and nutrition related knowledge deficit concerning energy intakes As evidenced by dietary intake of 14MJ Victorian ADIME/IDNT Working Party Version 3: May 2014

Excessive Energy PES Example 2 Excessive energy intake related to poor knowledge of appropriate portion sizes as evidenced by excess weight with BMI of 40 (ie: obese) Victorian ADIME/IDNT Working Party Version 3: May 2014

Excessive Energy PES Example 3 Excessive energy intake related to frequent consumption of large portions of high-fat meals as evidenced by average daily energy intake exceeding recommended amount by 2MJ and 6kg gain during the past 18 months Victorian ADIME/IDNT Working Party Version 3: May 2014

Examples: PES Statements Medical Diagnosis: T2DM Nutrition Diagnosis: Inconsistent CHO distribution related to lack of meal planning as evidenced by diet history and high blood glucose Obesity Excessive energy intake related to lack of access to healthy food choices (restaurant eating) as evidenced by daily energy intake 2MJ over estimated requirements, and BMI of 35 Medical Diagnosis: Hypercholesterolaemia Inappropriate intake of saturated and trans fats related to daily high fat fast food choices as evidenced by high total cholesterol, LDL and TC Victorian ADIME/IDNT Working Party Version 3: May 2014

Evaluating you PES statements When developing your PES statements, think about the following: { } can the dietitian resolve the nutrition diagnosis? { } if tossing up between 2 diagnoses, attempt to select the INTAKE domain first { } is the aetiology the “root cause” (ask “but why”) { } will measuring the ‘signs and symptoms’ tell you if the problem is resolved? { } are the signs and symptoms specific enough that you can measure them? Victorian ADIME/IDNT Working Party Version 3: May 2014

Weight Management Case Study 66 y.o. male referred for weight reduction Medical/Clinical: T2DM, HT, cholesteroleamia, hypothyroidism Anthropometry: Wt 99 kg, Ht 155 cm, BMI 41kg.m2 80kg 1 year ago, gain of 19kg Biochemistry: All within range Victorian ADIME/IDNT Working Party Version 3: May 2014

Weight Management Case study Social: Lives alone Office worker, full time Reports no time for exercise Patient reports nil prior dieting Diet: BF: nutrigrain and 2 toast with nutella MT: 2 timtams with hot chocolate L: takeaways, usually chinese AT: yoghurt, biscuits, cake, a few chips if around Dinner: pasta (lg serve), stirfrys with 2 cups rice Dinner takeaway 1/week, usually pizza, Wine occasionally, softdrink 2-3/7 Victorian ADIME/IDNT Working Party Version 3: May 2014

All Possible Diagnoses 1. Excessive oral intake (NI_2.2) 2. Excessive Energy Intake (NI_1.3) 3. Physical Inactivity (NB_2.1) 4. Overweight/obesity (NC_3.3) 5. Food & Nutrition-Related Knowledge Deficit (NB_1.1) Victorian ADIME/IDNT Working Party Version 3: May 2014

Key Diagnoses Most appropriate diagnoses for this case study: Excessive oral intake (NI_2.2) Physical Inactivity (NB_2.1) Food and Nutrition-Related knowledge Deficit (NB_1.1) Victorian ADIME/IDNT Working Party Version 3: May 2014

Other diagnoses and reason/s why you might not use them: 1. Excessive Energy Intake (NI_1.3) Can only use this diagnosis if you can calculate kJ from diet history & compare the standard 2. Overweight/obesity (NC_3.3) This is the least preferable option as “intake” statements are preferred over “behavioural” statements where possible. But if your assessment includes the “perfect” diet history and a desirable level of physical activity, you still have the option of “Overweight/obesity” as a nutritional diagnosis. Victorian ADIME/IDNT Working Party Version 3: May 2014

PES statement 1 Excessive oral intake (NI_2.2) as related to frequent consumption of energy dense foods due to food and nutrition related knowledge deficit as evidenced by reported intake of high fat, high energy meals and drinks Victorian ADIME/IDNT Working Party Version 3: May 2014

PES statement 2 Physical inactivity (NB_2.1) as related to competing priorities as evidenced by nil exercise Victorian ADIME/IDNT Working Party Version 3: May 2014

PES statement 3 Food and nutrition-related knowledge deficit (NB_1.1) as related to lack of prior exposure to nutrition-related information as evidenced by reported intake of high fat, high energy meals and drinks, with weight gain of 19kg in the last 12/12 and current BMI of 41. Victorian ADIME/IDNT Working Party Version 3: May 2014

Evaluating your PES Statement When developing your PES statements, think about the following: { } can the dietitian resolve the nutrition diagnosis? { } if tossing up between 2 diagnoses, attempt to select the INTAKE domain first { } is the aetiology the “root cause” (ask “but why”) { } will measuring the ‘signs and symptoms’ tell you if the problem is resolved? { } are the signs and symptoms specific enough that you can measure them?   Victorian ADIME/IDNT Working Party Version 3: May 2014

Example of A Medical Entry Using IDNT 66 y.o. male referred for weight reduction Medical/Clinical: T2DM, HT, cholesteroleamia, hypothyroidism Anthropometry: Wt 99 kg, Ht 155 cm, BMI 41kg.m2, 80kg 1 year ago Biochemistry: All within range Social: Lives alone, Office worker, full time, Reports no time for exercise, reports nil prior dieting Diet: BF: nutrigrain and 2 toast with nutella MT: 2 timtams with hot chocolate L: takeaways, usually chinese, large serve AT: yoghurt, biscuits, cake, a few chips if around Dinner: pasta (lg serve), stirfrys with 2 cups rice Dinner takeaway 1/week, usually pizza, Wine occasionally, softdrink 2-3/7 D Diagnosis: Excessive oral intake as related to frequent consumption of energy dense foods due to food and nutrition related knowledge deficit as evidenced by reported intake of high fat, high energy meals and drinks, with weight gain of 19kg in the last 12/12 and current BMI of 41. I Intervention: 1. Educated regarding relationship between excessive energy and obesity with an emphasis on: meal size (halve rice and pasta, double vegies, takeaway serves), healthier take away options (breadrolls vs Chinese), healthier snacks and water 2. Provided with an individualized meal plan and educational resources (name here). 3. Goal – To reduce weight by 0.5-1kg per week M&E Monitoring & Evaluation Will RV in 3/12 to assess dietary intake, weight and knowledge Victorian ADIME/IDNT Working Party Version 3: May 2014

Familiarising ourselves with Terminology If a patient has… heart disease? hypertension? hyponatremia? hyperkaleamia? underweight due to poor access of food? excessive alcohol? poor oral intake due to chewing difficulty? malnutrition due to swallowing difficulty? Lets have a go at getting familiar with this form. If a patient has heart disease, what diagnosis might you choose? heart disease? Excessive Mineral Intake (sodium) (NI 5.10.2) Excessive fluid intake (NI 3.2) inadequate oral intake (NI2.1) hypertension? Excessive alcohol intake (NI 4.3) Physical inactivity (NB2.1) hyponatremia? Inadequatemineral intake (sodium) (NI 5.10.1) hyperkaleamia? Excessive mineral intake (potassium) (NI 5.10.2) underweight due to poor access of food? malnutrition (NI5.2) limited access to food (NB 3.2) excessive alcohol? poor oral intake due to chewing difficulty? Inadequate oral intake (NI2.1) Chewing difficulty (NC1.2) malnutrition due to swallowing difficulty? swallowing difficulty (NC1.1) Victorian ADIME/IDNT Working Party Version 3: May 2014

Summary The new Nutrition care Process: ADIME The PES statement is the summation of the Nutrition Diagnosis Step It links the nutrition assessment with both intervention (through the aetiology) and monitoring and evaluation (through the signs and symptoms) The PES statements reflects your assessment of the problem (s) that are being addressed in the nutrition care process in that visit Victorian ADIME/IDNT Working Party Version 3: May 2014

What Next? This presentation is the first of a series of user friendly presentations for your department. The following presentations are: Introduction to E-Health Case Study 1: Poor oral intake Case Study 2: Weight Management Case Study 3: Diabetes Management Case Study 4: Hypertension Case Study 5: Hypercholesterolemia Case Study 6: High Fibre and Diverticulosis Case Study 7: Low Fibre and Diverticulitis Case Study 8: Not meeting core foods group Case Study 9: Refeeding Case Study 10: Enteral Nutrition Case Study 11: TPN Case Study 12: Mental Health Physical Inactivity Case Study 13: Coeliac Case Study 14: Food Allergy Case Study 15: Palliative Care Case Study 16: Predicted loss of weight Case Study 17: Renal Failure Case Study 18: Haemodialysis/Peritoneal Dialysis Victorian ADIME/IDNT Working Party Version 3: May 2014

Online reference manual www.adancp.com -Requires DAA membership for access Link on DAA: http://daa.asn.au/members/publications-and-resources/idnt-manual-and-resources/ Victorian ADIME/IDNT Working Party Version 3: May 2014

References PowerPoint Presentations Ferguson M, et al. Webinar 3: Implementation, DAA IDNT Working Party, www.daa.asn.au Vivanti A, Micallef N. Webinar 2: Diagnoses, PES statements and Case Study, DAA IDNT Working Party, www.daa.asn.au Capra S, Ferguson M, et al. Standardised Language: A powerful tool for dietetic professionals, 2009 www.daa.asn.au Voevodin M. IDNT – International Dietetics and Nutrition Terminology, Monash University, 2010 Bufalino L, et al. Introduction to IDNT, Victorian Wide IDNT Working Party, 2011 Journals Bueche J, et al. Nutrition Care Process and Model Part 1: The 2008 update, Journal of the American Dietetic Association, 2008 O’Sullivan T, et al. Just what the Doctor Ordered; Moving Forward with Electronic Health Records, Journal of Nutrition and Dietetics 2011; 68: 179-184 Manuals ADA, (2013) International Dietetics and Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process, Fourth Edition, American Dietetic Association, 2013 ADA, (2010) International Dietetics and Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process, American Dietetic Association, 2010 PES FAQ and Terminology IDNT Edition 3, v4, Nutrition and Dietetics Department, Princess Alexandra Hospital, Queensland Victorian ADIME/IDNT Working Party Version 3: May 2014