Victorian ADIME/IDNT Working Party Version 3: May 2014 Facilitator Notes Prior to presenting to your group, print out the final slide in A4 size and use this for your participants worksheet. It is recommended not to print out the presentation for use during the presentation The presentation will provide 1 refresher example for your participants and then proceed with case example. The presentation is designed so that your participants complete the diagnosis section first followed with a discussion about the most appropriate diagnosis to use. The completion of the PES statement should only be completed after this discussion. Victorian ADIME/IDNT Working Party Version 3: May 2014

Parenteral Nutrition case study Presented by Victorian ADIME/IDNT Working Party Version 3: May 2014

Refresher Example of PES Statement Excessive energy intake (NI_1.3) related to poor knowledge of appropriate portion sizes as evidenced by excess weight with BMI of 45 (ie: obese) Victorian ADIME/IDNT Working Party Version 3: May 2014

Parenteral Nutrition Case Study 75 year old male admitted via ED with a small bowel obstruction (SBO) referred on day 5 admission for TPN requirements Medical/Clinical: PHx: Bowel cancer and anterior resection in 2005, IHD, AF, COPD, cholecystectomy, prior SBO and emergency laparotomy, adhesiolysis and sml bowel resection 2011 SBO not resolving, not wanting to operate at this stage TPN has been running for the past 3 days without dietetic involvement and is running @ 50ml/hr providing 5.9MJ & 64g protein Anthropometry: Current weight = 76kg, Height = 175cm, BMI= 25kg/m² (RR 22-27) Weight Hx: Stable. Well nourished Biochemistry: Electrolytes all within normal range Albumin 25 (low), CRP 125 (high) Victorian ADIME/IDNT Working Party Version 3: May 2014

Parenteral Nutrition Case Study Social: Lives at home with his wife Wife prepares the meals Diet: NBM 5 days Good appetite and oral intake prior to bowel obstruction Estimated Requirements: (if appropriate for energy, protein, fluid) Estimated energy requirements: 7.6 - 9.5MJ (100 -125kJ/kg/day) Estimated protein requirements: 76 - 91g (1.0-1.2g/kg/day) Victorian ADIME/IDNT Working Party Version 3: May 2014

Victorian ADIME/IDNT Working Party Version 3: May 2014 Using the nutrition diagnosis reference sheet Identify possible nutrition diagnoses that could fit this case study 1. ____________________________________________________________ 2. ____________________________________________________________ 3. ____________________________________________________________ 4. ____________________________________________________________ 5. ____________________________________________________________ 6. ____________________________________________________________ 7. ____________________________________________________________ 8. ____________________________________________________________ 9. ____________________________________________________________ 10. ___________________________________________________________ Learners should find at least 9. Victorian ADIME/IDNT Working Party Version 3: May 2014 6

All Possible Diagnoses Inadequate energy intake (NI-1.4) Inadequate oral intake (NI-2.1) Inadequate parenteral nutrition infusion (NI-2.6) Less than optimal parenteral nutrition composition or modality (NI-2.8) Inadequate protein-energy intake (NI-5.3) Inadequate protein intake (NI-5.7.1) Altered gastrointestinal (GI) function (NC-1.4) Victorian ADIME/IDNT Working Party Version 3: May 2014

Victorian ADIME/IDNT Working Party Version 3: May 2014 Key Diagnoses Most appropriate diagnoses for this case study: Inadequate parenteral nutrition infusion (NI-2.6) Defined as parenteral infusion that provides fewer calories or nutrients compared to established reference standards or recommendations based on physiological needs Inadequate protein-energy intake (NI-5.3) Defined as Inadequate intake of protein and/or energy compared to established reference standards or recommendations based on physiological needs of short or recent duration Victorian ADIME/IDNT Working Party Version 3: May 2014

Other diagnosis’s and reason/s why you might not use them: Inadequate energy intake (NI-1.4) This diagnosis could potentially be used, but it is more appropriate to use the inadequate parenteral nutrition infusion or inadequate protein-energy intake. 2. Less than optimal parenteral nutrition infusion (NI-2.8) This is defined as parenteral nutrition composition or modality that is inconsistent with evidence-based practice, which does not necessarily fit with this case study. 3. Inadequate oral intake (NI-2.1) This diagnosis could potentially be used, but we can be more specific by using the inadequate parenteral nutrition infusion or inadequate protein-energy intake. 4. Inadequate protein intake (NI-5.7.1) 5. Altered gastrointestinal (GI) function (NC-1.4) This diagnosis could potentially be used, but there are already more appropriate diagnoses to use from the intake domain. Victorian ADIME/IDNT Working Party Version 3: May 2014

Based on the above case study write 2 to 3 possible PES statements ___________________ as related to E:______________________________ _________________as evidenced by S/S:_____________________________ ______________________________ 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

Victorian ADIME/IDNT Working Party Version 3: May 2014 PES statement 1 Inadequate parenteral nutrition infusion (NI-2.6) related to no early dietetic referral for calculation of requirements as evidenced by current TPN providing 75% EER & 85% EPR Victorian ADIME/IDNT Working Party Version 3: May 2014

Victorian ADIME/IDNT Working Party Version 3: May 2014 PES statement 2 Inadequate protein-energy intake related to no early dietetic referral for calculation of requirements for TPN as evidenced by current TPN providing 75% EER & 85% EPR Victorian ADIME/IDNT Working Party Version 3: May 2014

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 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

Contacts Alison Qvist alison.qvist@wh.org.au Ai Vee Lim AiVee.Lim@petermac.org Anna Cardamis Anna.Cardamis@easternhealth.org.au Anna Whitley Anna.Whitley@svhm.org.au Annika Dorey adorey@cabrini.com.au Caitlyn Green caitlyn.green@austin.org.au Lina Breik lina.breik@nh.org.au Loretta Bufalino LorettaBufalino@hotmail.com Kate Furness kate.furness@southernhealth.org.au Rubina Raja Rubina.Raja@southernhealth.org.au Sonia Brockington sonia.brockington@deakin.edu.au

Parenteral Nutrition Case Study 75 year old male admitted via ED with a small bowel obstruction (SBO) referred on day 5 admission for TPN requirements Medical/Clinical: PHx: Bowel cancer and anterior resection in 2005, IHD, AF, COPD, cholecystectomy, prior SBO and emergency laparotomy, adhesiolysis and sml bowel resection 2011 SBO not resolving, not wanting to operate at this stage TPN has been running for the past 3 days without dietetic involvement and is running @ 50ml/hr providing 5.9MJ & 64g pro Anthropometry: Current weight = 76kg, Height = 175cm, BMI= 25kg/m² (RR 22-27) Weight Hx: Stable. Well nourished Biochemistry: Electrolytes all within normal range Albumin 25 (low), CRP 125 (high) Social: Lives at home with his wife Wife prepares the meals Diet: NBM 5 days Good appetite and oral intake prior to bowel obstruction Estimated Requirements: Estimated energy requirements: 7.6 - 9.5MJ (100 -125kJ/kg/day) Estimated protein requirements: 76 - 91g (1.0-1.2g/kg/day) Using the nutrition diagnosis reference sheet, identify possible nutrition diagnoses that could fit this case study 1. _______________________________________________ 5. ____________________________________________________ 2. _______________________________________________ 6. ____________________________________________________ 3. _______________________________________________ 7. ____________________________________________________ 4. _______________________________________________ 8. ____________________________________________________ Based on the above case study write two-three possible PES statements PES Statement 1: P:__________________________________________________________________________________________as related to E:________________________________________________________________________________________as evidenced by S/S:___________________________________________________________________________________________________ PES Statement 2: PES Statement 3: A4 working sheet, write in font 12, when printing print to A4 size 16