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

Enteral Nutrition (ICU) 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

Enteral Nutrition - ICU Medical/Clinical: 48F presented with altered conscious state of unknown etiology to ICU PHx: Chronic Liver Disease, ETOH +++, morbid obesity, Ventilated, tolerating current feeds well Anthropometry: Weight : 101 Kg Height: 148 cm BMI : 46 Weight 4/12 ago : 118 kg (12 % LOW) Victorian ADIME/IDNT Working Party Version 3: May 2014

Enteral Nutrition - ICU Biochemistry: UEC/eGFR: WNL Albumin 20 g/L Mg: low - treated LFTs: elevated GGT Physical exam Mild temple and facial wasting; clavicles visible; other sites not examinable Social: Lives with mother; helps on the farm Lately apathy , boredom and ? Depression; socially isolated Victorian ADIME/IDNT Working Party Version 3: May 2014

Enteral Nutrition - ICU Diet: History : Poor quality dietary intake ; taking ½ usual amounts of food 4 months Erratic, irregular eating habits; unchanged ETOH intake 6 months (X 3-4 standard drinks about x 2 -3 per week) In ICU Day 3 on Standard Enteral Nutrition Protocol providing 9.1 MJ , 86 g protein, 2160 ml formula Estimated Requirements: Energy: Schofield (Adjusted weight 66 kg) : 6.3- 7.4 MJ Protein (1.2- 1.3 g /kg ) 99g /day Fluid (tube feed) allowance 2 0 – 2.5 litre 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 7

All Possible Diagnoses Inadequate oral intake (NI-2.1) Inadequate Enteral Nutrition Infusion (NI-2.3) Excessive Enteral Nutrition Infusion (NI-2.4) Less than optimal Enteral Nutrition Infusion (NI-2.4) Excessive alcohol intake (NI-4.3) Malnutrition (NI-5.2) Decreased nutrient needs (NI-5.4) Inadequate Protein intake (NI-5.7.1) Inadequate Fibre intake (NI-5.8.5) Altered GI Function (NI-5.10.1) Predicted suboptimal mineral intake (NI-5.11.1) Altered Gastrointestinal function (NC-1.4) Unintended weight loss ( NC -3.2) Obesity (NC-3.3) Poor nutrition quality of life (NB-2.5) 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: 1. Less than optimal Enteral Nutrition (NI-2.5) 2. Malnutrition (NI-5.2) Victorian ADIME/IDNT Working Party Version 3: May 2014

Victorian ADIME/IDNT Working Party Version 3: May 2014 Ruled-out Diagnoses Diagnoses Rationale Inadequate oral intake (NI-2.1) May be appropriate however not a priority at this stage Inadequate Enteral Nutrition Infusion (NI-2.3) The issue is inadequate protein and excessive energy hence not an appropriate description; may not be appropriate due to acute stressed state Excessive alcohol intake (NI-4.3) Not a priority for treatment Decreased nutrient needs (NI-5.4) Estimation of energy requirements indicates this but the cause cannot be addressed by us Inadequate Protein intake (NI-5.7.1) May be appropriate but already covered in what has been selected Predicted suboptimal mineral intake (NI-5.11.1) Refeeding risk in ICU is low due to aggressive treatment Unintended weight loss (NC -3.2) Overweight/Obesity (NC-3.3) Not for addressing at this stage Poor nutrition quality of life (NB-2.5) 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 1.Less than optimal Enteral Nutrition (NI-2.4) related to standard EN feeding protocol for high nutritional risk patient as evidenced by intake of Standard EN formula providing only 85% of protein requirements Victorian ADIME/IDNT Working Party Version 3: May 2014

Victorian ADIME/IDNT Working Party Version 3: May 2014 PES statement 2 2. Malnutrition (NI-5.2) related to History of decreased appetite of unknown etiology as evidenced by reported loss of weight of 12%, history of poor dietary intake 50 % , loss of muscle mass, SGA score B 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 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

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@monashhealth.org Rubina Raja rubina.raja@monashhealth.org Sonia Brockington sonia.brockington@deakin.edu.au

Case Study Medical/Clinical: 48F presented with altered conscious state of unknown etiology to ICU PHx: Chronic Liver Disease, ETOH +++, morbid obesity, Ventilated, tolerating current feeds well Anthropometry: Weight : 101 Kg ; Height: 148 cm ; BMI : 46 Weight 4/12 ago : 118 kg (12 % LOW) Bio: UEC/eGFR: WNL; Albumin 20 g/L; Mg: low - treated LFTs: elevated GGT Physical Exam : Mild temple and facial wasting; clavicles visible; other sites not examinable Social: Lives with mother; helps on the farm. Lately apathy , boredom and ? Depression; socially isolated Diet History : Poor quality dietary intake ; taking ½ usual amounts of food 4 months ; Erratic, irregular eating habits; unchanged ETOH intake 6 months , (X 3-4 standard drinks about x 2 -3 per week); In ICU Day 3 on Standard Enteral Nutrition Protocol providing 9.1 MJ , 86 g protein, 2160 ml formula Estimated Requirements: Energy: Schofield (Adjusted weight 66 kg) : 6.3- 7.4 MJ Protein (1.2- 1.3 g /kg )99g /day Fluid (tube feed) allowance 2 0 – 2.5 litre 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 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