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

Excessive GIT losses 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

Excessive GIT losses case study 63 year old female admitted via ED with dehydration and electrolyte disturbances due to a high output ileostomy, referred for dietary assessment. Medical/Clinical: PHx: Rectal cancer – ultra low anterior resection & loop ileostomy 12 weeks ago Stoma output ~2.5L/d past 10 days, now ~1.8L/d Appetite low post surgery 12 weeks ago but has since improved to normal. Commenced on Loperamide and Codeine Phosphate 3 days ago Anthropometry: Current weight = 56kg Height = 167cm BMI= 20kg/m² (RR 18.5-25) Weight Hx: UBW= 58kg, 2kg weight loss in 10 days (fluid), well nourished Victorian ADIME/IDNT Working Party Version 3: May 2014

Excessive GIT losses case study Biochemistry: K+ 3.5mmol/L (RR 3.5-5.5) on IV normal saline + KCl Mg+ 0.54mmol/L (RR 0.7-1.10), commenced on IV MgS04 Social: Lives with husband, retired. Patient prepares the meals Diet: Eating reasonable amounts, trying to eat foods that can help to thicken output (white bread/cereals, rice, pasta, bananas) Trying to drink plenty of fluids, mainly fruit juices/cordials/soft drinks/powerade /water ~1.5-2L/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 fluid intake (NI-3.1) Increased nutrient needs (K+, Mg+) (NI-5.1) Imbalance of nutrients (NI-5.5) Less than optimal intake of types of carbohydrates (sugars) (NI-5.8.3) Altered gastrointestinal (GI) function (NC-1.4) Impaired nutrient utilisation (NC-2.1) Altered nutrition-related laboratory values (K+, Mg+) (NC-2.2) 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: Increased nutrient needs (K+, Mg+) (NI-5.1) Inappropriate intake of types of carbohydrates (sugars) (NI-5.8.3) Victorian ADIME/IDNT Working Party Version 3: May 2014

Other diagnosis’s and reason/s why you might not use them: Inadequate fluid intake (NI-3.1) The fluid intake at 2-2.5L/day is not actually inadequate Imbalance of nutrients (NI-5.5) This diagnosis is more suitable for refeeding syndrome or side effects associated with vitamin/mineral supplements. Altered gastrointestinal (GI) function (NC-1.4) This diagnosis could potentially be used but it is not a nutrition related diagnosis Impaired nutrient utilisation (NC-2.1) The definition does not fit this case study. It is also more appropriate to choose a diagnosis from the intake domain Altered nutrition-related laboratory values (K+, Mg+) (NC-2.2) This diagnosis could potentially be used but it is more appropriate to choose a diagnosis 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 Increased nutrient needs (K+, Mg+, Na2+) (NI-5.1) related to excessive GIT losses via ileostomy as evidenced by low K+ & Mg+ levels requiring supplementation and known increased salt requirements Victorian ADIME/IDNT Working Party Version 3: May 2014

Victorian ADIME/IDNT Working Party Version 3: May 2014 PES statement 2 Inappropriate intake of types of carbohydrates (sugars) (NI-5.8.3) related to lack of knowledge regarding dietary management of high output stoma as evidenced by regular consumption of sweetened beverages >750ml/day with stoma output 1.8L/day. 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 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

Excessive GIT losses Case Study 63 year old female admitted via ED with dehydration and for dietary assessment. Medical/Clinical: PHx: Rectal cancer – ultra low anterior resection & loop ileostomy 12 weeks ago Stoma output ~2.5L/d past 10 days, now ~1.8L/d Appetite low post surgery 12 weeks ago but has since improved to normal. Commenced on Loperamide and Codeine Phosphate 3 days ago Anthropometry: Current weight = 56kg , Height = 167cm BMI= 20kg/m² (RR 18.5-25) electrolyte disturbances due to a high output ileostomy, referred Weight Hx: UBW= 58kg, 2kg weight loss in 10 days (fluid) Biochemistry: K+ 3.5mmol/L (RR 3.5-5.5) on IV normal saline + KCl Mg+ 0.54mmol/L (RR 0.7-1.10), commenced on IV MgS04 Social: Lives with husband, retired. Patient prepares the meals Diet: Eating reasonable amounts, trying to eat foods that can help to thicken output (white bread/cereals, rice, pasta, bananas) Trying to drink plenty of fluids, mainly fruit juices/cordials/soft drinks/powerade /water ~1.5-2L/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 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