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

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

3. 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

4. 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

5. PES = Problem, Etiology, Signs and symptoms
Victorian ADIME/IDNT Working Party
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6. Basic Structure of a PES Statement
Problem (P)
related to etiology (E)
as evidenced by signs & symptoms (S)
Victorian ADIME/IDNT Working Party
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7. 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

8. 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

9. 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

10. 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

11. 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
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12. 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
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13. 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

14. 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

15. 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

16. 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

17. 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
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18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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 )
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 )
hyperkaleamia?
Excessive mineral intake (potassium) (NI )
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

27. 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

28. 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

29. Online reference manual
-Requires DAA membership for access
Link on DAA:
Victorian ADIME/IDNT Working Party
Version 3: May 2014

30. References PowerPoint Presentations
Ferguson M, et al. Webinar 3: Implementation, DAA IDNT Working Party,
Vivanti A, Micallef N. Webinar 2: Diagnoses, PES statements and Case Study, DAA IDNT Working Party,
Capra S, Ferguson M, et al. Standardised Language: A powerful tool for dietetic professionals,
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:
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