1. 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

2. Poor Oral Intake Case Study
Presented by
Victorian ADIME/IDNT Working Party Version 3: May 2014

3. Refresher Example of PES Statement
Excessive energy intake (NI-1.3) related to frequent consumption of large portions of high-fat meals as evidenced by average daily energy intake exceeding recommended amount by 2000kj & 6kg gain during the past 18 months
Victorian ADIME/IDNT Working Party Version 3: May 2014

4. Poor Oral Intake Case Study
84 yo female referred for high energy and high protein
diet on background of stroke
Anthropometry:
Wt 63 kg, Ht 150cm, BMI 28kg/m2 ,
Weight 69kg (2/52 ago) weight 69kg (6/12)
Loss of 6 kilos in past 2 weeks (8.7% )
SGA B Moderate malnutrition
Signs of moderate muscle wastage and fat loss
Biochemistry:
Nil current issues
Social:
Patient lives alone, cleaning by council 1/7
Victorian ADIME/IDNT Working Party Version 3: May 2014

5. Poor Oral Intake Case Study
Medical/Clinical:
Left haemorrhagic stroke 2/52 ago
SP assessment completed : pureed (Texture C), regular fluids
Nil nausea, vomiting or diarrhoea
Requires assistance with feeding from nursing staff and currently receiving
assistance
Patient dislikes pureed diet
Diet:
Diet history revealed patient only eating <50% of hospital meals.
Estimated energy intake 3MJ
Estimated Requirements:
6-7MJ/d
Victorian ADIME/IDNT Working Party Version 3: May 2014

6. 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 6.
Victorian ADIME/IDNT Working Party Version 3: May 2014

7. All Possible Diagnoses
1. Inadequate oral intake (NI_2.1) 2. Malnutrition (NI_5.2) 3. Inadequate energy intake (NI_1.2) 4. Not ready for diet/lifestyle change (NB_1.3) 5. Inadequate protein - energy intake (NI_5.3) 6. Inadequate protein intake (NI_5.7.1) 7. Unintended weight loss (NC_3.2) 9. Swallowing Difficulty (NC_1.1) 10. Limited adherence to nutrition related Recommendations (NB_1.6) 11. Biting/chewing difficulty (NC_1.2) 12. Inability to mange self care (NB_2.3) 13. Self-feeding difficulty (NB_2.6)
Victorian ADIME/IDNT Working Party Version 3: May 2014

8. Victorian ADIME/IDNT Working Party Version 3: May 2014
Key Diagnoses
Most appropriate diagnoses for this case study: 1. Malnutrition (NI_5.2) 2. Inadequate energy intake (NI_1.2) 3. Limited food acceptance (NI_2.9)
Explanation of “Limited food acceptance”
Definition
Oral food/beverage intake that is inconsistent with reference standard intake for type, variety, or quality.
Note: May not be an appropriate nutrition diagnosis for individuals with anorexia nervosa, bulimia nervosa, binge
eating disorder, or eating disorder not otherwise specified (EDNOS). Please consider using Disordered Eating Pattern
(NB-1.5).
Etiology (Cause/Contributing Risk Factors)
Factors gathered during the nutrition assessment process that contribute to the existence or the maintenance
of Pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental problems:
Physiological causes, e.g., pain, discomfort, or functional issues in the GI tract, developmental delay,
neurological disorders
Aversion to food/beverages in mouth, throat, or hands
Self-limitation of foods/food groups due to food preference
Behavioural issues including caregiver issues and eating behaviour that serves a purpose other than
nourishment
Harmful beliefs and attitudes
Victorian ADIME/IDNT Working Party Version 3: May 2014

9. Other diagnoses and reason/s why you might not use them:
Inadequate oral intake (NI_2.1)
In this case, inadequate energy intake diagnosis is used over this diagnosis as there is a reference value provided
2. Inadequate protein - energy intake (NI_5.3)
3. Inadequate protein intake
Can only use both of these diagnoses if you can calculate protein from diet history & compare the standard. There is not enough information in this case study to do this.
Unintended weight loss (NI_3.2)
This diagnosis is used for weight loss associated with a medical
condition (i.e.: stroke, paralysis)
Swallowing Difficulty (NC_1.1)
The SP has already diagnosed the Swallowing Difficulty so therefore not
an issue
Biting/chewing difficulty (NC_1.2)
Nil issues with biting/chewing
14. Not ready for diet/lifestyle change (NB_1.3)
10. Limited adherence to nutrition related Recommendations (NB_1.6)
12. Inability to mange self care (NB_2.3)
13. Self-feeding difficulty (NB_2.6)
Victorian ADIME/IDNT Working Party Version 3: May 2014

10. Other diagnoses and reason/s why you might not use them:
5. Not ready for diet/lifestyle change (NB_1.3)
Limited adherence to nutrition related Recommendations (NB_1.6)
These statements are also fine to use, however preference for intake statement
Inability to mange self care (NB_2.3)
Self-feeding difficulty (NB_2.6)
Patient is already receiving feeding assistance therefore there should not be any issues with feeding
Victorian ADIME/IDNT Working Party Version 3: May 2014 10

11. 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

12. 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

13. Victorian ADIME/IDNT Working Party Version 3: May 2014
PES statement 1
Inadequate energy intake (NI_1.2) related to disliking food texture (puree and extremely thick) as evidenced by patient meeting only 50% of estimated requirements, reported 8.7% weight loss in past 6 months, moderate signs of muscle wasting and subcutaneous fats loss. SGA B: moderately malnourished
Victorian ADIME/IDNT Working Party Version 3: May 2014 13

14. Victorian ADIME/IDNT Working Party Version 3: May 2014
PES statement 2
Malnutrition (NI_5.2) related to disliking food texture (puree and extremely thick) as evidenced by patient meeting only 50% of estimated requirements, reported 8.7% weight loss in past 6 months, moderate signs of muscle wasting and subcutaneous fats loss. SGA B: moderately malnourished
Victorian ADIME/IDNT Working Party Version 3: May 2014 14

15. Combining similar PES statements (PES statement 1 and 2)
Inadequate energy intake (NI_1.2) and Malnutrition (NI_5.2)
related to disliking food texture (puree and extremely thick)
as evidenced by patient meeting only 50% of estimated requirements, reported 8.7% weight loss in past 6 months, moderate signs of muscle wasting and subcutaneous fats loss. SGA B: moderately malnourished Or
Inadequate energy intake (NI_1.2) &
Malnutrition (NI_5.2)
related to disliking food texture (puree & extremely thick),
as evidenced by
patient meeting only 50% of requirements
as well as reported 5-10% weight loss in the past 2 months, moderate signs of muscle wasting & subcutaneous fat loss. SGA B: Moderately malnourished.
Victorian ADIME/IDNT Working Party Version 3: May 2014

16. Victorian ADIME/IDNT Working Party Version 3: May 2014
PES statement 3
Limited food acceptance (NI_2.9) related to Patient not accepting food texture modification recommendations as evidenced by diet history revealing <50% consumption of hospital meals
Now based on the information provided and your PES statements what might you suggest are some interventions you might use to fix your diagnosis?
-commence nutrition support
-meal plan
How would you evaluate?
Monitor weight, oral intake, SGA
Victorian ADIME/IDNT Working Party Version 3: May 2014

17. Victorian ADIME/IDNT Working Party Version 3: May 2014
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,
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

18. Contacts Alison Qvist alison.qvist@wh.org.au
Ai Vee Lim
Anna Cardamis
Anna Whitley
Annika Dorey
Caitlyn Green
Lina Breik
Loretta Bufalino
Kate Furness
Rubina Raja
Sonia Brockington

19. Poor Oral Intake Case Study
84 yo female referred for high energy and high protein diet on background of stroke
Anthropometry:
Wt 63 kg, Ht 150cm, BMI 28kg/m2 ,
Weight 69kg (2/52 ago) weight 69kg (6/12)
Loss of 6 kilos in past 2 weeks (8.7% )
SGA B Moderate malnutrition
Signs of moderate muscle wastage and fat loss
Social:
Patient lives alone, cleaning by council 1/7
Biochem:
Nil issues
Medical/Clinical:
Left haemorrhagic stroke 2/7 ago
SP assessment completed : pureed (Texture C), regular fluids
Nil nausea, vomiting or diarrhoea
Requires assistance with feeding from nursing staff and currently receiving assistance
Patient dislikes pureed diet
Diet:
Diet history revealed patient only eating <50% of hospital meals.
Estimated energy intake 3MJ
Estimated Requirements:
6-7MJ/day
Using the nutrition diagnosis reference sheet, identify possible nutrition diagnoses that could fit this case study
1. _______________________________________________ ____________________________________________________
2. _______________________________________________ ____________________________________________________
3. _______________________________________________ ____________________________________________________
4. _______________________________________________ ____________________________________________________
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