1. Victorian ADIME/IDNT Working Party
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. Victorian ADIME/IDNT Working Party
Refeeding
Risk
Presented by
Victorian ADIME/IDNT Working Party

3. Victorian ADIME/IDNT Working Party
Refresher Example
Excessive energy intake 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

4. Victorian ADIME/IDNT Working Party
Refeeding Risk
Medical/Clinical:
48 yr old male transferred for surgery to remove bowel obstruction.
Pt has had a bowel obstruction for the past week which remains unresolved
TPN is planned to commence post surgery.
IV Dextrose 10/24
Anthropometry:
Current weight = ~60kg
Height = 182cm
BMI= 18.1kg/m2
Weight Hx: estimate pt lost ~10kg during the week, SGA B, signs of muscle wasting and subcutaneous fat loss.
Victorian ADIME/IDNT Working Party
Version 3: May 2014

5. Estimated Requirements Victorian ADIME/IDNT Working Party
Refeeding Risk
Biochemistry:
Phosphate 0.85mmol/L
(RR )
Potassium 3.5mmol/L
(RR )
Magnesium 0.8mmol/L
(RR )
Diet:
Patient has consumed minimal solids past 3 weeks
Estimated Energy Intake = ~1000kJ/day, mainly through clear fluids
Estimated Protein Intake = ~15g/day
Estimated Requirements
EER
x 60kg = 5.9
S.F. 1.3
A.F. 1.1
Total: 8.4MJ/d
EPR
GIT Surgery g/kg/d
Total: 78-90g/d
EFR
35-45ml/kg/d
Total: L/d
Victorian ADIME/IDNT Working Party
Version 3: May 2014

6. Victorian ADIME/IDNT Working Party
Using the nutrition diagnosis reference sheet
Identify 1-4 possible nutrition diagnosis codes that
could fit this case study
_________________________________________________________
2. __________________________________________________________
3. __________________________________________________________
4. __________________________________________________________
Victorian ADIME/IDNT Working Party
Version 3: May 2014

7. All Possible Diagnoses
Malnutrition NI-5.2 Inadequate protein-energy intake NI-5.3 Predicted suboptimal nutrient intake NI (4,5,6) Inadequate energy intake NI-1.2 Inadequate protein intake NI Altered GI function NC-1.14 Unintended weight loss NC-3.2 Inadequate parenteral nutrition infusion NI-2.6
Victorian ADIME/IDNT Working Party
Version 3: May 2014

8. Victorian ADIME/IDNT Working Party
Key Diagnoses
Most appropriate diagnoses for this case study:
Malnutrition
Inadequate Energy & Protein intake
Predicted suboptimal nutrient intake
Other diagnosis’s and reason/s why you might not use them:
Inadequate energy intake (Covered with inad E+P intake)
Inadequate protein intake (Covered with inad E+P intake)
Altered gastrointestinal function (clinical domain)
Unintended weight loss (covered by malnutrition)
Inadequate parenteral nutrition infusion (not commenced yet)
Victorian ADIME/IDNT Working Party
Version 3: May 2014

9. Based on the above case study write two possible PESS statements
___________________ as related to
E:______________________________
_________________as evidenced by
S/S:_____________________________
______________________________
Victorian ADIME/IDNT Working Party
Version 3: May 2014

10. Suggested PES statement 1
Malnutrition NI-5.2 and inadequate protein-energy intake NI-5.3 related to mechanical obstruction & minimal oral intake for one weeks as evidenced by 10kg LOW, BMI 18 (underweight), SGA score B, & meeting ~10%EER & ~19%EPR.
Victorian ADIME/IDNT Working Party
Version 3: May 2014

11. Suggested PES statement 2
Predicted sub optimal nutrient intake (Mg, K, PO4) NI (4,5,6)
related to mechanical obstruction preventing oral intake, increased requirements post surgery
as evidenced by malnourished state, PO4, Mg & K levels all at the lower end of the normal range, not meeting nutritional requirements for last week
Unfortunately, based on the US terminology there is no diagnostic term for refeeding risk. It is important to write somewhere that the pt is at risk of refeeding (using that term)
Victorian ADIME/IDNT Working Party
Version 3: May 2014

12. Victorian ADIME/IDNT Working Party
TPN Commences
Anthro:
Pt is weighed at 61kg- currently stable
Biochem:
Clinical:
NGT on FD, o/p 500ml
Bowels not opened, BS present, abdo soft
No nausea/vomiting
Diet:
TPN at 21ml/hr, currently meeting 30% EER/EPR K
PO4 Mg
Level
3.0
0.5 RR
Victorian ADIME/IDNT Working Party
Version 3: May 2014

13. Suggested PES Statement
Imbalance of nutrients NI-5.5
related to patient malnourished before current reintroduction of nutrition via TPN,
as evidenced by low serum K_, Mg_, & PO4_ (list values)
Note: Dietitians can diagnose the change in biochemical markers suggestive of refeeding risk, but cannot diagnose refeeding syndrome.
Victorian ADIME/IDNT Working Party
Version 3: May 2014

14. Victorian ADIME/IDNT Working Party
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

15. 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

16. Estimated Requirements
Refeeding
Estimated Requirements
EER
x 60kg = 5.9
S.F. 1.3
A.F. 1.1
Total: 8.4MJ/d
EPR
GIT Surgery g/kg/d
Total: 78-90g/d
EFR
35-45ml/kg/d
Total: L/d
Medical/Clinical:
48 yr old male transferred for surgery to remove bowel obstruction.
Pt has had a bowel obstruction for the past 3 weeks which remains unresolved
TPN is planned to commence post surgery.
Anthropometry:
Current weight = ~60kg
Height = 182cm
BMI= 18.1kg/m2
Weight Hx: estimate pt lost ~10kg during the 3 weeks, SGA B, signs of muscle wasting and subcutaneous fat loss.
Biochemistry:
Phosphate 0.85mmol/L
Potassium 3.5mmol/L
Magnesium 0.8mmol/L.
Social:
From home with wife
Diet:
Patient has consumed minimal
solids past 3 weeks
Estimated Energy Intake
= ~1000kJ/day, mainly through
clear fluids
Estimated Protein Intake
= ~15g/day
Using the nutrition diagnosis reference sheet, identify 1-4 possible nutrition diagnoses that could fit this case study
1. ________________________________________________________________________
2. _________________________________________________________________________
3. _________________________________________________________________________
4. _________________________________________________________________________
Based on the above case study write two possible PESS statements
A4 working sheet, write in font 12, when printing print to A4 size
PES Statement 1:
P:__________________________________________________________________________________________as related to
E:________________________________________________________________________________________as evidenced by
S/S:___________________________________________________________________________________________________
PES Statement 2:
P:________________________________________________________________________________as related to
E:_____________________________________________________________________________as evidenced by
S/S:________________________________________________________________________________________