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. Enteral Nutrition (ICU)
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 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. 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 : Kg
Height: cm
BMI : 46
Weight 4/12 ago : 118 kg (12 % LOW)
Victorian ADIME/IDNT Working Party Version 3: May 2014

5. 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

6. 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) : MJ
Protein ( g /kg ) 99g /day
Fluid (tube feed) allowance – 2.5 litre
Victorian ADIME/IDNT Working Party Version 3: May 2014

7. 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

8. 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 )
Predicted suboptimal mineral intake (NI )
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

9. 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

10. 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 )
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

11. 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

12. 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

13. 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

14. 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,
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

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. 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) : MJ
Protein ( 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. _______________________________________________ ____________________________________________________
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 16