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1. answer all the questions in the blank. 2. Complete ADIME Form and write SOAP Note. Write 3 PES statements. One of the statements must be malnutrition PES statement, using Malnutrition criteria from page 3 of Malnutrition Handout (I uploaded)
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What is a PES Statement, also known as
a Nutrition Diagnostic Terminology Statement?
A PES statement (or Nutrition Diagnosis Statement) is a structured sentence that describes
the specific nutrition problem that you (the dietitian) is responsible for treating and working
toward resolving, the cause/s of the problem and the evidence that this problem exists.
Three components make up the PES statement :



The Problem (P)- the Nutrition Diagnosis
The Etiology (E)- the cause/s of the nutrition problem (Nutrition Diagnosis)
The Signs and Symptoms (S)- the evidence that the nutrition problem (Nutrition
Diagnosis) exists.
The PES statement is a structured sentence, hence has a specific format:
Nutrition Diagnosis term (the nutrition problem)
related to
The Etiology (the cause/s of the problem or Nutrition Diagnosis)
as evidenced by
The Signs and Symptoms (the evidence that the nutrition problem or Nutrition Dx. exists).
Example: Excessive energy intake, related to limited access to healthful food choices at
work, as evidenced by estimated intake of energy (3000 calories /day) in excess of estimated
energy needs (2400 calories/day) and BMI of 45.
Lets look at its parts:
The Problem (P) (Nutrition Diagnosis): is excessive energy intake. This is the specific
nutrition problem that the Nutrition Intervention aims to treat and resolve.
related to
The Etiology (E) (the cause/s of the nutrition problem/Nutrition Diagnosis): is that the client
has limited access to healthful food choices. Healthful (e.g. adequate amounts for fresh fruit and
vegetables) food choices are not provided as an option.
as evidenced by
The Signs and Symptoms (S) (the evidence that the nutrition problem (or Nutrition
Diagnosis) exists: the client’s estimated intake of energy is in excess of his estimated energy
needs The client’s BMI equals 45 (obesity class III).
Now let’s discuss each component of the PES statement.
The Problem (P)- the Nutrition Diagnosis
The Nutrition Diagnosis identifies the specific nutrition problem that the dietitian is
responsible for treating and works towards resolving.
The Nutrition Diagnosis comes from specific terminology as determined by the Academy of
Nutrition and Dietetics.
The Nutrition Diagnosis terms are classified into three categories:
Intake: these diagnoses relate to intake and nutrition related problems (oral, enteral and
parenteral nutrition). Intake diagnosis cover the areas including energy balance, fluid intake and
nutrient intake.
Examples: excessive energy intake, less than optimal intake of types of carbohydrate, inadequate
calcium intake.
Clinical: these diagnoses include medical or physical conditions that have a nutritional impact.
The clinical category covers the areas of functional changes or impairments, biochemical
changes (altered ability to metabolize nutrients) and weight.
Examples: altered GI function, impaired nutrient utilization, overweight/obesity.
Behavioral-Environmental: this category covers the nutritional problems associated with
nutrition knowledge and belief (including attitude), physical activity and function (e.g. ability to
self care) and food access and safety).
Examples: undesirable food choices, physical inactivity and limited access to food or water.
As a general rule (as with most rules there are exceptions) choose from Intake related
Nutrition Diagnosis first, Clinical related Nutrition Diagnosis second and BehavioralEnvironmental last.
Diagnosis should be specific to the role of dietitians. Behavioral-Environmental related Nutrition
Diagnosis often fit better as the etiology (E) (the cause of the nutrition problem), and not the
Nutrition Diagnosis itself. Remember the aim of your Nutrition Intervention is to resolve
(ideally) the Nutrition Diagnosis.
Make sure you check that your Nutrition Diagnosis is something that you as a dietitian
can resolve (ideally) or improve. Some of the Behavioral-Environmental related Nutrition
Diagnosis can be a bit tricky for a dietitian to solve.
How to choose the correct Nutrition Diagnosis
There are no right or wrong diagnosis choice (truly). Some choices may be better than others.
Things to consider include:
1. Is it a nutrition based diagnosis, not a medical diagnosis (e.g. increased nutrient needs v.s.
altered GI function)?
2. Is it the nutrition problem what your intervention aims to solve? Even though the client
may have a particular nutrition problem e.g. inadequate fiber, if your intervention is not
focused on increasing fiber intake i.e. your nutrition goals are around reducing saturated
fat intake, leave that diagnosis for another time.
3. Can Nutrition Diagnosis be resolved (ideally) or improved?
4. Is the Nutrition Diagnosis specific to the role of the dietitian (i.e. something you as a
dietitian is responsible for resolving)? For example Altered nutrition related laboratory
values vs. Excessive carbohydrate intake.
5. Does your Nutrition Assessment data support the Nutrition Diagnosis?
The Etiology (E) -the cause/s of the nutrition problem/Nutrition Diagnosis
The ‘E’ in the PES Statement stands for Etiology. The definition of etiology is “the cause, set of
causes, or manner of causation of a disease or condition.”
Hence the Etiology in a PES Statement describes the cause of the nutrition problem (Nutrition
Diagnosis). The Nutrition Intervention should be aimed at resolving the underlying cause of the
nutrition problem (the Etiology).
The etiology in a PES Statement is free text.. It’s an important skill for a dietitian to is able to
identify the root cause of a client’s nutrition problem.
Etiologies are also grouped into categories based on the type of cause or contributing risk. Below
is the list of categories with an example etiology for each. I have not listed the related Nutrition
Diagnosis, why not try to list them yourself?


Access: e.g. community and geographical constraints (patient lives in urban area with
limited access to fresh fruit and veg. markets). Patient can’t get to a gym and lives in
unsafe area for walking.
Behavior e.g. unwilling or disinterested in making or tracking progress.








Beliefs–Attitudes Etiologies e.g. perception that time and financial constraints prevent
dietary changes.
Cultural: e.g. the practice of Ramadan prevents the intake of regular meals.
Knowledge: lack of or incorrect
Physical: e.g. lack of self-feeding ability
Physiologic–Metabolic: e.g. altering fatty acid needs due to chyle fluid leak.
Psychological: e.g. binge eating behaviors associated with a diagnosed anxiety disorder.
Social–Personal: e.g. lack of social and family support for implementing dietary
modifications.
Treatment: e.g. reduced appetite associated with the use of Ritalin.
How to choose the correct Etiology
Again there is no incorrect choice when deciding between Nutrition Diagnosis Etiology.
Remember: use your critical thinking skills to identify the root cause.
1. The Etiology is the “root cause” of the nutrition problem (Nutrition Diagnosis).
2. The Nutrition Intervention, should aim to resolve the Etiology (ideally).
3. The Etiology is supported by the nutrition assessment data.**
Identifying the root cause
Here is a good trick for finding the root cause for a particular Nutrition Diagnosis. When
looking for an etiology, ask WHY 5 times (or until you come to the last etiology, that you as a
dietitian can address).
For example:
Excessive oral intake
Why? Excessive intake of high calorie-density foods and beverages.
Why? Excessive take away food intake.
Why? Client purchases most of his meals from fast food restaurants with limited healthful
choices.
Why? The client does not prepare meals at home.
Why? The client lacks the food preparation skills to prepare healthful food at home -root cause.
Signs and Symptoms (S) -evidence that the nutrition problem (Nutrition
Diagnosis) exists
Yes we start again with more definitions. Consistency is king! Signs and Symptoms detail the
evidence or defining characteristics that prove that the nutrition problem (Nutrition Diagnosis)
exists.


Signs are objective data obtained through direct physical examination, anthropometics,
observation, lab values and test results.
Symptoms are subjective data reported by the client’s or their family’s rather than
actual results. Example 1 : fatigue as evidence that the person perform self care.
Example2 : patient report of usual intake.
Signs and Symptoms are also used during the last stage of the Nutrition Care ProcessMonitoring and Evaluation, to determine the amount of progress made toward resolving the
Nutrition Diagnosis (more on this in future blogs).
It is an important skill for a dietitian to is able to identify the evidence (or Signs and Symptoms)
that demonstrate that a Nutrition Diagnosis exists.
How to choose the correct Signs and Symptoms
1. Do the Signs and Symptoms support and provide evidence that the Nutrition Diagnosis
(nutrition problem) exists?
2. Are the Signs and Symptoms supported by the Nutrition Assessment data?**
3. Are the Signs and Symptoms specific enough that they can be monitored to
measure/evaluate changes from one visit to another?
4. Can measuring the Signs and Symptoms tell you that the problem is resolved or
improved?
Case Study, Lower GI Tract Disorders- Crohn’s Disease – GRADED CASE
LG (Lee) is a 32 Y.O.F, admitted to the hospital for intractable, bloody diarrhea and
abdominal pain X 5 days. Pt has a long hx. of Crohn’s disease . Pt. states she has
lost approx. 6 # in the past two weeks and that she has only tolerated small amounts of
clear lx’s. Pt. tells you that she is currently on medical leave from her job as a
teacher. She reports that she tries to follow a high fiber diet when she is feeling well.
Pt’s husband says that they rarely eat out.
PHX:




Macrocytic anemia, s/p resection of terminal ileum 5 years ago.
Ht: 162.5 cm. Wt: 44kg.
Diet order: NPO
Meds: Infliximab, Corticosteroid, Metronidazole, B12 1x/month
Based on the usual [recent] intake interview, you determine that she has been
consuming <25% of her estimated energy needs for ~ 2 weeks Medical Treatment Plan: (Doctor writes orders and follows through on these) ◦ R/O small bowel obstruction versus acute exacerbation of Crohn’s disease ◦ CT scan of abdomen and Esophagogastroduodenoscopy ◦ D5W w/60meq KCL @ 125ml/hr (IV fluids- not nutrition) ◦ Lab work: CBC and Chemistries ◦ Surgical consult and Nutrition consult Labs: Na++ 139, K+ 3.2, BUN 11, Hgb: 9.5, HCT 32, Vit B12: 70, 25 OH Vit D 17 Answer the following questions: Use all the space you need to provide thorough answers Define esophagastroduodenoscopy (EGD)? List Lee’s symptoms of Crohn’s disease: Define macrocytic anemia - discuss role of nutrients. Why does this patient have anemia? Which nutrients are malabsorbed after ileal resection? MNT for Crohn’s disease that is not active? (no current inflammation). Which labs are impacted by dehydration? Complete ADIME Form and write SOAP Note. Write 3 PES statements. One of the statements must be malnutrition PES statement, using Malnutrition criteria from page 3 of Malnutrition Handout (in Syllabus Folder). Attach Grading Rubric- next page CASE STUDIES Case studies will be initiated in class in groups. All work assigned for outside of class is to be done individually. There will be consequences for using any part of another student’s work or for sharing your work with another student. You will both receive a zero grade. Pediatric case studies must include growth charts with all anthropometrics plotted and with z-scores identified and interpreted. Please refer to Documentation Guide and Malnutrition Packet, when working on cases. Grading Rubric, Case Studies- copy and paste and add to each of the graded case studies. Excellent Good Fair Inadequate CC: Dx., PMHx., FHx. 3 2 1 0 Interpretation of laboratory values 7 5 4 <4 Interpretation of medications 5 4 3 <3 Complete, accurate anthropometrics (growth charts, z-scores also) 8 7 6 <6 Identification of problems, nutrition status 5 4 3 <3 Pt./family Interview 5 4 4 <3 Determination of nutritional requirements 10 8 7 <7 PES statements 15 12 11 <10 Goals 9 8 7 <7 Interventions 9 7 7 <7 Monitoring and Evaluation 4 3 3 <3 Structure of SOAP Note 10 8 7 <7 Miscellaneous 10 8 7 <6 Total 100 80 70 varies ADIME Form- In-patient Date: Time: Age: Sex: NUTRITION ASSESSMENT Chief Complaint: Adm. Diagnosis: PMH: Current Labs (denote high with + and low with – after the number). Medications/Treatments. Interpret laboratory values, based on the case patient include reasons for all, based on the case patient ANTHROPOMETRICS Ht: Admit Wt: or Current Wt: Estimated Dry Wt. Pediatrics: or IBW: % IBW: UBW: % UBW: Recent Wt. Hx: Wt. % BMI: BMI Class (adults only) UBW % Ht. or length % BMI % Weight for length% Pediatrics: z-scores Patient/Family Interview Notes: Intake/Digestive Problems  NPO ______days Physical & Mental Status  Hearing Impaired  Diarrhea  Anorexia  Constipation  Chewing Problem  Nausea/Vomiting  Poor Dentition Food Intolerance  Swallowing Problem _______________  Aspiration Precautions  Food Allergy  Assist w/ Meals ________________  Limited Vision  Dementia  Language Barrier  Mental Status Changes  ETOH/Drugs  N/A Metabolic Stressors Access  PO  Post-op/Surgery  NJT  Fever/Infection  NGT  Wounds  JT  NJT  Trauma/Fracture  GT  Sepsis  Other_______________  PIV PHYSICAL ASSESSMENT Notes on Visual Physical Assessment: examples: thin, dry hair, visibly low subcutaneous fat  Adequately Nourished  Obese  At risk for malnutrition  Malnourished ESTIMATED NUTRITON NEEDS & INTAKE ASSESSMENT Quantified Intake PTA or in hospital (Usual Intake, Calorie Count, and/or results from Intake Analysis): Special Diet PTA: Current Diet Order/Nutrition Support: Estimated Nutrition Needs BMR________ Maintenance kcal__________ Protein(g) Fluid(ml) Method used:_________________________ Disease or stress factor______ Calories added or subtracted for weight gain/ loss_________ Activity factor______ Total kcal:_______ _______ _______ NUTRITION DIAGNOSTIC STATEMENTS (PES)1 2. 3. GOALS 1. PO intake will increase to 50-75% of meals/supplements consistently within days. 2. 3. INTERVENTIONS/RECOMMENDATIONS 1. 2. 3. 4. 5. MONITORING AND EVALUATION:  I&0 Form  Laboratory values__________________________________________________________________________ __________________________________________________________________________________________________________  Calorie Count X ______ days  Patient Meal Rounds  RD participation in Patient Care Team Rounds  Review changes in clinical status & discuss pt. progress with team including: _____________________________________________ _____________________________________________________________________________________________________________  Other: _____________________________________________________________________________________________________  Follow-Up: RD f/u in Signature and Credentials: _2__days to further evaluate ______________________________________________________ Date: Nutrition Diagnostic Terminology Each term is designated with an alpha-numeric NCPT hierarchical code, followed by a five-digit (e.g., 99999) Academy SNOMED CT unique identifier (ANDUID). Neither should be used in nutrition documentation. The ANDUID is for data tracking purposes in electronic health records. NCPT Code ANDUID NCPT Code ANDUID INTAKE (NI) Nutrient (5) Actual problems related to intake of energy, nutrients, fluids, bioactive substances through oral diet or nutrition support Actual or estimated intake of specific nutrient groups or single nutrients as compared with desired levels Energy Balance (1) q Increased nutrient needs NI-5.1 10656 (specify) __________________________________ Actual or estimated changes in energy (calorie/kcal/kJ) balance q Increased energy expenditure NI-1.1 10633 q Malnutrition NI-5.2 10657 q Inadequate energy intake NI-1.2 10634 q Starvation related malnutrition NI-5.2.1 11130 q Excessive energy intake NI-1.3 10635 q Chronic disease or condition related malnutrition NI-5.2.2 11131 q Predicted suboptimal energy intake NI-1.4 10636 q Acute disease or injury related malnutrition NI-5.2.3 11132 q Predicted excessive energy intake NI-1.5 10637 q Inadequate protein-energy intake NI-5.3 10658 q Decreased nutrient needs NI-5.4 10659 NI-5.5 10660 q Inadequate fat intake NI-5.6.1 10662 q Excessive fat intake NI-5.6.2 10663 q Intake of types of fats inconsistent with needs NI-5.6.3 10854 q Inadequate protein intake NI-5.7.1 10666 10644 q Excessive protein intake NI-5.7.2 10667 q Intake of types of proteins or amino acidsinconsistent with needs (specify) __________________________________ NI-5.7.3 10855 q Inadequate carbohydrate intake NI-5.8.1 10670 q Excessive carbohydrate intake NI-5.8.2 10671 q Intake of types of carbohydrateinconsistent with needs (specify) __________________________________ NI-5.8.3 10856 q Inconsistent carbohydrate intake NI-5.8.4 10673 q Inadequate fiber intake NI-5.8.5 10675 q Excessive fiber intake NI-5.8.6 10676 Oral or Nutrition Support Intake (2) Actual or estimated food and beverage intake from oral diet or nutrition support compared with patient/client goal q Inadequate oral intake NI-2.1 10639 q Excessive oral intake NI-2.2 10640 q Inadequate enteral nutrition infusion NI-2.3 10641 q Excessive enteral nutrition infusion NI-2.4 10642 q Enteral nutrition composition inconsistent with needs NI-2.5 11142 q Enteral nutrition administration inconsistent with needs NI-2.6 11143 q Inadequate parenteral nutrition infusion NI-2.7 q Excessive parenteral nutrition infusion NI-2.8 10645 q Parenteral nutrition composition inconsistent with needs NI-2.9 11144 q Parenteral nutrition administration inconsistent with needs NI-2.10 11145 q Limited food acceptance NI-2.11 10647 Fluid Intake (3) Actual or estimated fluid intake compared with patient/client goal q Inadequate fluid intake NI-3.1 10649 q Excessive fluid intake NI-3.2 10650 Bioactive Substances (4) Actual or estimated intake of bioactive substances, including single or multiple functional food components, ingredients, dietary supplements, alcohol q Inadequate bioactive substance intake NI-4.1 10859 q Inadequate plant stanol ester intake NI-4.1.1 11077 q Inadequate plant sterol ester intake NI-4.1.2 11078 q Inadequate soy protein intake q Inadequate psyllium intake q Inadequate β-glucan intake q Excessive bioactive substance intake q Excessive plant stanol ester intake q Excessive plant sterol ester intake q Excessive soy protein intake q Excessive psyllium intake q Excessive β-glucan intake q Excessive food additive intake NI-4.1.3 NI-4.1.4 NI-4.1.5 NI-4.2 NI-4.2.1 NI-4.2.2 NI-4.2.3 NI-4.2.4 NI-4.2.5 NI-4.2.6 11080 11079 11076 10653 11084 11085 11087 11086 11081 11083 q Excessive caffeine intake NI-4.2.7 11082 q Excessive alcohol intake NI-4.3 10654 (specify) __________________________________ q Imbalance of nutrients Fat and Cholesterol (5.6) (specify) __________________________________ Protein (5.7) Carbohydrate and Fiber (5.8) Vitamin (5.9) q Inadequate vitamin intake (specify) NI-5.9.1 10678 q A (1) 10679 q C (2) 10680 q D (3) 10681 q E (4) 10682 q K (5) 10683 q Thiamin (6) 10684 q Riboflavin (7) 10685 q� ... 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