Welcome to Part 3 of my journey through the of IDNT and the Nutrition Care Process. I hope you enjoyed Part 1 Nutrition Assessment and Part 2 Nutrition Diagnosis.

The Nutrition Care Process is the systematic approach to providing high-quality nutrition care developed the Academy of Nutrition & Dietetics. Kalix’s electronic documentation feature was built on the back of the nutrition care process. Electronic documentation systems like Kalix make charting a lot quicker. They can even limit the need to learn and memorize standardized terminology.

So it is time to delve deeper into the PES Statement.

What is a PES Statement?

When discussing any topic, I like to start with a definition. Definitions help to check that we’re all on the same page before progressing further. So here goes… 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.

Hence 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 Diagnosis exists).

An Example

Excessive energy intake, related to limited access to healthful food choices (healthful food choices not provided as an option by carer), as evidenced by estimated intake of energy (9 500kJ/day) is in excess of estimated energy needs (7 500kJ/day) and BMI equals 45kg/m2.

Lets look at its parts:

The Problem (P)  (Nutrition Diagnosis): is excessive energy intake (NI-1.3). 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. The carer provides the client’s meals.  Healthful (e.g., adequate amounts of fresh fruit and vegetables) food choices are not provided as an option by the carer. 

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 (9 500kJ/day) is in excess of his estimated energy needs (7 500kJ/day). The client’s BMI equals 45kg/m2 (obesity class III).

Now lets discuss each component of the PES statement.

The Problem (P)– the Nutrition Diagnosis

I discussed the Nutrition Diagnosis in my previous post, it’s worth a read for a quick refresher. Let’s start with a definition again:

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 found in eNCPT (previously the IDNT Reference Manual) .

The Nutrition Diagnosis terms are classified into three categories:

Intake: these diagnosis relate to intake and nutrition related problems (oral, enteral and parenteral nutrition). Intake diagnosis cover the areas including energy balance, fluid intake, bioactive substances and nutrient intake.

Examples: excessive energy intake, less than optimal intake of types of carbohydrate, inadequate calcium intake. 

Clinical: these diagnosis 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 Behavioral-Environmental 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.” (Oxford Dictionary).

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. The eNCP includes some examples of etiologies for Nutrition Diagnosis terminology as well as the online Etiology Matrix.  These resources are very useful, however, they are examples only. It’s an important skill for a dietitian to is able to identify the root cause of a client’s nutrition problem.   

Etiology 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 (client lives in rural area with limited access to public transport).
• Behavior e.g. unwilling or disinterested in 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: e.g. food- and nutrition-related knowledge deficit concerning appropriate fluid intake.
• 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

A colleague of mine suggests a very 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, observation, lab values and test results.
• Symptoms are  subjective data reported by the  client’s or their family’s rather than actual results. 

Signs and Symptoms are also used during the last stage of the Nutrition Care Process- Monitoring and Evaluation, to determine the amount of progress made toward resolving the Nutrition Diagnosis (more on this in future blogs).

The Signs and Symptoms data is obtained during the first stage in the Nutrition Care Process, Nutrition Assessment.  Like Etiology, Signs and Symptoms in the PES Statement are free text. The eNCP includes some examples of Sign and Symptoms for Nutrition Diagnosis terminology. They are examples only. 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?

**Think back to the Nutrition Care Indicators mentioned in the previous blogs (assessment data that is used to identify a client’s Nutrition Diagnosis and its etiology and signs/symptoms.) 

So that’s about it for now. I will go before this post turns into an essay. I hope you find it useful. Next time: Nutrition Intervention!! (One day!)