Suggested initial PES for chylothorax

 After several discussion groups, the collective recommendations for what the initial PES statement might have been after the initial dietitian admission nutrition assessment are summarized in the video below.

Simpler is better

Consider:

Excessive Fat Intake related to no prior need for fat restriction,  current lymph leakage/chylothorax treatment needing reduced fat as evidenced by 70 gm fat intake prior to hospitalization vs new recommendation of <10 gm fat for chylothorax.

Nutrition Diagnosis: New

Etiology category:  Physiological -Metabolic

See the video that summarizes the discussion group results on this topic.

Considerations were that this was the initial PES statement on the first day of hospitalization, other nutrition diagnoses were related to malnutrition, and acknowledging that other PES statements would be appropriate as the care progressed.

The list of other potential nutrition diagnoses included:

• Intake of types of fat inconsistent with needs
• Inadequate oral intake
• Altered GI tract
• Impaired nutrient utilization
• Food and nutrition-related knowledge deficit

Click on the image to listen to the 9 minute video summarizing the background and discussion describing the critical thinking that occurred during the discussions.

If you would like to submit a topic for the next session on June 8, use this link.  

Chylothorax,,,,lets explore what to consider when writing PES statement

 Listen to the < 4 minute introduction to our first Do NCP II session.  After the session we will also post the summary.  

Register for our thought-provoking inaugural discussion on May 4th by selecting the time that’s most convenient for you:

 

Do NCP II, 8:00-8:30 am CDT

Do NCP II, 11:00-11:30 pm CDT

Do NCP II, 7:30-8:00 pm CDT

 

To submit a scenario for future Do NCP II sessions, click here.

DO NCP II - A new concept...sign up now for inaugural session

 

Have you or your colleagues or students ever struggled with determining an appropriate PES statement, and you wish you had a group of experts to discuss it with? Do you have questions on implementing the Nutrition Care Process in your facility?

NCPro is launching a free forum for users of the NCP called Do NCP II, or Dialogue on the Nutrition Care Process II.  Our goal is to address real life scenarios encountered by clinicians and students/educators. Questions will be discussed in a group and reasonable solutions identified.  The topic will be introduced, followed by a brief overview and discussion, and a recorded summary will be provided to registered participants following completion of all sessions on the topic. Topics will range from beginner to advanced and may be posed by practitioners in the field, educators or students.   The first session to be held is directed to practitioners and will discuss a PES statement appropriate for a patient prescribed a low-fat diet due to lymph leakage/chylothorax.

Register for our thought-provoking inaugural discussion on May 4th by selecting the time that’s most convenient for you:   Do NCP II, 8:00-8:30 am CDT Do NCP II, 11:00-11:30 pm CDT Do NCP II, 7:30-8:00 pm CDT   To submit a question for future Do NCP II sessions, click here.

Refeeding Syndrome: Opportunity for Dietitians

Dietitians’ participation on the healthcare team is enhanced if we can accurately describe the problem(s) we are addressing.  Refeeding syndrome may present an opportunity for dietitians.

Refeeding syndrome is a documented problem encountered during certain situations when a severely malnourished person starts receiving significant energy from oral, enteral or parenteral nutrition support. 

It was first named when parenteral nutrition was emerging as a nutrition intervention and malnourished patients received excessive calories, mostly from dextrose.¹   There continues to be lack of clear and consistent definition of refeeding syndrome, however key risk factors are known and include those who are malnourished, have a very low BMI or who have received negligible nutrient intake over the last 5 days. ²

The rapid start of metabolism of carbohydrate increases the need for intracellular thiamin and electrolytes (e.g. phosphate, magnesium and potassium).  When these nutrients rapidly enter the cells, the result is a decrease in serum levels.  In addition, alterations in insulin levels can lead to significant sodium and fluid retention. These metabolic disruptions or are known as 'refeeding syndrome".

But is there one "best" way to create a PES statement that leads to appropriate intervention?

If you look at the guidelines for refeeding malnourished patients you will find that recommendations include screening, assessment/monitoring and evaluation of the following types of data:

-NICE guidelines identify that SNAQ may be used as a screening tool to identify those at risk for refeeding syndrome³

-Nutrition Assessment/Monitoring and Evaluation parameters used prior to initiating feeding and monitoring after initiation of feeding

Aspen Guidelines include criteria for identifying moderate or significant risk for refeeding syndrome using a combination of BMI, amount and rate of weight loss, caloric intake,  potassium, phosphorus, or magnesium serum concentrations (hypokalemia, hypophosphatemia, or hypomagnesemia), loss of subcutaneous fat, loss of muscle mass, and presence of higher risk co-morbidities.²

-Nutrition interventions include supplementation of thiamin and electrolytes (phosphate, potassium and magnesium if levels are low) prior to the start of nutrition therapy followed by a gradual increase in  energy intake to meet energy requirements by Day 2 to 4 as long as electrolyte levels are stable.

What are the appropriate PES statements?⁷

If you are using criteria to identify individuals "at risk" for refeeding syndrome prior to initiating feeding, then a dietitian may consider using these two PES statements:

·        Starvation related malnutrition, severe, related to prolonged nutrition inadequacies as evidenced by unintentional weight loss  (adults- of  >20% in 1 year; >10% in 6 months; >7.5% in 3 months; or >5% in 1 month), severe loss of subcutaneous fat stores, and severe muscle loss⁴

·        Predicted Inadequate Nutrient Intake (thiamine, phosphorus, potassium and magnesium) related to increased nutrient need during initiation of refeeding after severe malnutrition as evidenced by diagnosis of severe malnutrition, pre-feeding laboratory values for phosphorus, potassium and magnesium (as applicable) and plan to initiate refeeding to estimated requirements by Day 2.⁵

However if it is now Day 2 and there are documented electrolyte imbalances, then the dietitian may consider the following that reflect the actual presence of refeeding syndrome:

·        Starvation related malnutrition (severe), related to prolonged nutrition inadequacies as evidenced by unintentional weight loss  (adults- of  >20% in 1 year; >10% in 6 months; >7.5% in 3 months; or >5% in 1 month), severe loss of subcutaneous fat stores, and severe muscle loss⁴

·        Imbalance of nutrients related to increased need for electrolytes and thiamine during refeeding as evidenced by (hypokalemia (data), hypophosphatemia(data), and/or hypomagnesemia (data) with TPN currently contributing 75% of estimated energy needs.  ⁶

It is important to remember there may be alterations in electrolytes from other causes, so the dietitians' clinical judgement is necessary to determine whether the evidence is present that reflects a true refeeding syndrome versus an "Altered nutrition related laboratory values.” ⁸

There may be situations where an "Altered nutrition-related laboratory value" may be identified first and as the clinical picture becomes more clear, this may be elevated to “imbalance of nutrients” that reflects refeeding syndrome.  ^6-8

BOTTOM LINE:

Since refeeding syndrome is associated with SEVERE malnutrition, the clinical picture being represented will usually include the severe malnutrition nutrition diagnoses in addition to an "imbalance of nutrients" if refeeding syndrome has occurred, or "predicted inadequate intake" where it is determined that patient is at risk for developing refeeding syndrome.

Acknowledgements:  A special thank you to Ainsley Malone, MS, RDN, LD, CNSC, FAND, FASPEN and Sandra Capra, BSc(Hons), DipNutr&Diet, MSocSc, PhD,  for providing input to concepts included in this blog. 

References:

 

1.      Weinsier RL, Krumdieck CL.  Death resulting from overzealous total parenteral nutrition:  the refeeding syndrome revisited.  Am J Clin Nutr. 1980; 34: 393-399  https://doi.org/10.1016/j.jpeds.2020.01.042

2.      da Silva, JWV et al.  ASPEN Consensus Recommendations for Refeeding Syndrome.  Nutrition in Clinical Practice.  35(2); 2020 178–195 DOI: 10.1002/ncp.10474

3.      Nutrition support in adults:  Evidence update August 2013.  National Institute for Health and Care Excellence (NICE).  Available at:  https://www.nice.org.uk/guidance/cg32/evidence/evidence-update-pdf-194887261.  Accessed December 4, 2020.

4.      Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care.  Starvation Related Malnutrition (undernutrition) (NC-4.1.1). Reference Sheet.  Available at: https://www.ncpro.org/pubs/encpt-en/codeNC-4-1-1  Accessed November 22, 2020.

5.      Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care.  Predicted Inadequate Nutrient Intake (Specify) (NI-5.11.1). Reference Sheet.  Available at https://www.ncpro.org/pubs/encpt-en/codeNI-5-11-1  Accessed November 22, 2020

6.      Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care.  Imbalance of Nutrients (NI-5.4). Reference Sheet.  Available at https://www.ncpro.org/pubs/encpt-en/codeNI-5-4 Accessed November 22, 2020

7.      Matthews,KL, Palmer, MA, Capra SM.  The accuracy and consistency of nutrition care process terminology use in cases of refeeding syndrome.  Nutrition and Dietetics 2018: 75 p 331-336.  DOI: 10.1111/1747-0080.12389

8.      Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care.  Altered Nutrition Related Laboratory Values (Nc-2-2). Reference Sheet.  Available at https://www.ncpro.org/pubs/encpt-en/codeNC-2-2, Accessed November 22, 2020

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Evolving PES Statements for Basic Elimination Diet Protocol

Lets consider a situation where you receive a consultation for a client that has been experiencing GI symptoms when on a normal diet.  The physician is concerned that it may be a food intolerance, allergy, or other inflammation-related health condition.  

The Basic Elimination Diet Protocol is one method of  determining which foods are leading to the GI discomfort.  There are the two phases...the elimination phase and the re-introduction phase.  

I received a question from dietitians in Sweden about what the PES statements might be for these two different phases.

PHASE ONE:  

For the first stage where most products are eliminated to eliminate the adverse GI signs and symptoms, the PES statement might be as follows:

Intake of protein inconsistent with needs 

    related to allergy or malabsorption syndrome from unknown protein substance 

as evidenced by medical diagnosis of potential food allergy/malabsorption and symptoms of diarrhea, nausea, vomiting when consuming normal diet.  

PHASE TWO:  

However after the foods have been eliminated from the diet, signs and symptoms of GI distress are no longer present.  You are now entering the testing in the re-introduction phase.  The PES statement might be:

Altered GI Function 

related to allergy or malabsorption syndrome from unknown protein substance

as evidenced by medical diagnosis of potential food allergy/malabsorption and symptoms of diarrhea, nasuea, vomiting when consuming normal diet.  

In this case we assumed that the substance was a protein, however it could be a carbohydrate, such as in the FODMAP Diet (e.g. short chain carbohydrates).  In some circles a variation of this is called the Autoimmune Protocol Diet. 

In this discussion we also assumed that the signs and symptoms would be GI disturbances.  However, in some cases, the Basic Elimination Diet may also be used to test whether there are food allergies or intolerances related to atopic dermatitis or eczema signs and symptoms.  This science in this area is less clear, however some believe that there may be some intrinsic skin defect (in this case in the GI tract) that allows allergens to enter the skin and results in an allergic/autoimmune response.  One way to verify that there might be a connection between food consumption and skin disruptions for an individual patient is using the Basic Elimination Diet Protocol/Autoimmune Protocol.  

While the current reference sheet included in eNCPT for Altered GI Function only includes GI symptoms, it does include reference to abnormal antibodies as one of the signs and symptoms.  It also includes Celiac Disease as one of the medical conditions that might be documentation of altered GI function.  

Whether this term, Altered GI Function, can also be used to describe altered GI functions that are thought to be associated with symptoms for dermatitis could be submitted to the Academy for consideration of whether this is an appropriate use of the term.  If so, the question might also ask whether the reference sheet should be expanded to clearly indicate the appropriateness of this use of the term in this type of situation.

Bottom Line

Your intervention for both PES statements is addressing the etiology BY affecting the signs and symptoms (usually GI discomfort).  

In the first phase you are actively removing the stimulus for the signs and symptoms.  In the second phase are are attempting to identify the unknown substance that is causing the symptoms by noting if the signs and symptoms re-appear when the food is re-introduced.  

References:

Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care.  Intake of Types of Proteins Inconsistent with Needs (Specify) (NI-5.6.3), Reference Sheet.  Available at: https://www.ncpro.org/pubs/encpt-en/codeNI-5-6-3.  Accessed November 19, 2020

Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care.  Intake of Types of Carbohydrates Inconsistent with Needs (Specify) (NI-5.8.3), Reference Sheet.  Available at:  https://www.ncpro.org/pubs/encpt-en/codeNI-5-8-3.  Accessed November 19, 2020
 
Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care.  Altered Gastrointestinal (GI) Function (NC-1.4), Reference Sheet.  Available at:  https://www.ncpro.org/pubs/encpt-en/codeNC-1-4.  Accessed November 19, 2020.

Using your "Crystal Ball!! What about "predicted" nutrition diagnoses?

 What about "predicted" nutrition diagnoses?

One of the general principles for constructing PES statements is that you use actual data that reflect the current situation.  However there are some circumstances where the situation is emerging or is likely to occur.  You are identifying a future nutrition problem and want to be proactive and intervene early.

Let's consider the use of a "predicted" nutrition diagnosis.  Re-consider your options in the previous post about the patient who has been placed on a ventilator, is unable to eat, and you believed should have enteral tube feeding.  

In the previous example we assumed that it was Day 4 and there had already been documented inadequate oral intake and/or inadequate energy intake signs and symptoms from the patient.  

BUT what if it were Day 1 or 2?  Assume the patient had been admitted in the afternoon, placed on a ventilator and it is now the morning of Day 2 of the hospitalization.  In your estimation it appears that the need for ventilator support is likely to continue for a significant amount of time.  

Then you may want to consider using a predicted nutrition diagnosis and you can use recommendations or citations from other research that supports your PES statement in lieu of actual patient signs and symptoms.

In this case a PES statement might look like:

Predicted inadequate energy intake related to inability to maintain volitional intake while on ventilator as evidenced by nutrition guidelines recommending early enteral nutrition for ventilator patients, current diet order as NPO, and ongoing ventilator therapy.

In this case there is limited data available for this specific patient to document actual inadequate energy intake as they have been in the hospital less than 24 hours, however you have a strong case for suggesting that this situation is likely to occur in the future AND you want to be proactive.

BOTTOM LINE:  If you do not have actual signs and symptoms of a nutrition diagnosis that you believe is likely to emerge you can consider a "Predicted nutrition diagnosis.  The following nutritional diagnostic terms are available:

Energy Balance (1)

Predicted inadequate energy intake (NI-1.4)

Predicted excessive energy intake (NI-1.5)

Multinutrient (5.11)

Predicted inadequate nutrient intake (specify)_______(NI-5.11.1)

Predicted excessive nutrient intake (specify)________(NI-5.11.2)

References

Predicted Inadequate Energy Intake (NI-1.4).  Reference Sheet.  Electronic Nutrition Care Process Terminology (eNCPT).  Available at: https://www.ncpro.org/pubs/encpt-en/codeNI-1-4.   Accessed Nov 16 2020.

Predicted Excessive Energy Intake (NI-1.5)   Reference Sheet.  Electronic Nutrition Care Process Terminology (eNCPT).  Available at: https://www.ncpro.org/pubs/encpt-en/codeNI-1-5.   Accessed Nov 16 2020.

Predicted Inadequate Nutrient Intake (NI-5.11.1)   Reference Sheet.  Electronic Nutrition Care Process Terminology (eNCPT).  Available at: https://www.ncpro.org/pubs/encpt-en/codeNI-5-11-1.   Accessed Nov 16 2020.

Predicted Excessive Nutrient Intake (NI-5-11.2)   Reference Sheet.  Electronic Nutrition Care Process Terminology (eNCPT).  Available at: https://www.ncpro.org/pubs/encpt-en/codeNI-5-11-2.   Accessed Nov 16 2020.

Inadequate Oral Intake vs more specific nutritional diagnoses

Deciding on which nutrition diagnosis will best describe the problem/issue that you are addressing is one aspect of the critical thinking and clinical judgement used by dietitians.  

The whole purpose of identifying the most accurate nutrition diagnosis is to BEST describe your assessment of the client condition that needs nutritional care.  The nutrition diagnosis and etiology chosen will lead to the most appropriate nutrition intervention and the signs and symptoms listed usually lead to appropriate monitoring and evaluation indicators.  

Our documentation in the nutrition progress is a key way to communicate with the rest of the healthcare team.  Your choice of nutrition diagnosis should allow them to understand your logic and ensure that all the healthcare team interventions are consistent and working together.  

Lets consider the initial evaluation of a patient on a ventilator where the diet order has been NPO for 4 days and patient is unable to eat due to being on a ventilator.

Following are the types of questions that you may want to ask yourself as you make the decision about a more general nutrition diagnosis (e.g. Inadequate oral intake) versus a more specific nutrition diagnosis (Inadequate energy intake).  

The table below also includes some thoughts on what the implications of a general versus more specific nutrition diagnosis might be:

Question to ask your self	Some implications of general nutrition diagnoses (e.g. Inadequate Oral Intake)	Some implications of a more specific nutritional diagnosis (e.g. Inadequate Energy Intake)
Will it make a difference in the nutrition intervention that I choose?	Inadequate oral intake might suggest that the intervention focus is on getting oral food and beverage intake.	Inadequate energy would indicate an intervention focus on high energy foods and or beverages.
Will it make a difference in the Monitoring and Evaluation (M&E)   indicators that I choose?	M&E Indicators would most likely focus on estimates of % food on trays, or number of servings of food groups (e.g. those used in My Plate, diabetic exchanges, or renal exchanges).	M&E Indicators will likely be energy targets, e.g. 85% of estimated energy requirements.
Am I concerned about lack of intake - all nutrients, or am I really only focused on a specific nutrient or only focused only on energy?	Inadequate oral intake indicates that ALL nutrients plus energy are inadequate.  Your intervention focus will likely be on increasing all nutrients.	Inadequate energy intake could represent an intake that is adequate in some nutrients, but not adequate in energy.  Your intervention focus will be first and foremost on providing energy.
Do I have the data necessary or is it worth the extra effort to calculate the additional data?	If you are in a nursing home, and the resident is no longer eating (meals or snacks) as per the nursing staff.  They may report…"she is leaving almost everything on the tray".   You may not have a good estimate of the actual intake, and you do not need to calculate the specific energy requirements to know that she is not consuming enough food and beverages.   There is no additional benefit to converting this to a more specific nutrient(s) or energy nutritional diagnosis.   The intervention will be the same, provide frequent small quantities of foods/beverages with high nutrient/energy density according to preferences  You are not likely to need the estimated energy or nutrient needs to guide your intervention.	If you are in acute care setting and the intervention that you are considering is going to be based on a specific energy level or specific protein level, then you may decide that it IS worth taking the extra time and energy to estimate the energy and protein requirements.   You will most likely need this information to guide enteral feeding or very specific nutrition intervention.  The intervention is very specifically designed to meet specified targets.   If it is enteral or parenteral the rate and type of formula is based on estimated requirement.
Should I start with Inadequate Oral Intake and change to more specific as I gain more information and get a clearer picture of the patient/client's condition or as the situation becomes more critical?	In some cases, the inadequate oral intake may be a preliminary nutrition diagnosis while you gather more specific information.  This may be especially appropriate if the duration of being on the ventilator is uncertain (only 1 more day vs at least another week).  If the patient remains on the ventilator and you are ready to change to a more specific nutrition diagnosis (e.g. Inadequate Energy Intake which you will intervene via enteral nutrition)  you can indicate that Inadequate Oral Intake is no longer relevant and replace it with Inadequate Energy Intake.	In some cases it may be more appropriate to go directly to a specific nutrition diagnosis.   Especially if you have the necessary data and you are ready for a specific nutrition intervention targeted to the nutrient or energy used as the signs and symptoms in the more specific nutrition diagnosis.
Is there something unique to the issue that deals with ORAL intake?  Do you want to focus on the oral aspect of inadequate intake?	In some circumstances, the focus may be on ORAL intake.    For example in a residential care setting, the goal may be to enhance the resident's independence and ability to self feed.   The intervention may be to enter the resident into restorative dining.  In this case the Oral intake really is the focus of the intervention and appropriate to be used as the nutrition diagnosis	However in some situations the problem is that adequate ORAL intake is likely impossible (e.g. patient is on ventilator).   In this case, this PES statement could incorporate the inability of maintaining volitional oral intake as an etiology and statement may signal that oral intake is the issue and alternative means of providing nutrition is needed (e.g.enteral tube feeding).   In this case, your etiology would likely be tied to justifying why oral intake is not possible.   For example with a patient on a ventilator, the etiology could be inability to maintain volitional oral intake while on ventilator.
Does a more general nutrition diagnoses accurately describe the level of concern to the rest of the healthcare team. Does the situation require a more compelling nutrition diagnosis?	Inadequate oral intake related to inability to maintain volitional oral intake while on ventilator AEB no nutritional intake for 4 days- Diet order of NPO vs recommendations for early enteral nutrition in ventilator patients. This PES statement would be most appropriate as a preliminary nutrition diagnosis where the duration of the ventilator has not been determined and there is a possibility that the ventilator will be discontinued soon. .   This PES statement would be most appropriate as a preliminary nutrition diagnosis where the duration of the ventilator has not been determined and there is a possibility that the ventilator will be discontinued soon. .	Inadequate energy related to inability to maintain volitional oral intake while on ventilator as evidenced by 0 energy intake for the past 4 days (Diet order NPO) compared to recommendations for early enteral nutrition with estimated requirements of 2000 kcal per day with cumulative energy deficit of 8,000 kcal  You could also keep it simpler as follows:   Inadequate energy related to inability to maintain volitional oral intake while on ventilator AEB no significant energy intake vs recommendations for early enteral nutrition in ventilator patients.   These types of PES Statements would be most appropriate if it is highly likely that the need for the ventilator will continue.  It is more straightforward since you are addressing the inability to maintain volitional intake through recommending enteral feeding.   In subsequent nutritional diagnoses you can continue to use energy and "resolve" this problem, but would use enteral nutrition diagnoses if you needed to adjust the formula.

 BOTTOM LINE:  Neither is technically "WRONG", but depending on your situation one may fit better than the other.  Your decision should be based on what best describes your clinical judgement of the situation and what you want to convey to the rest of the healthcare team.  

Usually simpler is better, as long as it accurately describes the situation.

References:

Inadequate Oral Intake NI-2.1.  Reference Sheet.  Electronic Nutrition Care Process Terminology (eNCPT).  Available at:  https://www.ncpro.org/pubs/encpt-en/codeNI-2-1.   Accessed Nov 14 2020.

Inadequate Energy Intake NI-1.2.  Reference Sheet.  Electronic Nutrition Care Process Terminology (eNCPT).  Available at:  https://www.ncpro.org/pubs/encpt-en/codeNI-1-2.   Accessed Nov 14 2020.

Myers EF, Orrevall Y.  Using the Nutrition Care Process:  Critical Thinking Vignettes From Eight Clinical Cases.  St Louis, Mo.  EF Myers Consulting.  2018