Wednesday, April 23, 2014

Is there a one "right" PES statement??

Dietitians are concerned about getting the PES statements "right" and are looking for an "answer" to a case that shows the perfect PES statement.

Frequently during NCP/IDNT workshops they are assured that usually there isn't a single "right" PES statement to describe the nutrition problem that they have identified.  And then the discussion goes on to elaborate on how various PES statements could be used to describe the dietitian's judgments about a patient/client's problem that they have chosen to address in their nutrition care.

In some cases, the attendees may interpret this to mean that "anything goes" when it comes to writing a PES statement...this couldn't be further from the truth.  The original point that was being made during the workshop was the importance of focusing on creating PES statements that were as descriptive as possible.  However, the underlying assumption is that the dietitian is competent and has indeed evaluated the nutrition assessment data appropriately and selected one or more appropriate nutrition problem(s) to address--and the focus of the workshop is to help that competent dietitian to best use the IDNT terms available to create one or more PES statements that describe their approach to the nutrition care.

This in no way means that dietitians, or dietetics students in particular, will always appropriately assess the nutrition assessment data and correctly identify a relevant or the most relevant nutrition problem(s) to address. Certainly if the dietitian or dietetics student has made an error in collecting the nutrition assessment data, has selected an inappropriate standard for comparison, or has not appropriately identified the most critical nutrition problem (in the context of the medical conditions and patients' preferences) this will lead to selection of an inappropriate nutrition diagnoses and therefore a PES statement that is "wrong".  

Assuming that the nutrition assessment has been properly completed, a set of questions/criteria have been developed to assist dietitians in creating documentation that best describes the nutrition problem/diagnoses that they have selected and demonstrates the logical thinking of the Nutrition Care Model.  These questions focus on evaluating each component of the PES statement to see if there are opportunities for improvement in constructing the PES statement.

First look at the Nutrition Diagnosis term (Problem) that has been selected and answer the following questions:'
     
          – Can the dietitian resolve or improve the nutrition diagnosis?     
          – Consider the intake domain as the preferred problem     

Then, look at the wording that has been selected for the etiology and answer the following questions:

          - Is the etiology the “root” cause?     
          – Will dietitian intervention resolve the problem by addressing the etiology?     

           Note :If the dietitian intervention can not directly affect or resolve the stated etiology then can RD
                          intervention at least lessen the signs and symptoms?     

Next look at the Signs and Symptoms and answer the following questions:

          – Will measuring the signs and symptoms indicate if resolved or improved?     
          – Are the signs and symptoms specific enough?     

And finally look at the overall PES statement and ask yourself:

          – Does nutrition assessment data support the nutrition diagnosis, etiology, and signs and symptoms?

Educators who are training dietetics students know that students can have a great deal of difficulty identifying the most relevant nutrition problems to address.  There are other teaching strategies to assist students in first identifying the most appropriate nutrition diagnoses, and then these questions may be useful to help them construct their PES statements.

However the ability to think critically in the nutrition assessment step is a topic unto itself and is definitely a separate critical skill to be developed and honed.  The November 2013 Academy practice paper authored by Pam Charney and Sarah Peterson discusses the critical thinking that is necessary during the nutrition assessment and diagnosis that will lead the dietetics student and dietitian to the appropriate nutrition diagnosis(es).

Bottom line:  Is there a "right" and "wrong" PES statement?  Certainly there are instances where a "wrong" problem/nutrition diagnosis is identified and this will obviously lead to a "wrong" PES statement.  However if we spend too much effort on creating the perfect PES statement we may miss the entire point of providing the right nutrition care.  Just as there is not a "right" nutrition progress note or a "wrong" nutrition progress note, there are some that are more clear and concise than others and better describe the patient care episode...the same is true for the construction of a PES statement.

Our energy is better spent on honing our nutrition assessment skills and diagnostic reasoning to identify the most appropriate nutrition problem and the most effective intervention to improve the nutrition problem than obsessing about getting the perfect PES statement!.

Links of Interest:

Academy Practice Paper- November 2013.  Critical Thinking in Nutrition Assessment and Diagnosis





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