Sunday, December 23, 2018

To Use or Not to Use The Medical Diagnosis in a PES statement??  
That is the question!!

When developing the dietetics standardized language, now called the eNCPT, there was considerable debate about the connections between the medical diagnosis and nutrition diagnoses. 

We concluded that a medical diagnoses alone was insufficient to describe the problems that dietitians address..

But ...

Can a medical diagnosis be used in the PES as an etiology (or underlying cause) of the nutrition diagnosis?
   (Actively discouraged)

Can a medical diagnoses be used in the PES a sign and symptom for a nutrition diagnoses?
   (Can be used WITH other data)

Medical Diagnoses as Etiology
Relying on a medical diagnosis as the etiology is not particularly useful.  Using the medical diagnoses as the etiology is problematic since dietitians are not expected to directly "intervene" to resolve a medical diagnoses.  Using a medical diagnoses also can limit the dietitian's thinking about what etiologies exist for a nutrition diagnoses that dietitians can impact.

Examples have been created to demonstrate this difficulty and show alternative ways to construct the PES statement..

For Example the two following PES statements for a person with COPD are accurate, but one is not helpful in directing the nutrition intervention

  • Inadequate energy intake related to COPD as evidenced by energy intake ~800 kal less than estimated energy needs.

While this may be accurate, the dietitian is not usually able to intervene directly on the shortness of breath caused by COPD. 

So the dietitian is encouraged to identify a more nutrition related etiology which may focus on the specific activities that are caused by the COPD.  For example:

  • Inadequate energy intake related to inability to eat large quantities of food OR inability to cook and serve food as evidenced by reports of SOB and fatigue prior to finishing meal and limitations on ADL of cooking and serving food.

Both of these etiologies are certainly a results of shortness of breath caused by COPD, but they are etiologies that a dietitian can reasonably create nutrition interventions to address.

So the recommendation given has been given.....whenever possible find an etiology that is not a medical diagnosis that the dietitian can independently address.

Medical Diagnoses as Signs and Symptoms

So if we are not recommending using a medical diagnoses as an etiology, why is it included in the Nutrition Diagnoses Reference Sheet?

Data from the medical history, including medical diagnoses, are shown as signs and symptoms in the Nutrition Diagnosis reference sheets.  Signs and Symptoms are nutrition assessment data that are clustered together to identify whether a specific nutrition diagnoses exists.  You can use a medical diagnosis as "proof" or "evidence" that a specific nutrition diagnosis is present, along with other specific data. 

For example including the medical diagnosis of diabete mellitus along with Hemoglobin A1C value and carbohydrate intake will fully describe how the dietitian identified and verified that excessive carbohydrate intake was a nutrition diagnosis.   The medical diagnosis usually would not be sufficient by itself to support a nutrition diagnosis.

Bottom line:  Use of medical diagnoses as an etiology is discouraged since it is not usually helpful in guiding the selection of a nutrition intervention.  However a medical diagnosis may be PART of the cluster of data used to determine whether a nutrition diagnosis exists and may be used as a sign to support selection of a Nutrition Diagnoses.

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