Transcript Poor Oral Intake Case Study

Facilitator Notes
•
Prior to presenting to your group, print out the final slide in
A4 size and use this for your participants worksheet.
•
It is recommended not to print out the presentation for use
during the presentation
•
The presentation will provide 1 refresher example for your
participants and then proceed with case example.
•
The presentation is designed so that your participants
complete the diagnosis section first followed with a
discussion about the most appropriate diagnosis to use.
The completion of the PES statement should only be
completed after this discussion.
Victorian ADIME/IDNT Working Party
Version 3: May 2014
Food
Intolerance
(FODMaPs)
Presented by
Victorian ADIME/IDNT Working Party
Version 3: May 2014
Refresher Example of PES Statement
Excessive energy intake (NI-1.5) related to frequent
consumption of large portions of high-fat meals as evidenced
by average daily energy intake exceeding recommended
amount by 2000kj & 6kg gain during the past 18 months
Victorian ADIME/IDNT Working Party
Version 3: May 2014
Food Intolerance (FODMaPs)
Nutrition Assessment (A)
36 year old male referred for diet advice to assist with management of
irritable bowel syndrome (IBS)
Medical/Clinical:
• Normal gastroscopy and colonoscopy whilst consuming gluten
• Reported symptoms include abdominal pain, bloating, flatulence and
frequent loose bowel motions ( ~ 6 per day)
• Has not previously undergone any nutrition elimination diet or food
challenges
• Patient unable to identify trigger foods, states reacts to everything
• Positive hydrogen breath tests for fructose, lactose and sorbitol
Anthropometry:
• Ht: 175cm
Wt: 75kgs
BMI: 24.5kg/m2
• Weight has been stable for years
Biochemistry:
• Nil significant
Victorian ADIME/IDNT Working Party
Version 3: May 2014
Food Intolerance (FODMaPs)
Social:
• Lives with wife. No children.
• Works full time as a barrister
• Frequency of bowel motions is affecting his work
• Runs for ~30 minutes 3-4 times per week.
Diet:
• Consumes wheat based breakfast cereals, bread and pasta, onion in pasta
sauces/casseroles and stock, 600ml fruit juice per day and chews sugar free
gum. Eats pears and apples regularly. Uses full cream dairy in latte, no
yoghurt.
• Irregular meal pattern – often misses lunch
• 1-2 x coffees per day
• ETOH – 1 x glass of wine with the evening meal
Victorian ADIME/IDNT Working Party
Version 3: May 2014
Using the nutrition diagnosis reference sheet
Identify possible nutrition diagnoses that
could fit this case study
1. ____________________________________________________________
2. ____________________________________________________________
3. ____________________________________________________________
4. ____________________________________________________________
5. ____________________________________________________________
Victorian ADIME/IDNT Working Party
Version 3: May 2014
All Possible Diagnoses
• Excessive bioactive substance intake (specify) (NI 4.2)
• Less than optimal intake of types of carbohydrate (specify) (NI – 5.8.3) ie:
fructose, lactose, sorbitol
• Less than optimal intake of types of proteins or amino acids (specify) (NI
5.7.3)
• Food and Nutrition knowledge deficit (NB – 1.1)
• Inconsistent Carbohydrate Intake (NI-5.8.4)
• Altered Gastrointestinal (GI) function (NC-1.4)
• Inadequate Carbohydrate Intake (NI-5.8.1)
• Undesirable food choices (NB-1.7)
Victorian ADIME/IDNT Working Party
Version 3: May 2014
Key Diagnoses
Most appropriate diagnoses for this case study:
• Less than optimal intake of types of carbohydrate
(specify) (NI – 5.8.3) ie: fructose, lactose, sorbitol
• Food and Nutrition knowledge deficit (NB – 1.1)
• Altered Gastrointestinal (GI) function (NC-1.4)
Victorian ADIME/IDNT Working Party
Version 3: May 2014
Other diagnosis’s and reason/s why you
might not use them:
•
•
•
•
•
Excessive bioactive substance intake (NI-4.2) - FODMaPs are not bioactive
substances
Less than optimal intake of types of proteins or amino acids (specify) (NI-5.7.3) –
FODMaPs are not protein or amino acids
Inconsistent Carbohydrate Intake (NI-5.8.4) – has to do with blood glucose levels
Inadequate Carbohydrate Intake (NI-5.8.1) – lower intake of carbohydrate
compared to reference standards
Undesirable food choices (NB-1.7) – has to do with inconsistency in regards to
dietary reference intake standards
Victorian ADIME/IDNT Working Party
Version 3: May 2014
Based on the above case study
write 2 to 3 possible PES statements
• P:______________________________
___________________ as related to
• E:______________________________
_________________as evidenced by
• S/S:_____________________________
______________________________
Victorian ADIME/IDNT Working Party
Version 3: May 2014
Evaluating your PES Statement
When developing your PES statements, think about the following:
{ } can the dietitian resolve the nutrition diagnosis?
{ } if tossing up between 2 diagnoses, attempt to select the INTAKE domain first
{ } is the aetiology the “root cause” (ask “but why”)
{ } will measuring the ‘signs and symptoms’ tell you if the problem is resolved?
{ } are the signs and symptoms specific enough that you can measure them?
Victorian ADIME/IDNT Working Party
Version 3: May 2014
PES statement 1
Less than optimal intake of types of carbohydrate (NI – 5.8.3) ie:
fructose, lactose and sorbitol
related to new diagnosis of fructose, lactose and sorbitol malabsorption
based on hydrogen breath tests
as evidenced by GIT symptoms - abdominal pain, bloating, flatulence and
frequent loose bowel motions ( ~ 6 per day) and positive intake of
fructose, lactose and sorbitol containing foods
Victorian ADIME/IDNT Working Party
Version 3: May 2014
PES statement 2
Food and Nutrition knowledge deficit (NB – 1.1)
related to no previous education or understanding of the details of sugar
malabsorption required for a low FODMaP diet
as evidenced by patient unable to identify foods high in fructose, lactose and
sorbitol and such foods being present in diet history.
Victorian ADIME/IDNT Working Party
Version 3: May 2014
PES statement 3
Altered Gastrointestinal (GI) function (NC-1.4)
related to malabsorption of fructose, lactose and sorbitol
as evidenced by positive hydrogen breath tests indicating fructose, lactose
and sorbitol malabsorption, GIT symptoms - abdominal pain, bloating,
flatulence and frequent loose bowel motions ( ~ 6 per day) and positive
intake of fructose, lactose and sorbitol containing foods
Victorian ADIME/IDNT Working Party
Version 3: May 2014
If NO Hydrogen breath tests?
– Unable to make a diagnosis on the initial consultation. In
this case it would be a ‘suspected diagnosis’ which can be
confirmed on review consultations.
Victorian ADIME/IDNT Working Party
Version 3: May 2014
References
o PES FAQ and Terminology IDNT Edition 3, v4, Nutrition and
Dietetics Department, Princess Alexandra Hospital,
Queensland
Victorian ADIME/IDNT Working Party
Version 3: May 2014
Case Study
Newly Diagnosed fructose, lactose and sorbitol malabsorption
referred for diet advice to assist with management of irritable
bowel syndrome (IBS)
Medical/Clinical:
• Normal colonoscopy and gastroscopy whilst consuming gluten
• Positive hydrogen breath tests for fructose, lactose & sorbitol
• Reported symptoms include abdominal pain, bloating, flatulence
& frequent loose bowel motions (~6 per day)
Anthropometry:
Ht: 175cm Wt: 75kgs BMI: 24.5kg/m2
Weight has been stable for years
Biochemistry:
• Nil significant
Exercise:
• Runs for ~30 minutes 3-4 times per week
Social:
• Lives with wife. No children.
• Works as a barrister
• Frequency of bowel motions is affecting his work
Diet:
•Consumes wheat based breakfast cereals, bread and pasta, onion
in pasta sauces/casseroles and stock, 600ml fruit juice per day and
chews sugar free gum. Eats pears and apples regularly. Uses full
cream dairy in latte, no yoghurt.
•Irregular meal pattern – often misses lunch
•1-2 x coffees per day
•ETOH – 1 x glass of wine with the evening meal
Using the nutrition diagnosis reference sheet, identify possible nutrition diagnoses that could fit this case study
1.
2.
3.
4.
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
5. ____________________________________________________
6. ____________________________________________________
7. ____________________________________________________
8. ____________________________________________________
Based on the above case study write three possible PES statements
PES Statement 1:
P:__________________________________________________________________________________________as related to
E:________________________________________________________________________________________as evidenced by
S/S:___________________________________________________________________________________________________
PES Statement 2:
P:__________________________________________________________________________________________as related to
E:________________________________________________________________________________________as evidenced by
S/S:___________________________________________________________________________________________________
PES Statement 3:
P:__________________________________________________________________________________________as related to
E:________________________________________________________________________________________as evidenced by
S/S:___________________________________________________________________________________________________