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Nutrition Care Process PES Statement Samples: Problem Related To As Evidenced by

The resident is experiencing inadequate oral intake due to dysphasia and swallowing difficulties, as evidenced by coughing, pocketing food, and spitting out majority of meals. Nutrition status is also impacted by decreased appetite and difficulty feeding self. The resident requires nutrition interventions to address these problems and support adequate intake and nutrition.

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Bayan Abid
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10K views2 pages

Nutrition Care Process PES Statement Samples: Problem Related To As Evidenced by

The resident is experiencing inadequate oral intake due to dysphasia and swallowing difficulties, as evidenced by coughing, pocketing food, and spitting out majority of meals. Nutrition status is also impacted by decreased appetite and difficulty feeding self. The resident requires nutrition interventions to address these problems and support adequate intake and nutrition.

Uploaded by

Bayan Abid
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Nutrition Care Process

PES Statement Samples

Problem Related To As evidenced by


Inadequate calorie / protein intake Dysphasia, swallowing difficulty Coughing, Pocketing, spitting out food
Chewing difficulty Spilling of majority of meal
Inadequate oral intake Decreased appetite Weight loss of X3 in time frame
Difficulty feeding self Resident reports ill fitting or unavailable dentures
Altered taste perception from chemo/radiation, SLP reports . . .
chronic disease, multiple meds PO < 50%
Stroke, MS, Parkinson’s Resident states trouble eating
Inadequate oral intake Impaired oral intake NPO, Sedation, Vent
Unable to consume po safely Resident wishes no artificial nutrition
Inadequate fluid intake Dementia Physical findings of dry mucous membranes, poor skin
Decreased desire to urinate turgor, dark urine, cloudy urine
Decreased thirst perception Dx UTI,
Dislike of thickened liquids Inadequate output per nursing
Oral intake of < XXX cc fluid per daily average
Impaired nutrient utilization Compromised function of the GI tract due to Diarrhea
radiation therapy Nausea, Vomiting x frequency
Vomiting, Emesis Weight loss of X# in timeframe
S/P GI surgery
Excessive CHO intake Unrestricted diet order Weight gain of XX # in timeframe
Non compliant to diet Blood sugars elevated (list lab / accuchecks and values)
Excessive energy intake Excessive snacking from vending machine Increased Na or K lab values
Excessive mineral intake Limited adherence to nutrition related Snacking from vending machine, consuming outside foods
recommendations Ordering out or requesting additional food
Overweight Decrease energy expenditure associated with BMI > 30
Obese sedentary lifestyle, limited physical activity Weight gain of XX # in timeframe
Underweight Increased energy needs Recent ___ diagnosis and treatment (ie cancer)
Inadequate intake Weight loss X in timeframe
Weight < IBW, BMI < 20

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Problem Related To As evidenced by
Increased calorie / protein needs Increased involuntary physical activity Recent weight loss of x# in timeframe
(Parkinson’s disease) Inadequate protein stores (list alb or prealb value)
Wound, Surgery, Infection, Septic Wound (stage and location)
Cancer, MS
Altered GI function Non compliance with gluten free diet Diarrhea
Excessive consumption of sugar free candy Constipation
Non compliance with GERD prevention advice GI complaints per resident
Impaction, Illeus NPO status
No bowel sounds Need for TPN for nutrition support
Altered nutrient related lab value Impaired utilization from renal disease State lab and value
Excessive CHO intake
Excessive fat intake
Inadequate fluid intake
Nutrition related knowledge deficit Dietary management of (name specific disease Resident reports lack of knowledge regarding (be specific)
process ie DM, CHF, Renal, Diverticular, HTN,
edema, constipation)
Inadequate intake from Tube Low rate of infusion Current order less than goal rate of __ cc/hr
feeding, enteral formula Resident pulled out tube TF meeting <100% needs
TF not at goal
Diet order as written does not meet needs or
goal
Excessive Intake from TF or TPN TF or TPN order > or < estimated needs Inappropriate lab value (list)
Inadequate Intake from TF or TPN Blood sugars elevated (list)
Weight loss or gain of X# in timeframe
Inability or lack of desire to manage Physical inactivity Admission in LTC / rehab care.
self care Diagnosis (stroke, wound, dementia, etc)
Impaired ability to prepare foods / Limited mobility
meals Limited knowledge

If no new problems exist, weight stable, all labs WNL, no new wounds, etc then state,
“Nutrition interventions in place, no new nutrition problems, pes as above.”

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