NCP PES Samples

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Nutrition Care Process
PES Statement Samples
Problem
Related To
As evidenced by
Inadequate calorie / protein intake
Dysphasia, swallowing difficulty
Chewing difficulty
Decreased appetite
Difficulty feeding self
Altered taste perception from chemo/radiation,
chronic disease, multiple meds
Stroke, MS, Parkinson’s
Impaired oral intake
Unable to consume po safely
Dementia
Decreased desire to urinate
Decreased thirst perception
Dislike of thickened liquids
Coughing, Pocketing, spitting out food
Spilling of majority of meal
Weight loss of X3 in time frame
Resident reports ill fitting or unavailable dentures
SLP reports . . .
PO < 50%
Resident states trouble eating
NPO, Sedation, Vent
Resident wishes no artificial nutrition
Physical findings of dry mucous membranes, poor skin
turgor, dark urine, cloudy urine
Dx UTI,
Inadequate output per nursing
Oral intake of < XXX cc fluid per daily average
Diarrhea
Nausea, Vomiting x frequency
Weight loss of X# in timeframe
Inadequate oral intake
Inadequate oral intake
Inadequate fluid intake
Impaired nutrient utilization
Excessive CHO intake
Excessive energy intake
Excessive mineral intake
Overweight
Obese
Underweight
Compromised function of the GI tract due to
radiation therapy
Vomiting, Emesis
S/P GI surgery
Unrestricted diet order
Non compliant to diet
Excessive snacking from vending machine
Limited adherence to nutrition related
recommendations
Decrease energy expenditure associated with
sedentary lifestyle, limited physical activity
Increased energy needs
Inadequate intake
Weight gain of XX # in timeframe
Blood sugars elevated (list lab / accuchecks and values)
Increased Na or K lab values
Snacking from vending machine, consuming outside foods
Ordering out or requesting additional food
BMI > 30
Weight gain of XX # in timeframe
Recent ___ diagnosis and treatment (ie cancer)
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
(Parkinson’s disease)
Wound, Surgery, Infection, Septic
Cancer, MS
Non compliance with gluten free diet
Excessive consumption of sugar free candy
Non compliance with GERD prevention advice
Impaction, Illeus
No bowel sounds
Impaired utilization from renal disease
Excessive CHO intake
Excessive fat intake
Inadequate fluid intake
Dietary management of (name specific disease
process ie DM, CHF, Renal, Diverticular, HTN,
edema, constipation)
Low rate of infusion
Resident pulled out tube
TF not at goal
Diet order as written does not meet needs or
goal
TF or TPN order > or < estimated needs
Recent weight loss of x# in timeframe
Inadequate protein stores (list alb or prealb value)
Wound (stage and location)
Altered GI function
Altered nutrient related lab value
Nutrition related knowledge deficit
Inadequate intake from Tube
feeding, enteral formula
Excessive Intake from TF or TPN
Inadequate Intake from TF or TPN
Inability or lack of desire to manage
self care
Impaired ability to prepare foods /
meals
Physical inactivity
Diagnosis (stroke, wound, dementia, etc)
Limited mobility
Limited knowledge
Diarrhea
Constipation
GI complaints per resident
NPO status
Need for TPN for nutrition support
State lab and value
Resident reports lack of knowledge regarding (be specific)
Current order less than goal rate of __ cc/hr
TF meeting <100% needs
Inappropriate lab value (list)
Blood sugars elevated (list)
Weight loss or gain of X# in timeframe
Admission in LTC / rehab care.
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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