Malnutrition PES Statement: Your GO TO Resource!

A Malnutrition PES Statement will probably be one of your most frequently used statements. Some studies have found malnutrition rates at 44% (using SGA tools).

It’s important that you fully understand the criteria for a malnutrition diagnosis before diagnosing.  

Below you can find the ASPEN criteria for diagnosing malnutrition, also how to write the perfect malnutrition PES statement with examples!

And read until the end to find a Malnutrition Care Plan too!

What is Malnutrition?

Malnutrition can technically be both over and undernutrition.  Though for a long term care dietitian, it will always refer to undernutrition.

Diagnosing malnutrition may seem a bit scary when you start working in long term care.  But with time, you will understand that it is a necessary part of the job.

As a long term care Dietitian, make sure that you have a great nutrition assessment form.  Your nutrition assessment form should include an area to check off ‘malnutrition’!

If you don’t have one yet, check this one out.  It has a built-in SGA assessment that makes your job so much faster when assessing a patient.

We’ll use Dementia throughout as an example for Malnutrition. You will find a significant portion of patients have malnutrition by the end stages of Dementia.

Malnutrition will happen frequently in patients with Dementia.  From the middle to end stages of Dementia, malnutrition will be a combination of factors.  All contributing to poor nutrition status. 

Diagnosing Malnutrition

There is the ASPEN Malnutrition Criteria that most Dietitians tend to agree is a solid way to diagnose.

They categorise Malnutrition to include at least two of the following:

  1. Insufficient energy intake
  2. Unintentional weight loss
  3. Decreased muscle mass
  4. Decreased subcutaneous fat
  5. Fluid accumulation
  6. Decreased functional strength (eg. hand grip strength)

Though I do tend to agree with their list of diagnosing malnutrition, I think you have to use YOUR clinical judgement when diagnosing.  

I am supportive of standardized tools, such as the ASPEN Malnutrition criteria. But I do believe that we need to leave room for our professional opinion.

I have had patients that:

  1. Ate a sufficient amount (>75% at all meals)
  2. Lost a non-significant amount of weight, but weight loss was increasingly happening
  3. BMI 20.0
  4. Muscle mass was not noticeable
  5. Had lost some subcutaneous fat, but was always thin
  6. No fluid accumulation
  7. Still upwardly mobile

According to ASPEN, my patient wouldn’t be quantified as malnourished.  But I noticed over a 6 month time period that this patient was a malnourished patient.  

Why did I think they were malnourished?

They had colon cancer, slow but progressive, decreased fluid intake, refused snacks, and low BMI.

All that to say, use your clinical judgement and at times you may need to go beyond what the narrow definitions are.

If you want to read more about ASPEN Malnutrition Criteria, click here.

What is a PES Statement?

P = The Nutrition Problem

This is going to be the issue that you are trying to resolve, only put a problem here that your nutrition interventions are going to address. 

For example if you’re putting ‘unintentional weight loss’, your interventions may be to increase calories. 

E = Etiology

This is what you think is causing the problem that you just chose. If you went through the how to treat and prevent weight loss blog, (click here if you missed it) you will have a pretty comprehensive understanding of how to perform a nutrition assessment.  

Your nutrition assessment will help you find out the etiology and will help guide your nutrition interventions.  Only give an etiology after you have done a full nutrition assessment, you can’t write this statement blind. 

You need your subjective and objective data to support your statement.

S/S = Signs & Symptoms

This is fairly self explanatory, but this is the evidence of your problem and root cause. The signs can be objective data that you discovered in your nutrition assessment.  

Ensure that your S/S are evidence to back up the rest of your statement. Also ensure that your nutrition intervention will try to reduce the signs and symptoms that you have measured/observed.

Your statement will always follow this format:

Problem related to Etiology as evidenced by Signs & Symptoms 

It’s standardised language and this includes the format that the statement is written in.

Top 7 Malnutrition PES Statements!

Writing out a malnutrition PES statement is going to look vastly different for every patient.

They will have similar criteria overall, but the evidence will be different.  Here are some Malnutrition PES statement examples that you could use though.

1.Malnutrition related to inadequate energy intake as evidenced by <50% intake at meals and significant weight loss of 10.9% in 6/12.

2. Malnutrition related to colon cancer as evidenced by reduced muscle mass, significant weight loss (7.6% in 1/12) and BMI 17.7.

3. Malnutrition related to advanced age and disease progression as evidenced by inadequate intake (<25% at meals), severe fat loss, and severe muscle wasting.

4. Malnutrition related to end stage Dementia as evidenced by severe muscle wasting, meal refusal (>50% of the time) and significant weight loss (10.5% in 1/12)

5. Malnutrition related to end stage Dementia as evidenced by inadequate food intake, BMI 15.8, and significant cachexia.

6. Malnutrition related to severe Dysphagia secondary to Dementia as evidenced by SLP assessment, difficulty with pureed foods, and inadequate food intake.

7. Malnutrition related to extreme fatigue secondary to Dementia as evidenced by declining meal times, intake <25% on average weekly and severe fat and muscle wasting.

As you can see, you can take Malnutrition in multiple different directions.  If you don’t know of any exact cause, I prefer to use:

Advanced age and disease progression as the etiology or Dementia.

We are taught historically that the ethology is nutrition related, and something that you are trying to correct. But this isn’t always possible.

When Dementia is the cause of the nutrition issues, I select Dementia as my etiology. Some may dispute this, but in my clinical judgement, it’s the best selection.

Malnutrition Care Plan

The malnutrition care plan will vary based on why your patient is malnourished.  

If a patient has Dementia, you will want to look at all the different factors that are affecting their nutrition status.

I’ve talked about in previous articles about how to build nutrition care plans. If you missed them, check out this one and this one (there’s more than these two!).

For this example, I’m only going to look at ONE aspect of the overall picture of a patient with Dementia. A patient with Dementia may have inadequate intake, unintentional weight loss, inadequate fluid intake, and more.

For each of those nutrition diagnosis, I recommend having a separate nutrition goal and nutrition interventions. But you can read more about the justification in previous articles.

I’ll just look at inadequate intake, as I have covered other nutrition diagnosis in previous nutrition care plan articles.

Nutrition Diagnosis:

Inadequate intake.

Nutrition Goals:

  1. Adequate food and fluid intake at all meals.
  2. Maintain body weight within normal weight range (Based on BMI 23.0 – 29.9 = 64.4 kg – 80.9 kg).

Nutrition Interventions:

  1. Mr. S will be provided with three meals daily in the main dining room.
  2. Mr. S will be provided with Medpass (60 mL TID).
  3. Mr. S will be provided with a pm and hs snack of his choosing daily.
  4. Mr. S will be provided with a minimum 2000 mL of fluids daily.

Another approach for a Malnutrition care plan, you can have one central nutrition diagnosis: Malnutrition. It’s not my preference, but it’s definitely an option.

If you do it that way, then you would have your multiple nutrition goals and nutrition interventions targeting all the causes of malnutrition.

Closing Thoughts on Malnutrition PES Statement

The Malnutrition PES Statement you choose will look different all the time.  I encourage you to have good supportive evidence and individualise WHY your patient is malnourished.

This will make it much easier to target your nutrition interventions, and hopefully discharge a malnutrition diagnosis once the issues have resolved.

Did you know that I offer one-on-one Dietitian email support?  You can sign up and I am available to chat whenever you need regarding a patient’s clinical status!  You can also select to have video calls!  
You can read more here.

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Michelle Saari is a Registered Dietitian based in Canada. She has a Master's Degree in Human Nutritional Sciences and is a passionate advocate for spreading easy to understand, reliable, and trustworthy nutrition information. She is currently a full time online entrepreneur with two nutrition focused websites.

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