c ase s tudy oluremi famodu wvu dietetic intern. o utline the patient hiv (background/prevalence)...
DESCRIPTION
P ATIENT D EMOGRAPHICS 50 yo ♂ 52.7 kg (115.9 pounds) 5’11’’ ( cm) BMI 16.2 – Protein/Energy Malnutrition Grade II Ideal Wt: 75.3 kg (165.7 pounds) 70% IBW Former smoker and drinkerTRANSCRIPT
CASE STUDYOluremi Famodu WVU Dietetic Intern
OUTLINE The Patient HIV (Background/Prevalence) HIV and Wasting Syndrome Nutrition and HIV Nutrition Assessment of Patient
Diagnosis Intervention Monitoring and Evaluation
PATIENT DEMOGRAPHICS 50 yo ♂ 52.7 kg (115.9 pounds) 5’11’’ (180.34 cm) BMI 16.2 – Protein/Energy Malnutrition Grade
II Ideal Wt: 75.3 kg (165.7 pounds) 70% IBW Former smoker and drinker
PATIENT MEDICAL HISTORYCurrent Medical Hx HIV positive Possible Tuberculosis
(TB) >110 pound weight loss
in 5 years Cachexia (Wasting
Syndrome) Weakness s/p PEG placement Pancytopenia Hyponatremia
Past Medical Hx HIV PEG tube placement Bilateral Hip
replacement
THE VIRUS
THE HUMAN IMMUNODEFICIENCY VIRUS (HIV) Zoonotic retrovirus (transfer between
species: monkey human) Rapid or severe loss of CD4+ T lymphocytes
Lentivirus (slow replicating) Causes Acquired Immunodeficiency
Syndrome (AIDS) Progressive failure of the immune system
allowing life-threatening opportunistic infections and cancers to thrive
No cure…but it can be controlled! Average life expectancy for untreated HIV= 10
years
HIV TIME COURSE
HIV/AIDS PANDEMIC Over one million
people living with HIV/AIDS in the United States (CDC)
1 in 5 people living with HIV are unaware of infection (~18% in the U.S.)
Having long-term controlled HIV infection shows ↑ risk of Cardiovascular disease and Osteoporosis/Osteopenia
HIV NUTRITION & COMPLICATIONSWasting Syndrome
WASTING SYNDROME/DISEASE Defined as
Involuntary weight loss (skeletal muscle and adipose tissue) greater than 10% from baseline OR
Chronic diarrhea OR Documented fever for more than 30 days AND associated weakness
In 2002, wasting incidence rates as high as 10.6/100 in HIV-infected women.
Nutrition for Healthy Living Cohort: 33.6% incidence rate in 2000.
WASTING SYNDROME CONT. ↑ rate of survival if overweight or obese Presence of opportunistic infection:
CLINICAL FINDINGS CONSISTENT WITH WASTING DISEASESubjective Lethargy Anorexia Food Insecurity Loose Fitting ClothingPhysical Function Difficulty or inability to stand w/o
assistanceVital Signs Unintentional weight loss
>10% >5% within 6 months
BMI <18.5 or marked decline from usual
BMI Mid-upper arm circumference
<10th NHANES percentile
Physical Findings Head
Temporal wasting, periocular edema or fat loss, prominent zygomatic process
Torso Subclavicular muscle loss, angular
shoulders, visible articulations of ribs at junction with sternum
Sacral edema (in bed rest/bound patient)
Extremities Diminished mass interosseous
dorsalis when pressing thumb to forefinger
Diminished mass quadriceps femoris and vastus medialis when leg bent at right angle
Delayed mid-upper arm skin fold return, loss of turgor
Lower extremity edema
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HIV AND NUTRITION Maintaining good nutrition may help:
Limit weight loss Reduce risk of infections Diarrhea Lipodystrophy (fat distribution syndrome) Limit nutrient deficiencies Help process medications and manage side
effects Keep immune system stronger
BASIC PRINCIPLES OF HIV AND NUTRITION General Healthy Diet
High in vegetables, fruits, whole grains and legumes Choosing lean, low-fat sources of protein Limiting sweets, soft drinks, and foods with added
sugar Balanced meals: protein + carbohydrate + little good
fat Multivitamin-Vitamin A, C, E, B Vitamins, Selenium and
Zinc High-Energy High-Protein
1.5 g/kg Mediterranean Diet? Physical Activity
NUTRITION ASSESSMENTDiagnosisInterventionMonitoring and Evaluation
INITIAL ASSESSMENT Assessing for:
Admitting diagnosis of HIVAlbumin <2.5,New Tube Feed
Braden Scale Score = 21; No skin breakdown IV Fluids: NS @ 100mL/hour Receiving folic acid Regular diet
INITIAL ASSESSMENT CONT. Sister and mom state concerns for pt’s
mental status and not able to take care of him
Conflicting reports of 110# weight loss over 8 months versus 5 years per H&P and MD notes
Per physician, pt on nightly tube feed regimen (unsure of formula)
NUTRITION ASSESSMENT: MEDICATIONS
Medication Pharmacologic ActionPrezista Antiretoviral (HIV/AIDS)Diflucan AntifungalIsentress Antiretoviral (HIV/AIDS)Zantac Antiulcer, AntiGERD, AntisecretoryZofran PRN Antiemetic, AntinauseantKlor-Con PRN Potassium SupplementSenokot-S PRN Stimulant Laxative; Stool SoftenerZithromax AntibioticDapsone AntibacterialNeupogen Colony Stimulating FactorZosyn Antibiotic Vancomysoin Antibiotic
NUTRITION ASSESSMENT: LAB VALUES
Constituent
Reference Admission Values
Cause/Significance
Glucose 70-99 mg/dL 92 mg/dL ---BUN 8-23 mg/dL 9 mg/dL ---Creatinine 0.6-1.2 mg/dL 0.5 mg/dL---L Decrease in muscle mass;
↓ protein intakeGFR 85-125 mL/min >60 mL/min ---Magnesium 1.8-2.6 mEq/L 1.5 mEq/L---L Malabsorption;
MalnutritionAlbumin 3.5-5 gm/dL 2.7 gm/dL---L Malabsorption;
Malnutrition; ↓ protein intake; acute illness/stress
WBC 3200-10,600/μL 1600/μL---L HIV/AIDSRBC 4.7-6.1
million/mm33.73 million/mm3---
LAnemia
Hb 14.6-17.5 g/dL 12.1 g/dL---L Anemia; HIV/AIDSHCT 41-51% 35.9% ---L Anemia; Blood loss
SUBJECTIVE: THE CALL (UNABLE TO VISIT 2° TO TB PRECAUTIONS) “Lost 110# in 2 years” Top weight 216#; ↓ after bit by a recluse
spider Reports good appetite and cooks for himself Has PEG tube for medication administration
2° to pill dysphagia “I put (pureed) Cornish hens, corn dogs, and
protein supplements down PEG tube” Unsure of home tube feeding formula
DIAGNOSISProblem = Underweight
Etiology = related to HIV
Symptoms = as evidenced by need for supplemental enteral nutrition
INTERVENTION Estimated Energy
35-40 kcal/kg: 1855-2120 kcal Estimated Protein
1.4-1.6 g/kg: 74-85 grams
Risk ScoreNutrition Support 6BMI <18.5 2Weight Loss 2Admitting Diagnosis 2
Total = 12 (High Risk)
INTERVENTION
Recommend initiating nightly tube feedingsBoost Plus 60mL/hour over 12 hours (20:00-8:00)
1080 calories, 42 grams of protein and 555 mL water Initiate Calorie Count x 3 days Monitor and encourage adequate po intake Monitor weight and labs Recommend education on proper PEG tube
feeding/care before discharge IPOC
Nutrition GoalsImprove protein statusImprove po intakeIntake of ≥ 50% Tolerate po diet
MONITOR & EVALUATE Po intake per RN note
Weight
Meal 11/4/2013 11/05/2013
11/08/2013
Breakfast 50-75% 75-100% 75-100%Lunch 25-50% 75-100% 0-25%Dinner --- --- ---
11/3/2013 11/05/2013 11/08/201352.7 kg 50.6 kg 53 kg
Bed Scale Standing Scale Standing Scale
MONITOR & EVALUATE Calorie Count and Tube Feeding
Estimated Calorie Needs
Estimated Protein Needs
(g)1855-2120 74-85
Date 11/06/2013
11/07/2013 11/08/2013
Daily Total Calories
1670 600 190
Daily Total Protein
67 17 7
% Estimated Calories Met
90 32 10
% Estimated Protein Met
91 23 9
Comment Tube feeding provided 1080 calories and 42 g protein.
No intake recorded for lunch or dinner. Tube feeding ran from 2000-2400 turned off d/t NPO. TF recorded under dinner slot.
No intake recorded for breakfast or dinner. Pt receiving TF from 2000-0800 but has been messing with pump. Pt changing rate throughout night.
MONITOR AND EVALUATE Calorie Count & Tube Feed Assessment
Average calorie intake = 44% 816 calories
Average protein intake = 41% 30 g protein
Estimated Calorie Needs
Estimated Protein Needs
(g)1855-2120 74-85
MONITOR AND EVALUATE Labs
Constituent Admission Values Discharge ValuesGlucose 92 mg/dL 74 mg/dLBUN 9 mg/dL 6 mg/dL---LCreatinine 0.5 mg/dL---L 0.5 mg/dL---LGFR >60 mL/min > 60 mL/minMagnesium 1.5 mEq/L---L ---Albumin 2.7 gm/dL---L ---WBC 1600/μL---L 1400/μL---LRBC 3.73 million/mm3---L 2.81 million/mm3---LHb 12.1 g/dL---L 9.1 g/dL---LHCT 35.9% ---L 27.6%---L
ENDING DIAGNOSIS Lung masses (two cavity) s/p bronchoscopy;
no hemoptysis or persistent coughing HIV/AIDS treatment Hyponatremia --- resolved Hypokalemia --- resolved Malnutrition with cachexia, 2° to mass & HIV Pancytopenia 2° to HIV Chronic pancreatitis
WHERE IS HE NOW? Key West?
OR
Camper in Clendenin?
To be continued…
REFERENCES Centers for Disease Control and Prevention:
http://www.cdc.gov/hiv http://www.webmd.com/hivaids www.aidsinfonet.org Fazia, A. (2012, October 01). Hiv and
nutrition. http://emedicine.medscape.com/article/2058483-overview
AND Nutrition Care Manual Mahan LK, Escott-Stump S. Krause’s Food
and Nutrition Therapy: 12th ed. 2008
QUESTIONS?