mnt case presentation · case presentation ! 58 year old male from nearby nursing home ! pmh: aids,...

MNT Case Presentation

Case Report: Nutritional Management of Comorbidities in AIDS

By Jeanette Kimszal

Disease Description �  Acquired Immune Deficiency Syndrome (AIDS) is

the result of the human immunodeficiency virus (HIV)1

�  Global Epidemic – Rural & Developed Countries1

�  Pathogenesis1 �  HIV: Infects T-helper lymphocyte cells (CD4+ cells) �  4 Stages of HIV

�  Acute à Clinical Latency à Symptomatic HIVàAIDS

�  Results in Immuno Deficiency à No CD4+ cells1

�  Diagnosis of AIDS �  Blood Tests: ELISA2 & Western Blot3

Disease Description Continued

�  Transmitted via sexual contact or IV drug use1

�  Mean age: 40-44 years1

�  Common in ethnic populations1 �  52% Blacks �  25% Latinos

HIV/AIDS & Malnutrition �  Immuno suppression à opportunistic infections (Ois)1

�  Fungal and Bacterial Infections

�  Compromised immunity causes metabolic changes leading to:1

�  Wasting

�  Malabsorption

�  Obesity

�  Nutritional Deficiencies (B12, Beta-Carotene, A, E, D, Zinc, Fe)

�  Poor Intake, Early Satiety

�  Dementia

�  Medication Drug Side Effects1

�  Insulin resistance à Diabetes

�  éLipids éTriglycerides àHeart Disease

�  HIV-Associated Lipodystrophay Syndrome (HALS)

�  Hepatitis C Virus (HCV)

Evidence-Based Recommendations

�  Enhance nutrition intake à Increase immune function4

�  Sufficient micro- & macronutrients4

�  Maintain Healthy weight with lean body mass1

�  Energy requirements vary à need adequate kcal1

�  RDI for Protein: 0.8-1.0 gram/kg/day1

�  Diets high éin Ca2+, fruits, & vegetables may prevent metabolic syndrome4 �  A study of HIV patients showed >2 servings/day of dairy

had lower BMI, waist circumference, and blood pressure4


�  There is a relationship between obesity, hypertension and calcium intake in this population4

�  Functional foods help to improve immune status and reduce oxidation of immune cells5

�  éMicronutrients éCD4+ counts5

�  Probiotics improve intestinal health and immunity5

�  êBMI correlated with higher intakes of dairy & grains and overall better nutrition6

�  HIV/AIDS patients with poor nutrition tend to be overweight6


�  100% RDI of Vitamin/mineral supplementation éhealth benefits

�  éLevels of Vitamins A, zinc & selenium êrisk of infection1

�  éVitamin C slowed disease progression1

�  éMVI êoral & GI problems, fatigue, and sudden upper respiratory infections

�  Micronutrients increase intestinal mucosa cells7

�  Decrease side effects of ART therapy7


�  Antioxidants improve immunity8

�  Probiotics protect the gut and increase WBC8

�  Micro and macronutrients help maintain lean body mass8

�  Balanced diet and exercise can decrease lean body wasting9


�  Nutrition Support may benefit HIV/AIDS patients with poor intake

�  Enteral Nutrition (EN) in the 1st week of hospitalization leads to positive health outcomes11

�  HIV/AIDs patients with AKI receiving early PN have longer hospital stay, greater infections, and longer periods of renal replacement therapy12

�  éEN intestinal, immune function, CD4+, & body weight13

�  Early nutrition support helps émetabolic absorption13

�  EN in sepsis patients linked with better outcomes compared with EN and PN or PN alone14

Nutrition Care Process (NCP)

�  Standard form of practice for dietetic professionals when giving care

�  Established to enhance treatment & ensure reliable outcomes of nutrition care

�  Treat patients individually

Case Presentation �  58 year old male from nearby nursing home

�  PMH: AIDS, DM, Dementia, CAD, HTN, PEG tube

�  Brought in for Low Blood Pressure & Low Body Temperature

�  Dx: Acute Kidney Infection, Diabetic Acidosis, Dehydration, Hypotension, Acute Perforation and anion metabolic acidosis.

�  Taken to MICU to stabilize patient’s hypotensive state

�  Enteral nutrition was ordered due to unstable mental condition and possible dysphagia

Assessment: Client History �  From a nearby nursing home

�  Nonverbal, incoherent, unable to provide information �  Information taken from nursing home transfer sheets

�  Hx of AIDS, dementia, DM, anemia, hypertension, CAD, and schizophrenia

�  Admitted due to hypotension and lethargy

�  Deteriorating mental state

Assessment: Client History Medications Prescribed

Medication Rationale Nutrition Related Side-effects

Calcium Gluconate Antacid mineral supplement, phosphate binder, also used as antidiarrheal

Slightly increased calcium, decreased phosphorus, kidney stones with large doses, decrease PTH in ESRD, hypercalcemia, Increase Ca++ in urine, decrease diarrhea, chalky taste, dry mouth, with excessive dose: nausea & vomiting, abdominal pain, bloating, constipation, flatulence, do not use with hypercalcemia, kidney stones16(p70)

Ceftriaxone Antibotic

Conider Na content with ↓Na+ diet, ↑ oral candidiasis and sore mouth and tongue with long term use, ↑AST, ↑ALT, ↑bilirubin, ↑LDH, ↑alkaline phosphatase, ↑GGT, ↑BUN, ↑Creat,Rare-gallbladder sludge, angioedema, anemia, ↓albumin16(p80)

Clopidogrel

Prevention of repeat Myocardial infarctin (MI),Cardiac Vascular Accident (CVA), or vascular event, decrease rate of ischemic stroke,platelet aggregration inhibitor

Dyspepsia, nausa, vomiting, abdominal pain, GI bleeding/hemorrhage, diarrhea, constipation, pain, flu-like symptoms, URTI, dizziness, headache, purpura, Hypertension, hypotension, edema, depression, nosebleed, gout, cough, dyspnea, syncope, palpitation, bradycardia, atrial fibrillation,insomnia, paraesthesia, leg cramps, fever, rash, bleeding (can be fatal), bruising16(p89)



Emtricitabine Antiretroviral Nucleoside Reverse Transcriptase (NRTI)

Avoid ETOH, fat redistricution, ↑triglycerides, ↑creatine phosphokinase, ↑AST, ↑ALT, ↑amylase, ↓neutrophils, Rare-lactic acidosis, hepatomegaly, with steatosis16(p123)

Heparin Sodium Anticoagulant

Nausea & vomiting, abdominal pain, GI bleeding,constipation, black tarry stools, caution with diabetes & ESRD-hyperkalemia, caution with severe ↓ renal function, ↑AST, ↑ALT, ↑PT/INR, ↑K+, ↑FFA, ↓triglycerides, ↓cholesterol, ↓T416(p 161)

Memantine

Alzheimer’s Disease Treatment, N-methyl-D-aspartate receptors (NMDA) Receptor Antagonist, treat vascular dementia

Take with regard to food, do not mix with other liquids, resulting in alkaline urine(eg predominantly milk/milk product, citrus fruit) ↑drug blood levels due to ↓excretion, vomiting, constipation (sorbitol may ↑ risk of diarrhea), caution with moderate ↓renal function, anemia, Rare- ↑ALT, ↑AST, ↑uric acid16(p207)


Medication Rationale Nutrition Related Side-effects Norepinephrine/Dextrose IV solution

Emergency treatment of blood pressure

Headache, weakness, dizziness, tremor, pallor, respiratory difficulty or apnea, precordial pain

Sodium Bicarbonate Antacid, stablize metabolic acidosis

Increased thirst, increased weight (edema), belching, gastric distention, cramps, inflatulence16(p294)

Sodium Polystyrene Antihyperkalemia, Cation Exchange Resin

Avoid potassium supplements, consider Na+ content with ↓Na+ diet, take Ca++ or Mg supplement or antacids separately by several hours, not with salt substitutes or sorbitol, anorexia, nausea & vomiting, gastric irritation, constipation, fecal impaction, diarrhea, bezoars, GI ulceration/necrosis, significant edema with CHF, HTN, not with obstructive bowel disease severe constipation or hypokalemia, edema, sodium retention hypokalemia, hypocalcemia, ↓K+, ↓Mg, ↓Ca++, ↑ Na+ (pg 294)

Tenofovir Antiretroviral

Ca++ and vitamin D supplement may be needed to help ↓bone loss, Anorexia ↓ wt, nausea & vomiting, dyspepsia, abdominal pain, diarrhea, flatulence, ↑AST, ↑ALT, ↑amylase, ↓neutrophils, ↓phos, caution with renal function16(p306)



Sodium Bicarbonate Antacid, stablize metabolic acidosis Increased thirst, increased weight (edema), belching, gastric distention, cramps, inflatulence16(p294)

Sodium Polystyrene Antihyperkalemia, Cation Exchange Resin

Avoid potassium supplements, consider Na+ content with ↓Na+ diet, take Ca++ or Mg supplement or antacids separately by several hours, not with salt substitutes or sorbitol, anorexia, nausea & vomiting, gastric irritation, constipation, fecal impaction, diarrhea, bezoars, GI ulceration/necrosis, significant edema with CHF, HTN, not with obstructive bowel disease severe constipation or hypokalemia, edema, sodium retention hypokalemia, hypocalcemia, ↓K+, ↓Mg, ↓Ca++, ↑ Na+ (pg 294)



Assessment: Food/Nutrition-Related History

�  Admitted with PEG tube �  Glucerna bolus: 1.5 can 4x a day

�  Puree with thin liquids �  Chewing problems

�  No documented food allergies

�  Current Medications:

�  lorazepam, amlopidine, aspirin, tenofovir, clopidogrel, lisinopril, lantus, nameda, and a sliding scale of insulin as needed

�  MVI docusate

Assessment: Food/Nutrition-Related Findings


Amlopidine Antihypetensive, Antiangina, Calcium-Channel Blocker

May take with food to ↓GI distress, ↓Na+, ↓Ca++ may be recommended, avoid natural licorice, dysphagia, nausea, cramps, ↓BP with possible hypotension, edema16(p32)

Aspirin Analgesic

Food slightly delays absorption of SR form, bitter taste with hot drink, avoid ETOH or limit to <3 drinks/day, ↓ WBC, ↑bilirubin, ↑LDH, ↑AST, ↑ALT, ↑PT/INR, false ↓ or ↑glucose with some glucometers 16(pg 23)

Clopidogrel

Prevention of repeat Myocardial infarctin (MI),Cardiac Vascular Accident (CVA), or vascular event, decrease rate of ischemic stroke,platelet aggregration inhibitor

Dyspepsia, nausa, vomiting, abdominal pain, GI bleeding/hemorrhage, diarrhea, constipation, pain, flu-like symptoms, URTI, dizziness, headache, purpura, Hypertension, hypotension, edema, depression, nosebleed, gout, cough, dyspnea, syncope, palpitation, bradycardia, atrial fibrillation,insomnia, paraesthesia, leg cramps, fever, rash, bleeding (can be fatal), bruising16(p89)



Docusate Sodium Stool softener

Not with mineral oil, alters intestinal absorption of water and electrolytes, bitter taste, throat irritation, nausea, cramps, diarrhea, ↑glucose, ↑K+16(p115)

Lantus Injections Antidiabetic, hypoglcyemia

↑ wt, no ↑ wt increase in T1DM, caution with ETOH increases hypoglycemic effect of insulin, stress increase insulin needs, ↓ glucose, ↓ HBA1c, ↓ K+, ↓ Mg, ↓ phos, ↑ T4, ↓urinary glucose16(p25)

Lisinopril Angioconverting Enzyme (ACE) Inhibitor, antihypertensive

Take with food, ensure adequate fluid/hydration, ↓ Na+ & ↓ Ca++ may be recommended, Avoid salt substitutes, Anorexia, ↓ wt reported, rare-dysgeusia, dry mouth, nausea & vomiting, abdominal pain, constipation, caution with diabetes and on insulin ↓ glucose, possible hypotension, ↑ K+, ↓ Na+, ↑ AST, ↑ ALT, - alkaline phosphatase, - bilirubin, anemia, - uric acid, Transient ↑ BUN & ↑ creatinine, ↓ WBC16(pg 36-37)



Lorazepam Anti-anxiety, skeletal muscle relaxant, antiepileptic

Limit caffeine to <400 -500 mg/day, caution with sedative herbal products (eg chamomile or kava (↑ sedative effect) or stimulant products (caffeine, guaran, mate) ↓ sedative effects, dry mouth, ↑salivation, nausea & vomiting, constipation, diarrhea, avoid ETOH, ↑AST, ↑ ALT, ↑ LDH, ↑ bilirubin, ↑alkaline phosphatase16(p 54)

Memantine

Alzheimer’s Disease Treatment, N-methyl-D-aspartate receptors (NMDA) Receptor Antagonist, treat vascular dementia

Take with regard to food, do not mix with other liquids, resulting in alkaline urine(eg predominantly milk/milk product, citrus fruit) ↑drug blood levels due to ↓excretion, vomiting, constipation (sorbitol may ↑ risk of diarrhea), caution with moderate ↓renal function, anemia, Rare- ↑ALT, ↑AST, ↑uric acid16(p207)



Assessment: Nutrition-Focused Physical Findings

�  Altered mental state, not able to communicate

�  Appeared thin

�  Pre-existing pressure ulcers �  Risk for nutrition deficiency

�  Poor oral health due to puree diet

�  White discoloration around PEG tube with drainage �  Leads to inadequate intake

�  Negative outcome of nutritional status

Assessment: Anthropometrics

�  BMI 18.93 normal weight

�  Ht: 68 inches, Wt: 124#

�  UBW: 138# (September 9 2014)

�  13.6# (10% body weight) loss

�  90% of UBW

�  DBW + or – 154# (81% of DBW)

Assessment: Biochemical Data Measurement Value Normal Range

Sodium 157 (H) 136-145 mEq / L

Potassium 6.4(H) 3.5-5.2 mEq / L

Chloride 123 (H) 96-108 mEq/L

Blood Urea Nitrogen (BUN) 212 (H) 6-20 mg / dl

Creatinine 16.2(H) 0.9-1.3 mg / dl

Glucose 383 (H) < 110 mg / dl

Hgb 9.9 (L) 14-18 g/dL

Hct 32.2(L) 42-52%

MCV 104.3(H) 32-35 g/dL

MCH 32.1(H) 27-31pg

MCHC 30.8(L) 3.2-10.0 x 103 / cells/mm3

Albumin 2.1 (L) 20-40 mg/dL

Anion Gap 27.4(H) 10-20 mmol/L

Assessment: Nutrient Needs17

�  33-35 kcal/kcal ABW

�  Kcal based on DBW 27-29 kcal/kg

�  Estimated Kcal needs: 1900-2000 kcal/day

�  Protein needs lowered due to patient’s AKI �  0.8 – 1.0 gram Protein/kg

�  56-70 grams Protein

�  2100 – 2450 ml H2O per day �  (35 ml/kg)

Assessment: ARAMARK Nutrition Status Classification

�  Nutrition hx 2 difficulty chewing

�  Feeding modality: 4 (PEG)

�  Weight Status: 2 (80% of DBW)

�  Unintentional wt loss: 3

�  Serum albumin: 4 (2.1g/dL)

�  Diagnosis: 4 (sepsis/AKI/uncontrolled DM)

Level Four Severely Compromised = 19 points

Re-assessd Every 1-4 days19

Assessment: Malnutrition Identification

�  Malnutrition occurs when there is inadequate intake comparison of intake to estimated requirements indicates malnutrition occurred19

�  Diagnosis-Related Group (DRG) “Other Protein Calorie Malnutrition” by having an inadequate intake for 3 days and an albumin of less than 3.5 g/dL20

Diagnosis Nutrition Diagnosis Terminology / PES Statements

Domain Problem or Nutrition Diagnosis Label Etiology Signs and/or Symptoms

Intake (NI-5.1)

#1 Increased nutrient needs related to

Skin integrity, wound healing,

HIV/AIDS, medical stress,

possible poor PO intake

as evidenced by

Braden Score of 10, skin breakdown (stage II

pressure ulcers)

Clinical (NC-2.2)

#2 Altered nutritional-related

lab values related to

AKI, Diabetes, medication,

sepsis, HIV/AIDS, medical stress

as evidenced by

Elevated BUN, creatinine, glucose, phosphorus, Na+,

Cl-, MCH, MCV, Low H/H, Albumin, & MCHC

Intake (NI-2.3)

#3 Inadequate intake of enteral

nutrition related to

New admission, mental status, hemodynamic

instability

as evidenced by

Feeds not infusing at present time

Intervention Nutrition Intervention Terminology

Problem#1: Increased nutrient needs (NI-5.1) Etiology: Skin integrity, wound healing, HIV/AIDS, medical stress, possible poor PO

intake

Signs/Symptoms: Braden Score of 10 and Stage II pressure ulcers.

Interventions #1. Adjust feeding prescription, monitor tolerance to feed. Recommend Nepro at 45 ml

per hour.

#2.Vitamin and mineral supplements; Multivitamin/mineral (ND-3.2.1). Recommend multivitamin mineral supplement to provide adequate vitamins to help heal skin and

increase Braden Score.

Goal Short-term:

Change enteral formula to Nepro and reach the goal rate. Long-term:

Patient’s renal function will improve. Patient will get 100% of required calorie intake.

Patient’s pressure ulcers will heal and Braden score will increase to above 18

Patient’s bowel function will normalize

Intervention

GOALS Short-term:

Medical doctor to adjust insulin as needed to maintain normal range of daily glucose (60-110 mg/day)

Deter further skin breakdown; heal current pressure ulcers and prevent any new ones from developing.

Stabilized potassium and phosphorus levels with Nepro to maintain normal electrolyte balance.

Provide an enteral formula that gives adequate protein but for limited renal function. Long-term:

Deter weight loss, gain 10% of body weight to be within the patient’s DBW Maintain glycemic control with a Hemoglobin A1c of 5-6%. Maintain good renal function and prevent further deterioration

Nutrition Intervention Terminology Problem#2:Altered nutritional-related lab values (NC-2.2) Etiology: AKI, Diabetes, Medication, HIV/AIDS, medical stress

Signs/Symptoms: Elevated BUN, creatinine, glucose, phosphorus, Alkaline phosphatase, Na+, Cl-, MCH, MCV, Low H/H, Albumin, and MCHC

Problem#3:Inadequate intake of enteral nutrition (NI-2.3) Etiology: New admission, mental status, hemodynamic instability Signs/Symptoms: Enteral feeds not running at time of assessment Interventions #3. Monitor Labs, Check prealbumin and A1c levels (RC-1). Monitor Sodium, Phosphorus, BUN, Creatinine, and Glucose levels. Check prealbumin and A1c levels to decipher protein status and diabetes control. MD to adjust insulin levels as needed.

#4. Enteral Nutrition Therapy (ND-2.1). Provide calorie dense/electrolyte controlled, low-protein enteral formula (Nepro) at 45 ml/hr to provide at total of 1944 calories, 87 grams of protein, and 783 ml of fluid.

Monitoring and Evaluation Nutrition Monitoring and Evaluation Terminology

Signs/Symptoms from PES Statement #1: Braden Score of 10 and stage II pressure ulcers

Interventions and Goals Nutrition Outcomes Indicators/Criteria

Intervention: Change enteral formula to Nepro at 45 ml/hr. Add

MVI Food and Nutrient Intake: Enteral nutrition intake – Formula/solution

(FH-1.3.1.1).

Pt will be receiving Nepro at goal rate of 45 ml/hr.

Goal: Feeds will reach goal rate for 100% of needed calories.

Monitoring and Evaluation Nutrition Monitoring and Evaluation Terminology

Signs/Symptoms from PES Statement #2: Elevated BUN, creatinine, glucose, phosphorus, Na+, Cl-, MCH, MCV, Low H/H, Albumin, and MCHC.

Signs/Symptoms from PES Statement #3: Feeds not running at time of assessment

Interventions and Goals Nutrition Outcomes Indicators/Criteria

Intervention: Monitor Labs. MD to adjust insulin levels as needed. Micronutrient Intake (1.6). Braden score will increase and nutrition risk

will decrease; pressure ulcers will heal.

Intervention: Calorie dense/electrolyte controlled, low-protein enteral formula

Biochemical Data, Medical Tests, and Procedures (BD). Glucose (1.5).

Glycemic control will stabilize with daily normal ranges (60-110 mg/dl)

Goals: Stabilized potassium and phosphorus maintain electrolyte balance. Maintain normal range of daily glucose (60-110 mg/day). Deter further skin breakdown; heal pressure ulcers Give adequate protein to maintain renal function

Biochemical Data, Medical Tests, and Procedures (BD). Prealbumin (1.11.2).

Prealbumin status will increase to a normal range (15-36 ml/dL)

Biochemical Data, Medical Tests, and Procedures (BD). Electrolyte and renal profile (1.2).

BUN, creatinine, sodium, potassium, chloride, and phosphorus levels will be within the normal range

Biochemical Data, Medical Tests, and Procedures (BD). Anemia (BD 1.10).

The patient’s hemoglobin, hematocrit, MCH, MCV, and MCHC will be within normal range

Conclusion �  HIV/AIDS patients can become malnourished

�  Nutrition needs vary depending on other present diseases

�  Optimize calories and protein to prevent weight loss

�  Nutrients important and should be supplemented if needed

�  Nutrition support may be needed if PO intake inadequate

�  Monitor Blood Glucose, TG, and chol in those on ART therapy

�  Monitor renal function in individuals with HTN

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23. Anion Gap (Blood). Health Encylopedia. University of Rochester Medical Centor.org http://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=167&ContentID=anion_gap_blood Accessed December 21, 2014.

mnt case presentation · case presentation ! 58 year old male from nearby nursing home ! pmh: aids,...

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