Stephanie Yednak Disease Description HIV causes a progressive decline in cellular immunity Leads to Acquired Immunodeficiency Syndrome AIDS Attacks CD4 thelper lymphocyte cells 4 stages of the infection categorized by ID: 580439
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Case Report: Nutritional Management of a Critically Ill HIV-1 Infected Patient
Stephanie YednakSlide2
Disease Description
HIV causes a progressive decline in cellular immunity
Leads to Acquired Immunodeficiency Syndrome (AIDS)
Attacks CD4+ t-helper lymphocyte cells
4 stages of the infection, categorized by
Symptoms
CD4 countSlide3
Stages of the Disease
Acute HIV infection
2-4 weeks after contraction, flulike symptoms
Asymptomatic Chronic HIV infection
8-10 years with no symptoms
Symptomatic HIV infection
Symptoms start to appear, CD4 starts to decline <500 mm
3
AIDS or advanced HIV
A life threatening condition attached to a CD4 count < 200 mm
3Slide4
How is HIV transmitted?
The HIV retrovirus can be transmitted through:
Blood and blood transfusions
Semen, vaginal and other bodily fluids
Intravenous drug use
Unprotected sexual contact
Occupational exposure
Passage from mother to child from the womb
Breast milkSlide5
A Cure? Medications
Antiretroviral Therapy (ART)
A combination of medications used to suppress or kill viral replication and progression of HIV
Recommended when CD4 counts <350mm3
Prescribed when CD4 counts <200mm3
Examples include:
Combivir, Epivir, Retrovir, Epzicom and Zerit Slide6
Medication Facts
Drug resistance and tolerance develops over time
At least 95% adherence to medication regimen is necessary in order to work properly
Not all patients tolerate the drugs
Common side effects
HIV may cost one upwards of $34,000 annually
Not all insurances cover all HIV medsSlide7
Biochemical ParametersSlide8
Evidenced-Based Nutrition
Blood work of 43 HIV and AIDS patients
No significant differences observed in:
BMI
Total protein
Albumin
Transthyretin
RBP
However, HIV/AIDS patients have significantly lower albumin levels compared to reference range
Stambullian M, Feliu S, Slobodianik NH. Nutritional status in patients with HIV infections and AIDS.
British Journal of Nutrition
. 2007. 98:Suppl.1, S140-S143. Slide9
Predictors of SurvivalSlide10
Evidenced-Based Nutrition
Case report following a 44 y/o male
Medication noncompliance secondary to swallowing difficulty
Consequences of non-compliance
:
Critical illness
Suppressed CD4 count
Elevated viral load
+ for numerous psychological barriers
Percutaneous endoscopic gastronomy (PEG) tube placementSlide11
Major Conclusions
PEG is safe to use in the HIV/AIDS pt
PEG insertion results in:
improved quality of life
improved nutritional status in HIV infected patients
After 15 mo of use:
undetectable viral load
elevated CD4 count
remission of opportunistic infections (OI)
Leipe J, Hueber AJ, Rech J, Harrer T. Bypassing non-adherence via PEG in a critically ill HIV-1-infected patient.
AIDS Care
. 2008. 20(7): 863-867.Slide12
Health Policy
The nutritional adequacy of HIV + adults was assessed and compared by:
Whether the household used nutrition care support (NCS) services including:
Nutritional assessment
Nutrition education/ counseling
Food and nutrient supplementation
Food assistance
Livelihood strengtheningSlide13
Results of the Screening
65.3% prevalence of risk of malnutrition
49% of the participants had a high BMI >25.
QOL was similar
Those who received NCS had diminished:
general health
self care functioning
QOLSlide14
Results
NCS participants also:
were more frequently taking ART
Had more money
reporting good eating plans
twice as likely to have oral thrush
NCS recipients were from households with more than one provider (p<0.05)
The non-NCS recipients had been generally sick, reported fatigue, nausea, appetite loss and diarrhea
Oketch JA, Paterson M, Maunder EW, Rollins NC. Too little too late: Comparison of nutritional status and quality of life of nutrition care and support recipient and non-recipients among HIV-positive adults in KwaZulu-Natal, South Africa.
Health Policy
. 2011. (99) 267-276. Slide15
Nutrition Care Process (NCP)
Case PresentationSlide16
Case Presentation
A 45-year-old Caucasian female
Arrived to the ED c/o fever and SOB
Other symptoms:
aphasia
slurred speech
persistent drooling
right sided weakness
unable to move her jawSlide17
Previous Medical HistorySlide18
Nutrition Care Process: Assessment
Seropositive for HIV-1 confirmed by:
ELISA
Western blot
Living 23 years with the virus
Contraction through infected tattoo
CD4 count 247
Viral Load 563Slide19
Patient Data
Pt had PEG placed this year at SOMC
Due to impaired swallowing ability
Non-compliance with ART regimen
Pt receives all nutrition and hydration through PEG tube
Patient smokes half a pack of cigarettes a day
Pt continues to attempt po consumption of food and medicationsSlide20
Diet/ Physical Activity
TF regimen
Jevity 1.2 @ 89 ml/hr for 14 hours nocturnally
Family encourages po feeds during the day
Pt has not consumed any food po due to SOB
No episodes of nausea and vomiting at home
Physical Activity
The patient has recently lost the ability to ambulate and is bedriddenSlide21
NCP: Assessment (con’t)
General Appearance:
thin and cachecitic looking
signs of lipoatrophy in arms, legs and face
poor dentition, missing teeth
denies any appetite or significant weight loss Slide22
NCP: Assessment (con’t)
Anthropometric Measurements:
Height:
5’7
Weight 138#, 63 kg
BMI = 21.2
IBW= 135#, 61.3 kg
% IBW = 102%Slide23
Parameter
12/11/11
12/13/11
Significance
Sodium
134 L
136
Deficient dietary intake, diarrhea
Potassium
3.8 L
4.1Δ
GI disorders, vomiting, diarrhea, deficient intake
BUN
23 H
14
MI, GI bleed, alimentary tube feeding, excessive protein catabolism, starvation
Glucose
177 H
104
Extensive liver disease, starvation, medication induced
Total protein
8.9 H
7.2
Resolved
Albumin
3.4
2.6 L
Albumin levels plummeted and remained low over the course of the hospital which may be attributed to inflammation and not a marker of nutritional status.
Alk Phos
138 H
95
Liver tumor, cirrhosis, ischemia, bililary obstruction
Hemoglobin
13.1
Normal
hematocrit
39
NormalSlide24
Medications
Medication
Dosage
Rationale
Side Effects
Oxycotin
80 mg bid
Used for the management of moderate to severe pain
Respiratory depression, constipation, nausea, dry mouth, vomiting
Epivir
15 ml bid
HIV infection, antiretroviral
Anorexia, diarrhea, nausea, vomiting, abnormal LFT, abdominal discomfort
Ziagen
15 ml bid
Management of HIV infection
Hepatotoxicity, nausea, vomiting, diarrhea, anorexia, lactic acidosis
Compazine
10 mg prn
Antiemetic, management of nausea and vomiting
Constipation, dry mouth, anorexia, ileus
Skelaxin
800 mg bid
Muscle relaxant
Nausea, anorexia, dry mouth, GI upset, vomiting
Dulcolax
Prn
Laxative, treatment of constipation
Abdominal cramps, nausea, diarrhea, hypokalemia, muscle weakness
Bactrim
20 mg daily
Anti-infective, prevention of PCP in HIV + patients
Nausea, vomiting, diarrhea, stomatitis
Intelence
200 mg daily
Treats and prevents the spread of HIV.
Nausea, vomiting, abdominal pain, diarrhea, increased blood pressure Slide25
Needs were based in actual body weight of 63 kg
Nutrient NeedsSlide26
NCP: Nutrition Diagnosis
Swallowing difficulty (NC-1.1) related to decreased lingual strength and PML as evidenced by dysphagia, aphasia and failed swallow evaluation
Inadequate enteral nutrition infusion (NI-2.3) related to inadequate provision of nutrients as evidenced by loss of muscle mass secondary to client history of human immunodeficiency virus
PES #1
PES #2Slide27
NCP: Intervention
Intervention #1
: Implement nutrition education, specifically the nutrition relationship to health/disease (E-1.4)
Intervention #2:
Collaboration/referral to other providers (RC-1.3). Requested Speech language pathologist- aspiration precautions education
Intervention # 3:
Change formula solution (ND-2.1.1) to TwoCal HN @ 55 ml/hr. Slide28
Nutrition Prescription
In order to adequately meet increased needs due to HIV disease progression:
increase protein (95-126 g/day)
kilocalorie (2205-2835 kcal/day)
fluid needs (2205-2520 ml/day)
TwoCal HN @ 55 provides:
2640 kcal
105 g protein
2217 ml water
215 ml water flushes q 4 hours.Slide29
NCP: Intervention
Short term goals and expected outcomes:
The patient will be provided with 100% adequate nutrition and hydration to meet needs
The patient will tolerate feedings with minimal residual volumes with low occurrence and volume of diarrhea
The patient will maintain weight on the prescribed regimen
Patient will recognize severity of consuming foods by mouth at this point in time Slide30
NCP: Intervention
Long term goals:
The patient will replete nutritional stores with adequate nutrition
Tube feedings will continue to be tolerated with no significant weight change or skin breakdown
The patient will work with an outpatient speech language pathologist to condition her muscles and lessen the degree of dysphagiaSlide31
NCP: Monitoring and Evaluation
Food/Nutrition- Related History (FH) Food and Nutrient Administration: enteral and parenteral nutrition administration (FH-2.1.4)
With the provision of recommended change in tube feeding and formula, patient received and met 100% of needsSlide32
NCP: Monitoring and Evaluation
Biochemical Data, Medical Tests, and Procedures (BD): Gastrointestinal (BD-1.4)
Patient had minimal diarrhea
Constipation relief
Gastric residual volumes were minimal
Tube feeding continuedSlide33
NCP: Monitoring and Evaluation
Anthropometric Measurements (AD) Body composition/growth/weight history (AD-1.1)
patient’s weight remained stable throughout her clinical course
Food/ Nutrition –Related History (FH) Behavior: Avoidance (5.1)
per patient and family the patient did not consume or attempt any foods by mouth in the course of the hospital stay Slide34
Conclusion
HIV-1 positive patients require adequate nutrition to meet needs and to suppress the virus from further replication
The specific interventions in this case presentation can be prescribed in other HIV-1 infected patients
HIV/AIDS can be managed with adequate provision of energy, protein and fluids, combined with life-sustaining ART therapy
The practice of feeding through a PEG tube has approved as safe and has shown increased adherence to nutrition, hydration and medication administrationSlide35
QUESTIONS??