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Case Study

Case Study. Oluremi 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)

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Case Study

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  1. Case Study Oluremi Famodu WVU Dietetic Intern

  2. Outline • The Patient • HIV (Background/Prevalence) • HIV and Wasting Syndrome • Nutrition and HIV • Nutrition Assessment of Patient • Diagnosis • Intervention • Monitoring and Evaluation

  3. 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

  4. Patient Medical History Current 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

  5. The Virus

  6. 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

  7. HIV Time Course

  8. 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

  9. HIV Nutrition & Complications Wasting Syndrome

  10. 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.

  11. Wasting Syndrome Cont. • ↑ rate of survival if overweight or obese • Presence of opportunistic infection:

  12. Clinical Findings Consistent with Wasting Disease Subjective • Lethargy • Anorexia • Food Insecurity • Loose Fitting Clothing Physical Function • Difficulty or inability to stand w/o assistance Vital 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 √ √ √ √

  13. 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

  14. 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

  15. Nutrition Assessment Diagnosis Intervention Monitoring and Evaluation

  16. Initial Assessment • Assessing for: • Admitting diagnosis of HIV • Albumin <2.5, • New Tube Feed • Braden Scale Score = 21; No skin breakdown • IV Fluids: NS @ 100mL/hour • Receiving folic acid • Regular diet

  17. 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)

  18. Nutrition Assessment: Medications

  19. Nutrition Assessment: Lab Values

  20. 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

  21. Diagnosis Problem = Underweight Etiology = related to HIV Symptoms = as evidenced by need for supplemental enteral nutrition

  22. Intervention • Estimated Energy • 35-40 kcal/kg: 1855-2120 kcal • Estimated Protein • 1.4-1.6 g/kg: 74-85 grams

  23. Intervention • Recommend initiating nightly tube feedings • Boost 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

  24. Monitor & Evaluate • Po intake per RN note • Weight

  25. Monitor & Evaluate • Calorie Count and Tube Feeding

  26. Monitor and Evaluate • Calorie Count & Tube Feed Assessment • Average calorie intake = 44% • 816 calories • Average protein intake = 41% • 30 g protein

  27. Monitor and Evaluate • Labs

  28. 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

  29. Where is he now? • Key West? OR • Camper in Clendenin? • To be continued…

  30. 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

  31. Questions?

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