KAYLEE MCBRAYER, DIETETIC INTERN APRIL 22, 2015 NUTRITION IN HIV AND END STAGE AIDS.
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Transcript of KAYLEE MCBRAYER, DIETETIC INTERN APRIL 22, 2015 NUTRITION IN HIV AND END STAGE AIDS.
Part 1 Part 2
Disease StateHistory3 Ts Nutrition &
HIV/AIDSBarriersRelevant Research
Patient CJNutrition Care PlanOutcome Conclusion
Overview
WHAT IS AIDS?
Acquired Immunodeficiency SyndromeFinal Stage of HIVCD4 count is <200 cells/mm3 AND/OR1 Opportunistic Infection (OI)High Viral Load in Blood*
It is false to think that everyone who has HIV will get AIDS
AIDS DEFINING OI’s
Candidiasis *Cervical CancerCoccidioidomycosisCryptoccosisCrytosporidiosisCMV RetinitisHIV EncephalopathyChronic Herpes SimplexHistoplasmosisIsosporiasisLymphoma
Kaposi’s Sarcoma *Mycobacterium Avium
Complex *TuberculosisPneumocystis Carinii
Pneumonia (PCP) *Recurrent Pneumonia *Progressive
LuekoencephalopathySalmonella SepticemiaToxoplasmosisHIV Wasting Syndrome *
HISTORY
1884-1924
1966/1970
1981/1982
1983/1984
1990
1996
2012
Today
HIV is no longer a death sentence, dealing with new HIV health complications
STATS/ PROGNOSIS
1,201,100 aged 13 and older living with HIV
# of ppl living increases but infection rate is stable
MSM most effected (in US), African American MSM, African Americans
2013- 47,352 diagnosed
Prognosis is individual
3 Ts - TRANSMISSION
TRUE HIV can’t survive for long in air Blood Sex Secretions/Delicate
Membranes Breastmilk* Spinal Cord Fluids HIV has to get into bloodstream
NOT TRUE Daily Activities Animals Human Touch Kissing HAART Therapy = Safe
3 T’s TRANSMISSION
1. HIV is carried to CD4
2. Binding & Fusion3. Reverse
Transcription4. Integration5. Transcription6. Assembly7. Budding8. Cycle RepeatsThis concept is important because
of HAART
3Ts -TREATMENT
HAART THERAPYPrEPoPEPnPEP
5 Different HIV drug classes
Generally take 3 ART drugs from 2 classes
Important for Drug Resistance
Genotype/ Phenotype Testing
Can be complicatedMANY interactionsMANY side-effects
COMPLIANCE BARRIERS
Side Effects of DrugsSchedulingSize of PillAIDS StigmaFear of Seeking Healthcare“Sentenced” to MedsCAMReligion/ Conspiracy TheoriesCentral Nervous System IssuesSupport
NUTRITION IN HIV
Nutrition & ImmunityPreserve Lean Body Mass Aid with LipodystrophyPrevent/Reverse
DeficienciesFood SecurityFood SafetyQuality of LifeSupport Medication
RegimenCAMComorbidities and Meds
NUTRITION RELATED SIDE EFFECTS
Metabolic ChangesInsulin ResistanceNauseaVomitingDiarrhea/
MalabsorptionLoss of AppetiteBone Mineral DensitySwallowing
Ability/Sores
Mitochondrial ToxicitiesHormone Changes
KEY NUTRIENTS
Multivitamins & Trace ElementsB-Vitamins Vitamin C, E, ASeleniumZincIronCalcium/ Vitamin D/ Phosphorous
ADDITIONAL SUPPLEMENTS OF BENEFIT*
ProbioticsWhey ProteinAntioxidantsAlpha Lipoic AcidN-Acetyl Cysteine
ACADEMY POSITION PAPER SUMMARY, 2010
Prevent & reverse wt loss and wasting
Maintain energy balance ALWAYS support
medication goals Physical Activity No evidence of
supplementation effecting morbidity or mortality
MCT aids with fewer stools/absorbtion
BMI, protein stores, wt loss of any kind, LBM
HIV increases REE Higher Protein Diets seem
to be beneficial Fiber intake Alterations of zinc, Fe, Se,
B-vitamins, CHO, Fat may be shunted in HIV whether altered metabolism or inflammatory response or both
HOSPITAL COURSE OVERVIEW
LOS – 10 DaysInitial Assessment (Screen & Consult)2 Follow Ups, Visited OftenNutrition Education – Very Limited
Patient Overview
22 y/o MEthnicity UnknownAdmit for SOB, Coughing w/ Sputum,
Hypoxia, Tachycardia, Severe Respiratory Distress
Recent Hospitalization at University for PCP PNA
At ER, Disclosed not taking PCP or HAART Therapy
Unsure of last CD4 count or Viral LoadIntial Dx: Respiratory Failure/Distress
Patient Overview, cont.
PCP PNA* – recurrent*, on steroidsEsophageal Thrush*AIDS Cachexia, 15 lb wt loss in 2 mos.*Swallowing Difficulties, not taking oral medsConstipation
Medical History & Social Background
HIV+ (AIDS)Bipolar disorder, depression, no drug or
alcohol abuse, cachexia, insomniaUnemployedLives w/ Brother, who is deaf
ANTHROPOMETRICS
63 inches32 kgBMI: 12.5% IBW: 57IBW: 56 kg82% of Usual BW, UBW: 39 kg% Wt Loss: Severe
LAB DATA
LAB Value NormalGlucose 129BUN 6Na 134HCO3 21Albumin 2.1Lactate 5.6Mg 1.7WBC 2.8
LAB ValueCD4 Count <20LCD4% 2LCD4/CD8 Ratio .10LCD 8% 74H
• Glucose, Lactate, Albumin, HCO3 remained abnormal
• NS @ 75ml/hr – d/c when I saw him
MEDICATIONS
AzithromycinCefepimeEnoxaparinFluconazoleNystatinProtonixSulfamethox-TMPSolu-medrolVancomycin
AcylovirMirtazapineProtonixPrednisoneSeptraRatepravir
HOME MEDICATIONS
AcyclovirAzithromycinCyproheptadineIsentressVitamin D3AbilifyDepakoteHydroxyzine PamoateNexium
PrednisoneZofranZyprexaRaltegravirErgocalcifeol
INTITAL ASSESSMENT
Per pt, appetite is fine but says swallowing is difficult for his PO meds, very lethargic
Follows a normal diet, occasionally drinks Boost that is provided – hates it. Prefers Ensure, Food Security, Received some nutr edu
Denies wt loss, says always thinRegular DietPES: Increased Protein/Energy Needs
Related to Metabolic Stressors/Current Condition AEB by BMI of 12.5, 57% IBW, Severe Wt Loss
Intervention Monitoring/Evaulation
1. Continue w/ current diet, will send Ensure TID along w/ HP Milkshakes TID/ HNS Snacks
2. Recommend swallow study to assess dysphagia prescence – pt may benefit from nutrition support
3. Request PAB4. Provide edu as
appropriate
Preserve LBMMaintain Skin
Integrity
INTIAL ASSESSMENT, Cont
First Follow Up
PAB of 21! Suspected PellagraMitochondrial Toxicity 2/2 to AZTMetabolic Acidosis w/ Primary Respiratory
AlkalosisPlaced on Thiamine & B-Vitamin ComplexNepro 1 can BID ? (Renal Fxn normal)Thrush is responding to treatmentInfectious Disease to re-evaluate for new
HAART
First Follow Up, Cont
Eating fine, Nursing reporting eating fine, Very hungry
Reports he can’t swallow HAART, uncomfortable
Denies N/V/Diarrhea – BMSome Stomach PainPES: REMAINS
Intervention Monitoring/Evaluation
1. Continue w/ current diet and supplements. Will honor food prefs
2. D/C Nepro3. Revaluate
medication regimen if feasible for swallowing
Preserve LBMMaintain skin
integrity
First Follow Up, Cont.
NUTRITION EDUCATION
Fortification of FoodsBrief Food SafetyTouched on Importance of Meds and
Following Instructions
SECOND FOLLOW UP
Nursing Staff to Check for Outside DrugsStill not taking HAART, but taking all other PO medsMD had spoke w/ pt regarding Meds*Pt wishes for DNR status, contemplating hospice PCP not responding to treatmentLeft Pneumothroax discovered- chest tubeLactic Acidosis resolved (d/c AZT)Metabolic Acidosis continues, cause unclearAdd some chipsPES Remains
Intervention Monitoring/Evaluation
1. Continue w/ current care plan, will honor food prefs
Preserve LBMMaintain skin
integrity
Second Follow Up, cont
PERSONAL IMPRESSION
HORRIBLERecommended Vitamin A or B-Vitamin
Complex in BeginningBetter, more in-depth Nutrition EducationOutreach assistance, websites