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Transcript
MEDICAL NUTRITION
THERAPY IN THE
PATIENT WITH HIV/AIDS:
A CASE STUDY
Britt Berger, MS
Sodexo DI
Februar y 2014
OUTLINE
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History
Statistics
Biology
Disease Course and Lifecycle
Antiretroviral Therapy
Medical Nutrition Therapy
Case Study Patient
Medical Hospital Course
Nutritional Hospital Course
Comments
Questions
HISTORY OF HIV/AIDS
 Late 1800s: first human
infection
 Likely source: chimpanzees
in West Africa infected with
Simian Immunodeficiency
Virus (SIV)
 Humans hunted
chimpanzees for their meat
and were infected by
contact with their blood
 Virus slowly spread across
Africa and to other parts of
the world
 HIV in the US: since at least
the mid- to late 1970s
 First cases of AIDS
described in 1981
UNITED STATES STATISTICS
 More than 1 .1 million people are living with HIV
 Almost 1 in 5 are unaware of their infection
 Gay, bisexual, and other men who have sex with
men (MSM) are most affected
 Blacks/African Americans face the most severe burden of HIV
 HIV incidence has remained relatively stable in recent years at
about 50,000 new infections per year
 15,529 people in the US with an AIDS diagnosis died in 2010
 636,000 people in the US with an AIDS diagnosis have died since
the epidemic began
GLOBAL STATISTICS
 33.4 million people are currently living with HIV/AIDS
 More than 25 million people have died of AIDS since the first
cases were reported in 1981
 2 million people died due to HIV/AIDS in 2008
 2.7 million people were newly infected in 2008
 Cases have been reported in all regions of the world
 Almost all those living with HIV (97%) reside in low - and middle-income
countries
 Sub-Saharan Africa (10% of world’s population/68% of HIV)
 Prevention has helped reduce HIV rates in small but growing
numbers
 New infections are believed to be on the decline
BIOLOGY OF HIV
 HIV = retrovirus
 Retroviruses
 Contain RNA as their genetic material
 Use reverse transcriptase to convert
RNA into DNA
 Replicate using the cell’s machinery
 Lentivirus
 “Slow” viruses
 Long period of time between initial infection and beginning of serious
symptoms
 Many people unaware of their infection and spread the virus to others
TWO IMPORTANT TERMS
 CD4 cells:
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Critical part of the immune system
Type of white blood cell (fight infection)
Send signals to activate the body’s immune response
Normal CD4 count = 500 – 1000
As HIV infection progresses, CD4 count decreases
Also known as T cells
 Viral load:
 Measurement of the amount of HIV in the blood
 As HIV infection progresses, viral load increases
COURSE OF DISEASE
 HIV infection has a well documented progression
 If an HIV-infected person does not get treatment, HIV will
eventually overwhelm their immune system
 When used consistently, antiretroviral therapy (ART) prevents
the HIV virus from multiplying and destroying the immune
system
 Research has shown that taking ART can help prevent the
spread of HIV to others
STAGE 1: ACUTE INFECTION
 2 – 4 weeks after HIV infection
 Many, but not all, people develop flu -like symptoms
 Often described as “the worst flu ever”
 Body’s natural response to HIV infection
 “Acute antiretroviral syndrome” (ARS)
 Or “primary HIV infection”
 Large amounts of virus being produced
 High risk of transmitting HIV to sexual or drug using partners
during this stage
STAGE 2: CLINICAL LATENCY STAGE
 Period where the virus is living/developing in a person without
producing symptoms
 No HIV-related symptoms
 Some people experience mild symptoms
 Virus continues to reproduce at low levels
 Clinical latency may last for several decades for people who
take ART
 Lasts an average of 10 years for people not on ART
 Still possible to transmit HIV to others
STAGE 3: AIDS
1. CD4 cells <200
2. Opportunistic infection
 Regardless of CD4 count
 Immune system is badly damaged
 Vulnerable to infections
 Without treatment, people typically survive 3 years
 Once a person has an opportunistic infection, life -expectancy
without treatment falls to about 1 year
 If a person takes ART and maintains a low viral load, they may
have a near normal lifespan and never progress to AIDS
HIV LIFECYCLE AND
ANTIRETROVIRAL THERAPY
 HIV enters the body through sexual contact, transfusions with
infected blood, or by injection
 Virus attaches to dendritic cells (type of immune system cell)
 Found in the mucosal membranes that line the mouth, vagina,
rectum, penis, and upper GI tract
 Dendritic cells transport the virus from the site of infection to
the lymph nodes where HIV can infect other immune system
cells
 The steps of the lifecycle are important to understand
 Medications used to control HIV infection act to interrupt the cycle
STEP 1: BINDING AND FUSION
 HIV binds to a specific type of CD4 receptor and a co -receptor
on the surface of the CD4 cell
 Similar to a key entering a lock
 Once unlocked, HIV can fuse with the host CD4 cell and
release its genetic material into the cell
STEP 2: REVERSE TRANSCRIPTION
 The enzyme reverse transcriptase changes the genetic
material of the virus so it can be integrated into the host DNA
STEP 3: INTEGRATION
 The virus’ new genetic material enters the nucleus of the CD4
cell and uses the enzyme integrase to integrate itself into the
body’s own genetic material where it may “hide” and stay
inactive for years
STEP 4: TRANSCRIPTION
STEP 5: ASSEMBLY
 When the host cell becomes activated, the virus uses the
body’s own enzymes to create more of its genetic material
 Also creates a more specialized genetic material which allows
it to make longer proteins
 The enzyme protease cuts the longer HIV proteins into
individual proteins
 When these come together with the virus’ genetic material, a
new virus has been assembled
STEP 6: BUDDING
 Final stage of the virus’ lifecycle
 Virus pushes itself out of the host cell, taking part of the cell
membrane with it
 Outer part covers the virus
 Contains all of the structures necessary to bind to a new CD4 cell
 Process begins again
HIGHLY ACTIVE ANTIRETROVIRAL
THERAPY (HAART or ART)
 Introduction of 3-drug combination ART in 1996
revolutionized treatment
 Significantly decreased AIDS-related morbidity and mortality
 5 classes of HIV drugs
 Each class attacks the virus at a different point in the lifecycle
 A person taking ART will generally take 3 dif ferent drugs from
2 dif ferent classes
 Best job of controlling the amount of virus in
the body and protecting the immune system
 Protects against resistance
 Nutritional implications
NUCLEOSIDE/NUCLEOTIDE REVERSE
TRANSCRIPTASE INHIBITORS (NRTIs)
 Blocks a very important step in HIV’s reproduction process
 Act as faulty building blocks in production of viral DNA
 Blocks HIV’s ability to use reverse transcriptase to correctly
build new DNA
 Without reverse transcriptase the virus is unable to make copies of
itself
NON-NUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBITORS (NNRTIs)
 Work in a very similar way to NRTIs
 Also block reverse transcriptase and prevent HIV from making
copies of its own DNA
 NRTIs work on the genetic material
 NNRTIs act directly on the enzyme itself to prevent it from
functioning correctly
PROTEASE INHIBITORS
 When HIV replicates it creates long strands of its own genetic
material
 These long strands must be cut into shorter stands in order
for HIV to create more copies of itself
 Protease acts to cut up these long strands
 Protease inhibitors block this enzyme
 Prevent the long strands of genetic material from being cut up into
functional pieces
ENTRY/FUSION INHIBITORS
 Block the virus from entering the cells in the first place
 HIV needs a way to attach and bond to CD4 cells
 Special structures on cells called receptor sites
 Found on both HIV and CD4 cells
 Fusion inhibitors can target those sites on either HIV or CD4
cells and prevent HIV from attaching onto healthy cells
INTEGRASE INHIBITORS
 HIV uses the cells’ genetic material to make its own DNA
 Reverse transcription
 The virus then has to integrate its genetic material into the
genetic material of the cells
 Uses the enzyme integrase
 Integrase inhibitors block this enzyme and prevent the virus
from adding its DNA into the DNA of the CD4 cells
 Preventing this process prevents the virus from replicating
and making new copies
MEDICAL NUTRITION THERAPY
 Overall goals of MNT for HIV and AIDS patients are to:
 Optimize nutritional status, immunity, and well-being
 Maintain a healthy weight and lean body mass
 Prevent nutrient deficiencies
 Reduce the risk of comorbidities
 Maximize the effectiveness of medical and pharmacological
treatments
MEDICAL NUTRITION THERAPY
 Good nutrition is important to all people, whether or not they
are living with HIV
 Eating well is key to maintaining:
 Strength
 Energy
 Healthy immune system
 Some conditions related to HIV/AIDS and treatment mean
that proper nutrition is EXTREMELY IMPORTANT
 Wasting
 Diarrhea
 Lipid abnormalities
 Immune suppression
 Food safety and proper hygiene
ESTIMATED NUTRITIONAL NEEDS
 Adequate intake of macro - and micronutrients is essential to
restoration and maintenance of body cell mass and normal
body function, including immunity
 The benefits of providing adequate amounts of energy,
protein, and micronutrients for people living with HIV are clear
 However, the EXACT amount of each type of nutrient needed is less
clear
 Long-term clinical trials are needed to provide evidence -based
formal recommendations for all nutrients
 There is no single “diet” that is appropriate for all individuals
living with HIV
ENERGY
 Studies show that low energy intake combined with increased
energy demands due to HIV are the major driving forces
behind HIV-related weight loss and wasting
 Asymptomatic HIV-infected adults:
 Goal = maintain body weight
 10% increase in energy needs
 25 – 30 kcal/kg  28 – 33 kcal/kg
 Symptomatic HIV-infected adults (with opportunistic
infections):
 20 – 30% increase in energy needs
 30 – 40 kcal/kg
 Intake should be increased to the extent possible during recovery
phase
PROTEIN
 DRI for healthy adults = 0.8 grams/kg
 Likely adequate for asymptomatic HIV-infected adults
 Patients with wasted lean body mass
 Increased protein intake may be beneficial
 1.2 – 2.0 grams/kg
 Currently no evidence to support protein intake in excess of this
range
 Sources of dietary protein include both animal and plant based sources
 Strict vegetarians need to consume a wide variety of foods to ensure
that they obtain adequate amounts of all essential amino acids
 May benefit from protein, energy, iron, and vitamin B12 supplementation
FAT
 No evidence that total fat needs are increased beyond normal
requirements
 Special advice regarding fat intake may be required for
patients undergoing antiretroviral therapy or experiencing
persistent diarrhea
 Malabsorption syndromes may require changes in timing,
quantity, and type of fat intake
 Researchers are currently studying the potential of omega -3
fats in immune function
 Recommendations are currently no different than for the general
population
MICRONUTRIENTS
 Foods rich in micronutrients are likely to help fight infections
and improve overall health
 Studies suggest that deficiencies and/or high intakes of
certain micronutrients may af fect the course of HIV
 Selenium deficiency may increase HIV-related mortality
 Excessive intake of zinc may be linked to poorer survival
 Increased intake of vitamins B1 (thiamin) and B2 (riboflavin) may
enhance survival
 Other micronutrient deficiencies may exacerbate oxidative stress
associated with HIV infection
 The patient is likely to benefit from consuming a varied diet
that is rich in micronutrients
MICRONUTRIENT SUPPLEMENTATION
 WHO’s position on micronutrient supplementation in HIV infected individuals:
 Healthy diet is best
 Dietary intake of micronutrients at RDA levels may not be sufficient
to correct nutritional deficiencies
 Legitimate use of dietary supplementation is to restore nutritional
status to normal
 No conclusive evidence to support use of dietary supplements to
improve outcomes
 Risk of adverse reactions with other medications
NUTRITION ASSESSMENT
 Food and nutrient intake
 Lifestyle
 Medical history
 Important medical factors to consider with HIV/AIDS patients:
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Stage of disease (CD4 count, viral load)
Comorbidities (CV disease, DM, hepatitis)
Opportunistic infections
Metabolic complications (DLD, insulin resistance)
Biochemical measurements (CD4 count, viral load, albumin,
hemoglobin, iron status, lipid profile, LFTs, renal function, glucose,
vitamin levels)
PHYSICAL APPEARANCE
 Very important
 Noted and documented during initial assessment and all follow -up
assessments
 Patients must be made aware of possible body shape changes
 Medical team (including RD) should ask patients about body shape
changes every 3 – 6 months
 Anthropometric measurements
 Measure changes in body shape and fat redistribution
 Physical changes = HIV -associated lipodystrophy syndrome
 Unintentional weight loss often indicates progression of
disease
SOCIAL AND ECONOMIC FACTORS
 Mental status and psychosocial issues may take precedence
over nutrition counseling
 Depression is common
 Habits, food aversions, and timing of meals with medications
must be taken into consideration
 Access to safe, af fordable, and nutritious food?
 Common barriers:
 Cost, location of supermarkets, lack of transportation, lack of
knowledge of healthier choices
 Antiretroviral medications are expensive and often compete with food
for available monetary resources
INTERDISCIPLINARY CARE
 All HIV patients should have access to a Registered Dietitian
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Baseline nutrition assessment after HIV diagnosis
Reassessment 1 – 2x per year for asymptomatic patients
2 – 6x per year for symptomatic but stable patients
Patients that have been diagnosed with AIDS usually need to be seen
more frequently and may require nutrition support
 RD must implement MNT and coordinate care with the
interdisciplinary medical team and community resources
 Many cities/towns/communities have resources available for
HIV and AIDS patients
 Food assistance programs
 Support systems
 Recreational facilities
CUSTOMIZING A NUTRITION PLAN
 No specific medical nutrition therapy for HIV and AIDS beyond
adequately meeting additional energy, protein, fluid, and
micronutrients needs
 MNT should be individualized for each patient
 Focus on:
 High quality foods
 Variety of fruits and vegetables
 Problems identified during
nutrition assessment (CV risk,
liver disease, DM)
NUTRITION EDUCATION
 Education and counseling should focus on:
 Appropriate and adequate food intake
 Food behaviors
 Symptoms that may affect appropriate food intake
 Benefits and risk of supplemental nutrients
 Strategies for symptom management
 Reduce effects of disease
 Reduce medication intolerance
SUPPLEMENTS AND NUTRITION SUPPORT
 When a patient does not/cannot eat well, supplements may
be necessary for getting suf ficient calories, protein, vitamins,
and minerals
 Not perfect substitutes for food
 Can be helpful
 Nutritional supplements can be toxic
 Safe limits are usually 100 – 200% of the nutrient’s DRI
 Vitamins A and D are most safely obtained through eating food
 Zinc and selenium are important for immunity, but are toxic at fairly
low doses
 Patients with significant weight loss may be candidates for
enteral nutrition (not very common)
 Unless GI function is severely abnormal, there is no reason to
consider parenteral nutrition
GI SYMPTOMS AND SIDE EFFECTS
 Diarrhea is common
 Causes dehydration, malabsorption, food/nutrient losses
 Caused by:





Infection
GI damage
Increased motility
Lactose/other food intolerances
Medication (ART)
 Short-term:
 Antidiarrheal medications
 Long term:
 Large fluid losses/dehydration
 Investigation by MD
GI SYMPTOMS AND SIDE EFFECTS
 ART medications:
 Diarrhea, GERD, nausea, vomiting, constipation
 PI and NRTI classes are most commonly associated with GI distress
 Diarrhea can make it difficult for ART medications to be as effective
as possible
 Reduce caffeine and alcohol
 Test for lactose intolerance
 Fat malabsorption
 Feeling full too fast, bloating, foul-smelling stools that float
 Low-fat diet
 Pancreatic enzyme supplementation
GI SYMPTOMS AND SIDE EFFECTS
 Nausea
 Also a common problem
 Food, medications, odors
 Psychological aversions
to food may develop
 Look at food-medication
interactions
 Add antinausea/antiemetic
medications if necessary
 If associated with food
intake, implement
nutritional strategies
FOOD SAFET Y
 Food safety is especially important for patients with low CD4
counts (<200)
 More likely to get sick from foods that are not safe to eat
 Food safety rules:
Avoid eating raw eggs, meat, and seafood
Wash fruits and vegetables thoroughly
Use a separate cutting board for raw meats
Wash hands, utensils, and cutting boards with
soap and water after each use
 Water safety is extremely important
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 Water can carry parasites, bacteria, and viruses
CHOICE OF CASE STUDY PATIENT
 Dietetic internship primary site = St. Barnabas Hospital in the
Bronx
 Urban level I trauma center
 Many patients are HIV -positive in addition to condition that
they are hospitalized for
 Ideal opportunity to learn more about HIV and AIDS
 Nutritional implications
PATIENT
 45 year-old black woman
 Brought to the emergency department by EMS with shortness
of breath, elevated heart rate, fevers, sweating, frequent
vomiting/diarrhea, severe cough with whitish phlegm for two
weeks
 Past Medical History
 HIV (non-compliant with ART medications, last known CD4 count =
172 in January 2012)
 Hypertension
 Depression
 PCP pneumonia (required hospitalization)
 Anemia
 History of IV drug abuse and tobacco use
PATIENT
 Height: 5’2” (62” / 156.4cm)
 Admission weight: 90# / 40.8kg
 BMI 16.4
 Questionable accuracy of admission weight
 No mention of what type of scale was used (standing scale,
bed scale, etc.)
 Was the weight stated by the patient?
 Visibly cachectic
 Report of 40# (31%) weight loss from usual body weight
130# over the last month
 Severe weight loss
PATIENT
 Currently unemployed
 Lives alone in an elevator building in the Bronx
 Completed high school, did not go to college
 Baptist
 Patient’s best friend/on-and-off boyfriend spent
almost every day with her during hospitalization
 Sister in Staten Island
MEDICAL HOSPITAL COURSE
 October 21 , 2013 –
November 19, 2013
 30 days
 High nutritional risk
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Followed-up every 2 – 3 days
Initial assessment
4 reassessments
Several progress notes
Emergency department 
Medical/surgical floor 
ICU 
Step-down ICU 
General medicine floor 
Home 
Admitting Diagnosis:
AIDS
Multilobar/PCP pneumonia
Candida infection of the mouth
and esophagus
AIDS
 Acquired Immunodeficiency Syndrome
 Final stage of HIV infection
 Badly damaged immune system
 One or more specific opportunistic infections
 Certain cancers
 CD4 count <200
 Medical intervention necessary to prevent death
PCP PNEUMONIA
 AIDS-defining condition
(opportunistic infection)
 Serious illness caused
by the fungus
Pneumocystis jirovecii
 One of the most
frequent and severe
opportunistic infections
in people with HIV/AIDS
 Symptoms:
 Fever
 Dry cough
 Shortness of breath
 Fatigue
 In HIV-infected
patients:
 Develops sub-acutely
 Low-grade fever
 No vaccine to prevent
PCP
 3 week treatment with
antibiotics
ORAL/ESOPHAGEAL CANDIDIASIS
 AIDS-defining condition (opportunistic infection)
 Also known as thrush
 Fungal infection - Candida overgrowth
 A small amount of this fungus normally lives in the mouth
 Usually kept in check by the immune system and other bacteria
 Fungus can overgrow when the immune system is weak
 Common in HIV/AIDS
 Nutritional implications
HOSPITAL DAYS 1 – 8
MEDICAL/SURGICAL FLOOR
 PCP pneumonia
 Antibiotics
 O2 supplementation
 Follow-up O2 saturation
 Respiratory and sputum
cultures
 Severe oral thrush
 Fluconazole and Nystatin
Swish and Swallow
 Mostly resolved within
the first week
 AIDS (non-compliant
with ART)
 CD4 <20
 Rule out TB
 Airborne precautions
 3 sputum cultures
 Diarrhea
 Flagyl
 Stool workup
HOSPITAL DAYS 1 – 8
MEDICAL/SURGICAL FLOOR
 O2 saturation
 Red blood cells must carry sufficient oxygen through the arteries to
all internal organs to keep a person alive
 Percentage of hemoglobin binding sites in the bloodstream occupied
by oxygen
 95%  91%  87%  88%  75%
 Possible sepsis
 WBC 8.2  16.7
 Patient states she feels like she is going to die
 Transferred to ICU
HOSPITAL DAYS 9 – 15
ICU
 Patient appears emaciated and weak, dry crusted lips,
minimal oral thrush
 May require intubation if condition worsens
 Discussion about end of life issues
 Appoints best friend as medical proxy
 Wishes to be intubated and resuscitated if necessary
 Patient begins to feel better





O2 saturation improves
WBCs trend down
Diarrhea resolved
Medically stable
Ready for transfer to general medicine floor
HOSPITALS DAYS 16 & 17
STEP-DOWN ICU
 Patient had episode of Ventricular tachycardia
 Rapid heartbeat that starts in the ventricles
 5 beats
 Most likely caused by medication interaction
 Transferred to step-down ICU instead of general medicine floor
for observation
 93 – 100% O2 saturation
HOSPITAL DAYS 18 – 30
GENERAL MEDICINE FLOOR
 C. diff negative
 Diarrhea resolved
 Flagyl discontinued
 Able to walk to
bathroom without
significant SOB
 Chest X-ray shows
improvements
 Reglan added for GI
upset
 Polypharmacy
 Patient tells MD she is
interested in restarting
ART
 St. Barnabas Designated
AIDS Center appointment
scheduled
 Patient will need home
O2 when discharged
 Social work coordinated
with VNS for delivery
 PATIENT DISCHARGED

DISCUSSION OF MEDICAL NUTRITION
THERAPY
 Very sick
 Extremely advanced AIDS
 CD4 <20
 Two opportunistic infections
 Both with nutritional implications
 Difficult PO intake
 First 10 days in hospital
 21.6# weight loss
 Lowest BMI = 12.5
 Cachexia and severe protein-calorie malnutrition
WEIGHT DURING HOSPITALIZATION
Weight (in lbs.)
95
90
85
80
75
70
65
60
55
50
HD 1
HD 10
HD 11
HD 12
HD 16
HD 23
HD 29
NUTRITION INITIAL ASSESSMENT (HD 2)
 Chewing problem:
 Poor dentition
 Swallowing problem:
 Painful/difficult
swallowing caused by
severe oral/esophageal
thrush
 Vomiting:
 Persistent PTA, currently
resolved
 Diarrhea:
 Persistent PTA, multiple
episodes today
 Appetite/Intake:
 Fair, making an effort to
eat
 ~25% breakfast
completion
 Diet PTA:
 <1 meal/day x2 weeks
 Inability to cook because
of lack of energy
 Appearance:
 Cachectic
NUTRITION INITIAL ASSESSMENT (HD 2)
 Anthropometrics
 BMI: 16.4
 Ideal body weight: 110# / 50kg
 %IBW: 82%
 Usual body weight: 130# / 59kg
 %UBW: 69%
 Estimated nutritional needs
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


Based on current body weight 41kg
Calories: 1435 – 1640 kcals (based on 35 – 40kcal/kg)
Protein: 61 – 82 grams (based on 1.5 – 2.0gm/kg)
Fluid: 1230 – 1435 ml (based on 30 – 35ml/kg)
 High nutritional risk
NUTRITION INITIAL ASSESSMENT (HD 2)
 Diagnosis:
 Malnutrition related to poor PO intake, persistent vomiting and
diarrhea, painful and difficult swallowing, and oral/esophageal
thrush as evidenced by 40# (31%) unintentional weight loss x 1
month, BMI 16.4
 Intervention:
 Discussed the importance of adequate PO intake and
strategies to achieve adequacy
 Recommended patient eat protein portion of meal first
 PO supplement use between meals, rather than meal
replacement
 Discussed food preferences
NUTRITION INITIAL ASSESSMENT (HD 2)
 Recommendation plan:
 SLP consult for diet consistency and upgrade from pureed
consistency to soft consistency for palatability and PO intake
optimization
 Ensure Plus 8oz PO supplement TID (1050kcal + 39gm protein) for
consumption between meals
 Continue MVI supplementation, maintain hydration status, replete
electrolytes as necessary
 Reassess PO intake
 Weekly weights
HOSPITAL WEEK 1
 Poor – fair PO intake
 10 – 50% meal completion
 Consistency upgrade to soft foods
 Added yogurt and applesauce to breakfast, lunch, and dinner
trays
 Food from outside
 Grapes, candy
 Less painful swallowing
 Patient seen drinking Ensure Plus supplements
NUTRITION REASSESSMENT 1 (HD 9)
 Day after ICU transfer
 0% breakfast completion, patient was told not to remove her O2
mask
 Patient believes Ensure Plus supplement causes diarrhea
 Weight: 74.5# / 33.8kg (bed scale)
 15.5# (17%) weight loss
 BMI: 13.6
 Estimated nutritional needs (based on IBW 50kg)
 Calories: 1500 – 1750 kcals (based on 30 – 35kcal/kg)
 Protein: 75 – 100 grams (based on 1.5 – 2.0gm/kg)
 Fluid: 1250 – 1500 ml (based on 25 – 30ml/kg)
NUTRITION REASSESSMENT 1 (HD 9)
 Interventions and recommendations:
 Added tuna sandwich and gelatin to patient’s lunch and dinner trays
to give more options
 Continue soft diet
 Discontinue Ensure Plus supplements
 Add TwoCal HN 8oz PO supplement BID (950kcal + 40gm protein)
 Reassess PO intake
 Daily weights
 During ICU stay:
 Added chocolate cake to patient’s dinner trays
 Added Ensure pudding once daily (170kcal + 4gm protein)
NUTRITION REASSESSMENT 2 (HD 17)
 Fair appetite
 75% breakfast completion
 Observed patient drinking a TwoCal supplement
 Patient noted with 2.8kg (6.2#) weight gain from lowest
weight
 BMI: 13.6
 Patient encouraged by weight gain and motivated to continue
gaining weight
NUTRITION REASSESSMENT 3 (HD 23)
 Good appetite




75% meal completion
Finishes at least 1 TwoCal supplement per day
Eats 2 sandwiches as snacks between meals
Loves the chocolate cake
 Weight: 91 .8# / 41 .6kg (bed scale)
 BMI: 16.8
 17.3# (23%) weight gain since lowest weight during
hospitalization 
 2% weight gain since admission 
 Connection between PO intake and medical condition
 VERY motivated to continue gaining weight and to leave the
hospital
 Soft  regular consistency foods
 Linezolid Rx added – Tyramine restriction added to diet order
NUTRITION REASSESSMENT 4 (HD 29)
 Continued good appetite
 Occasional dif ficulty swallowing due to sore throat
 Patient requests mechanical soft consistency foods
 Weight: 88.1# / 40kg (standing scale)
 BMI: 16.1
 3.6# (4%) weight loss x 6 days
 Possibly due to bed scale vs. standing scale
 Patient feels much better and is able to walk around room
 Pending discharge, reinforced nutrition education
COMMENTS ON MNT PROVIDED
 Initial diet
 Discussion about end of life issues




Patient realized she was not ready to die
Motivated to do anything possible to get better
Gaining weight became top priority
SUCCESS!
 Nutrition at home
 Supplements covered by insurance?
 Trusting relationship
 Doctors and nurses frequently changed, but my presence and concern
remained constant
 Significant weight gain = big part of recovery
 Importance of nutrition team as part of multidisciplinary care
A BIG THANK YOU TO THE
CLINICAL NUTRITION
DEPARTMENT AT ST.
BARNABAS HOSPITAL…
for being amazing
preceptors, teachers, and
mentors!
Amy (CNM), Allison, Rachel,
Bing, Jess, Rebecca, and
especially Michelle for
helping me find the perfect
case study patient 
QUESTIONS/DISCUSSIO
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