Imbalanced Nutrition: Less Than Body Requirements — AIDS

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements

May be related to

• Inability or altered ability to ingest, digest and/or metabolize nutrients: nausea/vomiting, hyperactive gag reflex, intestinal disturbances, GI tract infections, fatigue
• Increased metabolic rate/nutritional needs (fever/infection)

Possibly evidenced by

• Weight loss, decreased subcutaneous fat/muscle mass (wasting)
• Lack of interest in food, aversion to eating, altered taste sensation
• Abdominal cramping, hyperactive bowel sounds, diarrhea
• Sore, inflamed buccal cavity
• Abnormal laboratory results: vitamin/mineral and protein deficiencies, electrolyte imbalances

Desired Outcomes

• Maintain weight or display weight gain toward desired goal.
• Demonstrate positive nitrogen balance, be free of signs of malnutrition, and display improved energy level.

Nursing Interventions	Rationale
Assess ability to chew, taste, and swallow.	Lesions of the mouth, throat, and esophagus (often caused by candidiasis, herpes simplex, hairy leukoplakia, KS and other cancers) and metallic or other taste changes caused by medications may cause dysphagia, limiting patient’s ability to ingest food and reducing desire to eat.
Auscultate bowel sounds.	Hypermotility of intestinal tract is common and is associated with vomiting and diarrhea, which may affect choice of diet/route. Note: Lactose intolerance and malabsorption (e.g., with CMV, MAC, cryptosporidiosis) contribute to diarrhea and may necessitate change in diet/supplemental formula (e.g., Advera, Resource).
Weigh as indicated. Evaluate weight in terms of premorbid weight. Compare serial weights and anthropometric measurements.	Indicator of nutritional needs/adequacy of intake. Note:Because of immune suppression, some blood tests normally used for testing nutritional status are not useful.
Note drug side effects.	Prophylactic and therapeutic medications can have side effects affecting nutrition, e.g., ZDV (altered taste, nausea/vomiting), Bactrim(anorexia, glucose intolerance, glossitis), Pentam (altered taste and smell, nausea/vomiting, glucose intolerance), protease inhibitors (elevated lipids and blood sugar secondary to insulin resistance).
Plan diet with patient/SO, suggesting foods from home if appropriate. Provide small, frequent meals/snacks of nutritionally dense foods and nonacidic foods and beverages, with choice of foods palatable to patient. Encourage high-calorie/nutritious foods, some of which may be considered appetite stimulants. Note time of day when appetite is best, and try to serve larger meal at that time.	Including patient in planning gives sense of control of environment and may enhance intake. Fulfilling cravings for noninstitutional food may also improve intake. Note: In this population, foods with a higher fat content may be recommended as tolerated to enhance taste and oral intake.
Limit food(s) that induce nausea/vomiting or are poorly tolerated by patient because of mouth sores/dysphagia. Avoid serving very hot liquids/foods. Serve foods that are easy to swallow, e.g., eggs, ice cream, cooked vegetables.	Pain in the mouth or fear of irritating oral lesions may cause patient to be reluctant to eat. These measures may be helpful in increasing food intake.
Schedule medications between meals (if tolerated) and limit fluid intake with meals, unless fluid has nutritional value.	Gastric fullness diminishes appetite and food intake.
Encourage as much physical activity as possible.	May improve appetite and general feelings of well-being.
Provide frequent mouth care, observing secretion precautions. Avoid alcohol-containing mouthwashes.	Reduces discomfort associated with nausea/vomiting, oral lesions, mucosal dryness, and halitosis. Clean mouth may enhance appetite.
Provide rest period before meals. Avoid stressful procedures close to mealtime.	Minimizes fatigue; increases energy available for work of eating.
Remove existing noxious environmental stimuli or conditions that aggravate gag reflex.	Reduces stimulus of the vomiting center in the medulla.
Encourage patient to sit up for meals	Facilitates swallowing and reduces risk of aspiration.
Record ongoing caloric intake.	Identifies need for supplements or alternative feeding methods.
Maintain NPO status when appropriate.	May be needed to reduce nausea/vomiting.
Insert/maintain nasogastric (NG) tube as indicated.	May be needed to reduce vomiting or to administer tube feedings. Note: Esophageal irritation from existing infection (Candida, herpes, or KS) may provide site for secondary infections/trauma; therefore, NG tube should be used with caution.
Administer medications as indicated: Antiemetics, e.g., prochlorperazine (Compazine), promethazine (Phenergan), trimethobenzamide (Tigan); Sucralfate (Carafate) suspension; mixture of Maalox, diphenhydramine (Benadryl), and lidocaine (Xylocaine); Vitamin supplements; Appetite stimulants, e.g., dronabinol (Marinol), megestrol (Megace), oxandrolone (Oxandrin); TNF-alpha inhibitors, e.g., thalidomide; Antidiarrheals, e.g., diphenoxylate (Lomotil), loperamide (Imodium), octreotide (Sandostatin); Antibiotic therapy, e.g., ketoconazole (Nizoral), fluconazole (Diflucan).	Reduces incidence of nausea/vomiting, possibly enhancing oral intake. Given with meals (swish and hold in mouth) to relieve mouth pain, enhance intake. Mixture may be swallowed for presence of pharyngeal/esophageal lesions. Corrects vitamin deficiencies resulting from decreased food intake and/or disorders of digestion and absorption in the GI system. Note:Avoid megadoses; suggested supplemental level is two times the recommended daily allowance (RDA). Marinol (an antiemetic) and Megace (an antineoplastic) act as appetite stimulants in the presence of AIDS. Oxandrin is currently being studied in clinical trials to boost appetite and improve muscle mass and strength. Reduces elevated levels of tumor necrosis factor (TNF) present in chronic illness contributing to wasting/cachexia. Studies reveal a mean weight gain of 10% over 28 wk of therapy. Inhibit GI motility subsequently decreasing diarrhea. Imodium or Sandostatin areeffective treatments for secretory diarrhea (secretion of water and electrolytes by intestinal epithelium). May be given to treat/prevent infections involving the GI tract.