Question

Discuss at least 3 evidence-based strategies the nurse can incorporate into the patient care plan to improve the nutritional status for HIV/Cancer patients.

Answer 1

HIV/AIDS: Medical Nutrition Therapy (MNT)
Medical nutrition therapy (MNT) provided by a registered dietitian (RD) is recommended for individuals
with HIV infection. Four studies regarding MNT (with or without oral nutritional supplementation)
report improved outcomes related to energy intake, symptoms and cardiovascular risk indices. Two
studies regarding nutritional counseling (non-MNT) also report improved outcomes related to weight
gain, CD4 count and quality of life.

HIV/AIDS: Frequency of Medical Nutrition Therapy (MNT)
The Registered Dietitian (RD) should provide at least one to two Medical Nutrition Therapy (MNT)
encounters per year for people with HIV infection (asymptomatic) and at least two to six (or more) MNT
encounters per year for people with HIV infection (symptomatic but stable, acute or palliative), based
on the following:
-Appropriate disease classifications
-Nutritional status
-Comorbidities
-Opportunistic infections
-Physical changes
-Weight or growth concerns
-Oral or gastrointestinal symptoms
-Metabolic complications
-Barriers to nutrition
-Living environment
-Functional status
-Behavioral concerns or unusual eating behaviors.
Studies regarding MNT (with or without oral nutritional supplementation) report improved outcomes
related to energy intake, symptoms, and cardiovascular risk indices, especially with increased frequency
of visits.

HIV/AIDS: Screening for People with HIV Infection
The registered dietitian (RD) should collaborate with other health care professionals, administrators and
public policy decision-makers to ensure that all people with HIV infection are screened for nutrition-
related problems, based on referral criteria regardless of setting, at every visit. People with HIV
infection are at nutritional risk at any time-point during the course of their illness.

As radiation therapies continue to evolve it is important that supportive care, including effective nutrition support, also improves for best patient care and outcomes. Several sets of evidence based nutritional management guidelines have been developed for patients with cancer. There is strong evidence to suggest that nutritional counselling by a dietician and/or supplementation is beneficial in improving nutritional status and quality of life in patients with gastrointestinal and head and neck cancer receiving radiotherapy. There is also some evidence to suggest that specialised supplements including omega 3 fatty acids and or immunonutrition may be beneficial in particular patient groups. In order to provide timely and appropriate nutrition intervention and improve patient outcomes, early and ongoing nutrition screening and assessment needs to be implemented. As new cancer care centres and treatments become available it is important that evidence based nutritional care is provided as part of multidisciplinary care for best patient outcomes. Patients with cancer are one of the diagnostic groups at greatest nutritional risk. A recent observational study oncology patients receiving cancer services at a public Australian hospital found that almost one half of patients were malnourished, and common symptoms impacting on dietary intake included taste changes, poor appetite and nausea. Consequences of malnutrition include increased risk of infections, poor wound healing, decreased quality of life and transfer to higher level care. Malnutrition is particularly of concern as it has been shown to independently lead to increased hospital readmissions and in hospital mortality, even after adjusting for disease type and severity. Strong evidence exists to support the prevention and early detection of malnutrition, with nutrition intervention significantly improving patient and clinical outcomes. While radiotherapy techniques are continually improving they may result in significant side effects to the patient. Radiotherapy has a localised anti-tumour effect, damaging rapidly dividing cells, but can also affect healthy tissue within the treatment field. Radiotherapy acts by directing X-rays to cause damage to cell DNA so cells cannot replicate. Rapidly dividing cells (e.g. blood cells and gut mucosa) are the most susceptible to radiation change. Therefore tumours that require radiotherapy to an area of the head and neck or gastrointestinal tract are likely to lead to nutritional problems. Potential side effects of radiation therapy to the head and neck area may include mucositis, odynophagia, thick saliva, xerostomia, trismus, pharyngeal fibrosis and decreased appetite due to changes in sense of smell and taste. Radiotherapy can also exacerbate tooth decay due to induction of xerostomia and removal of dental floride. Patients with head and neck cancer should see a dentist prior to commencing treatment and decayed teeth should be removed at least 7 days prior to commencement of radiation therapy. Radiotherapy to the thyroid gland in the neck area may lead to hypothyroidism so patients should have their neck area checked regularly. Consuming enough calories to prevent additional weight loss is therefore vital for survivors at risk of unintentional weight loss, such as those who are already malnourished or those who receive anticancer treatments affecting the gastrointestinal tract. Patients receiving radiotherapy to the gastrointestinal area may experience diarrhoea, constipation, gastric pain, indigestion and or flatulence which can impact on nutritional status and quality of life.
An aspect of treatment not usually considered is that during radiotherapy patients are required to spend large amounts of time receiving medical treatment and waiting for appointments which can disrupt routines and lead to missed meals. In our experience, rural patients may be at increased nutritional risk as they often need to travel large distances to receive treatment. Their alternate accommodation may not have suitable cooking facilities or equipment such as a blender for softer, pureed foods that may be required if experiencing swallowing difficulties. The patient may not have the energy or skills to prepare suitable foods and fluids during this time. Therefore having an occupational therapist, social worker and or nurse who can liaise with the patient, care givers, if available, and/or organise home help may be particularly important for the patient at nutritional risk without sufficient support to help with shopping and cooking.

Patients may not be aware that side effects of radiotherapy are often experienced a few weeks after commencement, continue during treatment but may also continue to build and be experienced for 4-6 weeks after completing radiotherapy treatment. This period is an important time for review e.g. a telephone review by a nurse to see how the patient is progressing. Often the patient thinks that the side effects will stop and they will feel better after finishing radiotherapy treatment. However, as the side effects can continue and even become worse for 2 weeks after treatment completion, if the patient does not have adequate support, they can become dehydrated and/or malnourished. These nutritional issues may not be picked up unless the patient is admitted to hospital or when they next come in for a medical review which may be 4-6 weeks later. Therefore a follow up telephone review in the first few weeks following radiotherapy treatment can be useful to identify any problems that may require additional medication and/or support.

Patients receiving radiotherapy to the head and neck area may also experience long term swallowing difficulties. These swallowing difficulties may increase the risk of malnutrition. Therefore ongoing liaison and review by the multidisciplinary team, including a dietician and speech pathologist, may be required.