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August is a 48-year-old Zulu-speaking man who lives with his wife and two sons in an informal settlement near the Sefako Makgatho Health Sciences University Hospital (SMHSU) where you work as a clinical dietitian. August was diagnosed with human immunodeficiency virus (HIV) at the age of 28 (horizontal transmission) and is currently on fixed-dose combination regimen of tenofovir, lamivudine and dolutegravir. He reports to be compliant with treatment. He is admitted SMHSU hospital with a clinical picture of parapneumonic effusion with a possible etiology of streptococcus pneumonia.
(1 South African Rand (R) is the equivalent of 0.082 Australian Dollars (AUD)
August is unemployed and receives a disability grant of R2090 ($170 AUD) per month, from the South African Social Security Agency (SASSA). August’s wife is employed as a cleaner at the local school and earns a monthly salary of R6000 ($500 AUD). August’s children contribute R7500 ($600 AUD) to the household monthly income. Together, this income covers the living expenses of four people. Typically, 60% of this sum is spent on food, while the remainder goes towards transportation and household expenses.
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+ Introduction
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DIETITIAN'S INTRODUCTION 0. Introduction to August
The patient interaction protocol mandates strict adherence to hand hygiene before patient contact.
Before engaging with patients, the dietitian emphasizes hand hygiene and evaluates the need for additional personal protective equipment (PPE).
Refer to the the WHO hand-washing technique.by clicking here.
Next the dietitian introduces themselves and verifies the patient's identity using two forms of identification: the patient's chart and verbal confirmation..
Consider cultural sensitivity and the patient's emotional well-being.
Please take a moment now to practice your patient introduction technique. Practice introducing yourself and explaining the purpose of your visit to August.
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+ 1. Food/Nutrition-Related History (FH)
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The dietary history is a retrospective structured interview consisting of questions about habitual intake of foods from the core food groups (e.g. protein foods, grains, fruit and vegetables, dairy, fats and oils, sugar, and beverages). Additionally, it encompasses dietary behaviours like missing meals, cultural influences and the nutrition impact factors.
The diet history is particularly valuable when the objective is to capture information about habitual food intake or dietary habits during a specific life stage or time frame. For instance, in the case study of August, a dietitian is analyzing his dietary intake over the past six months. This period is significant as it aligns with the onset of his weight loss. By examining August's eating habits and food choices during this time, the dietitian can gain insights into potential nutritional deficiencies or imbalances that may have contributed to his weight loss. This approach is integral in forming a comprehensive nutritional assessment and developing a tailored dietary plan.
Nutrition Assessment Tools
TOOL KIT
— Australia: Ready Reckoner: Dietary Guidelines
— USA: Exchange List: Dietary Guidelines
— South Africa: Dietary GuidelinesWatch and Read Patient's Story Dietitian's Rationale Home Diet
To gain a comprehensive understanding of the dietitian's rationale,
please read the Practice Considerations.Protein-energy Malnutrition
READ MORE...Protein Sources
READ MORE...Discover additional information about Augusts's protein intake in the Diet History Tab.
1. Do you eat red meat and or fish?
Fish
August includes fish in his diet, including hake. However, he expresses a dislike for canned fish. It would be beneficial to have a broader understanding of what he describes as a canned fish allergy. Asking August to elaborate will provide clarity and help determine the specific issue or reaction he experiences with canned fish. READ MORE to reveal how the dietitian might approach this.2. Cannot eat prime meat very often.
3. Other meal choices.
Legumes
August enjoys consuming beans. Beans contain fructooligosaccharides (FOS) and GOS galactooligosaccharides (GOS). READ MORE...
Hospital Diet
4. Appetite getting better - **doubled up**
4. In video 4, the dietitian discovers that August's appetite is improving. Consider the additional information the dietitian requires to conduct an accurate comparison of August's previous dietary intake and his current intake.
Refer to the Diet History Tab for information about August's intake at each meal.
5. What did you have for breakfast this morning?
6. Never misses medicine
7. If you keep up with your medication/treatment, there is no need to communicate HIV status.
Please click here to review August's Medication list
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8. What are healthy foods for you pt1
9. What are healthy foods for you pt2
10. What are healthy foods for you pt3
11. How does nutrition help your health?
written format Knowledge, Beliefs and Attitudes
12. Nutrition intake & health
Eligibility for Government Programs
13. Are you part of any community HIV support groups?
Physical Activity
14. Energy Levels
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+ 2. Anthropometric Measurements (AD)
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Anthropometry
August reports he has lost 7.5 kg over the past 6 months. He recognizes a recent decrease in weight over the last month but isn't certain of the exact amount. His height stands at 1.72 meters, and his mid-upper arm circumference (MUAC) measures 19 cm. Upon admission, his weight was recorded at 58 kg, and since then, he has gained 1 kg, reaching his current weight of 59 kg. His BMI is approximately 19.94. This falls within the healthy weight range according to BMI categories. As you progress through the Nutrition Assessment please consider August's current BMI in the context of his recent health concerns.
Watch and Read Patient Story Dietitian's Information Weight
Anthropometry Video (rename)
15. Have you been losing weight?
16. Tell Me About Your Weight?
17. Effect of sickness on weight
In the hospital setting, the dietitian will obtain information about the patient's anthropometry from a variety of sources. Conduct a search for August's Anthropometry information looking at the following sources:
Medical Record: The patient's medical records are a primary source. They often contain historical data on the patient's weight, height, BMI (Body Mass Index), MUAC and possibly other measurements like waist circumference or skinfold thickness.
Allied Health Clinical Assessments: During a clinical visit, the dietitian or other healthcare professionals can directly measure the patient's weight, height, and other relevant anthropometric data using scales, stadiometers, and measuring tapes. They will assess the patient for signs of wasting or lipodystrophy, which are considerable nutritional challenges in HIV.
Clinical Assessments: During a clinical visit, the dietitian or other healthcare professionals can directly measure the patient's weight, height, and other relevant anthropometric data using scales, stadiometers, and measuring tapes. They will assess the patient for signs of wasting or lipodystrophy, which are considerable nutritional challenges in HIV.
Nursing Staff Measurements: In many hospital and community healthcare settings, nursing staff routinely measure and record patients' anthropometric data as part of their initial assessment and ongoing care. This data is usually accessible in the patient's chart or electronic health record.
Self-Reported Data: If recent measurements are not available in medical records, the dietitian might rely on self-reported data from the patient. However, it's important to note that self-reported measurements can be less accurate.
Specialized Equipment: In some cases, especially for detailed body composition analysis, specialized equipment such as bioelectrical impedance analysis (BIA) machines or DEXA (dual-energy X-ray absorptiometry) scans might be used. This equipment is typically found in some hospitals, research facilities, or specialized clinics.
Mid-upper Arm Circumference
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Watch and Read Patient Story Dietitian's Information XXXX
Biochem Video (Rename)
Refer to the medical chart
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+ Check-in
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Check-in 18. Are you feeling tired?
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+ 4. Nutrition-Focused Physical Findings (PD)
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Watch and Read Patient Story Dietitian's Information Appetite
Nutrition-focused video (rename)
19. How has your appetite been?
20. Appetite getting better - **duplicated**
21. Previous dietetic intervention: do you get any supplements?
22. Do you think it will help you if you took supplements?
23. Watching the Patient Drinking Supplement
August presented to emergency 3 days ago with fever, shortness of breath and severe pain in the left upper quadrant.
His chart notes mucositis, oral candidiasis, mouth ulcers, dysgeusia and a lack of appetite. In the assessment he mentions a persistent cough, weakness and a general feeling of malaise which he has experienced for the past 3 weeks.
He expresses disinterest in his regular activities and mentions spending most of his day resting.
Oral Pain
24. Struggling and Painful to Eat
Symptoms
25. Symptoms Before Hospital
26. Do You have Any Symptoms Today?
27. Energy Levels (also under 1. Nutrition XXXX)
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+ 5. Client History (CH)
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Watch and Read Patient Story Dietitian's Information Patient Medical History
Client History Video (rename)
28. HIV diagnosis & testing procedures.
29. Maybe they can drain out the infection
Budget
30. Where do you cut on your budget?
31. My wife must take care of the kids.
32. Things are too expensive
33. Currently Unemployed
34. How much money do you spend on food in a month?
35. Do you feel like you are struggling to buy food?
36. 2000 Rand does not buy a lot of food.
37. Promised food that never arrives.
38. Not qualified to get food
The Stigma of HIV 39. Do people in your community know your HIV status?
40. Do people treat you different?
Community Support
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+ Comparative Standards
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Watch and Read Patient Story Dietitian's Information Comparative Standards Video (rename)
- Assessment, Monitoring and Evaluation Tools (AT)
- Etiology Category (EY)
- Comparative standards (CS)
- Progress Evaluation (EV)