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Kaitlyn Click
Professor Matuszak
KNH 411
4 September 2014
Cardiovascular Case Study #5
Questions:
I. Understanding the Disease and Pathophysiology
1. Mr. Klosterman had a myocardial infarction. Explain what happened to his heart.
The purpose of the cardiovascular system is to regulate blood flow to the tissues with oxygenated
blood. Mr. Klosterman had a myocardial infarction, also known as a heart attack. In his case,
oxygenated blood could no longer circulate like it normally would be able to because of
prolonged ischemia. Due to the buildup of atherosclerotic plaque in his vascular wall, there was a
restriction of blood flow and, therefore, oxygen to part of his heart. At first the plaque was fatty
and fibrous but it hardened and thickened the walls of the vessels in his heart forming a blood
clot. This hardening is what restricted the blood flow severely and cut off the blood supply to
part of his heart. The progression started with monocytes, or phagocytic white blood cells,
circulating and responding to injury in the artery wall. They engulf LDL cholesterol and become
foam cells. A layer of these foam cells is called a fatty streak. The fatty streak is what thickens
and hardens and becomes the plaque that blocks the artery and ultimately, the blood flow
(Nelms, Sucher, Lacey & Roth, p. 284, 298-299). The myocardial infarction occurred when the
myocardial cells, or cells of the heart muscle, in this area died as an outcome of an infarct, or
death of cells (necrosis) from oxygen deprivation. The cell death was not instantaneous but
rather took around twenty minutes. Complete necrosis, or cell death, could take between two and
four hours.
Heart attack: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved September 1, 2014, from
http://www.nlm.nih.gov/medlineplus/ency/article/000195.htm.
Thygesen, K., Alpert, J., & White, H. (2007, January 1). Universal definition of myocardial
infarction. Retrieved September 2, 2014, from
http://eurheartj.oxfordjournals.org/content/28/20/2525.full
2. Mr. Klostermans’ chest pain resolved after two sublingual NTG at 3-minute intervals
and 2 mgm of IV morphine. In the cath lab he was found to have a totally occluded distal
right coronary artery and a 70% occlusion in the left circumflex coronary artery. The left
anterior descending was patent. Angioplasty of the distal right coronary artery resulted in
a patent infarct-related artery with near-normal flow. A stent was left in place to stabilize
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the patient and limit infarct size. Left ventricular ejection fraction was normal at 42%, and
a posterobasilar scar was present with hypokinesis. Explain angioplasty and stent
placement. What is the purpose of this medical procedure?
Angioplasty is a treatment procedure for individuals who have undergone a myocardial
infarction or have narrowed or blocked arteries in the heart because of a plaque build up. The
procedure is done to restore the blood flow in the artery that was narrowed or blocked. During
this procedure, thin tube, or catheter, is put into a blood vessel in the arm or groin through a
minimally invasive, small incision, which is connected to the affected artery. A sheath is first
placed into the artery and then the thin tube is guided by x-rays and maneuvered within the
artery. When the tube reaches the site of the blockage, an angiogram is taken before a tiny
balloon on the tip of the catheter is inflated to help push the plaque. After the artery is widened
and the plaque moved, the balloon is deflated and the thin tube is removed. X-rays also
determine if the blood flow has improved during the procedure before removal. This widening of
the artery helps to restore blood flow and minimize the damage from the heart attack. During
stent placement in an angioplasty, before the catheter is removed, a tube made of wire mesh or
plastic is placed in the recently opened artery to keep it open and maintain blood flow. Machines
that monitor heart rate and blood pressure are important during the procedure as well. In Mr.
Klosterman’s case, his distal right coronary artery was given a stent to keep blood flow going
and limit infarct size.
Angioplasty: MedlinePlus. (n.d.). Retrieved September 2, 2014, from
http://www.nlm.nih.gov/medlineplus/angioplasty.html
Angioplasty and Vascular Stenting. (n.d.). Retrieved September 3, 2014, from
http://www.radiologyinfo.org/en/info.cfm?pg=angioplasty
3. Mr. Klosterman and his wife are concerned about the future of his heart health. What
role does cardiac rehabilitation play in his return to normal activities and in determining
his future heart health?
Cardiac rehabilitation will help Mr. Klosterman recover after his myocardial infarction. It is a
medically controlled program that will aim at strengthening his heart and getting him back to
living a normal life as soon as possible. It will also help prevent him from experiencing further
complications. Rehabilitation is a long-term commitment between the patient, Mr. Klosterman,
and his team of doctors, exercise specialists, nurses, therapists, dieticians, and mental health
specialists that have the goal of getting him back on his feet to recovery from many different
angles. Rehabilitation will start out slowly and gradually increase activity over time. In the first
couple months, a reasonable exercise plan will be started as well as education about reducing risk
factors. Some benefits of the program include safely increasing physical activity, learning to
follow a heart healthy diet, learning how to reduce risks for future complications, and enhancing
mental and emotional health as well. An exercise plan may include a warm up, stretching and
flexibility exercises, and a warm down with aerobic activity 3-5 days a week and strength
activity 2-3 days a week. The plan will be specific to the patient in order to obtain the goals set
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out for them. The patient will also learn how to meet their calorie needs with foods that will
improve their health while avoiding foods that will cause future risks. Other goals include blood
pressure, cholesterol, weight, blood sugar levels, lifestyle habits such as smoking, and other
concerns that could get in the way of a healthy life. Mr. Klosterman will have many benefits
from cardiac rehabilitation including, but not limited to, reducing stress, lessening pain,
improving quality of life and staying independent.
What Is Cardiac Rehabilitation? (n.d.). Retrieved September 4, 2014, from
http://www.nhlbi.nih.gov/health/health-topics/topics/rehab/printall-index.html
II. Understanding the Nutrition Therapy
4. What risk factors indicated in his medical record can be addressed through nutrition
therapy?
Mr. Klosterman has many of the risk factors for heart problems such as a myocardial infarction,
which include things he cannot change and things he can change in his lifestyle. The
uncontrollable risk factors include his increasing age, his gender, and his heredity with his father
having had CAD at a similar age. His risk factors that are controllable include smoking, high
cholesterol, physical inactivity, and being mildly overweight. Other factors could include stress
level and diet and nutrition.
Among these risk factors, several are controllable and can be addressed through nutrition
therapy. His abnormal lab values including high cholesterol, high LDL, high LDL/HDL ratio,
low Apo A, and low HDL can be addressed. His mildly overweight status and BMI can be
addressed through diet and nutrition as well. A dietitian can teach Mr. Klosterman and his wife
about eating healthy, balanced meals and paying more attention to the amount of sodium,
cholesterol, sugar, and saturated fat in his foods. The dietitian can also address appropriate
portion sizes at meals.
Understand Your Risk of Heart Attack. (2014, July 16). Retrieved September 4, 2014, from
http://www.heart.org/HEARTORG/Conditions/HeartAttack/UnderstandYourRiskofHeart
Attack/Understand-Your-Risk-of-Heart-Attack_UCM_002040_Article.jsp
5. What are the current recommendations for nutritional intake during a hospitalization
following myocardial infarction?
The current recommendations for nutritional intake during hospitalization following myocardial
infarction are first decreasing the oral intake and limiting it to just clear liquids. This will help
alleviate pain, fatigue, and anxiety before a more gradual increase in oral intake is made.
Caffeine will be avoided to prevent arrhythmias, vomiting, and aspiration. The diet should
gradually progress from liquid foods to soft foods that are easy to chew. The frequency of meals
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should also increase gradually. Mr. Klosterman will then be assessed on an individual basis for
his specific nutrition therapy goals and what his diet should include once he stabilizes.
(Nelms, Sucher, Lacey & Roth, 2011, p. 319)
III. Nutrition Assessment
6. What is the healthy weight range for an individual of Mr. Klosterman’s height?
A healthy BMI range for Mr. Klosterman, according to the values provided by the CDC, would
be between 18.5 and 24.9. Mr. Klosterman is currently at a BMI of 26.6 and weighs 185 lbs.
Using these BMIs in the normal range, a healthy weight range would be between 129 lbs and 174
lbs (see work below).
BMI= kg/m2
Current weight:185 lbs/2.2= 84.1 kg
Height: 70 in x 2.54 = 177.8 cm=1.78 m= 3.17 m2
Healthy BMIs used to find healthy weight range:
18.5=kg/3.17m2= 58.6 kg x 2.2= 129 lbs
24.9=kg/3.17m2=78.9 kg x 2.2= 173.7 lbs
About BMI for Adults. (2014, July 11). Retrieved September 4, 2014, from
http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html?s_cid=tw_ob064
7. This patient is a Lutheran minister. He does get some exercise daily. He walks his dog
outside for about 15 minutes at a leisurely pace. Calculate his energy and protein
requirements.
Mr. Klosterman’s energy needs are about 2500-2600 kcal a day to maintain his weight. This was
obtained using the Hamwi method to get the ideal body weight and then the Mifflin-St.Jeor
equation and activity factor for his actual energy needs. The activity factor of 1.6 was used
because he has some movement walking his dog for 15 minutes a day and occasional standing
during his Lutheran gatherings. The RDA for protein for men is 0.8 g per kg per day so he
should be getting around 67 grams of protein a day based on his current weight.
Hamwi Method to obtain Ideal Body Weight:
106 lbs + 6(10)= 172 lbs
172 lbs/2.2= 78.2 kg
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IBW + 0.25 (usual- IBW)= 172 + 0.25 (185-172)= 175.25 lbs
175.25 lbs/2.2= 79.7kg
Mifflin-St.Jeor:
REE= 10 x wt(kg) + 6.25 x ht(cm) – 5 x age (yrs) + 5
= 10 x 79.7 kg + 6.25 x 177.8 cm – 5 x 61 + 5
= 797 + 1111.25 – 305 + 5
= 1608.25 kcal
Actual energy needs using the activity factor of 1.6:
TEE= REE x activity factor
1608.25 x 1.6=2573.2 kcal
~2500-2600 kcal needed to maintain weight
Protein requirements:
RDA: 0.8 g/kg/day
0.8 g x 84.1 kg= 67.3 g protein/day
(Baur, Liou & Sokolik, 2012, pg.118)
(Mitchell, 2003, p. 398)
8. Using Mr. Klosterman’s 24-hour recall, calculate the total number of calories he
consumed as well as the energy distribution of calories for protein, carbohydrate, and fat
using the exchange system.
From logging Mr. Klosterman’s 24-hour recall into Fitday, it was calculated that he consumed
approximately 2834 calories. The energy distribution was broken down into about 48%
carbohydrates, 22% protein, and 29% fat (see calculations below).
Carbohydrates:
345.6 g x 4 kcal/g= 1382.4 kcal
1382.4 kcal/2834= 48 %
Protein:
156.8 g x 4 kcal/g= 627.2 kcal
627.2 kcal/2834= 22%
Fat:
92.6 g x 9 kcal/g= 833.4 kcal
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833.4 kcal/2834= 29%
Mr. Klosterman’s 24-hr recall:
Breakfast
Midmorning snack
Lunch
Dinner
Snack
none
1 large cinnamon raisin bagel with 1 tbsp fat-free cream cheese, 8 oz
orange juice, coffee
1 c canned vegetable beef soup, sandwich with 4 oz roast beef, lettuce,
tomato, dill pickles, 2 tsp mayonnaise, 1 small apple, 8 oz 2% milk
2 lean pork chops (3 oz each), 1 large baked potato, 2 tsp margarine,
½ c green beans, ½ c coleslaw (cabbage with 1 tbsp salad dressing), 1
slice apple pie
8 oz 2% milk, 1 oz pretzels
Food log from Fitday based on Mr. Klosterman’s 24-hr recall:
Food
Amount
Calories
Fat (g)
Cinnamon
raisin bagel
Fat-free
cream cheese
Orange juice
Coffee
Canned
vegetable
beef soup
Sandwich
with Roast
Beef
Lettuce
Tomato
Dill pickles
Mayonnaise
Apple
2% milk
Lean pork
chops
Baked potato
Margarine
Green beans
Coleslaw
1 large
359
2.2
Carbohydrates Protein (g)
(g)
72.3
12.8
1 tbsp
30
2.3
1.2
1.2
8 oz
1 cup
1 cup
110
5
94
0.3
0.1
0.9
26.0
0.3
19.0
1.5
0.5
2.7
4 oz of roast
beef
441
26.1
26.4
23.4
1 large leaf
3 slices
3 slices
2 tsp
1 small
8 oz
2 x 3 oz
chops
1 large
2 tsp
½ cup
1.2 cup
(cabbage with
1 tbsp salad
dressing)
1 slice
2
3
3
31
77
113
470
0
0
0
3.4
0.3
4.5
12.7
0.4
0.6
0.5
0
20.6
10.9
0
0.1
0.1
0.1
0
0.4
7.5
82.9
324
50
43
47
6.1
5.6
1.8
1.6
62.3
0
6.5
7.4
7.4
0
1.2
0.8
411
19.4
57.5
3.7
Apple pie
Click 7
2% Milk
Pretzels
8 oz
1 oz
Totals:
113
109
2834
4.5
1.0
92.6
10.9
22.7
345.6
7.5
7.5
156.8
Exchange System Breakdown:
Food
Group
Choices
Starches
Fruit
Milk
Vegetables
Meat &
Meat
Substitutes
Fats
Breakfast
Midmorning Lunch
Snack
4
2
Dinner
3
2
1
1
4
3
2
2
Snack
Total
2
12
4
2
3
10
1
2
6
4
35
Food Log. (n.d.). Retrieved September 4, 2014, from
http://www.fitday.com/app/journal/foods#04SEP2014
Food Exchange Lists. (n.d.). Retrieved September 4, 2014, from
http://dtc.ucsf.edu/pdfs/FoodLists.pdf
9.Examine the chemistry results for Mr. Klosterman. Which labs are consistent with the
MI diagnosis? Explain. Why were the levels higher on day 2?
The labs that are consistent with the MI diagnosis include ALT, AST, CPK, CPK-MB, Troponin
I, and Troponin T (listed below in the table). The values that are red indicate when they are
outside of the reference range. When his MI occurred, there was necrosis (death) of the
myocardial cells from the oxygen deprivation. Creatine kinase and cardiac troponin T was
biological markers that indicate that the ischemia was severe and that an MI occurred. The cells
that died do not regenerate and instead form scar tissue. The elevated CPK and Troponin levels
indicate the MI occurred. The AST and ALT, found in high amounts in the liver, are elevated
because of the MI as well. The levels were higher on day 2 for these labs because they have peak
elevation times. For example, the CPK has a peak elevation time of 12-24 hours; therefore, it did
not show up until a day after the initial heart attack (Nelms, Sucher, Lacey & Roth, p. 318).
ALT (U/L)
AST (U/L)
Reference Range
4-36
0-35
12/1
30
25
12/2
215
245
12/3
185
175
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CPK (U/L)
CPK-MB (U/L)
Troponin I
(ng/dL)
Troponin T
(ng/dL)
30-135 F
55-170 M
0
<0.2
75
500
335
0
2.4
75
2.8
55
<0.03
2.1
2.7
(Nelms & Roth, p. 51)
AST: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved September 4, 2014, from
http://www.nlm.nih.gov/medlineplus/ency/article/003472.htm
10. What is abnormal about his lipid profile? Indicate the abnormal values.
The chart below shows Mr. Klosterman’s lipid profile. The numbers in red indicate which are
abnormal. His cholesterol, LDL, and LDL/HDL ratio are much higher than the reference range,
while his HDL-C and Apo A levels on day 1 and 2 are much lower than the reference range. His
Apo B and triglyceride values are in the normal reference range.
Cholesterol
(mg/dL)
HDL-C (mg/dL)
LDL (mg/dL)
LDL/HDL ratio
Reference Range
120-199
>55 F, >45 M
<130
<3.22 F
<3.55 M
Apo A (mg/dL)
101-199 F
94-178 M
Apo B (mg/dL)
60-126 F
63-178 M
Triglycerides
35-135 F
(mg/dL)
40-160 M
(Nelms & Roth, p. 51-52)
12/1
235
12/2
226
12/3
214
30
160
5.3
32
150
4.7
33
141
4.3
72
80
98
115
110
105
150
140
130
11. Mr. Klosterman was prescribed the following medications on discharge. What are the
food-medication interactions for this list of medications?
Medication
Lopressor 50 mg daily
Possible Food-Medication Interactions
Lopressor is a brand name beta-1-blocker that
decreases heart rate and cardiac output. It can
cause nausea, diarrhea, upset stomach, dry
mouth, gas or bloating, and heartburn. A
possible interaction is calcium, which could
decrease absorption and should be avoided.
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Lisinopril 10 mg daily
Nitro-Bid 9.0 mg twice daily
NTG 0.4 mg sl prn chest pain
ASA 81 mg daily
(Nelms, Sucher, Lacey & Roth, p. 291)
Lisinopril is a generic ACE inhibitor that
reduce blood pressure. Possible foodmedication interactions are natural licorice and
salt substitutes which should be avoided.
(Nelms, Sucher, Lacey & Roth, p. 291)
Nitro-Bid is a brand name nitrate that could
cause nausa, vomiting, abdominal pain, and
dryness of mouth. It works by relaxing blood
vessels for better blood and oxygen flow and
delivery. Therefore, alcohol, which could add
to this effect, should be avoided to prevent a
dangerously low blood pressure.
(Nelms, Sucher, Lacey & Roth, p. 291)
NTG (Nitroglycerin) is a generic nitrate that
could cause nausea, vomiting, abdominal pain,
and dryness of mouth. It works by relaxing
blood vessels for better blood and oxygen flow
and delivery. Therefore, alcohol, which could
add to this effect, should be avoided to prevent
a dangerously low blood pressure.
(Nelms, Sucher, Lacey & Roth, p. 291)
ASA, or aspirin, is a NSAID (Non-steroidal
anti-inflammatory drug) that should be taken
with food or milk to prevent upset stomach.
Alcohol should be avoided to prevent stomach
bleeding.
(Nelms, Sucher, Lacey & Roth, p.291)
Avoid Food-Drug Interactions. (n.d.). Retrieved September 4, 2014, from
http://www.fda.gov/downloads/drugs/resourcesforyou/consumers/buyingusingmedicinesa
fely/ensuringsafeuseofmedicine/generaluseofmedicine/ucm229033.pdf
12. You talk with Mr. Klosterman and his wife, a math teacher at the local high school.
They are friendly and seem cooperative. They are both anxious to learn what they can do
to prevent another heart attack. What questions will you ask them to assess how to best
help them?
It will be very important to make Mr. Klosterman and his wife feel comfortable and confident in
your abilities to guide them and help them learn new ways to prevent another heart attack. You
will want to take into consideration many factors in his life and work around them so that he is
more likely to follow through with lifestyle changes. Some questions that should be addressed
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should be regarding his diet, his activity level, his lifestyle habits, and his goals. Some examples
of these questions are:
 What are your favorite foods?
 What are your least favorite foods?
 Do you like fruits and vegetables?
 Who goes grocery shopping?
 What kind of environment do you eat in? With or without other people?
 Who does the cooking in the house?
 How is the food prepared?
 How long does it take?
 What is a normal portion size at each meal?
 Do you eat at restaurants often?
 What activities are enjoyable for you?
 Do you feel satisfied after breakfast? Lunch? Dinner?
 Do you snack during the day? What times?
 What is your normal stress level?
 What causes your stress?
 Is there a local gym by you?
 What are your goals?
 How do you think you can obtain your goals?
 What does a typical day look like for you?
 Do you abstain from any type of food?
 What is your energy level and mood on a normal day?
 Do you purchase food on a particular budget?
13. What other issues might you consider to support successful lifestyle changes for Mr.
Klosterman?
Some other issues that I would consider to support successful lifestyle changes for Mr.
Klosterman would be his weight, his inactivity, and his smoking habit. Some ways to address
these issues include modifying his diet, gradually increasing his physical activity, and potentially
taking baby steps to decrease his smoking habit. For the diet modification, once he is stable and
back to everyday life, I would educate him about either the TLC or DASH diet. These eating
plans will help with heart health by increasing his fruit and vegetable consumption and
decreasing his saturated fat and high sodium foods.
14. From the information gathered within the assessment, list possible nutrition problems
using the correct diagnostic terms.
NC-3.3: Overweight/obesity
NI-1.3: Excessive energy intake
NI-2.2: Excessive oral intake
NB-2.1: Physical inactivity
NC-2.4: Predicted food-medication interaction
NB-1.7: Undesirable food choices
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(Academy, 2014)
IV. Nutrition Diagnosis
15. Select two of the identified nutrition problems and complete the PES statement for
each.
1. Excessive caloric intake related to being mildly overweight as evidenced by BMI of 26.6,
weight of 185 pounds, and patient’s 24-hour recall.
2. Physical inactivity related to sedentary lifestyle as evidenced by self-report of lack of
activity during the day.
V. Nutrition Intervention
16. For each of the PES statements you have written, establish an ideal goal (based on the
signs and symptoms) and an appropriate intervention (based on the etiology).
1. Since Mr. Klosterman is consuming an excess amount of calories in his diet (as seen from
his 24 hour recall), the first goal for him will be to slowly decrease this amount. Instead
of consuming 2800 kcal a day, he should decrease that amount to 2600 for two weeks
while focusing on choosing nutrient dense foods with less sodium and saturated fat. After
two weeks, he should set a goal to consume 2400 calories and so forth. By gradually
decreasing the amount of calories he consumes and choosing healthier options, he will be
more likely to stick with these habits. Before he does this, however, he will be educated
on appropriate portions and food choices/alternatives to common favorites that he already
consumes. For example, instead of apple pie for dessert, he can make an easy homemade
banana frozen yogurt recipe with his wife. He will also be educated on the importance of
breakfast, which he is currently skipping. In addition, it will be his goal to keep a food
log with specific amounts and times that he eats. I will have him email these regularly
and then set up frequent meetings to make sure he stays on track.
2. To address Mr. Klosterman’s physical inactivity, it will be his goal to be active for 20-45
minutes a day, 3-5 times a week. He can walk his dog like he already does during this
time or do other enjoyable activities such as gardening, going to a local gym, or light
biking or swimming. He will also become involved in light muscle-strength activities
such as lifting small weights for 2-3 days a week. This amount of activity is also
important for his cardiac rehabilitation program that he will be involved in. Similar to his
food log, he will keep an activity journal, which will be regularly monitored as well to
hold him accountable to his health and well being.
What Is Cardiac Rehabilitation? (n.d.). Retrieved September 4, 2014, from
http://www.nhlbi.nih.gov/health/health-topics/topics/rehab/printall-index.html
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17. Mr. Klosterman and his wife ask about supplements. “My roommate here in the
hospital told me I should be taking fish oil pills.” What does the research say about omega3-fatty acid supplementation for this patient?
Fish is an excellent source of protein without the extra saturated fat that is normally in meat
products. For healthy individuals, fish is usually adequate enough for getting omega-3 fatty acids
in order to gain the many benefits such as heart health. However, for patients such as Mr.
Klosterman, omega-3 supplementation should be considered in order to reap the benefits.
Omega-3 fatty acids have been known to decrease triglyceride levels, slow the rate of plaque
formation, and decrease BP. If a patient is taking more than 3 grams of supplementation a
professional should monitor it. There is some risk of bleeding as well as high levels of mercury
or environmental toxins; however, the benefits seen for patients such as Mr. Klosterman
outweigh the risks. If he does take supplementation, it would be recommended that he be closely
monitored to prevent any risks.
Fish and Omega-3 Fatty Acids. (2014, May 14). Retrieved September 4, 2014, from
http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyDietGoals/Fi
sh-and-Omega-3-Fatty-Acids_UCM_303248_Article.jsp
VI. Nutrition Monitoring and Evaluation
18. What would you want to assess in three to four weeks when he and his wife return for
additional counseling?
In three to four weeks when Mr. Klosterman and his wife return for additional counseling, I will
want to assess his progress with the goals that we set out for him. Before doing so, I would have
his lipid profile checked again so see if any values that were abnormal before have leveled out
into the reference range. Then, I would talk with the couple about the changes they have started
to make in their life such as diet and physical activity. We would go over his food and activity
logs and talk about what he is doing that is helpful and what still needs to be addressed or
improved upon, specifically with the amount of saturated fat, sodium, and lack of nutrient dense
foods. We will go over another 24-hour recall and compare it with the last one to see if changes
are being made for the better. Also, I will inquire if he has made any baby steps to limit or
eliminate smoking. We will also address his stress level and the connection it plays in his daily
routine.
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References
About BMI for Adults. (2014, July 11). Retrieved September 4, 2014, from
http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html?s_cid=tw_ob064
Academy of Nutrition and Dietetics (2014). Pocket guide for international dietetics & nutrition
terminology (IDNT) reference manual: Standardized language for the nutrition care
process. Chicago, Ill: Academy of Nutrition and Dietetics.
Angioplasty: MedlinePlus. (n.d.). Retrieved September 2, 2014, from
http://www.nlm.nih.gov/medlineplus/angioplasty.html
Angioplasty and Vascular Stenting. (n.d.). Retrieved September 3, 2014, from
http://www.radiologyinfo.org/en/info.cfm?pg=angioplasty
AST: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved September 4, 2014, from
http://www.nlm.nih.gov/medlineplus/ency/article/003472.htm
Avoid Food-Drug Interactions. (n.d.). Retrieved September 4, 2014, from
http://www.fda.gov/downloads/drugs/resourcesforyou/consumers/buyingusingmedicinesa
fely/ensuringsafeuseofmedicine/generaluseofmedicine/ucm229033.pdf
Bauer, K. D., Liou, D., & Sokolik, C. A. (2012). Nutrition counseling and education skill
development (2nd ed.). Belmont, CA: Wadsworth, Cengage Learning.
Fish and Omega-3 Fatty Acids. (2014, May 14). Retrieved September 4, 2014, from
http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyDietGoals/Fi
sh-and-Omega-3-Fatty-Acids_UCM_303248_Article.jsp
Food Exchange Lists. (n.d.). Retrieved September 4, 2014, from
http://dtc.ucsf.edu/pdfs/FoodLists.pdf
Click 14
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