Download Case Study Presentation - Emily Phillips

Aortic Valve Stenosis, Congestive
Heart Failure, and Chronic
Obstructive Pulmonary Disease
Exacerbation with Development
of an Ileus
By Emily Phillips
St. Helena Hospital, Napa Valley
3/11/2015
Introduction to Mr. H
• Personal data: 61 year old male
• Social History: 40 – pack per year smoker, Retired
• Reason for admission: Non-ST Segment Elevation Myocardial Infarction
(NSTEMI) and Congestive Heart Failure (CHF)
• Chief complaint: increasing shortness of breath for 3 days and “flu-like”
symptoms resolved 1 month ago, which have now returned.
Symptoms included: fever, chills, cough, and productive sputum
Admitting Diagnoses
• NSTEMI – Non-ST Segment Elevation Myocardial Infarction. The
complete occlusion of a minor coronary artery resulting in myocardial
infarction, better known as a heart attack.
• CHF – Congestive Heart Failure. Impairment of the ventricles’ capacity
to eject blood from the heart or to fill with blood.
• COPD exacerbation – Chronic Obstructive Pulmonary Disease
Exacerbation. Persistent progressive airflow obstruction and dyspnea
(shortness of breath). This includes chronic bronchitis, emphysema,
and asthmatic bronchitis.
Admitting Diagnoses
• Right Lower Lobe Pneumonia – Inflammation of the alveoli often
caused by foreign material. These air sacs become filled with fluid or
pus, causing cough (with phlegm), fever, chills, and labored
breathing.
• Hyponatremia – Low sodium concentration in the blood. Serum
sodium below 135 mEq/L.
Medical/Surgical Data
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Past Medical History:
Smoker (½ pack per day) for 40 years, currently 5 cigarettes per day
COPD (not on breathing treatment)
Hypertension
Hyperlipidemia
Obesity
Anxiety disorder
Has not seen a primary care physician for 20 years
No previous pneumonia or sick contact
Alcohol use
Medical/Surgical data
• Surgical History: None
• Family Medical History: Father had a heart attack at age 60, died at
82
• Medications Prior To Admission:
Medication
Purpose
Nutrition implications
Tylenol
Pain medication, analgesic
Avoid alcohol, caffeine
increase s rate of absorption
and effect of drug
Multivitamin
Provide additional vitamins
and minerals
Excess may cause vitamin
toxicity
Aleve
NSAID, antiarthritic,
analgesic
GI pain, constipation,
nausea/vomiting, dyspepsia
Admission Physical Data
• General: Not lethargic, not dehydrated, looks septic, lying in bed with
mild paroxysmal nocturnal dyspnea (PND/postnasal drip) and mild
orthopnea (breathing discomfort aggravated by lying flat). Not in
acute pain. Answers questions appropriately
• Heart: Sinus rate and sinus rhythm. Normal S1, S2, no S3. No gallop
• Abdomen: Benign. Bowel sounds present in all 4 quadrants, soft, nontender. No guarding, no rigidity, no hepatosplenomegaly, no midline,
pulsatile mass, or abnormal mass palpable
• Extremities: No pedal edema, peripheral pulses palpable
Overview of Disease States:
NSTEMI vs. Aortic Valve Stenosis
• Normal function of the heart
Overview of Disease States: Aortic
Valve Stenosis vs. NSTEMI: Etiologies
• Aortic Valve Stenosis
- Obstruction at the valvular level
- Degenerative calcification
(long standing hemodynamic
stress on the valve)
- Rheumatic heart disease
- Deformed aortic valve
- Increasing age
- Chronic Kidney disease
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NSTEMI
Diabetes Mellitus
Physical Inactivity
Lifestyle
Diets deficient in fresh fruits/vegetables
and polyunsaturated fat
Hypertension
Dyslipidemia
Cigarette smoking
Increasing age
Male
Family History
Overweight/Obese
Excess alcohol and carbohydrate
consumption
Symptoms and Clinical
Manifestations
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Aortic Valve Stenosis:
Chest pain/tightness
Heart failure
Syncope
Systolic Hypertension
Shortness of breath
Fatigue
Heart palpitations
Elevated Troponins
Lower perfusion pressure
Altered heart sounds
• NSTEMI:
• Difficulty breathing/Shortness of
breath
• Cardiogenic Shock
• Elevated Troponins
• Pain in the sub-sternal area radiating
to the arm and neck
• Indigestion
• Nausea/vomiting
• Sweating
• Weakness/fatigue
• Rhythmic abnormalities palpitations
• Syncope
• Dizziness
Pathophysiology: NSTEMI vs.
Aortic Valve Stenosis
• NSTEMI:
• Atherosclerotic plaque build up
compromises oxygen flow to heart
• Plaque ruptures and develops a
thrombus or a blood clot causing a
blockage of blood flow
• Lack of blood flow causes
cardiomyocytes to become
oxygen starved
• Cardiomyocytes slow contraction,
rupture and die, releasing troponins
into the artery
• Adrenaline is released, the rest of
the heart compensates by beating
faster
Aortic Stenosis
• When the heart contracts the aortic
valve opens and blood is pumped into
the aorta
• When the heart relaxes, the aortic
valve closes
• A narrowed aortic valve limits the
amount of blood ejected from the
ventricle into the aorta
• Increases afterload by increasing
pressure
• Increases contractility to overcome the
outflow resistance
• This results in ventricular hypertrophy
and followed by degeneration and
death of the cardiac myocytes
NSTEMI and CHF
• After myocardial infarction
Loss of heart muscle cells
Ventricular Hypertrophy
Dilated Cardiomyopathy
Aortic Stenosis and CHF
Aortic Stenosis
Chronic Pressure
Increase in
afteroad/contractility
Ventricular Hypertrophy
Dilated Cardiomyopathy
Nutrition Interventions: Aortic
Valve Stenosis vs. NSTEMI
• Aortic Valve Stenosis
- Main therapy is surgical
replacement
- Before surgery NPO (nothing by
mouth)
- Fluid may be restricted
- Diuretics may be used to
remove fluid around heart and
lungs
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NSTEMI
Low fat
Low cholesterol
Low sodium
High fiber
Manage weight
Omega-3 fatty acids
Emphasis on fruits, vegetables,
and whole grains
Overview of Disease States:
Congestive Heart Failure (CHF)
Pathophysiology: CHF
• Chronic inflammation causing
the heart to beat inefficiently
• Impairing these functions:
1. Afterload – the pressure the
ventricle opposes against the
aorta
2. Contractility – the force the
ventricle contracts with
3. Preload – how much blood fills
the ventricle before it is ejected
Etiology: CHF
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Myocardial Infarction
Aortic Stenosis
Heart valve disorders
Chronic Hypertension
Coronary Artery Disease/Chronic Ischemia
Constrictive Pericarditis
Restrictive cardiomyopathy
Dilated cardiomyopathy
Clinical Manifestations: CHF
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Decreased blood flow leads to:
Dyspnea
Fatigue
Weakness
Exercise intolerance
Poor adaptation to cold temperatures
Hyponatremia
Ascites
Edema
Cough with productive sputum
Orthopnea
PND
Nutrition Therapy: CHF
• Fluid modified diet: Less than 2 L fluid per day (for sodium levels below 130
mEq/L)
• Sodium restriction: less than 2 gm of sodium per day
• Thiamine and Potassium supplementation to compensate for losses in
patients on diuretics
• Limit or discontinue alcohol use
• Small frequent meals for patients experiencing early satiety
• Educating patient on how to season food without the use of salt
• Nutrition support:
• Low volume feedings for enteral feedings
• TPN only indicated for patients with limited gut function and may be
maximally concentrated
Overview of Disease States: COPD
exacerbation
• Normal Pulmonary Function:
- Supply the body with oxygen while
removing carbon dioxide
- Air enters the lungs through the
trachea, which divides into the right
and left bronchi supplying the lungs
- The bronchi divide again into smaller
bronchioles
- The bronchioles end in small air sacs
(alveoli), which are responsible for the
exchange of oxygen and carbon
dioxide
Pathophysiology: COPD
exacerbation
• Progressive obstruction and inflammation of the airways
• Irritants cause neutrophils, T-lymphocytes, and other inflammatory cells
to accumulate in the airways
• Inflammatory mediators attempt to destroy and remove inhaled
foreign debris
• In chronic scenarios, the response is ongoing, which inevitably causes
structural and physiological lung changes
• The airways become narrowed and swollen
• Excess mucus production and poorly functioning cilia makes airway
clearance especially difficult
• Build up of mucus creates an environment where bacteria can thrive
Etiology: COPD
• Chronic bronchitis
• Productive cough and shortness of breath that lasts 3+ months for at
least 2+ years in a row
• Cigarette smoking
• Repeated exposure to secondhand smoke, air pollution, and
occupational exposure
• Inflammation of the airways and lung tissue
• Deficiency of the protein alpha 1-antitrypsin (ATT)
Signs and Symptoms: COPD
Dyspnea with possible wheezing
Persistent cough with sputum production
Increased breathing rate
Lung hyperinflation
Diminished breath sounds (crackles and wheezes)
Cyanosis in hypoxemic patients – this could lead to heart failure due to
the heart’s increased work to pump blood through the lungs
• Digital clubbing
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COPD exacerbation
• Defined as “worsening of COPD symptoms, or a change in the
patient’s baseline dyspnea, cough, and/or sputum beyond day-today variations
• Causes: bacteria/viral lung infections and air pollution
• Additional causes include: smoking, lack of pulmonary rehabilitation,
poor adherence to drug therapy
Nutrition Interventions: COPD
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Goals: Prevent weight loss, maintain and restore lean body mass
Small, frequent meals to accommodate shortness of breath
Food choices easy to chew, swallow, and digest
Nutrient-dense nourishment and/or supplements
Vitamin/mineral supplement
Avoid overfeeding and excessive carbohydrate intake
Chronology of Medical and Nutritional
Interventions: Newly Developed Conditions
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Newly developed conditions:
Cardiogenic shock following aortic valve replacement (2/6/15)
Patent Ductus Arteriosus (2/8/15)
Fluid overload (2/9/15)
Alcohol withdrawal (2/10/15)
Respiratory Failure (2/12/15)
Leukocytosis and Ileus (2/14/15)
Intra-abdominal free air of unknown origin (2/15/15)
Perforated cecum and septic shock – (2/16/15)
Heparin-Induced Thrombocytopenia – (2/20 – 2/26)
Vancomycin-Resistant Enterococci (VRE) (3/9)
Definitions of Newly Developed
Conditions:
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Cardiogenic Shock: inadequate circulation of blood due to primary failure of the ventricles of the
heart to function effectively. There is insufficient perfusion to the tissues
Patent Ductus Arteriosus (PDA): a congenital disorder in the heart wherein a neonate’s ductus
arteriosus fails to close, with age PDA may lead to congestive heart failure
Fluid overload: too much fluid in the blood. Can be caused by excess sodium content in the body
and subsequently increase in extracellular volume
Alcohol withdrawal: cessation of alcohol use after prolonged usage. The response is a hyperexcitable response of the central nervous system to lack of alcohol.
Leukocytosis: elevated white blood cell count
Septic shock: A systemic inflammatory response and immunosuppressive process that prevents an
adequate response to infection or trauma. This may result in organ dysfunction or hypoperfusion
abnormalities. It can cause multiple organ dysfunction and death.
Respiratory Failure: occurs when the respiratory system is no longer able to perform its normal
functions. It can result from long standing chronic lung disease like COPD or cystic fibrosis, or as a
result of an acute insult to the lung as seen with acute lung injury or acute respiratory distress
syndrome
Heparin-Induced Thrombocytopenia: deficiency of platelets in the blood caused by the
anticoagulant Heparin
Vancomycin Resistant Enterococci: type of bacteria called enterococci that developed a
resistance to an antibiotic called vancomycin
Chronology of Medical and Nutrition Treatments
Date
Procedure
Nutrition Intervention
2/5/15
Aortic Valve Replacement and Ascending Aortic
Aneurism Graft
NPO
2/9/15
Thoracentesis
NPO
2/10/15
Cardioversion and Aortic Aneurism Replacement
NPO
2/15/15
Exploratory laparotomy with subtotal colectomy
and end-ileostomy
NPO
2/16/15
Patient on mechanical ventilation
NPO, TPN @ 63 mL/hr (1590 kcals, 100 gm
protein)
2/19/15
Thoracentesis
NPO, TPN @ 85 mL/hr (1790 kcals, 150 gm
protein)
2/22/15
Thoracentesis
NPO, TPN @ 44 (895 kcals, 75 gm protein)
2/26/15
Tracheostomy
NPO, PN @ 50 mL/hr (1195 kcals, 75 gm
protein). Tube feed stopped
3/4/15
PEG placed
Enteral feeding stopped from 3/3 at midnight,
restarted through PEG on 3/5
Normal Intestinal Function
• Small intestine:
- Primary site of digestion and
absorption
• Large intestine:
- Bacterial fermentation of
remaining carbohydrates and
amino acids
- Synthesis of small amounts of
vitamins, storage, and excretion
of fecal residues
- Absorb water
Ileus
• Definition: decreased or absent motility of the bowel and forward movement of
bowel contents
• Causes:
- Appendicitis
- Botulism
- Medications (opiates/sedatives)
- Diabetic ketoacidosis
- Electrolyte imbalance
- Gastroenteritis
- Obstruction of the mesenteric artery
- Pancreatitis
- Hypomotility
- Crohn’s disease
- Surgical complications
Pathophysiology: Ileus
• Exact pathogenesis remains unclear
• Surgical stress response leads to systemic generation of endocrine and
inflammatory responses
• Increased number of macrophages, monocytes, dendritic cells, T cells,
natural killer cells, and mast cells
Clinical Manifestations: Ileus
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Abdominal pain/cramping
Nausea
Vomiting
Diarrhea
Constipation
Abdominal distention
Hypoactive bowel sounds
Ileus Nutrition Therapy
• Delay oral feeding until ileus resolves clinically
• Parenteral/Enteral feedings indicated
• Having patients chew gum may simulate gastrointestinal feedings
Perforated Cecum and
Pneumoperitoneum
• Perforated Cecum – a hole or
piercing through the wall of the
cecum
• Pneumoperitoneum – presence
of air or gas in the peritoneal
cavity
Ileostomy and Subtotal Colectomy
• Opening of the ileum at the
abdominal wall
• Removal of part of the large
intestine
• Opening into the abdominal
wall
• The end of the ileum is brought
through the stoma, typically on
the lower right side of the of the
abdomen
Nutritional Management of
Ileostomies
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Begin with clear liquids
Small frequent meals, low fiber
Limiting fluids with meals
Encourage higher sodium intake (unless otherwise indicated)
Rehydration beverages if excessive fluid is lost
Admission Nutrition Assessment
• Diet history: “eating well prior to admission”. Mr. H. is unsure of exact
weight change before admit, but believes overall weight has
increased over the past few months.
• Allergies: no known food allergies
• Admitting nutrition order: Cardiac (2 gram sodium, low cholesterol, low
fat)
• Admitting intake: approximately 88% of meals, ~930 kcals averaged
over 3 days.
Admission Nutrition Assessment
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Anthropometrics:
Height: 180 cm
Weight: 90.9 Kg (standing scale)
Body Mass Index (BMI): 28
Ideal Body Weight (IBW): 78.1 Kg
Percent IBW: 116%
Estimation of macronutrient needs:
Carbohydrate: 176 – 276 gm/day (35-55% estimated calorie needs for COPD)
Fat: 67 – 100 gm/day (30-45% estimated calorie needs for COPD)
Protein: 109 – 136 gm/day (1.2 – 1.5 g/kg for pulmonary disease)
Calories: 2008 – 2454 kcals (Ireton Jones)
Evaluation of current intake: intake is low (~46% of estimated needs), however
patient appeared well nourished. No interventions were recommended upon initial
assessment.
Date
Chronology of weights
Weight in Kg
2/1/15
90.9
2/4/15
90.7
2/8/15
96.9
2/10/15
95.6
2/11/15
96
2/14/15
97.6
2/15/15
95.2
2/17/15
101.6
2/19/15
102.8
2/21/15
103.2
2/23/15
98.4
2/26/15
93.4
3/2 /15
91.8
3/4/15
88.5
3/9/15
87.4
3/9/2015
3/8/2015
3/7/2015
3/6/2015
3/5/2015
3/4/2015
3/3/2015
3/2/2015
3/1/2015
2/28/2015
2/27/2015
2/26/2015
2/25/2015
2/24/2015
2/23/2015
2/22/2015
2/21/2015
2/20/2015
2/19/2015
2/18/2015
2/17/2015
2/16/2015
2/15/2015
2/14/2015
2/13/2015
2/12/2015
2/11/2015
2/10/2015
2/9/2015
2/8/2015
2/7/2015
2/6/2015
2/5/2015
2/4/2015
2/3/2015
2/2/2015
2/1/2015
Chronology of Weights
Weight Trend
Nutrition related laboratory values
Date
2/2/ 2/4
15
2/8
2/10 2/11
2/14
WBC
23.
6
18.6 21.4
Hgb
8.8
8.5
126 122
124
K
2.8
2.8
Glucose
177
132
132
136
164
BUN
23
27
33
41
38
Mg
2.4
2.3
2.6
3.1
2.6
Na
Pre
albumin
Albumin
3.2
2/16
2/17
2/19
2/21
2/23
2/26
3/2
3/4
45.1
23.1
18.7
11.7
14.5
8.7
10.2
7.5
9.9
9.1
11.2
8.7
10.4
10.2
126
123
3.2
3.4
3.1
3.0
133
144
134
29
31
27
30
28
146
2.4
8.1
4.0
5.1
2.6
1.8
1.7
10.7
1.7
1.9
16.3
17
WBC
Albumin
Prealbumin
5-Mar
4-Mar
3-Mar
2-Mar
1-Mar
28-Feb
27-Feb
26-Feb
25-Feb
24-Feb
23-Feb
22-Feb
21-Feb
20-Feb
19-Feb
18-Feb
17-Feb
16-Feb
15-Feb
14-Feb
13-Feb
12-Feb
11-Feb
10-Feb
9-Feb
8-Feb
7-Feb
6-Feb
5-Feb
4-Feb
3-Feb
2-Feb
Chronology of Labs
Nutrition related medications
Vitamin/
Minerals
Antibiotics/
antifungals
Gastrointestinal Fluid
medications
medications
Sedatives
Other
Multivitamin
Vancomycin
Miralax
Potassium
Chloride
Propofol
Sliding Scale
Insulin
Thiamine
Levofloxacin
Colace
Sodium
Chloride @75
mL/hr
Ativan Drip
Methylprednisone
Folic acid
Caspofungin
Docusate Senna
Lasix
Lipitor
Zosyn
Protonix
Metolazone
Warfarin
Flagyl
Reglan
Vasopressin
Lactobacillus
Nutrition Diagnoses
• Inadequate oral food/beverage intake R/T decreased appetite, shortness of
breath, and status/post surgery AEB Estimated energy needs, consuming 2675% - 2/8
• Inadequate oral food/beverage intake R/T compromised function of the
Gastrointestinal (GI) tract AEB Need for NPO status – 2/17
• Inadequate intake from enteral/Parenteral nutrition (PN) R/T compromised
function of GI tract and high enteral nutrition residuals and fluid overload
requiring decreased PN rate AEB patient meeting 45% of estimated caloric
needs – 2/23
• Inadequate intake from enteral/parenteral nutrition R/T compromised
function of the GI tract and restricted fluids AEB tube feed/TPN less than
estimated needs and PN currently provides ~65% of estimated needs – 2/26
• Inadequate intake from enteral/parenteral nutrition R/T procedure schedules
AEB tube feeding stopped for over 24 hours
Date
Nutrition intervention
Purpose
2/1/15
Cardiac (2 gm sodium, low cholesterol, low fat)
Admitting diagnosis, NSTEMI and CHF
2/8/15
Regular
2/9/15
EnsurePlus BID (twice a day)
Poor oral intake
2/16/15
PN @ 63 mL/hr (1590 kcals, 100 gm protein)
Ileus, perforated cecum, unable to take
needs orally
2/19/15
PN @ 85 mL/hr (1790 kcals, 150 gm protein)
TPN running at goal, meeting estimated
needs
2/20/15
PN @ 85 (1790 kcals, 150 gm protein) + Jevity 1.2 @ 10 mL/hr
(288 kcals, 13 gm protein)
Enteral nutrition added to prevent gut
atrophy
2/22/15
PN @ 44 mL/hr (895 kcals, 75 gm protein) + Jevity 1.2 @ 10
mL/hr (288 kcals, 13 gm protein)
PN decreased due to patient volume
overloaded
2/24/15
Increase Jevity 1.2 by 10 mL/hr Q6 hours to goal rate of 55
mL/hr (2448 kcals, 113 gm protein)
Ileus appears resolved, enteral feedings
increased to replace parenteral nutrition
2/25/15
Pivot 1.5 @ 20 mL/hr, increase by 10 mL/hr every 6 hours to
goal rate of 55 mL/hr (1980 kcals, 124 gm protein) + PN @ 50
mL/hr (1195 kcals, 75 gm protein)
Formula changed to more concentrated
formula to minimize fluid and easier to
digest.
2/28/15
TPN stopped
Enteral feedings provided needs
3/5/15
NPO, Pivot 1.5 @ 10 mL/hr, goal rate 55 mL/hr via PEG
New PEG placement
Diet liberalized due to poor oral intake
Nutrition Interventions
Nutrition Monitoring and
Evaluation
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Monitor and Evaluate:
Tolerating parenteral nutrition
Fluids/Intake/Output
Bowel function
Weight
Enteral residual volume/tube feeding tolerance
Gut function
Lab values
Swallowing ability
Fat malabsorption
Lactose intolerance
Discharge Plan
• Issues with insurance
• Medical improvements
Summary
• Mr. H’s hospital course was complex and lengthy
• Medical nutrition therapy improved his overall outcome despite
challenges faced with surgeries, procedures, and new disease states
References:
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http://nstemi.org/
http://www.cvphysiology.com/Heart%20Disease/HD009b.htm
http://emedicine.medscape.com/article/163062-overview#aw2aab6b2b3
http://www.cardiothoracicsurgery.org/content/7/1/108
http://www.intechopen.com/books/principles-and-practice-of-cardiothoracicsurgery/gastrointestinal-complications-in-cardiothoracic-surgery-a-synopsis
http://emedicine.medscape.com/article/2242141-clinical#showall
http://ajpgi.physiology.org/content/287/3/G685
http://emedicine.medscape.com/article/150638-overview#aw2aab6b2b4aa
http://www.mayoclinic.org/diseases-conditions/aortic-stenosis/basics/riskfactors/con-20026329
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2913510/
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5803&lv2=
8585&ncm_toc_id=8585&ncm_heading=Nutrition%20Care
References
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2913510/#B3
http://copd.about.com/od/copdbasics/a/copdpathophysiology.htm
http://copd.about.com/od/copd/a/copdexac.htm
http://www.healthgrades.com/right-care/digestive-health/paralytic-ileus--causes
http://www.healthcarebulletin.com/uploads/media/Gastrointestinal_Complications_Following_Heart_Surger
y_01.pdf
http://emedicine.medscape.com/article/2242141-overview
http://en.wikipedia.org/wiki/Cardiogenic_shock
http://www.bing.com/search?q=septic%20shock%20defi&qs=n&form=QBRE&pq=se
ptic%20shock%20defi&sc=2-17&sp=1&sk=&cvid=02eb7217d1b24d2c9a89488dba9148ff
Nutrition Therapy and Pathophysiology
Krause’s Food and the Nutrition Care Process.