Download File - Annelise Chmelik

Annelise Chmelik
CV Case Study #5
KNH 411
I.
Understanding the Disease and Pathophysiology
1. Mr. Klosterman had a myocardial infarction. Explain what happened
to his heart.
The middle layer of the heart, the myocardium, contracts to force the
blood from the heart; myocardial cells are the cells within the
myocardium. Myocardial infarction is the necrosis, or cellular death, of
the myocardial cells due to oxygen deprivation resulting from an
occluded or blocked coronary artery. Myocardial infarction is also
commonly referred to as a heart attack. Myocardial infarction results
from the buildup of atherosclerotic plaque that contributes to the
occlusion of the lumen of the coronary artery. Inadequate blood supply to
the heart and heart tissue due to the occlusion is a direct result of the lack
of oxygen delivered; thus, resulting in myocardial infarction. [pg 315.]
Nutrition Therapy and Pathophysiology. 2nd ed. Blemont, CA; Brooks/Cole
Cenage Learning; 2011.
2. Mr. Klosterman’s chest pain resolved after two sublingual NTG at 3minute 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 the patient
and limit infarct size. Left ventricular ejection fraction was normal
at 42%, and a postero-basilar scar was present with hypokinesis.
Explain angioplasty and stent placement. What is the purpose of this
medical procedure?
Angioplasty restores blood flow to the heart. During this procedure, a
thin catheter with a balloon attached to the end is inserted into the blood
vessel. A stent, which is a wire mesh tube, is placed around the deflated
balloon. Once the balloon is in place, the balloon is inflated to widen the
narrow or obstructed artery by pressing the plaque against the artery
wall. The stent is put into place by the fully inflated balloon. Once the
stent is pushed into place in the artery, the balloon is deflated and
removed along with the catheter. The stent remains pressed firmly
against the artery to establish blood flow to the heart. This procedure
significantly increases blood flow, reduces chest pain, and can be used in
neck and brain arteries to help prevent stroke.
National Heart, Lung, and Blood Institute (2011). How Are Stents Placed?.
Retrieved from http://www.nhlbi.nih.gov/health/healthtopics/topics/stents/placed.html
National Heart, Lung, and Blood Institute (2012). What is Coronary
Angioplasty?. Retrieved from http://www.nhlbi.nih.gov/health/healthtopics/topics/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 is a personalized program of exercise and
education, designed to help patients recover from heart attacks and other
heart problems. With a team dedicated to reducing the risk of future
heart problems, one will learn how to be more active and live a healthier
lifestyle through gradual exercise and lifestyle changes. Based on a
program personal to the patient, the goals of cardiac rehabilitation
include regaining the individual’s strength, as well as reducing the future
risk of heart problems. [pg 308]
Nutrition Therapy and Pathophysiology. 2nd ed. Blemont, CA; Brooks/Cole
Cenage Learning; 2011.
II.
Understanding the Nutrition Therapy
4. What risk factors indicated in his medical record can be addressed
through nutrition therapy?
Mr. Klosterman’s total cholesterol level is very high. More specifically,
his LDL levels are high and his HDL levels are low. This is a condition
known as dyslipidemia, which increases the risk of plaque buildup. Mr.
Klosterman is also considered overweight as evidenced by his body mass
index of 26.6. According to his 24-hour dietary recall, Mr. Klosterman
consumes a high amount of sodium. Foods such as pretzels, canned soup,
roast beef, and cream cheese are high in sodium and contribute to his
condition. [pg 301]
Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA; Brooks/Cole
Cenage Learning; 2011.
5. What are the current recommendations for nutritional intake
during a hospitalization following a myocardial infarction?
Mr. Klosterman is currently on an NPO (nothing by mouth) diet until
the procedure, which indicates that he is not to take in any sort of food or
liquid. Additionally, in patients with heart failure and heart problems,
sodium and fluid intake should be restricted. Fluid requirements are
typically calculated at 35 mL/kg. Fluid intake should not exceed 2,000
mL/day and sodium should not exceed 2,000 mg/day. A multivitamin
should also be recommended daily
Nutrition therapy has proven to be most effective when limiting the
initial oral intake to clear liquids and restricting caffeine. Caffeine
restriction is essentially to prevent arrhythmias and reduce the risk of
vomiting. Oral intake is limited to decrease pain, anxiety, fatigue, and
shortness of breath. As the patient stabilizes, there is a gradual transition
from a clear liquid diet to a soft mechanical diet. Once the patient has
transitioned to a soft mechanical diet, smaller and more frequent meals
are introduced. As the patient continues to improve, the nutrition therapy
should be individualized according to the specific needs of the patient. [pg
326-27]
Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA; Brooks/Cole
Cenage Learning; 2011.
III.
Nutrition Assessment
6. What is the healthy weight range for an individual of Mr.
Klosterman’s height?
BMI = wt (kg) ÷ ht (meters) sq
18.5 = wt (kg) ÷ 1.778 m2
wt = 58.48 kg; 128.65 lbs
24.9 = wt (kg) ÷ 1.778 m2
wt = 78.684 kg; 173.1 lbs
A healthy weight range for an individual of Mr. Klosterman’s height is
128.65 – 173.1 lbs
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.
a) Calculate energy needs:
To calculate Mr. Klosterman’s energy requirements, I used the
Mifflin-St. Jeor equation. First I converted pounds into kilograms and
inches into centimeters:
185 lbs ÷ 2.2 lbs = 84.09 kg
70 inches × 2.54 cm = 177.8 cm
Then I used these values to calculate Mr. Klosterman’s energy needs
using the Mifflin-St. Jeor equation:
10 × wt (kg) + 6.25 × ht (cm) – 5 × age (yrs) + 5
10 × (84.09 kg) + 6.25 × (177.8 cm) – 5 × (61 yrs) + 5
= 1,652.15 kcal/day
Total Energy Needs: 1,652. 15 × 1.4 × 1.0= 2,313 kcal/day
I utilized a physical activity level of 1.4 because Mr. Klosterman has a
low activity level by walking his dog for 15 minutes at a leisurely pace. I
also included an injury factor of 1.0, which is a surgery injury factor. Thus,
Mr. Klosterman’s total energy needs equals 2,313 kcal/day
b) Calculate protein requirements:
0.8 g/kg × 84.09 kg = 67.27 grams of protein
To calculate Mr. Klosterman’s protein requirements, I used 0.8 grams
of protein per kilogram. Since he did not experience severe trauma,
burns, sepsis, wounds or a bone marrow transplant, I did not feel it was
necessary to increase his protein intake from the recommended amount
for adults. [pg 60]
Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA; Brooks/Cole
Cenage Learning; 2011.
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 proteins, carbohydrate, and fat using the exchange system.
Food
Carbohydrate Protein (g)
Fat (g)
Energy
(g)
(k/cal)
Cinnamon
60
12
4
320
Raisin Bagel
Fat-free
0
0
0
0
Cream
Cheese
Orange Juice
30
----------------120
Coffee
0
0
0
0
Vegetable
15
3
2
80
Beef Soup
Roast Beef
30
34
14
180
Sandwich
with
- lettuce
--------------------------------- tomato
5
-----------------25
- dill pickles
0
0
0
0
- mayonnaise
0
0
0
0
Apple
15
--------------------60
2% Milk
12
8
5
120
Lean Pork
-----------42
18
270
Chops
Baked Potato
Margarine
Green Beans
Coleslaw
Apple Pie
2% Milk
Pretzels
TOTAL
CALORIES
Energy
Distribution
of Calories
60
----------5
15
45
12
19
12
----------2
3
9
8
4
4
10
-----------9
13
5
-------------
320
90
148
148
380
120
100
323 g CHO
1,292
51.3%
137 g PRO
548
21.7%
83 g FAT
747
29.6%
2,518
Calculations to Determine Calories:
A) Carbohydrates: 323 g CHO × 4 g/kcal = 1,292 k/cal
B) Protein: 137 g PRO × 4 g/kcal = 548 k/cal
C) Fat: 82 g FAT × 9 g/kcal = 747 k/cal
Calculations to Determine the Energy Distribution of Calories:
A) Carbohydrates: 1,292 k/cal ÷ 2,518 k/cal = 51.3%
B) Protein: 548 k/cal ÷ 2,518 k/cal = 21.7%
C) Fat: 747 k/cal ÷2,518 = 29.6%
[pg A-109]
Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA; Brooks/Cole
Cenage Learning; 2011.
9. Examine the chemistry results for Mr. Klosterman. Which labs are
consistent with the MI diagnosis? Explain. Why were his levels
higher on day 2?
The lab results that are consistent with the myocardial infarct
diagnosis is as follows; aspartate aminotransferase (AST), lactic
dehydrogenase (LDH), creatinine phosphokinase, LDL- and HDLcholesterol, Troponin I, Troponin T, and triglyceride.
Mr. Klosterman’s total cholesterol level was 235 mg/dL, far exceeding
the recommended upper level of about 200 mg/dL. His LDL-cholesterol is
also extremely elevated at 160 mg/dL, whereas his HDL-cholesterol is
significantly low at 30 mg/dL. The high levels of LDL-cholesterol along
with the low levels of HDL-cholesterol create plaque buildup within the
arteries, which can result in a myocardial infarction. The elevated levels
of Troponin I (2.4 ng/dL) and Troponin T (ng/dL) are also consistent
with the MI diagnosis because these proteins are released from the
myocardial cells and the levels become elevated after a cardiac injury,
such as myocardial infarction. Creatinine phosphokinase (CPK), aspartate
aminotransferase (AST), and lactic dehydrogenase (LDH) are all cardiac
enzymes that are released into the blood stream as cells die from oxygen
deprivation, such as necrosis of the heart muscle. The elevated levels of
these three enzymes clearly suggest oxygen deprivation of the cells,
which is a direct result of myocardial infarct.
Mr. Klosterman’s levels on day two were higher. By analyzing the lab
results, one can notice that levels of the three enzymes (AST, LDH, and
CPK) were all within the normal range on day 1; however on day two
these levels increased significantly. Aspartate aminotransferase increased
from 25 on day one to 245 on day two. Lactic dehydrogenase increased
from 325 on day one to 685 on day two. Finally, creatinine
phosphokinase increased from 75 on day one to 500 on day two. These
sharp increases in the levels of these cardiac enzymes indicate that the
cells in Mr. Klosterman’s body were being deprived of oxygen, and
therefore dying, which could indicate myocardial infarction. [pg 320]
Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA; Brooks/Cole
Cenage Learning; 2011.
10. What is abnormal about his lipid profile? Indicate the abnormal
values.
Lipid
Ref. Range
Total
Cholesterol
HDL
LDL
120-199
mg/dL
>45 mg/dL
<130
mg/dL
94-178
mg/dL
40-160
mg/dL
Apo-A
Triglyceride
Abnormal
Day #1
235
Abnormal
Day #2
226
30
160
32
150
72
80
150
140
Abnormal
Day #3
214
33
141
____________
130
From this chart, one can see that Mr. Klosterman’s lipid profile is
abnormal. Mr. Klosterman’s high total cholesterol, low HDL-cholesterol
level, and high LDL-cholesterol level contributes significantly to the
buildup of plaque within his arteries. This increases his risk of myocardial
infarction, and can be used as evidence as to why he endured a
myocardial infarction. Although the triglyceride levels are within the
reference range, they are on the much higher side. Therefore, the
triglyceride levels can be analyzed as abnormal. [pg 253]
Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA; Brooks/Cole
Cenage Learning; 2011.
11. Mr. Klosterman was prescribed the following medications on
discharge. What are the food-medication interactions for this list of
medications?
Medication
Possible Food-Medication Interactions
Lopressor 50 mg daily
 Mixing with alcohol can lower blood
pressure
 Can increase blood glucose
 Food can enhance levels of Lopressor
Lisinopril 10 mg daily
 Avoid moderately high to high
potassium intake
Nitro-Bid 9.0 mg 2x daily
 Avoid alcohol use
NTG 0.4 mg sl prn chest
pain
ASA 81 mg daily
 Avoid caffeine
 Avoid alcohol
[Pg 215-225]
Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA; Brooks/Cole
Cenage Learning; 2011.
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 best to help
them?
1) Do you know how to properly read a food label?
2) Do you know which foods can help lower your cholesterol levels?
3) Which foods are staples in your diet?
4) Are you willing to try new foods?
5) What are your eating patterns at home like?
6) Is the grocery shopping handled by one individual, or do you both
go grocery shopping together?
7) Are you willing to begin and maintain an active lifestyle by
incorporating moderate physical activity into your daily routine?
8) What are some courses of action you are willing to try to help with
nutrition intervention?
13. What other issues might you consider to support successful lifestyle
changes for Mr. Klosterman?
Mr. Klosterman has been an avid smoker, smoking a pack per day, for
the last 40 years. Since smoking is considered a risk factor of myocardial
infarction, I would strongly urge Mr. Klosterman to gradually begin the
process of quitting smoking. Additionally, I would suggest that Mr.
Klosterman engage in a more physical activity. Although he does walk his
dog about 15 minutes a day, increased physical activity can greatly
improve his health and reduce his risk for future heart problems.
14. From the information gathered within the assessment, list possible
nutrition problems using the correct diagnostic terms.
NI-1.3 : Excessive Energy Intake
NI-2.2 : Excessive Oral Intake
NI-5.6.2 : Excessive Fat Intake
NC-3.3 : Overweight
NB-1.1 : Food- and Nutrition-related knowledge deficit
NB-2.1 : Physical Inactivity
IV.
Nutrition Diagnosis
15. Select two of the identified nutrition problems and complete the PES
statement for each.
1) PES statement for NI-5.6.2: Inappropriate fat intake related to poor
understanding of proper nutrition as evidenced by high levels of total
cholesterol and LDL-cholesterol and low levels of HDL-cholesterol
2) PES statement for NC-3.3: High body mass index related to inadequate
physical activity as evidenced by patient recall.
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) Goals and Interventions for PES statement NI-5.62:
GOAL: Reduce total cholesterol to <200 mg/dL, reduce LDLcholesterol to <130 mg/dL, and increase HDL-cholesterol to >55
mg/dL.
INTERVENTION: Educate Mr. Klosterman on how to reduce his
cholesterol intake in his diet. Educate Mr. Klosterman on how to
properly read food labels. Educate him on how to grocery shop for
healthy yet reasonably priced items. Offer diet and meal options that
are low in saturated fat and cholesterol. Finally, educate Mr.
Klosterman on the Therapeutic Lifestyles Changes diet.
2) Goals and interventions for PES statement NC-3.3:
GOAL: Reduce Body Mass Index from 26.6 to a normal body mass
index range of 18.5-24.9 by gradual weight reduction over a period of
6 months.
INTERVENTION: Incorporate physical activity into Mr. Klosterman’s
daily routine. Encourage him to walk his dog for longer periods of
time. Present brochures and information packets for gym
memberships suited for senior citizens. Encourage Mr. Klosterman to
weigh himself regularly and to record his weight, BMI, and waist
circumference.
17. Mr. Klosterman and his wife ask about supplements. “My roommate
here in the hospital told me that I should be taking fish oil pills.”
What does research say about omega-3-fatty acid supplementation
for this patient?
According to the American Heart Association, fish intake is correlated
with a decreased risk of coronary heart disease. The American Heart
Association encourages patients with documented heart disease to
consume about 1 gram of EPA and DHA, which are types of omega-3 fatty
acids, preferably from fish. Although supplementation is a viable option,
omega-3 supplementation would have to require consultation with a
physician. [pg 313]
Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA; Brooks/Cole
Cenage Learning; 2011.
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?
When Mr. and Mrs. Klosterman would return for additional
counseling, I would want to analyze any lab data, particularly his lipid
profile, as well as his AST, CPK, and LDH levels. Next, I would want to
weigh Mr. Klosterman to see if there has been any weight loss and I
would ask if he is keeping track of his weight, his BMI, and his waist
circumference to see if he is making progress.
I would ask Mr. Klosterman to perform a 24-hour diet recall in order
to note if he has made any diet changes and implemented them within his
diet. I would want to know if Mr. Klosterman has expanded his food
palate. Next, I would want to ask Mrs. Klosterman if they have
implemented any healthy lifestyle changes within their daily routine,
whether it would be eliminating butter from their diet, or weighing their
food for accurate portion control. Next, I would inquire about the grocery
shopping. I would ask if they have had an easy or a difficult time with
shopping for healthy and reasonably priced foods, and offer any helpful
tips.
Finally, I would ask Mr. Klosterman about any lifestyle changes
specifically addressed towards physical activity and quitting smoking. I
would want to know if Mr. Klosterman is participating in physical activity,
and if so, how many minutes per week, how intense the physical activity
level is, and what types of exercise he participates in. In regards, to Mr.
Klosterman’s smoking habit, I would encourage him to contemplate
quitting if he has not already chosen to. I would stress the importance of
maintaining a healthy life across all areas, not only in the nutrition and
food aspect of health.