Download MyoCardial Infarction Case Study

Laura Asbury
KNH 411
9/1/15
Dr. Matuszak
Case Study #5 Myocardial Infarction
1. Mr. Klosterman had a myocardial infarction. Explain what happened to his
heart.
When Mr. Klosterman had a myocardial infarction, a section of his heart
muscle became blocked which caused the heart to not take in any oxygen.
The heart muscle began to die because of the lack of blood flow to that
section of the heart. Myocardial infarctions happen because there is a
reduction in the blood flow caused by atherosclerosis or plaque on the inner
wall of the coronary artery (PubMed Health).
2. Mr. Klosterman’s 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 infarctrelated 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 posterobasilar scar was present with hypokinesis.
Explain angioplasty and stent placement. What is the purpose of this
medical procedure?
Angioplasty is a procedure that is done to restore blood flow through the
artery, to the heart. An angioplasty is usually used for heart attack patients and
can minimize the damage to the heart muscle. Specifically, during the procedure,
the doctor will inflate a small balloon inside the blood vessel. By inflating the
balloon, it helps widen the artery so that the blood can flow through easier
(Medline Plus, 2015). Stents are wire mesh tubes that are usually used after an
angioplasty is performed. These tubes are put in to support the artery wall and
allow adequate blood flow. By opening the artery up, blood flow will be able to
flow more smoothly and this can reduce pain and future risks of clotting. Overall,
these two procedures are to open the blood vessel for increased blood flow and
to protect against further blockages in that artery (John Hopkins Medicine).
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 rehab is a program that provides counseling and education for patients
who are recovering from heart attack, heart surgery or different heart
procedures and issues. The purpose of Mr. Klosterman attending cardiac
rehabilitation is to improve health and awareness, reduce cardiac symptoms and
problems, reduce risk of future hospital visits, and to increase physical health
and quality of life. Cardiac rehabilitation will get him back into his normal
activities and will improve the outlook for his future heart health (American
Heart Association, 2014).
4. What risk factors indicated in his medical record can be addressed through
nutrition therapy?
Looking at Mr. Klosterman’s medical record, his tobacco use, lack of physical
activity and poor diet all put him at risk of having an myocardial infarction. He
also has low levels of HDL, the ‘good’ cholesterol and high levels of LDL, the ‘bad’
cholesterol that can be associated with heart disease. Nutrition therapy can help
Mr. Klosterman choose foods that are heart healthy and that are nutrient dense.
By doing nutrition therapy, he can change his health in a positive way (Nelms &
Roth, 2013, p. 50-53).
5. What are the current recommendations for nutritional intake during a
hospitalization following a myocardial infarction?
Some recommendations for nutrition intake after an MI is to incorporate more
fruits, vegetables, whole grains and legumes, watch saturated fat intake, eat a
variety of protein sources, limit dietary cholesterol, consume complex carbs
instead of simple carbs, watch sodium intake. While in the hospital he should not
consume any caffeine. Mr. Klosterman should also eat more frequent, small
meals (Nelms, Sucher, & Lacey, 2011, p. 307, 328).
6. What is the healthy weight range for an individual of Mr. Klosterman’s
height?
Height: 5’10’’ 70 inches
Weight: 185 lbs
BMI: 26.6
Hamwi Method:
106 + 6 lbs for every inch over 5 ft.
106 + (6x10) = 166 lbs. (ideal body weight)
A healthy weight based on BMI chart is between 131-174 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.
Energy requirements:
Mifflin-St.Jeor Equation for men: 10 x wt + 6.25 x ht – 5 x age + 5
10 (84.09) + 6.25(177.8) – 5(61) + 5 = 1652 kcal
1652(1.5)= 2478 kcal/day
Mr. Klosterman should get around 2,478 kcal/day
Protein requirements:
>50 years = .8 g/kg/day to 1.0 g/kg/day
84.09 kg (.8 g/kg/day)= 67 g of protein
84.09 kg (1.0 g/kg/day)= 84 g of protein
Mr. Klosterman should get 67-84 g of protein per day.
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.
SuperTracker
Calories consumed: 2,277
Carbohydrates: 294 g  1176 kcal or 51.6%
Protein: 124 g  496 kcal or 21.8%
Fat: 28%
(Choose MyPlate, 2015).
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?
Looking at Mr. Klosterman’s lab results, on the second day he had elevated levels
of ALT, AST, CPK, CPK-MB, Troponin I and Troponin T. AST levels increase after
a heart attack and ALT levels increase because they are associated with
atherosclerosis. CPK and CPK-MB levels are elevated on the second and third day
because there was damaged tissue from the heart attack. Troponin I and
Troponin T increase on the second day because they are proteins that are found
in the heart and are released into the blood when there is damage to the heart.
High cholesterol and high LDL show that he is at risk for cardiovascular disease
(Bellentani, 2008) (Lab Tests Online, 2015).
10. What is abnormal about his lipid profile? Indicate the abnormal values.
An abnormal lipid profile indicates that something in the body is wrong
(Nelms, Sucher, & Lacey, 2011, p. 325).
Cholesterol:
Normal: 120-199
Mr. Klostermans: 214-235 (high)
HDL:
Normal: greater than 50
Mr. Klostermans: 30-33 (low)
LDL:
Normal: less than 130
Mr. Klostermans: 141-160 (high)
LDL/HDL ratio:
Normal: less than 3.55
Mr. Klostermans: 4.3-5.3 (high)
Apo A:
Normal: 94-178
Mr. Klostermans: 72-80 (low)
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
Lisinopril 10 mg daily
Nitro-Bid 9.0 mg twice daily
NTG 0.4 mg sl prn chest pain
ASA 81 mg daily
Possible Food–Medication
Interactions
Avoid Licorice, reduce sodium intake
Avoid high potassium intakes, salt
substitutes, alcohol
Avoid alcohol
Avoid alcohol
Avoid alcohol, ginger, ginseng, garlic,
limit caffeine
(Nelms, Sucher, & Lacey, 2011, p. 225-228)
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?
Where do you grocery shop at?
What types of food do you like and dislike?
How are your foods prepared and by who?
Do you eat regularly or do you go for long periods without eating?
Are you willing to change the way you eat?
How much free time do you have?
Do you usually plan out your meals ahead of time?
13. What other issues might you consider to support successful lifestyle
changes for Mr. Klosterman?
I would encourage Mr. Klosterman to stop smoking because this is negatively
affecting his health. I would also encourage participating in cardiac rehab and
then working into regular exercise on his own. By exercising, eating a healthy
diet and stopping smoking, he will be on the right track to losing some weight
that will better his overall daily life.
14. From the information gathered within the assessment, list possible
nutrition problems using the correct diagnostic terms.




Excessive oral intake: NI-2.2
Overweight: NC-3.3.1
Physical inactivity NB-2.1
Undesirable food choices NB-1.7
(Academy of Nutrition and Dietetics, 2013)
15. Select two of the identified nutrition problems and complete the PES
statement for each.


Physical inactivity related to obesity as evidenced by a sedentary
lifestyle
Overweight related to overconsumption of food as evidenced by a BMI
of 26.6
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).
NB- 2.1
Goal: Increase Mr. Klosterman’s physical activity to 30-45 minutes each day
incorporating different intensities of moderate to vigorous workouts.
Intervention: Have Mr. Klosterman keep a physical activity, stress and how he is
feeling log to keep track of the exercises he is doing. Incorporate personal
training if he needs direction.
NC-3.3.1
Goal: Decrease Mr. Klosterman’s caloric intake and lower his BMI to the normal
range between 18.5-24.9.
Intervention: Have Mr. Klosterman keep a food log to track what foods he is
eating throughout the day. Mr. Klosterman should come back every other week
to share his comments and concerns about his diet (Academy of Nutrition and
Dietetics).
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 omega-3-fatty acid supplementation for this patient?
Omega-3-fatty acids benefit the heart of those who have cardiovascular disease.
Research has said that ingesting appropriate amounts of omega-3-fatty acids can
decrease triglyceride levels and slightly lower blood pressure. Fish such as
salmon and sardines are great sources of omega-3. Supplements are also a great
way to incorporate omega-3-fatty acids into a diet (American Heart Association,
2015).
18.
What would you want to assess in three to four weeks when he and his
wife return for additional counseling?
When Mr. Klosterman returns in 3-4 weeks, I would want to assess his food log
and his weight. By looking at his food log, I can steer him in the right direction
and give him tips on foods to eat that are heart healthy. Looking specifically into
his fat, sodium and caloric intake is important because these are the most
important factors for this patient. By taking his weight, we can also compare this
to his diet and what he is eating. The last thing I would assess is his exercise log
and check his lipid profile to make sure they are back to normal ranges.
References
Academy of Nutrition and Dietetics (2013). Pocket guide for international dietetics &
nutrition terminology (IDNT) reference manual: Standardized language for the
nutrition care process. Chicago, Ill: Academy of Nutrition and Dietetics.
American Heart Association (2014, April 1). What is Cardiac Rehabilitation?
Retrieved from
http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/Whatis-Cardiac-Rehabilitation_UCM_307049_Article.jsp
American Heart Association (2015, June 15). Fish and Omega-3 Fatty Acids.
Retrieved from
http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/Health
yDietGoals/Fish-and-Omega-3-Fatty-Acids_UCM_303248_Article.jsp
Bellentani, S. (2008, May 22). Liver and heart: ALT Predicts Heart Disease. Retrieved
from http://www.natap.org/2008/HCV/052708_09.htm
Choose MyPlate (2015, April 3). SuperTracker. Retrieved from
http://www.choosemyplate.gov/tools-supertracker
John Hopkins Medicine (n.d.). Stent Placement. Retrieved from
http://www.hopkinsmedicine.org/vascular/procedures/stents/
Lab Tests Online (2015). Troponin. Retrieved from
https://labtestsonline.org/understanding/analytes/troponin/tab/test/
MedlinePlus (2015, August 1). Angioplasty. Retrieved from
https://www.nlm.nih.gov/medlineplus/angioplasty.htm
Nahikian-Nelms, M., & Roth, S. L. (2013). Medical nutrition therapy: A case study
approach. Stamford, Connecticut: Cengage Learning.
Nelms, M. N., Sucher, K., & Lacey, K. (2011). Nutrition therapy and pathophysiology.
Belmont, CA: Brooks/Cole Cengage Learning.
PubMed Health (n.d.). Heart Attack (Myocardial Infarction). Retrieved from
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0021982/