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Transcript
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/