Download Case Questions I. Understanding the Disease and Pathophysiology

Case Questions
I. Understanding the Disease and Pathophysiology
1. Outline the typical pathophysiology of heart failure. Onset of heart failure usually can be
traced to damage from an MI and atherosclerosis. Is this consistent with Dr. Peterman’s history?
Heart failure is the end stage of cardiovascular disease. Many different conditions that
cause damage to the heart’s muscles lead to the development of heart failure. These include:
hypertension, diabetes, ischemic heart disease, infections, and use of cardiotoxic medications. In
heart failure, the heart loses its ability to effectively pump blood throughout the body in order to
meet metabolic requirements. Additionally, the heart loses its ability to retain systemic venous
return. As heart failure worsens, and the ability of the heart to adequately pump blood throughout
the body lessens, several compensatory mechanisms occur. For instance, the kidneys secrete the
hormones renin and aldosterone when it thinks there is a need for more fluid in the blood vessels;
these hormones cause vasoconstriction, and cause sodium and water retention. These actions
increase the blood volume. The increase in blood volume creates a more strenuous task for the
heart: it has to pump harder to move the larger blood volume. As the heart works harder, it grows
in size – a decrease in the efficacy of the heart occurs (decreased cardiac output; decreased stroke
volume). This hormone compensatory mechanism eventually exacerbate heart failure.
Damage from a previous MI and atherosclerosis usually lead to the development of heart
failure. This is consistent with Dr. Peterman’s history, as he has a history of an anterior MI.
Cardiac remodeling occurs after MIs as the body attempts to restore the heart’s function. This
remodeling leads to cardiac dysfunction (e.g., impaired contractility, and decreased cardiac
output), which can cause eventual heart failure as seen with Dr. Peterman.
2. Identify the specific signs and symptoms in the patient’s physical examination that are
consistent with heart failure. For any three of these signs and symptoms, narratively connect
them to the physiological changes that you described in question #1.
In Dr. Peterman’s physical examination there were several signs and symptoms that are
consistent with heart failure; these include:
 low blood pressure (90/70)
 high heart rate (110 BPM)
 high respiration rate (24)
 temporal wasting
 grade 2 holosystolic murmur at the apex
 4 + pedal (swelling of the ankles and feet) edema
 ascites (accumulation in the peritoneal cavity)
 liver tenderness
 rales (abnormal crackling) in both bases posteriorly (chest/lungs)
 jugular venous distention
Based on nursing assessment:
 skin tenting
 gray and moist skin

abdominal distention
Gray skin
As the heart fails, its ability to pump oxygen rich blood throughout the body becomes
compromised. As a result, oxygen deprivation occurs which manifests as gray/blue skin.
Increased respiratory rate
When left-sided failure of the heart occurs, fluid tends to accumulate in the lungs. This
results in difficulty breathing, increasing respiratory rate.
Increased heart rate:
In heart failure, the heart muscles do not pump blood well throughout the body. To make
up for the decreased pumping capability, the heart muscles speed up to effectively deliver
oxygen rich blood throughout the body, thereby increasing the BPM.
3. Heart failure is often described as R-sided or L-sided failure. What is the difference? How are
the clinical manifestations different?
There are two sides of the heart: right and left, which are separated by the septum. The
function of the right side of the heart is to pump blood to the lungs where it picks up oxygen. The
function of the left side of the heart is to receive the oxygenated blood and pump it to the rest of
the body.
R-sided heart failure results in the inability of the heart to pump blood through
pulmonary circulation resulting in the accumulation of fluid throughout the body; this manifests
as edema, and swelling in the legs and feet, as well as the abdomen (ascites). There are two types
of L-sided heart failure: systolic failure (inability to contract), and diastolic failure (inability to
relax). L-sided heart failure results in the inability of the heart to pump blood through systemic
circulation resulting in the build up of fluid in the lungs. Common manifestations of L-sided
heart failure are shortness of breath (dyspnea), fatigue, irregular pulse, fluid retention and
consequent weight gain, and cough. In L-sided heart failure predominance, dyspnea, as well as
shortness of breath upon lying in the supine position are common. In R-sided heart failure
predominance, edema (which affects the abdominal cavity resulting in hepatomegaly,
splenomegaly, and ascites), headaches, distended neck veins, and flushed face are common.
4. Dr. Peterman’s admitting diagnosis was cardiac cachexia. What is cardiac cachexia? What
are the characteristic symptoms? Explain the role of the underlying heart disease in the
development of cardiac cachexia.
Cardiac cachexia is a form of malnutrition that leads to severe and unintentional weight
loss; it is caused by heart disease. It is assumed that the causes of cardiac cachexia are
multifactorial and involve both metabolic and hormonal abnormalities. Myocardial
deficiencies of L-carnitine, coenzyme Q10, creatine, thiamin, and taurine may contribute to
the development of cachexia in heart failure. Common characteristic symptoms of cardiac
cachexia include extreme skeletal muscle wasting, fatigue, and anorexia.
Patients with heart failure experience difficulty eating and many develop cardiac
carchexia as a result of malnutrition. In addition to difficulty eating, many patients
experience various complications of heart failure which lead to malnutrition and cardiac
cachexia, these include: Possible nutrient malabsorption, slow peristalsis, and early satiety
caused by decreased blood flow to the GI tract; nausea, vomiting, and anorexia (caused by
side effects of medications such as ACE inhibitors, beta blockers, etc.).
II. Understanding the Nutrition Therapy
5. Dr. Peterman’s wife states that they have monitored their salt intake for several years. What is
the role of sodium restriction in the treatment of heart failure? What level of sodium restriction
is recommended for the outpatient with heart failure?
High sodium consumption causes the body to retain water, worsening the fluid build-up
that occurs in heart failure. Therefore, sodium must be restricted in patients with heart failure.
The standard initial recommendations of sodium for heart failure patients are 2000 mg/day.
Depending on the condition and needs of the patient, sodium recommendations may be adjusted
to 1000 or 500 mg/day. It is difficult to monitor a patient’s sodium level outside of the hospital;
therefore it is critical to evaluate the patient’s oral food and beverage intake to understand their
sodium intake before making sodium recommendations.
6. Should he be placed on a fluid restriction? If so, how would this assist with the treatment of
his heart failure? What specific foods are typically “counted” as a fluid?
Dr. Peterman has been placed on a fluid restricted diet, as he should be for his condition.
All patients with heart failure should be put on a fluid restricted diet of no more than 2000 mL
fluid/day. In order to prevent fluid overload, adjustments to fluid requirements can be made
based on renal and cardiac status. Fluid restricted diets are needed in patients with heart failure
as it takes away from the need for diuretics. A reduction in fluid intake is needed to minimize the
edema and swelling that is often seen in patients with heart failure.
Dr. Peterman, specifically, should be placed on a fluid restricted diet due to results of his
physical assessment and lab values indicating the need for fluid restriction. His physical
examination revealed 4+ edema – this common heart failure symptom is indicative of fluid
overload. Dr. Peterman’s intake/output assessment revealed that he was overhydrated upon
admission. The edema that was observed during his physical assessment is also an indicator of
overhydration.
Foods that are “counted” as fluids include: soups, popsicles , sherbet, ice cream, yogurt,
custard and gelatin.
7. Identify any common nutrient deficiencies found in patients with heart failure.
Malnourishment is common in patients with heart failure due to the aforementioned
causes (question #4). It is estimated that approximately 50% of patients with heart failure
experience malnourishment. Specifically, it is common for these patients to be placed on
diuretics. The use of diuretics often causes malnourishment of potassium, magnesium, thiamin,
calcium, and zinc.
8. Identify factors that would affect interpretation of Dr. Peterson’s weight and body
composition. Look at the I/O record. What will likely happen to Dr. Peterson’s weight if this
trend continues?
The edema and ascites that Dr. Peterman is experiencing affect his weight and body
composition. If Dr. Peterman’s intake continues to exceed his output as seen on his I/O record,
then he will gain weight.
9. Calculate Dr. Peterman’s energy and protein requirements. Explain your rationale for the
weight you have used in your calculation.
The only record of Dr. Peterman’s weight is his admission weight.
Energy requirements using Harris – Benedict equation and using an activity factor of 1.2 (little to
no exercise), and a 1.5 stress factor due to increased energy requirements for patients with heart
failure experiencing cardiac cachexia.
66.5 + (13.8 x wt) + (5.0 x ht) – (6.8 x age)
66.5 + (13.8 x 75) + (5.0 x 177.8) – (6.8 x 85)
66.5 + 1035 + 889 – 578
= 1412.5 x (1.5 SF) x (1.2 AF) = 2542.5 kcal/day
Protein needs: range of 0.8 – 1.0 grams protein / kg depending on the needs of the patient (renal
status).
75 kg  0.8 = 60
75 kg  1.0 = 75
Protein needs = 60-75 grams protein / day
10. Dr. Peterman was started on an enteral feeding when he was admitted to the hospital. Outline
a nutrition therapy regimen for him that includes formula choice, total volume, and goal rate.
The enteral formula choice best suited for CP would be Jevity 1.5 as it is a calorie dense
product. Calorie dense products are used for patients with fluid restrictions because as you
increase calories/mL it reduces the water content.
Continuous feeding volume: 1680mL
Goal rate: 70ml/hr (start at 10 ml/hr and increase 20 ml/hr every 4 hours to goal)
11. Identify any abnormal biochemical values and assess them using the following table:
Parameter
Normal Value Pt’s Value
Bilirubin
(mg/dL)
<0.3
1.0,1.1,0.9
Reason for
Abnormality
Decreased liver
function or
increased
Nutrition
Implication
Avoid fatty
foods and fried
foods
hemolysis
Overhydration,
malnourishment
(eating 5% of
meals)
Albumin
(g/dL)
3.5-5
2.8,2.7,2.6
Total protein
(g/dL)
6-8
5.8,5.6,5.5
Prealbumin
(mg/dL)
16-35
15,11,10
4-36
100,120,115
AST (U/L)
0-35
70, 80, 85
CPK (U/L)
55-170
180,200,205
Troponin T
(ng/L)
HDL-C
(mg/dL)
LDL-C
(mg/dL)
Apo A
(mg/dL)
Apo B
(mg/dL)
BUN (mg/dL)
<0.03
>45
0.035, 0.037,
0.036
30,31,30
Evaluate
energy and
protein
requirments
once patient
achieves fluid
balance
Overhydration; Evaluate
malnourishment protein
(eating 5% of
requirements
meals)
Overhydration, Evaluate
malnourishment energy and
protein
requirments
once patient
achieves fluid
balance
Compromised
Increase
liver
protein,
health/function monitor liver
Compromised
Increase
liver
protein,
health/function monitor liver
Damage or
Heart healthy
injury to heart
diet
Damage or
Heart healthy
injury to heart
diet
Heart disease
Fat restriction
<130
180,160,152
Heart disease
Fat restriction
94-178
60,65,70
Heart disease
Fat restriction
63-133
140,138,136
Heart disease
Fat restriction
8-18
32,34,30
Decreased
kidney
function;
decreased renal
blood flow
Decreased
kidney
function;
decreased renal
Ensure
meeting
protein
requirements
ALT (U/L)
Creatinine
0.6-1.2
serum (mg/dL)
1.6,1.7,1.5
Ensure
meeting
protein
requirements
Sodium
(mEq/L)
136-145
132,133,133
blow
Hyponatremia:
excessive fluids
in the body
dilutes normal
sodium
amounts
Decrease
fluids
12. The following chart lists drugs/supplements that were prescribed for Dr. Peterman. Give the
rationale for the use of each. In addition, describe any nutrition implications for these
medications.
Medication
Lanoxin
Lasix
Dopamine
Thiamin
Rationale for Use
Treats heart failure and
atrial fibrillation
Diuretic used to treat
hypertension and edema
Treats circulation
problems caused by heart
attack, heart failure,
kidney failure, and low
blood pressure
Water-soluble vitamin
that may be depleted with
diuretic use
Nutrition Implications
May interact with certain nutrients such as
calcium, magnesium, fiber, and potassium.
Discuss adequate potassium and sodium intake
and levels with prescribing doctor
Possible vitamin and herbal medicine interactions
Likely safe when taken orally. May cause nausea
and vomiting in some people.
IV.
Nutrition Diagnosis
13.
Select two nutrition problems and complete a PES statement for each.
Inadequate oral food/beverage intake related to poor appetite in the past two weeks, SOB and
nausea as evidenced by the less than 5% meal intake and the sips of liquids for past 24 hours.
Impaired nutrient utilization related to sodium and fluid retention as evidenced by low sodium
levels of 132-133 mEq/L, ascites, 4+ pedal edema.
V. Nutrition Intervention
14. Dr. Peterman was not able to tolerate the enteral feeding because of diarrhea. What
recommendations could be made to improve tolerance to the tube feeding?
Because Dr. Peterman was not able to tolerate enteral feeding due to his diarrhea, we
could take measures to improve his tolerance. If we determine that it is necessary to continue
using his current enteral formula, then Dr. Peterman can be put on anti-diarrheal medication. Or,
if it is possible to change his formula, then we could change it to one that contains added fiber in
order to effectively treat his diarrhea. Fiber itself as a supplement cannot be simply added to the
formula as it may interact with various components in the formula.
15. The tube feeding was discontinued because of continued intolerance. Parenteral nutrition was
not initiated. What recommendations could you make to optimize Dr. Peterman’s oral intake?
To address this issue, Dr. Peterman will be given foods that he likes and that are soft,
easy to eat, and are nutrient dense. He should eat small, frequent meals throughout the day. If
oral intake becomes difficult, after taking into account his fluid restrictions, he may be given
nutrient dense liquid supplements such as Ensure.
16. An echocardiogram indicated severe cardiomegaly secondary to end-stage heart failure. Mr.
Peterson had a living will that stated he wanted no extraordinary measures taken to prolong his
life. He was able to express his wishes verbally and requested oral feedings and palliative care
only. Mr. Peterman expired after a two-week hospitalization. What is a living will? What is
palliative care?
A living will is defined as:
A written statement detailing a person's desires regarding their medical treatment
in circumstances in which they are no longer able to express informed consent, especially an
advance directive.
Palliative care is defined as:
Palliative care is specialized medical care for people with serious illnesses. It
focuses on providing patients with relief from the symptoms and stress of a serious illness. The
goal is to improve quality of life for both the patient and the family.
17. During his final days of life, Dr. Peterman was not receiving parenteral or enteral nutritional
support. What is the role of the registered dietitian during palliative care?
The registered dietitian continues ensuring adequate nutrition while adhering to patient
food preference during the palliative care process
References
Chen, M. (2013, May 1). Heart Failure Overview. Retrived from http://www.nlm.nih.gov/medli
neplus/ency/article/000158.htm
Heart Failure (2015, January 17). Retrieved from http://www.mayoclinic.org/diseasesconditions/heart-failure/basics/definition/con-20029801
How the Heart Works (2011, July 1) Retrieved from http://www.nhlbi.nih.gov/health/healthtopics/topics/holes/heartworks
Pai, R. (2014, March 2014). Heart Failure: Compensation by the Heart and Body. Retrieved from
http://www.uofmhealth.org/health-library/aa86963
Parrish, C (2005, June 7). Enteral Formula Selection: A Review of Selected Product Categories.
Retrieved from http://www.medicine.virginia.edu/clinical/departments/
medicine/divisions/digestive-health/clinical-care/nutrition-support-team/nutritionarticles/MaloneArticle.pdf
What is Palliative Care (n.d.) Retrieved from http://getpalliativecare.org/whatis/