Download Allie McTighe Professor Matuszak Case Study #5 Cardiovascular

Allie McTighe
Professor Matuszak
Case Study #5 Cardiovascular Disorder
3 September 2015
I. Understanding the Disease and Pathophysiology
1. Mr. Klosterman had a myocardial infarction. Explain what happened to his
heart.
Myocardial infarction is also known as a heart attack. It is a condition in which
the heart muscle is deprived of oxygen and blood, as a result of atherosclerosis.
Atherosclerosis is the thickening and narrowing of the coronary arteries by
plaque. Because Mr. Klosterman smokes cigarettes, his nitric oxide is decreased,
inflammatory markers such as C-reactive protein are increased, and the oxidation
of LDL is increased, all of which contribute to the development of plaque in his
arteries. Plaque is a combination of many factors including fat, cholesterol,
smooth muscle cells, and macrophages. The build up of plaque causes reduced or
complete deprivation of blood and oxygen to the myocardium. The complete stop
of blood and oxygen to the heart is a result of the rupture of plaque, which causes
a blood clot formation. Overall, the heart muscle dies because of the lack of
supply of blood and oxygen to sustain its function (307-311).
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.
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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 sent placement. What is the purpose of this medical
procedure?
Both angioplasty and sent placement are used to keep the artery open, ultimately
restoring blood and oxygen flow, and minimize symptoms and heart damage.
Angioplasty is a non-surgical procedure where a sheath is inserted in either the
patients groin or arm. The first catheter is inserted to determine the damaged
artery location by the use of x-ray imaging. Then a catheter with a balloon tip is
placed where the narrowed or damaged artery is. The balloon is then inflated,
expanding the artery and pushing the plaque outward against the artery wall. On
the other hand, sent placement is the insertion of small wire mesh tube into the
blocked or damaged artery. This treatment follows the same procedure as
angioplasty but deflates the balloon leaving only the stent to keep the artery
patent. Both treatments ensure the opening of the artery for normal blood and
oxygen flow to prevent another blocked or obstructed artery (Angioplasty/
Balloon 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?
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Cardiac rehabilitation is a program, supervised by professionals, used by patients
recovering from a heart related condition. The program plays a role in the
improvement of the health and wellbeing of a recovering patient. This program
works to help the client, like Mr. Klosterman, regain strength, prevent future heart
related problems, decrease risk factors by adopting healthy behaviors, and
improvement in quality of life. Cardiac rehabilitation will help him to return to
daily activities and improve heart health by, increasing physical activity, nutrition
education, controlling risk factors, and improving mental and emotional health.
Physical activity will help strengthen the heart muscle, endurance, and flexibility.
It will also improve normal daily activities. The nutrition education component
teaches a heart healthy diet, low in saturated and trans fats, cholesterol, and
sodium, which will help him to lose weight, and reduce cholesterol levels. Also,
the rehab team will work with him to quit smoking, which will help him to reduce
future heart problems and cholesterol level. Lastly, the rehab team may suggest
joining a support group, or seeing a mental health physician for guidance
throughout the recovery process (What to Expect During Cardiac Rehabilitation,
2013).
II. Understanding the Nutrition Therapy
4. What risk factors indicated in his medical record can be addressed through
nutrition therapy?
Many of the risk factors indicated in his medical record can be addresses through
nutrition therapy. For instance, Mr. Klosterman is slightly overweight, has high
cholesterol, and consumes higher amounts of refined carbohydrates, fat, and salt.
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Mr. Klosterman has a BMI of 26.6, which classifies him as overweight. His
cholesterol level is roughly in the low 200’s, compared to the normal range of 120
to 199 mg/dL. Contributing to this level is his considerably low HDL cholesterol
in the low 30’s compared to the optimal level of above 45 mg/dL. Also, his LDL
cholesterol is in the mid 100’s, roughly 150, compared to the recommended level
of less than 130 mg/dL. Overall, his diet consists of refined carbohydrates such as
a cinnamon raisin bagel and pretzels, as opposed to whole grain carbohydrates.
He consumes more fat and salt in food sources, such as roast beef, canned
vegetable beef soup, various condiments, dill pickles, and 2% milk. All of these
risk factors can be addressed through nutrition therapy, primarily using the
Therapeutic Lifestyle Changes guidelines (48-51).
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What are the current recommendations for nutritional intake during a
hospitalization following a myocardial infarction?
Until the angioplasty procedure is completed Mr. Klosterman is on a NPO
(nothing by mouth) diet. After the procedure it may be difficult and painful for the
patient to consume food orally. Initially after surgery he will be able to consume
clear liquids without caffeine. Gradually he will be able to make his way to
consuming soft easily chewed foods in small quantity. Once he has gained
stability his diet will be individualized, however will follow the Therapeutic
Lifestyle Changes. The TLC guide will educate him what foods to choose more
often, recommendations for weight loss and exercise, and what foods to choose
less often (325).
III. Nutrition Assessment
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What is the healthy weight range for an individual of Mr. Klosterman’s
height?
For Mr. Klosterman’s height, 5’ 10, the ideal body weight would be 166 pounds.
Hamwi Method:
106 lbs for 5 ft + 6 lbs per inch over 5 ft
106 lbs + (6 lbs x 10 inches)= 166 lbs
A healthy weight range for an individual of Mr. Klosterman;s height would be
129 lbs to 173 lbs, because the BMI for an optimal weight is 18.5 to 24.9 (52).
BMI= weight (kg)/ height (m)2
BMI x height (m)2 = weight (kg)
1 inch= 2.54 cm
1 kg= 2.2 lbs
12in x 5ft = 60 in + 10 in = 70 in x 2.54 cm = 177.8 cm/ 100 cm= 1.778 m
18.5 x (1.778 m)2= 58.4 kg x 2.2 lbs= 129 lbs
24.9 x (1.778)2 = 78.71 kg x 2.2 lbs = 173 lbs
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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.
Mifflin- St Jeor Equation:
REE= 10 x wt (kg) + 6.25 x ht (cm) – 5 x age (yrs) + 5
185 lbs/ 2.2 lbs = 84 kg
REE= 10 x 84 kg + 6.25 x 177.8 cm – 5 x 61 + 5= 1651.25 kcal/day (67).
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Physical Activity Level (PAL) is 1.6, because he is a minister and has some
movement throughout work, and he also takes a light walk for 15 minutes. He
does not significantly work out or stand throughout his day, however he does have
some movement.
1651.25 kcal x 1.6 = 2642 kcal/ day
RDA for protein, for adults, is typically 0.8 g protein per kg body weight (66).
0.8 g protein x 84 kg= 67.2 grams of protein
RDA for protein, for patients in metabolic stress, trauma, and disease may need
additional protein (66). For instance, after Mr. Klosterman’s surgery he may
need additional protein sources for recovery. The RDA for him will be between
84g and 126g of protein:
1.0 g protein x kg body weight to 1.5 g protein x kg body weight
1.0 g protein x 84 kg = 84 g protein
1.5 g protein x 84 kg = 126 g protein
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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.
Total Calories
2648 calories
Protein (g)
120g
Protein (% calories)
18%
Carbohydrate (g)
343g
Carbohydrate (% calories)
52%
Total Fat (g)
91.2g
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Total Fat (%)
31%
(SuperTracker)
Energy distribution of calories for protein:
120g x 4cal/g = 480 calories
480cal / 2648cal = 0.18 x 100%= 18% calories from protein
Energy distribution of calories for carbohydrate:
343g x 4cal/g = 1372 calories
1372cal / 2648cal = 0.518 x 100%= 52 % calories from carbohydrates
Energy distribution of calories for fat:
91.2g x 9cal/g= 820.8 calories
820.8cal/ 2648cal = 0.31 x 100% = 31% calories from fat
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Examine the chemistry results for Mr. Klosterman. Which labs are
consistent with the MI diagnosis? Explain. Why were the levels higher on day
2?
Mr. Klosterman’s chemistry lab results were positively correlated with the
diagnosis of myocardial infarction. First, his HDL cholesterol was considerable
low, 32 mg/dL, compared to the recommended 45 mg/dL. HDL removes
cholesterol from tissues and transports it to the liver, however when HDL is low
there is an accumulation of cholesterol in the arteries as plaque. Secondly, his
LDL cholesterol is considerably high 150 mg/dL, in relation to the optimal range
of less than 130 mg/dL. The oxidation of LDL is one of the most prominent
components in the accumulation of plaque in the arteries. Additionally, the
cardiac enzymes, lactic dehydrogenase (LDH), aspartate aminotransferase (AST),
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and creatinine phosphokinase (CPK- MB or CPK) are excreted as cells die from
oxygen depletion, hence a myocardial infarction. The chemistry lab is in
accordance with this because LDH, AST, and CKPK-MB and CPK are all
elevated, compared to the standard. Additionally cardiac troponin I, T is a protein
released from myocardial cells after a cardiac injury, and its level is considered a
benchmark for diagnosing heart attacks. Both troponin I and T are elevated in
comparison to the optimal level. Furthermore, the levels of each chemical
component were higher on day two because they were being deprived of oxygen
or were released in response to the cardiac injury (325).
10 What is abnormal about his lipid profile? Indicate the abnormal values.
Chemistry
Ref. Range
12/1
12/2
12/3
Cholesterol
120-199
235
226
214
HDL- C
> 55 F
30
32
33
(mg/dL)
> 45 M
LDL (mg/dL)
< 130
160
150
141
Apo A (mg/dL)
101-199 F
72
80
98
(mg/dL)
94-178 M
Mr. Klosterman’s lipid profile is abnormal based upon his lab results. His overall
cholesterol level was considerably higher, at roughly 225, compared to the range
of 120- 199. Additionally, his HDL cholesterol was abnormally low for his
recommendation of 45 mg/dL compared to his average of 31.5 mg/dL. His LDL
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cholesterol was high around roughly 150 mg/dL compared to the optimum of less
than 130 mg/dL. Furthermore, the Apolipoprotein A, was below the
recommended level for the first two days, at a medium of 76 mg/dL. Apo A
works in coordination with HDL to transport cholesterol to the liver, therefore at a
decreased level there is an accumulation of cholesterol in the arteries (APOA1
gene, 2012).
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 Interaction
Lopressor 50 mg daily
- Alcohol may contribute to drowsiness.
- Calcium may inhibit absorption (300).
- Allergic reactions may not respond to
normal doses of epinephrine.
- Look out for side effects such as,
wheezing, bloating, weight gain, irregular
heartbeat, dry mouth, and shortness of
breath.
Lisinopril 10 mg daily
-Take caution when using potassium
supplements or salt substitutes containing
potassium, natural licorice, antiinflammatory drugs, diuretics, and lithium
(300).
- Look out for serious side effects such as,
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swelling, difficulty breathing/swallowing,
dry cough, fever, yellowing of skin, chest
pain, and fainting.
Nitro- Bid 9.0 mg twice daily
-Take caution when consuming alcoholic
beverages, it may make the side effects
worse.
- Consult doctor if taking medications for
high blood pressure, heart failure, or an
irregular heartbeat.
- Diet may remain as normal.
- Some side effects include slow heartbeat,
worsening chest/abdominal pain, fainting,
rash, and difficulty breathing or
swallowing.
NTG 0.4 mg sl prn chest pain
-Avoid use with alcohol.
- Common side effects are blurred vision,
dry mouth, chest pain, rash, paleness, or
peeling of skin, difficulty breathing or
swallowing, and weakness.
ASA 81 mg daily
- Avoid use with alcohol and other pain
medications.
- Side effects include vomiting, stomach
pain, heartburn, hives, cold clammy skin,
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loss of hearing, blood in stools and vomit,
and black or tarry stools.
(MedlinePlus Drug Information, 2015)
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?

What is your daily schedule?

Who primarily does the cooking/grocery shopping at home?

How often do you eat out?

Do you add salt to your food?

How many meals/snacks do you have throughout the day?

Are there any financial restrictions?

How often do you exercise?

Do you know how to read a nutrition label?

Are you familiar with the DASH diet?

What types of fresh fruits, vegetables, lean protein, and whole grains do you
consume? And how often?

Do you consume sugary beverages and sweets regularly?

Are you willing to try new foods and make behavior changes?

What motivates you to make a nutritional change?
13 What other issues might you consider to support successful lifestyle changes
for Mr. Klosterman?
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Additional issues to consider, to support successful lifestyle changes for Mr.
Klosterman are:
1. Smoking will be addressed in order to help Mr. Klosterman live a healthy
lifestyle. Smoking contributes to a decrease nitric oxide, an increase in
inflammatory response and cholesterol levels, which contribute to the formation
of plaque in the walls of arteries. To help support a heart healthy lifestyle, joining
a support group and contributing in intervention strategies will help to weed Mr.
Klosterman from smoking and towards a healthier lifestyle. Also, it is important
for him to be educated on the affects of smoking and for him to be able to
distinguish why he is quitting smoking (306, 309).
2. Physical activity will be addressed to help Mr. Klosterman maintain a healthy
lifestyle. He is only active slightly through work, as walking around as a minister,
and taking his dog for a leisure walk for 15 minutes. Physical activity is important
in lowering blood pressure, triglycerides, increasing HDL, improving endothelial
function, and decreasing platelet aggregation. Having a partner, for instance his
wife, to spend 30 minutes of moderate exercise daily with is a way to keep
motivated and get exercise. As a dietitian, I would stress the importance of
physical activity, and also design a plan that would keep him motivated, such as
including his wife in his daily physical activity (309).
3. Family history, age, and sex of Mr. Klosterman put him at a higher risk of
developing atherosclerosis. It is important to educate him on how these factors
may contribute to his heart condition, however his behavior change will be
helpful in combating against these unchangeable risk factors. First, I would
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educate him on the genetic component of developing atherosclerosis. The genetic
component is related to how the body metabolizes lipids, which results in
hypercholestermia. However, environmental factors such as diet and exercise
influence hypercholstermia more. Second, I would address that at his age of 61,
he is at a higher risk than someone who is in their early 20s. Additionally, males
develop atherosclerosis at a faster rate. Although these unchangeable factors
affect him, I would emphasize the factors that are changeable, such as his diet,
exercise, and smoking habits (309).
14 From the information gathered within the assessment, list possible nutrition
problems using the correct diagnostic terms.
Excessive fat intake NI-5.6.2
Overweight/ obesity NC- 3.3
Predicted food- medication interaction lopressor, lisinopril, nitro-bid, NTG, and
ASA. NC- 2.4
Food- and nutrition- related knowledge deficit NB- 1.1
Physical inactivity NB- 2.1
(Nutrition Terminology Reference Manual, 2015)
IV. Nutrition Diagnosis
15. Select two of the identified nutrition problems and complete the PES
statement for each.
1. Excessive fat intake related to consumption of red meat, full fat milk products,
and processed foods as evidence by diet history and an average cholesterol level
of 225, over a three-day period.
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2. Overweight/ obesity related to excess intake of fat and physical inactivity as
evidence by a BMI of 26.6, average cholesterol level of 225, and 15 minutes of
physical activity per day.
V. Nutrition Intervention
16. For each of the PES statements you have written, establish an ideal goal
(based on the sign and symptoms) and an appropriate intervention (based on
the etiology).
1. Primary goal is to decrease fat intake and cholesterol level to below 200 mg/dL;
this can be accomplished by decreasing the amount of red meat and full fat milk
products, and instead choosing lean cut meat, poultry and fish and fat free or low
fat dairy products, fresh fruits and vegetables, and whole grains. Additionally, 38
grams of fiber will be added to his diet because of its ability to decrease LDL
cholesterol (319).
2. Primary goal is to decrease BMI to a healthy weight between 18.5 and 24.9,
aiming to lose one pound per week, by increasing physical activity initially in the
form of cardiac rehabilitation, and gradually increasing to 3-5 days of aerobic
training and 2-3 days of anaerobic training. Also, he can lose weight by
consuming 3 to 5 serving of vegetables, 2 to 4 serving of fruits daily, and
choosing low-fat dairy products, lean meat, and high fiber foods.
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?
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Omega-3 fatty acids are essential fatty acids and are a component of a heart
healthy diet. They are an important component in immune and anti-inflammatory
response, platelet function, regulation of blood pressure and cholesterol, and
cellular processes (319). Omega 3- fatty acids can be found in cold-water fish,
fish oils, and flaxseed. There are mixed studies on the affect of omega- 3 fatty
acid supplementation on the diet. It is recommended that he consumes 1 g of EPA
and DHA daily. Some dietitians’ recommend supplementation for those with high
cholesterol and coronary heart disease, others recommended having fish twice a
week (Omega- 3 fatty acids, 2015).
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?
In three to four weeks when Mr. Klosterman and his wife return for additional
counseling I would want to assess first his dietary intake, looking at calories, and
total amount of fat, carbohydrate, protein and fiber consumed. Next, I would
assess his laboratory tests, primarily his lipid panel, which would give his
cholesterol results. Then, I would look at his BMI, and determine if the dietary
and physical activity recommendations are working. Lastly, I would evaluate their
knowledge on a heart healthy diet. I would do this by looking at their diet history,
evaluating their food choices. Throughout the monitoring and evaluating process I
would look to see if the couple is still motivated to maintain a healthy lifestyle
and also ask if they have any questions or concerns (322).
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Work Cited
APOA1 gene. (2012, November 1). Retrieved September 3, 2015, from
http://ghr.nlm.nih.gov/gene/APOA1
Angioplasty / Balloon Angioplasty. Retrieved September 3, 2015, from
http://www.cts.usc.edu/hpg-angioplasty.html
MedlinePlus Drug Information. (2015, August 25). Retrieved September 3, 2015, from
https://www.nlm.nih.gov/medlineplus/druginfo/meds/a682878.html
Nelms, M., Sucher, K., & Lacey, K. (2011). Nutrition therapy and pathophysiology (2nd ed., pp.
48-325). Belmont, CA: Wadsworth, Cengage Learning.
Nutrition Terminology Reference Manual. (2015). Retrieved September 3, 2015, from
https://ncpt.webauthor.com
Omega-3 fatty acids. (2015, August 5). Retrieved September 3, 2015, from
http://umm.edu/health/medical/altmed/supplement/omega3-fatty-acids
SuperTracker: My Foods. My Fitness. My Health. Retrieved September 3, 2015, from
https://www.supertracker.usda.gov
What To Expect During Cardiac Rehabilitation. (2013, December 24). Retrieved September 3,
2015, from http://www.nhlbi.nih.gov/health/health-topics/topics/rehab/during
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