Case

5: Myocardial Infarction
Sam Ballard
KNH 411
9.3.2015

I. Understanding the Disease and Pathophysiology
1. Mr. Klosterman had a myocardial infarction. Explain what happened to his heart.

Blood flow was restricted to his heart due to plaque buildup blocking an artery. This
lack of oxygen carrying cells deprived the myocardial cells of oxygen, leading to
necrosis of those cells. This death of myocardial cells weakens the heart muscle
(Nelms, 293).

2. Mr. Klostermans 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 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 posterobasilar scar was present with hypokinesis.
Explain angioplasty and stent placement. What is the purpose of this medical
procedure.

Angioplasty is the surgical insertion of a balloon that, when inflated, opens a
blockage in a blood vessel or coronary artery. The balloon is surrounded by a mesh
tube known as a stent. After the balloon is inflated and has cleared the blocked
artery, it is then deflated and removed, allowing the stent to be put in place. The
stent will hold up and support the artery in hopes of preventing future blockages
and allowing the blood to flow smoothly (University of Michigan Health System:
Cardiac Surgery, 2014).


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 will provide the couple with education, counseling services,
and physical fitness activities and regimens to help reduce his present symptoms,
reduce risk of future heart issues, and improve his overall health and quality of life.
Cardiac rehabilitation is tailored to Mr. Klostermans specific needs. His physical
activity program will include physical activity where his heart rate and blood
pressure are monitored and he will eventually work up to intense aerobic activity.
His counseling and education will address creating a healthy eating plan, smoking
cessation, and stress management. Using this comprehensive team of professionals,
Mr. Klosterman will learn how to return to work and normal activities while
managing his heart condition (American Heart Association, 2015).


II. Understanding the Nutrition Therapy
4. What risk factors indicated in his medical record can be addressed through
nutrition therapy?

Mr. Klostermans weight status and BMI (26.6) indicate he is overweight. Nutrition
therapy can be used to reduce his excessive calorie intake. His cholesterol intake
and the types of cholesterol he is consuming can also be addressed. Lastly, his
dehydration, which is evidenced by tenting of his skin, can be reversed through
increased fluid intake.

5. What are the current recommendations for nutritional intake during a
hospitalization following a myocardial infarction?

While hospitalized, Mr. Klosterman is on an NPO diet until his procedure is
completed. He is currently on a clear liquid diet and he is allowed no caffeine.
Caffeine increases heart-rate, causes abnormal heart rhythms, and would contribute
to his dehydration (MedlinePlus, 2015).

III. Nutrition Assessment
6. What is the healthy weight range for an individual of Mr. Klostermans height?

Hamwi Method:

IBW = 106 lbs. + (6 lbs. x every inch over 5 ft.)
IBW = 106 lbs. + (6 lbs. x 10 inches)
IBW = 106 lbs. + 60 lbs.
IBW = 166 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 place. Calculate his energy and protein
requirements.

Mifflin-St. Jeor Method:

EER = (10 x wt (kg) + 6.25 x ht (cm) 5 x age (yrs) + 5) x PAL
EER = (10 x (185 lbs./2.2 kg) + 6.25 x (70 x 2.54 cm) 5 x 61 + 5) x 1.6
EER = (10 x (84.1 kg) + 6.25 x (177.8 cm) 5 x 61 + 5) x 1.6
EER = (841 + 1,111.25 305 + 5) x 1.6
EER = 1,652.25 x 1.6
EER = 2,643.6 kcal/day

Protein Requirements:

1.0 g/kg/day x 84.1 kg = 84.1 g/kg/day

8. Using Mr. Klostermans 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. (www.fitday.com)

Total Calories = 2,506 kcal
Total Fat = 76.6 g


Total Protein = 128.5 g
Total Carbohydrate = 330.1 g

Fat % = (76.6 g x 9 kcal/g = 689.4 kcal/2,506 kcal = 27.5%
Protein % = (128.5 g x 4 kcal/g = 514 kcal/2,506 kcal = 20.5%
Carbohydrate % = (330.1 g x 4 kcal/g = 1,320.4 kcal/2,506 kcal = 52.7%




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?



Elevated troponin I and troponin T are consistent with the MI diagnosis. Troponin
proteins are released if there has been damage to the heart muscle and these levels
increase with the severity of damage (MedlinePlus, 2014). If troponin levels were
higher on day 2, this must mean that more damage was done to the heart on day 2
since troponin levels increase with the severity of damage. Since the MI was caused
by lack of oxygen to the heart muscle, it is reasonable to assume that the cells
deprived of oxygen finally died, causing necrosis of the myocardium and elevating
the troponin levels on day 2.

10. What is abnormal about his lipid profile? Indicate the abnormal values.

Mr. Klostermans lipid profile indicates that since his admission date on 12/1, he has
had
High cholesterol (214 mg/dL as of 12/3)
Low HDL-C levels (33 mg/dL as of 12/3)
High LDL levels (141 mg/dL as of 12/3)
High HDL/LDL ratio (4.3 as of 12/3)
Apo A levels were low, but have returned to normal (98 mg/dL as of 12/3)

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
Alcohol
Lisinopril 10 mg daily
Alcohol, salt substitutes that contain
potassium, potassium supplements
Nitro-Bid 9.0 mg twice daily
N/A
NTG 0.4 mg sl prn chest pain
Alcohol
ASA 81 mg daily
Alcohol


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?

How often do you eat out?
Could you describe how often and at what times you eat on a regular day?
Are there any foods you will absolutely not eat (due to taste, texture)? If so,
what are they?
Do you have any favorite foods? If so, what are they?
How confident are you in your ability to examine food labels for calories,
carbohydrate, fat, protein, sodium, and cholesterol content?
What activities do you engage in to stay physically active?

13. What other issues might you consider to support successful lifestyle changes for Mr.
Klosterman?

Mr. Klosterman should first stop or reduce his tobacco use. This will improve his
cardiovascular and overall health almost immediately. Weight loss would also
improve his quality of life. This could be done by increasing his daily physical
activity and implementing a diet for his heart health and weight loss, such as a
therapeutic lifestyles (TLC) diet.

14. From the information gathered within the assessment, list possible nutrition
problems using the correct diagnostic terms.

Excessive energy intake (NI-1.3)
Inadequate fluid intake (NI-3.1)

IV. Nutrition Diagnosis
15. Select two of the identified nutrition problems and complete the PES statement for
each.

Excessive energy intake (NI-1.3) R/T skipping breakfast AEB BMI of 26.6.
Inadequate fluid intake (NI-3.1) R/T diaphoresis AEB skin turgor test
resulting in tenting.




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).

The ideal goal for his excessive energy intake would be to reduce his BMI to a
healthy level by losing about 10-15 pounds. This would bring him closer to
his ideal weight of 166 pounds. One way to work towards this goal would be

for him to eat breakfast daily so he would be less hungry throughout the day.
A food log may be appropriate in order to create a self-awareness of his
eating habits.
The ideal goal for his inadequate fluid intake would be to increase fluid
intake so that a reassessment of skin turgor would yield positive results (i.e.
good or fair). His is likely dehydrated due to his diaphoresis, or excessive
sweating, so although we can not control his sweating, Mr. Klosterman can be
in control of how much fluids he intakes to offset this deficit.

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?

According to the American Heart Association, omega-3 fatty acids are beneficial for
cardiac patients. Although obtaining omega-3 fatty acids through food intake is
preferable, supplements may be necessary for heart patients who need more
omega-3 fatty acids than they can get from food alone. It is important, however, to
ensure the supplement is high-quality and free from contaminants in order to use it
extensively (Kris-Etherton, Harris, & Appel, 2002).



VI. Nutrition Monitoring and Evaluation
18. What would you want to assess in three or four weeks when he and his wife return
for additional counseling?

In three or four weeks, I would like to assess Mr. Klostermans eating regimen. I
would like to see that he is regularly eating breakfast in hopes of controlling his
intake throughout the day. Hopefully, this will eventually yield some amount of
weight loss, bringing him closer to his IBW. I would also like to see that his skin
turgor has improved, indicating that he has become properly hydrated. If lab values
were available to me at that time, I would look at his lipid profile again to see if there
were any suggestions I could make about his diet that may alter those values. Also, I
would like to discuss how at home meal making is going for him and his wife to see
if I can make any suggestions or adjustments to meal planning as necessary. Lastly, I
would like to check up on how cardiac rehabilitation is going for him! I want to see
that he is confident in his ability to comply with the multiple fitness, diet, and
lifestyle changes he has made in the past month.

References

American Heart Association (2015). What is cardiac rehabilitation?. Retrieved from
http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-
is-Cardiac-Rehabilitation_UCM_307049_Article.jsp

Kris-Etherton, P.M., Harris, W.S., & Appel, L.J. (2002). Fish consumption, fish oil,

omega-3 fatty acids, and cardiovascular disease. Circulation, 106, 2747-2757.

doi: 10.1161/01.CIR.0000038493.65177.94

MedlinePlus (2014). Troponin test. Retrieved from

https://www.nlm.nih.gov/medlineplus/ency/article/007452.htm

MedlinePlus (2015). Caffeine. Retrieved from

https://www.nlm.nih.gov/medlineplus/caffeine.html

*MedlinePlus (2015). Nitroglycerine topical. Retrieved from
https://www.nlm.nih.gov/medlineplus/druginfo/meds/a682346.html#spec
ial-dietary

Nelms, M.N., Sucher, K.P., & Lacey, K. (2014). Nutrition therapy and pathophysiology

(3rd ed.). Boston, MA: Cengage Learning.

*RxList (2015). Bayer. Retrieved from http://www.rxlist.com/aspirin-drug/patient-
avoid-while-taking.htm

*RxList (2015). Lopressor. Retrieved from http://www.rxlist.com/lopressor-
drug/patient-avoid-while-taking.htm

*RxList (2015). Nitrostat. Retrieved from http://www.rxlist.com/nitrostat-
drug/patient-avoid-while-taking.htm

*RxList (2015). Prinivil. Retrieved from http://www.rxlist.com/prinivil-
drug/patient-avoid-while-taking.htm

University of Michigan Health System: Cardiac Surgery (2014). Coronary angioplasty
and stenting. Retrieved from http://www.med.umich.edu/cardiac-
surgery/patient/adult/adultcandt/coronary_angioplasty.shtml
www.fitday.com





*References for food-medication interaction chart


24-Hour Recall Diet Analysis
www.fitday.com