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Group 5 Molly Chaffin Karly Childress Claire Holladay Lauren Mitchell Denielle Saitta Nutrition 415 November 10, 2013

Case 5- Myocardial Infarction Understanding the Disease and Pathophysiology 1. Mr. Klosterman had a myocardial infarction. Explain what happened to his heart. A heart attack occurs when blood flow to the heart muscle is decreased or blocked completely, keeping the heart from getting enough oxygen, which can damage or destroy part of the heart muscle. Heart attacks are most often caused by the buildup of plaque in the arteries that lead to the heart. Plaque is a sticky substance made up of cholesterol and other substances. Hypertension is also a key contributor of MI. 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 to open narrowed or blocked blood vessels that supply blood to the heart. These blood vessels are called the coronary arteries. A coronary artery stent is a small, metal mesh tube that expands inside a coronary artery. A stent is often placed during or immediately after angioplasty. It helps prevent the artery from closing up again. A drug-eluting stent has medicine embedded in it that helps prevent the artery from closing in the long term. Arteries can become narrowed or blocked by deposits called plaque. Plaque is made up of fat and cholesterol that builds up on the inside of artery walls. This condition is called atherosclerosis. Angioplasty is used to treat a blockage in a coronary artery after a heart attack.
Comment [HMB1]: 46.5/50

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 usually provides education and counseling to help heart patients increase physical fitness, reduce cardiac symptoms, improve health, and reduce the risk of future heart problems. Counseling and education sessions can help Mr. Klosterman quit smoking, eat right, lose weight, and lower blood pressure and cholesterol levels. Counseling can also help him learn to manage stress and to feel better about his health. Understanding the Nutrition Therapy 4. What risk factors indicated in his medical record can be addressed through nutrition therapy? Mr. Klosterman has elevated levels of LDL-C while his HDL-C levels are low which is dyslipidemia. Dyslipidemia increases the risk of atherosclerosis and is reported to cause the highest prevalence in cardiovascular disorders. It is a condition where LDL-C levels are high and HDL-C levels are low. He is also overweight. His 24-hour recall illustrates a greater than recommended sodium intake, which is a contributing factor to his condition. 5. What are the current recommendations for nutritional intake during a hospitalization following a myocardial infarction? Mr. Klosterman is on a NPO (Nothing by mouth) diet until the procedure, which means he is not allowed to eat or drink anything. A nutrition therapy eating plan with a low intake saturated fat, trans fat, and cholesterol and a cardioprotective dietary pattern is nutritionally adequate. Lowering saturated fat intake to 5-6% of total daily energy intake and lowering cholesterol to a moderate level since the new guidelines have no specific limit for cholesterol. Sodium intake should also be limited. Food choices such as whole grains, fruit and vegetables, low-fat dairy, and lowfat meats are necessary to meet nutrient adequacy. Nutrition Assessment 6. What is the healthy weight range for an individual of Mr. Klosterman’s height? BMI healthy range (18.5 – 24.9) = Weight (kg)/height (m)2 Kg/(70in x 0.0254m/in)2 = 18.5 low (58.4 kg or 128.5 lbs) Kg/(70in x 0.0254m/in)2 = 24.9 high (78.7 kg or 173.1 lbs)

Comment [HMB2]: Per guidelines, to 1,500 mg/day for him. Comment [HMB3]: Yes, DASH diet pattern or similar.

Healthy range according to BMI would be between 128.5 to 173.1 pounds. 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. Mifflin-St. Jeor REE= (10 * 84) + (6.25 * 178) – (5 * 61) + 5 = 1,652 kcal TEE= 1,652 * 1.4 = 2,313 kcal/day Post surgery = 1,652 * 1.2 = 1,982 An activity factory of 1.4 is used for Mr. Klosterman because he has a low activity level by walking his dog for only 15 minutes per day. An injury factory of 1.2 is used during his hospital stay in replace of his activity factor. Protein requirements: 84 kg x 0.8-1.0= 67.2-84 g protein/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. Mid-Morning Snack Food List Large Cinnamon Raisin Bagel (4 carb exchanges) 1 tbsp fat free cream cheese (1 free exchange) 8 oz orange juice (2 fruit carb exchange) coffee TOTAL 90g 0-12g 0-4g =440 30g 120 Carbohydrate (g) Protein (g) 60g (0-12)g Fat (g) (0-4)g Calories 320

Lunch Food List 1 c. canned vegetable beef (1 carb exchange) Sandwich bread 4 oz roast beef lettuce, tomato, pickles 2 tsp mayo 1 small apple (1 fruit carb exchange) 8 oz 2% milk TOTAL Carbohydrates (g) 15g Protein (g) (0-3)g Fats (g) (0-1)g Calories 80

30g 30g

28-34g (0-6)g 28g

10-15g (0-1)g (0-4)g

434 160 184

10g 15g

90 60

12g 72g

8g 36-45g

5g 15-21g

120 =694

Dinner Food List 2 lean pork chops (6 meat exchanges) Large baked potato (4 starch exchange) ½ cup green beans (2 low carb exchanges) ½ cup coleslaw (1 carb + 1.5 fat exchanges) 60g Carbohydrate (g) Protein (g) 42g Fat (g) (0-18)g Calories 600

(0-12)g

(0-4)g

320

10g

4g

50

Comment [HMB4]: It doesn’t appear that the portion size is listed in the food lists, but ½ c of cooked vegetables generally is equal to one choice.

15g

(0-3)g

7.5g

147.5

1 slice apple pie (3 carb + 1 fat exchange) TOTAL

45g

(0-9)g

(5-6)g

285

130g

46-70g

12.535.5g

=1,402.5

Snacks Food List 2 lean pork chops (6 meat exchanges) Large baked potato (4 starch exchange) ½ cup green beans (2 low carb exchanges) ½ cup coleslaw (1 carb + 1.5 fat exchanges) 1 slice apple pie (3 carb + 1 fat exchange) TOTAL 60g Carbohydrate (g) Protein (g) 42g Fat (g) (0-18)g Calories 600

Comment [HMB5]: I think you intended to put pretzels and milk here?

(0-12)g

(0-4)g

320

10g

4g

50

15g

(0-3)g

7.5g

147.5

45g

(0-9)g

(5-6)g

285

130g

46-70g

12.535.5g

=1,402.5

Comment [HMB6]: What was the daily total for everything using the food lists?

Printable Nutrition Report for Mollychaffin

11/ 12/ 13 9:40 AM

Printable Diary for Mollychaffin
From: To: Show: Food Diary Exercise Diary Food Notes Exercise notes
change report

November 10, 2013
FOODS Breakfast Thomas' - Bagels Cinnamon Raisin, 1 Bagel Kraft - Cream Cheese Fat Free, 1 Tbsp (31g) Tropicana - Orange Juice - 100% Juice, 8 fl oz Lunch Great Value Vegetable Beef Soup, 1 Can - Vegetable Beef Soup, 1 cup Lettuce - Iceberg (includes crisphead types), raw, 1 serving Subway - Tomato Slice, 3 slicse (34 g) Generic - Dill Pickel, 1 oz Kraft - Mayonnaise 1 Tbsp, 26 g Fruit - Gala Apple - Small 100 Grams, 100 g Milk - Reduced fat, 2% milkfat, 1 cup Kroger - Deli Thin Sliced Roast Beef, 4 (oz) Snack Rold Gold - Classic-Style Tiny Twist Pretzels, 1 oz package Milk - Reduced fat, 2% milkfat, 1 cup Dinner Safeway Bakery - Apple Pie, 1/6 pie Beans - Snap, green, cooked, boiled, drained, without salt, 0.5 cup Imperial - Margarine - (53% Vegetable Oil Spread), 2 tbsp (14 g) Generic - Large Russet Baking Potato (Metric) (Net Carbs), 175 g Publix - Lean Pork Chop, 6 oz Cabbage - Raw, 0.5 cup, chopped Hidden Valley - Dressing - Coleslaw, 1 tbsp (30 g) TOTAL: 280 22 140 170 210 11 75 2,201 39g 5g 0g 33g 0g 2g 3g 280g 21g 0g 14g 0g 6g 0g 8g 89g 3g 1g 0g 5g 35g 1g 0g 106g 5mg 0mg 0mg 0mg 98mg 0mg 8mg 224mg 220mg 1mg 210mg 25mg 105mg 8mg 85mg 5,064mg 18g 1g 0g 2g 0g 2g 2g 101g 1g 2g 0g 4g 0g 1g 0g 19g 110 122 23g 11g 1g 5g 2g 8g 0mg 20mg 450mg 100mg 0g 12g 1g 0g 180 12 5 5 180 52 122 120 30g 3g 2g 0g 0g 14g 11g 2g 2g 0g 0g 0g 22g 0g 5g 3g 8g 1g 0g 0g 0g 0g 8g 20g 10mg 0mg 0mg 0mg 10mg 0mg 20mg 50mg 1,760mg 9mg 0mg 280mg 140mg 1mg 100mg 1,060mg 4g 2g 0g 0g 0g 10g 12g 2g 4g 1g 0g 0g 0g 2g 0g 0g 260 15 110 52g 1g 49g 2g 0g 0g 10g 2g 2g 0mg 3mg 0mg 390mg 105mg 15mg 11g 1g 22g 3g 0g 0g Calories Carbs Fat Protein Cholest Sodium Sugars Fiber

http:/ / www.m yfitnesspal.com / reports/ printable_diary/ m ollychaffin?from = 2013- 11- 10&to= 2013- 11- 10

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Carbohydrate 280 g x 4 cal/g= 1,120 calories =54% carbohydrates Protein 106 g x 4 cal/g = 424 calories = 19% Fat: 89 g x 9 cal/g = 801 calories = 36%

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? Total cholesterol is high (235) and LDL-C was high (160). His high LDL-C and low HDL-C (30) indicates plaque buildup which is consistent with his diagnosis. His troponin I and T levels are very high. His troponin I level was 2.4 when the reference range is <0.2, and his troponin T level was 2.1 when the

reference range is <0.03. Troponin is a protein that is released when there has been damage to the heart muscles. The more damage to the heart, the more proteins that can seep out into the blood stream. This is why is levels were higher on day two. 10. What is abnormal about his lipid profile? Indicate the abnormal values. Total Cholesterol LHDL HLDL LDL/HDL ratio Apo-A Apo-B Triglycerides Day One 235 mg/dl H 160 mg/dl H 30 mg/dl L 5.3 mg/dl H 72 mg/dl L 115 mg/dl 15o mg/dl Day Two 226 mg/dl H 150 mg/dl H 32 mg/dl L 4.7 mg/dl H 80 mg/dl L 110 mg/dl 140 mg/dl Day Three 214 mg/dl H 141 mg/dl H 33 mg/dl L 4.3 mg/dl H 98 mg/dl L 105 mg/dl 130 mg/dl Normal Range 120-199 mg/dl >45 mg/dl <130 mg/dl < 3.55 mg/dl 94-178 mg/dl 63-133 mg/dl 40-160 mg/dl

Comment [HMB7]: What about elevation in enzymes that also support the MI dx?

Comment [HMB8]: I think you just plugged his values into the incorrect rows.

11. Mr. Klosterman was prescribed the following medications on discharge. What are the food-medication interactions for this list of medications? Purpose Mechanism Nutritional Interaction Lopressor Blood Pressure Beta blocker Calcium interferes with absorption, avoid licorice Lisinopril Blood Pressure ACE inhibitor Avoid high potassium Nitro-Bid Chest Pain Vasodilator Avoid alcohol NTG Chest Pain Vasodilator Avoid alcohol Aspirin Blood thinner COX inhibitor Vitamin K affects thickness of blood, Calcium decreases absorption

Unclear as to why Mr. Klosterman was not prescribed a statin drug. 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? Who does the grocery shopping? Who cooks the meals? What kinds of foods do you cook and how are they prepared? How often do you eat out at a restaurant?

What do you like to do in your free time? How much free time do you typically have in a day? Do you frequently feel stressed? 13. What other issues might you consider to support successful lifestyle changes for Mr. Klosterman? Mr. Klosterman could consider smoking cessation. 14. From the information gathered within the assessment, list possible nutrition problems using the correct diagnostic terms. NC-2.2 Altered nutrition-related laboratory data: Cholesterol, LDL, HDL NC-2.4 Predicted food-medication interaction: Lopressor, Lisinopril, ASA NC-3.3 10767 Overweight, adult NB-1.1 Food-and nutrition-related knowledge deficit NB-1.7 Undesirable food choices NB-2.1 Physical inactivity Nutrition Diagnosis 15. Select two of the identified nutrition problems and complete the PES statement for each. (P) Physical inactivity related to (E) sedentary lifestyle as evidenced by (S) only walking 15 minutes each day (P) Modified Altered nutrition-related laboratory values related to (E) high saturated fat diet as evidenced by (S) total cholesterol >200mg/dL, HDL <45mg/dL, and LDL >130mg/dL

Comment [HMB9]: And what do they already know about the relationship between diet/lifestyle and CVD …

Comment [HMB10]: What about diagnostic terms from the intake domain?

Comment [HMB11]: I neglected to comment on this in your draft – done correctly in your presentation, though.

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 (base on etiology). PES #1: Altered nutrition-related laboratory values related to high saturated fat diet as evidenced by total cholesterol >200 mg/dL, HDL <45 mg/dL, and LDL >130 mg/dL Nutrition Rx: Modify diet to consume less than 5-6% of daily calories from saturated fats; this translates to between 99.1-118.92 calories from saturated fat or 16 grams of saturated fat per day for Mr. Klosterman Nutrition Intervention: This can be done by decreasing dietary consumption of saturated fats by choosing a lower fat milk option. Provide
Comment [HMB12]: Here you have it correct!

Comment [HMB13]: For both nutrition interventions – need to use nutrition intervention terms – most likely for his case they will fall under the Nutrition Education or Nutrition Counseling domains.

nutrition education to promote healthy cooking and appropriate portion sizes. Also, continue to replace butter with oil when cooking and reduce fried foods. Participate in the DASH diet to reduce sodium intake and have a better heart healthy diet and help reduce BMI. PES #2 Physical inactivity related to sedentary lifestyle as evidenced by only walking 15 minutes each day Nutrition Rx: Increase physical activity to 150 minutes per week of moderate intensity physical activity. Nutrition intervention: From Nutrition Care Manual, increase walking to 30 minute per day, five or more times per week. Discuss other options for physical activity to decrease sedentary time. Gradually increase daily activity time to walking the dog for 30 minutes twice daily two times per week. Also, meet with a personal trainer to set and achieve specific goals. 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? In the DART trial conducted by the American Heart Association, it is stated that omega-3 fatty acids have been shown in epidemiological and clinical trials to reduce the incidence of CVD. Studies have also shown that individuals at risk for CHD benefit from the consumption of EPA and DHA supplementation. The Lyon Diet Heart Study, a randomized, controlled trial, tested the effectiveness of a Mediterranean-type diet (consisting of fish/omega-3 fatty acids) on composite measures of the coronary recurrence rate after a first myocardial infarction. A research cardiologist and dietitian conducted the Lyon Study. The study showed that omega-3 fatty acids exerted cardioprotective effects via multiple mechanisms such as prevent arrhythmia, have anti-inflammatory properties, decrease synthesis of cytokines and mitogens, stimulate endothelial-derived nitric oxide, are anti-thrombotic, are prostaglandin and leukotriene precursors, and inhibit atherosclerosis. However a few research articles have shown evidence that omega-3 fatty acid supplementation has only been proven to prevent secondary MI. Mr. Klosterman could participate in the DASH Diet to help reduce sodium and have a better heart healthy diet.

18. What would you want to assess in three to four weeks when he and his wife return for additional counseling? We would like to evaluate the effectiveness of the nutrition interventions in meeting the nutrition goals. W would want to assess any lab values such as Cholesterol and LDL to make sure these values have lowered to where

we would like to see them. We would also want to check on his AD to see if he has been successful in losing weight and decreasing his BMI. We would ask Mr. Klosterman to perform a 24-hour diet recall to see if he has been making the recommendation dietary changes to decrease calorie and fat intake. Also, we would like to see how the grocery shopping and healthy cooking has changed to suit his new heart healthy diet. We would also like to see how well his cardiac rehabilitation program is going and where he is at with his progress in cessation of smoking. If he is still having trouble with this, we could provide more information on the benefits of quitting and more tips on how to quit.

Comment [HMB14]: Right, so mostly to follow up and see how things are going with regard to dietary changes, physical activity (this was one of your major interventions, so must monitor!). Identify challenges he is having and help the Klosterman’s troubleshoot, answer follow-up questions, etc. Comment [HMB15]: This isn’t really a RD role, although you can and should be supportive of smoking cessation.