Inpatient Presentation

A Deidentified Case Study on Cerebrovascular Accident (CVA)

Your Name
Cedar Crest College
NTR 340: Nutrition Counseling, Spring 2019

Tessa Guarino
NTR 572 : Clinical Nutrition, Fall 2021
OBJECTIVES
The audience will be able to:
1. Select the three major predisposing conditions for stroke when given
4 choices.
2. Select three medications that aid in lowering high blood pressure to
reduce the risk of stroke when given 4 choices.
3. Identify the appropriate equation to calculate energy needs for stroke
when given 2 choices.
BACKGROUND
• 75yo female admitted to ER with a right intracerebral hemorrhage (ICH)
and transferred to inpatient rehab for recovery. The etiology of the
stroke was HTN.
• Why this case?
• The first patient interview I conducted by myself.
• Plan: Cardiovascular diet education.
• During the assessment, the patient reported that she is always hungry and
“knows she is only supposed to consume ~800kcals per day.”
ASSESSMENT
• Consulted by RN for nutrition assessment for CVA patient.
• Medical HX:
• HTN, T2DM, Hyperlipidemia, Hypothyroidism, Anxiety, Breast Cancer.
• Medications:
• Norvasc – High BP
• Atenolol – High BP
Interactions (UpToDate):
• Lisinopril – High BP • Consider therapy modification
• Simvastatin – High Cholesterol and TG for Norvasc and Simvastatin.
• Levothyroxine – Hypothyroidism
ASSESSMENT ASPEN Criteria for Malnutrition
• Reduced Energy Intake:
• Anthropometric Measurements • Moderate chronic illness:
<75% for >/= 1 month
• Height: 157.5cm (5’2”)
• Unintentional Weight Loss:
• Weight: 67.9kg (149 lbs.) • None (weight loss was
• BMI: 27.36 (Overweight) INTENTIONAL)
• NFPE:
• UBW: 148-151lb per patient interview. • No fat or muscle wasting
• IBW: 50.45 kg (110 lbs.)
• Pt reported INTENTIONAL weight loss of 36lb over the past year to lower
HbA1c.
• This patient did not meet ASPEN criteria for malnutrition.
ASSESSMENT
• Food/Nutrition Related History
• Diet order: General/normal diet.
• Dietary Recall:
• ~2 meals per day at home with some snacks.
• Patient did not state any cultural/dietary preferences.
• NKFA
ASSESSMENT
• Biochemical Data
• Glucose – Elevated at 124mg/dL (reference 65-99mg/dL)
• Glucose POC – Elevated at 149mg/dL (reference 65-99mg/dL)
• HbA1c – Elevated at 6% (reference <5.7%)
• Medical Tests/Procedures
• Head CT – Showed a hemorrhage
LITERATURE REVIEW
• American Heart Association (AHA) 1
• 2021 Guidelines for the Prevention of Stroke
• Academy of Nutrition and Dietetics Nutrition Care Manual under the
CVD and CVA condition tabs 2
• Peer Reviewed Journal Article – Nutrients 3
• Nutrition and Risk of Stroke (Published in 2019)
 RECOMMENDATIONS FOR PRACTICE
• Estimating Needs: 2
• Energy:
• Indirect calorimetry
• Mifflin-St. Jeor with an activity
factor
• Protein:
• 0.8-1g/kg (with adjustments for
special conditions)
• Fluid:
• No specific standard found.
Assessment: 2
• Labs: Lipid profile (Chol, HDL,
LDL, TG), Glucose, HbA1c
• Meds: High BP, Statins,
Metformin, Insulin
• BMI Classification
Dietary Considerations:
• Foods high in sodium,
saturated fat, cholesterol.
RECOMMENDATIONS FOR PRACTICE
• Pertinent MNT:
• Nutrition therapy for CVA: Identifying/treating modifiable risk factors 1, 2
• The three major predisposing conditions for CVA:
• CVD, HTN, and DM. 2
• Limit intake of salt and red meat.3
• DASH or Mediterranean diet. 3
• Texture-modified diet, liquid nutrition supplements, or tube feeds. 2
INTERACTIVE DISCUSSION
• What would you do?
• 75yo female patient with CVA due to HTN and in rehab
• Medical HX: HTN, T2DM, Hyperlipidemia.
• Diet order: General/normal diet.
• 157.5cm, 67.9kg
• BMI: 27.36 (Overweight Classification)
• Assessment revealed reduced energy intake at home
DIAGNOSIS
• PES:
• Inadequate energy intake is related to food and nutrition related
knowledge deficit as evidenced by per pt interview and dietary recall
showing po approximately ~50% estimated energy needs prior to
admission.
 INTERVENTION
• Interventions: • Calculated Estimated Needs:
• Meals & snacks to meet energy needs • 157.5cm, 67.9kg
and education on adequate intakes +
low Na/saturated fat intakes • Energy: 1,470-1,700kcals
• Patient denied supplements • Mifflin-St. Jeor x 1.3-1.5 AF
• Prescription: Cardiovascular diet, Na for rehab
restricted. • Protein: 68-84g
• Rationale: • 1-1.25g/kg (0.8-1g/kg
• Important to ensure she was consuming unless special conditions:
>/=75% of meals and educate on importance.
stroke/rehab)
• Interventions and PES: • Fluid: 1mL/kcal
• Etiology of inadequate intake: knowledge deficit
• No standard found
MONITORING & EVALUATION
• Criteria: Food and beverage intake >/= 75% of meals and snacks
• Evaluate whether the patient was meeting her estimated needs.
• Assigned for her follow-up assessment a week later
• The patient met her criteria of intakes >/= 75% and gave 100% teach back
of importance of low sodium/saturated fat.
APPLICATION IN PRACTICE
• Intervention of meals and snacks addresses this patient’s chronic inadequate
intake
• Intervention of low sodium/saturated fat education does match the AHA
guidelines
• Possible future changes to patient care:
• Difficulty chewing/swallowing (need soft/moist/pureed foods)
• Could discuss increasing physical activity if the patient is younger
REFERENCES
1. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the prevention of
stroke in patients with stroke and transient ischemic attack: a guideline from the
american heart association/american stroke association. Stroke. 2021;52(7).
doi:10.1161/str.0000000000000375.
2. Cardiovascular Disease Comparative Standards . Nutrition Care Manual.
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=272984&lv2=2
55501&lv3=271997&ncm_toc_id=271997&ncm_heading=Nutrition Care. Accessed
September 22, 2021.
3. Spence JD. Nutrition and risk of stroke. Nutrients. 2019;11(3). doi:10.3390/nu11030647
Q&A
• Any Questions?
 QUIZ
Please scan the QR code or use
the URL below to take the CVA
quiz!

https://forms.office.com/Pages/ResponsePage.aspx?id=FrKA2D4d
PEyUVfxD2YE31nxC8mKlKjJFpBV0e3N9LBRUQUtQVEtCS0RJRjc1N
1haNkhCSk1DWTUwVS4u