Solution Manual for Medical Nutrition Therapy A Case Study Approach, 4th Edition

Solution Manual for Medical Nutrition Therapy A

Case Study Approach, 4th Edition

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Answer Guide for Medical Nutrition Therapy: A Case Study Approach 4th ed.
Case 6 – Heart Failure with Resulting Cardiac Cachexia
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 a MI and atherosclerosis. Is this consistent with Dr. Peterman’s history?

• Many different events can lead to the development of congestive heart failure.
• Previous myocardial infarction, valve defect, or increased work demand on the heart from other conditions
such as hypertension all can damage the heart.
• This damage results in a decreased ability of the heart to pump adequately.
• When there is reduced blood flow to tissues, the body compensates in several ways.
• The kidney responds to decreased blood flow by secreting renin and aldosterone, causing
vasoconstriction and an increase in blood volume.
• The heart then has to work even harder to handle the increased blood volume.
• Over time, the heart enlarges (cardiomegaly) with its attempt to handle the increased workload.
• Cardiac output and stroke volume decrease.
• Compensation mechanisms do work for a time but eventually the heart muscle weakens.
• Dr. Peterman’s medical history is consistent with the typical pathophysiology of heart failure. He has a
long history of coronary artery disease, hypertension, and mitral valve disorder. He also experienced a
myocardial infarction. His previous medical diagnoses are all indicative of damage to the heart muscle,
which is the first step in the progression of heart failure.

2. Identify specific signs and symptoms in the patient’s physical examination that are consistent with heart
failure. For any three of these signs and symptoms, write a brief discussion that connects them to
physiological changes that you described in question #1.

• Jugular venous distention

• Ascites
• 4+ pedal edema
• Shortness of breath
• Increased pulse and respirations
• Left-sided heart failure results in pulmonary congestion, causing dyspnea (shortness of breath), whereas
right-sided failure causes marked peripheral edema (4+ pedal edema and jugular venous distention) and
congestion in the liver, spleen, and other organs (ascites).
• This may further impair respirations by pressing up on the diaphragm and limiting pulmonary function
(increased respirations).
• Signs of compensation include tachycardia (increased pulse), pallor, polycythemia, and oliguria.

3. Heart failure is often described as R-sided failure or L-sided failure. What is the difference? How are the
clinical manifestations different?

Left-sided heart failure results from a weakening of the left ventricle of the heart, typically due to cardiac
remodeling following a myocardial infarction. The weakened ventricle cannot pump out the proper amount of
blood, thus further decreasing cardiac output. Blood that is not able to be pumped out of the ventricle backs up
into the pulmonary veins, resulting in pulmonary congestion, orthopnea, coughing, shortness of breath, and
hemoptysis.
Right-sided heart failure results from a weakened right ventricle that cannot maintain a constant and adequate
cardiac output. The decreased output causes a back-up of blood into systemic circulation and eventual
development of edema in the legs and internal organs, distended neck veins, headache, and flushing of the skin.

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6-2

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 development of cardiac
cachexia.

• Cardiac cachexia is a serious condition that can result from severe congestive heart failure.
• It is a type of malnutrition characterized by a progressive and extreme loss of lean body mass.
• Some factors associated with development of this condition are as follows: low caloric intake due to
anorexia, difficulty eating, breathlessness, nausea and vomiting, increased BMR, fat malabsorption,
diuretics, renal protein loss, and poor absorption secondary to congestion of intestinal veins.
• Characteristic symptoms include: cardiomegaly, edema, muscle wasting (supraclavicular and temporal),
weight loss, anorexia, and malabsorption with steatorrhea or diarrhea.
• The heart of this patient was damaged due to a previous myocardial infarction and mitral valve disease.
• The cardiac muscle had an impaired ability to pump blood to the gastrointestinal tract.
• Malabsorption and eventually malnutrition developed.

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?

• Some level of sodium restriction is necessary in the treatment of heart failure because of the complications
associated with severe fluid retention. Sodium in the body attracts fluid, meaning that an excess of sodium
from the diet will cause additional fluid retention. Excessive fluid retention causes peripheral edema,
ascites, and pulmonary congestion in heart failure patients. It is essential that these patients control their
intake of sodium, which in turn controls their level of fluid retention.
• A 2,000 mg sodium diet is a standard initial recommendation.
• Adjustments to levels of 1,000 mg or 500 mg may be prescribed depending on an individual patient’s
medical condition—specifically, fluid and volume states as well as overall oral intake.
• These levels of sodium restriction are a challenge to manage outside a hospitalized setting, so it is critical to
evaluate the patient’s actual PO intake to determine the level of sodium the patient is consuming prior to
putting any further modifications in place.

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?

• On admission he was overhydrated and had prerenal azotemia.

• Physical exam reveals 4+ edema that demonstrates his fluid overload and overhydration.
• The patient’s creatinine and BUN are also elevated.
• These findings are compatible with low kidney perfusion.
• Yes, he should be placed on a fluid restriction.
• Fluid restriction will improve clinical symptoms and quality of life.
• Foods “counted” as fluid: All beverages (including water, milk, juices, coffee, tea, soft drinks), yogurt,
soups, gelatins, fruit ice, Popsicles™, liquid nutritional supplements, ice cream, puddings, custard, sherbet,
soups, and anything liquid (or that melts) at room temperature.

7. Identify any common nutrient deficiencies found in patients with heart failure.

Common nutrient deficiencies found in patients with heart failure include: potassium, magnesium, thiamin,
riboflavin, pyridoxine, calcium, and zinc. Many of these nutrient deficiencies are caused by drug-nutrient
interactions. A common drug-nutrient interaction in heart failure patients is the loss of water-soluble nutrients
when a combination of multiple diuretics is used to remove excess fluid from the body.

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 6-3

III. Nutrition Assessment

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?

• Ascites and peripheral edema.

• Dr. Peterman’s I/O record shows an overall net fluid retention of 408 mL over a 24-hour period since his
admission. If this trend continues, Dr. Peterman’s measured weight will increase to reflect additional fluid
retention. A negative net I/O value would correlate with a decrease in measured weight.

9. Calculate Dr. Peterman’s energy and protein requirements. Explain your rationale for the weight you have
used in your calculation.

• Dr. Peterman’s actual weight is used for calculations. The Mifflin-St. Jeor equation was established using
actual weight.
• Energy: energy needs for cardiac cachexia may be calculated at 50% above basic needs.
Mifflin St. Jeor = 10W + 6.25H – 5A + 5
10(75) + 6.25(177.8) – 5(85) + 5 = 750 + 1111.25 – 425 + 5 = 1441.25 or 1400 kcal
1400  1.2 (AF)  1.5 (SF) = 2520 kcal
• Protein: Protein needs for cardiac cachexia should be estimated at a rate of 0.8 to 1.0 g/kg (increasing or
decreasing depending on renal or hepatic status)
75 kg  0.8 = 60; 75  1.0 = 75
Protein needs = 60-75 g/d

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.

• Formula choice: Two-Cal HN (high-protein formula that provides 2 kcal/mL) = 2200 kcal
• Total volume: 1100 mL
• Goal rate: 46 mL/hr
• Osmolality of Two-Cal NH is 725 mOsm/kg H2O; therefore, the initial rate should be 23 mL/hr for first 8
hours, then advanced 10 mL/hr every 4 hours until goal rate is reached.

11. Identify any abnormal biochemical values and assess them using the following table:

Parameter Normal Patient’s Reason for Abnormality Nutrition Implication

Value Value
Sodium (mEq/L) 136-145 132 Fluid overload resulting in Fluid restriction required to
133 dilution of serum sodium normalize fluid balance
133
BUN (mg/dL) 8-18 32 Cardiac cachexia (protein Diet should include
34 catabolism, muscle wasting) adequate kcal and protein
30 to stop muscle wasting and
reverse malnutrition
Creatinine serum 0.6-1.2 1.6 Cardiac cachexia (protein Diet should include
(mg/dL) 1.7 catabolism, muscle wasting) adequate kcal and protein
1.5 to stop muscle wasting and
reverse malnutrition
Bilirubin, direct <0.3 1.0 Abnormal liver function; Fluid and sodium
(mg/dL) 1.1 hepatomegaly resulting from restrictions required to
0.9 edema in liver prevent further damage
from fluid overload

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6-4

Parameter Normal Patient’s Reason for Abnormality Nutrition Implication

Value Value
Protein, total (g/dL) 6-8 5.8 Fluid overload resulting in Fluid and sodium
5.6 dilution of serum protein restrictions required to
5.5 normalize fluid balance
Albumin (g/dL) 3.5-5 2.8 Fluid overload resulting in Diet should include
2.7 dilution of serum albumin; adequate kcal and protein
2.6 increased protein catabolism to stop muscle wasting and
due to cardiac cachexia treat malnutrition; sodium
and fluid restrictions
required to normalize fluid
balance
Prealbumin 16-35 15 Fluid overload resulting in Diet should include
(mg/dL) 11 dilution of serum prealbumin; adequate kcal and protein
10 malnutrition (cardiac to reverse malnutrition;
cachexia); possible abnormal sodium and fluid
liver function (hepatomegaly) restrictions required to
normalize fluid balance
ALT (U/L) 4-36 100 Impaired liver function No nutritional implications
120 resulting from edema in liver at this time
115 (hepatomegaly)
AST (U/L) 0-35 70 Impaired liver function N/A
80 resulting from edema in liver
85 (hepatomegaly)
CPK (U/L) 55-170 180 Damage to heart muscle; fluid N/A
200 overload resulting in dilution
205 of serum CPK
Troponin T (ng/L) <0.03 0.035 Past cardiac injury N/A
0.037 (myocardial infarction)
0.036
HDL-C (mg/dL) >45 30 History of coronary artery Diet should include
31 disease; lifestyle and diet adequate levels of
30 monounsaturated fatty
acids with reduced intake
of trans fatty acids but at
this stage of HF this is not
a priority
LDL (mg/dL) <130 180 History of coronary artery Diet should include
160 disease; lifestyle and diet adequate levels of
152 monounsaturated fatty
acids with reduced intake
of trans fatty acids but at
this stage of HF this is not
a priority
LDL/HDL ratio <3.55 5 History of coronary artery Diet should include
5.23 disease; lifestyle and diet adequate levels of
4.97 monounsaturated fatty
acids with reduced intake
of trans fatty acids but at
this stage of HF this is not
a priority
Apo A (mg/dL) 94-178 60 65 70 Impaired liver function No nutritional implications
resulting from edema in liver
(hepatomegaly)

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 6-5

Parameter Normal Patient’s Reason for Abnormality Nutrition Implication

Value Value
Apo B (mg/dL) 63-133 140 Cardiovascular damage No nutritional implications
138
136
WBC ( 103/mm3) 4.8-11.8 12 Inflammation and overall Diet should provide
12 disease state adequate protein and
10.5 energy to facilitate immune
response and resistance to
infection

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 Rationale for Use Nutrition Implications

Lanoxin Increases myocardial Side effects of this medication include diarrhea, loss of
contraction. appetite, stomach pain, nausea, and vomiting; all of these
side effects can make eating difficult and unpleasant,
resulting in suboptimal oral food and nutrient intakes.
Lasix Diuretic used in edematous Hypokalemia, hypomagnesemia, thiamin deficiency,
states to improve fluid calcium deficiency; supplementation may be necessary
balance; sometimes used to depending of severity of electrolyte or nutrient deficiency.
lower blood pressure.
Dopamine Increases myocardial Side effects include potential decrease in serum potassium,
contraction and has a pressor proteinuria, nausea, and vomiting; may require potassium
effect to help support blood supplementation or high-potassium diet choices; nausea and
pressure when low. vomiting may inhibit adequate caloric intake.
Thiamin Diuretic use can lead to Ensure adequate intake of B vitamins to help prevent
thiamin deficiency. deficiency.

IV. Nutrition Diagnosis

13. Select two nutrition problems and complete a PES statement for each.

In this case students should be able to identify that different nutrition problems are present as the hospital stay
extends over time. The first PES might document the need for beginning nutrition support, while the second
PES might be appropriate during the on-going monitoring and evaluation of nutrition care.
• Inadequate oral food/beverage intake related to poor appetite during previous two weeks as evidenced by
few sips of liquids, soft foods, and “trying to take Ensure.”
• Inadequate intake from enteral/parenteral nutrition related to intolerance secondary to uncontrolled diarrhea
as evidenced by ___ (more data would be needed regarding the specific amount that was either provided or
withheld during this period of time, e.g. “only X mL of formula compared to goal rate”).
• Inadequate intake from enteral nutrition infusion related to patient’s request via living will to provide
palliative care at end of life as evidenced by diet and fluids as tolerated. (This type of PES statement could
be used to document the role of the dietitian as described in question #20 below.)
• Altered nutrition-related laboratory values related to protein-calorie malnutrition as evidenced by SA 2.6
and total protein 5.5 (once diuresed). It is important for the students to recognize that the admission values
would not be accurate data as they are reflective of overhydration.

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?

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Solution Manual for Medical Nutrition Therapy A Case Study Approach, 4th Edition

6-6

• The formula could be changed to one with added fiber (such as Jevity) or fiber could be added to Dr.
Peterman’s medications.
• It is important to remember that fiber supplements should not be added separately to the enteral formula or
placed down the feeding tube. It may cause interactions with the formula and could result in a tube
blockage.
• Additionally, an antidiarrheal agent such as loperamide could be used.

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?

• If he is able to eat, provide him foods that he likes with increased nutrient density.
• Small, frequent feedings work well to minimize the volume of food consumed and stress on both the
cardiac and respiratory systems.
• Within his fluid allowance, use of a nutrient-dense liquid supplement may be easier than attempting to
consume solid food.

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 a document directing the physician to withhold or withdraw certain life-sustaining
procedures if a patient is in a terminal condition and unable to decide for him/herself.
• A life-sustaining procedure is any mechanical or artificial means which sustains, restores, or supplants a
vital body function, and which would only prolong the dying process for a terminal patient.
• A mechanical respirator is an example.
• Laws differ by states, but many do not permit withholding or withdrawing nutrition or hydration (food
or water) unless a feeding tube or intravenous feeding provides them.
• In addition, medication or medical procedures necessary to provide comfort or ease pain are not life-
sustaining procedures and would not be withheld under a living will.
• Palliative care is treatment in which goals are centered toward a relief of symptoms and measures are taken
to ensure the patient’s comfort.
• This is different from medical care where the goal is striving for a cure.

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 can play a crucial role in the health care team providing palliative care.
• Food is such a critical part of daily life that mealtime often becomes a source of conflict for family
members.
• Supporting the patient in her/his decisions to eat (or not to eat) while alleviating fears of family members is
critical.
• Providing the patient’s food preferences and supporting the patient and family during this time can be a
significant contribution to the patient’s care.

© 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

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