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Taylor PondCase Study 5KNH 4111.?????? Mr. Klosterman had a myocardial infarction. Explain what happened to his heart.a.?????? Mr. Klosterman had many issues with his heart. Chief among these issues was a 100% occluded right coronary artery, and a 70% occluded left circumflex coronary artery. Coronary arteries deliver oxygen-rich blood to the heart tissue, but can become clogged by plaque. Thus, a blockage in a coronary artery results in serious damage to the heart muscle as the cells are starved of oxygen and die. A myocardial infarction, otherwise known as a heart attack, is the result of this blockage. Signs of myocardial infarctions include, but are not limited to, pain in the left arm, pain in the jaw, dizziness, and fainting.b.????? .?????? Angioplasty and stent placement are two of the leading procedures for patients with angina, atherosclerosis, or those who have suffered a myocardial infarction. Angioplasty is a procedure in which a catheter is placed into an artery in the arm or groin of the patient. Die is placed into the catheter to see plaque. The catheter is then threaded through the body until it reaches the coronary artery in question. The catheter is guided into the artery until it reaches a point of occlusion. At the end of the catheter is a small balloon that the doctor inflates once it is in place. The balloon then acts to compress the plaque against the walls of the artery. This process allows blood to flow more freely through the artery, and lessens the risk of a plaque rupture. A small stent is present on the balloon and pops into place when the balloon is inflated. Once the stent is in place, the balloon and catheter are removed. The stent then aids in holding the artery open allowing for more blood to pass through the artery.a.?????? .????? ????? Cardiac rehabilitation is essential for regaining strength and vigor after a myocardial infarction. Rehab is often divided into phases, with the first phase being centered around reaching a state of stability in the ICU, and providing the patient with information about how to eat healthy, exercise, and take precautions to not damage the heart. Many medical professionals? are involved in this phase, including cardiologists, psychologists, dietitians, nurses, exercise specialists, and many more. Much care needs to be taken by the patient and the professionals to ease the patient back into an active lifestyle. In the case of Mr. Klosterman, doing too much too fast, a task as negligible as climbing a flight of stairs, could result in serious damage to the heart. Additionally, many patients are urged to modify their diet during cardiac rehabilitation. The new diet should be high in fiber, whole grains, fruits, and vegetables, and very low in saturated fat, cholesterol, and sodium. Saturated fat and cholesterol contribute heavily to plaque buildup, and thus continuing to consume them is counterproductive to the rehabilitation process. Mr. Klosterman will need to increase his fruit and vegetable intake, and cut out foods such as apple pie, full-fat salad dressing, mayonnaise, and canned soup.?a.?????? .????? .?????? Nutrition therapy can be very effective are relieving risk factors for myocardial infarction. In the case of Mr. Klosterman, his body weight, cholesterol, tobacco use, HDL-C, LDL, and LDL/HDL ratio can all be relieved through nutrition therapy. To lower Mr. Klosterman’s body weight, he would be encouraged to eat a low-fat diet that is high in whole grains and fiber, and low in saturated fats. In order to lower his cholesterol, he will consume less cholesterol and more whole grains. If Mr. Klosterman does not quit smoking, he can increase his vitamin C intake to block the free radicals that increase his risk of another coronary episode. In order to increase HDL levels to safe ranges, 60 is ideal, and Mr. Klosterman is at 33, he will need to increase his intake of omega-3 fatty acids. These are found in fatty fish, such as salmon. Additionally, he will need to decrease his intake of refined sugars and carbohydrates, ultimately cutting dessert out of his meal plan (Umassmed.edu). Mr. Klosterman’s LDL levels are at 160, while they should be under 130. To address this issue, Mr. Klosterman should reduce his intake of saturated fat, and increase his intake of fiber-rich foods.a.?????? ???? . What are the current recommendations for nutritional intake during a hospitalization following a myocardial infarction??Immediately following a myocardial infarction, dietitians aim to reduce pain and stabilize cardiac function. Once these goals are complete, the focus shifts to rehabilitating the patient. Patients are limited to clear liquids without caffeine, to eliminate risk of arrythmias and decrease risk of aspiration or vomiting. After this point, they are moved to a soft diet, and eat small meals frequently. Dietitians then use a specially designed diet to treat the patient.This diet is designed taking the patient’s risk factors into consideration, and follows the Therapeutic Lifestyle Changes Dietary Recommendations. Some of these risk factors could be hypertension, smoking, high LDLs, low HDLs, atherosclerosis, or diabetes. The Therapeutic Lifestyle Changes Dietary Recommendations suggests that less than 7% of the daily caloric intake come from saturated fat. 25-35 percent of daily calories should come from fat. A patient should consume less than 200 mg of dietary cholesterol each day. Sodium should be limited to 2400 mg per day, and eating to excess should be avoided (each patient should only eat as many calories as it takes to maintain a healthy body weight).Nutrition and pathophysiology, p. 321. What is a healthy weight range for an individual of Mr. Klosterman’s height?Mr. Klosterman is 185 pounds, and 70 inches tall, with a BMI of 26.6. Using the Hamwi method, Mr. Klosterman should weigh 160-170 pounds. This number was found by adding 60 lbs, or 6 lbs for every inch over 5 ft, to 106 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 pace. Calculate his energy and protein requirements.?First, Mr. Klosterman’s Adjusted body weight was found using the formula: (0.25)(ABW-IBW) +IBW. Then, the Mifflin-St. Jeor equation was applied. The equation is: 10 x wt(kg) +6.25 X ht(cm) -5 x age (yrs) +5 x PAL of 1.6. Inputting Mr. Klosterman’s data: 10 (77.6) + 6.25 x 177.8 - 5 x 61 +5 x 1.6. This comes out to 2,536 kilocalories per day.?The ADA recommends .8-1 g of protein/kg body weight. Using Mr. Klosterman’s adjusted body weight, he needs 77.6 g of protein for day. He is in recovery, so he needs high levels of protein, or 1 g/kg body weight.. Using Mr. Klosterman’s 24-hour recall, calculate the total number of calories he consumed as well as the enrgy distrivution of calories for protein, carbohydrate, and fat using the exchange system.?Fat Carbs Protein KcalBagel 1 15 3 160Orange Juice 0 15 0 120Soup 5 5 0 150Bread 0 30 2 160Beef 14 0 14 300Veggies 0 5 2 25Mayo 10 0 0 90Apple 0 15 0 60Milk 5 12 8 120Pork Chops 6 0 14 270Baked Potato 2 30 6 160Margarine 10 0 0 90Green beans 0 5 0 25coleslaw 0 5 0 25Salad Dressing 10 0 0 135Apple Pie 10 15 0 200Milk 5 12 8 120Pretzels 0 15 1 80TOTAL 163 179 58 2290Resource: Nutrition Therapy and Pathophysiology, A-1099. Examine the chemistry results for Mr. Klosterman. Which labs are consistent with the MI diagnosis? Explain. Why were the levels higher on day 2??The labs for Troponin I, Troponin T, CPK, and CPK-MB were consistent with the MI diagnosis. CPK and CPK-MB are present in the myocardial tissue. The levels of CPK and CPK-MB spike after injury, or in this case, infarction. CPK levels fall faster than CPK-MB levels, so CPK-MB levels elevated for longer than CPK levels. Mr. Klosterman’s angioplasty procedure and stent installment created more damage to the heart, making the levels of CPK and CPK-MB rise even more markedly than they had after the MI. This accounts for the higher levels of CPK and CPK-MB on the second day of the hospital stay. Troponins T and I also spiked after the infarction and remained were higher on the second day. Troponins T and I are released from damaged myocardial tissue. Neither troponin is found in the blood of healthy person at levels higher than 0.2 for Troponin I, and 0.03 for Troponin T. Troponins increase in blood at 4-9 hours after an MI, peak at 12-24 hours, and can remain elevated for 14 days (American Society for Clinical Pathology, S96). Troponins are more pertinent to heart damage, and thus have become the gold standard for diagnosing an MI from a chemistry panel.. What is abnormal about his lipid profile? Indicate the abnormal values.?Mr. Klosterman’s lipid profile is startling. He entered the hospital with high cholesterol, 235 mg/dL, low HDL-C values, 30 mg/dL, high LDLs, 160 mg/dL, and a high LDL/HDL ratio, 5.3. Each of these categories improved markedly in the 3-day period. By day three, Mr. Klosterman’s cholesterol dropped to 214, HDLs raised to 33, LDLs fell to 141, and LDL/HDL ratio fell to 4.3.These are very large changes for such a small amount of time. However, after an MI, LDL levels can fall to nearly half of the baseline value. This generally happens 6-12 hours after the onset of the MI. It is not until a month to a month and a half later that the levels return to baseline. Food-Medication InterationsLopressor 50 mg daily alcohol, multivitamins with minerals, high-cholesterol foodsLisinopril 10 mg daily NoneNitro-Bid 9.0 mg twice daily alcoholNTG 0.4 mg sl prn chest pain alcoholASA 81 mg daily caffeine, alcohol. 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 then can do to precent another heart attack. What questions will you ask them to assess how to best help them?First, it will be extremely important to ask them both to walk through their daily routines. This will provide information about behaviors that are detrimental to Mr. Klosterman’s health. Perhaps this will create an opportunity to ask them if they would be able to incorporate more walking into their day, or encourage them to use the stairs. Then, it would be helpful to ask what foods they normally prepare and consume, and how the foods are prepared. At this point, I would recommend switching to whole grain products, and would encourage them to consume less fat and more fruits and vegetables. I would ask them what their favorite foods are, and make recommendations of what could be added to the foods (peas, other vegetables, etc.) to make them more healthful. Next, I would ask the Klostermans how much time they are willing to dedicate to cooking and exercising. I would encourage them to set goals, once Mr. Klosterman is recovered. These goals could be exercising for a half hour each day, or making sure a fruit and vegetable is on the plate for each meal.13. What other issues might you consider to support successful lifestyle changes for Mr. Klosterman?There are many changes that Mr. Klosterman could make to smooth the transition into a healthier lifestyle. Increasing exercise would be an extremely beneficial action to take. Currently, Mr. Klosterman only exercises for 15 minutes a day, and at a leisurely pace. In order to prevent the worsening of atherosclerosis, a patient exercise 6 days a week for 30 minutes. I would also consider Mr. Klosterman’s profession as a Lutheran minister to increase the challenge to eating healthfully. Typically, ministers are gifted by their congregations with delicious, but not nutritious, treats. I would stress the importance of educating Mr. Klosterman’s congregation about his illness, and encourage them to bring no food, or bring high-fiber, low saturated fat foods.??. From the information gathered with the assessment, list possible nutrition problems using the correct diagnostic terms.Dehydration, evidenced by skin tenting, iron-deficiency anemia, as indicated by paleness. Select two of the identified nutrition problems and complete a PES statement for each.Dehydration related to lack of fluid intake and myocardial infarction as evidenced by skin tenting.?Iron-deficiency anemia related to inadequate iron intake as evidenced by pale skin.?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).?Mr. Klosterman should not have skin tenting by day 3 of his hospital stay. As an intervention, he shall consume an additional 16 oz of water each day orally until tenting ceases.?Mr. Klosterman should regain appropriate skin hue in one month. He shall begin with a low-dose supplement of iron to make sure that he is getting sufficient iron during recovery.?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?The current recommendation of the American Heart Association say that adults with coronary heart disease should supplement 1 gram daily of EPA and DHA. Omega-2 fatty acids reduce inflammation, something which could aid in the healing process. Also, several studies have shown that fish oil can decrease triglycerides and increase HDL. Omega-3s can also be consumed in fatty fish, like salmon and mackerel. Omega-3 supplementation should be done under the supervision of a physician.?. What do you want to assess in three to four weeks when he and his wife return for additional counseling?In three to four weeks, I want to assess the changes that the Klostermans have made to their lifestyle, diet, and exercise. The labs will hopefully show positive movement in the lipid profiles. At this point, after gaging the progress, I will encourage the Klostermans to take the changes a step further, and up the exercise to 30 minutes a day.? ................
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