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Libby Sells

Professor Matuszak

KNH 411

5 September 2013

Case Study 5:Myocardial Infarction

I. Understanding the Disease and Pathophysiology

1.Mr. Klosterman has a myocardial infarction. Explain what happened to his heart.

a. A myocardial infarction is more commonly known as a heart attack. The heart needs its own supply of oxygen in order to survive, and the coronary arteries are responsible for the task of delivering oxygen to the heart. If one or both of these arteries become blocked, the heart cannot get adequate oxygen; this is called an ischemia. If an ischemia continues to occur, cardiac muscle begins to die due to lack of oxygen-this is a myocardial infarction.

i. From American Heart Association

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 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 postero-basilar scar was present with hypokinesis. Explain angioplasty and stent placement. What is the purpose of this medical procedure?

a.In an angioplasty, arteries that are too narrow or blocked are opened up so that blood flow to the heart is improved, and so cardiac cells can get the oxygen they need to survive. The procedure is done by inserting a small balloon into the clogged part of the artery and then blowing it up, thus opening up the artery. A stent (small, mesh tube) is then placed in the artery to keep it open to prevent future clogging or narrowing of the arteries.

i. From American Heart Association

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?

a. Recommended by the American Heart Association, cardiac rehabilitation plays an important role in recovery and the return f a patient to their normal lives. It includes important components of exercise and education. Goals for the program are: regain strength and stamina, prevent worsening of heart condition, and reduce future risk for cardiovascular complications. Aspects of the program include nutritional counseling, monitored and controlled exercising, and support and education about changes necessary to improve cardiac condition.

I. From the American Heart Association

II. Understanding the Nutrition Therapy

4.What risk factors indicated in his medical record can be addressed through nutrition therapy?

a.Mr. Klosterman has high total cholesterol and LDL levels, as well as low HDL levels.This lipid profile can end up in resulting in atherosclerotic development and heart disease. The patient is also overweight as evidenced by his BMI of 26.6 kg/m^2. From high 24 hour recall, it can be seen that he consumes a number of high fat, processed, and high sodium foods such as roast beef, cream cheese, 2% milk, canned goods, and pretzels. While smoking and a family history of heart disease are risk factors, they would not be part of his nutrition therapy but could be addressed.

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

a. Mr. Klosterman will be on an NPO, or nothing per orem diet until after his angioplasty.

This means he cannot consume any food or liquid. Following a myocardial infarction, areas of

dietary focus include sodium intake and saturated fat intake, which should be reduced.After

surgery, initial intake is limited to intake of clear liquids with no caffeine. This gradually

becomes a diet with soft, chewable foods and patient should start to following

the TLC or Therapeutic Lifestyle Changes diet. Some aspects of this diet include: limiting total fat intake to 25-35% of total calories, limiting saturated fat to 7% of total calories, limit sodium intake to less than 2400 mg/day,add 5-10 grams of fiber per day, consume less than 200 mg of cholesterol per day, and increase physical activity.

i.From DHHS Guide to Lowering your Cholesterol with TLC

III Nutrition Assessment

6.What is the healthy weight range for an individual of Mr. Klosterman’s height?

a. Using the Hamwi method,106 lbs. for the first 5 ft of ht; add 6 lbs for every inch over 5 ft. for males, the patients recommended weight is 106 + [6(10))]=166 pounds. Using a BMI chart, a healthy weight range for a 5’10 male is (149-183 pounds).

i. From Rush University Medical Center BMI Chart

7.The 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

a.Using the Mifflin St. Jeor equation: Patient’s REE is about 1650 kcal per day. For weight, 185 lbs x .4536 kg=83.92 kg and height is 70 inches x 2.54 cm=177.8 cm. Plugging these numbers into the formula:[(10W + 6.25H – 5A +5) or (10*83.92 kg + 6.25 * 177.8 cm – 5*61 +5)]=1650.4. REE is multiplied by 1.2 for a sedentary lifestyle. I chose a sedentary lifestyle over a lightly active lifestyle, because walking a dog for 15 minutes is a hard activity to categorize, but since patient is overweight anyway, airing on the side that would give a less caloric requirement would be better, so 1650.4 x 1.2 =1980.5 or 1981 kcal. Often times, energy needs increase after surgery. By using either a factor or 1.0 or 1.1 for post surgery caloric needs: 1980.5 x 1.0=1980.1 kcals or 1980.5 x 1.1=2178.6 kcals would give a range of about 1980 to 2179 kcals.

b. For his protein requirements, Mr. Klosterman should have been consuming 0.8 g per kg of body weight or 0.8 g x 83.92 kg=67.1g or 67 g of protein. After surgery, 1.0 g protein per kg of body weight is suggested because the extra protein is important for post-surgery wound healing. So, 1.0 g x 83.92 kg=83.92g or 84 g of protein during recovery time after surgery.

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 energy exchange system.

a.Using FitDay, the patient’t 24 hour dietary recall was entered and analyzed.

According to the program, Mr. Klosterman consumed 2663 calories for the day.

When the percentage of calories from Mr. Klosterman’s diet analysis are used, the following are the total number of grams from each macronutrient that the patient consumed:

Fat: (2663 x .34) / 9 = 100.6 grams of fat

Carbohydrates: (2663 x .46) /4 =306.3 grams of carbohydrates

Protein: (2663 x .20) / 4=133.2 grams of protein

Using more appropriate percentages of macronutrient intake of total calories, it would be more ideal for the patients macronutrient consumption distribution to be:

Fat: (2663 x .3) / 9 = 88.8 grams of fat

Carbohydrates: (2663 x .55) /4 =366.2 grams of protein

Protein: (2663 x .15) / 4=99.9 grams of carbohydrates

9.Examine the chemistry results for Mr. Klosterman. Which labs are consistent with the diagnosis? Explain. Why were the levels higher on day 2?

a. Troponin 1 and T are used to diagnose Mr. Klosterman with a MI diagnosis. These levels were both high (2.4 I and 2.1 T). These numbers are indicative of the structural components of cardiac muscle that are much higher when there has been an injury to the heart. Cholesterol levels (total, LDL, LDL/HDL ratio,and HDL) are also used. The patient’s high total cholesterol and LDL levels combined with low HDL (indicated by low Apo A) levels can be indicative of plaque build up that can lead to MI. High triglyceride levels are also indicative of cardiac issues. Levels were higher on day 2 because more cardiac cells were being deprived of oxygen and destroyed as evidenced by high AST levels and creatine phosphate levels.

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

|Abnormal Lab Result For |Normal Range |Patients Value 12/1 1957 |

|Cholesterol (mg/dL) |120-199 |235 |

|HDL-C mg/dL |>55 F; >45 M |30 |

|LDL | ................
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