ࡱ> SUR -bjbj,, $RNN#58#T2ww(zzzDFFFFFFuFzzzz~FL[LLLDLzDLLL@E|Lhq0LgLgLLLzzz :   Case Questions for Medical Nutrition Therapy: A Case Study Approach 4th ed. Title: Case 5 Myocardial Infarction Instructions: Answer the questions below. Please print the questions out with your answers and bring to class on the due date. Questions: 1. Mr. Klosterman had a myocardial infarction. Explain what happened to his heart. When someone has an MI or heart attack, it is because the heart muscle is not getting enough oxygen. The cells surrounding the heart start to die, which leads to a heart attack. Often times this is caused by a blockage of plaque, which causes a roadblock to the heart and oxygen can not reach it, eventually leading to a heart attack. 2. Mr. Klostermans 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 posterobasilar scar was present with hypokinesis. Explain angioplasty and stent placement. What is the purpose of this medical procedure? Angioplasty is used when someone has a blockage in their arteries. This is what starts as coronary heart disease and leads to a heart attack if nothing is done. Angioplasty is done by inserting a catheter through the arm or thigh. The tip of the catheter has a balloon like object on it, and when it is by the clotted artery, it inflates and pushes the plaque aside to help open the artery back up. When a stent is used, it is usually used after the angioplasty is performed, and it is placed in the artery to help ensure that the artery stays open. 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 is a supervised program for people who are recovering from a heart attack or other heart complications. By going to rehab, Mr. Klosterman and his wife will learn helpful education on how to deal with the aftermaths of an MI. In rehab, more patients learn how to safely increase their exercise levels, improve their health, and lower their risk of future heart problems. 4. What risk factors indicated in his medical record can be addressed through nutrition therapy? Looking at his records, he has a history of smoking, a poor diet with a high intake of fat, as well as low physical activity all of which puts a person at high risk of having an MI. 5. What are the current recommendations for nutritional intake during a hospitalization following a myocardial infarction? Mr. Klosterman was ordered NPO until procedure is completed and then clear liquids- no caffeine. 6. What is the healthy weight range for an individual of Mr. Klostermans height? 106 + 6 lbs for every inch over 5 ft. 106 + (6 x 10) = 166 lbs Range between 131-174 for a healthy BMI 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. 5 + 10 (84) + 6.25 (178) 5 (61)= 845+ 1112.5-305 = 1652 kcal 1652 (1.3)= 2148 kcal 67 g/d- protein 8. Using Mr. Klostermans 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. Using sparkpeople.com his calorie intake was 2405 kcal 149 g for protein (25%) 305 g for carbs. (51%) 71 g for fat (27%) 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? CPK and CPK-MB is elevated day 2 and 3 indicating damage to cardiac muscle (clot was broken and that decreased levels some on day 3); Trop I and T are increased day 1 and 2 indicating a MI had occurred; LDH is elevated day 2; it is used to help diagnose and monitor a heart attack; AST is elevated day 2 and 3; it increases after a heart attack; High cholesterol, high LDL, and low HDL increase risks for cardiovascular disease. 10. What is abnormal about his lipid profile? Indicate the abnormal values. Cholesterol (mg/dL)- Mr. Klostermans: 235-214 normal: 120-199 HDL (mg/dL)- Mr. Klostermans: 30-33 normal: >55 (low) LDL (mg/dL) Mr. Klostermans: 160-141 normal: <130 (high) Apo A (mg/dL) Mr. Klostermans: 72-98 normal: 94-178 (low) Apo B: (mg/dL) Mr. Klostermans: 115-105 normal: 63-133 (normal) Triglycerides (mg/dL) Mr. Klostermans: 150-130 normal: 40-160 (normal/ toward high end) Mr. Klostermans lipid values are abnormal and not in the right ranges for almost all of them. However, it is strange that his LDL levels are high, but his Apo B levels are normal. The Apo B levels are a better indicator for LDL values, and are what are a good sign for having heart issues. High levels of Apo B are what can lead to plaque build up which eventually leads to heart issues. Its also a bit strange that all of the other levels are abnormal but his triglycerides are in the normal ranges. 11. Mr. Klosterman was prescribed the following medications on discharge. What are the foodmedication interactions for this list of medications? MedicationPossible FoodMedication InteractionsLopressor 50 mg dailyNatural licorice Lisinopril 10 mg dailyAvoid foods with high potassium, reduce Na intake, Vit. DNitro-Bid 9.0 mg twice dailyAvoid alcoholNTG 0.4 mg sl prn chest painAvoid alcoholASA 81 mg dailyAvoid alcohol and limit caffeine, insure adequate fluid intake, avoid ginger and garlic  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? Do you know the common risk factors for having an MI? Do you know which foods to reduce after an MI? Are you willing to change your diet? Are you willing to add more exercise to your daily routine? 13. What other issues might you consider to support successful lifestyle changes for Mr. Klosterman? The main issue I would address is his smoking habits. Smoking is a major health threat when looking at heart attack and heart issues. Another I would address is his weight. Obesity is also a leading indicator of a heart attack. Upping his physical activity would benefit him greatly. 14. From the information gathered within the assessment, list possible nutrition problems using the correct diagnostic terms. Inadequate fat intake Physical inactivity 15. Select two of the identified nutrition problems and complete the PES statement for each. NI-5.6.2: Excessive fat intake RT food and nutrition related knowledge deficit concerning appropriate amount of dietary fat AEB high levels of cholesterol (235 mg/dL), LDL (160 mg/dL), and low HDL levels (30 mg/dL) and MI NB-2.1: Physical inactivity RT 15 minutes of leisurely walking AEB BMI, weight, and lipid profile. 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). Goal: lipid profile in normal ranges and change in diet regarding high fatty foods Intervention: educate both he and his wife on foods that are lower in fat, and healthier carbohydrates. Increasing the amount of fruits and vegetables at each meal would be a good start for healthier carbs, Goal: up exercise to 30 min of walking while reaching a level where heart rate increases. Ease into this as he has just had an MI Intervention: contact a personal trainer about setting up an exercise plan to get him started on a healthy routine after his MI. 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? Research suggests that omega-3 fatty acid supplementation aids in reducing risk for CVD and has many benefits for people with heart problems. The American Heart Association (AHA) recommends getting omega 3s from food, such as fatty fish, but supplements also work. It is recommended that 3 grams are taken daily, but one should still consult a doctor before starting any supplements. 18. What would you want to assess in three to four weeks when he and his wife return for additional counseling? I would want to check his lipid profile and see if the levels are back in normal ranges. Next I would check his weight and BMI to see if they are also in healthy ranges. Another thing I would ask would be to complete a 3-day food dairy to see what kinds of foods hes been eating. And lastly, I would want to ask him about his physical activity.     5- PAGE 2 5- PAGE 3 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. 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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