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Lauren Hoover

KNH 411

September 8, 2016

Cardiovascular Case Study

I. Understanding the Disease and Pathophysiology

1. Define arterial blood pressure (BP) and explain how it is measured.

Arterial blood pressure can be defined as force exerted on by the blood on the walls of the arteries during contraction and relaxation of the heart. Arterial blood pressure is measured using a sphygmomanometer (Nelms, Sucher, Lacey, p294).

2. Discuss briefly the mechanisms that regulate arterial blood pressure including the sympathetic nervous system, the renin-aniotensin-aldosterone system (RAAS), and renal function.

Arterial pressure is determined partially by cardiac output, which is a function of heart rate and stroke volume. Heart rate is determinate on the balance between the parasympathetic and sympathetic nervous systems. The parasympathetic system decreases heart rate, while the sympathetic system increases heart rate. The sympathetic fibers stimulate the SA node and ventricles, which in turn release norepinephrine to increase heart rate, increasing blood pressure. Sympathetic activity also causes vasoconstriction and increased resistance of blood flow, increasing blood pressure (Nelms, Sucher, Lacey, p295-296).

The renin-angiotensin-aldosterone system (RAAS) regulates the balance of fluids and electrolytes which effects blood volume, which effect venous return, stroke volume, and cardiac output. This is a main component of arterial blood pressure. A hormone renin is released from the kidney to stimulate conversion to Angiotensin I, which eventually gets converted to Angiotensin II. Increased levels of this will stimulate Aldosterone production, causing kidneys to retain sodium, increasing blood volume, which in turn increases blood pressure. Angiotensin II also stimulates vasoconstriction, additionally causing an increase in blood pressure (Nelms, Sucher, Lacey, p132).

The kidney is responsible for fluid and electrolyte balance, so if renal function is low, changes in blood volume will occur, affecting cardiac output, and in turn, lowering or raising blood pressure (Nelms, Sucher, Lacey, p295).

3. What is essential hypertension? What is the etiology?

Essential hypertension is also known as primary hypertension. Essential hypertension is of unknown cause of which involves a complex interaction between lifestyle choices and gene expression. Of individuals who have hypertension, 90-95% of them have essential hypertension (Mahan, Escott-Stump, Raymond, p758).

4. What are the common symptoms of essential hypertension?

Often time hypertensive patients are asymptomatic. However, there are some cardiac, cerebrovascular, and renal signs that can be observed as a result of chronic hypertension. For example, left ventricular hypertrophy, stroke, absence of pulse in extremities, microalbuminuria, etc. are all signs of a person with chronic essential hypertension (Mahan, Escott-Stump, Raymond, p760).

5. Using the JNC 8 guidelines, how is the diagnosis of hypertension made? What blood pressure readings are used to identify normal, stage 1 hypertension, and stage 2 hypertension?

Based on the JNC 8 guidelines, the diagnosis for stage 1 hypertension is made when the systolic blood pressure is between 140-159 mm Hg for people ages 18-59, and greater than or equal to 150 mm Hg for people older than 60 years old or when diastolic blood pressure is between 90-99 mm Hg for all ages. The diagnosis for stage 2 hypertension is made when the systolic blood pressure is above 160 mmHg for people of all ages or when the diastolic blood pressure is greater than 100 mm Hg for people of all ages (Nelms, Sucher, Lacey, p297).

6. List the risk factors for developing hypertension. What risk factors does Mrs. Moore currently have? Discuss the contribution of ethnicity to hypertension, especially for African Americans.

Risk factors for developing hypertension include individuals of black race, male gender, youths, having a persistent diastolic pressure greater than 115 mm Hg, smokers, individuals with diabetes mellitus, hypercholesterolemia, obese individuals, individuals with excessive alcohol intake, and individuals with evidence of end organ damage (Mahan, Escott-Stump, Raymond, p760). Currently, Mrs. Moore’s risk factors include being of African American ethnicity, having a diastolic blood pressure of 160 mm Hg, and being a previous smoker (Nelms, p38-39).

The prevalence of high blood pressure in African American is higher than other races, at 43.0% for males and 45.7% for females (Nelms, Sucher, Lacey, p296). Since many factors play a role in the development of hypertension, cultural, social and/or biological components of African American individuals’ lives could be the reason for this trend. Also, since they develop hypertension earlier in life and maintain higher levels, their risk of fatal stroke, heart disease, and end-stage kidney disease is also much higher (Mahan, Escott-Stump, Raymond, p759).

7. What are the four major modes of treatment for hypertension?

The four major modes of treatment for hypertension involves a comprehensive plan involving weight reduction, physical activity, nutrition therapy, and pharmacological interventions (Nelms, Sucher, Lacey, p298).

8. Dr. Evans indicated in his note that he will “rule out metabolic syndrome”. What is metabolic syndrome?

There is no universally accepted definition for metabolic syndrome, and it is a culmination of a variety of factors. Individuals with metabolic syndrome have at least three or more of the following: waist circumference of more than 102 cm in men and 88 cm in women, serum triglycerides of at least 150 mg/dL, HDL levels less than 40 mg/dL in men and 50 mg/dL in women, blood pressure 135/85 mm Hg, or fasting glucose of 100 mg/dL or higher (Mahan, Escott-Stump, Raymond, p471). Metabolic syndrome is a combination of metabolic risk factors including abdominal obesity, insulin resistance, dyslipidemia, hypertension, and prothrombotic state (Nelms, Sucher, Lacey, p311).

9. What factors found in the medical and social history are pertinent for determining Mrs. Moore’s coronary heart disease (CHD) risk category?

Factors that are important in determining Mrs. Moore’s CHD risk category are her family medical history, of which her mother had chronic hypertension. Also, age, of which she is in the risk range of older than 55. Her sex is something to consider as well as her BMI. She is in the “overweight” category and not classified as obese, so this is not necessarily a risk factor to consider. Her lipid profile should also be considered. Her LDL level is elevated, and her HDL level is low, also contributing to the risk. Her hypertension and previous cigarette smoking are also risk factors to be considered (Nelms, Sucher, Lacey, p309-311).

10. How is hypertension related to other cardiovascular disorders? What are the possible complications of uncontrolled hypertension?

Hypertension is the most prevalent contributory cause of cardiovascular diseases and deaths. Chronic hypertension and when the hypertension goes uncontrolled, many adverse diseases arise. Individuals can have coronary artery disease, left ventricular hypertrophy, cardiac failure, cardiac enlargement, myocardial infarction, cerebrovascular accident, aneurysm, impaired renal function, retinal exudates and hemorrhages, and papilledema (Mahan, Escott-Stump, Raymond, p760).

II. Understanding the Nutrition Therapy

11. Briefly describe the DASH eating plan and discuss the major nutrients that are components of this nutrition therapy.

DASH stands for Dietary Approaches to Stop Hypertension and aims to not only reduce sodium intake, but also to increase potassium, magnesium, calcium, and fiber intakes within a moderate energy intake. With a daily intake of 2000 kcal, the DASH diet would provide 4700 mg potassium, 500 mg magnesium, 1240 mg calcium, 90 g protein, 30 g fiber, and 2400 mg sodium. The DASH diet stresses the incorporation of grains, vegetables, fruits, low-fat dairies, lean meats, nuts and seeds, and other foods into the diet (Nelms, Sucher, Lacey, p301-302).

12. Using the 2015 Dietary Guidelines, describe why decreased sodium intake is targeted as a focus to improve the health of Americans.

The 2015 Dietary Guidelines list increased sodium intake as having an association with increased risk in blood pressure and even an increased risk in cardiovascular disease. Since hypertension is a precursor for a plethora of detrimental conditions and diseases, sodium reduction definitely is a targeted focus to improve American’s health (Mahan, Escott-Stump, Raymond, p763).

13. What do the current literature and Evidence Analysis Library (EAL) indicate regarding the role of sodium intake in the control of hypertension? Is there a significant correlation between sodium intake and cardiovascular risk?

According to the EAL, seventeen studies have shown the benefit of reducing sodium in the diet on lowering blood pressure. This correlation was given a Grade I, meaning there is good supporting evidence ().

Current literature also supports lowering blood pressure by reducing sodium intake. The Trials of Hypertension Prevention and several other randomized trials have confirmed the positive effects of this dietary reduction (Mahan, Escott-Stump, Raymond, p763).

14. What is the Mediterranean diet? How might this dietary approach be appropriate for Mrs. Moore? Would this be culturally appropriate for her?

The Mediterranean diet emphasizes fruits, root vegetables, leafy green vegetables, breads and cereals, fish, foods high in alpha linoleic acid, vegetable oil products, and nuts and seeds. Red wine is also a key part of the Mediterranean diet, containing resveratrol, appearing to lower blood pressure in some studies. At every meal, this diet suggests fruits, vegetables, grains (mostly whole), olive oil, beans, nuts, legumes and seeds, herbs and spices. Fish and seafood are to be eaten often, and with poultry, eggs, cheese, and yogurt moderately. Meat and sweets are eaten least often (Mahan, Escott-Stump, Raymond, p757).

Many studies have shown that the Mediterranean high fat diets are associated with lower CHD incidence. Their main source of fat is olive oil, which happens to be high in monounsaturated fatty acids, which can help lipoprotein levels, a hypertension risk. Therefore, since Mrs. Moore has hypertension, this diet is appropriate for her (Mahan, Escott-Stump, Raymond, p755).

This diet could be incorporated in some ways into her diet now. One thing that Mrs. Moore could do is to season her foods with more herbs and spices, instead of table salt. She could also try substituting the beer she drinks with red wine. She could try to incorporate more fruits and vegetables as well as some nuts/seeds/legumes. Since she is the one who goes shopping and cooks the meals, she is in control of what she eats. She also does not have any food allergies or aversions that would get in the way of maintaining this diet (Nelms, p39-40).

15. Lifestyle modifications reduce blood pressure, enhance the efficacy of antihypertensive medications, and decrease cardiovascular risk. List lifestyle modifications that have been shown to lower blood pressure.

Some lifestyle modifications that have been shown to reduce blood pressure are reducing weight to maintain a normal body weight, adopt a DASH eating plain, lower overall sodium intake, consuming no more than 2400 mg per day, possibly more depending on level of hypertension, increase physical activity to at least 30 minutes a day most days a week, and limit alcohol consumption to no more than two drinks per day for men and one drink per day for women (Nelms, Sucher, Lacey, p304).

III. Nutrition Assessment

16. What are the health implications of Mrs. Moore’s body mass index (BMI)?

Mrs. Moore’s BMI is 25.8, which puts her at the lower end of the overweight range (25.0-29.9). The health implications for being overweight are increased risk of developing type 2 diabetes, sleep apnea, liver and gallbladder diseases, reproductive disorders. osteoarthritis, and cancers of the endometrium, breast, prostate, and colon. Overweight individuals also often suffer from psychosocial and emotional consequences (Nelms, Sucher, Lacey, p260).

17. Calculate Mrs. Moore’s energy and protein requirements.

Height in meters: 66 inches = 1.676 m

Weight in kilograms: 160 lbs./2.2 = 72.727 kg

Protein requirement = 0.8g/kg body weight = 0.8g * 72.727 kg = 58.18 g protein

(Nelms, Sucher, Lacey, p66)

I chose to use the Estimated Energy Expenditure Equation for a Normal and Overweight or Obese Woman 19 years and older (BMI greater than 18.5 ). For the physical activity level, I chose to use 1.14, classified as low active. Mrs. Moore says she walks 30 minutes 4-5 times a week, however she says sometimes she misses these walks.

Estimated Energy Requirement = 387 – 7.31 x 57 + 1.14 x (10.9 x 72.727 + 660.7 x 1.676) = 2136.4 calories per day

(Mahan, Escott-Stump, Raymond, p28)

18. Identify the major sources of sodium and saturated fat in Mrs. Moore’s diet. Compare her typical diet to the components of the DASH diet.

Major sources of sodium in Mrs. Moore’s diet include the Campbell’s tomato soup, saltine crackers, popcorn, and added salt on her chicken and naked potato. The major sources of saturated fat in her diet include the glazed donut, ranch dressing, buttered popcorn, and added butter to her carrots and baked potato. She also expressed how when she eats out, she will get either pizza or go to steakhouses, both of which could be high in sodium and saturated fat (Nelms, 39-40).

Compared to the DASH diet, her diet lacks in fruits, while she seems to be adequate in vegetables. She uses butter instead of the margarine or vegetable oil in the DASH diet. Also, she doesn’t seem to get many nuts, seeds, or dry beans, which is a component of the DASH diet. Her sweets choices are generally high in fat, like the ice cream and glazed donut, which does not coincide with the DASH diet. And lastly, her sodium intake is high, which is what is mainly limited in the DASH diet (Nelms, Sucher, Lacey, p304).

19. What dietary assessment tools that target nutrients known to be associated with hypertension and CVD risk might be useful in assessing Mrs. Moore’s diet?

Some dietary assessment tools that could be useful include looking at biochemical and medical tests, such as lipid profiles, albumin levels, electrolytes, and glucose or HgbA1c values. In Mrs. Moore’s diet, it would be useful to obtain glucose cholesterol, HDL, LDL, triglyceride levels from lab tests. Also, it would be helpful to obtain information involving her food and nutrition-related history. Assessing her pattern and frequency of her meals and snacks, her portion sizes, total fat and cholesterol, saturated fats, types of carbohydrates, alcohol intake, sources of sodium, frequency of restaurant meals, and physical activity would be very helpful (Nelms, Sucher, Lacey, p302).

20. From the information gathered within the intake domain, list possible nutrition problems using the diagnostic terms.

Possible nutrition problems include excessive energy intake, excessive fat intake, inconsistent carbohydrate intake, inadequate fiber intake, and excessive sodium intake (eNCPT).

21. Dr. Evans ordered the laboratory tests listed in the following table. Complete the table with Mrs. Moore’s values from 6/25 and the potential cause of any abnormalities.

|Parameter |Normal Value |Pt’s Value |Reason for Abnormality |

|Glucose (mg/dL) |70-99 |101 |High sugar intake |

|BUN (mg/dL) |6-20 |20 |High protein diet or early signs|

| | | |of kidney malfunction (however, |

| | | |technically no abnormality – |

| | | |within normal range) |

|Creatinine (mg/dL) |0.6-1.1 |0.9 |No abrnomality – within normal |

| | | |range |

|Total cholesterol (mg/dL) |59 |30 |Low MUFA/PUFA intake, high SFA |

| | | |intake |

|LDL-cholesterol (mg/dL) | ................
................

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