CHELSIE FELLMAN

CASE STUDY #5
CARDIOVASCULAR
SEPTEMBER 3, 2015

Understanding the disease and pathophysiology:

1) Mr. Klosterman had a myocardial infarction. Explain what

happened to his heart.

According to Nelms, a myocardial infarction is defined

as: necrosis of the myocardial cells as a result of
oxygen deprivation. Another term more commonly used
for a myocardial infarction is a heart attack. Mr.
Klosterman had a blockage caused by plaque build-up,
which resulted in his heart being incapable of working
properly (p. 293).

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 curcumflex
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 a procedure performed to open narrowed

or blocked blood vessels that supply blood to the heart.
These arteries have become blocked from a buildup of
plaque causing them to be insufficient in supplying
blood to the heart. These blood vessels are called
coronary arteries. The stent is what is used in the
procedure and is the object placed into the coronary
arteries to expand the inside of the blocked or closed
artery. The stent is very small which allows for articulate
movement and an effective outcome (NIH, 2015).

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?

According to the National Institute of Health (NIH),

cardiac rehabilitation is a medically supervised program
that aims to help improve the health and well-being
individuals that suffer from heart problems (NIH, 2015).
Mr. Klosterman will return home and have to take it easy
for a while until his heart gains the strength back. This
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means limiting his physical exercise and eating a

healthy, low fat diet. It is important that Mr. Klosterman
follows this regimen carefully in order to speed up the
process of healing. Following a myocardial infarction,
the body is in deep distress and has to work very hard
to re-gain strength (p. 307).

Understanding the Nutrition Therapy

4) What risk factors indicated in his medical record can be

addressed through nutrition therapy?

The 1 pack of cigarettes a day for 40 years

Patients denial of hypertension
Patients denial of type two diabetes
Patients denial of high cholesterol
1 glass of wine per day consumed by the patient
Low amount of physical activity performed daily as
reported by him walking his dog 15 minutes/day at a
leisurely pace. The chart does not specifically address
the physical exercise performed by Mr. Klosterman

5) What are the current recommendations for nutritional

intake during a hospitalization following a myocardial
infarction?

 The time frame following a myocardial infarction is

critical for the patients health. According to Nelms,
during the immediate post-MI period, oral intake may be
decreased due to pain, anxiety, fatigue, and shortness
of breath. Many hospitals use the treatment of a clear
liquid diet without caffeine initially following the
patients myocardial infarction. Oral diets usually then
progress from liquids to soft, easily chewable foods with
smaller, more frequent meals. The goals of nutrition
therapy are individualized among patients according to
their risk factors and should all abide by Therapeutic
Lifestyle Change dietary recommendations (p. 325).

Nutrition Assessment
6) What is the healthy weight range for an individual of Mr.
Klostermans height?

Using the Hamwi Method, the calculation for a healthy

weight range of Mr. Klostermans height is 149.4 lbs. to

182.6 lbs.
Math calculation: 106 + 6(10) = 166 10% = 149.4

lower end.
Math calculation: 106 + 6(10) = 166 + 10% =182.6
higher end.

7) The patient is a Lutheran minister. He does get some

physical exercise daily. He walks his dog outside for about 15
minutes at a leisurely pace. Calculate his energy and protein
requirements.

Energy requirements per day: 10 X (84.1kg) + 6.25 X

(177.8cm) 5 X (61yrs.) +5 =1,652 kcal/day

1,652 kcal/day X 1.6(PAL factor) =2,643 kcal/day
Protein requirements should be 25-30% of total daily
calories. If Mr. Klosterman consumed 28% of his caloric
intake in protein, he would be consuming 740kcals/day

in protein alone.
Math calculation: 2,643 kcal/day X .28 =
740kcals/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.
After entering Mr. Klostermans 24-hour recall into
SuperTracker, his total caloric intake for one full day was
2,984 kcal.
Protein % Calories: 19%

Carbohydrate % Calories: 51%

Fats % Calories: 31%
o 11% Saturated fats
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o 6% Polyunsaturated fats
o 11% Monounsaturated fats

Klosterman's Nutrients Report 24hour recall

Your personal Calorie goal is 2,643. Your plan amounts are based on meeting your
nutrient needs.

Nutrients

Target

Average Eaten

Total Calories

2643 Calories

2984 Calories

Protein (g)***

56 g

142 g

Protein (% Calories)***

10 - 35% Calories

19% Calories

Carbohydrate (g)***

130 g

377 g

Carbohydrate (% Calories)***

45 - 65% Calories

51% Calories

Dietary Fiber

30 g

27 g

Total Sugars

No Daily Target or

128 g

Limit
Added Sugars

No Daily Target or

44 g

Limit
Total Fat

20 - 35% Calories

31% Calories

Saturated Fat

< 10% Calories

11% Calories

Polyunsaturated Fat

No Daily Target or

6% Calories

Limit
Monounsaturated Fat

No Daily Target or
Limit

11% Calories

Linoleic Acid (g)***

14 g

19 g

Linoleic Acid (% Calories)***

5 - 10% Calories

6% Calories

-Linolenic Acid (% Calories)***

0.6 - 1.2% Calories

0.7% Calories

-Linolenic Acid (g)***

1.6 g

2.5 g

Omega 3 - EPA

No Daily Target or

6 mg

Limit
Omega 3 - DHA

No Daily Target or

3 mg

Limit
Cholesterol

< 300 mg

278 mg

Minerals

Target

Average Eaten

Calcium

1000 mg

1535 mg

Potassium

4700 mg

4977 mg

Sodium**

1500 mg

4797 mg

Copper

900 g

1495 g

Iron

8 mg

26 mg

Magnesium

420 mg

375 mg

Phosphorus

700 mg

2050 mg

Selenium

55 g

167 g

Zinc

11 mg

22 mg

Vitamins

Target

Average Eaten

Vitamin A

900 g RAE

905 g RAE

Vitamin B6

1.7 mg

3.2 mg

Vitamin B12

2.4 g

7.8 g

Vitamin C

90 mg

177 mg

Vitamin D

15 g

9 g

Vitamin E

15 mg AT

6 mg AT

Vitamin K

120 g

137 g

Folate

400 g DFE

890 g DFE

Thiamin

1.2 mg

3.3 mg

Riboflavin

1.3 mg

2.9 mg

Niacin

16 mg

39 mg

Choline

550 mg

524 mg

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?
The labs that are consistent with the MI diagnosis
are as follows:
ALT (U/L)
AST (U/L)
CPK (U/L)
CPK-MB (U/L)
Lactate

Day 1
30
25
75
0
325

Day 2
215
245
500
75
625

2.4

2.8

Dehydrogenase
(IU/L)
Troponin I (ng/dL)

The increase in ALT from 30 (U/L) to 215 (U/L) indicates

that the enzyme alanine aminotransferase was released
into the blood stream, which is indicative of liver damage
(AACC, 2015).

The increase in AST from 25 (U/L) to 245 (U/L) indicates

that there is liver damage if the amount is higher than
usual in the blood. A high amount of AST (aspartate
aminotransferase) in the blood could also indicate that

there is damage to the heart which is exactly why this

number is very high in a patient that just recently suffered
a myocardial infarction like Mr. Klosterman (AACC, 2015).

The dramatic increase of CPK and CPK-MB from 75-500 and

0-75 indicates that there was an acute myocardial
infarction in the patient. The CPK-MB test is a cardiac
marker used to assist diagnoses of an acute myocardial
infarction. It measures the blood level of CK-MB, the bound
combination of two variants (isoenzymes CKM and CKB) of
the enzyme phosphocreatine kinase (AACC, 2015).

Lactate dehydrogenase nearly doubled in Mr. Klosterman

on the second day and this is the result of tissue damage
in the body. The normal range for LDH in the blood is 105333 (IU/L). Mr. Klosterman has extremely high levels of
LDH, which indicates that there is tissue damageparticularly in his heart (AACC, 2015).

A troponin test is conducted in order to see if there was a

myocardial infarction in the patient as well as to see if the
angina is worsening in the patient (AACC, 2015).

10) What is abnormal about his lipid profile? Indicate the

abnormal lipid values.

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The patients Triglycerides are on the higher end of the

scale as evidenced by the 150mg/dL reading for day 1.

The LDL/HDL ratio is abnormally high for all three days
consecutively. The vales for a male should be <3.55 and

Mr. Klostermans values were 5.3, 4.7, and 4.3.

His cholesterol levels were very high. The healthy range
is between 120-199. Mr. Klostermans data indicates he
has poor cholesterol levels: day one- 235, day two- 226,

and day three- 214.

HDL levels were very low at 30, 32, and 33. Normal

values >45 for males.

LDL cholesterol was very high at 160, 150, and 141.
Normal values <130.

11) Mr. Klosterman was prescribed the following medications

on discharge. What are the food-medication interactions for
this list of medications?

Medication

Possible Food-Medication

Lopressor 50 mg daily

Interactions
May cause dry mouth, which
causes the patient to become
more thirsty. May also cause
nausea, upper stomach pain, and

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overall loss of appetite. Lopressor

may also cause diarrhea, sleep
problems and fatigue (Mayo Clinic,
Lisinopril 10 mg daily

2015).
Patients taking Lisinopril cannot
use salt substitutes or potassium
supplements. Lisinopril may also
cause nausea, vomiting, diarrhea,
and upset stomach (Mayo Clinic,

Nitro-Bid 9.0 mg twice daily

2015).
Nitro-Bid does not have any foodmedication interactions but
exercise could induce fainting
while using Nitro-Bid so it is
important to rest and take it easy
while using this medication (Mayo

NTG 0.4 mg sl prn chest pain

Clinic, 2015).
NTG may induce nausea,
vomiting, upset stomach, diarrhea
and overall weakness (Mayo

ASA 81 mg daily

Clinic, 2015).
May cause upset stomach,
vomiting, diarrhea (Mayo Clinic,
2015).

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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?
What motivates you to be healthier overall?
What have you learned from this experience?
How can you improve your diet with your new knowledge of
sodium intake?
How can you improve your diet with your new knowledge of
fat intake?
What can you do daily to improve your overall lifestyle?

13) What other issues might you consider to support

successful lifestyle changes for Mr. Klosterman?

According to Mr. Klostermans nutrition analysis, his overall

sodium intake was nearly double what it should be according
to Nelms (p. 307). Educating both Mr. Klosterman and his wife
on the impact of high amounts of sodium alone would change

his lifestyle by volumes.

Encouraging Mr. Klosterman to exercise a little more than 15
minutes a day would benefit him too, in the long run. Just
after discharge, he will need to rest and take it easy for the
very reason that his heart underwent a myocardial infarction,

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but once he is able to move around and eat regularly again,

he should be encouraged to get outside more and be more
active. This will enable him to have a healthy lifestyle and a

healthy heart.
Educating Mr. Klosterman and his wife the difference between
a saturated fat and an unsaturated fat will benefit them
greatly, too. Unsaturated fats such as oil have many benefits
on the body and individuals are encouraged to consume 2-3

servings a day of these types of fats (p. 304).

Nutrition education overall summarizing the benefit of fruits
and vegetables and whole grains alone will help the
Klostermans greatly in the end.

14) From the information gathered within the assessment,

list the possible nutrition problems using the correct
diagnostic terms.

NI 1.3: Excessive energy intake.

NI 5.6.1: Inadequate fat intake.
NI 5.7.2: Excessive protein intake.
NI 5.10.2: Excessive mineral intake; sodium
(International dietetics and nutrition terminology, 2011)

Nutrition Diagnosis

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15) Select two of the nutrition problems stated and complete

PES statements for each.

Excessive caloric intake related to patients high intake of

macronutrients as evidenced by 24-hour recall stating patient

consumed 2,984kcal/day.
Excessive sodium intake related to patients elevated
consumption of high-salt food as evidence by 24-hour recall
stating the patient consumed 4,797mg sodium in one day.

Nutrition Intervention

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).

Excessive sodium intake related to patients elevated

consumption of high-salt food as evidence by 24-hour recall
stating the patient consumed 4,797mg sodium in one day.
o GOAL: Achieve average sodium intake of <2,000mg
sodium daily
o INTERVENTION: Inform patient on foods that tend to be
very high in sodium. Education on how to read a nutrition
label for food will be an appropriate intervention to help
achieve the goal of <2,000mg/sodium daily. Informing the

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patient on how to properly log food into a tracker will also

take place in the intervention.

Excessive caloric intake related to patients high intake of

macronutrients as evidenced by 24-hour recall stating patient
consumed 2,984kcal/day.
o GOAL: Total daily caloric intake of 2,600 kcal.
o INTERVENTION: Introduce food-logging applications online
such as SuperTracker to Mr. Klosterman to inform him how
to log his food to keep track of total caloric intake daily.
Education on lower calorie foods such as fruits and
vegetables will also benefit in this intervention.

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?
According to the American Heart Association, foods
containing Omega-3 fatty acids are extremely beneficial
to heart health. Fish, for example is a good source for
Omega-3 fatty acids. Omega-3 fatty acids have also
proven to decrease triglycerides and overall slow the
growth rate of atherosclerotic plaque buildup in the

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heart. Inevitably, supplementation works, however

encouraging Mr. Klosterman to consume foods
containing Omega-3 fatty acids prior to
supplementation will benefit him more than
supplementation alone. Consuming the actual food itself
proves to be healthier than taking oral supplementation
(American Heart Association, 2015).

Monitoring and evaluation

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 assess a three-day nutrition assessment

analyzing what he is improving if anything and what he
still needs to improve in his nutrition care process. I
would mainly focus on his overall fat intake and his
sodium intake values for these are the extenuating
factors directly related to heart disease. Monitoring how
much physical exercise Mr. Klosterman is able to get on
a weekly basis following the first week home (he should
be resting during the first week) is essential to a
successful aftercare process. Keeping track overall of Mr.

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Klostermans daily caloric consumption will be a part of

his final assessment as well.

References

AACC. (2015, July 8). Troponin. Retrieved September 2, 2015, from

https://labtestsonline.org/understanding/analytes/troponin/

International dietetics and nutrition terminology (IDNT) reference

manual:

Standardized language for the nutrition care process. (3rd

ed.). (2011).
Chicago, IL: American Dietetic Association.

National Institutes of Health (NIH). (2015, July 16). Retrieved

September 2, 2015.

Nelms, M. (2011). Nutrition Therapy and Pathophysiology (2nd ed.).

Belmont, CA: Wadsworth, Cengage Learning.

Nelms, M., & Roth, S. (n.d.). Medical nutrition therapy: A case study
approach (Fourth ed.).

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