Case Study

By: Kaitlyn Taylor

Dietetic Intern
Loyola University Chicago
 Patient Background
● 77 year old caucasian male
● Lives at home with wife
● Retired car salesman
● No illicit drugs, alcohol occasionally
● Admitting diagnosis: Abdominal pain
● Symptoms upon presentation:
Epigastric pain, dyspnea
● Current medical conditions: CAD,
NSTEMI, Sepsis, AKI
● Past medical history: Diabetes, CAD,
bladder cancer, and anemia
● Full thickness wound on coccyx
Anthropometrics
● Height: 198 cm (78 in)
● Weight:
○ Current: 101.5 kg (223 lbs)
○ Ideal: 97.3 kg (214 lbs)
○ Ideal%: 104%
○ UBW: 109 kg (240 lbs)
○ %UBW: 93%
○ % wt change: 7% in 2 years (not severe)
● BMI: 25.3, Overweight
● ABW not appropriate in this case
Cardiovascular Disease (CVD)
● Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD
includes coronary artery diseases (CAD) such as angina and myocardial infarction.
● CAD occurs when plaque builds up in your arteries (atherosclerosis). The plaque reduces the amount of
oxygen-rich blood getting to your heart, which can cause chest pain
○ Plaque can also lead to blood clots, which block blood flow and are the most common cause of a
heart attack
● 11.7% of American adults (that’s more than 1 of every 10) have been diagnosed with heart disease
● More than 800,000 people die of CVD every year in the United States
○ About 366,000 Americans died from coronary heart disease in 2015
○ 1 in 3 deaths are due to CVD
● Framingham heart study (1948)
○ Objective: Identify the common factors or characteristics that contribute to CVD by following its
development over a long period of time in a large group of participants
 CABG
● Coronary Artery Bypass Graft (CABG) is a
type of surgery that improves blood flow to
the heart
○ A healthy artery or vein from the body
is connected (grafted) to the blocked
coronary artery. The grafted artery
bypasses the blocked portion and
creates a new path for oxygen-rich
blood to flow to the heart muscle
○ Surgeons can bypass multiple
coronary arteries during one surgery
CABG (cot’d)
● Used during or after a heart attack to treat blocked arteries
○ Especially if your heart’s pumping action has grown weak
● CABG generally provides excellent outcomes and resolves angina symptoms in most
patients
○ Symptom free for as long as 10-15 years
○ Lowers risk for heart attack down the line
● Factors that can affect your candidacy for a CABG:
○ The presence and severity of CHD symptoms
○ The severity and location of blockages in your coronary arteries
○ Your response to other treatments
○ Your quality of life
○ Any other medical problems you have
Nutrition Care Process: Assessment
● Evaluation of intake:
○ Per family, patient was just given sedative
○ Dentures (prefers soft foods), no swallowing issues
○ Poor intake PTA, lower than normal for 1 week
○ Drinks Glucerna at home
● NFPE: Nonsevere malnutrition related to acute disease as evidenced by mild muscle loss
and poor PO intake (performed at F/U, patient still with AMS)
● Energy needs:
○ Calories: 25-30 kcal/kg = 2,530-3,045 kcals/day
○ Protein: 1.5 gm/kg = 152 gm pro/day
○ Fluids: Per medical team
Laboratory Data
Labs/ BUN/Cr Albumin FBS Miscellaneous
Date

2/19 25/1.55 2.3 163 2/18: A1C: 7.2%

2/22 51/3.04 2.3 173

2/25 55/4.74 2.1 117 Phos: 6.2

2/27 38/3.42 2.1 221 Phos: 2.1,

↑AlkPhos
Nutrition Related Medications
Medication Use Nutritional Implication

Lipitor (Atorvastatin) Statin; lowers cholesterol Avoid grapefruit juice

Pepcid (Famotidine) Decreases the amount of acid Constipation, diarrhea

the stomach produces

Insulin: Anti-diabetic, hypoglycemic Lispro: Cramps, weight gain

Lispro (Humalog) Glargine: SOB, weight gain
Glargine (Lantus)

Iron (FeSO4) To treat iron deficiency Constipation, nausea

(especially on an empty
stomach)

Haldol (Haloperidol) Antipsychotic Weight Gain

Zofran (Ondansetron) Anti-nausea Dry mouth, abdominal pain,

nausea, diarrhea, constipation
Nutrition Care Process: Diagnosis
1. Inadequate oral intake related to abdominal discomfort as evidenced by need
for NPO status, reported fair intake PTA

2. Inadequate oral intake related to confusion and/or mental status changes as

evidence by documented/reported poor oral intake

3. Inadequate oral intake related to confusion and/or mental status changes as

evidenced by documented/reported poor oral intake, need for swallow
evaluation
Nutrition Care Process: Intervention
2/17: NPO (for possible CABG)

2/18: Soft for dentition (chopped) with cardiac restrictions and Chocolate Glucerna
and Magic Cup BID

2/25: Calorie Count started in the A.M. during rounds

● By the afternoon, there was a consult for tube feeding recommendations

Nutrition Care Process: Intervention (cot’d)
2/27: Dysphagia Level 1 pureed, Chocolate Magic Cup and Glucerna BID
& Nepro 60 mL x 12 hours with 1 liquid protein supplement (6p-6a) and bolus
feeds of 240 mL Nepro TID (at meal times if <50% of meal consumed). Each
provided 1406 kcals (50%) and 82 gm protein (50%)
*Calorie count results showed 0% of meals consumed of the 2 tickets
saved; all kcals and protein coming from EN*

2/28: Continuous feeds of Nepro @ 65 mL/hr with 1 liquid protein supplement. This
provided 2918 kcals (100%) and 150 gm protein (100%)
Nutrition Care Process: Monitoring and
Evaluation
Monitoring:
● Food and beverage intake
● Enteral nutrition prescription
● Swallow status
● Labs

Evaluation:
● Tolerating diet order (oral and/or EN)
● Meeting needs through enteral nutrition
Current status update
3/3: SLP re-assessed patient and upgraded his diet to Dysphagia 2 diet, tube
feeding discontinued

3/6: Diet upgraded to Soft for dentition (chopped) and appetite improving with
improved mental status

3/8: Transfer to rehab before CABG

3/19: CABGx4 and mental status WNL

Study
“Secondary Prevention After Coronary Artery Bypass Graft Surgery”

● Secondary prevention aims to reduce the impact of a disease or injury that

has already occurred
● Barriers do exist
● Participation in a hospital based outpatient cardiac rehab (CR) program
compared with a home based program helps improve exercise adherence for
both men and women, increases knowledge about the condition
Personal Reflection
● Helped me to understand the treatment options for CAD
● Feel more confident in choosing an EN formula
● Feel more confident calculating tube feeding recommendations
○ Nocturnal AND bolus
● Ended up being a little more complex patient but was able to work through it
○ Helped to look at the big picture and root cause
● Prevention is seriously key! Even secondary
Questions?

THANK YOU!
References
1. Mahan, L. K., Raymond, J. L., & Escott-Stump, S. (2013). Krause's food & the nutrition care
process (13th ed.). Saint Louis: Saunders.
2. Ischemic Heart Disease. (n.d.). Retrieved from https://www.nhlbi.nih.gov/health-topics/ischemic-
heart-disease
3. Framingham: Past and Present. (n.d.). Retrieved from https://www.framinghamheartstudy.org/
4. Understand Your Risks to Prevent a Heart Attack. (n.d.). Retrieved from
https://www.heart.org/en/health-topics/heart-attack/understand-your-risks-to-prevent-a-heart-
attack
5. Coronary Artery Bypass Grafting. (n.d.). Retrieved from https://www.nhlbi.nih.gov/health-
topics/coronary-artery-bypass-grafting
6. Kulik, A., Ruel, M., Jneid, H., Ferguson, T. B., Hiratzka, L. F., Ikonomidis, J. S., . .Zimmerman,
L. (2015). Secondary Prevention After Coronary Artery Bypass Graft Surgery. Circulation,
131(10), 927-964. doi:10.1161/cir.0000000000000182