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Major Case Study

Major Case Study. The University of Southern Mississippi Ashley Bryant. Overview. Patient Information Disease Information ADIME. General Information. T.M. 76 yo Caucasian male Lives in Hattiesburg with wife Adult sons Employed at trucking company. Report on Admission.

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Major Case Study

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  1. Major Case Study The University of Southern Mississippi Ashley Bryant

  2. Overview • Patient Information • Disease Information • ADIME

  3. General Information • T.M. • 76 yo Caucasian male • Lives in Hattiesburg with wife • Adult sons • Employed at trucking company

  4. Report on Admission • Admitted 2/9/14 & discharged 3/25/14 (45 days) • Brought to ED immediately after onset of chest pain & left-sided weakness • Admitted to Internal Medicine • Primary Diagnosis: • Right pontine cerebrovascular accident (CVA) • Secondary Diagnoses: • Coronary artery disease (CAD) • Critically stenosed left internal carotid artery (ICA)

  5. Special History • PMH: • CAD, MI, HTN, PVD, hyperlipidemia, skin cancer, arthritis • Family History: • Heart Disease • Social Conditions • Supportive wife & children • No economic, emotional, or psychological issues impacting health noted • Pt has insurance coverage

  6. CVA • Etiology • Age, gender, race, genetics, HTN, CVD, DM, dyslipidemia, carotid stenosis, AF, cigarette smoking, physical inactivity, alcohol intake >30 grams/day, obesity, poor diet • Pathophysiology • Result of an interruption of blood flow to the brain • Brain cells are deprived of oxygen disrupted cellular metabolism & cell injury • Symptoms • Depends on area of brain that is impacted • Typically vision/speech loss, paralysis, muscle weakness, altered mental status—from confusion to coma (Nelms, Sucher, Lacy, & Roth, 2011)

  7. Pt’s Treatment • Scheduled for carotid endarterectomy (CEA) of left carotid artery & coronary artery bypass graft (CABG) x 3 to correct the triple vessel CAD • Clinical nutrition assessment prior to surgeries • Pt reports great appetite, no problems • Eating cheeseburger & fries • Politely declined nutrition education

  8. Pt’s Treatment • Surgeries on 2/17transferred to ICU for monitoring cardiac floor on 2/25 • Received & accepted nutrition education • Worked closely with therapy • Improved with speech therapy & was discontinued from their care • Transferred to inpatient rehab on 4/2 • PT & OT to regain function & decrease burden of care once he returned home • Met or surpassed all goals

  9. Medical Nutrition Therapy • Treatment for CVA will vary depending on pt • Common dx: • Inadequate energy intake, inadequate oral food/beverage intake, inadequate fluid intake, inadequate protein-energy intake, swallowing difficulty, &self-feeding difficulty (Nelmset al., 2011) • Interventions: • Address any chewing/swallowing/self-feeding difficulty • Nutrition support could be indicated • Should be updated based on progression of rehab • Heart Healthy Diet • Post-CABG Recommendations • 1.) Optimize intake • 2.) NAS • 3.) 1500 mL fluid restriction • 4.) Heart Healthy/TLC after 6 weeks

  10. Research • Cholesterol • Consumption of one egg per day is not associated with CHD or stroke • Consumption of more than seven eggs per week has been associated with an increased risk (EAL, 2014) • Fiber • Consuming more than 25 grams of fiber per day is associated with a decreased risk of CVD (EAL, 2014). • Moreover, dietary fiber and fiber-rich food intake inversely associated with risk of CVA in male smokers (Larsson et al., 2009) • Mediterranean Diet • Results in greater reduction of cardiovascular events in persons with high cardiovascular risk than low-fat diet (Glasziou, 2013) • Associated with lower mortality from all causes for patients with CVD (Lopez-Garcia, 2014)

  11. Nutrition Prescription • At time of NST initial assessment • 1601-2002 kcal [based on 20-25 kcal/kg of body weight] • 96-120 grams [based on 1.2-1.5 grams of protein per kilogram of body weight] to promote healing and to prevent loss of lean mass

  12. MNT • Diet Orders • Regular, NPO, TF, Dental Soft with TF, Dental Soft + Supplement, Regular NAS 1500 mL fluid restriction • Needs—Post-Op (ICU) [2/17-2/24] • 1601-2002 kcal & 96-120 grams protein • Actual Intake—Post-Op (ICU) • NPO [2/17-2/19] • ~1800 kcal & 112 grams protein [2/19-2/25] meets needs

  13. Nutrition Care Process:Assessment • Medications • Norvasc (HTN) • Lipitor (Cholesterol) • Lovenox (DVT) • Lisinopril (HTN) • Metoprolol (HTN) • Miralax (Constipation) • Diet • Preference for high-fat foods • Right-sided weakness • NPO prior to surgery • Anthropometrics • 5’11”, 208 lbs • BMI 29.1 (overweight) • IBW 75.3, 125.3%IBW • Labs • Na 148 (H) • Cl 114 (H) • BUN 46 (H) • Ca 8.2 (L) • Glucose 127 (H) • Albumin 3.3 (L) • Cholesterol 203 (H) • TG 317 (H)

  14. Diagnosis • Inadequate protein-energy intake related to (RT) NPO diet order post-operation as evidenced by (AEB) patient meeting 0% of estimated energy &protein needs • Undesirable food choices RT preference for foods high in saturated fat AEB abnormal lipid panel (Cholesterol: 203 and Triglycerides: 317) patient’s dietary recall of high fat foods, & RD’s observation of patient consuming a cheeseburger and fries after prior to his surgeries

  15. Intervention • Initiate immune-enhancing formula Impact Peptide @ 25 mL/hr for six hours, then 40 mL/hr for six hours, then 50 mL/hr thereafter to provide 1800 kcal and 112 grams protein per day. • When advanced to oral diet • Obtained food preferences & provided an oral nutritional supplement to provide additional calories and protein for healing

  16. Intervention • Nutrition Education • Increased protein for healing, no added salt, and a 1500 mL fluid restriction, as well as the TLC diet to begin six weeks after surgery

  17. Monitoring & Evaluation • Goals • Intake meets at least 2/3 of needs • Maintain weights • Labs WNL • Verbalizes good understanding/compliance with diet • Dietary intake no longer reveals undesirable foods • Lipid panel WNL

  18. Summary • Effectiveness of Dietary Intervention • Nutritional status improved • Verbalized interest in heart healthy diet post-op • Discharged to FGH home health for therapy & wound care • Influence Post-Discharge • Family support beneficial to pt’s success & psychological health • Insurance covered home care, beneficial to recovery • Prognosis • Good if compliant with diet & medications

  19. Update • One week ago: • Lipids WNL with exception of HDL 39 L (increased from 34 L) • Chol 150 (decreased from 203) • TG 144 (decreased from 317)

  20. References • Academy of Nutrition and Dietetics Evidence Analysis Library. (2004). What does the evidence indicate is the relationship between fiber intake and coronary heart disease outcomes?Academy of Nutrition and Dietetics. Retrieved from http://andevidencelibrary.com/ • Academy of Nutrition and Dietetics Evidence Analysis Library. (2014). What effect does folic acid supplementation have on risk of stroke among persons with or without pre-existing vascular disease?Academy of Nutrition and Dietetics. Retrieved from http://andevidencelibrary.com/ • Academy of Nutrition and Dietetics Evidence Analysis Library. (2014). What is the effect of dietary cholesterol intake on risk of cardiovascular disease, including effects on intermediate markers such as serum lipid and lipoprotein levels and inflammation? Academy of Nutrition and Dietetics. Retrieved from http://andevidencelibrary.com/ • Academy of Nutrition and Dietetics Evidence Analysis Library. (2014). What is the relationship between supplemental vitamin E and incidence of non-fatal MI and non-fatal stroke?Academy of Nutrition and Dietetics. Retrieved from http://andevidencelibrary.com/ • Dietetics in Health Care Communities. (2009). Lab values. In C. Piland & K. Adams (7th ed.) Pocket Resource for Nutrition Assessment (pp.71-82) United States. • Glasziou, P. (2013) Mediterranean diet reduced cardiovascular events more than a low-fat diet in high-risk persons. American College of Physicians, 158(12), 1279-90. doi: 10.7326/0003 • Larsson, S. C., Männistö, S., Virtanen, M. J., Kontto, J., Albanes, D., & Virtamo, J. (2009). Dietary fiber and fiber-rich food intake in relation to risk of stroke in male smokers. European Journal of Clinical nutrition, 63(8), 1016-1024. doi:10.1038/ejcn.2009.16 • Lopez-Garcia, E., Rodriguez-Artalejo, F., Li, T. Y., Fung, T. T., Shanshan, L., Willett, W. C., & ... Hu, F. B. (2014). The Mediterranean-style dietary pattern and mortality among men and women with cardiovascular disease. American Journal Of Clinical Nutrition, 99(1), 172-180. doi:10.3945/ajcn.113.068106 • McMahon, M., Nystrom, E., Braunschweig, C. Miles, J., & Compher, C. (2013). A.S.P.E.N. clinical guidlenes: Nutrition support of adult patients with hyperglycemia. Journal of Parenteral and Enteral Nutrition, 37(1), 23-36. • RxList-The Internet Drug Index. (n.d). Prescription drugs. Retrieved April 11, 2014, from http://www.rxlist.com. • Sebregts, E., Falger, P., Bar, F., Kester, A., & Appels, A. (2003). Cholesterol changes in coronary patients after a short behavior modification program. International Journal of Behavioral Medicine 10(4), 215-330.

  21. Questions?

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