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5:
Myocardial
Infarction
Sam
Ballard
KNH
411
9.3.2015
I. Understanding
the
Disease
and
Pathophysiology
1.
Mr.
Klosterman
had
a
myocardial
infarction.
Explain
what
happened
to
his
heart.
Blood
flow
was
restricted
to
his
heart
due
to
plaque
buildup
blocking
an
artery.
This
lack
of
oxygen
carrying
cells
deprived
the
myocardial
cells
of
oxygen,
leading
to
necrosis
of
those
cells.
This
death
of
myocardial
cells
weakens
the
heart
muscle
(Nelms,
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
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
the
surgical
insertion
of
a
balloon
that,
when
inflated,
opens
a
blockage
in
a
blood
vessel
or
coronary
artery.
The
balloon
is
surrounded
by
a
mesh
tube
known
as
a
stent.
After
the
balloon
is
inflated
and
has
cleared
the
blocked
artery,
it
is
then
deflated
and
removed,
allowing
the
stent
to
be
put
in
place.
The
stent
will
hold
up
and
support
the
artery
in
hopes
of
preventing
future
blockages
and
allowing
the
blood
to
flow
smoothly
(University
of
Michigan
Health
System:
Cardiac
Surgery,
2014).
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
rehabilitation
will
provide
the
couple
with
education,
counseling
services,
and
physical
fitness
activities
and
regimens
to
help
reduce
his
present
symptoms,
reduce
risk
of
future
heart
issues,
and
improve
his
overall
health
and
quality
of
life.
Cardiac
rehabilitation
is
tailored
to
Mr.
Klostermans
specific
needs.
His
physical
activity
program
will
include
physical
activity
where
his
heart
rate
and
blood
pressure
are
monitored
and
he
will
eventually
work
up
to
intense
aerobic
activity.
His
counseling
and
education
will
address
creating
a
healthy
eating
plan,
smoking
cessation,
and
stress
management.
Using
this
comprehensive
team
of
professionals,
Mr.
Klosterman
will
learn
how
to
return
to
work
and
normal
activities
while
managing
his
heart
condition
(American
Heart
Association,
2015).
II. Understanding
the
Nutrition
Therapy
4.
What
risk
factors
indicated
in
his
medical
record
can
be
addressed
through
nutrition
therapy?
Mr.
Klostermans
weight
status
and
BMI
(26.6)
indicate
he
is
overweight.
Nutrition
therapy
can
be
used
to
reduce
his
excessive
calorie
intake.
His
cholesterol
intake
and
the
types
of
cholesterol
he
is
consuming
can
also
be
addressed.
Lastly,
his
dehydration,
which
is
evidenced
by
tenting
of
his
skin,
can
be
reversed
through
increased
fluid
intake.
5.
What
are
the
current
recommendations
for
nutritional
intake
during
a
hospitalization
following
a
myocardial
infarction?
While
hospitalized,
Mr.
Klosterman
is
on
an
NPO
diet
until
his
procedure
is
completed.
He
is
currently
on
a
clear
liquid
diet
and
he
is
allowed
no
caffeine.
Caffeine
increases
heart-rate,
causes
abnormal
heart
rhythms,
and
would
contribute
to
his
dehydration
(MedlinePlus,
2015).
III. Nutrition
Assessment
6.
What
is
the
healthy
weight
range
for
an
individual
of
Mr.
Klostermans
height?
Hamwi
Method:
IBW
=
106
lbs.
+
(6
lbs.
x
every
inch
over
5
ft.)
IBW
=
106
lbs.
+
(6
lbs.
x
10
inches)
IBW
=
106
lbs.
+
60
lbs.
IBW
=
166
lbs.
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
place.
Calculate
his
energy
and
protein
requirements.
Mifflin-St.
Jeor
Method:
EER
=
(10
x
wt
(kg)
+
6.25
x
ht
(cm)
5
x
age
(yrs)
+
5)
x
PAL
EER
=
(10
x
(185
lbs./2.2
kg)
+
6.25
x
(70
x
2.54
cm)
5
x
61
+
5)
x
1.6
EER
=
(10
x
(84.1
kg)
+
6.25
x
(177.8
cm)
5
x
61
+
5)
x
1.6
EER
=
(841
+
1,111.25
305
+
5)
x
1.6
EER
=
1,652.25
x
1.6
EER
=
2,643.6
kcal/day
Protein
Requirements:
1.0
g/kg/day
x
84.1
kg
=
84.1
g/kg/day
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.
(www.fitday.com)
Total
Calories
=
2,506
kcal
Total
Fat
=
76.6
g
Total
Protein
=
128.5
g
Total
Carbohydrate
=
330.1
g
Fat
%
=
(76.6
g
x
9
kcal/g
=
689.4
kcal/2,506
kcal
=
27.5%
Protein
%
=
(128.5
g
x
4
kcal/g
=
514
kcal/2,506
kcal
=
20.5%
Carbohydrate
%
=
(330.1
g
x
4
kcal/g
=
1,320.4
kcal/2,506
kcal
=
52.7%
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?
Elevated
troponin
I
and
troponin
T
are
consistent
with
the
MI
diagnosis.
Troponin
proteins
are
released
if
there
has
been
damage
to
the
heart
muscle
and
these
levels
increase
with
the
severity
of
damage
(MedlinePlus,
2014).
If
troponin
levels
were
higher
on
day
2,
this
must
mean
that
more
damage
was
done
to
the
heart
on
day
2
since
troponin
levels
increase
with
the
severity
of
damage.
Since
the
MI
was
caused
by
lack
of
oxygen
to
the
heart
muscle,
it
is
reasonable
to
assume
that
the
cells
deprived
of
oxygen
finally
died,
causing
necrosis
of
the
myocardium
and
elevating
the
troponin
levels
on
day
2.
10.
What
is
abnormal
about
his
lipid
profile?
Indicate
the
abnormal
values.
Mr.
Klostermans
lipid
profile
indicates
that
since
his
admission
date
on
12/1,
he
has
had
High
cholesterol
(214
mg/dL
as
of
12/3)
Low
HDL-C
levels
(33
mg/dL
as
of
12/3)
High
LDL
levels
(141
mg/dL
as
of
12/3)
High
HDL/LDL
ratio
(4.3
as
of
12/3)
Apo
A
levels
were
low,
but
have
returned
to
normal
(98
mg/dL
as
of
12/3)
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
Interactions
Lopressor
50
mg
daily
Alcohol
Lisinopril
10
mg
daily
Alcohol,
salt
substitutes
that
contain
potassium,
potassium
supplements
Nitro-Bid
9.0
mg
twice
daily
N/A
NTG
0.4
mg
sl
prn
chest
pain
Alcohol
ASA
81
mg
daily
Alcohol
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?
How
often
do
you
eat
out?
Could
you
describe
how
often
and
at
what
times
you
eat
on
a
regular
day?
Are
there
any
foods
you
will
absolutely
not
eat
(due
to
taste,
texture)?
If
so,
what
are
they?
Do
you
have
any
favorite
foods?
If
so,
what
are
they?
How
confident
are
you
in
your
ability
to
examine
food
labels
for
calories,
carbohydrate,
fat,
protein,
sodium,
and
cholesterol
content?
What
activities
do
you
engage
in
to
stay
physically
active?
13.
What
other
issues
might
you
consider
to
support
successful
lifestyle
changes
for
Mr.
Klosterman?
Mr.
Klosterman
should
first
stop
or
reduce
his
tobacco
use.
This
will
improve
his
cardiovascular
and
overall
health
almost
immediately.
Weight
loss
would
also
improve
his
quality
of
life.
This
could
be
done
by
increasing
his
daily
physical
activity
and
implementing
a
diet
for
his
heart
health
and
weight
loss,
such
as
a
therapeutic
lifestyles
(TLC)
diet.
14.
From
the
information
gathered
within
the
assessment,
list
possible
nutrition
problems
using
the
correct
diagnostic
terms.
Excessive
energy
intake
(NI-1.3)
Inadequate
fluid
intake
(NI-3.1)
IV. Nutrition
Diagnosis
15.
Select
two
of
the
identified
nutrition
problems
and
complete
the
PES
statement
for
each.
Excessive
energy
intake
(NI-1.3)
R/T
skipping
breakfast
AEB
BMI
of
26.6.
Inadequate
fluid
intake
(NI-3.1)
R/T
diaphoresis
AEB
skin
turgor
test
resulting
in
tenting.
V. 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).
The
ideal
goal
for
his
excessive
energy
intake
would
be
to
reduce
his
BMI
to
a
healthy
level
by
losing
about
10-15
pounds.
This
would
bring
him
closer
to
his
ideal
weight
of
166
pounds.
One
way
to
work
towards
this
goal
would
be
for
him
to
eat
breakfast
daily
so
he
would
be
less
hungry
throughout
the
day.
A
food
log
may
be
appropriate
in
order
to
create
a
self-awareness
of
his
eating
habits.
The
ideal
goal
for
his
inadequate
fluid
intake
would
be
to
increase
fluid
intake
so
that
a
reassessment
of
skin
turgor
would
yield
positive
results
(i.e.
good
or
fair).
His
is
likely
dehydrated
due
to
his
diaphoresis,
or
excessive
sweating,
so
although
we
can
not
control
his
sweating,
Mr.
Klosterman
can
be
in
control
of
how
much
fluids
he
intakes
to
offset
this
deficit.
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,
omega-3
fatty
acids
are
beneficial
for
cardiac
patients.
Although
obtaining
omega-3
fatty
acids
through
food
intake
is
preferable,
supplements
may
be
necessary
for
heart
patients
who
need
more
omega-3
fatty
acids
than
they
can
get
from
food
alone.
It
is
important,
however,
to
ensure
the
supplement
is
high-quality
and
free
from
contaminants
in
order
to
use
it
extensively
(Kris-Etherton,
Harris,
&
Appel,
2002).
VI. Nutrition
Monitoring
and
Evaluation
18.
What
would
you
want
to
assess
in
three
or
four
weeks
when
he
and
his
wife
return
for
additional
counseling?
In
three
or
four
weeks,
I
would
like
to
assess
Mr.
Klostermans
eating
regimen.
I
would
like
to
see
that
he
is
regularly
eating
breakfast
in
hopes
of
controlling
his
intake
throughout
the
day.
Hopefully,
this
will
eventually
yield
some
amount
of
weight
loss,
bringing
him
closer
to
his
IBW.
I
would
also
like
to
see
that
his
skin
turgor
has
improved,
indicating
that
he
has
become
properly
hydrated.
If
lab
values
were
available
to
me
at
that
time,
I
would
look
at
his
lipid
profile
again
to
see
if
there
were
any
suggestions
I
could
make
about
his
diet
that
may
alter
those
values.
Also,
I
would
like
to
discuss
how
at
home
meal
making
is
going
for
him
and
his
wife
to
see
if
I
can
make
any
suggestions
or
adjustments
to
meal
planning
as
necessary.
Lastly,
I
would
like
to
check
up
on
how
cardiac
rehabilitation
is
going
for
him!
I
want
to
see
that
he
is
confident
in
his
ability
to
comply
with
the
multiple
fitness,
diet,
and
lifestyle
changes
he
has
made
in
the
past
month.
References
American
Heart
Association
(2015).
What
is
cardiac
rehabilitation?.
Retrieved
from
http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-
is-Cardiac-Rehabilitation_UCM_307049_Article.jsp
Kris-Etherton,
P.M.,
Harris,
W.S.,
&
Appel,
L.J.
(2002).
Fish
consumption,
fish
oil,
omega-3
fatty
acids,
and
cardiovascular
disease.
Circulation,
106,
2747-2757.
doi:
10.1161/01.CIR.0000038493.65177.94
MedlinePlus
(2014).
Troponin
test.
Retrieved
from
https://www.nlm.nih.gov/medlineplus/ency/article/007452.htm
MedlinePlus
(2015).
Caffeine.
Retrieved
from
https://www.nlm.nih.gov/medlineplus/caffeine.html
*MedlinePlus
(2015).
Nitroglycerine
topical.
Retrieved
from
https://www.nlm.nih.gov/medlineplus/druginfo/meds/a682346.html#spec
ial-dietary
Nelms,
M.N.,
Sucher,
K.P.,
&
Lacey,
K.
(2014).
Nutrition
therapy
and
pathophysiology
(3rd
ed.).
Boston,
MA:
Cengage
Learning.
*RxList
(2015).
Bayer.
Retrieved
from
http://www.rxlist.com/aspirin-drug/patient-
avoid-while-taking.htm
*RxList
(2015).
Lopressor.
Retrieved
from
http://www.rxlist.com/lopressor-
drug/patient-avoid-while-taking.htm
*RxList
(2015).
Nitrostat.
Retrieved
from
http://www.rxlist.com/nitrostat-
drug/patient-avoid-while-taking.htm
*RxList
(2015).
Prinivil.
Retrieved
from
http://www.rxlist.com/prinivil-
drug/patient-avoid-while-taking.htm
University
of
Michigan
Health
System:
Cardiac
Surgery
(2014).
Coronary
angioplasty
and
stenting.
Retrieved
from
http://www.med.umich.edu/cardiac-
surgery/patient/adult/adultcandt/coronary_angioplasty.shtml
www.fitday.com
*References
for
food-medication
interaction
chart
24-Hour
Recall
Diet
Analysis
www.fitday.com