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In Patients with
Congestive Heart Failure
Rory Costigan
Dietetic Intern
University of Maryland, College Park
Table of Contents
I.
Executive Summary3
II.
III.
IV.
V.
VI.
VII.
VIII.
Case Report.....4
Hospital Course of Patient...6
Case Discussion...9
Appendices12
Glossary.....15
References.15
Executive Summary
Congestive heart failure is described as a condition in which the heart
cannot pump enough blood to supply the bodys tissue with sufficient
oxygen and nutrients; back up of blood in vessels and the lungs cause
a buildup of fluid congestion in the tissues. With congestive heart
failure, blood moves through the heart and body at a slower rate, and
pressure in the heart increases. As a result the chambers of the heart
may respond by stretching to hold more blood to pump through the
body or becoming stiff and thickened. This helps to keep the blood
moving, but the heart muscle walls may eventually weaken and
become unable to pump efficiently. As a result the kidneys may
respond by causing the body to retain fluid and salt. When fluids build
up in the arms, legs, ankles, feet, lungs or organs, the body becomes
congested. (4) Research suggests heart failure often occurs in elderly
patients who have multiple comorbid conditions such as angina,
coronary artery disease, hypertension, renal disease, diabetes, and
chronic lung disease. (4) Symptoms of congestive heart failure include
shortness of breath, increased heart rate, lightheadedness, fatigue,
edema, wheezing or coughing and swelling in the extremities such as
legs, ankles and feet (2).
Patients suffering from congestive heart failure can also have
symptoms that can affect their food intake, for example fatigue during
food preparation, breathing difficulties and gastrointestinal symptoms
like nausea and ascites. Research supports that specific diet plans aid
the management of congestive heart failure (7). A sodium and fluid
restriction diet is commonly prescribed for individuals admitted with
congestive heart failure to control swelling caused from fluid build-up
(edema) and control hypertension (in salt sensitive individuals).
Research has suggested that supplementation of specific vitamins and
minerals might improve heart function (8). Diuretics are often
administered to patients with congestive heart failure to relieve
symptoms of fluid build-up, breathing difficulty and swelling of the
legs ankles and feet.
Treating congestive heart failure from a nutrition perspective is a
crucial component in the management of heart function. The ultimate
goal of the dietitian is to initiate a diet plan that will help decrease
fluid retention and fluid overload. Dietitians must educate and inform
the patient about the effect sodium plays in fluid retention. Because
congestive heart failure is a chronic disease the dietitian is also
responsible for educating the patient on diet management post
hospitalization to manage heart failure.
Case Report
GENRAL INFORMATION
XX is a 90-year-old African America man admitted to the DC VA
Medical Center on December 2nd 2014. Patient complained of
worsening edema of the extremities, SOB and wheezing. The patient
was diagnosed with fluid overload associated with CHF. XX was
transferred to a nearby rehabilitation facility on December 11th, 2014.
SOCIAL HISTORY
XX lived at the Armed Services Retirement Home in Washington DC in
an independent apartment. Patients daughter, his primary durable
power of attorney, was present for facility: family meetings and
frequently visited XX during hospitalization. The family was trying to
transition XX into an assisted living home due to decreased ability to
live independently. The patients family medical history was unknown
as XX was adopted. The patient denied use of tobacco, drugs or
alcohol. The patient currently has Medicare part A, B, D, which is
supplemented by Kaiser insurance.
MEDICAL/SURGICAL DATA
Past Medical History
Past medical history included Congestive Heart Failure (CHF), Coronary
Artery Disease (CAD) status post coronary artery bypass grafting (s/p
CABG), Cerebral Vascular Accident, Hypertension (HTN), Hyperlipidemia
(HLD), Diabetes Mellitus Type 2 (DM2), Parkinsons disease, Zenkers
diverticulum, mild cognitive impairment, benign prostate hyperplasia,
and gout. Patient did not have any known food allergies.
Past Surgical History
The patient did undergo a coronary artery bypass grafting surgery in
2005 at Holy Cross Hospital.
Admitting Physical Examination
Upon admission, the patient complained of shortness of breath and
wheezing. Peripheral edema was present.
Laboratory Results
Refer to Appendix A for laboratory results during this hospitalization.
Medications
Echocardiog
ram
Dec 3
Cystoscopy
Dec 4
Chest x-ray
Dec 7
Pacemaker
evaluation
Weight (in
pounds)
Source of
Weight
% UBW
% IBW
Dec 2
154
Measured
115%
99%
Dec 4
155
Measured
115%
100%
Dec 5
141.2
Measured
105%
91%
Dec 7
137.7
Measured
102%
88%
Dec 8
136.7
Measured
102%
88%
Dec 9
134.2
Bed Weight
100%
87%
Dec 10
134.9
Bed Weight
100%
87%
Protein
Requirements
Fluid
Requirements
Facility
Standards
25-30 kcal/kg
1761-2115
kcal
0.8-1 g/kg
56-72 g
25-30 ml/kg
1761-2115 ml
Evidence
Analysis Library
(EAL)
n/a
n/a
n/a
Date
Diet
Modifications
Avera
ge
Intak
e
Nutrition
Supplement(s)
Avera
ge
Intak
e
Nov 14
2G
NA+
6075%
Nov 17
2G
NA+
85%
Nov 18
NPO
for
testing
Labs (admission):
Na: 136
K: 4.7
Cl: 106
Cr: 1.2
Glucose: 135 (H)
BUN: 28 (H)
correct ht
BMI: 22.3 (Normal, healthy weight)
PMH: CAD s/p CABG in 2005, CHF
Ca: 9.4
Mg: 2.2
WBC 6.0
Medications prior to admission:
Simvastatin 20 mg, Ergocalciferol
(Vit D2) 200
Current Diet: Regular texture 2G
NA+
Nutrition Intervention
Nutrition Prescription
2G NA + DIA 2000
Energy Requirements: 1761-2115 kcal/day (25-30
kcal/kg)
Protein Requirements: 56-71 gm/day (0.8-1g/kg)
Fluid Requirements: 1761-2115 ml/day (25-30ml/kg)
10
discharge.
Criteria
Patient consumes >75% of meals <
2 days
Adherence (FH-4.1)
Nursing aides verbally repot
resident is eating appropriate foods
at meal rounds.
Weight (AD-1.1.2)
Date
Diet
Modifications
Averag Nutrition
e
Supplements
Intake
Dec 2 2G NA
75%
Dec 4 2G NA
50%
Avera
ge
Intake
0%
Case Discussion
MEDICAL CONSIDERATIONS
12
Nutritional Therapy
XX had a discharge reported weight of 134.9lbs in December 2014,
and a dry weight of 128lbs in June 2014. XXs recorded weight upon
admission was 154lbs and XX reported a 20-pound weight gain over
the last two months. Based on the facilities standards for determining
energy and protein needs the following was calculated: 1761-2115
kcals, 56-71 gm protein, and 1761-2115 mL fluids.
The patient initially was put on a 2G NA diet upon admission. The
patients PO intake for the first 24 hours was poor most likely related
to pain from the Foley catheter placement. After the pain resolved the
patients appetite increased to normal. The next day the patient
reported abdominal pains from gas that resolved with Simethicone
therapy. On the 4th day of hospitalization the patient complained of
mild nausea with abdominal pain, which the patient believed due to
stomach blockage. GF reported no Bowel Movement (BM) for 5 days.
After the patient had a BM his abdominal pain diminished and his
appetite again increased.
During GFs hospitalization he never consumed 100% of his estimated
requirements, but his intake had been increasing. The patient was
discharged to a sub-acute facility for physical therapy to improve his
ambulation. Patient is planned for a follow-up visit on 12/15/2014.
Implications of Findings to the Practice of Dietetics
Malnutrition, muscle wasting and cachexia may be present in patients
with severe congestive heart failure due to a combination of fatigue
on exertion (e.g. food preparation), breathing difficulties (from impact
of fluid overload), and gastrointestinal symptoms like nausea and
ascites. Initially when patients are admitted with congestive heart
failure a low sodium diet is prescribed to reduce peripheral swelling
from fluid build up (edema) and to assist in blood pressure control (7).
In patients with very severe CHF, a fluid restriction may be necessary
to reduce the need for excessive diuretic drugs and limit further fluid
retention. Some research suggests that folate supplementation (0.85.0mg daily) and Vitamin B12 supplementation (200mcg to 500 mcg
daily) given with other micronutrient supplements, may result in
decreased homocysteine levels, improvements in left ventricular
volume, ejection fraction and quality of life scores (8). Limited
evidence is available to determine protein needs for congestive heart
failure patients. Studies report that patients with congestive heart
failure have significantly higher protein needs than those without
heart failure as measured by a negative nitrogen balance. One study
indicates at least daily intake of 1.37 grams of protein per kilogram
for clinically depleted patients with heart failure and daily intake of
13
14
Appendices
APPENDIX A: LABORATORY RESULTS
Lab
Reference
Range
12/2
12/3
12/
4
12/
5
12/
6
12/7
12/8
12/9
12/1
0
12/1
1
Na
135-147
mmol/L
136
135
138
137
135
136
134
135
132
3.5-5.3
mmol/L
4.7
4.3
4.2
3.6
3.9
4.0
3.6
3.9
3.8
Cl
100-109
mmol/L
106
106
106
103
103
102
101
101
97
CO2
21-31
mmol/L
22
21
26
27
27
29
28
28
24
Creat
inine
0.7-1.5
mg/dl
1.2
1.3
1.4
0.9
0.9
0.8
0.8
0.8
0.8
Gluco
se
10-121
mg/dl
135
198
157
156
162
158
179
165
195
BUN
6-23
mg/dl
28
29
31
16
17
19
18
16
16
Bili
Total
0.2-1.2
mg/dl
1.7
1.7
1.7
Ca
8.9-10.5
mg/dl
9.4
9.2
8.6*
8.5*
8.6*
8.4*
8.3*
Phos
2.5-4.5
mg/dl
3.0
2.9
2.6
2.2
2.1
2.1
2.0
2.1
Mg
1.5-2.5
mg/dl
2.2
2.0
2.0
1.8
2.0
1.9
2.1
1.9
AST
8-40 IU/L
28
24
25
ALT
6-33 IU/L
27
30
17
WBC
3.2-9.5
k/uL
6.0
6.5
5.7
10.
1
10.7
7.2
6.0
7.0
7.2
Home Medications
Medication
Dosag
e
Frequen
cy
Function
Simvastatin
30
mg
Daily
Reduces levels of
(bedtim low-density
e)
lipoprotein and
triglycerides in the
Nutritional
Implications
Ergocalciferol
(Vit D)
50,00 Weekly
0 unit
cap
blood, while
increasing levels of
high-density
lipoprotein
nausea,
stomachaches,
vomiting
A form of Vitamin D
that promotes the
absorption and use
of calcium and
phosphate
Increased thirst,
nausea,
constipation,
anorexia, weight
loss
Clopidogrel
Bisulfate
75
mg
Daily
Platelet aggregation
inhibitor that slows
or stops platelets
from sticking to
blood vessel walls or
injured tissues
Vomiting, nausea,
stomach pain,
abdominal swelling
Albuterol
(oral
inhalation)
90
mcg
4 times
a day
Bronchodilator that
relaxes muscles in
the airways and
increases air slow to
lungs
Difficulty
swallowing,
nausea, vomiting,
gagging
Colchicine
0.6
mg
Daily
Beta-tubulin
interactor, affects
certain proteins,
which relieves gout
symptoms
Nausea, vomiting,
stomach pain,
heartburn
Calcium/Vita
min D
200
Unit
Tab
2 times
a day
Stomach pain,
vomiting, loss of
appetite
Alendronate
10mg
Daily
(morni
ng
before
meals)
Alendronate is a
bisphosphonate
which works to slow
bone loss
Abdominal or
stomach pain,
difficulty
swallowing,
irritation or pain of
the esophagus,
diarrhea
Allopurinol
100m
g
Daily
Reduces the
production of uric
acid
Abdominal or
stomach pain,
ammonia-like
breath odor,
constipation,
diarrhea, dry
mouth
16
Insulin Aspart
(Novolog)
1-4
units
PRN
Daily
Dry mouth,
increased hunger,
increased thirst,
loss of appetite
Aspirin
81mg
Daily
A salicylate that
works to reduce
substances in the
body that causes
pain, fever and
inflammation
Vomiting, severe
stomach cramps,
nausea
In-Patient Medications
Medication
Function
Nutritional Implications
Albuterol (oral
inhalation)
(Lipitor)
Difficulty swallowing,
nausea, vomiting,
gagging
Alendronate
Alendronate is a
bisphosphonate which
works to slow bone loss
Abdominal or stomach
pain, difficulty
swallowing, irritation or
pain of the esophagus,
diarrhea
Allopurinol
Abdominal or stomach
pain, ammonia-like
breath odor,
constipation, diarrhea,
dry mouth
Carbidopa
(Levodopa)
Levodopa is converted to
dopamine in the brain to
treat muscle symptoms of
Parkinsons disease
Severe nausea,
vomiting or diarrhea
Dextrose in IV
fluid
Hyperglycemia
Docusate
(Senna)
Relieving occasional
constipation and
preventing dry, hard stools
by helping fat and water
into the stool mass to
soften the stool
Furosemide
(Lasix)
Sore throat,
constipation, diarrhea,
17
increased hunger,
increased thirst, loss of
appetite, nausea and
vomiting
Glucagon
Diarrhea, loss of
appetite, nausea and
vomiting
Insulin Aspart
(Novolog)
Losartan
Stomach pain,
increased hunger,
nausea, vomiting
Metoprolol
succinate
Ondansetron
Simvastatin
Spironolacton
e
For potassium-sparing
diuretic that prevents the
absorption of too much salt
while preventing potassium
levels from getting too low.
Abdominal or stomach
cramping, constipation,
diarrhea, increased
thirst, loss of appetite,
sore throat
Terazosin
18
Glossary
Ascites- the accumulation of fluid in the peritoneal cavity, causing
abdominal swelling
Costophrenic angle- Chest x-ray done to confirm the presence of
pleural fluid
Emesis- the action or process of vomiting
DIA 2000- Diabetic menu plan consisting of 2000 calories.
Hematura- the presence of blood in urine
Hyperplasia- the enlargement of an organ or tissue caused by an
increase in the reproduction rate of its cells, often as an initial stage
in the development of cancer
Inspiration- the drawing in of breath; inhalation
Natriuretic peptide- a peptide which induces natriuresis
- natriuresis- excretion of sodium in the urine
Ventricular volume- the volume of blood in a ventricle at the end of
contraction
References
1. Schoken, DD. "Result Filters." National Center for
Biotechnology Information. U.S. National Library of Medicine, 2
Aug. 1992. Web. 28 Mar. 2015.
2. Dundee, Neil. The Diagnosis and Management of Chronic
Heart Failure in the Older Patient. British Medical Council.
Oxford University Press. 22 Feb. 2006. Web. 28 Mar. 2015
3. Pasini, E. Malnutrition, muscle wasting and cachexia in chronic
heart failure: the nutritional approach. National Center for
Biotechnology Information. U.S. National Library of Medicine, 4
Apr. 2003. Web. 28 Mar. 2015.
4. Figueroa, Michael S. "Respiratory Care." Congestive Heart
Failure: Diagnosis, Pathophysiology, Therapy, and Implications
Apr. 2006. Web. 28 Mar. 2015.
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