FND 431 Neurological Case Study

R.B. is a 77 year old, right handed female whom arrives at the hospital with a new-onset weakness of the
right side involving the right arm and leg. Face and arm weakness is disproportionate to leg weakness.
Dysarthria with tongue deviation. She has had hypertension for the past 10 years and hyperlipidemia for
the past 2 years. Her 82 year old husband brought her to the hospital and stated My wife woke up this
morning with everything pretty normal, but in the middle of the morning, she became dizzy, and then she
couldnt talk or move on the right of her body. She is started on an acute stroke protocol.

She is 52 tall and weighs 165 lbs. She wears upper and lower dentures. She is NPO except for meds.
Her husband reports that his wife has a good appetite, and she has not been following any special diet,
except avoiding fried foods, and not using salt at the table, which she changed several years ago.
According to her husband she ate the following yesterday:
Breakfast: 1 cup orange juice
1 cup raisin bran with 6 oz 2% milk
1 medium banana
8 oz coffee with 2 tbsp 2% milk and sweetener
Lunch: 2 cups chicken tortellini soup (cheese tortellini in chicken broth)
8 saltine crackers
1 fresh pear
6 oz iced tea with sweetener
Dinner: 4-6 oz grilled chicken (with skin)
1 medium baked potato with 2 tbsp margarine
1 cup steamed broccoli with 1 tsp margarine
cup fresh fruit salad (strawberries, blueberries, apples and melon and chopped nuts)
6 oz iced tea with sweetener
Snacks: 3 cups popcorn
1 cup strawberry ice cream
12 oz coke
R.B. takes a multivitamin mineral supplement daily and 500 mg calcium 3 x daily.

Case Questions:
1. Define stroke. Describe the differences between ischemic and hemorrhagic stroke.

Stroke, also called a cerebrovascular accident (CVA), is an acute onset of neurological deficits occurs
for at least 24 hours (Mahan and Raymond, 2017). Stroke is the general term describing the clinical
syndromes associated with ischemic or hemorrhagic event in the brain (nutritioncaremanual.org).
In an ischemic stroke there is a lack of blood flow so that certain parts of the brain do not get
adequate amounts of oxygen. Many times people can have several small transient ischemic attacks (TIA)
without having any lasting neurological defects until the ischemic attack becomes permanent and is
classified as a stroke. There are two types of ischemic strokes that can occur, embolic stroke and
thrombotic stroke. An embolic stroke happens when an atherosclerotic plaque ruptures and causes many
platelets to aggregate and form a clot. This clot can then travel up to the brain where the blood flow is
blocked causing a stroke. A thrombotic stroke occurs when the atherosclerotic plaque has already formed
in the cerebral artery. The artery ruptures causing platelet aggregation and obstruction of the surrounding
cerebral arteries. The main take away from ischemic stroke is that it is caused by atherosclerotic plaque.
Hemorrhagic stroke is much less common than ischemic strokes. In this type of stroke a blood vessel
in the brain ruptures causing bleeding in that area of the brain. Again there are two types of this kind of
stroke, intraparenchymal hemorrhage and subarachnoid hemorrhage. In an intraparenchymal
hemorrhage the bleeding is directly in the brain. In a subarachnoid hemorrhage the bleeding goes into the
subarachnoid space that surrounds the brain. (nutritioncaremanual.org)
The main differences are that in an ischemic stroke the person will most likely not lose consciousness
but in a hemorrhagic stroke they most likely will lose consciousness. In ischemic stroke suddenly motor or
sensory issues will occur. For example, slurred speech or drooping of one side of the face will suddenly
arise. In a hemorrhagic stroke a headache and vomiting may most likely occur because of increasing
pressure in the brain. Finally the most importain difference is that a hemorrhagic stroke is often fatal
immediately after it happens. (Mahan and Raymond, 2017)

2. What are the factors that place an individual at risk for stroke?

The major risk factors for stroke are hypertension, diabetes, heart diseases, smoking, older age,
gender (women are more likely), race and ethnicity, and a family history of TIA or stroke. The controllable
risk factors include: alcohol and drug use, lack of physical activity, overweight and obesity, stress and
depression, hypercholesterolemia, chronic use of NSAIDs and an unhealthy diet. (NIH.gov, 2017)

3. What specific signs and symptoms are noted in the patients exam and history that are consistent
with her diagnosis?

The right-sided weakness in her arm and leg indicates an ischemic stroke. The fact that she has
dysarthria with tongue deviation also indicates an ischemic stroke. Another symptom was that at the
onset of the stroke she became dizzy. She is at a higher risk for stroke because she has a history of
hypertension and hyperlipidemia.

4. Which symptoms from above may place the patient at nutritional risk? Explain your rationale.

The dysarthria is alarming and may put the patient at nutritional risk because it may not only be
affecting the motor speech. Many times when dysarthria is present other parts of the mouth, tongue (as in
her case), throat, and esophagus can be hindered resulting in dysphagia. If dysphagia occurs she may
not be able to eat adequately enough and may be deficient in certain nutrients. Another symptom that
may put her at risk is that she cannot move her dominant hand or arm. There is a possibility that she
might have a problem trying to use her utensils during meal times when needing to use the other hand.
She has hemiparesis, which also puts her at risk for leaning to the affected side. If her leaning is not
controlled she may be at risk for additional dysphagia and/or aspiration on her food hen she is eating.

5. Define dysphagia, aphasia and hemiparesis.

Dsyphagia- difficulty swallowing. Symptoms of dysphagia could include: drooling, choking, or

coughing during or after eating certain foods, a gurgling in the voice after eating, pocketing food in the
mouth, absent or decreased gag reflex, and chronic upper respiratory infections. (Mahan and
Raymond, 2017)
Aphasia- most commonly due to a stroke or brain injury it is the impairment of language. It may affect
the production or the comprehension of speech and/or the ability to read or write. It can affect patients
to varying degrees depending on the severity of injury. (aphasia.org)
Hemiparesis- the weakness of one side of the body but not the other. It may cause the body to slump
to affected side and increase the risk of dysphagia or aspiration. (Mahan and Raymond, 2017)
 6. What is the primary nutrition implication of dysphagia?

Dysphagia can lead to malnutrition because the patient is not able to eat an adequate amount of
food for normal nutrition. The food cannot be delivered to the stomach and into the intestines to be
absorbed as usual.

7. She was evaluated for her ability to swallow, and it was determined that the patient is controlling
her oral secretions spontaneously and exhibits mild dysphagia. Some aspiration of thin liquids but
clear with cough. Based on the DOSS, which level of the NDD do you think the Speech
Language Pathologist will recommend?

The SLP will most likely recommend that she is at Level 5 of the Dysphagia Outcome and
Severity Scale (DOSS). This means that the recommended National Dysphagia Diet (NDD) level
would be Level 2, Dysphagia Mechanically-Altered with nectar or honey thickened liquids.

8. Select two high-priority nutrition problems for the patient. For each, establish a goal (based on
signs and symptoms) and an appropriate intervention (based on etiology).

PES1:
Swallowing difficulty related to recent stroke complications as evidence by barium swallow study
determining mild dysphagia with tongue deviation and dysarthria. (NC-1.1)
Goal: Prevent malnutrition and maintain body weight while following a NDD level 2 diet.
Intervention: Nutrition education will be implemented to help RB and her husband to understand how the
stroke affected her body, how to adhere to the level 2 diet, and to help create a meal plan with foods that
are nutritionally and consistency appropriate. PT, OT, and SLP therapies will be needed to increase her
strength so education will need to be altered as she gets stronger.

PES2: Excessive energy intake related to food and nutrition related knowledge deficit as evidence by
obesity, 24-hour recall, hypertension and hyperlipidemia. (NI-1.3)
Goal: Reduce weight through the DASH diet to decrease hyperlipidemia and hypertension.
Intervention: Nutrition education on the DASH diet to decrease salt and fat intake. Nutrition counseling to
prepare a meal plan that also incorporates the dysphagia mechanically-altered diet. Encourage patient to
increase physical activity with therapies, PT and OT, to become stronger and more active.

9. To maintain or attain normal nutrition status while reducing the danger of aspiration and choking,
texture (of foods) and viscosity (of fluids) are personalized for a patient with dysphagia. In the
following table describe each term used to define the characteristics of food and give an example.

Term Definition Example

Consistency A degree of density, firmness, Pureed foods vs. chopped food
softness, or viscosity etc
Texture The way the food is sensed by Apples are hard and crunchy
touch either in the mouth or with
the hands
Viscosity The measure of the fluids Honey is thick and flows slowly off of the
resistance to flow spoon.
 10. Using the previous 24 hour recall make suggestions for consistency changes or food
substitutions if needed.
24-hour recall Modifications
Breakfast 1 cup orange juice Thickener should be added or
pre-thickened juice can be
bought. Make sure it is pulp free
orange juice. Thicken to nectar or
honey consistency.
1 cup raisin brand with 6oz 2% I would replace raisin brand with
milk well cooked oatmeal.
1 medium banana Mash the banana and eat with a
spoon. You could mash it and
mix it into the oatmeal as well.
8oz coffee with 2 Tbsp 2%milk Thickener added for nectar or
and sweetened honey consistency.
Lunch
2 cups chicken tortellini soup If tolerated puree the soup to
(cheese tortellini in broth) honey or spoon thick consistency
making sure there are no large
pieces of tortellini. If not
tolerated, change to a soup such
as split pea and ham but make
sure ham bits are smaller that
an inch.
8 saltine crackers I would suggest a non-salted
cracker slurry. To make a slurry
just add the crackers and water
into a bowl and let it sit to
moisten the crackers.
1 fresh pear A cup of canned/cooked pears
6oz iced tea with sweetener Add thickener to the drink for
nectar or honey consistancy
Dinner
4-6oz grilled chicken (with skin) I would suggest a different way of
cooking the chicken because it
can become dry and the skin can
become crunchy when on the
grill. Eliminating the skin, make a
moist chicken casserole with very
small chunks of chicken, very
soft pasta noodles and a creamy
gravy.
1 medium Baked potato with 2tsp Creamy mashed potatoes with
margarine no large lumps
1 cup steamed broccoli with 1 tsp You could incorporate the
margarine steamed broccoli and some
creamy cheese into the mashed
potatoes for a different flavor. If
 that is not appealing, the broccoli
can be eaten if it is very well-
cooked and the pieces are less
than an inch.
cup fresh fruit salad You can either puree the fruit in a
blender or pick a canned/cooked
fruit cocktail to eat instead.
6oz iced tea with sweetener Add thickener to thicken to nectar
or honey consistency
Snacks
3 cups popcorn A cup of cottage cheese could be
a good substitution for a savory
snack.
1 cup strawberry ice cream If ice cream is melting too fast
and becoming to liquid, I would
suggest a pudding or custard.
12oz coke I suggest eliminating the soda
from the diet.

11. Describe R.B.s potential nutritional problems upon discharge. What recommendations would
you make to her husband to prevent each problem you identified? How would you monitor her
progress?

Because of their advanced age I would make sure to educate RBs husband and make sure he
understands all of his responsibilities and roles in providing care that are explained below. If he seems
overwhelmed with the lifestyle changes they need to make I would recommend a home-nurse or home
care provider for them to use.
The previous diagnosis of hyperlipidemia and hypertension and the current diagnosis of mild
dysphagia with tongue deviation need to be addressed together to prevent nutrition problems. My
recommendation would be to adopt the DASH. These modifications in her diet need to be incorporated
into the NDD level 2 because of the dysphagia with tongue deviation. RB is at risk for malnutrition
because of the dysphagia. I would work with RB and her husband on coming up with some meal plans
that cater to what she will tolerate and likes to eat and gives enough variety in her diet to prevent
malnutrition and adheres to the DASH diet. RBs husband will be responsible for making sure she is
eating adequate enough.
Due to the hemiparesis and weakened muscles RB may be at risk for problems such as inability to
prepare her own meals, inability to self feed, and becoming tired quickly during meals. She may require
assistance in feeding as in someone actually feeding her or she may need special feeding utensils. In
order to prevent her from becoming tired during meals I would suggest smaller more frequent meals that
take less time to eat. The area where she eats should be quite and non-distracting so she can focus on
sitting up straight and focus on swallowing each bite. This will lessen the risk of choking or aspiration.
Monitoring this patient will be through assessing lab data for malnutrition, recording BMI, any
weight change, and using food journaling from the husband. Hopefully she will be seeing the SLP
frequently so that she can be monitored for swallow function. When I see the patient I will assess for any
muscle wasting, check her swallow function, and note any physical appearance changes. I will ask her
about her appetite and review the food that she has eaten in the food journal.
 12. Include an educational handout from the NCM for this patient and her husband on the appropriate
NDD level with your submission. Also in the NCM under formularies, find two products that are
available in either nectar or honey consistency that would be appropriate for this patient and list
them here.

RESOURCE Thicekend Juice - Honey Consistency (Orange)

MightyShakes Vanilla NSA Honey Consistency 50/4oz

References:
th
Mahan, L.K. and Raymond, J.L. Krauses Food, Nutrition, and Care Process. 14 ed. Elsevier. St Louis,
MS. 2017.

The Nutrition Care Manual. Cerebrovascular disease. Retrieved on April 12, 2017 from
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=272984&lv2=8233&ncm_toc_id=
8233&ncm_heading=&

Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics
Language for Nutrition Care. Accessed April 12, 2017 from https://ncpt.webauthor.com/pubs/idnt-en/?

American Speech-Language-Hearing Association. (n.d.). Adult Dysphagia. (Practice Portal). Accessed

April 12, 2017 from www.asha.org/Practice-Portal/Clinical-Topics/Adult-Dysphagia/.

NIH: National Heart, Lung and Blood Institute. (2017). Who is at risk for stroke? Accessed on April 13,
2017 from https://www.nhlbi.nih.gov/health/health-topics/topics/stroke/atrisk.

National Aphasia Association. (n.d.) Aphasia definitions. Accessed on April 13, 2017 from
https://www.aphasia.org/aphasia-definitions/