Download - Mr. Klosterman
Myocardial Infarction
Ischemic necrosis
of part of the heart
muscle.
Daniel Lewis, Ariel Lebert, Courtney Kousser, Sarah Fecco11/28/2012
Mr. Klosterman
• Symptoms: Sudden onset of severe precordial pain
• Medical Diagnosis: Myocardial Infarction
• Medical Treatment: Emergency Angioplasty
Physical Findings @ 1354 3/25
• Age 61• BP: 118/78 mmHg• Temp: 98.4° F• RR: 20 bpm• SAO2: 80%• HR: 92 bpm• Pain: severe chest pain for past 1.5 hours• Last ate: 1030• Last drank: 1100
Client History (CH)
Smokes (1 pack/day) for 40 years
Patient Hx: • Emphysema/lung problems • Angina/chest pain• No HTN, Hypercholesterolemia, or diabetes
Family Hx: • CAD (Father) – MI age 59• Cancer (maternal grandmother)
PMH: Surgery; cholecystectomy 10 years ago, appendectomy 30 years ago
Allergies/reaction: Sulfa/hives
Anthropometric Data (AD)
• Height: 70”• Weight: 185 lbs• BMI: 26.5 kg/m2
• Weight history is not specifically stated.• Assumption that he has a longstanding history of being
overweight since there has been some attempt to change diet
Biochemical Data
Day One Day Two Day Three Optimal Values
Total Cholesterol 235 mg/dl H 226 mg/dl H
214 mg/dl H <200 mg/dl
LDL-C 160 mg/dl H 150 mg/dl H
141 mg/dl H <100 mg/dl
HDL-C 30 mg/dl L 32 mg/dl L 33 mg/dl L >/= 60 mg/dl
LDL-C/HDL-C ratio 5.3 H 4.7 H 4.3 H < 3.55
CPK 0 u/l 75 u/l H 55 u/l H 0 u/l
ALT 30 u/l 215 u/l H 185 u/l H 4-36 u/l
AST 25 u/l 245 u/l H 175 u/l H 0-35 u/l
LDH 325 u/l 685 u/l H 365 u/l 208-375 u/l
Troponin I 2.4 ng/ml H 2.8 ng/ml H -- < 0.2 ng/ml
Troponin T 2.1 ng/ml H 2.7 ng/ml H -- < 0.03 ng/ml
Biochemical Data Interpretation
Risk Factors for CAD and IHD• Elevated LDL-C levels and LDL-C/HDL-C ratio• Low HDL-C levels• Hypercholesterolemia
MI-related values (Day 2**)• Elevated LDH, ALT & AST: intracellular enzymes that
are indicative of tissue damage when present in plasma• Elevated CPK: Particularly notable is the CK3 isoform as
it is most abundant in heart muscle• Elevated Troponin I & Troponin T: Heart contractile
proteins
Medications
Lisinopril 10mg/day• Used to treat heart failure and HTN• Used to improve survival after MI• Angiotensin-converting enzyme (ACE) inhibitors• Decreases tension on vessels, decreases blood volume
Lipitor 10mg/day• Reduce the risk of heart attack and stroke; decrease
chance heart surgery will be necessary• Decrease cholesterol by slowing production• HMG-CoA reductase inhibitors (statins)
Medications cont…
Lopressor 50mg/day• Used to treat HTN, also to prevent angina, improve
survival after MI• Beta blocker• Relaxes blood vessels, slows HR to improve blood flow
and decrease BP
Nitro-Bid 9mg twice daily • Nitroglycerin ointment • Used to prevent angina associated with CAD • Vasodilator • Relaxes blood vessels
NTG 0.4mg sublingually prn chest pain
Medications cont…
ASA (acetylsalicylic acid—aspirin) 81 mg/day• Used to prevent MI and stroke • Antithrombotic• Inhibition of thromboxane A2 synthesis inhibition of
platelet aggregation • Inhibits cyclooxygenase activity that produces
prostaglandins pain relief
No vitamin/mineral supplements in use
Medications & Dietary Supplements
Medication Possible Food-Nutrient Interactions
Lopressor 50 mg daily Avoid natural licorice. Take 2 hours before or 6 hours after calcium supplements and/or fortified orange juice. Calcium salts may decrease absorption.
Lisinopril 10 mg daily Avoid salt substitutes. Caution with K and Mg supplements. Decreased Na and Ca may be recommended.
Nitro-Bid 9.0 mg twice daily Avoid alcohol. May result in dangerously low blood pressure.
NTG 0.4 mg sl prn chest pain Avoid alcohol.
ASA 81 mg daily (acetylsalicylic acid-aspirin)
Taking with food can decrease absorption and diminish drug effects.
Lipitor 10 mg daily Avoid grapefruit juice- increase risk of toxicity. Fibers such as oat bran and pectin may diminish drug effect.
Food/Nutrition Hx (FH)
24 hour recall• Breakfast: None• Midmorning Snack: 1 lg cinnamon raisin bagel w/ 1 tbsp fat-free
cream-cheese, 8 oz orange juice, coffee• Lunch: 1c canned veg beef soup; sandwich w/ 4 oz roast beef,
lettuce, tomato, dill pickles, 2 tsp mayonnaise; 1 sm apple; 8 oz 2% milk
• Dinner: 2 lean 3oz pork chops, 1 lg baked potato, 2 tsp margarine, ½ c green beans, ½ c coleslaw (cabbage w/ 1 tbsp of salad dressing), 1 slice apple pie
• Snack: 8 oz 2% milk, 1 oz pretzels
Drinks alcohol (1 drink/day)• Last drink: 3/24
Food/Nutrition Hx (FH)
24 hour recall• Breakfast: None• Midmorning Snack: 1 lg cinnamon raisin bagel w/ 1 tbsp fat-free
cream-cheese, 8 oz orange juice, coffee• Lunch: 1c canned veg beef soup; sandwich w/ 4 oz roast beef, lettuce,
tomato, dill pickles, 2 tsp mayonnaise; 1 sm apple; 8 oz 2% milk• Dinner: 2 lean 3oz pork chops, 1 lg baked potato, 2 tsp margarine, ½ c
green beans, ½ c coleslaw (cabbage w/ 1 tbsp of salad dressing), 1 slice apple pie
• Snack: 8 oz 2% milk, 1 oz pretzels
Drinks alcohol (1 drink/day)• Last drink: 3/24
Food/Nutrition Hx (FH)
24 hour recall• Breakfast: None• Midmorning Snack: 1 lg cinnamon raisin bagel w/ 1 tbsp fat-free
cream-cheese, 8 oz orange juice, coffee• Lunch: 1c canned veg beef soup; sandwich w/ 4 oz roast beef, lettuce,
tomato, dill pickles, 2 tsp mayonnaise; 1 sm apple; 8 oz 2% milk• Dinner: 2 lean 3oz pork chops, 1 lg baked potato, 2 tsp margarine, ½ c
green beans, ½ c coleslaw (cabbage w/ 1 tbsp of salad dressing), 1 slice apple pie
• Snack: 8 oz 2% milk, 1 oz pretzels
Drinks alcohol (1 drink/day)• Last drink: 3/24
Intake Analysis (NutriCalc)
Total kcal = 2879.32 kcal• CHO: 354g (~49.5% of total kcal)• Fiber: 29g• Sugars: 136g
• Protein: 152g (~21.3% of total kcal)• Fat: 95g (~30% of total kcal)• Sat. Fat: 37g• Trans Fat: 2g
Cholesterol: 371mg
Sodium: 5072mg
Iron: 262% DV
Comparative Standards
Recommended Intakes• TEE = 1086 - (10.1 x age in yrs [61]) + PA [1.12]
x (13.7 x wt. in kg. [84.1]) + (416 x ht. in m. [1.78]) = ~2500 kcal
• Daily protein = 0.8 g x 84.1 kg = 67.28g
Recommended Weight• IBW (based on Hamwi): 106 + 6*10 = 166lbs• %IBW: 185/166 = 111%• BMI : 26.5 kg/m2
Intake Problems
• Excessive energy intake -- 112% of DRI• Fat Intake -- 119% of DRI• Saturated Fat: -- 142% of DRI• Trans Fat
• Protein Intake -- 226% of DRI
• Excessive Sodium Intake – 390% of DRI• Inadequate fluid intake (Water)
Other Possible Problems
Clinical Domain• Altered nutrition-related lab values• Food-medication interactions• Overweight
Behavioral-Environmental Domain• Self-monitoring deficit • Willing to change• Adherence to nutrition-related recommendations
Physical Activity• Physical Inactivity
Diagnoses
• Altered nutrition-related lab values (NC-2.2) related to excessive macronutrient intake as evidenced by total cholesterol of 235, LDL-C of 160 and HDL-C of 30.
• Physical inactivity (NB-2.1) related to sedentary lifestyle as evidenced by physical activity limited to walking the dog for 15 minutes a day.
Prescriptions
• Reduction in total cholesterol (<200) and LDL-cholesterol (<100); Increase in HDL-cholesterol (>60).
• Increase amount of physical activity to 30 minutes/day minimum.
Interventions
• Comprehensive nutrition education to include:• recommended modifications regarding his daily intake (E-2.2) • skill development for the purposes of food selection and meal
preparation (E-2.5). • recommended modifications regarding physical activity (E-2.2).
• Nutrition Counseling including: • motivational interviewing (C-2.1); • goal setting regarding weight loss, physical activity level and
proper nutrient consumption (C-2.2) • self-monitoring regarding daily intake, weight and a daily/weekly
physical activity log (C-2.3)
Nutritional Therapy
Following MI:• NPO until after angioplasty• Limit oral intake to clear liquids w/o caffeine to
decrease risk of arrhythmia; decrease risk of vomiting and aspiration
• Follow-up with progression to the Therapeutic Lifestyle Changes (TLC) diet
TLC: Nutrient Composition
Nutrient Recommended Intake
Saturated Fat Less than 7% of total kcal
Polyunsaturated fat Up to 10% of total kcal
Monounsaturated fat Up to 20% of total kcal
Total Fat 25-35% of total kcal
Cholesterol <200mg/day
Fiber 20-30g/day
Protein Approx. 15% of total kcal
Sodium <2400 mg/day
Stanol esters 3-4 g/day
TLC: Foods to Eat More
Breads & Cereals • At least 6 servings per day
Vegetables**• 3-5 servings per day without added fat, sauce, salt
Fruit• 2-4 servings per day
Dairy Products**• 2-3 servings per day; low-fat or fat-free
Eggs• 2 or fewer egg yolks per week
Meat, Poultry, Fish***• 5 oz or fewer per day; lean cuts
Fats and Oils• Unsaturated oils, soft margarines, seeds and nuts
TLC: Foods to Choose Less
Breads and Cereals***• Baked and processed goods, grain-based snacks
Vegetables• Fried or prepared with butter, cheese or cream sauce
Dairy• Full-fat products, ice cream, cream and cheese
Eggs• Whole eggs, egg yolks
Meat, Poultry, Fish**• Higher-fat cuts; fried meats
Fats and Oils***• Butter, shortening, stick margarine• Trans Fats
TLC: Weight Reduction
Self-Monitor• Record weight, BMI & waist circumference
Gradual weight loss• Goal: lose 10% of body weight in 6 months• Lose ½ to 1 lb per week
Increase Physical Activity• Make PA part of daily routines and recreational activities
Cardiac Rehabilitation
Recommended by the American Heart Association and the American College of Cardiology to improve:• Risk of heart disease• Prevention of future hospital stays• Health and well-being
Through:• Exercise training • Nutrition education and counseling• Lifestyle coaching• Smoking cessation• Stress reducing techniques
Monitoring & Evaluation
3-4 week check up• Review TLC records• Assess changes in PA and nutrient intake• Review blood panel for changes in lipid levels• Smoking Cessation?
ADIME
Domain 1Medication: Lopressor 50 mg daily, Lisinopril 10 mg daily
Nitro-Bid 9.0 mg twice daily NTG 0.4 mg sl prn chest pain,
ASA 81 mg daily (acetylsalicylic acid-aspirin), Lipitor 10 mg daily
Physical Activity: 15min/day walking the dog
Food preparation: Wife shops and prepares meals
Intake:• Breakfast: None• Midmorning Snack: 1 lg cinnamon raisin bagel w/ 1 tbsp fat-free cream-
cheese, 8 oz orange juice, coffee• Lunch: 1c canned veg. beef soup; sandwich w/ 4 oz roast beef, lettuce,
tomato, dill pickles, 2 tsp mayonnaise; 1 sm apple; 8 oz 2% milk• Dinner: 2 lean 3oz pork chops, 1 lg baked potato, 2 tsp margarine, ½ c green
beans, ½ c coleslaw (cabbage w/ 1 tbsp of salad dressing), 1 slice apple pie• Snack: 8 oz 2% milk, 1 oz pretzels
ADIME
Domain 2• Height: 70”• Weight: 185 lbs• BMI: 26.5 kg/m2
• Weight history is not specifically stated.• Assumption that he
has a longstanding history of being overweight since there has been some attempt to change diet
Domain 3 (Day 2)Cholesterol: 226 mg/dl HLDL: 150 mg/dl HHDL: 32 mg/dl LLDL/HDL: 4.7 HTroponin I: 2.8 ng/ml HTroponin T: 2.7 ng/ml HALT: 215 u/l H AST: 245 u/l HLDH: 685 u/l HCPK: 75 u/l H
ADIME
Domain 4• Age 61• BP: 118/78 mmHg• Temp: 98.4° F• RR: 20 bpm• SAO2: 80%• HR: 92 bpm• Pain: severe chest pain for
past 1.5 hours• Last ate: 1030• Last drank: 1100
Domain 5Smokes (1 pack/day) for 40 yearsPatient Hx:
Emphysema/lung problems Angina/chest pain
Family Hx: CAD (Father) – MI age 59Cancer (maternal grandmother)
PMH: Surgery; cholecystectomy 10 years ago, appendectomy 30 years ago
Allergies/reaction: Sulfa/hives
ADIME
Altered nutrition-related lab values (NC-2.2) related to excessive macronutrient intake as evidenced by total cholesterol of 235, LDL-C of 160 and HDL-C of 30.
Physical inactivity (NB-2.1) related to sedentary lifestyle as evidenced by physical activity limited to walking the dog for 15 minutes a day.
ADIME
• Comprehensive nutrition education to include:• recommended modifications regarding his daily intake (E-2.2) • skill development for the purposes of food selection and meal
preparation (E-2.5). • recommended modifications regarding physical activity (E-
2.2).
• Nutrition Counseling including: • motivational interviewing (C-2.1); • goal setting regarding weight loss, physical activity level and
proper nutrient consumption (C-2.2) • self-monitoring regarding daily intake, weight and a
daily/weekly physical activity log (C-2.3)
ADIME
3-4 week check up• Review TLC records• Assess changes in PA and intake• Review blood panel for changes in lipid levels• Smoking Cessation?
References
• Nelms, Marcia. Nutrition Therapy & Pathophysiology. Belmont, Ca. Cengage Learning: 2011.
• Harvey, Richard. Biochemistry. Lippincott: 2011• http://www.nhlbi.nih.gov/• www.heart.org/ • www.acc.org/
Questions?