O’Neil 1

Jillian O’NeilKNH 41109/05/13

Case Study #5 – Myocardial Infraction

1. Mr. Klosterman had a myocardial infraction. Explain what happened to his heart.

A myocardial infraction is the medical term for heart attack. During this event, the blood flow to

a specific area of his heart was blocked. Usually, when this blood flow is blocked for a long

duration of time, that particular area of the muscle is damaged or dies.

When coronary arteries are blocked causing the blood flow to be compromised, the patient is

suffering form a myocardial ischemia. If the individual has myocardial ischemia for an extended

period of time, a myocardial infarction may occur – heart tissue cells die due to lack of oxygen.

The four mechanisms – sudden blockage of a coronary artery, arterial spasm, increase in

myocardial oxygen demand, and hemorrhage into an atherosclerotic plaque – can induce a

myocardial ischemia or angina. Both Ischemia and myocardial ischemia can cause heart failure,

rhythmic abnormalities and death. (Nelms 315)

2. Mr. Klosterman’s chest pain resolved after two sublingual NTG at 3-minute intervals and

2mgm of IV morphine. In the cath lab he was fount to have a totally occulted 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 patient infract-related artery with near-normal flow. A sent was left in place to stabilize

the patient and limit infract size. Left ventricular ejection fraction was normal 42%, and a

poster basilar scar was present with hypokinesis. Explain angioplasty and stent placement.

What was is the purpose of this medical procedure?

When a patient’s arteries are clogged or blocked, which can cause a narrow pathway, he or she

needs to go under the angioplasty procedure to open the closed areas. At the location of the

O’Neil 2

blocked artery, a balloon is inserted and blown up to unclog the area as well as allow proper

blood flow. A mesh tub, a stent, is also placed in this clogged area to help maintain the blood

flow and to prevent further issues.

Over the lifespan, plaque (a waxy substance) often builds up inside the arteries – called

atherosclerosis. Coronary heart disease is the condition developed when atherosclerosis affects

the coronary arteries. If the plaque ruptures, a blood clot is formed causing the arteries to harden

and narrow. A blood clot can also block the blood flow through the coronary artery – also known

as a heart attack. The procedure, called angioplasty, is used to restore this blood flow to the

heart. A flexible, thin catheter attached to a balloon is threaded to the affected artery through a

blood vessel. When positioned correctly, the balloon is inflated in order to condense the plaque

against the affected artery wall – restoring proper blood flow through the artery to the heart.

(National Heart, Lung, and Blood Institute)

3. Mr. Klosterman and his wife are concerned about the future of his hearth health. What

role does cardiac rehabilitation play in return to normal activities and in determining his

future heart health?

Cardiac rehabilitation plays a very important role in order to return to normal activities and in

determining future heart health. With cardiac rehabilitation, patients can have a team of doctors,

nurses and other medical professions that assist in the prevention of another cardiac problems as

well as aid in the improvement of a healthy life. A daily plan can be made to teach the patient on

how to improve his or her overall healthy by reducing the risk factors that caused the myocardial

infraction in the first place. It’s very difficult to walk out of the hospital and pretend like nothing

ever happened. Therefore, Mr. and Mrs. Klosterman should look greatly on how to improve their

health and wellness as well as encourage him to make healthy choices. By attending cardiac

O’Neil 3

rehabilitation, he can become a healthy weight, learn about better food choices and increase his

exercise levels.

Cardiac rehabilitation is important for the patient to return to normal activities as well as to have

a healthy heart future. This program provides the client with education, exercise training and

counseling in order to return to an active life. An additional benefit to cardiac rehab is to learn

how to manage stress – which can independently cause cardiovascular disease. Lifestyle changes

developed during the program is beneficial to improving the patient’s overall health as well as

for a healthy future. Cardiac rehabilitation addresses the current issues as well as aids in the

prevention of additional heart problems, diseases and premature death. (National Heart, Lung,

and Blood Institute)

4. What risk factors indicated in his medical record can be addressed through nutrition

therapy?

Based on Mr. Klosterman’s Laboratory results, he was admitted into the hospital with a high

glucose level. Throughout his stay, the glucose levels dropped from 136 mg/dL to 106mg/dL and

104 mg/dL. These initial levels may be due to his food habits prior to myocardial infraction and

should be addressed through nutrition therapy because hyperglycemia can develop. In addition,

the lab results showed low levels of HDL cholesterol, high levels of LDL cholesterol, and high

levels of LDL/HDL ratio. A healthy range for HDL levels is above 45 mg/dL while his were 30,

32, and 33 mg/dL. A healthy range for LDL is below 130mg/dL while Mr. Klosterman’s levels

were 160, 150 and 141 mg/dL. Lastly his ratio of LDL to HDL cholesterol was 5.3, 4.7, and 4.3

when ideally it should be below 3.55. Nutrition therapy can address and improve his eating

habits in order for his blood work to return to a healthy level. When referencing his food intake

for the past 24-hours, he consumed foods high in sodium and unhealthy fats. In addition, the

O’Neil 4

portion size he has been consuming is inaccurate. Nutrition therapy can provide him with portion

control tips as well as the daily limits for fats and sodium. Also, it is stated that he doesn’t take

vitamins and minerals. It may be a healthy option for him to start taking daily vitamins. Lastly,

his vital signs show a BMI of 26.6, which classifies him as overweight. Nutrition therapy can

assist him in weight loss to an ideal weight range of 149.4 to 182.6 pounds – or 67.9 to 83.1 kg.

(A Case Study Approach 51-53; National Heart, Lung, and Blood Institute)

5. The current recommendations for nutritional intake during a hospitalization following a

myocardial infraction?

Mr. Klosterman’s charts states that he cannot consume dense foods until the procedure is

completed – “nothing by mouth” or NPO. His meal type states “clear liquids, no caffeine.” This

means that he is allowed to consume clear broth, Jell-O, tea, and popsicles prior to the procedure.

After the procedure, the nutritional intake is similar to the pre-procedure recommendations. The

patient can consume “light” foods and will gradually increase the density to breads before

increasing to a normal diet. (National Heart, Lung, and Blood Institute; Nelms 319; National

Library of Medicine)

6. What is the healthy weight range for an individual of Mr. Klosterman’s height?

Using the Hamwi Method, Mr. Klosterman’s height of 5’10” would put him at an ideal body

weight range of 67.9 kg to 83.1 kg. (Nelms 48)

Calculations:

5 feet = 106 pounds; 10 inches = 6 pounds * 10 = 60 pounds

Total: 166 pounds / 2.2 = 75.5 kg

75.5kg * 10% = 7.6kg

Healthy weight range: 75.5kg ± 7.6kg = 67.9 kg to 83.1 kg

O’Neil 5

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 pace. Calculate his energy and protein

requirements.

With a PAL of 1.12 for a low active level, his calorie needs would be 2589 calories per day. The

average suggested amount of protein per day is 20% of the total energy intake. Mr. Klosterman’s

protein requirement would be 259 calories. With this, he would need to consume 65g of protein

per day. These calculations were determined using the TEE equation (in Nelms’ book) for

“Overweight and Obese Males Aged 19 years and older.” (Nelms 243)

Calculations:

Weight = 185 lb (1kg/2.2 lb) = 84.09 kg

Height = 70in (2.54cm/1in) = 177.8 cm

Age = 61 years

TEE = 1086- 10.1(age) + PA (13.7*weight + 416*height)

PA coefficient = 1.12 for low active

1086- 10.1(61) + PA (13.7*84.09 + 416*1.778)

1086- 616.1 + 1.12(1152 + 740)

470 + 2119 = 2589 calories

2589 calories/day * .10 = 258.9 calories of protein/day (1g/4calories) = 64.8g protein

8. Using Mr. Klosterman’s 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.

O’Neil 6

According to fitday.com, his total number of calories is 2,569. He had a total of 80.8g of Fat,

341.9 g of Carbohydrates and 123.6 g of Protein. This is equivalent to 718 calories of fat (28%),

1,356 calories of Carbohydrate (53%) and 493 calories of Protein (19%). (Nelms 492)

In regards to the diabetic exchange system, Mr. Klosterman consumed 16 carbohydrates, 9

meats, 3 fats and 4 “free” items. The following list shows how these values were determined:

Carbohydrates Meats Fats Free Items2 – Bagel2 – OJ1 – Veg. Soup2 – Beef Sandwich¼ - Lettuce¼ - Tomato¼ - Pickle1 – Apple1 – Milk3 – Potato1 – Pie1 – Milk1.25 - Pretzels

1 – Cheese1 – Beef Sandwich6 – Pork1 – Beans

1 – Beef Sandwich2 – Pie

1 – Coffee1 – Mayonnaise1 – Margarine1 - Coleslaw

16 carbohydrates 9 meats 3 fats 4 free items(Nelms 492)

O’Neil 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?

Mr. Klosterman’s Lactate dehydrogenase levels were only higher on day two of the laboratory

results. His value was 685 U/L and the healthy range is 208-378 U/L. Extra Lactate

dehydrogenase (LDH) is released into the bloodstream after a medical condition, injury or

disease. In this case, the high level of LDH was due to the heart attack Mr. Klosterman had

suffered from. (National Library of Medicine)

10. What is abnormal about his lipid profile? Indicate the abnormal values.

Mr. Klosterman’s lipid profile was not within the healthy ranges. His cholesterol was recorded as

high – 235 mg/dL on day 1, 226 mg/dL on day two and 214 mg/dl on day three. The healthy

range is 120-199 ml/dl. In regards to HDL, the healthy levels would be above 45 for a male. His

results were low – giving a value of 30mg/dL, 32mg/dL and 33mg/dL on the three days. In

regards to LDL, a healthy level would be below 130. Mr. Klosterman’s LDL levels were above

the desired value. On day 1 his value was 160mg/dL, day 2’s value was 150mg/dL and day 3’s

value was 141mg/dL. Lastly, his LDL/HDL ratio should have been below 3.55 and it was above

for all three days: 5.3, 4.7, and 4.3. A lipid profile would also include triglyceride levels but Mr.

Kloserman’s values were all in a healthy range of 40-160 mg/dL. (A Case Study Approach

Nelms 51-53)

11. Mr. Klosterman was prescribed the following medications on discharge. What are the food-

medications interaction for this list of medications?

Medications Possible Food-Medication InteractionsLopressor 50 mg daily Alcohol, natural licorice, calcium supplementsListinopril 10 mg daily Alcohol, salt substitutes, potassium,

magnesium, calcium; infection symptoms, yellowing of skin, stomach pain, nausea/vomiting, dark urine

O’Neil 8

Nitro-Bid 9.0 mg twice daily Alcohol; migraines, nausea, dizziness, fainting, irregular heart beat

NTG 0.4 mg sl prn chest pain Alcohol, sodium, calcium, licorice; headache, dizziness, light head, nausea

ASA 81 mg daily Alcohol, natural licorice, calcium supplements; bruise easily, confusion, fainting, nausea, vomiting, loss of hearing, bleeding, tarry stools, swelling of mouth and throat

(McCabe)

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?

I will ask: Which aspects of your eating habits do you feel need improvement or change? On a

day-to-day basis, what will your physical activity consist of? Can you commit to weekly cardiac

rehabilitation meetings? Will you be able to remember to take the daily medications? Based on

your laboratory work, you have a few nutritional imbalances – would you be willing to meet

with a Registered Dietitian for advice on how to improve these lab statistics?

13. What other issues might you consider to support successful lifestyle changes for Mr.

Klosterman?

I would encourage him to stop smoking for all aspects of his health – cardiovascular, pulmonary

and muscular. In addition, I would review the BMI scale. Mr. Klosterman has a BMI of 26.6

kg/m2, which puts him at the overweight category and ultimately at risk for further health

problems. (A Case Study Approach 49; National Library of Medicine)

14. From the information gathered within the assessment, list possible nutrition problems

using the correct diagnostic terms.

Excessive energy intake NI-1.3

O’Neil 9

Excessive fat intake NI-5.6.2

Excessive mineral intake NI-5.10.2 Sodium(7) 10736

Predicted food-medication interaction NC-2.4

Overweight NC-3.3

Food-and nutrition-related knowledge deficit NB-1.1

(Academy of Nutrition and Dietetics)

15. Select two of the identified nutrition problem and complete the PES statement for each.

A. Excessive Calorie Intake

Excessive caloric intake of 2,569 calories as related to lifestyle-diet choices as

evidence by a BMI of 26.6 and weight history of 185 pounds.

B. Excessive Fat Intake

Excessive fat intake of 80.8g as related to lack of nutrition knowledge as evidence

by diet history and laboratory results.

(A Case Study Approach 49)

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).

A. Ideal goal: reduce overall body weight by improving lifestyle choices. Examples for Mr.

Klosterman would be to increase daily activity and decrease caloric intake.

B. Ideal goal: choose healthy choices when eating by improve knowledge about healthy

eating habits. Examples for Mr. Klosterman would include attending nutrition seminars

and “classes” with Registered Dietitian to learn about basic nutrition that can be applied

for his lifestyle.

O’Neil 10

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 research say about omega-3-fatty acid

supplementation for this patient?

According to the University of Maryland Medical Center, cardiac patients can aid in the

prevention of stroke, blood clots and atherosclerosis by adding more omega-3-fatty acids into

their diet. It has shown that eating a diet low in saturated fats and high in monounsaturated fats

can help a cardiac patient. Therefore, I would encourage the patient to eat more fish first – such

as Pink Salmon, Cod and Flounder. If that doesn’t assist, then turn to supplements – 800mg to

1000mg per day for cardiac patients. (National Library of Medicine, University of Maryland

Medical Center)

18. What would you want to assess in three to four weeks when he and his wife return for

additional counseling?

First, I would want to assess his weight to see if he has lost any pounds. Then I would want to

have updated blood work to review the changes, if any – focusing on his total cholesterol, HDL,

LDL and triglyceride levels. Prior to leaving the hospital, I would request that he and his wife

create a food and exercise log to make note of what they ate, the portions and their activity. I

would also recommend for him to purchase a good quality scale to weigh himself every morning

as soon as he wakes up (without consuming anything yet after the first trip to the bathroom). I

would encourage this patient to try to begin to lose weight up to a weight loss goal of about 19

pounds. The first week it would be encouraged to lose one pound. The following weeks would

move up to one and a half then two pounds per week. As the counseling continues, the weekly

goal would be two pounds. To provide nutritional education, I would instruct him that there are

3,500 calories per pound which means a decrease in 500 calories a day – a combination of a

O’Neil 11

decrease of energy intake and increase in energy expenditure. When increasing to a two pound

weight loss per week, he will need to decrease by 1,000 calories per day – again, a combination

of physical activity expenditure and a decrease in energy intake. In this additional counseling, I

would review the last few weeks of their log to point out points of changes that need

improvement. I would also point out the good choices the couple made. Then, I would adjust the

plan accordingly based on the past four weeks. In regards to the patient’s TLC plan, the patient

should decrease the total calories of saturated fat to less than 7%, limit sodium intake to 2400mg

per day, and reduce cholesterol intake to less than 200mg/day. (Nelms 48, 319)

Calculations:

Adjusted body weight = 0.25(185 – 166) + 166 = 170.75

185 – 166 = 19 pounds He needs to lose about 19 pounds.

O’Neil 12

ReferencesAcademy of Nutrition and Dietetics (2013). International dietetics and nutrition terminology

(IDNT) reference manual: Standardized language for the nutrition care process. Chicago, IL: Academy of Nutrition and Dietetics.

Blood Test: Lactate Dehydrogenase (LDH) . (n.d.). KidsHealth - the Web's most visited site about children's health. Retrieved September 2, 2013, from http://kidshealth.org/parent/system/medical/test_ldh.html

Comparing Beta Blockers - National Library of Medicine - PubMed Health. National Center for Biotechnology Information. Retrieved September 3, 2013, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004918/

Diet - clear liquid: MedlinePlus Medical Encyclopedia. (n.d.). National Library of Medicine - National Institutes of Health. Retrieved September 2, 2013, from http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000205.htm

Geil, P.B. (2008). Choose Your Foods: Exchange Lists for Diabetes: The 2008 Revision of Exchange Lists for Meal Planning. Diabetes Spectrum, 21(4), 281-283.

Heart attack - National Library of Medicine - PubMed Health. (n.d.). National Center for Biotechnology Information. Retrieved September 2, 2013, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001246/

McCabe, Beverly J., Jonathan James Wolfe, and Eric H. Frankel. Handbook of food-drug interactions. Boca Raton, Fla.: CRC Press, 2003. Print.

Metoprolol - National Library of Medicine - PubMed Health. National Center for Biotechnology Information. Retrieved September 3, 2013, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0001180/stolic. (n.d.).

Nelms, Marcia. Medical nutrition therapy: a case study approach. 4th ed. Stamford, Connecticut: Cengage Learning, 2013. Print.

Nelms, Marcia Nahikian. Nutrition therapy and pathophysiology. 2nd ed. Belmont, CA: Wadsworth, Cengage Learning, 2011. Print.

Nitroglycerin: MedlinePlus Drug Information. (n.d.). National Library of Medicine - National Institutes of Health. Retrieved September 3, 2013, from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601086.html

Omega-3 fatty acids | University of Maryland Medical Center. (n.d.). Home | University of Maryland Medical Center. Retrieved September 3, 2013, from http://umm.edu/health/medical/altmed/supplement/omega3-fatty-acids

What Is Cardiac Rehabilitation? - NHLBI, NIH. (n.d.). NIH Heart, Lung and Blood Institute. Retrieved September 2, 2013, from http://www.nhlbi.nih.gov/health/health-topics/topics/rehab/mouth. (n.d.).

"What Is Coronary Angioplasty? - NHLBI, NIH." NIH Heart, Lung and Blood Institute. N.p., n.d. Web. 13 Sept. 2013. <http://www.nhlbi.nih.gov/health/health-topics/topics/angioplasty/>.