Carolyn Klempay & Ariana KulinczenkoKNH 411 Medical Nutrition Therapy

MatuszakIschemic Stroke Case Study #23

I. Understanding the Disease and Pathophysiology1. Define stroke. Describe the differences between ischemic and hemorrhagic strokes.

A stroke is also known as a cardiovascular accident. This condition occurs when there is a sudden interruption of the blood flow that travels to the brain. The neurons in the brain are deprived of necessary blood, oxygen, and nutrients. The result is an alteration of brain function. In the case of an ischemic stroke, the blood vessels that supply blood to the brain are obstructed. The obstruction may be because of a clot and this classifies the stroke as ischemic. Additionally, when a blood vessel in the brain ruptures, the result is a hemorrhagic stroke. As the walls of blood vessels are weakened due to conditions such as hypertension, there is increased risk of rupturing. In comparison, ischemic strokes are caused from blockages or clots in blood vessels, whereas hemorrhagic strokes occur from a rupture of a blood vessel [Nelms, p.617].______________________________________________________________________________2. The noncontrast CT confirmed the Mrs. Noland had suffered a lacunar ischemic stroke- NIH Stroke Scale Score of 14. What does Mrs. Noland’s score for the NIH stroke scale indicate?

The NIH Stroke Scale evaluates on a quantitative scale the degree of neurologic dysfunction related to cerebral infarction. The scale scores on a variety of cognitive and physical characteristics such as level of consciousness, responses to questions and commands, various visual and facial abilities, limb mobility, and sensory and language skills. Each attribute is evaluated on various scales and values are totaled to give a final resulting Stroke Score. Mrs. Noland’s score of 14 indicates that she suffered from a moderate stroke. The lower the scores correlate to less severe strokes, so comparatively, the higher scores indicate a more severe stroke [NIH, 2011]. ______________________________________________________________________________3. What factors place an individual at risk for stroke?

The risk factors for stroke are categorized as modifiable or unmodifiable. Some risk factors that a patient has no control over include age, gender, and race. Looking specifically at Mrs. Noland’s records, being 77 years old is one of the unmodifiable risk factors that largely affects her risk levels because risk of stroke doubles for each decade after age 55.

Additional risk factors for stroke may be controlled by the patient’s lifestyle. Some of these risk factors are hypertension, cardiovascular disease, diabetes mellitus, dyslipidemia, asymptomatic carotid stenosis, atrial fibrillation, cigarette smoking, physical inactivity, and obesity. Dietary habits play a large part in controlling many of these risk factors and therefore, could be a contributor to stroke risk. Individuals with healthy lifestyle have an 80% lower risk of developing a stroke. The characteristics of a “healthy lifestyle” may be described as not smoking, maintenance of a BMI of 25 kg/m2 or less, participating in at least 30 minutes of physical activity per day, consuming a healthy diet with appropriate balance of nutrients, vitamins, and minerals, and consuming a moderate amount of alcohol, specifically 5-15 grams daily for women and 5-30 grams daily for men [Nelms, p.618].______________________________________________________________________________

4. What specific signs and symptoms noted with Mrs. Noland’s exam and history are consistent with her diagnosis? Which symptoms place Mrs. Noland at nutritional risk? Explain your rationale.

Some signs and symptoms Mrs. Noland was experiencing that are consistent with her diagnosis of Ischemic Stroke are the weakness and partial paralysis she experienced in the right side of her body, including her arm, face, and leg. Dysarthria, difficulty saying words because of problems with muscles related to speaking, and tongue deviations are other symptoms of stroke as well. The sudden dizziness and inability to speak are obvious signs that Mrs. Noland was experiencing a stroke and actions needed to be taken to dissolve the blood clot leading to her brain [Nelms, p.618].

Taking a deeper look into Mrs. Noland’s history and medical records, being at an age of 77 years old, the patient has an increased likelihood of having a stroke with each decade after 55 years old. Additionally, Mrs. Noland has a BMI of 30.0 kg/m2. This places her in the obese range which is another risk factor for developing a stroke. Hypertension is another risk factor of stroke and Mrs. Noland has suffered from this disease for 10 years. Although she regularly takes Catopril, a medication used to treat high blood pressure and reduce stroke risk, upon arrival at the hospital, Mrs. Noland’s blood pressure was 138/88 which is relatively high. Lastly, hyperlipidemia is another stroke risk factor which contributed to Mrs. Noland’s diagnosis [Nelms, p.618].

Mrs. Noland is al nutritional risk because of the dysarthria, tongue deviation, and diminished motor function and strength. These symptoms would prevent Mrs. Noland from consuming food orally and receiving proper nutrition. Additionally, assessment of her swallowing abilities would be another potential contributor to nutritional risk. Through individualized intervention and collaboration between a speech-language pathologist and dietitian, an appropriate staged dysphagia diet could be administered for at least 24 hours to ensure Mrs. Noland is receiving adequate nutrient and fluid quantities [Nelms, p.620].______________________________________________________________________________5. What is rtPA? Why was it administered?

Recombinant Tissue Plasminogen Activator (rtPA) is beneficial when injected into an individual suffering from an ischemic stroke. This drug is often inserted through a vein in the arm and is useful in breaking through blood clots. If given within four hours and thirty minutes from the start time of the stroke, this medication will dissolve the blood clot that caused the stroke and assist in proper recovery [MayoClinic, 2012]. If the drug is given within three hours of initial stroke onset, the patient has a higher chance to see minimal or no disability outcomes three months after the stroke. The patient is also less likely to require nursing care or rehabilitation services if rtPA is given [Nelms, p.620]. In the case of an extreme emergency, the rtPA may be injected directly into the stroke source rather than passed through the veins for more immediate results [MayoClinic, 2012]. Since the top priority in the treatment of stroke is to eliminate the clot and restore blood flow as quickly as possible, rtPA was administered to encourage these outcomes. Additionally, rtPA was used to minimize potential long-term health detriments and promote optimal stroke recovery.______________________________________________________________________________

II. Understanding the Nutrition Therapy6. Define dysphagia. What is the primary nutrition implication of dysphagia?

Dysphagia is termed as the inability or difficulty swallowing. This is usually proclaimed as a symptom of a disease. Swallowing is an extremely complicated process of that is controlled by the central nervous system. It requires multiple parts of the brain to be in cohesion, executing multiple involuntary and voluntary muscle contractions. If this area of the brain is damaged from stroke, serious implications are necessary to follow or else the patient will have a slower recovery and post stroke complications. Difficulty swallowing can affect food consumption, cause dehydration, malnutrition and secondary illnesses such as aspiration pneumonia. The primary nutrition implications are weight loss and subsequent development of nutrition deficiencies that result from the inadequate nutrient intake [Nelms, p.355].______________________________________________________________________________7. Describe the four phases of swallowing [Anatomy & Physiology of Swallowing, 2011].

A. Oral preparation: This phase is when food or liquid is chewed and mechanically manipulated in the mouth for the preparation of swallowing. Movement patterns in this phase depend on the consistency of the material swallowed.

B. Oral transit: This phase is where the tongue propels food or liquid to the back of the mouth. This is the phase that triggers the swallowing response. Once it is pushed to the back of the mouth, the swallowing response begins.

C. Pharyngeal: This phase begins when food or liquid is quickly passed through the pharynx and straight into the esophagus for swallowing.

D. Esophageal: This final phase is where food or liquid from the previous phases passes through the esophagus and moves into the stomach.______________________________________________________________________________8. The National Dysphagia Diet defines three levels of solid foods and four levels of fluid consistency to be used when planning a diet for someone with dysphagia. Describe each of these levels of diet modifications.

According to the National Dysphagia Diet, there are three levels of solid foods when planning a diet with someone with dysphagia. The first level is pureed. These foods have a pudding-like texture and are very cohesive. They require little to no chewing. Some examples of the pureed level are foods similar to milk and dairy products, applesauce, gravies and sauces. The second level is the mechanically altered level. These foods are very moist and are in semisolid forms that require little chewing. That last level is considered advanced. These include soft foods that require a little more chewing than the previous level. This level is usually presented to patients with improved dysphagia.

Furthermore, there are also four levels of fluid consistency. The first frequently used term for the first level of fluid consistency is ‘thin’, and is 1-50 centiPoise. CentiPoise is a dynamic viscosity measurement. This unit measures the fluids force per unit or internal resistance. The thin consistency includes all liquids, jell-o, sorbet, Italian ice and ice cream. The second level is nectar-like. This is between 51-350 cP. Examples of the nectar phase include an apricot or tomato juice consistency. Honey-like is the third level between 351-1,750 cP. This includes liquids that can still be poured, but slowly. The final and last fluid level is spoon-thick which is greater than 1,750 cP and includes liquids that are spoon-able that will not stay upright when a spoon is held vertically [Dysphagia, 2013].

______________________________________________________________________________9. It is determined that Mrs. Noland’s dysphagia is centered in the esophageal transit phase and she has reduced esophageal peristalsis. Which dysphagia diet level is appropriate to try with Mrs. Noland?

Mrs. Noland’s dysphagia is centered in the esophageal transit phase. This means she is having trouble passing food from the esophagus to the stomach. Mrs. Noland is experiencing reduced esophageal peristalsis, which indicates she cannot handle foods of thick consistencies. In order for food to pass through to the stomach, she will likely need to stick to a pureed and thin liquid diet because liquids have the quickest transit time [Anatomy & Physiology of Swallowing, 2011].______________________________________________________________________________10. Describe a bedside swallowing assessment. What are the background and training requirements of a speech-language pathologist?

The bedside swallowing assessment was created to provide data for use in diagnosis and treatment planning. The exam has two parts. The first part is the preparatory exam with no swallowing involved. The second part is the initial swallowing exam where the physiology of swallowing is observed. The bedside swallowing exam specifically provides information over the following:

- Location of the patient's dysphagia (oral or pharyngeal)- The patient's readiness for a radiographic study- The patient's ability to accept food into the mouth-The oral reaction to the placement of various tastes, temperatures, and textures in oral cavity- The presence of any abnormal oral reflexes - Any particular postural and behavioral needs of the patient that must be observed during the radiographic study- The Laryngeal Function and if anything may affect airway protection and aspiration during the swallow.- Coughing status- Decision on Best Posture- Best Position of Food in Mouth- The Oral Sensitivity- The Best Food Consistency- Optimum Swallowing Instructions

It is also important to evaluate the following at rest:- Lips- Dentition- Mandible- Tongue- Velum and velopharyngeal port- Valleculae- Epiglottis- Hyoid

- Pharynx- Posterior pharyngeal wall- Pyriform sinuses- Larynx (thyroid, cricoid, arytenoid

cartilages)- Trachea- Upper esophageal sphincter- Cervical esophagus and spine

The speech-language pathologist evaluates, performs the diagnosis and treats swallowing disorders in the oral-pharyngeal phases. There are numerous requirements a speech pathologist must meet in order to become a professional. A speech pathologist must obtain a master's degree in speech pathology in this field, and it is the minimum requirement for obtaining professional certification and state licensure. Many employers require the Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP) credential offered by the ASHA as well. The training requirements include supervised training and clinical experience through clinics associated with their graduate programs. Students’ training typically provides opportunities to work with children and adults in areas of communication, speech and language development. Other locations that provide training are rehabilitation facilities, schools and other diagnostic and treatment centers. In addition to the master’s degree, the ASHA requires an additional 1,260 hours of full-time postgraduate clinical practice for certification [U.S. Bureau of Labor Statistics, 2013].______________________________________________________________________________11. Describe a modified barium swallow or fiberoptic endoscopic evaluation of swallowing.

A modified barium swallow is an x-ray examination performed while a person is swallowing barium-coated substances in order to assess the mouth, pharynx and esophagus’ ability to swallow. This procedure may help the doctor track the pathway foods and liquids take during swallowing. A fiberoptic endoscopic evaluation of swallowing is another test used to evaluate the swallowing mechanism. This examination includes the use of vocal tract visualization and imaging to assess the pharyngeal and laryngeal structures. This procedure enables a proper evaluation of the swallowing impairment a patient may be experiencing [Office of the Professions, 1998]. ______________________________________________________________________________12. Thickening agents and specialty food products are often used to provide texture changes needed for the dysphagia diet. Describe one of these products and how it may be incorporated into the diet.

Thickening agents are used to provide a thicker texture or consistency to liquids or foods. Generally, thickeners are added to liquids, because thin liquids may move too quickly down the esophagus when swallowed by a patient with dysphagia, and a thicker consistency slows it down. One thickening agent that is commonly used to provide texture changes to a dysphagia diet is starch-based corn flour. This is prescribed in accordance to the prescribed liquid diet from the speech-language pathologist. Corn flour can be incorporated into the diet by adding it to a sauce to make it a thicker consistency. Generally the proportions needed of corn flour to liquid are 1:1. Corn flour is normally used to enhance a liquid to a medium-thick consistency. This method is a safe way to thicken fluids for patients with difficulty swallowing [Dysphagia, 2013].______________________________________________________________________________

III. Nutrition Assessment13. Mrs. Noland’s usual body weight is approximately 165 lbs. Calculate and interpret her BMI.

Using Mrs. Noland’s current weight of 165 lbs or 75 kg, and her height in meters as 1.58 meters, her BMI is 30.0 kg/m2. This places her in the range of obesity [Nelms, p.249]. Since obesity is one risk factor that contributes to stroke, having a BMI that falls within the obese range is one influential factor as to why Mrs. Noland suffered from a stroke.

BMI = wt (kg) / ht2 (m2)BMI = 75 kg / (1.58m)2

BMI = 75/2.5BMI = 30.0 kg/m2

______________________________________________________________________________14. Estimate Mrs. Noland’s energy and protein requirements. Should weight loss or weight gain be included in this estimation? What is you rationale?

Initially, weight maintenance, not weight loss, should be considered while immediately treating Mrs. Noland to ensure she is getting adequate nutrition for optimal healing from the stroke. Eventually, with gradual healing and oral intake abilities, weight loss should be included in Mrs. Noland’s estimation of protein and energy requirements. Her current BMI of 30.0 kg/m2

places her in the obese category so weight loss should be introduced after complete recovery to decrease the risk of suffering a stroke again and to decrease the influence of other risk factors for stroke. The first calculations estimate her current energy and protein requirements at her current weight of 75 kg and physical activity level of low active. The second set of calculations use Mrs. Noland’s adjusted body weight to estimate her calorie and protein needs, again at a low physical activity level.

At her current weight of 75 kg :

TEE for Overweight and Obese Females Aged 19 Years and Older:TEE = 448 – 7.95 x age (yrs) + PA (1.16 for low active) x (11.4 x weight (kg) + 619 x height (m))TEE = 448 – 7.95 x 77yrs + 1.16 x (11.4 x 75kg + 619 x 1.58m)TEE = 1962 kcal = 1,900 kcal – 2,000 kcal

EER for Females 19 Years of Age and Older:EER = 354 – 6.91 x age (yrs) + PA (1.12 for low active) x ((9.36 x weight (kg) + 726 x height (m))EER = 354 – 6.91 x 77yrs + 1.12 x (9.36 x 75kg + 726 x 1.58m)EER = 1893 kcal = 1,800 kcal – 1,900 kcal

Protein Requirements:1.0 g/kg – 1.2 g/kg1.0 g x 75 kg = 75 g1.2 g x 75 kg = 90 g= 75 g – 90 g protein

At her ADJUSTED weight of 56.4 kg :

Ideal Body Weight: Hamwi Method: 100 + (5 x 2) = 110 lbsAdjusted body weight = .25 (current wt – ideal wt) + ideal wtABW = .25 (165lbs – 110 lbs) + 110lbsABW = 124 lbs = 56.4 kg

TEE for Overweight and Obese Females Aged 19 Years and Older:TEE = 448 – 7.95 x age (yrs) + PA (1.16 for low active) x (11.4 x weight (kg) + 619 x height (m))TEE = 448 – 7.95 x 77yrs + 1.16 x (11.4 x 56.4kg + 619 x 1.58m)TEE = 1716 kcal = 1,700 kcal – 1,800 kcal

EER for Females 19 Years of Age and Older:EER = 354 – 6.91 x age (yrs) + PA (1.12 for low active) x ((9.36 x weight (kg) + 726 x height (m))EER = 354 – 6.91 x 77yrs + 1.12 x (9.36 x 56.4kg + 726 x 1.58m)EER = 1698 kcal = 1,600 kcal – 1,700 kcal

Protein Requirements:1.0 g/kg – 1.2 g/kg1.0 g x 56 kg = 56 g1.2 g x 56 kg = 67 g= 56 g – 67 g protein______________________________________________________________________________15. Using Mrs. Noland’s usual dietary intake, calculate the total number of kilocalories she consumed as well as the energy distribution of kilocalories for protein, carbohydrate, and fat.Food Item Calories Carbohydrate

s (grams)Fat (grams) Protein

(grams)1 cup orange juice 120 30 - -1 cup raisin bran (2cho+1fruit)

220 45 1 3

6oz. 2% milk + 2 Tbsp 2% milk

120 12 5 8

1 banana 120 30 - -8oz. coffee 5 - - -Sweetener 5 - - -1.5 cups Chicken broth 120 22 2 5½ cup cheese tortellini (1cho + 1 fat)

125 15 6 3

8 saltine crackers 106 20 1 3canned pears = 1 whole pear equivalent

120 30 - -

6oz. iced tea + sweetener

5 - - -

5oz. baked chicken breast (with skin)

650 - 35 35

1 medium baked potato

160 30 1 3

2 Tbsp margarine 90 - 10 -1 cup steamed broccoli

50 10 - 4

1 tsp margarine 15 - 2 -7 slices canned peaches

60 15 - -

6oz. iced tea + sweetener

5 - - -

Total 2,096 kcal 259 g CHO 63 g fat 64 g protein

Total kilocalories: 2,096 kcalCarbohydrates: 259 g x 4 kcal/g = 1,036 kcal 56%Fat: 63 g x 9 kcal/g = 567 kcal 31%Protein: 64 g x 4 kcal/g = 256 kcal 13%______________________________________________________________________________16. Compare this to the nutrient recommendations for an individual with hyperlipidemia and hypertension. Should these recommendations apply for Mrs. Noland during this acute period after her stroke?

Initially, dietary changes to lower fat and sodium levels should not be the main priority of treatment. Since the client’s oral intake of food is limited, the focus should be on making sure the client is receiving appropriate nutrients to maintain weight to avoid unintentional weight loss or malnutrition. Post-recovery, the client should begin treatment to balance her fat intake, lower her blood pressure, and decrease weight.

Individuals with hypertension and hyperlipidemia should modify their diet to ensure blood pressure and lipid-level control. Modifications that should be made include following the DASH diet which is the Dietary Approaches to Stop Hypertension. Characteristics of this diet include incorporating foods into the diet that will lower sodium levels and saturated fat intake. This approach also aims to raise potassium, magnesium, calcium, and fiber content in the diet. Additionally, clients with hypertension should reduce alcohol intake and attempt to lose weight to see further benefits and improvements in the hypertension condition. Those with hyperlipidemia should focus on limiting lipid intake to fall within the recommended USDA standards for lipids. Lipid consumption should be mostly unsaturated fats, no more than 7% saturated fat, and extremely minimal intake of trans fats[Nelms, p.294-295]. When comparing these considerations to Mrs. Noland’s dietary recall, her protein intake is relatively low and her fat intake is slightly high. Additionally, personal statements add that Mrs. Noland stays away from fried foods and does not add table salt to her foods which are excellent practices that align with hypertension and hyperlipidemia guidelines. Mrs. Noland’s calorie intake is somewhat high in comparison to the intake for weight maintenance and even higher compared to the calorie designation for her adjusted weight.

Weight loss recommendations should not be administered in the acute period after her stroke. During this time period, the main concerns are to dissolve the clot that caused the stroke and the ensure that Mrs. Noland is getting appropriate nutrition due to the fact that she is unable to intake food orally. Administering drugs and medications to destroy the clot and starting Mrs. Noland on a dysphagia diet will be initial steps to take toward gradual healing. Eventually, with appropriate nourishment and as Mrs. Noland can tolerate oral foods, weight loss should be considered a method of nutrition intervention to prevent further stroke or heart disease and to improve the condition of her chronic health concerns.______________________________________________________________________________17. Estimate Mrs. Noland’s fluid needs using the following methods: weight; age and weight; and energy needs [Chidester, 1997].

Weight: 100 mL fluid per kg body weight for the first 10 kg50 mL per kg body weight for next 10 kg20 mL per kg body weight for each kg above 20kg (55kg)

1,000mL + 500 mL + 1,100mL = 2,600 mL fluid

Age and Weight: Standard fluid needs for people ages 65-85 years: 25-30 mL per kg(75 kg x 25 mL) and (75 kg x 30 mL)

1,875 mL – 2,250 mL fluid

Energy needs: 1 mL per kcal1,800 mL – 2,000 mL fluid

______________________________________________________________________________18. Which method of fluid estimation appears most reasonable for Mrs. Noland? Explain.

The upper end of the age and weight calculations and the weight only calculations seem most reasonable for Mrs. Noland. These calculations are appropriate because they provide an acceptable range of 2,250 mL – 2,600 mL fluid. This amount of fluid is reasonable because Mrs. Noland will be receiving an all pureed and thin liquid diet so her fluid levels should not be of dehydration concerns. Additionally, the fluid intake for the patient may be adjusted as the client can tolerate and will be essential in ensuring proper stroke recovery.______________________________________________________________________________19. Review Mrs. Noland’s labs upon admission. Identify any that are abnormal. For each abnormal value, explain the reason for the abnormality and describe the clinical significance and nutritional implications for Mrs. Noland.

All of these abnormal lab values are because of dyslipidemia. Mrs. Noland’s cholesterol, HDL, and LDL levels are abnormal because of dietary intake, physical inactivity, and being obese. Additionally, her age is a contributing factor to elevated cholesterol values because cholesterol increases with age and her less than ideal health status. Cholesterol levels above 200mg/dL place patients at higher risk for coronary heart disease and other health detriments. These high levels, especially since she has had high cholesterol for the past ten years, have likely played a large role in the cause of the stroke she experienced. Mrs. Noland’s low HDL levels place her at risk for heart disease and her high LDL levels negatively affect her heart disease and stroke risks. Nutritionally, high cholesterol and other lipid values will likely lead to

additional clots in her arteries and so, Mrs. Noland should increase her intake of heart-healthy foods such as fish, fruits, vegetables, beans, high-fiber grains, and healthy fats such as olive oil. [AHA, 2012].

The high triglyceride levels are likely related to Mrs. Noland’s obesity, in addition to her physical inactivity and fairly high carbohydrate intake. Since her triglyceride levels are above 150 mg/dL, Mrs. Noland is at risk for metabolic syndrome which increases the risk for other disorders and diseases. To correct these values, limiting added sugars and eating complex carbohydrates are two necessary lifestyle changes Mrs. Noland should make [AHA, 2012].

Chemistry Reference Range August 12Cholesterol (mg/dL) 120-199 210HDL-C (mg/dL) >55 40LDL (mg/dL) <130 155LDL/HDL ratio <3.22 3.875Triglycerides (mg/dL) 35-135 198

______________________________________________________________________________IV. Nutrition Diagnosis20. Select two nutrition problems and complete the PES statement for each.

1. Obesity (NC-3.3) related to excessive energy intake and physical inactivity as evidence by BMI of 30.0 kg/m2, elevated cholesterol levels of 210 mg/dL, low HDL of 40 mg/dL, high LDL of 155 mg/dL, elevated LDL/HDL ratio at 3.875, elevated triglyceride levels at 198 mg/dL, relation to hypertension development, and infrequent physical activity.

2. Excessive Fat Intake (NI-5.6.2) related to food and nutrition-related knowledge deficit as evidence by elevated cholesterol levels of 210 mg/dL, low HDL of 40 mg/dL, high LDL of 155 mg/dL, elevated LDL/HDL ratio at 3.875, elevated triglyceride levels at 198 mg/dL, hyperlipidemia, and BMI at 30.0 kg/m2.______________________________________________________________________________V. Nutrition Intervention21. 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).

Goal 1: After acute period of stroke has passed and client can intake food orally and receive 100% nutrition through oral intake, client will gradually (1-2 lbs. per week) decrease weight to 137 lbs which places her at the upper range of a normal BMI of 24.9 kg/m2. The client will achieve the goal through education on appropriate portion sizes and methods to make healthier food selections. The client will also initiate a walking regimen, as tolerated, which will gradually progress to a minimum of 15 walking minutes per day. Adding variety to the diet to incorporate all food groups, increasing fruit and vegetable consumption while decreasing

Goal 2: After acute period of stroke has passed and client can intake food orally and receive 100% nutrition through oral intake, client will decrease fat intake to between 25% and 30% of daily calorie intake. Client will also increase intake of unsaturated fats to ¾ of fat intake and decrease intake of saturated fat sources to ¼ intake. The patient will receive nutrition-related education in regards to added fats, how to make lower fat choices of similar foods, and cooking methods that will decrease fat intake.______________________________________________________________________________VI. Nutrition Monitoring and Evaluation22. To maintain or attain normal nutritional status while reducing danger of aspiration and choking, the texture (of foods) and/or viscosity (of fluids) are personalized for a patient with dysphagia. In the following table, define each term used to describe characteristics of foods and give an example [Definition, 2006].Term Definition ExampleConsistency The uniformity and coherence among things

or parts within a food or substancePureed Consistency in a dysphagia diet. Pureed is described as smooth and pudding-like. Ex: applesauce, gravies, pudding.

Texture The composition or structure of a food or substance

Adding corn flour to a substance to create a more gritty and thicker texture

Viscosity The resistance to flow or alteration of shape by any substance as a result of molecular cohesion

Applied to the resistance liquids have when swallowed, of a fluid to flow because of a shearing force. Ex: Honey-like 351-1750cP

______________________________________________________________________________23. Using Mrs. Noland’s 24-hour recall, make suggestions for consistency changes or food substitutions (if needed) to Mrs. Noland and her family.

Mrs. Noland’s 24-hour recall shows she consumed foods without smooth consistencies which would be difficult to swallow. With her condition, Mrs. Noland will have to alter some of the foods in her regular diet. The liquids and soups would be easily swallowed and because they are of pureed and liquid consistency they are accepted. However; many other changes will need to be implemented to Mrs. Noland’s diet to account for her dysphagia diagnosis. In addition to her thin liquid and pureed diet, we would include an enteral product called Ensure High Protein to help reach her energy and protein needs. She may not consume all of this food in her diet, or finish all of these meals and it is important for her to receive all the nutritional value in order to recover from her stroke.

Orange Juice: This is a liquid that is easily swallowed and does not need to be substituted. There should not be any pulp in this juice and should be strained.

Raisin Bran: Mrs. Noland consumes raisin bran in the morning that will require a lot of chewing to breakdown, and will be difficult to swallow. She should switch this with cream of wheat,

which is also a breakfast cereal, but is warm and is in a pureed consistency that can be swallowed easily.

Milk: Milk is a thin consistency and does not need to be substituted in Mrs. Noland’s diet.

Banana: The banana she consumes in the morning should be pureed until completely smooth for easier swallowing.

Coffee: Coffee is an easily swallowed liquid that can remain.

Sweetener: Sweetener will dissolve in the liquid and can be swallowed with the liquid.

Chicken Tortellini soup: Soup is a very easy consistency to swallow but the chicken may cause some difficulties. She should try to have the chicken pureed into its smallest form so that it can go down smoother. The tortellini, although soft, should be pureed with the rest of the soup as well. This soup should be strained before consumption.

Saltine Crackers: At lunch, the saltine crackers will need to be substituted for another easily swallowed thin liquid, anything in a pureed consistency will do. She can also puree this within her soup puree, but needs to be strained previously to consumption.

Canned Pears: These are generally soft but can still be hard to handle. Mrs. Noland should substitute this with applesauce or puree the pears for easier swallowing.

Iced Tea: This liquid can be tolerated by Mrs. Noland.

Baked Chicken: Chicken will be hard for Mrs. Noland to swallow and should be substituted. This good protein source should be substituted with another protein source such as pureed meats.

Baked Potato: She can continue Baked Potato: She can continue to eat potatoes but should consume them mashed.

Steamed broccoli: Substituting this food with vegetable juice or v8 would still provide essential vitamins and minerals but would allow for easier consumption.

Margarine: Margarine is a very soft consistency and should be easily tolerated by Mrs. Noland.

Canned Peaches Mrs. Noland should opt for a very thin fruit smoothie, or can substitute this for a fruit pudding, or yogurt.

Mrs. Noland should also consider a nutritional supplement, such as nutritional shakes, Ensure High protein, to ensure proper and sufficient nutrient and energy intake. Mrs. Noland needs a nutritional supplement drink that provides an adequate amount of protein because it will be difficult for her to include high protein foods in her diet. The diet doesn’t allow her to consume any pulp, cottage cheese, eggs, peanut butter, nuts or seeds, which are all high protein options. Ensure High Protein Nutrition Shake Milk Chocolate: 1 serving: 414 mL, 210 kcal, 25 g protein, 2.5 g Fat, 23 g Carbs, 3 g Fiber

______________________________________________________________________________24. Describe Mrs. Noland’s potential nutritional problems upon discharge. What recommendations could you make to her husband to prevent each problem you identified? How would you monitor her progress?

Mrs. Noland will still experience many problems once she is released from the hospital. It is important for her husband to be aware of these potential conditions to prevent problems from occurring or worsening. Mrs. Noland will still be struggling to swallow many foods and will need to eat very soft foods, with a pureed consistency. She will slowly be able to make progress to denser foods with thicker consistencies, but that progress will be very gradual.

It is important for Mr. Noland to either puree the food his wife consumes, or substitute the foods for liquid options. Mr. Noland should use the food substitutions made for Mrs. Noland and determine what foods would be appropriate for consumption. High-protein options are vital in Mrs. Noland’s recovery and Mr. Noland should become educated on the importance of protein and nutrient-dense foods that will aid in his wife’s recovery. Protein is tough to incorporate into the diet because many high protein foods are restricted from Mrs. Noland. Mr. Noland should try to puree as many meats as possible for her, or opt for a nutritional supplement drink that provides an adequate amount of protein. Mr. Noland should also stay away from nuts and seeds that can cause difficulties and pain as Mrs. Noland swallows. Mashing and blending are excellent preparation techniques to prepare Mrs. Noland’s food. Mr. and Mrs. Noland should go through nutrition counseling to become educated on proper nutrition, preparation, tracking and purchasing techniques that will aid in her recovery and prevent a future stroke from occurring.

In order to monitor the client’s progress, it is important for her to track her food intake and evaluate the food log. It is also important the client tracks foods she has difficulties swallowing and which are easily consumed. In order to monitor her fat levels it will be important to reassess her lipid profile and to note any changes. Her protein intake should be monitored by looking at lab values for visceral protein status. Assessment of her medication as well as her appetite and the need of nutrition support should be evaluated. The client’s weight should also be monitored in order to determine whether her intake is sufficient and recommendation of admission to a stroke rehabilitation center should be considered. ______________________________________________________________________________25. Would Mrs. Noland be an appropriate candidate for a stroke rehabilitation program? Why or why not?

Mrs. Noland would be an appropriate candidate for stroke rehabilitation because she experienced negative affects to her motor and brain functions. Nutrition treatment may prove to be difficult for Mr. Noland to carry out for his wife because he is not fully educated. A rehabilitation center will help Mrs. Noland recover quickly and will provide her with proper techniques to aid in her dysphagia and improve her condition. Rehabilitation will also help Mrs. Noland to relearn skills that have been lost through the damage of part of her brain. It will help her regain control of her motor skills for her arm and leg that experienced paralysis. It will also re-teach her to swallow properly and adjust to her new diet and eventually implement it herself. The client would benefit greatly from a stroke rehabilitation program and should be referred to one until she has made improvements in her dysphagia, overall diet and stroke conditions [Dysphagia, 2013].

Resources:

Anatomy & Physiology of Swallowing. (2011). Anatomy & Physiology of Swallowing. Retrieved November 25, 2013, from http://www.d.umn.edu/~mmizuko/5200/anat.htm

Chidester, J. (1997, June). Result Filters. National Center for Biotechnology Information. Retrieved December 1, 2013, from http://www.ncbi.nlm.nih.gov/pubmed/8990413

Clinic, M. (2012, July 3). Definition. Mayo Clinic. Retrieved November 12, 2013, from http://www.mayoclinic.com/health/stroke/DS00150/DSECTION=treatments-and-drugs

Definition: 'Viscosity'. (2006). Viscosity. Retrieved December 1, 2013, from http://www.medilexicon.com/medicaldictionary.php?t=99155

Dysphagia. (2013). Dysphagia. Retrieved December 1, 2013, from https://ehealth.gov.mt/HealthPortal/rehabilitation/speech_language_pathology/conditions_that_may_affect_sl/dysphagia.aspx

Heart Association. (2012, December 10). What Your Cholesterol Levels Mean. What Your Cholesterol Levels Mean. Retrieved November 24, 2013, from http://www.heart.org/HEARTORG/Conditions/Cholesterol/AboutCholesterol/What-Your-Cholesterol-Levels-Mean_UCM_305562_Article.jsp

Nelms, M. N. (2013). Nutrition Therapy and Pathophysiology 2/e. Belmont, CA, Wadsworth.

NIH. (2011). NIH Stroke Scale. National Institutes of Health. Retrieved November 12, 2013, from http://www.nihstrokescale.org/docs/HospitalStrokeScales.pdf

Office of the Professions. (1998, January). NYS Speech-Language Pathologists & Audiologists: Fiberoptic Endoscope. Retrieved December 1, 2013, from http://www.op.nysed.gov/prof/slpa/speechguidefiberoptic.htm

U.S. Bureau of Labor Statistics. (2013, November 20). U.S. Bureau of Labor Statistics. Retrieved November 30, 2013, from http://www.bls.gov/