FDNS4500 Case Study #18: Stroke
Emilie Koetter
October 3, 2012
1. Define stroke. Describe the differences between ischemic and hemorrhagic stroke. A stroke
occurs when blood supply to the brain is impeded or when a blood vessel in the brain bursts.
Ischemic strokes are the most common type of stroke and are caused by the blockage of an artery to
the brain, usually due to a blood clot or stenosis. This blockage causes a decrease or total stopping
of blood flow to the brain which in turn leads to infarction (the death of brain cells due to lack of
oxygen and nutrients).
Hemorrhagic stroke occurs when an artery in the brain bursts and crosses the blood-brain barrier and
disrupts the function of neurons. Hemorrhagic stroke can be caused by the bursting of an arterial wall
or a weak spot within the wall of an artery (bleeding aneurysm).
3. What are the factors that place an individual at risk for stroke?
Risk factors include age, gender, race/ethnicity, and stroke family history.
• Risk for stroke increases with age
• Men are more at risk for stroke than women, but more women die from stroke
• African Americans are at higher risk for stroke
The most significant risk factors are hypertension, heart disease, diabetes, and cigarette smoking.
High total cholesterol as well as high LDL and low HDL cholesterol are also risk factors for stroke.
High alcohol consumption will also increase risk.
4. What specific signs and symptoms that are noted with Mrs. Noland’s exam and history are
consistent with her diagnosis?
• hypertension and hyperlipidemia (high blood pressure, high total and LDL cholesterol, low HDL
cholesterol)
• heart problems
• symptoms: dizziness, inability to talk, weakness of right side of body (arm and leg);
• dysarthria with tongue deviation
• motor function tone and strength diminished
6. Which symptoms that you identified in question 4 may place Mrs. Noland at nutritional risk?
Explain your rationale.
• dysarthria- causes dysphagia; may require enteral feeding route; can lead to inadequate intake
• weakness- can lead to self-feeding difficulty and impaired ability to prepare foods/meals
• diminished motor function- inability to access food and prepare meals; inability to feed self
7. Define dysphagia.
Dysphagia: difficulty swallowing; can be caused by dysarthria (weakness or paralysis of the muscles
of the mouth, tongue, larynx, or vocal cords as a result of a nerve, brain, or muscle disorder)
One of the main causes of dysarthria is stroke.
15. Mrs. Noland’s usual body weight is approximately 165 lbs. Calculate and interpret her BMI.
BMI= kg/m^2= 74.84 kg/ 2.48 m= 30.18; her BMI indicates that she is obese (class I)
16. Estimate Mrs. Noland’s energy and protein requirements. Should weight loss or weight gain
be included in this estimation? What is your rationale?
• EER for overweight and obese females 19+:
• EER= TEE (kcal/day)= [448 - (7.95 x age) + PA x (11.4 x weight + 619 x height)]
• TEE= 448- (7.95 x 77) + 1 x (11.4 x 74.84) + (619 x 2.48)= 2224.146= 2224 kcal/day
• Weight loss is recommended for Mrs. Noland’s pre-existing conditions, as well as to prevent
another stroke. Weight loss will help lower total serum cholesterol. To factor in weight loss, energy
intake should be reduced by 500-1000 kcals per day as well as increasing energy expenditure. Mrs.
Noland’s energy requirement for weight loss would be between 1224-1724 kcals/day. Increasing
physical activity to increase energy expenditure is also recommended.
Protein requirements:
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FDNS4500 Case Study #18: Stroke
• RDA= 0.8 g protein/ kg body weight= 0.8 x 74.84= 59.872= 60 g protein/day
17. Using Mrs. Noland’s usual dietary intake, calculate the total number of kilocalories she
consumed as well as the energy distribution of kcals for protein, carbohydrate, and fat.
• Total kcals= ~2,417 kcals
• 99g protein= % kcals from protein= 16%
• 360 g carbohydrate= % kcals from carbohydrate= 60% (too many refined grains, not enough whole
grains)
• % kcals from fat= 27% (25 g saturated fat)
18. Compare this to the recommended intake for an individual with hyperlipidemia and
hypertension. Do these recommendations apply to Mrs. Noland at the present?
When comparing Mrs. Noland’s usual intake to intakes recommended for individuals with
hyperlipidemia and hypertension the most significant deviations are in sodium and fat intake. The
DASH Diet for individuals with hypertension recommends an upper level intake of 2,300 mg sodium
per day with 1,500 mg sodium per day being optimal for lowering blood pressure. Mrs. Noland’s
current intake is approximately 3,900 mg of sodium per day.
To lower serum cholesterol and triglycerides, Mrs. Noland should be consuming less fat, specifically
saturated fat, less refined grains and more whole grains, and more fiber. Using her reported 24-hour
dietary recall, her estimated average saturated fat intake is approximately 25 g per day. This value
should optimally be less than 7% of her daily calories. Increasing her physical activity level would also
promote weight loss, therefore helping to decrease blood pressure and blood lipid levels. In order to
lose weight, Mrs. Noland must also reduce her overall energy intake by 500-1000 kcals per day below
her recommended intake of 2,224 kcals/day.
19. Estimate Mrs. Noland’s fluid needs using the following methods: weight, age and weight; and
energy needs. Slide on hydration status
body weight: 1,500 + 20 mL/kg for each kg over 20 kg= 2596.8 mL fluid/day
age and body weight: adult >65 yrs- 25 mL/kg= 1871 mL fluid/ day
energy needs: 1 mL of fluid/ kcal= 2224 mL of fluid/ day
21. From the information gathered within the intake domain, list possible nutrition problems using
the diagnostic term.
• Excessive energy intake
• Excessive fat intake
• Less than optimal intake of types of fats
• Excessive protein intake
• Excessive carbohydrate intake
• Excessive sodium intake
22. Review Mrs. Noland’s labs upon admission. Identify any that are abnormal. Using the
following table, describe their clinical significance for Mrs. Noland.
Chemistry
Normal Value
Mrs. Noland’s
Value
Reason for abnormality
Transferrin
250-380 mg/dL
182 mg/dL
May reflect illness or
protein-energy
malnutrition
Inflammatory response
Alkaline
phosphatase
30-120 U/L
179 U/L
diminished renal function
special diet for treating
liver function
cholesterol
120-199 mg/dL
210 mg/dL
high fat intake, genetic
predisposition
excessive fat intake, less
than optimal intakes of
types of fat
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Nutritional Implications
FDNS4500 Case Study #18: Stroke
Chemistry
Normal Value
Mrs. Noland’s
Value
Reason for abnormality
Nutritional Implications
HDL-C
>55 mg/dL
40 mg/dL
low, below recommended
level
excessive fat intake, less
than optimal intakes of
types of fats
LDL
<130 mg/dL
155 mg/dL
high, above
recommended level
excessive fat intake,
especially saturated and
trans fats
TG
35-135 mg/dL
198 mg/dL
high; above
recommended level
excessive fat intake,
especially saturated and
trans fats
23. From the information gathered within the clinical domain, list possible nutrition problems
using the diagnostic term.
• Swallowing difficulty
• Obese Class I
• Altered nutrition-related laboratory values (total serum cholesterol, HDL cholesterol, LDL
cholesterol, triglycerides)
24. Select two high-priority nutrition problems and complete the PES statement for each.
• on page 4
25. For each of the PES Statements that you have written, establish an ideal goal and an
appropriate intervention.
see attached pages
28. 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?
• Risks after discharge:
• Weakness and fatigue may make cooking and food acquisition difficult. Mr. Noland may need
to assist Mrs. Noland with feeding and food preparation.
• Dysphagia may lead to inadequate energy intake. If Mr. Noland suspects inadequate intake or
notices a change in Mrs. Noland’s diet, he must respond immediately to prevent malnutrition.
• Because of the weakness and decrease in motor function, feeding may require addition time.
Mr. Noland should ensure adequate time for Mrs. Noland to consume sufficient amounts of
food and fluid.
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FDNS4500 Case Study #18: Stroke
Nutrition Assessment
Nutrition Assessment
Categories
Food/Nutrition History
Nutrition Assessment Data
Diet about 2,400 kcal/day, good appetite
Patient avoids fried foods, does not add salt at table
High sodium intake, few whole grains, high fat and saturated
fat intakes
Multivitamin/mineral supplement daily, 500 mg calcium 3 x
daily
Meds: catopril 25 mg twice daily; levastatin 20 mg once daily
Laboratory data
Transferrin: 182 mg/dL
Alk phos:179 U/L
CHOL: 210 mg/dL
HDL-C: 40 mg/dL
LDL: 155 mg/dL
TG: 198 mg/dL
Anthropometric Measurements 5’2”, 165 #, BMI= 30.18
Physical Examination
Client History
Unable to speak or move right side; New-onset weakness of
right side (arm and leg)
Dysarthria with tongue deviation; cranial nerves III, V, VII, XII
impaired
Motor function tone and strength diminished
BP: 138/88 mm Hg, HR: 91 bpm
female, age 77
PMH: hypertension x 10 years; hyperlipidemia x 2 years; heart
problems, arthritis, high blood pressure
Family Hx: noncontributory
Estimated energy and protein needs: ~2224 kcal/day, 60 g protein/day
Nutrition Diagnosis (Note: this is not a medical diagnosis)
Problem
Obese Class I
Etiology
excessive energy intake (~200 kcal excess)
Signs/Symptoms
BMI of 30.18
as related to
as evidenced by
Problem
Abnormal laboratory values
as related to
Etiology
excessive fat intake
as evidenced by
Signs/Symptoms total serum cholesterol 210 mg/dL, HDL cholesterol 40 mg/dL, LDL
cholesterol 155 mg/dL, triglycerides 198 mg/dL
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FDNS4500 Case Study #18: Stroke
Works Cited
Nelms M, Sucher K, Lacey K, Roth S. Nutrition Therapy and Pathophysiology 2nd ed. California:
Wadsworth, Cengage Learning, 2011.
US Department of Agriculture. Food-A-Pedia. Version current 31 July 2012. Internet:
https://www.supertracker.usda.gov/foodapedia.aspx (accessed 20 September 2012).
US Department of Health and Human Services, National Institute of Health, National Heart, Lung, and
Blood Institute. Your Guide to Lowering Your Blood Pressure With DASH. Version current April 2006.
Internet: http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf (accessed 29 September
2012).
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