CASE STUDY 18 STROKE
Group Members: Lystra Paul, Charis Adams, Asia Edwards
OVERVIEW OF CASE
STUDY
Mrs. Ruth Noland, a 77 year old woman, is
transported to the emergency room of
University Hospital with the symptoms of
slurred speech, numbness on the left side
of her face, and weakness of her left arm.
UNDERSTANDING THE DISEASE
AND PATHOPHYSIOLOGY
1. Define Stroke. Describe the differences between ischemic and hemorrhagic
stroke.
 A stroke occurs when the blood supply to part of your brain is interrupted or reduced,
depriving brain tissue of oxygen and nutrients. Due to this brain cells die within
minutes.
 Ischemic Stroke
 An ischemic stroke is caused by a blood clot that blocks or plugs a blood vessel in the
brain. This prevents blood flow to the brain and brain cells begin to die.it can also be
caused by stenosis, or narrowing of the artery. This occurs because of atherosclerosis,
a disease that causes plaque formation in the arteries.
 Hemorrhagic Stroke
 A hemorrhagic stroke is caused by a weakened blood vessel that ruptures and bleeds
into the surrounding brain. The blood accumulates and compresses the surrounding
brain tissue.
 There are two types of hemorrhagic strokes are namely intracerebral (within the brain)
hemorrhage or subarachnoid hemorrhage.
UNDERSTANDING THE
DISEASE AND
PATHOPHYSIOLOGY CONT’D
2. What does Mrs. Noland’s score for the NIH Stroke Scale
Indicate?
 Mrs. Noland’s score indicates significant impairment. Her
motor skills were severely affected and according to the
NIH stroke scale, high scores usually indicate high states of
impairment while 0 or lower indicates normal functioning.
The NIH stroke scale is an assessment done to determine
the effect of acute cerebral infraction. It includes 15
neurological-based questions/tasks scored ranging from 0-3
or 5 with 34 as a possibly.
UNDERSTANDING THE
DISEASE AND
PATHOPHYSIOLOGY CONT’D
3. What are the factors that place an individual at risk for
stroke?
 Family History/Race: risk increases if a close/immediate family have
had a stroke. It is mostly common in African Americans than
Caucasians
 Gender: Mostly common in men than women
 Age: Chances of a stroke increases above age 55 years
 Heart Attack: Causes the body to become weaken heightening the
tendency of a stroke
 Cigarette Smoking: The presence of nicotine and carbon monoxide
in cigarette smoke
UNDERSTANDING THE
DISEASE AND
PATHOPHYSIOLOGY
CONT’D
damages the cardiovascular system increasing
the risk of a

stroke.
 Hypertension: Causes the arteries to narrow which makes it
easier for cholesterol plaques or blood clots to block blood flow
to deep brain tissues.
 Poor Diet: Diets high in saturated fats, Trans fats and
cholesterol can lead to high blood increasing chances of
developing medical conditions and a stroke.
 Drug Abuse: The use of cocaine, amphetamines and heroin
can lead to medical complication as well as a stroke.
UNDERSTANDING THE
DISEASE AND
PATHOPHYSIOLOGY
CONT’D
4 What specific signs and symptoms are
noted with
 .
Mrs. Noland’s exam and history are consistent with her
diagnosis?
 Sudden Dizziness
 No Speech or Trouble speaking
 Paralysis of on the ride side of the body and face
UNDERSTANDING THE
DISEASE AND
PATHOPHYSIOLOGY
CONT’D
5. What is rtPA? Why was it administered?

 rtPA is short for Recombinant Tissue Plasminogen
Activator; commercially known as Alteplase, which
is used to alleviate central line blockages caused
by clot formation. Administered/ Prescribed at in
early stages of ischemic stroke can lead to early
detection and alleviation of the blockage, which
can cause stroke and partially restore neurologic
function.
UNDERSTANDING THE
DISEASE AND
PATHOPHYSIOLOGY
6. Which symptoms that you identified CONT’D
in question 4

may place Mrs. Noland at nutritional risk? Explain your
rationale.
 A symptom that can used to identify nutritional
risk would be Mrs. Noland’s inability to properly
move her face and operate her tongue for speech.
This can be considered a nutritional risk because
it may pose difficulty for her orally eating and
swallowing.

UNDERSTANDING
NUTRITION
THERAPY
7. Define Dysphagia
 Dysphagia is the medical term for swallowing
difficulties.
 Some people with dysphagia have problems
swallowing certain foods or liquids, while others
can't swallow at all.
 Other signs of dysphagia include:
 coughing or choking when eating or drinking
 bringing food back up, sometimes through the nose
UNDERSTANDING
NUTRITION THERAPY
 a sensation that food is stuck in your throat or
chest
 persistent drooling of saliva
 being unable to chew food properly
 a 'gurgly' wet sounding voice when eating or
drinking
 Over time, dysphagia can also cause symptoms
such as weight loss and repeated chest infections.
UNDERSTANDING
NUTRITION THERAPY
 8. What is the primary nutrition implication of
dysphagia?
 The primary nutrition implication of dysphagia in
the inability to deliver nutrients to the stomach for
absorption. This can reduce intake and inability to
eat or swallow causing depression.
UNDERSTANDING
NUTRITION THERAPY
 9. Describe the four phases of swallowing:
 Oral preparation: The chewing of food and mixing it with
saliva as the tongue mixes it around, forming bolus.
 Oral transit: The backward movement of the bolus to the
rear of the oral cavity by the tongue squeezing against the
hard and soft palates.
UNDERSTANDING
NUTRITION THERAPY
Pharyngeal: The phase begins when the bolus progressed past the facial
arches and is quickly followed in succession by the following steps:
 Elevation of the soft palate, closing off the nasopharynx (prevents
oropharyngeal regurgitation).
 Elevation of the hyoid and larynx with adduction of the vocal
cords, protecting the airway.
 Contraction of the pharynx while the cricopharyngeal sphincter
relaxes, allowing food to pass into the esophagus.
 Breathing resumes.
 Esophageal: This is the phase which the bolus continues to travel down
the esophagus into the stomach.
UNDERSTANDING
NUTRITION THERAPY
UNDERSTANDING
NUTRITION THERAPY
 10. It is determined that Mrs. Noland 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?
 Peristalsis is slow which causes transit of bolus
from the esophagus to stomach to be slow. More
time will be needed therefore for her to eat her
meals. An appropriate diet level for Mrs. Noland
would be level 3-Dysphagia Advanced soft foods
that require more chewing ability.
UNDERSTANDING
NUTRITION THERAPY
 11. Describe a bedside swallowing assessment. What
are the background and training requirements of a
speech-language pathologist?
 The bedside swallowing assessment is a
component of the diagnostic process which
comprises of: screening, clinical exam and
instrumental assessment. The (SLP) will
normally do this assessment.
UNDERSTANDING
NUTRITION THERAPY
 It is done to check for signs of dysphagia and
aspiration.
 Firstly the SLP will evaluate:
 the patient’s medical history;
 the nature of the patients swallowing problem;
 the substances that cause these problems;
 the frequency and severity of the symptoms;
 they may also ask family members about the patients
condition
UNDERSTANDING
NUTRITION THERAPY
 Secondly the SLP will observe:
 The patient’s teeth, lips, jaws, tongue, cheeks,
and soft palate.
 Particular movements like smacking of lips
together or sticking out your jaw.
 Particular sounds, coughs, or clearing of the
patients throat.
UNDERSTANDING
NUTRITION THERAPY
 Reflexes for gagging and coughing
 Voice quality after swallowing for “wetness”,
which is an indicator of aspiration
 Bolus control and laryngeal elevation
 Lastly, the patient will have to swallow multiple
substances from water, thicker liquids, pureed
foods, soft foods and even regular foods.
UNDERSTANDING
NUTRITION THERAPY
 A speech language pathologist works to prevent,
assess, diagnose and treat speech, language, social
communication, cognitive communication and
swallowing disorders in children and adults.
 They work in different research, education and health
care settings.
UNDERSTANDING
NUTRITION THERAPY
 Training;
Complete an undergraduate program in Communication
Sciences and Disorders.
 Courses done in this degree are: statistics, social/behavioral,
physical and biological sciences related to:
 Normal language development
 Language Disorders and Phonology
 Linguistics
 Anatomy of hearing speech and mechanisms
 1.
UNDERSTANDING
NUTRITION THERAPY
 2. Complete CAA-Accredited Graduate Program in
Speech- Language Pathology/ Communicative
Sciences and Disorders
 Clinical Practicum Requirement
 300-375 hours of supervised practice
 3. Complete Post Graduate fellowship
 1260 hours
UNDERSTANDING
NUTRITION THERAPY
 4. Take a national exam in Speech Language
Pathology (ETS) Educational Testing Services.
You can do it while doing the post graduate
fellowship or after doing the graduate degree.
 5. Apply for the state licensure as a speechlanguage pathologist
 6. Consider Professional Certification from
(ASHA)
UNDERSTANDING
NUTRITION THERAPY
 12. Describe a modified barium swallow or fiberoptic endoscopic
evaluation of swallowing.
 A modified barium swallow (MBS) is an x-ray procedure done, to examine problems
with swallowing. Liquid barium is a white, chalky solution that helps healthcare
providers see the pictures more clearly. Barium is mixed with foods and liquids of
different consistencies to show how they are swallowed. This helps healthcare
providers decide what foods or liquids are good for the patient to consume.
AND
 A fiberoptic evaluation of swallowing (FEES) test is a procedure used to assess how
well a patient can swallow. During the procedure, a speech-language pathologist
(SLP) passes a thin, flexible instrument called the endoscope through your nose
and pharynx. Then it sits in the epiglottis for most of the viewing and then moved
down after each swallow so the vocal folds can be seen. The endoscope has a tiny
camera and light attached to it. This test also helps to assess if you a patient is
having any problems with any part of the swallowing process.
UNDERSTANDING
NUTRITION
THERAPY
 13. What
is the National Dysphagia
Diet? Describe
the major difference among the four levels of the
diet.
 The National Dysphagia Diet (NDD), published in
2002 by the American Dietetic Association (now
Academy of Nutrition and Dietetics), aims to
establish standard terminology and practice
applications of dietary texture modification in
dysphagia management.
 The NDD was developed through consensus by a
panel of dietitians, SLPs, and a food scientist.
UNDERSTANDING
NUTRITION THERAPY
 N.B. This is where the (IDDSI) according to the academy
of nutrition and came about. The International Dysphagia
Diet Standardization Initiative seeks to create global
standardized terminology and definitions for texturemodified foods and thickened liquids to improve the
safety and care for individuals with dysphagia. The
academy and ASHA together supported May 1, 2019, as
the official launch date of the IDDSI implementation in the
US. This announcement was made in 2018 at the food
and nutrition conference and Expo in Washington D.C.
UNDERSTANDING
NUTRITION THERAPY
 NDD Level 1: Dysphagia-Pureed Diet (homogenous, very cohesive,
pudding-like, requiring very little chewing ability)- Hot cereals/porridge
 NDD Level 2: Dysphagia-Mechanical Altered Diet (cohesive, moist,
semisolid foods, requiring some chewing). -Bananas
 NDD Level 3: Dysphagia-Advanced Diet (soft foods that require more
chewing ability).-thin-sliced tender chunks or ground meats.
 Regular (all foods allowed). -Regular foods.
 Additionally, we have the viscosity levels of thickening liquids which are
as follows:
 Nectar -like level: Fluids run freely off of the spoon, but leaves a mild
coating on the spoon.
 Honey- like level: Fluids slowly drips off of the end of the spoon.
 Pudding-like level: Fluids remains on the spoon and does not flow off.
UNDERSTANDING
NUTRITION THERAPY
 14. Thickening agents and specialty food products are
often used to provide the texture changes needed for
the dysphagia diet. Describe one of these products and
how they may be incorporated into the diet.
 There are two types of thickening agents: xanthan gum
thickeners and starch based thickeners.
 One product that can be used is something called the THICKEN
UP CLEAR produced by NESTLE.
 It is a xanthan gum thickener
PICTURE
UNDERSTANDING
NUTRITION THERAPY
 It’s easy to use, thickens and stabilizes rapidly, won’t
continue to thicken overtime, clump free, and remain
transparent.
 It’s clear, odorless, tasteless and low calorie, which
are all characteristics of xanthan gum based
thickeners.
UNDERSTANDING
NUTRITION THERAPY
 Example of how it works;
 125 ml to 1 scoop- Gives mildly-thick, nectar-like consistency
 125ml to 2 scoops- Gives moderately thick, honey like
consistency
 125ml to 3-3.5 scoops- Gives extremely thick, pudding/spoon
thick consistency
 It can be used in juices and smoothies.
NUTRITION ASSESSMENT
 15. Mrs. Noland’s usual body weight is approximately
165 lbs. Calculate and interpret her BMI.
 UBW= 165lbs (75kg)
 BMI= kg/m2 (Do working)
 BMI= 30.5 Obese (Class 1)
NUTRITION ASSESSMENT
16. Estimate Mrs. Noland’s energy and protein requirements.
Should weight loss or weight gain be included in this estimation?
What is your rationale.
Nutrient Requirements
 Mifflin St. Jeor Equation: 10 (wt) + 6.25 (ht) -5(age) -161
(Female)
 10 (75) + 6.25(157.5)-5(77)-161
 = 1188 multiplied by 1.2 = 1426
 For stoke: 1-1.25 g/kg
 Protein = 1 x 75kg = 75g
NUTRITION ASSESSMENT
 16. Should weight loss or weight gain be
included in this estimation? What is your
rationale.
 Weight loss should be included in estimation or
weight maintenance because she is already obese
and one of the primary nutrition implications of
dysphagia is malnutrition which can lead to weight
loss.
NUTRITION ASSESSMENT
17. Using Mrs. Noland usual dietary intake, calculate the
total number of kilocalories she consumed as well as the
energy distribution of kilocalories for protein,
carbohydrate, and fat.
 Mrs. Noland typically consumes 2533 kcal daily
 Fat: 25%
 Carbohydrates: 59%
 Protein: 17%
18. Compare this to
the recommended
intake for an
individual with
hyperlipidemia and
hypertension. Do
these
recommendations
apply to Mrs. Noland
at the present?
Mrs. Noland is consuming
too much sodium and
cholesterol. Her sodium
intake is above normal.
So I wont say she is
following the
recommended intake at
the time.
She should be following
the TLC Diet, and DASH
diet.
NUTRITION
ASSESSME
NT
NUTRITION ASSESSMENT
 The TLC (Therapeutic Lifestyle Changes) diet is one of several
heart-healthy diets that can lower cholesterol and help lower
your risk of heart disease or stroke.
 You get 25% to 35% of your daily calories from fat, mainly
from unsaturated fat.
 You get 50% to 60% of your daily calories from carbohydrates
 You get less than 7% of your daily calories from saturated fat.
 You eat no more than 200 milligrams (mg) of cholesterol a day.
 You avoid trans fat.
 DASH Diet
 Diet used to treat hypertension.
 Standard DASH diet. You can consume up to
2,300 milligrams (mg) of sodium a day.
 Lower sodium DASH diet. You can consume
up to 1,500 mg of sodium a day.
 And the amount of servings:
NUTRITION
ASSESSMEN
T
 Grains: 6 to 8 servings a day
 Vegetables: 4 to 5 servings a day
 Fruits: 4 to 5 servings a day
 Dairy: 2 to 3 servings a day
 Lean meat, poultry and fish: 6 one-
ounce servings or fewer a day
 Nuts, seeds and legumes: 4 to 5
servings a week
 Fats and oils: 2 to 3 servings a day
 Sweets: 5 servings or fewer a week
NUTRITION ASSESSMENT
 EAT TRACKER ANALYSIS COMPARED
 Mrs. Noland had an intake of: 2621.2 mg sodium
 Saturated fat: 20.2 grams
Normal: 99 grams
 Trans fat: 4.4 grams
 Cholesterol: 239.6
Normal: Less than 200mg
 Fruits and Vegetables: 7 servings
 Grains: 5 servings
 Milk and alternatives: 2 servings
 Meat: 2.5 servings
19. Fluid needs:
By weight: 30 – 35 ml per weight in kg
• = 30ml x 75 kg
• = 2,250 ml
By age and weight: 1 10 kg of body weight
100ml/kg
st
• 2nd 10 kg of body weight
+50ml/kg
• Remaining kg of body weight (age >50)
+15ml /kg
• 10kg x 100ml = 1000ml
• 10kg x 50ml = 500ml
• 55kg x 15ml = 825ml
• TOTAL = 2325 ml
By energy needs: 1ml of fluid per calorie consumed
• =1426Kcal x 1ml
• = 1426 ml
NUTRITION
ASSESSMEN
T
NUTRITION ASSESSMENT
 20. Which method of fluid estimation appears most
reasonable for Mrs. Noland? Explain
 We believe that the age and weight fluid calculation is best for
Mrs. Noland because it takes into consideration her age which
causes major changes in her body and her current weight. This
method allows for an adjustment as her weight decreases or
increases.
NUTRITION ASSESSMENT
 21. From the information gathered within the intake
domain, list possible nutrition problems using the
diagnostic term.
 Excessive Energy Intake
 Excessive Oral food and Beverage Intake
 Inadequate Fluid Intake
Chemistry
Normal
Value
Mrs.
Noland's
Reason for Abnormality Nutritional Implications
Transferrin
250 -380
mg/dL
182 mg/dL
Poor production in the
liver indicating possible
liver disease
Treatment management should aim to maintain
an adequate protein and caloric intake and to
correct nutrient deficiencies
Alk
phosphate
30 -120 U/L
179 U/L
Caused by liver disease or
bone disorder
Increase caloric intake and include nutritional
supplements to compensate for deficiencies in fat
soluble vitamins.
CHOL
120-199
mg/dL
210 mg/dL
High levels of LDL
Increase in soluble fibre intake. Limit the amount
of animal fats and use good fats in moderation
Lose extra pounds and maintain a healthy weight
HDL-C
>55 mg/dL
40 mg/dL
High carb diet and
excessive weight
Increase levels of physical activity, limit intake of
saturated and transfat
LDL
<130 mg/dL
155 mg/dL
Low levels of HDL (HDL
fights LDL)
Increase in soluble fibre intake. Limit the amount
of animal fats and use good fats in moderation
Lose extra pounds and maintain a healthy weight
TG
35-135 mg/dL
198 mg/dL
Poor diet
Increase in soluble fibre intake. Limit the amount
of animal fats and use good fats in moderation
Lose extra pounds and maintain a healthy weight
NUTRITION ASSESSMENT
 23. From the information gathered within the clinical
domain, list possible nutrition problems using the
diagnostic term.
 Altered nutrition-related laboratory values
 Overweight/ Obesity
NUTRITION DIAGNOSIS
 24. TWO HIGH PRIORITY NUTRTION PROBLEMS AND PES
STATEMENT:
 Excessive sodium intake related to food and nutrition related
education deficit as evidenced by estimated sodium intake
that is more than recommended.
 Altered nutrition-related laboratory values related to the liver
as evidenced by ALT phosphate levels.
NUTRITION DIAGNOSIS
 25. For each of the PES statements that you have
written, establish an ideal goal (based on signs
and symptoms) and an appropriate intervention
 First PES: Based on the signs and symptoms the
goal is to reduce the amount of sodium intake
our patient consumes because of her
hypertension.
 She should be enrolled in counselling and put on the
DASH Diet where she will have salt restriction.
 The goal is to reduce her intake of sodium to1500 mg
per day for a month to bring her blood pressure down
120/80.
NUTRITION DIAGNOSIS
 Second PES Statement: The goal is to determine why her ALT phosphate levels are
high by referring her to a doctor to make a proper medical diagnosis which will then
determine if nutrition therapy is mandatory.
 Dietitians can only make a nutrition diagnosis, but some nutrition counseling can be
offered to her introducing her to different liver disease diets.
 Here are some pointers:
 What to avoid: Don’t eat foods high in fat, sugar and salt. Stay away from a lot of
fried foods including fast food restaurant meals.
 Talk to your doctor about alcohol and your liver health: Depending on the state
of your liver, you should avoid alcohol.
 Eat a balanced diet: Select foods from all food groups: Grains, fruits, vegetables,
meat and beans, milk, and oil.
 Eat food with fiber: Fiber helps your liver work at an optimal level. Fruits,
vegetables, whole grain breads, rice and cereals can take care of your body’s fiber
needs.
 Drink lots of water: It prevents dehydration and it helps your liver to function better.
Term
Consistency
Definition
Refers to the way in which a
substance holds together
Texture
Those properties of a food that are
sensed by touch in the mouth and
in the hands.
The state of being thick, sticky,
and semi-fluid in consistency. It
also refers to the resistance of a
fluid to change in shape. Viscosity
denotes opposition to flow.
Viscosity
NUTRITION
MONITORING AND
EVALUATION
Example
Pureed vegetables will be
smooth and moist. Spoon
would not be able to stand in
it.
Foods can be soft, hard,
crunchy, smooth, mushy.
Water has low viscosity as it is
thin and flows freely, easily
taking any shape.
26. To maintain or attain normal nutritional
status while reducing danger of aspiration
and choking, texture and/or viscosity are
personalized for a patient with dysphagia. In
the following table, define each term used to
describe characteristics of foods and give an
example.
Orange Juice
Raisin bran
2% milk
Banana
Coffee
Sweetener
Chicken tortellini
soup
Saltine crackers
Canned pears
Iced tea
Baked Chicken
Baked potato
Steamed broccoli
Margarine
Canned peaches
Popcorn
Coca-cola
Ice cream
add a gum thickner
can be softened by adding low fat milk
substitute with low fat milk
should be cut into bite sized pieces
should be eliminated as it causes a boost in blood
pressure
decrease usage graudally
ingredients should be cut into bite sized pieces
should be avoided
use fresh unprocessed pears as a substitute
replace with water
cut in thin slices/ strip
Mash potatoes
cut into small chunks
use butter as a replacement
substitute with fres, unprocessed peaches
unsalted plain popcorn, with no butter
eliminate
use low fat yogurt as a replacement
NUTRITION
MONITORING
AND EVALUATION
Using Mrs. Noland’s
24 hour recall, make
suggestions for
consistency changes or
food substitutions to
Mrs. Noland and her
family
 27.
NUTRITION MONITORING
AND EVALUATION
28. Mrs. Noland would have problems of unilateral paralysis on the
right side of her body. Her meals would have to be of the right
consistency and texture in order to maintain her nutritional intake
and avoid issues connected to dysphagia. Her intake of sodium and
fats need to be reduced in order to alleviate her issues of
hypertension and hyperlipidemia. This change would mean that Mr.
Noland should receive the necessary counselling in this area. Mr.
Noland should know that Mrs. Noland’s diet should include more
fruits, vegetables, and low-fat dairy foods. He should cut back on
foods that are high in saturated fat, cholesterol, and trans fats. Feed
her more whole-grain foods, fish, poultry, and nuts and limit sodium,
sweets, sugary drinks, and red meats.
 29. Yes Mrs. Noland would be an
NUTRITION
MONITORING
AND
EVALUATION
appropriate candidate for a stroke
rehabilitation program because her
situation though unfortunate has not
left her fully incapacitated. She can
benefit from stroke rehabilitation
which can help to give her back her
independence.