Case Study 3
Ischemic Stroke – Case 23
12/3/2013
Professor V. Fischer – FNES 365
Written by Kimberly Tierney
Case Questions for Medical Nutrition Therapy: A Case Study Approach 4th ed.
Title: Case 23 – Ischemic Stroke
Instructions: Answer the questions below. You may print your answers or e-mail them to your instructor.
Questions:
1. Define stroke. Describe the differences between ischemic and hemorrhagic strokes.
A stroke is a “vascular injury” or “cerebrovascular accident” as an occurrence which affects
the brain as a loss of blood flow resulting in a deficit of neurologic function with an acute
onset and duration exceeding twenty-four hours. Neurologic deficit occurs in relation with
brain cells and tissue are damage either by an occlusion in the oxygen-supplying artery by a
plaque or blood-clot, or as a result of hemorrhaging. Strokes are classified as either an
ischemic stroke, which is more common, or a hemorrhagic stroke.
An ischemic stroke occurs when a blood-clot or plaque occludes the flow of oxygenated
blood to the brain within the carotid artery resulting in necrosis of tissue and brain cell death.
Ischemic strokes result from either an embolus as a blood clot formation known as a
thrombus, or a fatty deposit or plaque. In a thrombotic ischemic stroke, the formation of the
thrombus occurs within the carotid artery and is further exacerbated by the narrowing of the
blood vessel as a result of platelet aggregation which occludes the supply of blood to the
brain, whereas in an embolic ischemic stroke, the occlusion within the carotid artery occurs
as a result of the embolus, as either plaque, fatty substance, or blood-clot, moves through the
bloodstream from a nearby vessel and becomes lodged within the artery supplying blood to
the brain. Embolic ischemic stroked commonly affect the middle cerebral artery. Ischemic
stroked, both as thrombotic and embolic, display as acute onset of motor and sensory deficit
in fully conscious individuals. However, in the case whereby the embolic stroke occludes the
middle cerebral artery, paresis is observed on the contralateral side of the occlusion
occurrence; for example, if the occlusion occurs within the right carotid artery, the left side
of the body may display hemiparesis. If an occlusion occurs within the left artery affecting
the middle cerebral artery during an ischemic embolic stroke, the sign and symptom is
presented as aphagia due to affected cranial nerves and regions of the brain which perform
the functions of speech and facial expression.
A hemorrhagic stroke occurs as a hemorrhage, as loss of blood or rupture, within the brain
resulting in damage to tissue and cells in regions surrounding the hemorrhage due to
increased cranial pressure and swelling. An intracerebral hemorrhagic stroke occurs within
the cerebral artery as a leak or rupture within the brain likely associated in individuals with
hypertension, whereas a subarachnoid hemorrhagic stroke occurs due to a bleed within the
membrane surface of the brain as a result of traumatic brain injury or ruptured aneurysm.
Hemorrhagic strokes often display signs as acute onset or prolonged over a few hours
accompanied by headache, nausea and diminished consciousness.
A lacunar stroke describes the change in pathological change within the brain which may or
may not be detectable as common signs and symptoms associated with a stroke caused by the
decreased blood flow an artery of the brain often occurring deep within the brain affecting
the areas of the internal capsule, basal ganglia, pons, thalamus, and cerebellum.
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(February 1, 2011). What is a Stroke?. In National Heart, Lung, and Blood Institute.
Retrieved December 1, 2013, from http://www.nhlbi.nih.gov/health/healthtopics/topics/stroke/.
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th Ed) (pp 933-34). St. Louis, MO: Elsevier.
Venes, D. (2005). Taber’s Cyclopedic Medical Dictionary (21st Ed)(pp 2221-2223).
Philadelphia, PA: F.A. Davis Company.
2. The noncontrast CT confirmed that 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 National Institute’s of Health Stroke Scale (NIHSS) exam score of 14 indicates a
moderate to severe stroke occurred, whereby 15 to 20 is considered severe, 0 is considered
normal, and the maximum score is 42. An NIHSS score between 12-14 has a positive
prognosis in recovery as an 80% good to excellent outcome, whereas more severe scores of
20 to 26 has a 20% possibility of good to excellent recovery outcome. The treatment of
recombinant tissue plasminogen activator (rtPA) provided post-stroke to break-up or lyse the
clot is limited to a maximum NIHSS score of 16 to 20, as well as not having severe scores all
three parameters of hemiparesis or hemiplegia, language or aphagia, and severe visual
impairment, not displaying atrial fibrillation and altered mental status. Therefore, the
patient’s score of 14 indicates treatment with rtPA is permitted and she has a positive
prognosis in recovery.
Sloan, E. (2001). Use of the NIH Stroke Scale (NIHSS) In Emergency Department Patients
with Acute Stroke. In University of Illinois: College of Medicine. Retrieved December 1,
2013, from
http://www.uic.edu/com/ferne/pdf/acep0604_alabama/nihss_sloan_acep0604_alabama.pd
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3. What factors place an individual at risk for stroke?
Factors which place individuals at risk for stroke include a body mass index greater than 25
kg/m2 in women, as well as a weight gain greater than 11 kg over 16 years in women, a
waist-to-hip ratio greater than 0.92 in men, but generally obesity increases the risk among
both genders. Gender also plays a role in risk of occurrence relating to a higher risk and
incidence of stroke in men, however a greater mortality in the occurrence of stroke in
women, as well as a greater risk in women utilizing birth control pills. The risk of occurrence
increases significantly with age, especially beyond 55 years of age. A risk of stroke is
increased relating to genetics if those in the family’s history have experienced an occurrence.
Those of African American, American Indian and Alaskan race have a greater risk of stroke
in comparison with Caucasian, Hispanic, and Asian American race. Factors increasing the
risk of stroke which may be prevented or changed include sedentary life style or poor
physical activity level, stress, smoking, alcohol consumption, and depression. Medical
conditions which may exacerbate the risk of stroke include bleeding disorders and blood
thinning medication, hypertension, cholesterol relating to elevated cholesterol,
atherosclerosis, and carotid artery disease, diabetes, chronic kidney disease, and conditions
pertaining to the heart and blood circulation such as coronary heart disease, heart failure,
atrial fibrillation and abnormal rhythms, and deformity of the arteries and veins.
(February 1, 2011). What is a Stroke?. In National Heart, Lung, and Blood Institute. Retrieved
December 1, 2013, from http://www.nhlbi.nih.gov/health/healthtopics/topics/stroke/causes.html.
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th Ed) (pp 936). St. Louis, MO: Elsevier.
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.
Signs and symptoms which are consistent with Mrs. Noland’s diagnosis of suffering a
lacunar ischemic stroke are slurred speech, acute onset of numbness on the right side of her
face, hemiparesis or hemiplegia and muscle weakness in her right arm and leg, decreased
motor function tone and strength bilaterally as sensory deficits, decreased right plantar reflex,
as well as impaired sensation on the contralateral side, dizziness, inability to talk as aphagia
and dysarthria with tongue deviation as slurred speech, a blood pressure slightly elevated
above the desired limit of 120/80 as 138/88 while on hypertensive medications, urinary and
bowel incontinence, pale skin color at a cool temperature, impaired cranial nerves III, V,
VII, and XII. Impairment of cranial oculomotor nerve (III) affects the nerve function relating
to eye movement and pupil constriction, cranial trigeminal nerve (V) affects the nerve
function relating to mastication, facial heat, cold, and sensitivity to touch, noxious odors, and
input for corneal reflex, cranial vestibulocochlear nerve (VII) affects the nerve function
relating to muscles used in facial expression, corneal reflex, facial pain, and taste upon the
anterior 2/3 portion of the tongue, and cranial hypoglossal nerve (XII) affects the nerve
function relating to tongue movement.
Factors increasing the risk of stroke which attribute to negative nutritional health thereby
increasing the occurrence of stroke include sedentary life style or poor physical activity level
and depression as a result of retirement from occupation as a hairdresser and no longer
responsible for caretaking of children whom are grown and do not live at home. Medical
conditions which may exacerbate the risk of stroke include bleeding disorders and blood
thinning medication such as the captopril and lovastatin for treatment of the patient’s
hypertension and hyperlipidemia, cholesterol relating to elevated cholesterol levels as Mrs.
Noland blood work shows as 210 mg/dL above the normal limits of 120 to 199 mg/dL, which
may lead to atherosclerosis and carotid artery disease further exacerbating the risk of stroke.
The risk of stroke and hypertension may be decreased from dietary intake as good sources of
potassium and low sodium content; Mrs. Noland’s bloodwork shows potassium blood levels
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at 3.8 mEq/L within the low end of normal limits of 3.5 to 5.5 mEq/L, and sodium blood
levels of 141 mEq/L within the high end of normal limits of 136 to 145 mEq/L.
The symptoms denoted within Mrs. Noland’s exam and history which place the patient at
nutritional risk for stroke include a body mass index greater than 25 kg/m2 in women in
which Mrs. Noland’s BMI can be calculated to 30.1% or interpreted through the BMI table
as 30% which is classified as grade II, class I obesity respectively, and obesity as rounded
abdominal appearance noted in the nursing assessment. These components will increase the
difficulty of the patient’s ambulatory capacity further increasing sedentary physical activity
as well as compounding with the hemiparesis, decreased muscle tone and strength. The
hemiparesis, numbness of the right facial side and dysarthria will necessitate dietary intake to
be assessed for ease of consumption due to the possible inability to chew or bring food to her
own mouth. The cranial nerve functions stated above will decrease the patient’s desire and
ability to eat foods due to deficits or inability to taste as dysgeusia and possible xerostomia as
dry mouth indicated by slightly dry mucous membranes, and furthermore be aggravated by
the difficulty to move food within the mouth to begin oral transit to the stomach due to
hypoglossal nerve damage and a deficit in the trigeminal nerve affecting the ability to chew
or masticate. Food item restrictions will apply relating to density, texture, consistency, as
well as possible alternative feeding route as a feeding tube or assistance to avoid aspiration
due to dysphagia and neuromuscular compromise. According to the 24-hour recall of dietary
intake, Mr. Noland states his wife had a good appetite and consumed a relatively healthy diet
without the addition of salts, however restriction of sodium content within foods, such as
saltine crackers and chicken tortellini soup, will aggravate the patient’s hypertension. The 24hour recall displays many food items which can be modified to increase nutrient density
beneficial to the health status of the patient and prevent recurrence of a stroke, such as
increasing intakes of fresh fruit, teas which provide flavonoids, fish and/or fish oil, and food
items which increase HDL and lower LDL cholesterol. However, due to the compromised
capability to consume food items, Mrs. Noland’s current health status may decrease placing
her at nutritional risk of poor energy intake, and malnutrition or decreased nutritional status.
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th Ed) (pp 287, 926-928, 936). St. Louis, MO: Elsevier.
Fischer, V. (2013, November 19). The Biology of Aging - Nutrition in Older Adults. FNES
365: Nutrition Assessment and Counseling. Lecture conducted from CUNY Queens
College, Flushing, NY.
Fischer, V. (2013, November 26). Enteral Feeding. FNES 365: Nutrition Assessment and
Counseling. Lecture conducted from CUNY Queens College, Flushing, NY.
5. What is rtPA? Why was it administered? Define dysphagia. What is the primary nutrition
implication of dysphagia?
Recombinant tissue plasminogen activator (rtPA) is an intravenous treatment administered to
individuals whom have experienced an ischemic stroke to dissolve, or lyse, the clot causing
an occlusion within an artery thereby restoring blood flow to the brain. The treatment with
rtPA is the only FDA approved noninvasive treatment of ischemic strokes.
Dysphagia is difficulty or inability to swallow. Mrs. Noland’s dysphagia is likely dysphagia
paralytica due to paresis pertaining to esophagus and deglutination muscles since she is
described to have reduced esophageal peristalsis and is centered around the esophageal
transit phase. The primary nutrition implication of dysphagia is malnutrition due to poor or
inadequate dietary intake associated with anorexia and weight loss. Dysphagia is seen in
individuals which have suffered a stroke, dementia, multiple sclerosis (MS) and amyotrophic
lateral sclerosis (ALS). As per the Krause textbook and Professor Fischer’s lecture entitled
“The Biology of Aging,” signs and symptoms of dysphagia are often displayed as drooling,
choking or coughing during and/or following meals, inability to such from a straw, gurgling
voice quality, absent gag reflex, chronic upper respiratory infection, and holding pockets of
food within buccal recesses.
(May 23, 2013). Stroke Treatments. In American Stroke Association. Retrieved December 1,
2013, from
http://www.strokeassociation.org/STROKEORG/AboutStroke/Treatment/StrokeTreatments_UCM_310892_Article.jsp.
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th Ed) (pp 929). St. Louis, MO: Elsevier.
Fischer, V. (2013, November 19). The Biology of Aging – Nutrition in Older Adults. FNES
365: Nutrition Assessment and Counseling. Lecture conducted from CUNY Queens
College, Flushing, NY.
Venes, D. (2005). Taber’s Cyclopedic Medical Dictionary (21st Ed)(pp 709, 2222).
Philadelphia, PA: F.A. Davis Company.
7. Describe the four phases of swallowing:
a. Oral preparation & oral transit
b. Pharyngeal
c. Esophageal
As per the Krause textbook, the three phases of swallowing include the oral phase, followed
by the pharyngeal phase, and then the esophageal phase. The oral phase is a voluntary phase
in which oral preparation is initiated when food is placed within the oral cavity where is
forms a bolus is combination with saliva and tongue movement, accompanied by mastication
if needed. The formed bolus is then moved to the posterior oral cavity in position to transit
into the pharynx directed by the tongue and assisted with movement against the anterior hard
and posterior soft palates.
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The involuntary pharyngeal phase begins as the bolus is moved between the tonsillar pillars,
past the palatoglossal arch, and beyond the palotopharyngeal arch triggering the nasopharynx
path to close by elevation of the posterior soft palate and respiration to temporarily cease.
This is followed by the elevation of the hyoid bone and larynx to cover and prevent entry by
food into the airway and choking, along with the vocal cords being drawn toward the body
midline, or performing adduction. The food bolus then proceeds into the esophagus by
contraction of the pharynx and relaxation of the cricopharyngeal sphincter. At this point,
respiration resumes.
The involuntary esophageal phase proceeds as the hypopharyngeal, also called the upper
esophageal, sphincter relaxes to allow the bolus to continue through the esophagus by
peristaltic waves, which some assistance of gravity, and into the stomach concluding the
three phases of swallowing.
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th Ed) (pp 929-930). St. Louis, MO: Elsevier.
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.
As per the Krause textbook, the three levels of solid food texture within the National
Dysphagia Diet are pureed as level one, mechanically altered characteristics as level two, and
transition to regular diet as level 3.The level one pureed diet contains foods which are
described as “pudding-like”, meaning the consistency is homogeneous without pulp, lumps
or chunks, and cohesive to avoid aspiration or necessitating mastication or manipulation in
food bolus formation. Coarse textures are omitted from the diet therefore excluding items
such as raw fruits and vegetable, and nuts. The pureed diet is used in instances requiring
supervision in oral consumption or alternative methods of feeding as in moderate to severe
dysphagia, whereby airway protection and oral phase are compromised. The level two
mechanically altered characteristics diet contains foods which require mastication and
differing textures are well tolerated following patient assessment of a dysphagia level as mild
to moderate or centered in pharyngeal dysphagia. It is established with level two that the
patient can withstand or tolerate a transition from pureed diet, while still including pureed
foods, to textures of more solid consistency including minced or ground cohesive meat, and
as the foods are describes as being moist, soft-textured, and readily manipulate to form a
food bolus. The level three transition to regular diet is considered the advances level whereby
it contains foods which are nearly an unrestricted regular diet with omission of textured foods
which are hard, sticky, and crunchy. This level requires competency of mastication and use
of teeth to manipulate small, moist pieces of solid foods within oral phase of swallowing.
Level three is utilized as a transition of those with mild oral or pharyngeal phase dysphagia to
a regular unrestricted diet.
Alterations to diet to increase desired to eat while adhering to restrictions of textures and
food items include smaller meals provided more frequently, as well as considering aroma,
seasoning, garnishing, color, plating, palatability, piping, layering, and molding.
The four levels of fluid consistency remain loosely regulated and are correlated between the
level title and fluids which are similar to those titles as well as measure of viscosity range.
The four levels include thin, nectar, honey, and spoon or pudding thick with respective
viscosity ranges as 1-50 centiPoise (cP), 51-350 cP, 351-1,750 cP, and greater than 1,750 cP
whereby the thin liquids require the most control and coordination in swallowing and highest
risk of aspiration.
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th Ed) (Appendix 35). St. Louis, MO: Elsevier.
Fischer, V. (2013, November 19). The Biology of Aging – Nutrition in Older Adults. FNES
365: Nutrition Assessment and Counseling. Lecture conducted from CUNY Queens
College, Flushing, NY.
McCullough, G., Pelletier, C., & Steele, C. (November 4, 2003). National Dysphagia Diet:
What to Swallow?. In The American Speech-Language-Hearing Association. Retrieved
December 1, 2013, from http://www.asha.org/Publications/leader/2003/031104/f031104c/
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?
The swallowing evaluation is first performed by a trained speech-language pathologist that
specializes in the assessment and treatment as diet modifications of disordered swallowing as
in dysphagia. The speech-language pathologist will then determine which level of the
National Dysphagia Diet is appropriate for the individual. However, in the absence of the
speech-language pathologist assessment, and upon discontinuation of the NPO order, and in
consideration of the symptoms described, the dysphagia diet which would be cautiously
appropriate for Mrs. Noland is level one pureed diet with supervision due to moderate to
severe dysphagia with tongue deviation and fluctuation of consciousness. However, the
dysphagia affecting the esophageal transit phase and esophageal peristalsis occurs in the final
phase of swallowing following the oral and pharyngeal phases and may incur difficulty as a
mechanical obstruction caused by textured, unchewed foods.
A determination of dysphagia pureed diet level one is based on the many impairments of the
cranial nerves affecting the ability to eat, feed herself, muscle weakness, non-ambulatory
state, and masticatory compromise. Nerves which would affect the ability to eat include the
cranial glossopharyngeal nerve (IX) affecting the nerve function relating to swallowing, gag
reflex, and palatal, glossal, and oral sensation, and the cranial vagus nerve (X) affecting the
nerve function relating to cough reflex and taste upon the posterior 1/3 portion of the tongue.
The nerves which may impair the ability to eat following the occurrence of the lacunar
ischemic stroke as described within the neurologic exam are cranial vestibulocochlear nerve
(VII) which affects the nerve function relating to muscles used in facial expression, facial
pain, and taste upon the anterior 2/3 portion of the tongue, and cranial hypoglossal nerve
(XII) which affects the nerve function relating to tongue movement.
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Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th Ed) (pp 927, 929, Appendix 35). St. Louis, MO: Elsevier.
10. Describe a bedside swallowing assessment. What are the background and training
requirements of a speech-language pathologist?
The background and training requirements of a speech-language pathologists (SLPs) include
an undergraduate degree, commonly in communication sciences and disorders, as well as a
graduate master’s degree, completion of clinical experiences, or internship, and successfully
pass a national exam. Some occupational areas require a PhD or state licensing. SLPs are
trained to assess, evaluate, diagnose and treat and/or prevent disorders relating to swallowing
and communication which often accompany stroke, traumatic brain injury, loss of hearing,
cleft palate, and cerebral palsy. As relating to Mrs. Noland’s status, an SLP would help Mrs.
Noland to develop and strength muscles used within the swallowing phases, improve
communication methods, and counsel her husband.
A bedside swallowing assessment performed by an SLP is an evaluation which determines
observations, assessment, and function as a scientifically established and quantitative
baseline test from which diagnostic tests, feeding and communication methods and
adjustments, and possible cause of dysphagia may be determined. A bedside swallowing
assessment includes analysis of the patient’s medical history and current condition through
radiographs and chart notes, as well as an interview if communication skills permit, cranial
nerve exam, cough assessment, oral hygiene and dentition, laryngeal elevation, and test
swallowing trials.
The swallowing evaluation performed will aid in determination of National Dysphagia Diet
level and appropriate expectation of tolerated consistency relating to the patient’s abilities or
possible necessitation of assistive feeding approaches with use of tools and positioning or
alternative feeding methods so as a feeding tube. The swallowing evaluation initiates with an
trained individual, such as an SLP and sometimes RD, observing control and manipulation
during the oral phase of swallowing in conjunction with laryngeal elevation for protection of
the airway; at first the patient is observed swallowing salivary secretions, followed by small
amounts of varying liquid consistencies if deemed to cause no harm or aspiration. The
evaluation proceeds as an assessment of voice quality wetness to conclude no aspiration
occurred and muscle manipulations are intact. If aspiration, choking, gagging or coughing
following the liquid trial, the examination is discontinued. Depending on the conclusion
determined with the evaluation, further examinations and procedures may need to be
performed, such as physiological exam and endoscopy.
(2013). Careers in Speech-Language Pathology. In The American Speech-Language-Hearing
Association. Retrieved December 1, 2013, from
http://www.asha.org/careers/professions/slp.htm.
(December 6, 2010). Dysphagia. In Everything Speech. Retrieved December 1, 2013, from
http://www.everythingspeech.com/evaluation/dysphagia/.
(March 29, 2012). Occupational Outlook Handbook: Speech-Language Pathologist. In
United States Department of Labor. Retrieved December 1, 2013, from
http://www.bls.gov/ooh/Healthcare/Speech-language-pathologists.htm.
Leighton, C. (June 13, 2013). Clinical Bedside Swallowing Assessment. In University of
Iowa Health Care. Retrieved December 1, 2013, from
https://wiki.uiowa.edu/display/protocols/Clinical+Bedside+Swallowing+Assessment.
11. Describe a modified barium swallow or fiberoptic endoscopic evaluation of swallowing.
A modified barium swallow is a procedure used to evaluate the anatomy and physiology of
muscle contraction and relaxation, as well as airway protection and bolus manipulation via
dentition and mastication relating to the transition of food from the oral cavity and
proceeding into the successive swallowing phases, specifically relating to the pharynx. The
pharynx and esophagus are observe via radiographic imaging following the oral
administration of thick, milk-shake-like barium sulfate-water solution which appears as a
clearly visible highlight to observed proceeding through the phases of swallowing and used
to evaluate the functions of swallowing, necessary dietary modifications, and competency.
A fiberoptic endoscopic evaluation is a procedure utilized by the SLP to evaluate the
competency of function through the swallowing phases by examining the anatomy and
physiology or the pharynx and trachea through imaging via a fiberoptic endoscope inserted
via the nasal cavity to observe the larynx; a fluorescent dye solution may or may not be
orally administered for observation of transit through the phases of swallowing. The
evaluation is used in assessment of larynx protection or possibility of aspiration via spillage,
adduction during coughing and swallowing, and remaining residues following swallowing to
determine modifications applied to dietary modifications, position during feedings, and if
further diagnostics or examinations are necessary.
(January 1998). Practice Guidelines: Fiberoptic Endoscopic Examination of Swallowing (FEES)
Procedure. In Office of the Professions: Speech-Language Pathology & Audiology.
Retrieved December 1, 2013, from
http://www.op.nysed.gov/prof/slpa/speechguidefiberoptic.htm.
Barium Swallow. In Johns Hopkins Medicine: Health Library. Retrieved December 1, 2013,
from
http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/barium_swa
llow_92,P07688/.
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.
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Due to the high requirement of control and coordination in the swallowing of thinner
liquids, thickening of thinner liquids may increase the ease of the swallowing process for
dysphagia patients. As per the Krause textbook, all liquids may be thickened by addition
of nonfat dry milk powder, cornstarch, modular carbohydrate supplements, or
commercial thickeners. However, to maintain hydration status of the patient, the ratio of
thickened liquids may need to contain large portions of water.
A common starch-based thickening agent called Nutilis is a powdered form thickening
agent which does not change the flavor of the food items or liquids it is mixed with, as
well as amylase-resistance to retain consistency in mouth for readily formed bolus. This
thickening agent can also retain fluid consistency through effects of temperature as
freezing and/or reheating. The website does emphasize the importance of food
presentation and appearance.
General Information. In Nutricia Nutilis. Retrieved December 2, 2013, from
http://www.nutilis.com/au/home.html.
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th Ed) (pp 932). St. Louis, MO: Elsevier.
13. Mrs. Noland’s usual body weight is approximately 165 lbs. Calculate and interpret her BMI.
Calculations of patient’s BMI:
Usual body weight = 165 lbs
Height = 5 ft., 2 in. = 62 in.
BMI = [weight (lb) / height (in2)] x 703
BMI = [165 lb / (62 in2)] x 703
BMI = 30.2 % = obesity class I, grade II
According to appendix 19 of Krause’s Food and Nutrition Care Process, the body mass index
table places Mrs. Noland, at a height of 62 inches and weight of 165 pounds, at a BMI of
30%. A BMI greater than 29.9% is considered obese with a range of 30.0 to 34.9% classified
as grade II, class I obesity.
A normal healthy weight is between 18.5 and 24.9% BMI, however Mrs. Noland exceeds the
healthy BMI range. A BMI greater than 30% is classified as grade II, class I obesity which
increases the risk of negative health effects as is the case of this patient with a BMI of 30.1%,
or 30% according to the BMI table. However, according to body composition changes, the
table for body fat ranges for standard adults as a female between the ages of 60 to 79 years of
age, a BMI composition between 24 and 36% is considered healthy. Due to the actual
incidence of stroke experienced by the patient, we will consider the first analysis as obese
and account for the obesity due to aging accompanied by loss of muscle, strength and
function.
Calculations of patient’s UBW:
If Mrs. Noland’s current UBW of 165 pounds were a result of gaining greater than 11 kg, or
24.2 pounds, over 16 years, her risk of stroke would significantly increase and the
calculations of UBW could be interpreted as follows, whereby the current UBW would be
determined as actual body weight (ABW) and the weight prior to gain determined as UBW:
UBW prior to 24.2 pound gain over 16 years = 149 lbs
ABW (as current ABW from given UBW) = 165 lbs
% UBW = (ABW/UBW) x 100
% UBW = (165 lb / 149 lb) x 100
% UBW = 110.7 % = 10.7 % body weight gain
Therefore, a weight gain of 1.5 pounds per year over a period of 16 years will result in a
body weight gain of 10.7% and significantly increase the risk of stroke compounded with the
patient’s age of 77 years.
Charny, A. (2013, September). NCP: A – Assessment, Physical, Functional. FNES 365:
Nutrition Assessment and Counseling. Lecture conducted from CUNY Queens
College, Flushing, NY.
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th Ed) (pp 166). St. Louis, MO: Elsevier.
Fischer, V. (2013, November 19). The Biology of Aging - Nutrition in Older Adults. FNES
365: Nutrition Assessment and Counseling. Lecture conducted from CUNY Queens
College, Flushing, NY.
14. Estimate Mrs. Noland’s energy and protein requirements. Should weight loss or weight gain
be included in this estimation? What is your rationale?
Weight loss or gain should not be included in the estimation, but rather the goal should be
weight maintenance because Mrs. Noland has endured a traumatic experience as a
ischemic stroke resulting in hemiparesis, muscle and sensory deficits, and damage to
cranial nerves affecting her ability to eat as relating to dysphagia. The patient’s diet will
necessitate modification per the National Dysphagia Diet which may lead to decreased
dietary intake and malnutrition. Therefore, weight loss due to an obese classification of
BMI would be ill intended at this point and possibly cause harmful effects, such as the
release of toxins or components stored within adipose tissue.
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Mrs. Noland’s estimated energy requirement is 1188.38 kcal/d and her estimated protein
requirement is 82.5 g/day.
Calculations of Energy Requirements:
Step 1: Estimated Energy Requirements (EER) utilizing Mifflin-St. Jeor Equations for
healthy adult females:
Mifflin-St. Jeor Equation: kcal/day = 10 (wt) + 6.25 (ht) – 5 (age) – 161
Weight = actual body weight in kilograms
Height = centimeters
Age = years
Patient’s values:
Weight = 165 lbs / 2.2 kg = 75 kg
Height = 62 inches = 157.5 centimeters
Age = 77 years
Kcal/day = 10 (75 kg) + 6.25 (157.5 cm) – 5 (77) – 161
Kcal/day = 1188.38 (EER of Mifflin-St. Jeor)
Step 2: Factoring in a physical activity level (PAL) in the sedentary category at a value of
1.0, to account for the patient’s low energy requirements in retirement, grown children no
longer living at home, and possible non-ambulatory state:
Patient’s EER = (EER of Mifflin-St. Jeor Equation) x (1.0 PAL value)
Patient’s EER = 1188.38 kcal/day x 1.0 PAL = 1188.38 kcal/day
Calculations of Estimated Protein Requirements:
Per “The Biology of Aging” lecture, adequate protein of 1.0 to 1.2 g/kg are required to
prevent loss of muscle mass, pressure ulcers or bed sores, and prevent immune compromise.
Protein requirement = 1.1 g protein/kg body weight
Patient’s UBW = 75 kg
Estimated protein requirement = (1.1 g/kg x 75 kg) = 82.5 g protein/day
Estimating Protein Requirements as Kilocalorie Intake:
82.5 g protein/day x 4 kcal/g protein = 330 kilocalorie of protein from daily energy intake
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th Ed) (pp 24-29). St. Louis, MO: Elsevier.
Fischer, V. (2013, November 19). The Biology of Aging - Nutrition in Older Adults. FNES
365: Nutrition Assessment and Counseling. Lecture conducted from CUNY Queens
College, Flushing, NY.
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.
Mrs. Noland’s 24-Hour Recall
Meal
Food / Beverage
Item
Quantity
Kilocalorie
Breakfast
Orange juice
1 cup
122
Raisin bran
1 cup
196
2% Milk
¾ cup
91
Banana
1 medium
105
Coffee with 2%
milk & sweetener
1 cup
36
Chicken
tortellini
soup
Cheese
tortellini
1 cup
354
Chicken
broth
1 cup
12
Saltine crackers
8 crackers
101
Canned pears
2 halves
71
Iced tea with
sweetener
¾ cup
6
Baked chicken
breast with skin
5 oz
276
Baked potato
1 medium
159
Steamed broccoli
1 cup
64
Lunch
Dinner
14
23-15
Margarine
7 tsp
235
Canned peaches in
juice
7 slices
49
Iced tea with
sweetener
¾ cup
6
Total kcal
1884
Dietary Reference Intakes as Ranges from Energy for Elder Adults
Macronutrient
Fat
Carbohydrate
Protein
Macronutrient Ranges
Dietary Reference Intake Ranges from
Energy
20 – 35 %
45 – 65 %
10 – 35 %
Distribution of Calories among Macronutrients
Calculations:
Part 1:
Total Amount Macronutrient Intake (g) x Calories per Gram of Macronutrient = Total Calories
from Macronutrient
Part 2:
(Total Calories from Macronutrient / Total Calorie Intake per Day) x 100 = Percent of Total
Calories from Macronutrient
Macro-nutrient
Fat
Carbohydrate
Protein
Total
Amount
Macronutrient
Intake
57 g
273 g
87 g
X
X
X
X
Macronutrient
Calories per
Gram
9 Cal / g
4 Cal / g
4 Cal / g
=
=
=
=
Total
Calories
from
Macronutrient
509 Cal
1092 Cal
348 Cal
/
/
/
/
Total
Caloric
Intake
Day 1
1884 Cal
1884 Cal
1884 Cal
=
=
=
=
% of
Total
Calories
from
Macronutrient
27 %
58 %
18 %
(2005). Dietary Reference Intakes: Macronutrients. In Institute of Medicine of the National
Academies.
Retrieved
December
1,
2013,
from
http://www.iom.edu/Global/News%20Announcements/~/media/C5CD2DD78405449
79A549EC47E56A02B.ashx.
Fischer, V. (2013, November 19). The Biology of Aging - Nutrition in Older Adults. FNES
365: Nutrition Assessment and Counseling. Lecture conducted from CUNY Queens
College, Flushing, NY.
SuperTracker. In United States Department of Agriculture. Retrieved December 1, 2013,
from https://www.supertracker.usda.gov.
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?
Nutrient Recommendations for Female >70 yoa
Nutrient
Healthy Dietary
Guidelines
DASH Goals
for
Hypertension
TLC Diet for
Hyperlipidemia
20 – 35%
27%
25-35%
Saturated Fat
< 10%
6%
< 7%
Carbohydrate
45 – 65%
55%
50-60%
Protein
10 – 35%
18%
~15%
21 g
30 g
Add 5-10 g
< 1.2 g
< 1.5 g
--------
Fat
Fiber
Sodium
or < 2.3 g
Potassium
4.7 g
4.7 g
--------
Calcium
1200 mg
1250 mg
--------
Cholesterol
< 300 mg
150 mg
< 200 mg
Trans-fatty acids
As low as possible
--------
0 or low as possible
Polyunsaturated
Fatty Acid
Within total fat allowance
--------
< 10%
Monounsaturated
Fatty Acid
Within total fat allowance
--------
< 20%
*Bold text is emphasized components per diet
16
23-17
Food Groups for 2000 kcal/d Diet
Food Group
Healthy Dietary
Guideline
DASH Guidelines
TLC Guidelines
Grains
6 ounces
7-8 servings/day
6 or more servings
Vegetables
2 ½ cups
4-5 servings/day
3-5 servings
Fruits
2 cups
4-5 servings/day
2-4 servings
Dairy
3 cups
2-3 servings/day
2-3 servings
Meat, poultry, fish
5 ½ ounces
(protein)
6 or less
servings/day
5 or less ounces
Nuts, seeds,
legumes
Not determined
4-5 servings/week
Moderation
Fats & Oils
6 teaspoons
2-3 servings/day
Depends on calorie
level
Sweets & added
sugars
Limit
5 or less/week
Reduce
A “healthy diet” as dietary guidelines issued by the USDA to reduce the risk of disease
and maintain or promote healthy lifestyle emphasizes intake of fruits, vegetables, grains
from whole grain sources, and reduced fat or fat-free dairy products while maintaining
adequate consumption of varied protein as lean sources of meat, poultry, fish, nuts and
eggs while reducing intake of simple or added sugar, sodium, cholesterol, saturated and
trans fat content. It is also recommended to participate in physical activity and exercise in
conjunction with healthy diet choices.
The Dietary Approaches to Stop Hypertension (DASH) diet to reduce hypertension
emphasizes intake as low saturated fat, cholesterol and total fat content while
recommending intake of fruits, vegetables, reduced or fat-free milk and dairy products
while including nutrient density of potassium, magnesium, calcium, protein and fiber.
Individuals which are classified as obese and have an actual body weight greater than
115% of ideal body weight should utilize a hypocaloric diet and increased physical
activity level to reduce blood pressure.
The Therapeutic Lifestyle Changes (TLC) diet to reduce cholesterol and lipid levels
emphasizes intake as a reduction in saturated fatty acid, trans fatty acids, and cholesterol
while increasing soluble fiber and adding plant stanols and sterols to the diet. The TLC
diet recommends a higher intake of fat as 30 to 35% of energy intake, but stresses a
modification in the sources of fat as low consumption of saturated and trans fats but
increased consumption of polyunsaturated and monounsaturated fatty acids to lower
triglycerides and LDL cholesterol while increasing HDL cholesterol. The TLC diet works
in combination with lifestyle changes of physical activity and weight management.
Some of these dietary recommendations should apply to Mrs. Noland during this acute
period following her stroke; however her current orders denote an NPO to dietary intake
and the treatment of a stroke focuses upon prevention of stroke occurrence. When the
NPO order is discontinued, the medical nutrition therapy should follow treatment of a
neurotrauma like that of a traumatic brain injury because her metabolism will respond as
a state of inflammation with hypercatabolism or hypermetabolism. Hypercatabolism will
affect the patient as an increases resting energy expenditure requiring increased caloric
intake as 100% to a 40% increase of current estimated energy requirement as well as
increased needs of protein due to rapid degradation accounted for as 1.0 to 1.2 g/kg
required to prevent loss of muscle mass, pressure ulcers or bed sores, and prevent
immune compromise. However, treatment of the patient’s hyperlipidemia and
hypertension must be considered as sodium restriction, potassium and calcium content
per the DASH diet and cholesterol and fatty acid content per the TLC diet. Compounding
the modifications applied to reduce hyperlipidemia, hypertension, and hypermetabolism;
Mrs. Noland is also faced with the difficulties of dysphagia and should follow the
National Dysphagia Diet at level one pureed diet, until tolerance of texture and solids is
established.
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th Ed) (pp 753, 766, Appendix 33). St. Louis, MO: Elsevier.
U.S. Department of Health and Human Services. (April 2006). Your Guide to Lowering
Your Blood Pressure with DASH: DASH Eating Plan. In National Heart, Lung, and
Blood Institute. Retrieved December 1, 2013, from
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf.
U.S. Department of Health and Human Services. (December 2005). Your Guide to Lowering
Your Cholesterol with TLC: TLC Eating Plan. In National Heart, Lung, and Blood
Institute. Retrieved December 1, 2013, from
http://www.nhlbi.nih.gov/health/public/heart/chol/chol_tlc.pdf
United States Department of Agriculture. (undefined). Dietary Guidelines. In
ChooseMyPlate.gov. Retrieved December 1, 2013, from
http://www.choosemyplate.gov/dietary-guidelines.html.
(17.) Estimate Mrs. Noland’s fluid needs using the following methods: weight; age and
weight; and energy needs. (not covered in class – this is not a question)
Weight: 100 mL per kg body weight for 1st 10 kg
50 mL per kg body weight for next 10 kg
20 mL per kg body weight for each kg above 20 kg
1000 + 500 + 1100 = 2600 mL fluid
Age & weight: 55-75 years: 30 mL per kg body weight per day
30 x 41 = 1230 mL
Energy needs: 1 mL per kcal = 1400 x 1 = 1400 mL
18
23-19
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.
Lipoprotein
Profile
Cholesterol
(mg/dL)
Abnormal Normal Limits
Lab Values
(Female)
210; above 120-199
NL
HDLcholesterol
(mg/dL)
40; below
NL
>55
LDL
(mg/dL)
155; above
NL
<130
LDL/HDL
3.875;
ratio
above NL
Triglycerides 198; above
(mg/dL)
NL
*NL; normal limit
<3.22
35-135
Desirable
Cholesterol Classifications
Lipid Profile
& Clinical Significance
<200
 <200; desirable
 200-239; borderline high
 >240; high
>40
 <40; significant clinical
risk factor (cardiac)
 >60; some protection against
risk (cardiac)
<130 (<100  <100; optimal
for high risk  100-129; near/ above
person)
optimal
 130-159; borderline high
 160-189; high
 >190; very high
<150
Lipid indices as the lipoprotein profile measure blood levels of total cholesterol, LDL, HDL,
and triglycerides as milligrams of cholesterol per deciliter, all of which can be identified as
abnormal, as well as the LDL/HDL ratio. The lipid profile may be used to assess and indicate
cardiovascular and ischemic vascular risk, such as atherosclerosis, hyperlipidemia, and
stroke. Atherogenic indicators include an elevation in blood levels of LDL and triglycerides.
Hyperlipidemia is an increased state of lipids within the blood which may be classified as
dyslipidemia if the lipid profile indicates elevated blood levels of total cholesterol or LDL
cholesterol, or low blood levels of HDL cholesterol. The clinically significant risk of
dyslipidemia, as well as hyperlipidemia, relating to abnormal values of the lipid indices is an
increased possibility of ischemic arterovascular occurrence such as stroke, atherosclerosis,
myocardial or ischemic infarct and angina; Mrs. Noland’s clinical risk is further aggravated
in conjunction with hypertension.
Cholesterol is a sterol, fat-like substance which can be synthesized by the liver or taken in
from dietary sources, commonly animal-fats, found in cell membranes of the blood and
nerves throughout the body, is used as a precursor to hormones, vitamin D, bile acids, and
wall reparation of blood vessels. Cholesterol travels in the bloodstream packaged within the
lipoproteins low-density lipoprotein (LDL) and high-density lipoprotein (HDL). The plasma
lipid LDL, bound to albumin, carries most of the cholesterol along with some triglycerides,
produced by the liver, to tissues such as arteries; high levels of LDL as a result of high
dietary fat intake can cause atherosclerosis, coronary artery disease, and heart disease. The
plasma lipid HDL, bound to albumin, contains larger portions of protein along with some
triglycerides than LDL and takes the cholesterol brought to tissues by LDL from the tissue
for transport to the liver. Thus high levels of HDL are clinically advantageous and decrease
the risk of atherosclerosis, ischemic vascular disease, heart disease and myocardial infarction,
whereas high levels of LDL may cause opposing clinically detrimental effects. If cholesterol
levels in the blood are too high, as with high LDL and low HDL, excess cholesterol builds
upon the arterial wall creating plaques narrowing the blood vessels and increasing vessel
rigidity which may lead to arterial obstruction and ischemic effects. Plaques may also rupture
or burst resulting in a blood clot formation upon the plaque site creating an occlusion within
the artery blocking oxygen-supplying blood.
The etiology of nutritional implications is that the patient is consuming poor dietary choices
high in unhealthy fat content in conjunction with a sedentary lifestyle. High triglycerides are
caused by high dietary content of carbohydrates, as well as simple and added sugars.
Abnormal values of lipoproteins, as high LDL and low HDL, are caused by high dietary
content of fats, saturated fats, and cholesterol. To normalize the lipoprotein levels, dietary
modifications should include a restriction of fat intake, healthy sources of the food groups,
and increased physical activity or exercise. To normalize cholesterol, nutritional adjustments
should include decrease intake of fat, especially from animal sources, and increase fiber
consumption. Triglycerides may be corrected by consuming healthier choices of
carbohydrates and limiting simple sugar intake. All lipid indices will benefit from increased
physical activity and exercise.
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th Ed) (pp 202, 743). St. Louis, MO: Elsevier.
Fodor, G. (2011, May) Primary Prevention of CVD: Treating Dyslipidemia. The American
Academy of Family Physicians, 83 (10), 1207-1208. Retrieved from
http://www.aafp.org/afp/2011/0515/p1207.html
U.S. Department of Health and Human Services. (December 2005). Your Guide to Lowering
Your Cholesterol with TLC: TLC Eating Plan. In National Heart, Lung, and Blood
Institute. Retrieved December 1, 2013, from
http://www.nhlbi.nih.gov/health/public/heart/chol/chol_tlc.pdf
Venes, D. (2005). Taber’s Cyclopedic Medical Dictionary (21st Ed)(pp 441, 1117, 1350).
Philadelphia, PA: F.A. Davis Company.
20. Select two nutrition problems and complete the PES statement for each.
Excessive fat intake related to hyperlipidemia and excessive dietary fat content and poor
fat sources as evidenced by dyslipidemia in abnormal lipoprotein profile, obese body
mass index, usual body weight exceeding desirable body weight, and excessive energy
and fat intake. (NI – 5.6.2.)
20
23-21
Swallowing and masticatory difficulty related to dysphagia with tongue deviation as
evidenced by paresis of right facial side, slurred speech and/or aphasia, damage to cranial
nerves III, V, VII, and XII, and dysphagia centered in the esophageal transit phase with
reduced esophageal peristalsis. (NI – 1.1 & NI – 1.2)
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th Ed) (Appendix 6). St. Louis, MO: Elsevier.
21. For each of the PES statements that you have written, establish an ideal goal (based on the
signs and symptoms) and an appropriate intervention (based on the etiology).
PES statement:
Excessive fat intake related to hyperlipidemia and excessive dietary fat content and poor
fat sources as evidenced by dyslipidemia in abnormal lipoprotein profile, obese body
mass index, usual body weight exceeding desirable body weight, and excessive energy
and fat intake. (NI – 5.6.2.)
Goal: Maintain current body weight and nutrition at estimated energy requirements due to
recent ischemic stroke causing hypermetabolism and hospitalization, however restore
lipoprotein profile to normal limits via reduced fat intake and healthier choices of dietary
fat sources.
Nutrition Intervention:

















ND – 1.1: General healthful diet
ND – 1.2: Modify distribution, type or amount of food & nutrients within meals or at
specified time
ND – 1.3: Specific food groups; fat, sodium, potassium, calcium, fiber containing sources
ND – 3.2.1: Multivitamin/mineral supplementation
ND – 3.3.1: Plant sterol and stanol esters
E – 1.1: Purpose of the nutrition education
E – 1.2: Priority modification
E – 1.4: Nutrition relationship to health/disease
E – 1.5: Recommended modifications; fat content and sources of intake
E – 2.1: Result interpretation
C – 2.1: Motivational interviewing
C – 2.2: Goal setting
C – 2.3: Self-monitoring
C – 2.4: Problem solving
C – 2.5 Social support
C – 2.5: Stress management
C – 2.9: Relapse prevention
PES statement:
Swallowing and masticatory difficulty related to dysphagia with tongue deviation as
evidenced by paresis of right facial side, slurred speech and/or aphasia, damage to cranial
nerves III, V, VII, and XII, and dysphagia centered in the esophageal transit phase with
reduced esophageal peristalsis. (NI – 1.1 & NI – 1.2)
Goal: Prevent malnutrition and anorexia while maintaining current body weight and
nutrition at estimated energy requirements through nutritional education and application
of the National Dysphagia Diet guidelines at tolerated diet level determined by speechlanguage pathologist to prevent aspiration and/or choking, as well as education as to
feeding posture and food positioning, assistive feeding tools and meal preparation,
supervision at meal consumption, consistent and correct use of vitamin supplementation
and smaller more frequent meals with enticing detail such as aroma, temperature,
garnishing, seasoning, color, plating, molding, and slurries.
Nutrition Intervention:
























ND – 1.1: General healthful diet
ND – 1.2: Modify distribution, type or amount of food & nutrients within meals or at
specified time
ND – 1.3: Specific food groups; fat, sodium, potassium, calcium, fiber containing sources
ND – 3.2.1: Multivitamin/mineral supplementation
ND – 3.2.4: Mineral calcium supplement
ND – 4.1: Adaptive equipment
ND – 4.2: Feeding position
ND – 4.3: Meal set-up
ND – 4.4: Mouth care
ND – 4.5: National Dysphagia Diet guidelines
ND – 5.2: Odors
E – 1.1: Purpose of the nutrition education
E – 1.2: Priority modification
E – 1.4: Nutrition relationship to health/disease
E – 1.5: Recommended modifications
E – 2.1: Result interpretation
E – 2.2: Skill development
C – 2.1: Motivational interviewing
C – 2.2: Goal setting
C – 2.3: Self-monitoring
C – 2.4: Problem solving
C – 2.5 Social support
C – 2.5: Stress management
C – 2.9: Relapse prevention
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th Ed) (Appendix 7). St. Louis, MO: Elsevier.
22
23-23
Fischer, V. (2013, November 19). Nutrition in Older Adults. FNES 365: Nutrition
Assessment and Counseling. Lecture conducted from CUNY Queens College,
Flushing, NY
23. Using Mrs. Noland’s 24-hour recall, make suggestions for consistency changes or food
substitutions (if needed) to Mrs. Noland and her family.
Orange juice: no pulp, homogenous liquid, addition of thickening agent to spoon-thick
consistency
Raisin bran: smooth homogenous cooked cereal, farina
2% milk: addition of thickening agent to spoon-thick consistency
Banana: well mashed or pureed
Coffee: addition of thickening agent to spoon-like consistency, replace coffee with
healthier choice such as fruit or vegetable juice
Sweetener: remove from diet
Chicken tortellini soup: replace with low sodium broth and pureed vegetable, such as
tomato, to a thick consistency
Saltine crackers: remove due to sodium, replace with pregelled slurried bread
Canned pears: avoid canned fruits, and fruits with seeds, pulp or chunks, puree pears to
thick consistency, possibly with addition of thickening agent
Iced tea: replace with healthier choice such as fruit or vegetable juice, and addition of
thickening agent to spoon-thick consistency
Baked chicken: avoid whole or ground meats, fish and poultry; puree chicken to thick
homogenous liquid, addition of seasoning to entice
Baked potato: mash potato, possibly replace with sweet potato for color and nutrient
density with addition of seasoning like cinnamon (if tolerated) to exclude margarine
Steamed broccoli: may be too fibrous if pureed, substitute a vegetable such as pureed
peas with vegetable juice
Margarine: remove due to high fat and sodium content; replace with seasoning
Canned peaches: puree, may need addition of thickening agent to spoon-like consistency
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th Ed) (Appendix 35). St. Louis, MO: Elsevier.
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’s potential nutritional problems upon discharge include the nutritional
complications associated with hyperlipidemia and hypertension in which she was
diagnose previous to hospital admission, but she will also now face nutritional problems
associated with dysphagia secondary to damages incurred by ischemic stroke.
Mrs. Noland is faced with many dietary modification as sodium restricted and increased
content of potassium and calcium per the DASH diet to reduce hypertension, as well as
reduction in fat content as cholesterol and fatty acids per the TLC diet to reduce
hyperlipidemia, compounded with hypermetabolism following the occurrence of stroke
required higher protein intake to prevent muscle wasting and pressure ulcers in a nonambulatory state. Furthermore, she now must apply these modifications in application of
the National Dysphagia Diet as a result of dysphagia with tongue deviation which
implicates a cautious dysphagia diet at level pureed until it is established that she can
tolerate more textures and solid food items.
Due to Mrs. Noland’s hemiparesis, facial paralysis, weakened muscle status, sensory
deficits and dysphagia with tongue deviation, she may face problems such as limited
mobility to prepare meals and self-feeding, may require proper feeding tools and
assistance, as well as small frequent and enticing meals to avoid malnutrition and
anorexia, as well as proper posturing for feeding as sitting upright with her chin down
and avoiding distractions to focus upon the task of swallowing, and positioning of food in
her mouth.
Mr. Noland will need to be educated upon all possible problems described above; for an
elderly individual, the modifications, responsibilities and tasks, as well as medicating his
wife, may be overwhelming and a home-nurse may be warranted if financially possible.
Factors monitored to assess the health status relating to hypertension, hyperlipidemia, and
dysphagia will be achieved in the monitored factors of nutritional status of food sources,
energy intake, adaption to the dysphagia diet, maintenance of protein to prevent muscle
wasting and pressure ulcers, repeat biochemical indices including the lipoprotein profile
with the chemistry panel, ambulatory status and restoration of overall metabolic health.
Factors monitored to assess status are total energy, protein, sodium, and fat intake, meal
duration, refusal to eat, spitting food out, rumination, ability to build and utilize social
network, access to food and nutrition-related supplies, access to assistive eating devices,
access to assistive food preparation devices, physical ability to complete tasks for meal
preparation, physical ability to self-feed, ability to position self in relation to plate,
receives assistance with intake, ability to use adaptive eating devices, cognitive ability to
complete tasks for meal preparation, physical activity strength, duration and frequency,
nutrition quality of life responses, body weight, frame size, weight change, body mass
index, electrolyte profile of sodium, potassium, and calcium, possible albumin, PT, PTT
and glucose tolerance test, full lipid profile, resting metabolic rate, overall appearance in
body composition and ambulatory state, extremity, muscle and bone strength,
cardiovascular function, reduced blood pressure vitals, total energy estimated needs,
estimated needs of total fat and type, estimated protein, fiber, and fluids, estimated
minerals needs of calcium, potassium and sodium, and recommended body mass index.
24
23-25
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition
Care Process (13th Ed) (Appendix 5). St. Louis, MO: Elsevier.
A - Assessment
S - Subjective
Chief Complaint: Mr. Noland states his wife woke up this morning with everything pretty normal, but midmorning patient became
dizzy, then couldn’t talk or move one side of her body. Presented to ER with slurred speech, numbness on right side of face, &
weakness of right arm & leg.
UBW: 165#
Nutritional supplement: 500 mg PO Calcium TID
Weight change: gain / loss: NA due to dysarthria with tongue deviation
Vitamins / herbs: PO Multivitamin/mineral SID
Appetite: Prior to stroke: good; Current: NA
Food preparation: prepared at home by patient & spouse
Chewing / swallowing problem / sore mouth: Post-stroke: dysphagia,
possible sore throat following endoscopy
Factors affecting food intake: Post-stroke: dysphagia
centered in esophageal transit phase & reduced
esophageal peristalsis, dysarthria with tongue deviation
Nausea / vomiting / diarrhea / constipation: none
Social / cultural / religious / financial: Possible limited
social interaction; Protestant religion; Possible financial
restrictions, occupation: retired hairdresser
Food intolerance / allergies: none
Diet prior to admit: no special diet, normal, no added sodium
Other: Education: High school diploma
Language: English only
Ethnicity: European American
O - Objective
Current Diet Order: NPO upon admit; when NPO is D/C: assessment for National Dysphagia Diet level
Medical Diagnosis: Prior to admit: Myopia
Past Medical History: Sx: Hysterectomy 10 years ago
Upon admit: Lacunar ischemic stroke; Dysphagia centered in esophageal
HTN x 10 years, hyperlipidemia x 2 years
transit phase & reduced esophageal peristalsis
Nutrition Focused Physical Signs & Symptoms: Acute onset of right facial numbness with pale color and cool temperature, hemiplegia
& muscle weakness in right arm & right leg, decreased motor function & bilateral strength, sensory deficits, decreased right plantar
reflex, aphagia, dysarthria with tongue deviation & slurred speech, impaired cranial nerves: III, V, VII, & XII, abnormal lipoprotein
profile, hyperlipidemia, increased BP: 138/88 mmHg, HTN, BMI: 30.2%, UBW: 165#, poor dietary sources, high sodium & energy
intake, sedentary lifestyle
Age:
77 yoa
Gender: Male

Female 
% UBW:
NA due to dysarthria
Ht:
5’ 2”
Wt:
165#
Admit 
Current 
% wt :
NA due to dysarthria
DBW: 110# +/- 10%
(99# to 121#)
BMI:
30.2 %
% DBW:
150 %
Other:
Nutritionally Relevant Laboratory Data:
Hyperlipidemia: Lipoprotein profile: inc Cholesterol: 210 mg/dL, dec HDL-C: 40 mg/dL, inc LDL: 155 mg/dL,
inc LDL/HDL ratio: 3.875, inc Triglycerides: 198 mg/dL
Hypertension: inc BP: 138/88 mmHg, Sodium WNL: 141 mEq/L, Potassium WNL: 3.8 mEq/L, Calcium WNL: 9.2 mg/dL
Drug Nutrient Interaction: Caution of interaction with medications
Medications: Prior to admit: 25 mg PO Captopril BID, 20 mg PO Lovastatin SID
In hospital: single dose 67.5 mg rtPA IV, 650 mg PO Acetaminophen PRN q 4 to 6 hr, IVF: 0.9% NS @ 75 mL/hr, Other orders: no
heparin, warfarin, u aspirin for 24 hr
Estimated Energy Need:
Estimated Protein Need:
Estimated Fluid Need:
____1188.38___ kcal / day
Based on:
15.8 kcal/kg/d
Nutrition Diagnosis (D)
A - Assessment (A)
_____82.5_____ g/day
Based on:
1.1 g/kg/d
____1400____ ml / day
Based on:
18.7 mL/kg/d
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State no more than 2 priority Nutrition Diagnosis statements in PES Format. Use Nutrition Diagnosis Terminology sheet
ND Term (Problem) related to (Etiology) as evidenced by (Signs and Symptoms) :
1. Excessive fat intake related to hyperlipidemia and excessive dietary fat content and poor fat sources as evidenced by dyslipidemia in
abnormal lipoprotein profile, obese body mass index, usual body weight exceeding desirable body weight, and excessive energy
and fat intake. (NI – 5.6.2.)
2. Swallowing and masticatory difficulty related to dysphagia with tongue deviation as evidenced by paresis of right facial side, slurred
speech and/or aphasia, damage to cranial nerves III, V, VII, and XII, and dysphagia centered in the esophageal transit phase with
reduced esophageal peristalsis. (NI – 1.1 & NI – 1.2)
Nutrition Intervention (I)
P - Plan
List Nutrition Interventions. Use Nutrition Intervention Terminology sheet. (The intervention(s) must address the problems
(diagnoses).
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ND – 1.1: General healthful diet
ND – 1.2: Modify distribution, type or amount of food & nutrients within meals or at specified time
ND – 1.3: Specific food groups; fat, sodium, potassium, calcium, fiber containing sources
ND – 3.2.1: Multivitamin/mineral supplementation
ND – 3.2.4: Mineral calcium supplement
ND – 3.3.1: Plant sterol and stanol esters
ND – 4.1: Adaptive equipment
ND – 4.2: Feeding position
ND – 4.3: Meal set-up
ND – 4.4: Mouth care
ND – 4.5: National Dysphagia Diet guidelines
ND – 5.2: Odors
E – 1.1: Purpose of the nutrition education
E – 1.2: Priority modification
E – 1.4: Nutrition relationship to health/disease
E – 1.5: Recommended modifications
E – 2.1: Result interpretation
E – 2.2: Skill development
C – 2.1: Motivational interviewing
C – 2.2: Goal setting
C – 2.3: Self-monitoring
C – 2.4: Problem solving
C – 2.5 Social support
C – 2.5: Stress management
C – 2.9: Relapse prevention
Goal(s):

To maintain current weight while applying the National Dysphagia Diet guidelines within adequate nutrient and energy
parameters, reduce hypertension and hyperlipidemia via reduced sodium and fat intake, and increased potassium and calcium
intake from nutrient dense, nutrient rich sources to restore normal lipoprotein status, restore overall metabolic equilibrium for
optimal health, and improving nutritional status by increasing nutritional education pertaining to self-feeding methods and
National Dysphagia Diet guidelines.
Plan for Monitoring and Evaluation (M E)
List indicators for monitoring and evaluation. Use Nutrition Assessment and Monitoring & Evaluation sheets. (Upon follow-up, the
plan for monitoring would indicate if interventions are addressing the problems).
Factors monitored to assess the health status relating to hypertension, hyperlipidemia, and dysphagia will be achieved in the monitored
factors of nutritional status of food sources, energy intake, adaption to the dysphagia diet, maintenance of protein to prevent muscle
wasting and pressure ulcers, repeat biochemical indices including the lipoprotein profile with the chemistry panel, ambulatory status
and restoration of overall metabolic health. Factors monitored to assess status are total energy, protein, sodium, and fat intake, meal
duration, refusal to eat, spitting food out, rumination, ability to build and utilize social network, access to food and nutrition-related
supplies, access to assistive eating devices, access to assistive food preparation devices, physical ability to complete tasks for meal
preparation, physical ability to self-feed, ability to position self in relation to plate, receives assistance with intake, ability to use
adaptive eating devices, cognitive ability to complete tasks for meal preparation, physical activity strength, duration and frequency,
nutrition quality of life responses, body weight, frame size, weight change, body mass index, electrolyte profile of sodium, potassium,
and calcium, possible albumin, PT, PTT and glucose tolerance test, full lipid profile, resting metabolic rate, overall appearance in body
composition and ambulatory state, extremity, muscle and bone strength, cardiovascular function, reduced blood pressure vitals, total
energy estimated needs, estimated needs of total fat and type, estimated protein, fiber, and fluids, estimated minerals needs of calcium,
potassium and sodium, and recommended body mass index.
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Determine progress made by patient in food sources, fat content and type, sodium content, nutrient, protein, and calorie
intake outcomes and if goals are met by the following follow up labs and dietary corrections:
Nutritional lipoprotein panel
Total caloric intake: actual dietary calorie intake & supplements, weight maintenance until metabolic equilibrium restored,
anthropometric measurements, ambulatory status, application of the dysphagia diet
Evaluation: Anticipate nutrient and diet adjustments at home with modified diet, calorie, fat, protein, sodium, and sources of
dietary intake, along with regular use of multivitamin and calcium supplementation, as well as increased physical activity if
non/ambulatory state permits.
Kimberly Tierney
Signature:
12/3/2013
Date:
Mrs. Noland’s Nutrients Report
Your personal Calorie goal is 1188. Your plan amounts are based on meeting your nutrient needs.
Nutrients
Target
Average Eaten
Status
Total Calories
1188 Calories
1884 Calories
Over
Protein (g)***
46 g
87 g
OK
Protein (% Calories)***
10 - 35% Calories
18% Calories
OK
Carbohydrate (g)***
130 g
273 g
OK
Carbohydrate (% Calories)***
45 - 65% Calories
58% Calories
OK
Dietary Fiber
21 g
27 g
OK
Total Fat
20 - 35% Calories
27% Calories
OK
Saturated Fat
< 10% Calories
8% Calories
OK
Monounsaturated Fat
No Daily Target or
Limit
10% Calories
No Daily Target or
Limit
Polyunsaturated Fat
No Daily Target or
Limit
7% Calories
No Daily Target or
Limit
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23-29
Linoleic Acid (g)***
11 g
11 g
OK
Linoleic Acid (% Calories)***
5 - 10% Calories
5% Calories
OK
α-Linolenic Acid (g)***
1.1 g
2.3 g
OK
α-Linolenic Acid (% Calories)***
0.6 - 1.2% Calories
1.1% Calories
OK
Omega 3 - EPA
No Daily Target or
Limit
15 mg
No Daily Target or
Limit
Omega 3 - DHA
No Daily Target or
Limit
45 mg
No Daily Target or
Limit
Cholesterol
< 300 mg
185 mg
OK
Minerals
Target
Average Eaten
Status
Calcium
1200 mg
677 mg
Under
Potassium
4700 mg
4062 mg
Under
Sodium**
1500 mg
2692 mg
Over
Copper
900 µg
1195 µg
OK
Iron
8 mg
17 mg
OK
Magnesium
320 mg
347 mg
OK
Phosphorus
700 mg
1364 mg
OK
Selenium
55 µg
78 µg
OK
Zinc
8 mg
8 mg
OK
Vitamins
Target
Average Eaten
Status
Vitamin A
700 µg RAE
928 µg RAE
OK
Vitamin B6
1.5 mg
3.6 mg
OK
Vitamin B12
2.4 µg
5.2 µg
OK
Vitamin C
75 mg
251 mg
OK
Vitamin D
15 µg
4 µg
Under
Vitamin E
15 mg AT
10 mg AT
Under
Vitamin K
90 µg
302 µg
OK
Folate
400 µg DFE
767 µg DFE
OK
Thiamin
1.1 mg
1.7 mg
OK
Riboflavin
1.1 mg
2.7 mg
OK
Niacin
14 mg
38 mg
OK
Choline
425 mg
321 mg
Under
Information about dietary supplements.
** If you are African American, hypertensive, diabetic, or have chronic kidney disease, reduce your sodium to 1500 mg a day. In
addition, people who are age 51 and
older need to reduce sodium to 1500 mg a day. All others need to reduce sodium to less than 2300 mg a day.
*** Nutrients that appear twice (protein, carbohydrate, linoleic acid, and α-linolenic acid) have two separate
recommendations:
1) Amount eaten (in grams) compared to your minimum recommended intake.
2) Percent of Calories eaten from that nutrient compared to the recommended range.
You may see different messages in the status column for these 2 different recommendations.
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