MNT in a
Patient with
Congestive
Heart Failure
E
l
Megan Smith
UMD Dietetic Intern
May 6, 2015
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Congestive Heart Failure
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Md Health
Most common
signs and
symptoms
Fatigue
Edema
Shortness of
breath
Chest
congestion
Congestive Heart Failure
Systolic Heart failure: Occurs when the heart cannot
pump, or eject, blood efficiently out of the heart.
Diastolic Heart Failure: Occurs when the heart
cannot properly fill with blood.
Pixshark
Congestive Heart Failure
Etiology most commonly includes:
• Coronary Artery Disease
• Myocardial Infarction
• Uncontrolled Hypertension
• Arrythmias, valve problems, drugs,and alcohol can
also contribute
Leading Predictors
• Coronary artery disease
• Poorly controlled blood pressure
• Elevated B natriuretic peptides
Congestive Heart Failure
Electrocardiogram
Test that checks for
problems with the
electrical activity of
the heart.
American Accreditation HealthCare Commission
Ejection Fraction
A test that determines
how well your heart
pumps with each beat.
Emory Health
Meet the Patient
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XX is a 59 year-old Caucasian male
Married with two daughters
Lives at home with wife
Employed as a physician by a local
Baltimore Hospital
Medical Considerations
Diagnosis: Acute left systolic heart failure with
aortic insufficiency. Broadly referred to as CHF.
Signs/Symptoms: Fatigue, loss of appetite, SOB
PMH: hypertension
Echocardiogram: Ejection Fraction was 20-25%
Nutrition Assessment
Food/Nutrient Related History
• Decreased appetite one month PTA
• Eating approx. 50% of meals PTA
• MD expressed basic understanding of nutrition
and wanted to maximize caloric intake prior to
surgery.
• MD is a physician so he understood his disease
state
• MD is on feet all day; in training for a marathon.
Nutrition Assessment
Anthropometric Measurements
• Height=168 cm Weight=194 lbs (88.2 kg) BMI=31
• UBW=210 lbs;16 pound wt loss, 7% weight change in
past month
Nutrition Assessment
Client History
• PMH: hypertension, dyslipidemia, hypercholesteremia
• No surgical history (hx)
• Employed as a physician as Chief of Orthopedics
• Denies family psychiatric hx, alcohol, and drug use
Nutrition Assessment
Nutrition Focused Physical Findings
• No edema present on admission
• Vital signs stable on admission
• Signs & Symptoms on admission: 3 weeks SOB,
orthopnea, upper back discomfort, fatigued, lower
energy levels during normal work activities, loss of
appetite, weight loss
Nutrition Assessment
Biochemical
BNP levels normal upon admission
BUN slightly elevated: 26 mg/dL on 12/11
XX Labs
were not nutritionally significant
throughout his stay in the hospital
Diagnosis
NI-1.2: Inadequate oral intake related to
decreased desire to consume sufficient
energy 2/2 to CHF symptoms of
shortness of breath and fatigue as
evidenced by patient report of poor po
intake (50% of meals) over last month.
NC-3.2: Unintended weight loss related
to decreased appetite 2/2 inadequate
oral intake caused by CHF symptoms
as evidenced by 15 pound weight loss
in past month (7% weight change).
Intervention
Nutrition Prescription
Energy Needs: 1870-2066 kcal (Mifflin St. Jeor)
Protein Needs: 65-78 grams (1-1.2 gram/kg)
Fluids: 1760-2200 mL
Intervention
Date
Diet
Average Intake
Nutrition
Supplements and
Intake
December 8th
Patient placed on a
cardiac diet upon
admission
25-50%
December 9th
Cardiac Diet
25-50%
December 10th
NPO at midnight for
impending surgery
-
December 11th
NPO
-
December 12th
CLD/FLD
50-75%
Ensure Clear TID
ordered, 1 consumed
December 13th
Cardiac diet
50-75%
Ensure Clear TID
ordered, 1 consumed
December 14th
Cardiac diet
25-50%
Ensure Clear TID
ordered, 2 consumed
December 15th
Cardiac diet
25-50%
Ensure Chocolate TID
ordered, 2 consumed
December 16th
Cardiac diet
40%
December 17th
Cardiac diet, patient
discharged today
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Ensure Chocolate TID
ordered, Patient
consumed one Ensure
before surgery
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Ensure Chocolate TID, 3
consumed
Magic Cup x 1/day,
consumed
-
Intervention
RC 1.3 Coordination with other providers: Recommend low sodium, cardiac Diet.
Goal: Implement once medically feasible after surgery.
ND-3.1 Medical food supplements: Initiate Ensure Chocolate TID once medically
feasible.
RC 1.3 Coordination with other providers: Recommend Ensure Chocolate TID.
Goal: Implement once advanced to Clear Liquid Diet after surgery.
RC 1.3 Collaboration with other providers: Patient will maintain current weight
throughout hospital stay.
E-1.1 Purpose of Nutrition Education: Prior to discharge educate patient and
patient family on importance of adhering to low sodium, cardiac diet after surgery
and discharge.
E-1.4 Nutrition relationship to health/disease: Prior to discharge help patient
recognize and understand importance of adherence to low sodium cardiac diet in
relation to his CHF
Monitor/Evaluate
FH 1.1.1.1 Energy Intake
FH-1.2.1 Fluid/beverage intake
FH 1.6.2 Sodium Intake
FH 4.1.1 Food and Nutrition Knowledge/Skill
FH 4.1.2 Diagnosis specific food and nutrition
knowledge
Nutrition Implications
• Severity of MD’s CHF was reflected in the medical
and nutritional therapy.
• Many CHF patients will require a fluid-modified diet
(ND-1.2.8)
• XX was not experiencing edema or
hypernatremia
• Dietary Approaches to Stop Hypertension (DASH)
• Implemented to help client make better choices
after surgery
• 2000 mg sodium/day
Nutrition Implications
• Self-monitoring (C-2.3)
• Reading nutrition labels
• Choosing salt-free additives
References
Academy of Nutrition and Dietetics. International Dietetics and Nutrition Terminology (IDNT) Reference Manual. Chicago, IL: American Dietetic Association;
2013;
Academy of Nutrition and Dietetics. Nutrition Care Manual®. http://www.nutritioncaremanual.org. Accessed several times from December 2014-February
2015. ϖ https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5803&lv2=8585&ncm_toc_id=8585&ncm_heading=Nutrition%20Care
Cotugna N, Wolpert S. Sodium Recommendations for Special Populations and the Resulting Implications. Journal of Community Health. 2011; 36: 874-882.
“Ejection Fraction picture” Emory Health http://www.emoryhealthsciblog.com
“Electrocardiogram” American Accreditation HealthCare commission-http://www.medicalwordmeanings.com/what-is-electrocardiogram-the-meaning-and-diagram/
Evidence Analysis Library. Academy of Nutrition and Dietetics Website. https://www.andeal.org. Accessed several times from December-February 2015.
https://www.andeal.org/topic.cfm?menu=5289&cat=2815
“Healthy heart vs. Congested Heart” MD Health http://www.md-health.com/Congestive-Heart-Failure.html
“Heart” El Corazon. http://www.efn.uncor.edu/departamentos/divbioeco/anatocom/Biologia/Los%20Sistemas/Circulatorio/Corazon.htm
Lavid CJ, Ventura HO. Analyzing the Weight of Evidence on the Obesity Paradox and Heart Failure—Is there a Limit to the Madness? Congestive Heart
Failure. 2013; 19:158-159.
Lennie TA, Moser DK, Biddle MJ, Walsh D. Nutrition Intervention to Decrease Symptoms in Patients with Advanced Heart Failure. Res Nurs Health. 2013;
36(2): 120-145.
Mahan LK. & S. Escott-Stump. 2012. 13th edition of Krause’s Food, Nutrition & Diet Therapy. W.B. Saunders Co.: New York.
Medical Reference Guide-Complementary and Alternative Medicine Guide. University of Maryland Medical Center. January 2012.
http://umm.edu/health/medical/altmed/condition/heart-failure Accessed April 2015.
Riegel B, Moser DK, Anker SD, Appel LJ. State of Science. Promoting Self-Care in Persons with Heart Failure-A Scientific Statement From the American
Heart Association.
“Systolic/Diastolic HF picture” http://pixshark.com/congestive-heart-failure-prevention.htm