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CASE STUDY #5
Case Study #5: Myocardial Infarction
Lynne Roller
KNH 411
September 4, 2013
CASE STUDY #5
I.
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Understanding the Disease and Pathophysiology
1. Myocardial Infarction- Mr. Klosterman had a myocardial infarction. This means
that one of his coronary arteries did not have proper blood flow due to a blockage,
and resulted in myocardial tissue death. Myocardial infarctions, or heart attacks,
usually occur from a build up of plaque on the inside of the artery wall. This
accumulation can rupture and blood flow will cease due to the formation of a clot in
the artery (Nelms 298).
2. Explain angioplasty and stent placement. What is the purpose of this medical
procedure? Mr. Klosterman was given an angioplasty procedure in order to restore
the flow of blood through his coronary artery. During this procedure, a thin tube is
guided through a blood vessel to reach the occluded artery. On the end of the tube is a
balloon that will inflate to push the plaque up against the artery walls. This pressure
will expand the artery and allow for more blood flow throughout. A stent placement
is inserted into the artery along with the balloon, and inflates to expand the wall. The
stent is a mesh tube that will remain in the artery to keep blood flowing
(Angioplasty).
3. What role does cardiac rehabilitation play in Mr. Klosterman’s return to normal
activities and in determining his future heart health? Cardiac rehab is very
important as Mr. Klosterman returns to normal activities. The rehab is designed to
improve one’s health after a heart attack or heart surgery. The patient is educated on
risk factors that can lead to heart disease and encouraged to adopt health lifestyle
changes (Cardiac).
CASE STUDY #5
II.
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Understanding the Nutrition Therapy
4. What risk factors indicated in his medical record can be addressed through
nutrition therapy? By looking at Mr. Klosterman’s laboratory results, we can see
that a few of his nutritional levels are not ideal. His LDL levels are too high and his
HDL levels are too low. These numbers show risk for Dyslipidemia, which is a
condition where LDL levels are elevated and HDL levels are low. Dyslipidemia is a
lipid profile that increases the risk of atherosclerotic development because the serum
LDL levels could initiate atherosclerotic plaque (300). It is also shown that Mr.
Klosterman’s cholesterol levels are too high. High cholesterol could lead to fatty
deposits in blood vessels, increasing his risk of another myocardial infarction or
stroke (Mayo).
5. What are the current recommendations for nutritional intake during a
hospitalization following a myocardial infarction? It was ordered that Mr.
Klosterman follow a NOP diet (nothing per Orem). This is a diet of clear liquid
intended to bring energy to the patient without excessive digestion needed. It is also
recommended for post-heart attack patients to increase their intake of nutrient dense
foods, and less sodium rich food items. A TLC, or Therapeutic Lifestyle Changes
Diet encourages 6 servings of whole grains, 3-5 servings of vegetables, 2-4 servings
of fruit, 2-3 servings of dairy, 2 or fewer eggs per week, 5oz of meat, and monitored
amounts of fats and oils per day. It is important to keep sodium levels <2400 mg/day,
and cholesterol <200 mg/day. Other important nutrients include less than 7% of total
kcal from saturated fat, up to 10% of total kcal from Polyunsaturated fat, and 20% of
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CASE STUDY #5
total kcal from Monounsaturated fat. It is also encouraged to receive 20-30 g/day of
fiber. Since poor nutrition is a risk factor for the development of Atherosclerosis, it is
important to monitor Mr. Klosterman’s nutritional intake closely post-heart attack
(Nelms 308).
III.
Nutrition Assessment
6. What is the healthy weight range for an individual of Mr. Klosterman’s
height?
By using the Hamwi Method, we can determine Mr. Klosterman’s healthy weight range.
106 lbs. for the first 5 ft of ht; add 6lbs for every inch over 5 ft.
106+ [6(10 in) ] = 166 lbs
Mr. Klosterman’s healthy weight is 166 lbs.
7. The patient is a Lutheran minister. He does get some exercise daily. He walks his dog
outside for about 15 minutes at a leisurely pace. Calculate his energy and protein
requirements.
By using the Mifflin-St. Jeor equation, we can calculate Mr. Klosterman’s energy needs.
Mifflin-St. Jeor equation: (Men)
10 X wt (kg) +6.25 X ht (cm) -5 X age (yrs) + 5
Weight: 185lbs=83.91 kg
Height: 5’10”= 177.8 cm
Age=61
Activity level= 1.4 low activity level aside from walking his dog.
10 (83.91kg) + 6.25 (177.8cm) -5 (61) +5 = 1650 kcal/day
Including total energy needs: 1652 X 1.4= 2310 kcal/day
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CASE STUDY #5
Protein Requirements
1.1 g protein/kg – this factor is used since Mr. Klosterman is healing.
83.91kgX1.1=92.3g protein/day= 92g protein/day
(Nelms 168).
9. Using Mr. Klosterman’s 24-hour recall, calculate the total number of calories he
consumed as well as the energy distribution of calories for protein, carbohydrate,
and fat using the exchange system.
NAME
AMOUNT
UNIT
CALS
Totals 2805
FAT(G) CARBS(G) PROT(G)
107.7
344.3
119.9
Bagel, with raisins, toasted
1
large
362
2
73
13
Cheese, cream, light or lite
1
tablespoon
35
3
1
2
Orange juice
1
cup
113
0
27
2
Coffee
1
mug (8 fl oz)
2
0
0
0
Vegetable beef soup, canned, undiluted
1
cup
158
4
20
11
Roast beef sandwich
1
sandwich
341
13
26
27
Lettuce, raw
1
cup, shredded or
chopped
8
0
2
0
Tomatoes, raw
1
medium slice (1/4"
thick)
4
0
1
0
Pickles
5
slice
4
0
1
0
Mayonnaise, regular
2
tablespoon
198
22
1
0
Apple, raw
1
small (2-1/2" dia)
(approx 4 per lb)
55
0
15
0
Milk, 2% fat
1
cup
122
5
11
8
Pork, fresh, loin, blade (chops or roasts),
6
oz
267
14
0
33
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CASE STUDY #5
NAME
AMOUNT
UNIT
CALS
FAT(G) CARBS(G) PROT(G)
White potato, baked, peel eaten
1
large (3" to 4-1/4" dia,
raw)
330
7
62
7
Margarine
2
tablespoon
150
17
0
0
Beans, string, green, raw
0.5
cup
17
0
4
1
Coleslaw, home-prepared
0.5
cup
47
2
7
1
Pie, apple, one crust
1
piece (1/8 of 9" dia)
363
14
59
3
Milk, 2% fat
1
cup
122
5
11
8
Pretzels
1
oz
108
1
23
3
bone-in, separable lean only, raw
CALORIE BALANCE Net Calories: 1226
2804 Calories Eaten
Carbohydrates:
344.3 g of carbohydrates were in Mr. Klosterman’s diet.
55% of his diet should ideally come from carbohydrates, and there are 4 kcal per gram
of carbohydrate. This allows us to determine his requirements.
(2804 X0.55) /4= 385 g/day
Fat:
107.7g of fat were consumed in Mr. Klosterman’s 24-hour recall diet.
30% of his diet should come from fats, and there are 9 kcal per gram of fat.
(2804g X 0.30) /9= 93 g/day
Protein:
119.9 g of protein were consumed in this 24-hour diet.
15% of his diet should come from protein, and there are 4 kcal per gram of protein.
(2804g X 0.15)/ 4= 105 g/day
CASE STUDY #5
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(Nelms 308)
9. Examine the chemistry results for Mr. Klosterman. Which labs are consistent with the
MI diagnosis? Explain. Why were the levels higher on day 2?
The laboratory results that were consisted with MR. Klosterman’s myocardial infarction include
his cholesterol levels along with his LDL and HDL levels.
A normal cholesterol level 120-199, however, his levels were an average of 225 mg/dL.
His LDL levels should be less than 130 mg/dL, but over 3 days, his levels averaged 150 mg/dL.
His HDL levels should be greater than 55 mg/dL, but his were 31.5 mg/dL. These numbers are
consistent for a patient that experienced a myocardial infarction. The high LDL levels, paired
with the low HDL levels can create plaque build up in the walls of arteries, which could cut off
blood flow throughout the heart (Nelms 313).
Another lab result that could also be linked to an MI, are his Triglyceride levels. With an
average of 140 mg/dL over 3 days, he is on the upper end of the ideal 40-160 mg/dL range. High
triglyceride levels can increase one’s risk for cardiovascular disease.
The last results that were not normal were his Troponin I and Troponin T levels. A
reference range for Troponin I is less that 0.2 ng/dL, but his results showed an average of 2.6
ng/dL between his two tests. Troponin T levels should be less than 0.03, where as his levels were
2.4 ng/dL.
On day 2, some of Mr. Klosterman’s levels were much higher than the other two days.
When cells die, certain enzymes are released into the blood, such as Aspartate Aminotransferase
(AST), Creatine Kinase (CPK), or Lactate Dehydrogenase. These enzymes are released at
different times, following the myocardial infarction, which is evident through his results, since
these enzymes did not accumulate until day 2 (Fausto 7).
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CASE STUDY #5
10. What is abnormal about his lipid profile? Indicate the abnormal values.
These are the values that are abnormal for Mr. Klosterman’s lipid profile.
Results
Cholesterol
HDL
LDL
Apo A
Apo B
Triglycerides
Reference Range
120-199 mg/dL
>45
<130
94-178
63-160
40-160
Patient Values
225
31.6 mg/dL
150 mg/dL
83 mg/dL
110 mg/dL
140 mg/dL
The highlighted values are abnormal according to the reference range, and the triglyceride levels
are on the upper end, close to being too high.
11. Mr. Klosterman was prescribed the following medications on discharge. What are the
food-medication interactions for this list of medications?
Medication
Lopressor 50 mg daily
Lisinopril 10 mg daily
Nitro-Bid 9.0 mg twice daily
NTG 0.4 mg sl prn chest pain
ASA 81 mg daily
Possible Food-Medication Interactions
Avoid alcohol. Mineral supplements such as
calcium may decrease the absorption of this
medication.
Avoid alcohol (lowers BP). Do not take in high
levels of potassium, because it may cause
hyperkalemia.
Avoid alcohol
No calcium supplementation.
Avoid alcohol
(Mayo Clinic)
12. You talk with Mr. Klosterman and his wife, a math teacher at the local high school.
They are friendly and seem cooperative. They are both anxious to learn what they can do
to prevent another heart attack. What questions will you ask them to assess how to best
help them?
Do you know how to read a food label?
CASE STUDY #5
Do you know which foods can help decrease cholesterol?
Do you know how to minimize saturated fat in your diet?
Are you willing to devote more time to exercising?
Are you willing to decrease your caloric intake, and try new foods?
13. What other issues might you consider to support successful lifestyle changes for Mr.
Klosterman? I would highly recommend Mr. Klosterman to stop smoking. By quitting this
harmful habit, one can reduce the risk of hypertension along with other forms of cardiovascular
disease (Nelms 297). I would also advise him to eat breakfast consistently in order to allow his
metabolism to start the day well, making it easier to digest foods throughout the remaining
meals.
14. From the information gathered within the assessment, list possible nutrition problems
using the correct diagnostic terms.
Inappropriate intake of fats- NI-5.6.3
Overweight- NC-3.3
Inadequate fiber intake- NI-5.8.5
Excessive energy intake- NI-1.5
(Nutrition).
IV. Nutrition Diagnosis
15. Select two of the identified nutrition problems and complete the PES statement for
each.

Excessive fat intake related to high consumption of processed meats and red meats as
evidence by 24-hour diet recall.
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CASE STUDY #5
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Overweight related to excessive energy intake as evidenced by BMI of 26.6, dietary
recall, and low activity level.
V. Nutrition Intervention
16. For each of the PES statements you have written, establish an ideal goal (based on the
signs and symptoms) and an appropriate intervention (based on etiology).
PES- Excessive fat intake related to high consumption of processed meats and red meats as
evidence by 24-hour diet recall.
Goal- Manage and maintain a healthy amount of fat in diet.
Intervention- Limit total fat to ~30% of daily calories. Limit saturated fat to 7%. Keep
cholesterol levels <200 mg/day
PES- Overweight related to excessive energy intake as evidenced by BMI of 26.6, dietary recall,
and low activity level.
Goal- lose 18.5 lbs to reach healthy body weight of 166 lbs within 6 months.
Intervention- guide Mr. Klosterman on the TLC diet and recommend lowering caloric
Intake to 2310 calories per day.
17. Mr. Klosterman and his wife ask about supplements. “My roommate here in the
hospital told me I should be taking fish oil pills.” What does the research say about omega3-fatty acid supplementation for this patient?
The American Heart Association does promote the consumption of omega-3-fatty acids in one’s
diet to help prevent heart disease. Eating two servings per week of fish can reduce the risk of
heart attack and stroke. Taking supplements to receive the same amount of omega-3-fatty acids
is allowed, however, it is important to not consume high doses, as this may increase the risk of
bleeding. It is important to look at the amount of EPA and DHA on the specific supplement to
CASE STUDY #5
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consume around 180mg of EPA and around 120mg of DHA, rather than determining the amount
by the capsule. It is not advised to take more than 3 grams daily of omega-3-fatty acids from
capsules, unless otherwise supervised (Omega).
VI. Nutrition Monitoring and Evaluation
18. What would you want to assess in three to four weeks when he and his wife return for
additional counseling?
I think it would be important to assess Mr. Klosterman’s weight to see if he has been able to lose
any excess weight. It would be useful to take another dietary recall in order to check his food
sources, making sure his fat levels are adequate, and his caloric intake is not too high. It would
also be wise to obtain new lab results to check his LDL, HDL, and cholesterol levels. I would
assess whether or not he had been exercising daily, and help brainstorm more ways that he could
continually increase his physical activity. Lastly, I would check to see if his habit of smoking has
ended, or at least decreased in amount.
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CASE STUDY #5
Works Cited
“Angioplasty.” Medicine Plus. http://www.nlm.nih.gov/medlineplus/angioplasty.html.
“Cardiac Rehabilitation.” Mayo clinic cardiac rehab.
http://www.mayoclinic.com/health/cardiac-rehabilitation/MY00771&gt.
Fausto, Nelson, M.D. “Cell Injury, Cell Death.” 2006.
Nelms, Marcia; Sucher, Kathryn; Lacey, Karen; Roth, Sara Long. Nutrition Therapy and
Pathophysiology. 2/e.
Nutrition Diagnostic Terminology. 2008.
http://chua2.fiu.edu/faculty/kalmand/HUN6248/ppp/Nutrition%20dx%20terms%20ADA%202008.pdf.
Omega-3-Fatty Acids. University of Maryland Medical System. June, 2013.
http://umm.edu/health/medical/altmed/supplement/omega3-fatty-acids.