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Corinne Smith
KNH 411 A
Case Study #5
I. Understanding the Disease and Pathophysiology
1. Mr. Klosterman had a myocardial infarction. Explain what happened to his heart.
Mr. Klosterman experienced a myocardial infarction (MI), or more commonly know as a heart
attack, due to ischemia of the heart tissue leading to myocardial cell death. The resulted blockage
of blood flow to the heart caused him severe precordial pain and radiating pain to his jaw and left
arm (Medline Plus 2014).
2. Mr. Klostermans chest pain resolved after two sublingual NTG at 3-minute intervals
and 2 mgm of IV morphine. In the cath lab he was found to have a totally occluded distal
right coronary artery and a 70% occlusion in the left circumflex coronary artery. The left
anterior descending was patent. Angioplasty of the distal right coronary artery resulted in
a patent infarct-related artery with near-normal flow. A stent was left in place to stabilize
the patient and limit infarct size. Left ventricular ejection fraction was normal at 42%, and
a posterobasilar scar was present with hypokinesis. Explain angioplasty and stent
placement. What is the purpose of this medical procedure?
Angioplasty is a procedure that opens narrowed or blocked blood vessels inside a coronary
artery, that supply blood to the heart. To open the vessels a small, metal mesh tube called a stent
is inserted and expands in the coronary artery to restore normal blood flow. This stent placement
also prevents the artery from closing up again in the future. The purpose of this medical
procedure is to remove blockage from the artery and restore normal blood flow and prevent
blockage from building up in the future (Medline Plus 2014).
3. Mr. Klosterman and his wife are concerned about the future of his heart health. What
role does cardiac rehabilitation play in his return to normal activities and in determining
his future heart health?
Cardiac rehabilitation is extremely necessary to return Mr. Klosterman to an active life and
prevent further heart problems. The supervised rehabilitation will include physical activity,

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education on living a heart healthy life, and counseling that will aid him in his recovery and
future. Mr. Klosterman will learn how to reduce his risk factors such as high blood cholesterol,
being overweight, smoking, and lack of physical activity (Medline Plus). He will learn how to
take his medications properly, how to eat a heart healthy diet, and how to exercise to keep his
heart healthy and strong. Taking part in cardiac rehabilitation and an active recovery is crucial in
preventing future heart complications and building a healthier life.
II. Understanding the Nutrition Therapy
4. What risk factors indicated in his medical record can be addressed through nutrition
therapy?
Mr. Klostermans medical history indicated that he has been smoking a pack a day for 40 years
and his BMI of 26.6 k/m^2 indicated he is mildly overweight.(Mayo Clinic 2014). These two
risk factors for a myocardial infarction can be addressed through nutrition therapy. The smoking
should cease right away and his BMI could be lowered to a healthier value near 18.5-24.9
K/M^2 (Nelms 256) with proper diet and exercise.
5. What are the current recommendations for nutritional intake during a hospitalization
following a myocardial infarction?
Right after surgery/during hospitalization, patients will be on a NPO diet (a traditional post-op
diet). This includes a liquid diet with no caffeine for the next 24 hours, progressing to soft foods
avoiding anything that may cause gas and eating small frequent meals throughout the day.
(Kate Willcots 2010).
For a heart healthy diet the AHA recommends
-

Grains: 6-8 servings per day (1/2 of those should be whole grains)
Vegetables: 3-5 servings per day
Fruits: 4-5 servings per day
Fat-free or low-fat dairy: 2-3 servings per day
Lean meat poultry, seafood: 3-6 oz per day (about the size of a deck of cards)
Fats and oils: 2-3 tbsp. per day (use unsaturated fats such as as olive oil or canola oil)
Nuts, seeds, legumes: 3-5 servings per week
Sweets, sugars: 5 or fewer servings per weeks (the fewer, the better)
Lowering sodium intake to 1,500 mg/day
Limiting saturated fat, trans fat, and cholesterol intake

In addition, the AHA also recommends eating 2 servings of fatty fish (such as salmon or lake

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trout) per week; holding sodium (salt, including salt already added to food) to 2,400 mg per day
or less; and limiting alcohol intake to one drink a day for women and two for men. (University of
Maryland Medical Center 2014).
III. Nutrition Assesment
6. What is the healthy weight range for an individual of Mr. Klostermans height?
Hamwi Method: 106 lbs for the first 5 ft of height; add 6 lbs for every inch over 5 ft
5 ft 10 inches
106+6(10)= 166 lbs (+/- 16.6)
A healthy weight for Mr. Klosterman would be 166 lbs.
Healthy weight range: 149.4-182.6
(+/- 10% for small or large body frame)
7. This 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.
Weight: 185 lbs or 185/(2.2)=83 kg
Height: 510 or 70in(2.54)=177.8 cm
Mifflin-St. Jeor (Nelms 253)
10 x (83 kg) + 6.25 x (177.8 cm) 5 x 61 + 5 = 1,631.25 kcal x 1.6=2,610 kcal
Based on his activity standing while working 40 hours a week and walking his dog, Mr.
Klostermans energy requirement is 2,610 kcal per day.
Protein Requirement
ADA recommends 0.8-1.0 grams protein per 1 kg body weight.
185lbs/ 2.2 kg=84 kg x 0.8g/kg = 67.3g protein84kg x 1.0g/kg= 84 g protein
Mr. Klosterman requires 67-84 g protein per day
(Nelms 66).
8. Using Mr. Klostermans 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.

Nutrients

Target

Average Eaten

Status

Total Calories

2610 Calories

2416 Calories

Over

Protein (g)***

56 g

119 g

OK

Protein (% Calories)***

10 - 35% Calories20% Calories

OK

Carbohydrate (g)***

130 g

OK

340 g

Carbohydrate (% Calories)*** 45 - 65% Calories56% Calories

OK

Dietary Fiber

30 g

23 g

Under

Total Sugars

No Daily Target
or Limit

117 g

No Daily Target
or Limit

Added Sugars

No Daily Target
or Limit

37 g

No Daily Target
or Limit

Total Fat

20 - 35% Calories25% Calories

OK

Saturated Fat

< 10% Calories

8% Calories

OK

Polyunsaturated Fat

No Daily Target
or Limit

5% Calories

No Daily Target
or Limit

Monounsaturated Fat

No Daily Target
or Limit

9% Calories

No Daily Target
or Limit

Linoleic Acid (g)***

14 g

13 g

Under

Linoleic Acid (% Calories)*** 5 - 10% Calories 5% Calories

OK

-Linolenic Acid (%
Calories)***

0.6 - 1.2%
Calories

0.5% Calories

Under

-Linolenic Acid (g)***

1.6 g

1.4 g

Under

Omega 3 - EPA

No Daily Target
or Limit

0 mg

No Daily Target
or Limit

Omega 3 - DHA

No Daily Target
or Limit

0 mg

No Daily Target
or Limit

Cholesterol

< 300 mg

216 mg

OK

Minerals

Target

Average Eaten

Status

Calcium

1000 mg

960 mg

Under

Potassium

4700 mg

4819 mg

OK

Sodium**

1500 mg

3858 mg

Over

Copper

900 g

1343 g

OK

Iron

8 mg

18 mg

OK

Magnesium

420 mg

348 mg

Under

Phosphorus

700 mg

1715 mg

OK

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Selenium

55 g

171 g

OK

Zinc

11 mg

15 mg

OK

Vitamins

Target

Average Eaten

Status

Vitamin A

900 g RAE

598 g RAE

Under

Vitamin B6

1.7 mg

2.9 mg

OK

Vitamin B12

2.4 g

5.2 g

OK

Vitamin C

90 mg

157 mg

OK

Vitamin D

15 g

7 g

Under

Vitamin E

15 mg AT

5 mg AT

Under

Vitamin K

120 g

105 g

Under

Folate

400 g DFE

707 g DFE

OK

Thiamin

1.2 mg

3.3 mg

OK

Riboflavin

1.3 mg

3.0 mg

OK

Niacin

16 mg

29 mg

OK

Choline

550 mg

450 mg

Under

Protein 119g (4 kcal/g)= 476 kcal from protein, 20% of daily calories
Carbohydrate 340 g (4kcal/g)= 1360 kcal from carbohydrates, 56% of daily calories
Fat = 25% of daily calories
(USDA Supertracker 2015)
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?
Chemistry

Ref. Range

12/1 1957

12/2 0630

Troponin I (ng/dL)
Troponin T (ng/dL)

<0.2
<0.03

2.4
2.1

2.8
2.7

Troponins I and T are proteins found in the blood that are released when the heart muscle has
been damaged. The more damage to the heart the greater amount of troponin will be in the blood.
Therefore, elevated levels, like in Mr. Klostermans blood chemistry, signal heart damage
resulting from a myocardial infarction. Mr. Klostermans troponin levels continued to increase on
the second day due to his angioplasty and stent placement. Troponin levels also increase during

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this medical procedure because of the stress put on the heart. Levels will continue to be elevated
for 1-2 weeks after a myocardial infarction and angioplasty. (Medline Plus 2014).
10. What is abnormal about his lipid profile? Indicate the abnormal values.
Chemistry
Cholesterol

Ref. Range
120-199

12/1 1957
235

12/2 0630
226

12/3 0645
214

(mg/dL)
HDL-C (mg/dL)
LDL (mg/dL)
LDL/HDL ratio
Apo A (mg/dL)

>45 M
<130
<3.55 M
94-178 M

30
160
5.3
72

32
150
4.7
80

33
141
4.3
98

His lipid profile shows that he in fact has high cholesterol even though he reported not having it.
As shown in the table above his cholesterol is well over the reference range. His HDL levels are
below the reference range and his LDL are well above. This resulted in an elevated LDL/HDL
ratio. Apo A, apolipoprotein A, is the major component of HDL and has a specific role in lipid
metabolism. Therefore, we see a low Apo A level compared to the reference range (HDLand
ApoAIStructurePrediction).
11. Mr. Klosterman was prescribed the following medications on discharge. What are the
foodmedication interactions for this list of medications?
Medication
Lopressor 50 mg daily

Possible Food- Medication Interactions

May cause dry mouth, constipation,
heartburn, vomiting, diarrhea may effect
diet intake, drinking alcohol can increase side
effects, should be taken with food or right

Lisinopril 10 mg daily

after a meal
May make you dizzy-limit alcohol beverages
Drink fluids to prevent dehydration
May increase potassium levels- avoid eating
high levels of potassium like bananas,

Nitro- Bid 9.0 mg twice daily

NTG 0.4 mg sl prn chest pain

oranges, leafy greens such as kale

None
Lifestyle changes such as dietary changes,

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exercise and stop smoking may help this drug
ASA 81 mg daily

work better
Take with food to avoid gastric irritation

(RxList 2015)
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 cook meals at home?

How many times to you eat out of this house?
What is your stress level?
Are you both willing to make changes?
What does a typical day of eating look like?
How much physical activity do you get daily?
How often do you grocery shop?

13. What other issues might you consider to support successful lifestyle changes for
Mr. Klosterman?
Quitting Smoking
Physical activity- specifically aerobic exercise
Alcohol intake
Diet change
Stress level- working 40 hours a week
14. From the information gathered within the assessment, list possible nutrition problems
using the correct diagnostic terms.
Excessive energy intake NI 1.3
Overweight NC 3.3.1
Excessive Mineral Intake; Sodium (7) NI 5.10.2
Inappropriate intake of fats (high saturated fat intake) NI 5.6.3
(eNCPT 2014)

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IV. Nutrition Diagnosis
15. Select two of the identified nutrition problems and complete the PES statement for
each.
1. Inappropriate intake of fats (high saturated fat intake) NI 5.6.3 related to regular
consumption of high fat foods as evidenced by diet history and high cholesterol level of
235 mg/dL and LDL levels of 160 mg/dL.
2. Excessive mineral intake; Sodium (7) NI 5.10.2 related to consumption of meals high in
sodium as evidenced by 24 recall diet history containing 3858 mg sodium.
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 the etiology).
1. Goal: Lower Cholesterol, increase HDL and decrease LDL
Intervention: TLC Diet Decrease intake of saturated fat, trans fat, and cholesterol,
increase physical activity; lower BMI by managing weight; higher HDL by eating heart
healthy fats such as olive oil, plant oils, and nut and seeds
Cook more at home
Give him the necessary materials to educate him on the TLC diet
2. Goal: Lower sodium intake
Intervention: Dont add salt to foods and stay away from canned, frozen and cured meats
Try to cook more at home with his wife
(Your Guide to Lowering your Cholesterol with TLC 2005).
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?
I would tell Mr. Klosterman that yes Omega-3 fatty acids are important to have in your diet,
research shows that taking a fish oil pill or omega-3 fatty acid supplements does not lower risk
for myocardial infarction, stroke, or cardiac death. I would suggest that Mr. Klosterman not take
a fish oil pill but try and incorporate omeg-3 fatty acids into his diet by eating fish like salmon
and tuna and eating nuts.

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(AssociationbetweenOmega3FattyAcidSupplementationandRiskofMajorCardiovascular
DiseaseEvents:ASystematicReviewandMetaanalysis2012)
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?
In three to four weeks I would want Mr. Klosterman to bring in a 3-day diet log. By assessing his
log I would want to find appropriate calorie, fat, sodium, and protein intake.
I will weigh him and check on any weight loss or gain.
His cholesterol should be re-tested and continue to be advised/educated on how to lower his
cholesterol and eat a heart healthy diet.
I would check in on his stress level and make sure that he is reducing it as much as possible.
Also, I would check in with the wife and see if she is giving him the support he need in recovery
and in prevention for the future.
Lastly, I would give him education materials on the TLC diet and set him up with the right tools
to help him quit smoking.

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