Brooke Bryant

Case Study Number Five

September 3, 2015
KNH 411

Understanding the disease and the Pathophysiology

1. Mr. Klosterman had a myocardial infraction. Explain what happened to his heart.
A myocardial infraction is necrosis of the myocardial cells as a result of oxygen deprivation
(pg.293). Myocardial infractions can occur when plaque builds up on coronary arteries. This
triggers blood platelets and other substances to form a blood clot that blocks oxygen and blood
from flowing to the heart muscle (Medline, 2011). According to the American Heart Association
a well-balanced diet that focuses on limiting saturated fats, Trans fats and sodium, will decrease
the risk of heart related diseases. Saturated fats, Trans fats, and sodium all increase blood
pressure and plaque buildup which results in a myocardial infraction (American Heart
Association, 2015).
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 infract-related artery with near-normal
flow. A stent was left in place to stabilize the patient and limits infract size. Left
ventricle ejection fraction was normal at 42% and a postero basilar scar was present
with hypokinesis. Explain angioplasty and stent emplacement. What is the purpose
of the medical procedure?
Angioplasty is a surgical procedure used to unblock arteries that have been blocked by plaque.
According to Medline a doctor takes a thin tube through a blood vessel in the arm or groin up to
the involved site in the artery. The tube has a balloon on the end and when it is in place the
balloon is inflated and it pushes the plaque outward towards the artery wall (Medline, 2010). The

purpose of this medical procedure is to return oxygen and blood flow to normal by clearing a
pathway through the arteries. Then a stent is put into place against the artery wall to keep it from
narrowing again (Medline, 2010).
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?
The beginning of the rehabilitation involves nutrition intervention; the start of the diet
normally consists of clear liquids without caffeine because of pain, anxiety, fatigue, and
shortness of breath (pg.325). The cardiac rehabilitation helps the patient get back to
normal exercise patterns and helps show risk factors that might have caused the heart
problem or lead up to the development of the disease. According to the American Heart
Association cardiac rehabilitation helps educate, council, and reduce patients stress so
that they can reduce the risk of another myocardial infraction (American Heart
Association,2015).
II. Understanding the Nutrition Therapy
4. What risk factors indicated in his medical record can be addressed through
nutrition therapy.
One risk factor indicated on Mr. Klostermans medical record is that he is a chronic
smoker of one pack a day and has been smoking for forty years. Counseling him on how
smoking affects his heart and the amount of nutrients he absorbs can result in getting him
to quit smoking. Addressing that smoking causes heart disease by increasing blood
pressure and decrease of calcium absorption (Nutrition, 2011). Informing Mr. Klosterman
that Cigarette smokers are two to four more times likely to develop heart disease than

non-smokers and have double the risk of stroke. And to inform him that smoking
increases oxidative modification of LDL, which aids in the development of
atherosclerosis or plaque building up in the arteries (pg.311). The patient eats a very high
sodium diet so going through nutrition therapy it will be addressed that he stays on a low
sodium diet which consists of staying away from high processed foods like canned
vegetables, soup, and lunch meats. Too much Sodium intake increases blood pressure and
it should be minimized to 2300mg per day (pg.305). The amount of physical activity that
the patient was receiving per day was not enough to meet his needs. The patient takes his
dog on a 15 minute leisurely walk every day and then minimizes all physical activity for
the day. Nutrition therapy will encourage 30 minutes of physical activity per day because
this decreases blood pressure by 4-9mm Hg. Exercising will also help with weight
management and decreasing the amount of workload the heart has to do when performing
everyday tasks (pg. 306).
5. What are the current recommendations for nutritional intake during a
hospitalization following a myocardial infraction?
According to Nelms oral intake will be decreased during this time due to pain, anxiety, fatigue
and shortness of breath form surgery. Solid foods will not be given until the patient has went
through the transition state of going from clear liquids, dark liquids, puree, mechanical soft, and
then return to regular foods (pg.325). Caffeine is taken away and minimized to not cause anxiety
or increase blood pressure. Fluid restrictions of 2000 mL/day for serum sodium below 130
mEq/L. This keeps patients from retaining water around vital organs and to prevent volume
overload (pg.331).
III. Nutrition Assessment
6. What is the healthy weight range for an individual of Mr. Klostermans height?

Using these formulas that calculate the average, low end and high end for Mr. Klostermans
height and weight gives theses values.
Average: 10x84.1 (kg) +6.25x177.8 (cm)-5x61+5= 166lb
Low End: 166x.10=16.6

166-16.6=149.4lb

High End: 166+16.6=182.6lb

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.
10x84.1 (kg) +6.25x177.8 (cm)-5x61+5x1.6= 1,655x1.6=2,648
The amount of calories Mr. Klosterman is allowed to consume per day is 2,648 and this is based
off of the Mifflin- St. Jeor calculations. Mr. Klosterman is supposed to get 30% of protein from
his calories. 2,648x.30=794 calories are recommended to come from protein.
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.
Mr. Klosterman was over on the amount of saturated fat that he consumed on the day of his
myocardial infraction. This would of caused his blood pressure to rise and cause pressure
through his arteries. He had only received 17% of his calories from protein when he should be
getting between 20-30%. He received 55% of his energy needs from carbohydrates and his range
should be between 45%-65% so he was in the middle of his percentile goal. He received 29% of
his calories from fat and almost reached his goal but was under 5g in dietary fiber. Not reaching

his amount of fiber needs could of aided in the myocardial infraction. The charts below that were
created on super tracker show all of the nutrients the patient took in on his 24 hour recall.

Nutrient
s

Target Average Eaten

Status

Total Calories

2648 Calories

2455
Calories

OK

Protein (g)***

56 g

107 g

OK

10 - 35%
Calories

17%
Calories

OK

130 g

337 g

OK

45 - 65%
Calories

55%
Calories

OK

Dietary Fiber

30 g

25 g

Under

Total Sugars

No Daily Target
or Limit

141 g

No Daily Target or
Limit

Added Sugars

No Daily Target
or Limit

55 g

No Daily Target or
Limit

Total Fat

20 - 35%
Calories

29%
Calories

OK

Saturated Fat

< 10% Calories

10%
Calories

Over

Polyunsaturated Fat

No Daily Target
or Limit

6%
Calories

No Daily Target or
Limit

No Daily Target
or Limit

10%
Calories

No Daily Target or
Limit

14 g

14 g

OK

Protein (%
Calories)***
Carbohydrate (g)***
Carbohydrate (%
Calories)***

Monounsaturated
Fat
Linoleic Acid (g)***
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

1.3 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

231 mg

OK

Minerals

Target

Average
Eaten

Statu
s

Calcium

1000 mg

1077 mg

OK

Potassium

4700 mg

4936 mg

OK

Sodium**

1500 mg

4621 mg

Over

Copper

900 g

1427 g

OK

Iron

8 mg

16 mg

OK

Magnesium

420 mg

338 mg

Under

Phosphorus

700 mg

1656 mg

OK

Selenium

55 g

133 g

OK

Zinc

11 mg

13 mg

OK

Target

Average
Eaten

Statu
s

Vitamin A

900 g
RAE

688 g RAE

Under

Vitamin B6

1.7 mg

2.6 mg

OK

Vitamin B12

2.4 g

4.7 g

OK

Vitamin C

90 mg

179 mg

OK

Vitamin D

15 g

7 g

Under

Vitamin E

15 mg AT 4 mg AT

Under

Vitamin K

120 g

142 g

OK

Folate

400 g
DFE

579 g DFE

OK

Thiamin

1.2 mg

3.0 mg

OK

Riboflavin

1.3 mg

2.9 mg

OK

Niacin

16 mg

25 mg

OK

Choline

550 mg

441 mg

Under

Vitamins

Grains

9 ounce(s)

8 ounce(s)

Under

Whole Grains

4 ounce(s)

0 ounce(s)

Under

Refined Grains

4 ounce(s)

8 ounce(s)

Over

3 cup(s)

5 cup(s)

Over

Dark Green

2 cup(s)/week

0 cup(s)

Under

Red & Orange

7 cup(s)/week

cup(s)

Under

Beans & Peas

2 cup(s)/week

0 cup(s)

Under

Vegetables

Starchy

7 cup(s)/week

2 cup(s)

Under

Other

5 cup(s)/week

2 cup(s)

Under

2 cup(s)

2 cup(s)

Over

Whole Fruit

No Specific Target

1 cup(s)

No Specific Target

Fruit Juice

No Specific Target

1 cup(s)

No Specific Target

3 cup(s)

2 cup(s)

Under

Milk & Yogurt

No Specific Target

2 cup(s)

No Specific Target

Cheese

No Specific Target

0 cup(s)

No Specific Target

6 ounce(s)

7 ounce(s)

OK

Seafood

10 ounce(s)/week

0 ounce(s)

Under

Meat, Poultry & Eggs

No Specific Target

7 ounce(s)

No Specific Target

Nuts, Seeds & Soy

No Specific Target

0 ounce(s)

No Specific Target

8 teaspoon

2 teaspoon

Under

Fruits

Dairy

Protein Foods

Oils

*All charts were made on SuperTracker.com

9. Examine the chemistry results for Mr. Klosterman. Which labs are consistent with
the MI diagnosis? Why were they higher on day two?
Referencing the labs, Mr. Klostermans LDL/HDL was 1.75 higher than what a normal male of
his age LDL/HDL should be. Having a blood pressure that is above normal causes the heart to
have to pump harder and faster than normal and with any blocked arteries from plaque would
cause a myocardial infraction (pg.295). Klostermans rise in lymphocytes on day two is from his
immune system fighting any infection that may have entered during surgery and for the repairing
of tissue around where the surgery took place (Health guide, 2015). There are high elevations of
AST and ALT on the second day due to muscle damage and the body beginning repairs on the
damaged areas of the arteries and body after undergoing surgery (Medicine Net, 2014).
Mr.Klostermans cholesterol was 235 which is above the average that it is supposed to be.
Cholesterol is directly linked to plaque buildup in arteries and complications with myocardial
infractions (pg.319).

10. What is abnormal about his lipid profile? Indicate the abnormal levels.
What was abnormal about Mr. Klostermans lipid profile is that his LDL/HDL ratio was 1.75
higher than what the average males blood pressure should be. His LDL by itself was over by 30
and his HDL was under by 5. His cholesterol was much higher than where it should be. An
average males cholesterol should be between 120-199 and his cholesterol was 235 on his first
day.
11. Mr. Klosterman was prescribed the following medications on discharge. What are

the food-medication reactions for this medication list?

Lopressor 50mg daily: Alcohol, Take with Food same time of day, Multivitamins, May

alter lipid profiles, Lasix, Norvsac, Synthroid, and Aspirin

Lisinopril 10mg daily: Avoid high doses of potassium, Lasix, Aspirin, and Lantus.
Nitro-bid 9.0mg twice daily: Alcohol, Aspirin, Lisinopril, and Omeprazole.
NTG 0.4mg sl prn chest pains: May induce vomiting and nausea.
ASA 81mg daily: Upset stomach and vomiting.

All information for food and drug interactions was found on Drugs.Com
12. You talk with Mr. Klosterman and his wife, a math teacher at the local high school.
They are friendly and seem corporative. They both are 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?
Some of the questions that would be asked are what does a normal day/ week look like for the
Klostermans. This question would be asked to try and assess how much physical activity they
get in a day and how much time they have to prepare meals or if they eat out more than they eat
at their house. Another question is what does your typical breakfast, lunch and dinner look like.
This will inform me on what kind of foods the Klostermans like to eat and if there is any

alternative we can put in place of any unhealthy foods that they consume. Finding out what they
do for their jobs will show if they are more sedentary or if they get extra physical activity at their
jobs. Assessing what kind of beverages they consume each day and how much water they take in
per day will help with if they are not taking in enough they can consume more and lower their
blood pressure to help lower Mr. Klostermans risk of a heart attack (Cleveland Clinic, 2015).
13. What other issues might you consider to support successful lifestyle changes for Mr.
Klosterman?
According to Nelms adding more fiber to a diet can lower serum cholesterol and LDL levels
(pg.319). So adding more whole grains to a diet will help lower blood pressure and decrease the
chances of another myocardial infarction. Soluble fiber is thought to bind bile acids and increase
their excretion rather than allow bile to enter enterohepatic circulation (pg.319). Having Mr.
Klosterman get down to his proper BMI and start exercising moderately three to four times a
week will decrease his chances of having another myocardial infraction. Losing weight
especially around the mid-section will help take any strain off of the vital organs like the heart,
lungs etc. Working out regular helps to strengthen the heart so it does not have to work as hard
when at a resting state or when doing physical activity (pg.317). According to Nelms cutting out
fried foods that contain high saturated fat contents and Trans fatty acids will help decrease the
LDL cholesterol levels (pg317). Getting on a well-balanced diet that contains more fresh fruits,
vegetables and less processed fried foods will help Mr. Klosterman lower his risk for another
myocardial infraction.
14. From the information gathered within the assessment, list possible nutrition
problems using correct diagnostic terms.

The patient came in with a myocardial infraction due to blockage in the arteries caused from a
buildup of plaque from inadequate nutrition and hypertension. High amounts of monounsaturated
fat and Trans fatty acids caused a 70% blockage in the left circumflex coronary artery. Too much
intake of monounsaturated fat is related to cardiovascular disease. High intakes of saturated fat
thats more than 7% per day will cause an increase in LDL and lead to the onset of hypertension
(pg.317). High intakes of high fat protein have been related to the risk of hypertension and the
onset of myocardial infractions. The hypertension that Mr. Klosterman denies caused the
initiation of an atherosclerotic lesion causing a change in pressure which made plaque rupture
and cause an infraction in his arteries. This was due to lack of nutrition education and a
misunderstanding of what hypertension is and what it can cause.

IV. Nutrition Diagnosis

15. Select two of the identified nutrition problems and complete the PES statement for

each.
Patient denies hypertension. This is related to lack of nutrition education and education

on hypertension. As evidence by a high fat diet and elevated cholesterol levels.

Patient denies diabetes. This is related to lack of nutrition education about diabetes. As
evidence by elevated glucose levels and traces of ketones in urine.

V. Nutritional Intervention
16. For each PES statements you have written establish a goal (based on the signs and

symptoms) and an appropriate intervention based on (etiology).

To inform the patient about what hypertension is and how it has lead up to the myocardial
infraction. Educating the patient on how the high amount of saturated fat and high foods

that the patient is consuming is causing the hypertension to occur (pg.302). The goal is to
get the patient on a well-balanced diet consisting of low fat and lower in saturated fat
foods. Educating the patient and a family member on how they can help prevent another
myocardial infraction by lowering cholesterol levels and maintaining the hypertension

will result in a healthier heart.

Educating the patient on diabetes and how it can affect your overall health if it is not
controlled will help aid in reducing the chances of another myocardial infraction. The
goal is to show the patient how to check blood sugar levels and to know when they are
too high or too low. Educating on keeping a dietary journal to understand how different
foods affect the patients blood sugar levels. Informing the patient and family that getting
regular physical activity and eating a healthy well balanced diet will keep them from
having other health problems. The risk of death from heart disease and strokes in
individuals with type 1 and type 2diabetes is two to four times greater than those without
diabetes (pg.311). Getting the diabetes maintained will help with blood flow that can
cause problems with someone who has had a myocardial infraction. The goal is to create
an understanding of the disease and help control risk factors for other heart problems.

17. Mr. Klosterman and his wife ask about supplements. My roommate here in the
hospital told me that I should be taking fish oil pills. What does the research say
about omega 3- fatty acid supplements for this patient?
Omega 3-fatty acids contain eicosanoids that include families of substances called
thromboxane, prostaglandins, and leukotrienes. This means they are important in cellular
processes, vasoconstriction, vasodilamatory response, anti-inflammatory effects, and has
been implicated as a mediator in asthma and allergic reactions (pg.319). The omega 3-

fatty acids would be beneficial for heart health and keeping blood pressure down to an
average level. This in return would help lower cholesterol and risk of another myocardial
infraction. It would be best to get the omega 3-fatty acid form regular food like lean fish
rather than a supplement but is beneficial to people who do not like to consume fish.
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?
According to Nelms after three to four weeks after returning for assessment the amount of
carbohydrates, protein, fat, fiber, and fluid that Mr. Klosterman has been taking in per day should
be at the correct amount of 10-35% of calories should go towards protein, 45-65% carbs, and 2035% from fat. Mr. Klostermans fiber intake should be up to his recommended amount per day
and a limit of saturated fat should be lower than his first 24 hour recall (pg.334). Blood pressure
should be assessed and checked to see if LDL/HDL ratio has went back to a normal blood
pressure level. Weight should be monitored to see if patient has lowered BMI to help reduce the
risk of another myocardial infraction. Speaking to the Klosterman and assessing if they have
added more physical activity to their daily lives to help strengthen the heart and lose weight will
help in knowing if more physical activity needs to be addressed. Also assessing if there has been
any signs or symptoms of another recurring myocardial infraction, will aid in helping get Mr.
Klosterman on different medications or doing something different with the nutrition therapy.

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