CARDIOVASCULAR Disease Congestive Heart Failure: Using the Nutritional Care Process, Stage of Changes, and Motivational Interviewing

Technique to address Nutritional Needs.

Najlaa Almohmadi 1, Alan Johnson, Ph.D., 2, Chimene Castor, EdD, MS. RD, LDN 3; 1. Student, Department of Nutritional Sciences, Howard University; 2. Professor and Director of Graduate
Program, Department of Nutritional Sciences, Howard University; 3. Assistant Professor and Clinical Coordinator of Dietetics Program, Department of Nutritional Sciences, Howard University

Howard University, Department of Nutritional Sciences, Division of Allied Health Sciences, Washington DC 20059

ABSTRACT
Introduction:
Cardiovascular disease CVD is the main cause of death worldwide. Racial
and ethnic minorities receive lower quality treatment, and experience
worse health outcomes than their White counterparts. Disparities are linked
to a number of factors such as income, education, genetic, access to care,
communication barriers.
Methods:
Data was collected for a 65-years old Hispanic patient admitted to Howard
University Hospital HUH with heart failure, swollen legs, shortness of
breath (SOB), and acute decompensated congestive heart failure (CHF)
secondary to cardiomyopathy. A medical record review was conducted
(Chart and Sorian) as well as interviews of the nurses and the patient.
Information collected included anthropometric measurements, medical
history (medication, past medical history, and diagnosis), a 24-hour food
recall, dietary pattern, Po (oral intake), and lab values.
Results:
Patients PO intake was 100%.
The nutritional diagnosis included: (1) Unintentional weight loss (NC -3.2)
related to inadequate protein/energy intake secondary to CHF and low
appetite as evidenced by weight loss % 12.6 x 180 day (significant), and
the patients statement that he ate from 1-2 meals per day; (2) Impaired
nutrient utilization (sodium and fluid) (NI -2.1) related to the diagnosis of
CHF as evidenced by edema, leg swelling, and weight gain due to edema
(9%); and (3) Increased nutrient needs (protein) related to metabolic stress
as evidenced by leg swelling and edema secondary to the CHF.
The recommended intervention was a Cardiac Diet of 2g sodium, energy
intake of 18712042 kcal, protein intake of 66-72g/day, and 1200mL fluid
restriction (5 cups/day). The patient was encouraged to eat small frequent
meals (5-6 per day), increase intakes of potassium, calcium, magnesium
and fiber; limit intakes of red/processed meat, high-salt snacks, canned
food (unless stated as low sodium), and an increase in physical activity.
Conclusion:
It is critical to address health disparities among minority populations.
Education, prevention, and treatment are the keys to eliminate these
disparities.

ASSESSMENT
Clinical Scenario

Food/ Nutrition Related History

H.H is 43 Y/O Hispanic male admitted with chest pain, legs swelling x 1
week and short of breath (SOB), acute dyspnea, macrocytic anemia , acute
decompensated (CHF secondary to cardiomyopathy. dilated ascending
aorta 4.5cm. Hx, w/HTN,CHF with impaired ejection EF 37% , and
GERD, alcohol and tobacco abuse. His BP145/63 on 11/09. Skin intact.
Patient is non compliance to medications. He is physically inactive. He is
currently employee at restaurant. He is married with wife and three
children.

Patient eats 1 to 2 meals per day. Skips breakfast and lunch. Eats late
dinner, sometimes eats snacks once a day.
No food allergies/intolerances/dislikes .
Current PO intake:100% plus snacks.

Anthropometrics
Category

Measurement

Height

55 = 65 in 165.1 cm

weight

131.1 lbs / 59.59 kg

Admitted
weight
BMI
IBW

142.9 lb due to edema.

PT gain 9%due to Edima142.9131.1/131.1x100 = 9%
59.59/ 2.72= 21.9Kg / m2 normal weight
136lbs +/- 10%

UBW
UBW%
changes

150
150- 131.1/150 x 100= 12.6 %x 180 days (
significant weight loss)

Laboratory Data

HEALTH DISPARATIES
Hispanics has significant socioeconomic challenges and nearly three
times more likely to lack health insurance.
face many types of stress related to discrimination.
less aware about heart disease, and if they have certain risk factors for
heart disease. They have higher rates of cardiovascular risk factors, such
as high cholesterol, diabetes and obesity. Less likely to seek treatment
and address these risk factors.

ASSESSMENT

Basic Metabolic
Panel
Sodium
Potassium
chloride
Glucose
Blood Urea Nitrogen
(BUN)
Creatinine Serum

Normal range

Current Value

135-148 mEq/L
3.5-5.0gm/dL
96-106 mEq/L
70-115 mg/dL
7-25 mg/dL

134
3.7
98
92
17

0.6-1.2 mg/dL

Hgb
HCT
Total cholesterol
HDL
LDL
TG

13.5-17.5 g/dL
38.8-50%
< 200 mg/ dL
> 60 mg/ dL
< 100 mg/ dL
< 200

1.1
13.7
41.1
123
30
77
160

Nutrition Focused Physical Findings

-

Skin is intact, warm and dry

Blood pressure 145/63 on 11/09
138/67 on 11/10

Medication List

Cardiovascular disease CVD is the main cause of death worldwide.

According to the CDC, each year approximately 1 in every 4 deaths.
(34.1%) Half of those patients are over 60 years old.
Over 50 percent of the deaths due to heart disease were in men.
Coronary heart disease (CHD) is now the most common type of heart
disease, killing over 370,000 people.
Deaths due to heart disease vary by race.
RESEARCH POSTER PRESENTATION DESIGN 2015

www.PosterPresentations.com

Medication
Hydreloizon 50mg po q
8h
Lisinopril 5mg po qd
Lasix 40mg po q 12
Lovenox 40 mg qd
Enoxaparin
(subcutaneous)
Aspirin 81mg po qd
Pantoprazole 40mg IV
q12 h

Purpose
Antihypertensive and CHF
treatment
Antihypertensive
Antidiuretic
Anticoagulant
Anticoagulant
Analgesic, prevent platelet
aggregation
Anti- GERD

Energy Needs
Using Mifflin to estimate his caloric needs with (1.2)Activities factor and
(1.1 1.2) Stress factor .
- Kcal: = 1800 2000 kcal
- Protein: 65- 75 g protein/ day (1.1- 1.2 g /kg )
- Fluid: 1200 mL ( fluid restricted) due to CHF.

NUTRITION DIAGNOSIS
PES #1:
Unintentional weight loss (NC-3.2) related to inadequate protein and
energy intake / low appetite secondary to CHF as evidenced by weight loss
% 12.6x 180 day (significant) and patient stated that he ate from 1-2 meals
l day.
PES #2:
Impaired nutrient utilization (sodium and fluid)(NI-2.1) related to
diagnosis of CHF as evidenced by edema and leg swelling and 9% weight
gain due edema.
PES #3:
Increase Nutrient needs (protein) related to metabolic stress as evidenced
by swelling leg and edema secondary to CHF.

INTERVENTION
Stages of Change
Preconception: Unwillingness of behavioral change in the next 6
months.
Contemplation: Possibility of change but ignorant or oblivious of the
process within the next 6 months.
Preparation: Expressing the desire to change within 30 days.
Action: Took steps to change in the past 6 months.
Maintenance: Consistent change for 6 months.
Barriers
Patient is non compliant to medications
Socioeconomic issues
Knowledge deficit about fluid restriction.
Patient is in contemplation stage. He is willing to change but doesnt know
how. Hes aware of his problem (Heart Failure and fluid restriction), but
does not know the source of fluid like broth, Jell-O, and popsicles.

Counseling strategies
Prepare and inform patient about his heart failure condition.
Educate patient about all options (importance of taking medication, fluid
restriction and fluid resources, eating small frequent meals), and the
importance of controlling HTN and the use of DASH diet.

INTERVENTION
The interventions that were giving to H.H aimed to educate patient and
prepare him for change of lifestyle.
PES #1
Goal: Maintain stable weight loss 131+/- 1-2 lbs.
Intervention: Diet Prescription: Cardiac diet, 2gm sodium diet
Education: Eat small frequent meals 5-6 per day
Increase physical activity as tolerated
Increase protein intake 1.1 to 1.2 (65- 75 g protein/ day)
PES #2
Goal 1: Limit sodium intake <2000 mg/ day
Intervention: Cardiac diet 2 gm sodium :
Education: Increase potassium, calcium, magnesium, and fiber
increase fruit and vegetable 5 serving a day, limit intake of red meat,
processed meat, high-salt snacks, canned food (unless stated low
sodium) and educate patient about DASH
Goal 2: Limit Fluid restriction 1200 ml / day.
Education :1200 mL fluid restriction = 5 cups per day 1 cup in each meal
and consider broth, Jell-O, juices, and popsicles as fluid.
PES#3
Goal: Increase protein intake 65-75 g protein/ day
Education: Increase protein intake

MONITORING AND EVALUATION

Weight change; prevent further weight loss (lean muscle mass) or gain
(edema) 133 lbs. +/-1to 2 lbs.
Lab values to include BNP and CMP
Skin; Skin breakdown analysis.

Coordination of Care
Financial support.
Social work.

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http://www.cdc.gov/DHDSP/data_statistics/fact_sheets/fs_heart_failure.ht
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