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normocephalic
EOMI, fundoscopic exam WNL. No evidence of atherosclerosis, diabetic retinopathy, or
early hypertensive changes.
Ears:
TM nl bilaterally
Nose:
WNL
Throat:
tonsils not infected, uvula midline, gag nl
Genitalia:
WNL
Neurologic:
No focal localizing abnormalities; DTR symmetric bilaterally
Extremities:
No C, C, E
Skin:
diaphoretic and pale
Chest/Lungs:
clear to auscultation and percussion
Peripheral vascular: PPP
Abdomen:
RLQ scar and midline suprapubic scar. BS WNL. No hepatomegaly, splenomegaly,
masses, inguinal lymph nodes, or abdominal bruits
Vital Signs:
Temp: 98.4
Pulse: 92
Resp Rate: 20
BP: 118/78
Ht: 510
Wt: 185 lbs.
BMI: 26.6
Nursing Assessment:
9/1
Abdominal appearance (concave, flat, rounded, obese, distended)
Flat
Palpation of abdomen (soft, rigid, firm, masses, tense)
soft
Bowel function (continent, incontinent, flatulence, no stool)
continent
Bowel sounds (P=present, AB=absent, hypo, hyper)
RUQ
P
LUQ
P
RLQ
P
LLQ
P
Stool color
Light brown
Stool consistency
Tubes/ostomies
NA
Genitourinary
Urinary continence
Catheter in place
Urine source
Catheter
Appearance (clear, cloudy, yellow, amber, fluorescent, hematuria, orange, blue, Clear, yellow
tea)
Integumentary
Skin color
Pale
Skin temperature (DI=diaphoretic, W=warm, dry, DL=cool,
D, M
CLM=clammy, CD+=cold, M=moist, H=hot)
Skin turgor (good, fair, poor, TENT=tenting)
TENT
Skin condition (intact, EC=ecchymosis, A=abrasions, P=petechiae,
Intact
R=rash, W=weeping, S=sloughing, D=dryness, EX=excoriated,
T=tears, SE=subcutaneous emphysema, B=blisters, V=vesicles,
N=necrosis)
Mucous membranes (intact, EC=ecchymosis, A=abrasions,
Intact
P=petechiae, R=rash, W=weeping, S=sloughing, D=dryness,
EX=excoriated, T=tears, SE=subcutaneous emphysema, B=blisters,
V=vesicles, N=necrosis)
Other components of Braden Scale: special bed, sensory pressure,
Activity; 22
moisture, activity, friction/shear (>18=no risk, 15-16=low risk, 13-
14=moderate risk, <12=high risk)
2
Ref. Range
136-145
3.5-5.5
95-105
23-30
8-18
0.6-1.2
70-110
2.3-4.7
1.8-3
9-11
285-295
<0.3
6-8
3.5-5
16-35
9-33
30-120
4-36
0-35
30-135 F
55-170 M
0
9/1 1957
141
4.2
103
20 !
14
1.1
136 !
3.1
2.0
9.4
292
0.1
6.0
4.2
30
26
75
30
25
75
9/2 0630
142
4.1
102
24
15
1.1
106
3.2
2.3
9.4
290
0.1
5.9 !
4.3
32
22
70
215 !
245 !
500 !
9/3 0645
138
3.9
100
26
16
1.1
104
3.0
2.0
9.4
291
0.2
6.1
4.2
31
25
68
185 !
175 !
335 !
75 !
55 !
MCV (um )
MCH (pg)
MCHC (g/dL)
RBC distribution (%)
3
3
Platelet count (x10 /mm )
Hematology, Manual Diff
Neutrophil (%)
Lymphocyte (%)
Monocyte (%)
Eosinophil (%)
Basophil (%)
Blasts (%)
Segs (%)
Bands (%)
Urinalysis
Color
Appearance
Specific Gravity
pH
Protein (mg/dL)
Glucose (mg/dL)
Ketones
Blood
Urobilinogen (EU/dL)
Leukocyte esterase
Protein check
WBCs (/HPF)
RBCs (/HPF)
Bacteria
208-378
<0.2
<0.03
120-199
>55 F, >45 M
<130
<3.22 F
<3.55 M
101-199 F
94-178 M
60-126 F
63-133 M
35-135 F
40-160 M
12.4-14.4
4.8-11.8
4.2-5.4 F
4.5-6.2 M
12-15 F
14-17 M
37-47 F
40-54 M
80-96
26-32
31.5-36
11.6-16.5
140-440
50-70
15-45
3-10
0-6
0-2
3-10
0-60
0-10
-
-
1.003-1.030
5-7
Neg
Neg
Neg
Neg
<1.1
Neg
Neg
0-5
0-5
0
325
2.4 !
2.1 !
235 !
30 !
160 !
5.3 !
685 !
2.8 !
2.7 !
226 !
32 !
150 !
4.7 !
365
214 !
33 !
141 !
4.3 !
72 !
80 !
98
115
110
105
150
140
130
12.6
11.0
4.7
12.6
9.32
4.75
12.4
8.8
4.68
15
14.8
14.4
45
45
44
91
30
33
13.2
320
55
17
4
0
0
3
45
15 !
Pale yellow
clear
1.020
5.8
Neg
Neg
Trace !
Neg
Neg
Neg
Neg
0
0
0
92
31
32
12.8
295
58
23
4
0
0
3
47
17 !
Pale yellow
clear
1.015
5.0
Neg
Neg
Neg
Neg
Neg
Neg
Neg
0
0
0
90
30
33
13.0
280
62
35
7
0
0
4
52
8
Pale yellow
clear
1.018
6.0
Neg
Neg
Neg
Neg
Neg
Neg
Neg
0
0
0
2.
RH had a myocardial infarction. Explain what happened to his heart during his MI. (1 pt.)
A myocardial infarction is also known as a heart attack. This can occur when the vessels (coronary arteries) surrounding
the heart are blocked so much so that there is a lack of oxygen supply to the heart. In RHs case, his coronary artery
was occluded (atherosclerosis) which ultimately led to lack of blood (and oxygen) supply to his heart. Infarction refers
to dead or damaged tissue of the heart muscle, hence, myocardial infarction (Medical Dictionary).
RHs 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 and describe what is an angioplasty and what is a stent placement. What is the purpose of these medical
procedures? (2 pts.)
An angioplasty refers to the reconstruction of a blood vessel (Medical Dictionary). The purpose of this procedure is to
reopen the artery to allow for better blood flow to prevent MI. A stent placement can be described as placing a straw
in the vessel to give the vessel walls support. It helps keep the tubular structure open (Medical Dictionary). The
purpose of this is similar to the angioplasty in that it helps keep blood flowing at a normal rate to prevent any further
damage.
3.
4.
5.
What are the current recommendations for the progression of nutritional intake during a hospitalization following a
myocardial infarction? (2 pts.)
The current recommendations for nutritional intake following a MI are: decreasing ones oral intake, clear liquids and
avoiding caffeine, and progression to soft, more frequent meals (CVD lecture slide 41).
Examine the chemistry results for RH. Which labs are consistent with the MI diagnosis and why? Why were the levels
higher on day 2? (4 pts.)
Cholesterol (high)
HDL (low)
LDL (high)
LDL/HDL ratio
APO A
(NTP p. 311)
These are consistent with MI diagnosis because they all contribute to atherosclerosis, which leads to MI.
Atherosclerosis, a plaque build up within the arteries, causes narrowing of the lumen thereby decreasing blood flow to
that part of the heart. This cuts off blood flow, hence oxygen, which then causes tissue death. These levels being high
indicate that RH is at risk for or has already suffered from CVD.
Interpret the results of RHs lipid panel, identifying which of the lipids are elevated based on the NCEP ATP III
Guidelines. List the desired therapeutic goals (TLC goal parameter) based on the NCEP guidelines. (3 pts.)
Parameter
RHs Value in mg/dL
Interpretation based on
Therapeutic goal
NCEP classification
Total Cholesterol
235 mg/dL
Borderline high
<200 mg/dL
LDL Cholesterol
160 mg/dL
High
<100 mg/dL
HDL Cholesterol
30 mg/dL
Major risk factor
>60 mg/dL
Apo A
72 mg/dL
Low
94-178 mg/dL
Triglycerides
150 mg/dL
Borderline high
<150 mg/dL
Overall, what does RHs lipid panel suggest?
RHs lipid panel suggests that he is at high risk of heart disease. He is more likely to develop atherosclerosis with those
HDL and LDL values (NTP p. 310).
6. List & number RHs risk factors for CHD, based on the presentation data from his medical record. (2 pts.)
1) Age (male >45 yo)
2) High total cholesterol (235 mg/dL)
5
8.
9.
Using RHs 24-hour recall and the food exchange lists, calculate the total number of servings of each exchange group
and number of calories he consumed as well as the energy distribution of calories for protein, carbohydrate, and fat
using the exchange system. (5 pts.)
Exchange
Kcal
PRO g
CHO g
FAT g
12.25 Starches
1,200
33.75
213.75
21.25
3 Fruits
180
0
45
0
11 Lean meats
565
77
15
22
5 Fats
180
0
0
20
2 Veg
95
4
10
5
2 LF milk
240
16
24
10
Total
2,460
130.75
307.75
78.25
% of total kcals
100%
21.3%
50.0%
28.6%
Compare RHs 24-hour recall with the TLC dietary plan. Briefly discuss the overall adequacy of RHs diet and what
recommendations you can make to align RHs current consumption with the TLC plan. (3 pts.)
TLC Goals:
Your Recommendations:
Total calories:
2,650 kcal/day
Keep food diary to keep track of kcals consumed.
Total fat:
25-35%
73.6-103.0 g/day Limit visible fats (such as mayonnaise)... intake
above is within this range.
Saturated fat:
< 7%
20.6 g/day Skim/low fat milk and dairy products
Monounsaturated
Up to 20%
58.9 g/day
Fat:
Polyunsaturated
Up to 10%
29.4 g/day Include beans/nuts
Fat:
Carbohydrate:
50-60%
331.3-397.5 g/dayintake above is less than this, but this is okay
because of MI condition.
Fiber:
20-30 g/day
20-30 g/day increase beans/legumes
Protein:
About 15% total kcal 99.4 g/day Lean meats/poultryintake above is above this but that is
good because RH is recovering from surgery so he needs more protein.
Cholesterol:
< 2,000 mg/dL
<2,000 mg/day Include whole grain options
Sodium:
< 2,400 mg/day
<2,400 mg/day
Potassium:
4,700 mg/day
4,700 mg/day
Plant
3-4 g/day
3-4 g sterols/day
stanols/sterols
RH was prescribed the following medications on discharge. Provide the generic name and indication of each
medication (specific to RH) and its effects. Also note any dietary recommendations, contraindications/precautions,
and interactions. What effect will these medications have on his nutritional care? Refer to the medication
information in the Food-Medication Interactions text. (5 pts.)
Lopressor 50 mg daily
Generic name:
Metoprolol
Classification:
Antihypertensive, antiangina
6
ASA 81 mg daily
Generic name:
Aspirin
Classification:
NSAID
Indication:
To prevent MI; platelet aggregation inhibitor
Diet:
Adequate hydration; foods rich in vitamin C and folate; avoid natural products that affect
coagulation.
Possible FoodGarlic, ginger, gingko, ginseng, horse chestnut; limit caffeine to decrease GI side effects.
Medication
Interactions:
Potential
Anorexia; sudden serious gastric bleeding; N/V; dyspepsia; black tarry stools
Nutrition/Oral/GI
Side Effects:
(All cited from Food Medication Interactions book)
10. Make an overall statement as to the discharge dietary advice you would give RH regarding his medications above.
(1 pt.)
You should take medication as directed. If you have any questions about your medications and how to take them you
should contact your physician. You may also contact your Pharmacist for questions you have about medication and
food interactions.
11. What is metabolic syndrome & does RH meet the criteria? Why or why not? (2 pts.)
Metabolic syndrome is a group of metabolic risk factors associated with increased CVD risk. It is defined by the
presence of any 3 of the following: increased waist circumference, increased TG, decreased HDL, HTN, and impaired
fasting glucose (NTP p. 311). RH does not meet the criteria because he does not have 3 of those characteristics. He has
1 of them, being low HDL cholesterol.
12. You talk with RH and his wife, an elementary school teacher. They are friendly and seem cooperative. They are both
anxious to learn what they can do to prevent another heart attack. List 4 questions you might ask them that will
assist you in assessing their lifestyle. (2 pts.)
1) Tell me more about how many times you exercise per week, and what type, how many minutes?
2) Is your job more sedentary or do you have opportunity to be more mobile?
3) How much sleep do you usually get each night?
4) How often do you guys eat out versus cooking at home?
13. List 4 lifestyle factors you might recommend to support realistic, successful lifestyle changes for RH? (2 pts.)
Increased physical activity
More frequent meals throughout the day
Cut back smoking maybe to pack per day
Increase sleep
14. RH is Muslim and from the SF Bay Area. Describe and explain Islamic dietary laws and any dietary restrictions you
would need to consider when counseling RH. (2 pts.)
The Islamic culture has specific laws when it comes to food consumption. There are Halal and Haram considerations.
Halal means that everything is allowed unless otherwise specified (lawful). Haram means God forbids certain
food/drinks (unlawful). In RHs case, he would not be allowed to eat his pork chops since the flesh of swine is
prohibited (Haram). When counseling RH, one would need to consider the meats he is able to consume and how they
were slaughtered, and also understand what is Halal and what is Haram (Islamic Dietary Law;
http://islam.about.com/od/dietarylaw/a/diet_law.htm).
8
Kimberly Kavanaugh
Kimberly Kavanaugh, Nutrition student, November 23, 2015
10