MED/SURG CASE STUDY

Heart Failure
The patient is a 60 year old woman with history of type 2 diabetes, Stage C heart failure,
and temporal arteritis, for which she was recently started on oral steroids. She lives with
her sister, who is responsible for cooking and food shopping. The sister also cared for
their mother who had diabetes and has since passed away. The patient has limited
mobility because of her heart failure and osteoarthritis, and does not work. She requires
assistance with activities of daily living. She is admitted to the hospital with a chief
complaint of shortness of breath, orthopnea, fatigue, and swelling of her legs, she is
diagnosed with exacerbation of heart failure based on her symptoms and elevated brain
natriuretic peptide (BNP). The physician prescribes an 1800 calories, 2 g sodium, low fat
diet, and consults the registered dietitian.

1. Anthropometric measurements
Ht: 5’7”
Wt: 245.5 lbs
Usual weight: 230 lbs. Gained approximately 15 lbs. in 2 weeks prior to
admission

2. Biochemical Data, Medical Tests, and Procedures

Parameter Value

Sodium 137 mEq/L

Potassium 4.8 mEq/L

Chloride 103 mEq/L

Carbon Dioxide 31 mEq/L

BUN 25 mg/dL

Creatinine 1.2 mg/dL

Glucose 237 mg/dL

Hemoglobin 11.3 g/dL

Hematocrit 36%

Albumin 3.0 g/dL

Magnesium 1.9 mEq/L

Phosphorous 3.5 mg/dL

BNP 450 pg/mL

 Test results, if pertinent:

Point of care blood glucoses range from 213 to 291 mg/dL

3. Nutrition-Focused Physical Findings

She appears obese, in no acute distress. Her skin is intact. She has bilateral lower extremity
pitting edema to the knee. She is missing a few teeth but denies problems chewing or
swallowing.

4. Client History

Social Hx: No smoking or alcohol

Family Hx: The client reports that she has been diabetic since she was 40 years old. Her mother
also had diabetes.

5. Food/Nutrition-Related history

She states that her sister prepares breakfast and fixes a lunch for her before leaving for work,
then prepares dinner when she returns from work. Patient reports that she does not use
any sugar or salt.

Usual Diet

Meal Description

Cereal, corn flakes, 1 ½ cups

Breakfast 2% milk, 1 cup
Banana
Orange juice, 8 oz
Tea with artificial sweetener, 12 oz mug

Lunch 2 slices ham or bologna with 1 slice American

cheese sandwich on white w/ 1 tsp mustard
Diet Jello, ½ cup
Diet cola, one 12-oz can

Dinner 1 chicken patty, baked or broiled

½ cup mashed or baked potato with 1 tbsp
Margarine
½ cup broccoli w/ 2 tbsp ready-to-serve cheese
Sauce
Lettuce & tomato salad w/ 2 tbsp bottled Italian
Dressing
Water, one 16 oz bottle
Pound cake, 1 slice w/ vanilla ice cream, 1
scoop
 Snacks

Pt denies snacking through the day; she drinks an additional 12 to 16 oz of diet soda or water.
Currently in the hospital, meal intake is recorded at 80%-100% consistently. She confirms
that her appetite is good.

Medications

Aldactone 100 mg/day, Humulin 70/30, 70 units BID plus sliding scale insulin, prednisone 40
mg/day, lasix 40 mg/dy

Supplements
None

QUESTIONS

1. Which weight would be the most appropriate to use as a starting point in your nutritional
assessment, the admission weight or her usual weight? Why?
Her usual body weight because she has edema and probably additional weight from fluid
retention related to her stage of CHF.

2. Calculate and interpret her BMI. How would you determine the energy and protein needs
of a HF patient? Estimate her needs and show your work.
BMI: 41 (usual body weight). She is still morbidly obese without taking into account her
fluid gains.
REE: 1700-1800 kcals. No activity factor because we want to adjust for her morbid obesity.

Protein: 80 g. Used adjusted weight of 72 kg because she is morbidly obese.

3. Do you think she would benefit from a multivitamin or any specific vitamin/mineral
supplements? Why or why not?
Recommend a MVT because of her low fruit and vegetable consumption and don’t want to
take a risk of thiamine deficiency.

4. What non-nutritional factors could be aggravating her hyperglycemia?

Prednisone is a steroid that raises blood sugars and increases inflammatory state.

5. Why do you think her albumin is low in the face of a good appetite?
Albumin is not a good indicator for protein/energy intake. Albumin can be low because of
its association to CRP related to inflammation. Also, albumin can be lower when
there is fluid retention in extracellular spaces (edema).

6. Estimate the sodium and fluid content of her usual diet.

2000-2200 ml from fluid. She is probably consuming closer to 3000 ml per day.
3300 mg of sodium.
 7. How does her sodium and fluid intake compare with common sodium and fluid
recommendations for diet in heart failure? What advice would you give her to improve her
diet habits and help avoid exacerbations of congestive heart failure?
Recommendations
1. limit fluid intake to 1.5-2 L per day.
2. Educate on fluid containing food. Explain that food still contributes to fluid intake.
Suggest strategies for managing thirst such as hard candies or gum.
3. Limit sodium to 2000 mg per day.
4. Educate on low sodium foods and how to look for low sodium on labels (below 300
mg per serving).

8. Writer a PES statement based on the available nutritional assessment data.

Excessive fluid intake related to heart failure as evidenced by an intake of 2200 ml, which
is above the recommended 1500 ml-2000 ml per day.

9. In addition to diet and fluid status, what other parameter might you monitor in a HF
patient?
Fat intake, protein intake, patient understanding of the HF diet, Weight gain/loss
(malnutrition).