Caroline Mooney

KNH 411
9/8/14
Case Study 5

Case Questions
I.

Understanding the Disease and Pathophysiology

1. Mr. Klosterman had a myocardial infraction. Explain what happened to his

heart.
Heart muscle cells are connected to one another by membranes called intercalated
discs, which allow electrical impulses to pass from one cell to the next. Though
myocardial cells are capable of generating spontaneous electrical activity, under
normal conditions electrical activity is initiated by the heart at the sinoatrial node. In
this case, blood stopped flowing to parts of Mr. Klostermans heart.
His heart was also not receiving enough oxygen. This could be due to one of his
coronary arteries that supplies the blood to the heart having blockage that could be
from fat, cholesterol, or white blood cells. When someone is experiencing a
myocardial infraction they usually have chest pain, shortness of breath, nausea,
vomiting, sweating, anxiety, and heartbeats that seem abnormal.
Nelms, M., Sucher, K., Lacey, K., Habash, D., & Roth, S. (2010). Diseases of the
Cardiovascular System. In Nutrition Therapy and Pathophysiology (Vol. 2).
Belmonte: Thompson Brooks/Cole.
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 infarctrelated 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?
An angioplasty is a procedure is done to open narrowed or blocked blood vessels,
more specifically, coronary arteries that supply blood to the heart. A coronary artery stent
is a small metal tube that expands inside a coronary artery. Usually, a stent is put in
during or after angioplasty. The stent helps prevent the artery from closing up again.
This procedure is usually performed because arteries can become narrowed or
blocked by plaque deposits. Plaque is made of cholesterol and fat and builds up on the

artery walls causing atherosclerosis. Angioplastys can also be used to treat blockage in a
coronary artery during or after a heart attack, blockage narrowing a coronary artery
putting you at risk for heart attack, and narrowings that reduce blood flow and cause
persistent chest pain.
Angioplasty and stent placement - heart: MedlinePlus Medical Encyclopedia. (n.d.).
Retrieved September 8, 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 health?
Cardiac rehabilitation is used to help those who have heart attacks, heart surgery, or
percutaneous coronary intervention procedures like angioplasty and stenting recover.
These programs provide education and counseling services to these patients, and help
them to increase their physical fitness, reduce any cardiac symptoms, and improve their
health and changes of having heart problems in their future. Cardiac rehabilitation will
help Mr. Klosterman to first of all become more educated, and then help him get back to
his normal every day activities. Education and counseling sessions will help him to be
more educated on eating right, losing weight, and lowering his blood pressure and
cholesterol. Regular physical activity will help his heart and body to work better, improve
his energy level, and become stronger. Physical activity will also help reduce the risk of
having a future heart attack.
What is Cardiac Rehabilitation? (n.d.). Retrieved September 8, 2014.

II.

Understanding the Nutrition Therapy

4. What risk factors indicated in his medical record can be addressed through
nutrition therapy?
On Mr. Klostermans medical record the risk factors that were listed that can be
addressed through nutrition therapy include: hypertension, diabetes, high LDL levels, low
HDL levels, and high cholesterol. He also has a family history of coronary artery disease,
and is mildly overweight.
To start, Mr. Klosterman should try to lose weight via nutrition therapy. By altering
his current diet, this will cause him to lose weight and will help prevent and slow down
the process of the other issues he is experiencing like hypertension and diabetes.
Especially when dealing with his hypertension, losing weight is the number one
thing he can do to help it, and his blood pressure will decrease from doing this alone.
Nutrition therapy is very important in preventing diabetes, helping existing cases and
diabetes, and slowing the process of diabetes. Here nutrition therapy is used to achieve
and maintain blood glucose levels, achieve and maintain a good lipid and lipoprotein

profile, keep blood pressures in a normal range, address nutrition needs, and prevent or
slow complications from diabetes.
His high LDL levels and low HDL could result in something called dyslipidemia.
To help his high cholesterol, Mr. Klosterman should start by reducing the amount of
saturated fat in his diet, which would include his meat and whole milk products. He
should also try to switch to low-fat products, and try to replace saturated fat with
unsaturated fat.
Diabetes Care. (n.d.). Retrieved September 8, 2014.

5. What are the current recommendations for nutritional intake during a

hospitalization following a myocardial infarction?
Since Mr. Klosterman was on an NPO until the end of his procedure, he could not
eat any solid foods or liquids. Following his procedure current recommendations say you
should follow a TLC diet, or a Therapeutic Lifestyle Changes Dietary Recommendation.
This diet says you should make 23-25% of your total calories from fat, you should have
less than 200mg of cholesterol a day, your sodium should be limited to 2400mg a day,
and you should be eating enough calories to maintain a healthy weight, or eating less
calories if you are overweight, and to reduce blood cholesterol levels. You should also try
and have less than 7% of your fat calories be from saturated fat.
Journey. (n.d.). Retrieved September 8, 2014.

III.Nutrition Assessment
6. What is the healthy weight range for an individual of Mr. Klostermans
height?
A healthy weight range for an individual of Mr. Klostermans height would be
166 pounds. To find this number you can use the Hamwi method.
For men-106 pounds for the first 5 feet of height, then add 6 pounds for every inch over 5
pounds, or subtract for under 5 feet in height.
For a male with a large frame your weight should be somewhere in between 158180. According to this chart, this also shows that Mr. Klosterman is slightly overweight.
Height and Weight Chart - height weight chart, weight height chart. (n.d.).
Retrieved September 8, 2014.
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.
To find Mr. Klostermans energy requirements we can use the Mifflin-St. Jeor
equation:

For men: 10x(84.09kg)+6.25x(177.8cm)-5x61+5=1,652 kcal a day

To find his total energy needs with his activity included we multiply 1,652x1.4=2,312.8
kcals a day. We used 1.4 since Mr. Klosterman did have some moderate activity.
To find Mr. Klostermans protein requirements we can multiply his weight in kg,
84.09kgx1.1 to get 93grams of protein a day. We multiplied by 1.1 since he has had a
minor surgery.
8. Using Mr. Klostermans 24-hour recall, calculate that total number of
calories he consumed as well as the energy distribution of calories for protein,
carbohydrate, and fat using the exchange system.
According to Mr. Klostermans 24-hour recall, he consumed approximately 2,500
calories. To find his carbohydrates, we did 55%-(2,500x0.55)/4= ~290 grams/day. To
find his protein needs we need 15%-(2,500x0.15)/4=~94 grams/day. To find his fat
calories we did 30%-(2,500x.30)/9=~83 grams/day.
Protein: ~94 grams/day
Carbohydrate: ~290 grams/day
Fat: ~83 grams/day
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?
After looking at Mr. Klostermans labs we can see that there are many factors that
are consistent with his MI diagnosis. First of all, his total cholesterol is high, and should
be under 200 mg/dl. Along with this his LDL cholesterol is too high, and his HDL
cholesterol is too low. He also has high triglyceride levels, which also increase his risk.
Mr. Klostermans levels were higher on day 2 because it is likely this is when he
was experiencing a Myocardial Infraction. If Mr. Klostermans body wasnt getting the
oxygen it needed this would have caused his Myocardial Infraction.
Nelms, M., & Roth, S. (2004). Medical nutrition therapy: A case study
approach (2nd ed.). Belmont, CA: Wadsworth/Thomson Learning.
10. What is abnormal about his lipid profile? Indicate the abnormal values.
There are a few abnormal values in Mr. Klostermans lipid profile. His total
cholesterol is 235 on day 1, and it should be between 120-199. His HDL is 30 on day 1,
and should be greater than 45. His LDL cholesterol is 160 on day 1, and should be below
130.
Nelms, M., & Roth, S. (2004). Medical nutrition therapy: A case study
approach (2nd ed.). Belmont, CA: Wadsworth/Thomson Learning.

11. Mr. Klosterman was prescribed the following medications on discharge.

What are the food-medication interactions for this list of medications?
Medication
Lopressor 50 mg daily
Lisinopril 10 mg daily
Nitro-Bid 9.0 mg twice daily
NTG 0.4 mg sl prn chest pain
ASA 81 mg daily

Possible Food-Medication Interactions

Diarrhea, Nausea, dry mouth, constipation
Avoid moderately high or high potassium
foods
Nausea
Headache
Nausea, Vomitting

Lopressor (Metoprolol Tartrate) Drug Information: Side Effects and Drug

Interactions - Prescribing Information at RxList. (n.d.). Retrieved September 8,
2014.
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?
Some questions that you could ask Mr. Klosterman and his wife to help assess
how you could best help them could be: is there somewhere you can exercise or do
physical activity near your house, and if so would you be interested in getting a gym
membership etc?, where do you usually buy your groceries and how often do you go
grocery shopping?, do you know which foods can increase your cholesterol, and which
foods you should avoid so your cholesterol doesnt get higher?, do you think keeping a
journal of all the foods you are eating everyday would be beneficial to you, and do you
know which of these foods you should be avoiding so you dont experience another heart
attack?, and most importantly, are you willing to listen to advice and try new things like
trying new foods and keeping a food journal. Along with these many more questions
could be used to assess the couples willingness to help Mr. Klosterman change.
13. What other issues might you consider to support successful lifestyle
changes for Mr. Klosterman?
First of all, Mr. Klosterman should try and get more exercise and do more
physical activity. Starting with adding a little more physical activity to his daily lifestyle
with not only help with him being overweight, but will also help with his diabetes and
high blood pressure. He also should try and stop smoking. Even if he does this at a
gradual pace before eventually quitting it will help. Smoking is a huge risk factor for
many heart diseases and increases his risk tremendously for having a heart attack. He
should try and avoid foods that will raise his cholesterol even more, and should cut back
on eating meats that are high in cholesterol. I think if Mr. Klosterman keeps a daily
journal of both his food and his exercise this will really help him to see if he is making
progress. By writing down exactly what he is doing everyday he can see where changes

still need to be made, and if he is losing weight. Keeping track of his weight will also be
very important in order to make positive changes to his lifestyle.
14. From the information gathered within the assessment, list the possible
nutrition problems using the correct diagnostic terms.
Some possible nutrition problems would be:
Knowledge deficit related to proper nutrition
Knowledge deficit related to proper nutrition for those with high
cholesterol
Knowledge deficit related to diabetes
Knowledge deficit about the effects of smoking on your heart and health
Knowledge deficit on the amount and type of exercise he should be doing
Knowledge deficit on what a healthy weight for him should be
Knowledge deficit on severe chest pains
IV.

Nutrition Diagnosis

15. Select two of the identified nutrition problems and complete the PES
statement for each.
P: Mildly overweight
E: related to excessive caloric intake
S: as evidenced by a BMI of 26.6
P: Excessive intake of high saturated fat foods
E: related to knowledge deficit on proper nutrition and cholesterol
S: as evidenced by a total cholesterol of 235
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).
For the first PES statement an ideal goal would be lower his total energy intake,
and to gradually add more exercise to his daily schedule. He should try to cut his calories
by 250 a day in order to lose half a pound per week, he can gradually cut calories by 500
a day to lose a pound per week. To add more exercise to his daily routine he can try and
go for a walk each day for 30 minutes, then gradually increase this time. He should
slowly increase his routine so eventually he could go to the gym or go for a short jog
daily. He should also begin to do some strength training.
For the second PES statement an ideal goal would be to reduce his saturated fat
intake to 13 grams a day or to be 5-6% of his daily calories from saturated fat. To do this
he must first be educated on what foods he is currently eating contain lots of saturated fat,
and what foods he can eat instead to substitute these foods. Once he has more knowledge

on what better options would be, he can incorporate these into his new diet. Him and his
wife should also be educated on where to find these new foods, how much they will cost,
etc.
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 omega-3 fatty acid supplementation for this patient?
Fish oil can be obtained from either eating certain fish, or taking fish oil
supplements. Some fish that are high in omega-3 fatty acids or fish oils include:
mackerel, tuna, salmon, sturgeon, mullet, bluefish, anchovy, sardines, herring, trout, and
menhaden. Each of these fish provide about 1 gram of omega-3 fatty acids in about 3
ounces of the fish.
Fish oil is recommended for those who have conditions related to the heart. Fish
oil can be used to lower blood pressure and triglyceride levels, which both are issues for
Mr. Klosterman, and they have been shown to prevent stroke and heart disease, which he
is at risk for. Scientific evidence has shown that fish oil does lower these levels, and helps
prevent heart disease and stroke when taken in the correct amounts. Taking too much fish
oil however, has been shown that it can increase the risk for many of these heart
conditions. It is almost recommended that oily fish be consumed at least twice a week,
and should be a variety of different fish.
Fish oil: MedlinePlus Supplements. (n.d.). Retrieved September 8, 2014.

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?
When Mr. Klosterman and his wife return for additional counseling there are
many factors that should be assessed right away. First of all I think Mr. Klosterman
should be weighed to see if he has lost or gained any weight. If he is beginning to lose
weight then he is making a step in the right direction, even if its just a small amount. His
current BMI should also be checked to see if this is decreasing. It would also be a good
idea to ask Mr. Klosterman if he has been keeping a food journal, and if he can do a 24hour recall for you. If he can, that will show that he has successfully been keeping a food
journal, and it will be much easier to see why his current lab values are where they are. It
should also be determined if Mr. Klostermans daily caloric intake has gone down or
stayed the same. Along with this his fat and saturated fat intake should be assessed, since
this was one of his biggest issues. I would also ask if Mr. Klosterman and his wife have
successfully been able to find subsitutes for the high saturated fat foods he was eating
before, and if he was able to eat and enjoy them regularly. I would also ask how this has
changed what they are eating and if they are cooking in different ways.
Next, Mr. Klostermans current lab values should all be determined, and should
be compared to his ones from his last visit. It should be noted which values have
changed, and those that have gone up should be especially noted and discussed with Mr.

Klosterman. When looking at his lab values his cholesterol should be the most important,
and his current LDL and HDL levels should also be assessed.
After this I would also Mr. Klosterman how his daily exercise is going, and if hes
been able to do some each day, and exactly how much. I would ask him to explain each
routine he has been doing and how easy or difficult it has been. I would also give him
more suggestions on different ways he can get exercise to make it more exciting and
different.
Lastly, I would ask Mr. Klosterman to honestly tell me if he has quit smoking or
tried to quit smoking in the last 3-4 weeks. If he has quit smoking completely then he is
already moving in the right direction. If he has not I would educate him more on the
harmful effects of smoking, not only for him, but also for his wife. I would give him
resources on the effects of smoking, and give him other tips to help quit. It would also
help to get Mrs. Klosterman to encourage him to quit.

Works Cited
Angioplasty and stent placement - heart: MedlinePlus Medical Encyclopedia. (n.d.).
Retrieved September 8, 2014.
Diabetes Care. (n.d.). Retrieved September 8, 2014.
Fish oil: MedlinePlus Supplements. (n.d.). Retrieved September 8, 2014.
Height and Weight Chart - height weight chart, weight height chart. (n.d.). Retrieved
September 8, 2014.
Journey. (n.d.). Retrieved September 8, 2014.
Lopressor (Metoprolol Tartrate) Drug Information: Side Effects and Drug Interactions Prescribing Information at RxList. (n.d.). Retrieved September 8, 2014.
Nelms, M., & Roth, S. (2004). Medical nutrition therapy: A case study approach (2nd
ed.). Belmont, CA: Wadsworth/Thomson Learning.
Nelms, M., Sucher, K., Lacey, K., Habash, D., & Roth, S. (2010). Diseases of the
Cardiovascular System. In Nutrition Therapy and Pathophysiology (Vol. 2). Belmonte:
Thompson Brooks/Cole.
What is Cardiac Rehabilitation? (n.d.). Retrieved September 8, 2014.