Laura Wendte

Case Study 3: Stroke

I. Understanding the diagnosis and pathophysiology

1. Define stroke. Give the most common stroke symptoms.

-A stroke is a sudden interruption in the blood supply of the brain. Most strokes are
caused by an abrupt blockage of arteries leading to the brain (ischemic stroke). Other
strokes are caused by bleeding into brain tissue when a blood vessel bursts (hemorrhagic
stroke). (The Internet Stroke Center)6

-Signs of Stroke in Men and Women; Sudden numbness or weakness in the face, arm, or leg,
especially on one side of the body, Sudden confusion, trouble speaking, or difficulty
understanding speech, Sudden trouble seeing in one or both eyes, Sudden trouble walking,
dizziness, loss of balance, or lack of coordination, Sudden severe headache with no known
cause.("Stroke Signs and Symptoms", 2017)5

2. What is the difference between an ischemic stroke and a hemorrhagic stroke? How do they determine
which type of stroke is occurring?

An Ischemic Stroke is caused by a blockage, while a hemorrhagic stroke is caused by bleeding

from a rupture.

They can determine the type of stroke by using diagnostic tests that view the Brain, Skull, or
Spinal Cord. A CT scan uses X-rays to produce a 3-dimensional image of your head. A CT scan can
be used to diagnose ischemic stroke, hemorrhagic stroke, and other problems of the brain and
brain stem. An MRI uses magnetic fields to produce a 3-dimensional image of your head. (The
Internet Stroke Center)6

3. What is a TIA (transient ischemic stroke)? If a person has multiple TIAs, what is their risk for a major
cardiovascular accident?

-TIAs are brief attacks of cerebral dysfunction of vascular origin with no persistent neurological
defects that often precede severe strokes. (Mahan, Escott-Stump, Raymond, & Krause, 2012
pg.933)3

- The clinical syndrome of TIA designates that the abnormality in the cardiovascular system
leading to compromised blood flow to the brain is unstable and, if not properly treated, may
also cause a debilitating ischemic stroke.

The most remarkable characteristic of TIA is, perhaps, the temporal information it
conveys that relates to the timing of an upcoming stroke. The excess risk after TIA can
be imminent; the risk is highest within hours of TIA and declines steadily within the
ensuing days, weeks, and months [3]; nearly half of strokes occurring within the next 30
days occur within the first 24 hours after TIA. It is estimated that 12% to 30% of patients
report a history of TIA soon before their stroke and approximately a quarter of them
occur during the hours before the stroke [4,5]. TIA constitutes a true medical emergency.
Early initiation of preventive treatment for TIA (for instance within 24 hours instead of 20
 days) can reduce the 90-day risk of stroke by approximately 80% [6]. While rapid and
accurate diagnosis and urgent initiation of treatment are key to the management of TIA,
given that nearly one half of population reports a brief episode of focal loss of brain
function (either TIA or TIA-mimics) at one point in their lifetime. (Sorensen & Ay, 2011)4

4. What symptoms do you typically see with a right-sided stroke? Left-sided stroke? (give at least 4
examples for each)

Symptoms
Right-sided stroke Anomia
You may not recognize faces or pictures of familiar people or objects.
Attention span
You may be unable to focus attention on a conversation or tasks for long periods of time.
Denial
You may deny that you had a stroke. Some people even deny that their paralyzed arm or leg
belongs to them. They look at the paralyzed arm or leg and believe it belongs to someone else.
Neglect
You may ignore the left side of your body or your environment. This means you may not turn
to look toward your left side or you may not recognize things that are on your left.
Perseveration
You may have difficulty following instructions or answering many questions asked one right
after the other. You may repeat answers or movement even though a new instruction was
given or a new question asked.
Visual / spatial problems
You may have problems judging distance, size, position and rate of movement and how parts
relate to a whole.
("Effects of right-sided stroke")7

Left-sided stroke Aphasia

You may have problems with:
speaking
listening
reading
writing
dealing with numbers
understanding speech
thinking of words when talking or writing
How much trouble you have with aphasia depends on the type and severity of your brain injury.
Aphasia means you have problems speaking and understanding language. You may be unable
to find the words you need to put sentences together. This is like having a word 'on the tip of
your tongue.
Language apraxia
When you have language apraxia (aPRAYX-ee-a), you know the right words but you have
problems forming words or putting sounds together. Muscle weakness or loss of feeling does
not cause this.
("Effects of left-sided stroke")8
5. Define dysphagia. Without intervention, name 3 outcomes it can lead to.

-Difficulty swallowing (dysphagia) means it takes more time and effort to move food or liquid from your
mouth to your stomach. Dysphagia may also be associated with pain. In some cases, swallowing may be
impossible. (Dysphagia, 2014)1

Without intervention, Dysphagia can lead to:

1. Malnutrition
2. Aspiration Pneumonia
3. Choking

6. Besides stroke, name 3 other diseases can lead to oropharyngeal dysphagia.

1. Guillain- Barre syndrome2

2. Multiple Sclerosis2

3. Parkinsons2

(Yarrow 2017 Chapter 41 Power Point: slides: 29,32,34)2

7. What is rtPA and how does it work? Why wasnt it administered to this patient?

- Reticulated tissue plasminogen activator is an enzyme that breaks down blood clots allowing
for blood flow to return to the previously blocked off site. It needs to be administered within
4.5 hrs after onset of stroke. Our pt suffered from an intracerebral hemorrhagic stroke, so
you would want to control the bleeding, not administer a medication that would dissolve
blood clots.

8. The patient's Troponin level was high. Describe what this is and how it relates to strokes.

Levels of the cardiac muscle regulatory protein troponin T (cTnT) are frequently elevated in
patients with acute ischemic stroke and elevated cTnT predicts poor outcome and mortality. The
pathomechanism of troponin release may relate to co-morbid coronary artery disease and
myocardial ischemia or, alternatively, to neurogenic cardiac damage due to autonomic
activation after acute ischemic stroke. (Scheitz, et al., 2011)

9. What is the relationship between diabetes and risk of stroke?

- The relationship between Diabetes and stroke is increased plaque buildup seen in DM that
can lead to HTN and clots that can break free ( increased risk of clots breaking free due to
inflammatory state of DM)

10. The patient had a history of atrial fibrillation. What is the relationship of atrial fib to stroke risk?

Atrial fibrillation increases stroke risk because the rapid heartbeat allows blood to pool in the
heart, which can cause clots to form and travel to the brain. ("High Blood Pressure, Afib and
Your Risk of Stroke", 2016)10
11. There are many risk factors for stroke. List at least 3 of the major risk factors for a stroke? Considering
both modifiable and non-modifiable, list at least 4 risk factors for stroke found in the patient's history

-Major Risk Factors for a Stroke:

1. Hypertension
2. Smoking
3. Obesity
4. Coronary Heart Disease
5. Diabetes
6. Physical Inactivity
7. Genetics

-In the pts medical history it listed: Diabetes, HTN, Obesity, HLP, atrial fib, family history of
heart disease and stroke.

12. The patient exhibited hemiparesis on the right side of her face and her right leg. She experienced
hemiplegia on her right arm and hand. Describe what each of these are.

-Hemiparesis is weakness on one side of body that may cause the body to slump toward the
affected side; it may increase the patients risk for aspiration (Mahan, Escott-Stump, Raymond,
& Krause, 2012 pg.928)3

-Hemiplegia is paralysis to one side of the body.

13. Describe the 3 phases of swallowing including what happens in each stage. Which stage did the patient
have trouble with? Describe how you determined this. (2 pts)

Phase 1: Oral Phase (voluntary): Tongue presses food against the hard palate, forcing it toward
the pharynx.

Phase 2:Pharyngeal Phase (involuntary): Early: wave of peristalsis forces a bolus between the
tonsillar pillars. Middle: soft palate draws upwards to close posterior nares, and respirations
cease momentarily. Late: vocal cords approximate, and the larynx pulls upward, covering the
airway and stretching the esophagus open.

Phase 3: Esophageal Phase (involuntary): Relaxation of the upper esophageal (hypopharyngeal)

sphincter allows the peristaltic waves to move the bolus down the esophagus. (Mahan, Escott-
Stump, Raymond, & Krause, 2012 pg.930)3

-The patient had trouble with Phase 2. In the swallow study it state that the pt was able to form
a bolus ( phase 1) but had some retention of food in the pharynx (phase 2). There was some
aspiration with thin liquids which also indicates phase 2 because it is during this phase that the
larynx should pull up to cover the airway.
14. Complete the following chart Worth 2pts

Drug Purpose of Drug Food-Med Interactions Side Effects

Norvasc Antihypertensive, Antiangina,
Ca Channel Blocker,
dihydropyridine derivative
Low Na & cal
recommended, avoid
natural licorice,
Dysphagia, nausea, cramps, take
with food to avoid GI distress, low
BP w possible hypotension,
edema, dizziness, flushing,
drowsiness, palpitations, muscle
pain, rash, monitor BP

Lipitor Antihyperlipidemic (to lower Low fat, low chol,low cal if
chol or TG) needed caution with
grapefruit/related citrus-
avoid etoh, not with
lactation
Nausea, dyspepsia, abdominal
pain, constipation, diarrhea,
flatulence, not with active hepatic
disease or high ALT/AST-
myopathy, back pain, weakness,
headache, rash, dizziness, chest
pain, insomnia, bronchitis, low risk
of fracture due to low bone
resorption, Edema- lowers: chol,
triglycerides, LDL, VLDL, apoB,
coenzyme Q10 CRP raises: HDL ,
ALT, AST, alk phos CPK, myoglobin

Lasix Diuretic, Antihypertensive K depleting- take on empty
stomach as it lowers food
bioavailability- may take
with food/milk if GI
distress occurs. Supp with
K & Mg, low ca, Low Na-
Avoid natural Licorice-
limit alcohol- caution with
lactation- caution with DM,
raises glucose
Lowers K and Mg, Anorexia,
increased thirst, oral irritation,
cramps, N/V, diarrhea,
constipation, lowers BP with
possible hypotension, dizziness,
blurred vision, headache, rash,
weakness, photosensitivity,
muscle cramps, ototoxicity ( high
risk with parenteral) Rare: gout,
pancreatitis, hyponatremia
Dehydration w IV Lowers: K, Mg,
Na, Cl, Ca Raises: Glucose, BUN,
crea, uric acid, dyscrasis, anemia,
chol, LDL, VLDL, TG, - Increased
urinary excretion of water, K, Na,
CL, Mg, Ca, glucose
Zestril Antihypertensive, ACE inhibitor Ensure adequate fluid
intake/hydration, - Avoid
Salt substitutions- caution
with K supp.- Caution with
IV iron Avoid natural
Licorice
Betapace Antiarrhythmic Food lowers absorption by
20%- take consistently
with or without food,
Avoid natural licorice, Take
separately from Al, CA, Mg
antacids or Ca or Mg suppl
by atleast 2 hr Avoid
Etoh
Plavix (used Platelet Aggregation Inhibitor Food significantly raises
prior to stroke) bioavailability, rake with
food if GI distress occurs.
Anorexia, low wt reported,
dyguesia, dry mouth, N?V,
abdominal pain, constipation,
diarrhea, limit alcohol- not with
lactation, caution with low renal
or hepatic function, caution with
DM on insulin- lowers glucose,
caution with geriatric, lowers BP
with possible hypotension, cough,
dyspnea syncope, rash, dizziness
headache fatigue, muscle pain,
insomnia, angioedema,
pancreatitis,
hepatotoxicity/jaundice, acute
renal failure, SJS Raises: K, AST<
ALT< alk phos, bil, anemia, uric
acid, transient BUN, crea urinary
transient pro Lowers: Na, WBS,
rare-dyscrasias, +ANA, glucose in
DM on insulin
Wt changes, N/V, dyspepsia,
flatulence, not w/ lactation,
caution w/ DM, not with
hypokalemia or hypomagnesemia,
caution with low renal function or
CHF. Extreme caution with
dialysis, not with severe lower
renal func. High QT interval or
asthma/bronchospasm. Lower BP
with possple hypotension,
dizziness, fatigue, weakness,
headache, dyspnea, edema, rash,
bradycardia, syncope,
palpitations, proarrhythmia,
depression, peripheral vascular
insufficiency, visual changes,
paresthesia, bleeding. Rare: raises
AST, ALT dyscrasias
Dyspepsia, N/V abdominal pain, GI
bleeding/hemorrhage, diarrhea,
constipation, not with lactation,
caution with low hepatic function.
Increases risk of bleeding, pain,
flu-like symptoms, URTI, dizziness,
headache, purpura, HTN,
 Hypotension, fatigue, edema,
depression, nosebleed, gout,
cough, dyspnea, syncope,
palpitations, bradycardia, a fib,
insomnia, paresthesia, leg cramps,
fever, rash, bleeding, bruising,
Increase: Bleeding time, bil, AST,
ALT, chol, NPN, uric acid, Lowers
platelets, neutrophils,

II. Nutrition Assessment

15. What would be a recommended body weight range for Mrs. Youngers?

Wt: 230#, Ht: 64, BMI: 39.5 67yo 230# x .454= 104.4 kg bw 64x2.54 =162.6cm

64x.0254 = 1.63m 1.632 = 2.64m2

18.5 x 2.64m2=48.8kg ( 48.8 kg x 2.2 = 107.4#
24.9 x 2.64m2=65.7kg ( 65.7 kg x 2.2 = 144.6#

-recommended weight range : 107.4-144.6# IBW 120#

16. Estimate Mrs. Youngers energy and protein requirements for maintenance. Should her energy
requirements be lowered for weight loss while she is in the hospital? Why or why not?

Protein = 1.0g x 104.4kg = 104 g protein.

Energy needs: 20kcal/kg body weight/day : 20kcal x 104.4kg =2088kcal

- I went with 20 kcal/kg bw because the this number equals a slight kcal restriction.
Permissive underfeeding was used because the pt is obese, and has a low activity
level. I did not want to go any lower due to the fact that the pt has dysphagia so
she will likely have a hard time getting enough kcals/day as it is plus she will need
energy to perform at the many therapy sessions she will have each day.

17. Due to dysphagia and use of thickened liquids, it may be challenging to achieve recommended fluid
levels. Calculate Mrs. Youngers fluid requirements using ml/kg bw and ml/kcal.

230 x .454 = 104kg bw daily kcal: 2088

ml/kg bw: 30-35 ml/kg bw = 30ml x 104.5kg=3135ml

ml/kcal:: 1 ml/kcal = 2088 ml

III. Nutrition Therapy

18. Describe a bedside swallowing assessment. What is the educational background and training
requirements of a speech-language pathologist?

- The speech-language pathologist (SLP) will first physically examine and observe the patient to
see if they are able to maneuver their mouth in a manner consistent with chewing, swallowing
and drinking. If they pass this physical exam they will move on to the actual swallowing
assessment. This will start with thickened liquids moving to thinner consistencies, starting with
the smallest measurement and moving up as far as the pt can progress ( tsp moving up to a
tsp, tbsp, spoon and finally a cup) If the pt has no issues with the cup of thin liquid than they will
move on to introducing solid foods starting with the softest solids pureed) up to progress up to
small shopped foods and soft vegetables to larger pieces with firmer consistencies, than finally
try adding bread. Once a pt can no longer successfully progress through the stages, the exam is
halted and at this time the SLP can recommend an appropriate dysphagia diet level. (Chicones,
M, 2017)

- A master's degree in speech pathology, commonly known as speech-language

pathology (SLP), is the basic requirement to practice in all states, though some hold doctorates.
Many speech pathologists also obtain clinical experience, certification, and most
states require licensing. (Speech Pathology Education and Training Requirements).

19. Describe a modified barium swallow study.

- A video fluoroscopic swallowing exam (VFSE), also referred to as a modified barium swallow
exam (MBS), or simply a swallow exam, is a radiologic examination of swallowing function that
uses a special movie-type x-ray called fluoroscopy. The patient is observed swallowing various
consistencies and textures, ranging from thin barium to barium-coated cookies, in order to
evaluate his or her ability to swallow safely and effectively. This exam is often performed with a
speech-language pathologist present. (Radiological Society of North America (RSNA) and
American College of Radiology (ACR))

20. Thickened liquids are often needed to prevent aspiration. Give two examples of commercial products
used to thicken liquids and describe how they can be used in a patient's diet.

- Simply Thick is a gel that can be added to liquids to thicken the consistency. It comes in
single packets or a pump bottle. You mix it with the liquid according to directions to achieve
the appropriate level of thickness. It can also be used to thicken pureed foods.

- Thick- It is a powdered corn starch based thickener that you mix into liquids and pureed
food items. The company also offers a concentrated variety to achieve the same level of
thickness from less product which means less added carbohydrates and calories to the diet.

- Pureed food can be thickened and shaped to make it more visually appealing or just to
adjust the level of thickness.
21. Complete the following chart:

Fluid consistency Characteristic Comparable to:

Thin Will not hold shape Water, tea

Runs quickly through fork

prongs, minimal coating on
prongs

Nectar-like Will not hold shape, but leaves asyrup, tomato juice, apricot
residue nectar, creamed soups

Will coat the prongs and sinks

quickly through the prongs

Honey-like Will hold shape momentarily- Yogurt, honey

Coats fork and slowly sinks through

the prongs

Spoon-thick Scoop-able- maintains shape Pudding, mayonnaise

Remains on top of fork prongs

(http://www.agelessonline.net/wp-content/uploads/2014/12/fluid-consistencies1.jpg )
22. Complete the following charts a & b:(2 pts)
a. National Dysphagia Severity
NDD Severity Description
1: Severe dysphagia: NPO: Unable to
tolerate any P.O. safely or need
pudding thick pureed foods
2: Moderately severe dysphagia:
Maximum assistance or use of
strategies with partial P.O. only
(tolerates at least one consistency
safely with total use of strategies)
3: Moderate dysphagia: Total assist,
supervision, or strategies, two or
more diet consistencies restricted
4: Mildmoderate dysphagia:
Intermittent supervision/cueing,
one or two consistencies restricted
2 Characteristics of diet
May exhibit one or more of the following
Severe retention in pharynx, unable to clear
Severe oral stage bolus loss or retention, unable to clear
Silent aspiration with two or more consistencies,
nonfunctional volitional cough
Or unable to achieve swallow
May exhibit one or more of the following
Severe retention in pharynx, unable to clear or needs
multiple cues
Severe oral stage bolus loss or retention, unable to clear or
needs multiple cues
Aspiration with two or more consistencies, no reflexive
cough, weak volitional cough
Or aspiration with one or more consistency, no cough and
airway penetration to cords with one or more consistency,
no cough
May exhibit one or more of the following
Moderate retention in pharynx, cleared with cue
Moderate retention in oral cavity, cleared with cue
Airway penetration to the level of the vocal cords without
cough with two or more consistencies
Or aspiration with two consistencies, with weak or no
reflexive cough
Or aspiration with one consistency, no cough and airway
penetration to cords with one, no cough
Non-oral nutrition necessary
May exhibit one or more of the following
Retention in pharynx cleared with cue
Retention in the oral cavity that is cleared with cue
Aspiration with one consistency, with weak or no reflexive
 cough

Or airway penetration to the level of the vocal cords with

cough with two consistencies

Or airway penetration to the level of the vocal cords

without cough with one consistency

5: Mild dysphagia: Distant May exhibit one or more of the following

supervision, may need one diet
Aspiration of thin liquids only but with strong reflexive
consistency restricted
cough to clear completely

Airway penetration midway to cords with one or more

consistency or to cords with one consistency but clears
spontaneously

Retention in pharynx that is cleared spontaneously

Mild oral dysphagia with reduced mastication and/or oral

retention that is cleared spontaneously

6: Within functional limits/modified Normal diet, functional swallow

independence
Patient may have mild oral or pharyngeal delay, retention
or trace epiglottal undercoating but independently and
spontaneously compensates/clears

May need extra time for meal

Have no aspiration or penetration across consistencies

Full P.O: Modified diet and/or independence

7: Normal in all situations Normal diet - No strategies or extra time needed

(The Dysphagia Outcome and Severity Scale)

b. National Dysphagia Diet Level

NDD Level Used for severity level Description of diet

NDD1: Dysphagia-Pureed 1,2 Homogenous, very cohesive, pudding-like,

requiring very little chewing ability
NDD2: Dysphagia-Mechanical Altered 2,3 Cohesive, moist, semisolid foods, requiring some
chewing

Nectar thick liquids and ground meats

NDD3: Dysphagia-Advanced 3,4 Soft foods that require more chewing ability

NDD4: Regular 4,5,6,7 All foods allowed3

(Zwiefelhofer, D. RD, LD, Making Dysphagia Easier to Swallow)

IV. Nutrition Diagnosis

23. Select two nutrition problems and write a PES for both. (2 pts)

1. NC-1.1 Swallowing difficulty related to recent Intracerebral Hemorrhagic Stroke as evidenced by dx of

dysphagia, retention of some food swallowed in pharynx and some aspiration with thin liquids.

2. N.B-1.1 Food and nutrition related knowledge deficits related to lack of knowledge or education
regarding management of HTN as evidenced by does not follow sodium restricted diet, reported usual
consumption of hamburgers, casseroles, Pizza Hut and Wendys and dessert foods 3-4 times per week

V. Nutrition Intervention

24. For each of the PES statements you wrote, identify an Intervention using the IDNT Intervention terms
and codes. Describe your intervention with details. (2 pts)

1. ND-1.2.1 Texture Modified Diet: To help pt cope with dysphagia resulting from recent stroke.
Modify diet to comply with NDD 2, meats ground to no larger than inch, moistened with gravy
or sauce, nectar thick liquids, soft fruits and vegetables no larger than inch. No fibrous fruits
or vegetables. Breads should be pureed and gelled/thickened.

2. N.D.-1.2.11.7.2 decreased sodium diet: To help manage HTN to reduce the risk of subsequent
strokes. DASH diet: Reduced sodium, increase lean protein from poultry & fish( 6 oz or less) 4-5
daily servings of vegetables and fruits, 4-5 weekly servings of nuts and seeds 6-8 daily servings
of whole grains.

25. It was determined the patient's diet order was NDD 2 with ground meats and nectar thickened liquids.
Using the regular diet offered for the lunch meal, alter each food item to fit within the NDD2 diet and
state your reason for the modification. (2 pts)

Pork Slice, Buttered Noodles, Broccoli Cuts, Mandarin Oranges and Bananas, Dinner Roll, Red Velvet Cake

Food Item Modification Reason

Pork Slice Diced/ ground to pieces no larger than inch Add Some ability to chew but small enough
in gravy or sauce to easily form into bolus
Sauce/gravy added to moisten and
ease swallowing
Buttered Noodles Well cooked in sauce Well cooked will be softer and easier to
form into bolus with minimal chewing
Broccoli Cuts pureed Fibrous vegetable not normally allowed
even when well cooked and chopped
so pureed and thicken to nectar thick
consistency
Mandarin Oranges Pureed High pulp fruits not allowed so puree
and thicken to nectar thick consistency
Banana Well ripe banana No real modification, chop to ease
chewing.
Chopped into -1/2 pieces
Dinner Roll Pureed/ pre-gelled or slurried that are gelled Breads can require a lot of chewing
throughout entire thickness and may get stuck to the roof of the
mouth or pocketed. not normally
allowed so pureed and thicken
Red Velvet Cake Can be slurried with milk or softened with c milk To soften , avoid crumbly texture
which can be hard to swallow and clear
from mouth which increases risk for
aspiration.

26. The patient was approved for the Frazier water protocol. Describe why this program was developed,
what benefits it can provide for the patient, and an example of how it is implemented with patients. (2
pts)

-The protocol was developed because many patients on thickened liquids become dehydrated
and thickened liquids do not quench thirst. It was found that clean water even if aspirated
caused a low incidence of aspiration pneumonia, therefore it is better to provide thin water
(ideally after a mouth wash rinse & make sure no food has been pocketed or remain in the
mouth no water until 30 min after meals). This will also help combat sneaking of liquids that
may be harmful if swallowed or aspirated.

Criteria of inclusion:

Patients are NPO or currently taking honey or nectar thick liquids

Patients are able to swallow water without demonstrating excessive coughing and discomfort.

Patients are able to maintain alertness and arousal.

Patients are able to elicit a timely/efficient swallow (determined by SLP)

Patients are able to maintain upright posture

Criteria for Exclusion:

Fragile patients with acute pulmonary disorders or a history of recurrent aspiration

pneumonia will not be included.

Patients who are unable to get out of bed consistently will not be candidates.

Patients with a fever of unknown origin will be excluded.

Patients with thrush will be excluded until adequate treatment and resolution

(https://medicine.temple.edu/sites/medicine/files/files/PMR_presentation_skills_Free_Water_
Protocol.pdf )

27. The patient will receive in-patient rehab. Give examples of how each of the following professionals will
assist the patient in the rehab process. For each, provide at least one example of rehab you expected to
 see and one example of rehab the professional provides that surprised you. This resource is very helpful
but you may also use others. (2 pts)http://stroke.nih.gov/materials/rehabilitation.htm

Professional Expected Examples Surprising Examples

Physical Therapist Emphasizes practicing isolated movements, A recent trend in physical therapy emphasizes
repeatedly changing from one kind of the effectiveness of engaging in goal-directed
movement to another, and rehearsing activities, such as playing games, to promote
complex movements that require a great coordination.
deal of coordination and balance, such as
walking up or down stairs or moving safely
between obstacles. People too weak to
bear their own weight can still practice
repetitive movements during hydrotherapy

Occupational Therapist Relearn skills needed for performing self- Teach some survivors how to adapt to driving
directed activities (also called occupations) and provide on-road training.
such as personal grooming, preparing
meals, and housecleaning. They often
teach people to divide a complex activity
into its component parts, practice each
part, and then perform the whole
sequence of actions.

Speech Therapist help stroke survivors with aphasia relearn
how to use language or develop alternative
means of communication. They also help
people improve their ability to swallow,
and they work with patients to develop
problem-solving and social skills needed to
cope with the after-effects of a stroke.
Speech-language pathologists also help stroke
survivors develop strategies for circumventing
language disabilities. These strategies can
include the use of symbol boards or sign
language. Recent advances in computer
technology have spurred the development of
new types of equipment to enhance
communication.

Recreational Therapist Utilize a wide range of activity and Animal therapy, card games, scrapbooking,
community based interventions and dances, arts & crafts.
techniques to improve the physical,
(http://www.agecomfort.org/what-is-recreation-
cognitive, emotional, social, and leisure
therapy-and-the-top-10-activities-that-
needs of their clients. Recreational
you-can-do/)
therapists assist clients to develop skills,
knowledge, and behaviors for daily living
and community involvement.
(https://www.atra-online.com/what/FAQ)

Vocational Therapist They can help people with residual
disabilities identify vocational strengths and
develop rsums that highlight those
strengths. They also can help identify
potential employers, assist in specific job
searches, and provide referrals to stroke
Vocational therapists frequently act as mediators
between employers and employees to negotiate
the provision of reasonable accommodations in
the workplace.
 vocational rehabilitation agencies.

Most important, vocational therapists

educate disabled individuals about their
rights and protections as defined by the
Americans with Disabilities Act of 1990

(http://stroke.nih.gov/materials/rehabilitation.htm)

28. If Mrs. Youngers is able to achieve independent living status, describe the MNT for stroke that she
should be counseled on. Give at least 5 examples of recommendations and why they are important. (2
pts)

-The pt should be counseled on the National Dysphagia Diet level 2 (NDD 2). The diet should be
modified to follow stroke MNT guidelines:

1.Emphasis on poultry and fatty fish, lean cuts of meat: should be no larger that inch pieces
and served with a sauce or gravy to ease swallowing and reduce aspiration.

2.Reduced sodium intake to help lower BP and decreases HTN

3.Increased vegetable and fruit intake, with an emphasis on high potassium varieties such as :
bananas, apricots, spinach, sweet potatoes, tomatoes, etc. Low potassium levels increases
stroke risk. Avoid fibrous varieties and make sure all are cooked or ripen to a soft texture (easily
mashable with a fork) and no larger than inch pieces not prevent aspiration and ease
swallowing.

4.Nectar thickened liquids and avoid caffeine beverages. Thickened liquids to prevent aspiration,
avoid caffeine because it contributes to dehydration through excess urinary output. Thickened
beverages diet order often leads to inadequate fluid intake and does not aid in thirst quenching.
Caffeine will exasperate these conditions.

5. Increase unsaturated fats and decrease saturated fats. Limit to less than 25-35% of total
kcal/day. Saturated fats raise LDL which raises your risk for stroke. Unsaturated fats have been
shown to be protective by raising HDL levels while lowering LDL offering a protective quality.

29. Mrs. Youngers states her blood pressure prior to the stroke was not well controlled. What MNT
education would help the patient achieve improved blood pressure control? (give at least 4
recommendations and describe their impact 2 pts)
 HTN: DASH Diet and Weight Reduction

For overweight or obese adults with HTN, the RDN should counsel on a calorie-controlled DASH
dietary pattern for weight management and BP reduction. Research indicates that the DASH diet
with a sodium range of 1,500 mg to 2,400mg reduced systolic blood pressure (SBP) by 2mm Hg
to 11mm Hg and diastolic blood pressure (DBP) by 0mm Hg to 9mm Hg in overweight or obese
hypertensive adults, regardless of anti-hypertensive medications. DASH plus weight reduction
resulted in greater reductions in SBP of 11mm Hg to 16mm Hg and DBP of 6mm Hg to 10mm Hg
than weight reduction alone.

HTN: Sodium

The registered dietitian nutritionist ( RDN) should counsel on reducing sodium intake for blood
pressure ( BP) reduction in adults with hypertension ( HTN). Research indicates that lowering
dietary sodium intake to 1,500mg to 2,000 mg per day reduced systolic blood pressure ( SBP)
and diastolic blood pressure ( DBP) up to 12 mm Hg and 6mm Hg, respectively.

HTN: Physical Activity

The registered dietitian nutritionist ( RDN) should encourage adults with hypertension (HTN) to
engage in regular aerobic activity to lower blood pressure (BP). Physical activity should be of
moderate intensity to vigorous intensity three to four times per week for an average of 40
minutes per session. Research indicates that among adult men and women at all BP levels,
including individuals with HTN, aerobic physical activity decreases systolic BP and diastolic BP,
on average by 2 mm Hg to 5mm Hg and 1mm Hg to 4mm Hg, respectively. Typical interventions
shown to be effective for lowering BP include aerobic physical activity of, on average, at least 12
weeks of duration, with three to four sessions per week, lasting on average 40 minutes per
session and involving moderate-intensity to vigorous-intensity physical activity.

HTN: Duration and Frequency of Medical Nutrition Therapy (MNT) Encounters

To reduce BP in adults with HTN, the RDN should provide MTN encounters at least monthly for
the first year. After the first year, the RDN should schedule follow up sessions at least two to
three times per year to maintain reductions in BP. A strong body of research indicates that
reductions in systolic blood pressure (SBP) up to 10 mm Hg and in diastolic blood pressure (DBP)
up to 6mm Hg were achieved in the first three months of MNT provided every other week for at
least three sessions. Similar significant reductions in BP were reported at six to 12 months when
MNT was provided at least monthly, or with follow-up provided after five or more sessions.
Sustained reductions in BP for up to four years was reported when MNT was provided at least
two to three times per year. (EAL MNT Hypertension).

VI. Nutrition Monitoring and Evaluation

30. In addition to starting stroke rehab, the patient will begin MNT with the RD. For the first MNT visit with
the patient, list at least 4 things you will monitor using the IDNT Monitoring and Evaluation terms and
codes. State why you chose them. (2 pts)

FH-1.2.1.1 Oral Fluids: Dysphagia and thickened liquid diet often lead to inadequate fluid intake.

FH-1.1.1.1 Total Energy Intake: Dysphagia can lead to inadequate oral intake. Pt also is obese so
need to ensure overnutrition is not happening as well. Ensure proper range of kcal/day.

FH-1.5.5.1 Total Carbohydrate Intake: Pt is T2DM with recent high HbA1c levels. Need to ensure
proper carbohydrates intake to manage glucose levels. Thickeners prescribed for NDD 2
contribute to carbohydrate intake.

FH-7.2.2 Physical Ability to self-feed: Is Pt able to prepare own food according to diet order and
feed herself.

AD-1.1.2 Weight: Assess to help assess for Dysphagia related anorexia, overnutrition, proper wt
loss for obese individual or maintenance wt.

References:
1. Dysphagia. (2014, October 12). Retrieved April 03, 2017, from http://www.mayoclinic.org/diseases-
conditions/dysphagia/basics/definition/con-20033444

2. Yarrow 2017 Chapter 30 Power Point

3. Mahan, L. K., Escott-Stump, S., Raymond, J. L., & Krause, M. V. (2012). Krause's food & the nutrition
care process (13th ed.). St. Louis, MO: Elsevier/Saunders.

4. Sorensen, A. G., & Ay, H. (2011, May). Transient Ischemic Attack Definition, Diagnosis, and Risk
Stratification. Retrieved April 03, 2017, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3109304/
5. Stroke Signs and Symptoms. (2017, January 17). Retrieved April 03, 2017, from
https://www.cdc.gov/stroke/signs_symptoms.htm
6. The Internet Stroke Center. (n.d.). Retrieved April 03, 2017, from
http://www.strokecenter.org/patients/about-stroke/what-is-a-stroke/
7. Effects of right-sided stroke. (n.d.). Retrieved April 04, 2017, from
https://www.allinahealth.org/Health-Conditions-and-Treatments/Health-library/Patient-
education/Understanding-Stroke/Effects-of-stroke/Effects-of-right-sided-stroke/
8. Effects of left-sided stroke. (n.d.). Retrieved April 04, 2017, from
https://www.allinahealth.org/Health-Conditions-and-Treatments/Health-library/Patient-
education/Understanding-Stroke/Effects-of-stroke/Effects-of-left-sided-stroke/
9. Scheitz, J. F., Mochmann, H., Nolte, C. H., Haeusler, K. G., Audebert, H. J., Heuschmann, P. U., . . .
Endres, M. (2011, August 08). Troponin elevation in acute ischemic stroke (TRELAS) - protocol of a
prospective observational trial. Retrieved April 04, 2017, from
http://bmcneurol.biomedcentral.com/articles/10.1186/1471-2377-11-98
10. High Blood Pressure, Afib and Your Risk of Stroke. (2016, September). Retrieved April 04, 2017, from
http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/High-Blood-Pressure-
Afib-and-Your-Risk-of-Stroke_UCM_443852_Article.jsp#.WOOmkfnDHIU
11. Speech Pathology Education and Training Requirements. (n.d.). Retrieved April 04, 2017, from
http://study.com/speech_pathology_education.html
12. Chicones, M. (n.d.) How to do a Bedside Evaluation of Dysphagia Patients. Retrieved April 04, 2017,
from http://www.personal.psu.edu/mmc5057/blogs/mallory_chicones_e-
portfolio/How%20to%20do%20a%20Bedside%20Evaluation%20of%20Dysphagia%20Patients.pdf)
13. Radiological Society of North America (RSNA) and American College of Radiology (ACR). (n.d.). Video
Fluoroscopic Swallowing Exam (VFSE) - Modified Barium Swallow (MBS). Retrieved April 04, 2017,
from https://www.radiologyinfo.org/en/info.cfm?pg=modbariumswallow
14. The Dysphagia Outcome and Severity Scale (PDF Download Available). Available from:
https://www.researchgate.net/publication/12957975_The_Dysphagia_Outcome_and_Severity_Scal
e [accessed Apr 5, 2017].
15. Zwiefelhofer, D. RD, LD(n.d.) Making Dysphagia Easier to Swallow :The National Dysphagia Diet is 10
years old this year. Retrieved April 04, 2017, from https://www.dysphagia-
diet.com/Images/Making%20Dysphagia%20Easier%20to%20Swallow%2011.pdf
16. https://medicine.temple.edu/sites/medicine/files/files/PMR_presentation_skills_Free_Water_Proto
col.pdf
17. (http://stroke.nih.gov/materials/rehabilitation.htm)
18. Hypertension. (n.d.). Retrieved April 05, 2017, from
https://www.andeal.org/topic.cfm?menu=5285&cat=5582