Case Study 2 HTN

Objectives
After completing this case, the student will be able to:
1. Describe the physiology of blood pressure regulation.
2. Apply knowledge of the pathophysiology of hypertension and dyslipidemias to identify and
explain common nutritional problems associated with these diseases.
3. Explain the role of nutrition therapy as an adjunct to pharmacotherapy, surgery, and other
medical treatments of cardiovascular disease.
4. Interpret laboratory parameters for nutritional implications and significance.
5. Analyze nutrition assessment data to evaluate nutritional status and identify specific
nutrition problems.
6. Determine nutrition diagnoses and write appropriate PES statements.
7. Develop a nutrition care plan-with appropriate measurable goals, interventions, and
strategies for monitoring and evaluation that addresses the nutrition diagnoses of this case.

Mrs. Jane Langley is a 58-year-old retired nurse. For the past year, she has treated her newly
diagnosed hypertension with lifestyle changes including diet, smoking cessation, and exercise.
She is in to see her physician for further evaluation and treatment for essential Hypertension.
Blood drawn 2 weeks prior to this appointment shows an abnormal lipid profile.
Patient Summary: 58-year-old female here for evaluation and treatment for essential
hypertension and hyperlipidemia.
History:
Onset of disease: Mrs. Langley is a 58-year-old female who is a retired nurse. She was diagnosed
1 year ago, with Stage 2 (essential) HTN. Treatment thus far has been focused on
nonpharmacological measures. She began a walking program resulting in a 10-pound weight loss
that she has been able to maintain during the past year. She walks 30 minutes 4-5 times per
week, though she some times misses on weekends and on nights when she is volunteering for
her church. She was given a nutrition information pamphlet in the MD office outlining a lower-
Na diet. Mrs. Langley was a 2-pack a-day smoker but quit ("cold turkey") when her HTN was
diagnosed last year. No c/o of any symptoms related to HTN. Pt denies chest pain, SOB,
syncope, palpitations, or myocardial infarction.
Medical history: Not significant before Dx of HTN
Surgical history: None
Medications at home: None
Tobacco use: No-quit 1 year ago Alcohol use: 2-4 beers/wk
Family history: What? HTN. Who? Mother died of Ml related to uncontrolled HTN.

Demographics:
Marital status: Married; Spouse name: Steve Langley, 60 yo
Number of children: Children are grown and do not live at home.
Years education: College degree
Language: English
Occupation: No employment outside of home-retired nurse
Hours of work: Varies-volunteers several times per month
Household members: 2
Ethnicity: African-American
Religious affiliation: Roman Catholic

MD Progress Note:
Review of Systems
Constitutional: Negative
Skin: Negative
Cardiovascular: No carotid bruits
Respiratory: Negative
Gastrointestinal: Negative
Neurological: Negative
Psychiatric: Negative

Physical Exam
General appearance: Healthy, middle-aged female who looks her age
Heart: Regular rate and rhythm, normal heart sounds-no clicks, murmurs, or gallops
HEENT: Eyes: No retinopathy, PERRlA Genitalia: Normal female Neurologic: Alert and
oriented 3 Extremities: Noncontributory
Skin: Smooth, warm, dry, excellent turgor, no edema Chest/lungs: lungs clear Peripheral
vascular: Pulse 4+ bilaterally, warm, no edema Abdomen: Nontender, no guarding, normal
bowel sounds
Vital Signs: Temp: 98.6 Pulse: 80 Resp rate: 15 BP: 160/100 Height: 5'6"
Weight: 160 lbs BMI: 25.8
Assessment and Plan: Dx: Stage 2 HTN, heart disease, early COPD; here for initiation of
pharmacologic therapy with thi- azide diuretics and reinforcement of lifestyle modifications. R/O
metabolic syndrome.
Medical Tx plan: urinalysis; hematocrit; blood chemistry to include plasma glucose, potassium,
BuN, creatinine, fasting lipid profile, triglycerides, calcium, uric acid; chest X-ray; nutrition
consult; 25 mg hydrochlorothiazide daily; 2.5 mg Altace daily 1 week; 5 mg Altace daily 3
weeks and then 10 mg Altace daily thereafter; evaluate for initiation of HMG-CoA reductase
inhibitor therapy; f/u on 3months.
Nutrition:
General: Mrs. Langley describes her appetite as very good. She does the majority of grocery
shopping and cooking, although Mr. Langley cooks breakfast on the weekends. She usually eats
3 meals each day, but on her volunteer nights, she may skip dinner. When she does this, she is
really hungry when she gets home in the late evening, so she often eats a bowl of ice cream
before going to bed. The Langleys usually eat out on Friday and Saturday evenings at pizza
restaurants or steakhouses (Mrs. Langley usually has 2 regular beers or 2 glasses of wine with
these meals). She mentions that last year when her HTN was diagnosed, the MDs office gave
her a sheet of paper with a list of foods to avoid for a lower-salt diet. She states that she certainly
is familiar with a low-salt diet from when she practiced as an RN. She and her husband tried to
comply with the diet guidelines, but they found foods bland and tasteless, and they soon
abandoned the effort.
24-hour recall:
AM: 1 c coffee (black)
Oatmeal (1 instant packet with 1 tsp margarine and 2 tsp sugar)
1 c orange juice
Snack: 2 c coffee (black)
1 glazed donut
Lunch: 1 can Campbells tomato bisque soup prepared with milk 10 saltines
1 can diet cola
PM: 6 oz baked chicken (white meat, no skin; seasoned with salt, pepper, garlic)
1 large baked potato with 1 tbsp butter, salt, and pepper 1 c glazed carrots (1 tsp sugar, 1
tsp butter) Dinner salad with ranch-style dressing (3 tbsp)lettuce, spinach, croutons,
sliced cucumber 2 regular beers
HS snack: 2 c buttered popcorn
Food allergies/intolerances/aversions: None
Previous nutrition therapy? Yes. If yes, when: 1 year ago.
Where? MDs office.
Food purchase/preparation: Self and usband
Vit/min intake: Multivitamin/mineral daily
Laboratory Results (Cont inued)

12/14 3/15
Ref. Range 6/25 (6 mos. later) (9 mos. later)
Hematocrit (Hct, %) 37-47 F 45 44 44
41- 51 M
Urinalysis
Collection method - rand. rand. rand.
spec. spec. spec.
Color - pale pale pale
yellow yellow yellow
Appearance - clear clear clear
Specific gravity 1.001- 1.035 1.025 1.021 1.02 4
pH 5-7 7.0 5.0 6.0
Protein (mg/dl) Neg Neg Neg Neg
Glucose (mg/dl) Neg Neg Neg Neg
Ketones Neg Neg Neg Neg
Blood Neg Neg Neg Neg
Bilirubin Neg Neg Neg Neg
Nitrites Neg Neg Neg Neg
Urobilinogen (EU/dl) < 1.0 0.02 0.01 0.09
Leukocyte esterase Neg Neg Neg Neg
Prat chk Neg Neg Neg Neg
WBCs (IHPF) 0-5 0 0 0
RBCs (IHPF) 0-2 0 0 0
Bact 0 0 0 0
Mucus 0 0 0 0
Crys 0 0 0 0
Casts (ILPF) 0 0 0 0
Yeast 0 0 0 0
Note: Values and units of measurement listed in these tables are derived from several resources. Substantial variation
exists in the ranges quoted as "normal" and these may vary depending on the assay used by different laboratories.
Sandy Le
DIE3213 TR 9:25-10:40 am
Case Study #2
11/4/17

Instructions: Please complete each question listed below. Be thorough in answering these
questions. With any calculations, please show your work. Use any resources available to
complete these questions; Make sure to look up any unfamiliar terms or concepts. Must
reference all answers in AMA format at the end of the document under a page titled
references. Answers can be typed directly onto this document leave the question and place
answers below each question. Please uploaded case study to Canvas prior to due date.

I. Understanding the Disease and Pathophysiology (30 points)

1. Define arterial blood pressure (BP) and explain how it is measured.

Arterial blood pressure is the pressure of the blood within an arterial vessel, typically the brachial
artery in the upper arm. It is measured using a sphygmomanometer on the upper arm. The systolic
and diastolic pressures that are measured represent the pressure within the brachial artery, which
is slightly different than the pressure found in other distributing arteries. It is calculated over a
cardiac cycle and determined by the cardiac output, systemic vascular resistance, and central
venous pressure.1, 2

2. Discuss briefly the mechanisms that regulate arterial blood pressure including the
sympathetic nervous system, the reninangiotensinaldosterone system (RAAS), and renal
function.
The renin-angiotensin system or RAS regulates blood pressure and fluid balance in the body.
When blood volume or sodium levels in the body are low, or blood potassium is high, cells in the
kidney release the enzyme, renin. Renin converts angiotensinogen, which is produced in the
liver, to the hormone angiotensin I. An enzyme known as ACE or angiotensin-converting
enzyme found in the lungs metabolizes angiotensin I into angiotensin II. Angiotensin II causes
blood vessels to constrict and blood pressure to increase. Angiotensin II stimulates the release of
the hormone aldosterone in the adrenal glands, which causes the renal tubules to retain sodium
and water and excrete potassium. Together, angiotensin II and aldosterone work to raise blood
volume, blood pressure and sodium levels in the blood to restore the balance of sodium,
potassium, and fluids. If the renin-angiotensin system becomes overactive, consistently high
blood pressure results. The sympathetic nervous system employs two distinct neural systems that
affect blood pressure, known as the alpha-adrenergic and beta-adrenergic systems. The alpha-
adrenergic neurotransmitters and receptor systems affect blood vessels by causing them to
constrict, whereas the beta-adrenergic system affects both the heart and the blood vessels. Beta-
adrenergic activity leads to increased heart pumping action (increased heart rate) as well as
vasodilation of blood vessels. This combination of neural influences represents an adaptive
response, as the increased blood flow caused by the increase in heart rate needs more space in the
vasculature in order for blood pressure to be properly regulated. The parasympathetic nervous
system influences only the heart via the vagal nerve, which results in slowed heart rate.3, 4

3. What is essential hypertension? What is the etiology?

Essential hypertension is high blood pressure that doesnt have a known secondary cause. It is also
referred to as primary hypertension. Hypertension occurs when the force of blood is stronger than
it normally should be. Most cases of high blood pressure are classified as essential hypertension.
The other kind of hypertension is secondary hypertension. Secondary hypertension is high blood
pressure that has an identifiable cause, such as kidney disease. Factors that can affect blood
pressure are how much water and salt a person has in their body, the condition of your kidneys,
nervous system, or blood vessels, and the levels of different hormones. A person who is older is
more likely to have hypertension. This is because their blood vessels will become stiffer, and
when this happens, the blood pressure will rise. Risk of hypertension include being of African
American decent, obese, often stressed or anxious, consuming too much alcohol, have a family
history of high blood pressure, have diabetes, or smoke.5,6

4. What are the common symptoms of essential hypertension?

Most of the time, there are no symptoms. In most people, high blood pressure is found when they
visit their health care provider and have it measured. Because there are no symptoms, people can
develop heart disease and kidney problems without knowing they have high blood pressure. If a
person has severe headaches, nausea or vomiting, confusion, changes in vision, or nosebleeds you
may have a severe and dangerous form of high blood pressure called malignant hypertension.6

5. Using the JNC 8 guidelines, how is the diagnosis of hypertension made? What blood
pressure readings are used to identify normal BP, stage 1 hypertension, and stage 2
hypertension?
A diagnosis of hypertension is made according to the JNC 8 guidelines by a blood pressure
reading higher than 140/80 mmHg. There is also a diagnostic workup of Hypertension, such as
assessing risk factors and comorbidities, revealing identifiable causes of hypertension, assess the
presence or target organ damage, conduct history and physical examination, obtain laboratory
test; urinalysis, blood glucose, hematocrit, and lipid panel, serum potassium, creatine, and
calcium. Optional laboratory tests can be urinary albumin/creatinine ratio. Lastly, to diagnose
hypertension, obtaining an electrocardiogram would be a good idea. Blood pressure readings that
are used to identify normal blood pressure are if the systolic blood pressure <120 and a diastolic
blood pressure < 80. Normal readings for hypertension stage 1 is systolic BP between 140 and
159 and a diastolic BP between 90-99. Whereas a normal reading of hypertension stage 2 is a
systolic BP >160 and a diastolic BP >100.7

6. List the risk factors for developing hypertension. What risk factors does Mrs.
Langley currently have? Discuss the contribution of ethnicity to hypertension,
especially for African Americans.
The risk factors for developing hypertension are unknown for primary hypertension or
essential hypertension. Thought the cause is unknown, it may be a result from individual
differences within the renin-angiotensin-aldosterone control of blood pressure, differences
in identified genes that affect sodium retention, and lifestyle choices that exacerbate the
problem. Lifestyle factors associated hypertension include diet, such as excess sodium
intake, low potassium intake, excessive alcohol intake, while other factors include lack of
exercise, smoking stress, and obesity. Secondary hypertension occurs as a result of another
primary problem, such as kidney disease, other cardiovascular diseases, endocrine disorders,
or neurogenic disorders. The risk factors that Mrs. Langley currently have are that his BP is
160/100 mmHg while consuming an excess amount of alcohol. The contribution of ethnicity
to hypertension, especially for African Americans are that the rates are highest among the
blacks, 43.0% for males, and 45.7% for females. The prevalence among whites, 33.0% men
and 31.1% for women. Mexican Americans have the lowest reported rates at 27.8% and
28.9% for males and females. Filipinos and South Asians, in contrast, have been identified
as ethnic groups with higher prevalence of hypertension.7
7. What are the four major modes of treatment for hypertension?
The four major modes of treatment for hypertension are medication, nutrition therapy, weight loss,
and lifestyle changes. The goals for treatment are to reduce the risk of cardiovascular and renal
disease and reduce the BP to <140/80 mmHg. This is achieved through a comprehensive plan
involving weight loss, physical activity, and medication intervention.7, 16

8. Dr. West indicated in his note that he will rule out metabolic syndrome. What is
metabolic syndrome?
A cluster of conditions that increase the risk of heart disease, stroke, and diabetes. Metabolic
syndrome includes high blood pressure, high blood sugar, excess body fat around the waist, and
abnormal cholesterol levels. The syndrome increases a person's risk for heart attack and stroke.8

9. What factors found in the medical and social history are pertinent for determining
Mrs. Langleys coronary heart disease (CHD) risk category?
Coronary heart disease is a general term for causes of heart disease characterized by
narrowing of vessels supplying blood to the heart. The factors found in the medical and
social history that are pertinent for determining Mrs. Langleys coronary heart disease risk
category are that she was diagnosed with hypertension, has a heavy smoking history, and
a high LDL.7

10. How is hypertension related to other cardiovascular disorders? What are the
possible complications of uncontrolled or untreated hypertension?
Hypertension is related to other cardiovascular disorders because it is both a
cardiovascular condition and a risk factor for other forms of cardiovascular disease. An
increase in BP increases the forces applied to the endothelium and can cause the
initiation of an atherosclerotic lesion. Atherosclerosis which is cause of coronary heart
disease. The disease, atherosclerosis, begins as a response to injury that results in an
inflammatory process. The injury is damage to the endothelial lining of the arterial wall,
which may be caused by pressure on the wall exerted by the blood, as a result of
hypertension, or by vasospasm.7

II. Understanding the Nutrition Therapy (15 points)

11. Briefly describe the DASH eating plan and discuss the major nutrients that are
components of this nutrition therapy.
The DASH eating plan is examines the effect of diet on blood pressure in individuals with
hypertension. These clinical trials focused on a diet composed of a variety of foods that not
only reduced sodium intake but increased potassium, magnesium, calcium, and fiber intakes
within a moderate energy intake.7

12. Using 2015 Dietary Guidelines, describe why decreased sodium intake is targeted as a
focus to improve the health of Americans.
Sodium is an essential nutrient for normal body function. It plays a major role in the regulation
of body fluids, in partnership with potassium and chloride. Together, these three maintain proper
body water distribution and blood pressure. The rationale behind sodium restriction is based on
the numerous studies conducted showing decreases in BP due to low sodium diets. However,
sodium has many effects on physiology aside from controlling blood pressure. These other
effects can be negatively impacted when sodium intake is reduced such as causing an electrolyte
imbalance by offsetting the sodium potassium pump.16

13. What do the current literature and the Evidence Analysis Library (EAL) indicate
 regarding the role of sodium intake in the control of hypertension? Is there a significant
correlation between sodium intake and cardiovascular risk?
The current literature and the EAL indicate regarding the role of sodium intake in the control
of hypertension are the sodium range of 1,500mg to 2,400mg in the DASH diet, reduced
systolic blood pressure (SBP) by 2.0mmHg to 11mmHg and the diastolic blood pressure (DBP)
by 0.0mmHg to 9.0mmHg in overweight or obese adults with hypertension regardless of the
anti-hypertension medications. There is a significant correlation between sodium intake and
cardiovascular disease (CVD) because sodium elevates blood pressure known to be associated
with increased the risk of CVD.10, 11

14. What is the Mediterranean diet? How might this dietary approach be appropriate
for Mrs. Langley? Would this be culturally appropriate for her?
The Mediterranean diet is full of healthy fats, whole grains, legumes, fish and produce, with
moderate amounts of wine, has been shown to be one of the healthiest ways to eat. It's been
linked to better heart health and lower risk of obesity. Luckily, it's just as nice on your taste
buds as it is on your health. This dietary approach might be appropriate for Mrs. Langley
because it has been known to have a positive effect on a range of medical conditions beyond
mortality due to cardiovascular disease. Increasing evidence suggests it could counter
diseases associated with chronic inflammation, including metabolic syndrome,
atherosclerosis, cancer, diabetes, obesity, pulmonary diseases and cognition disorders. The
diet would not be culturally appropriate for Mrs. Langley, but looking back at her 24-hour
recall, she does not seem to be eating many culturally known food items, so suggesting this
diet would be fine.12, 13

15. Lifestyle modifications reduce blood pressure, enhance the efficacy of antihypertensive
medications, and decrease cardiovascular risk. List lifestyle modifications that have been
shown to lower blood pressure.
Lifestyle modifications that have been shown to lower blood pressure are maintaining a normal
body weight with a body mass index between 18.5-24.9, adopt a DASH diet, consume no more
than 2400 mg of sodium/day. A lower intake of sodium is always better. Engage in regular
aerobic physical such as brisk walking, and limit consumption of alcohol to no more than two
drinks per day.7

III. Nutrition Assessment (40 points)

16. What are the health implications of Mrs. Langleys body mass index (BMI)?
Mrs. Langley is 56 with a BMI of 25.8. The health implications of Mrs. Langleys BMI are she
is overweight and her waist circumference should be measured. She should also think about losing
weight through the DASH diet.7

17. Calculate Mrs. Langleys energy and protein requirements.

(Total kcals = 3218.71)

Grams consumed Factor Answer/Total Kcals Percentage

Carbohydrate 283.64 4 1134.56/3218.71 35%
Protein 89.24 4 356.96/3218.71 11%
Lipid 164.91 9 1484.19/3218.71 46%
 It is recommended to have carbohydrates at 45-60%, Protein at 20-35%, and Fat 10-15% of
total daily calories. These percentages show low carbs and protein and too high fat.16
72.7kg, 167.6cm
Harris Benedict Equation
Resting Energy Expenditure for females:
655.1 + (9.6 x 72.7kg) + (1.9 x 167.6cm) (4.7 x 54yrs)
655.1 + 697.92 + 318.44 253.8 = 1417.66 kcals
Total daily energy expenditure:
1417.66 (REE) x 1.375 (activity factor) = 1949.28 kcals

18. Identify the major sources of sodium and saturated fat in Mrs. Langleys diet.
Compare her typical diet to the components of the DASH diet.
The major sources of sodium and saturated fat in Mrs. Langleys diet are Campbells soup,
ranch dressing, croutons, buttered popcorn, and the glazed donut. Her typical diet compared to
the components of the DASH diet show she does not consumes to much sodium, and saturated
fat. She needs to incorporate more grains, vegetables, fruit, nuts, healthier fats and oils, and a
smaller portion of sweets.7

19. What dietary assessment tools that target nutrients known to be associated with
hypertension and CVD risk might be useful in assessing Mrs. Langleys diet?
The dietary assessment tools that target nutrients known to be associated with hypertension and
CVD risk that might be useful in assessing Mrs. Langleys diet are the food/nutrient related
history, client history, anthropometric measurements, and biochemical data.7

20. From the information gathered within the intake domain, list possible nutrition
problems using the diagnostic terms.
The possible nutrient problems from looking at the intake domain, using the diagnostic
terms are excessive sodium and fat intake, inadequate fiber intake, and predicted inadequate
nutrient intake. Excessive energy intake, Excessive fat intake, Excessive protein intake,
Excessive carbohydrate intake, Inadequate fiber intake, and Inadequate mineral intake
(magnesium, potassium, calcium, and zinc). 7, 16

21. Dr. West ordered the laboratory tests listed in the following table. Complete the
table with Mrs. Langleys values from 6/25 and the potential cause of any
abnormalities.7

Parameters Pts Values Normal Value Reason for Abnormalities

Glucose 101 77-99 Impaired fasting glucose, poor diet
BUN 20 6-20 Poor diet, hypertension
Creatinine 0.9 0.6-1.1 Poor diet, hypertension
Total Cholesterol 270 <200 Poor diet, hypertension
HDL-Cholesterol 30 >59 Poor diet, hypertension
LDL-Cholesterol 210 <130 Poor diet, hypertension
Apo A 75 80-75 Poor diet, hypertension
Apo B 140 45-120 Poor diet, hypertension
Triglycerides 150 35-135 Poor diet, hypertension
 22. Go to http://cvdrisk.nhlbi.nih.gov/. Using this online calculator, determine Mrs.
Langleys risk of CVD based on her lipid profile. Are there other factors that contribute
to her CVD risk?
CVD is caused by plaque build up inside the arteries. This occurs when fat consumption is
high and causes a narrowing of the arteries. Her lipid profile indicates that she is at high risk
for developing CVD along with many other conditions related to a high fat diet and
overweight/sedentary lifestyles.16

23. How do Mrs. Langleys labs change between 6/25 and 3/15? What factors in her
history may have made an impact on these?

Mrs. Langleys lab changed between 6/25 and 3/15 by having a decrease in her glucose, BUN,
total cholesterol, LDL-cholesterol, Apo B, and triglycerides. Whereas there is an increase in
creatinine, HDL-cholesterol, and Apo A. The factors in her history may have an impact on these
are her smoking history, Pt denies chest pain, SOB, syncope, palpitations, or myocardial
infarction.16

24. Indicate the pharmacological differences among the antihypertensive agents listed
below.

Medication Mechanism of Action Nutritional side effects and

Contraindications
Diuretics Decrease blood volume by Hypokalemia, hyperuricemia,
increasing urinary output; inhibit anorexia, N/V, diarrhea,
renal sodium and water constipation. Avoid natural
reabsorption.7 licorice. Avoid excessive
potassium intake.7
Beta blockers Block beta-receptors in heart to Nausea, diarrhea. Calcium may
decrease heart rate and cardiac interfere with absorption. Dry
output.7 mouth, gas or bloating. May mask
hypoglycemia.7
Calcium Channel Blockers Affect the movement of calcium, Edema, nausea, heartburn.
cause blood vessels to relax; Contraindications: heart failure or
therefore, reduce greater that first degree heart
vasoconstriction.7 block. Avoid natural licorice, limit
caffeine, avoid or limit alcohol.7
Ace inhibitors Vasodilators that reduce BP by Hypotension, especially in older
decreasing peripheral vascular patients. Can worsen renal
resistance by interfering with the function, hyperkalemia, dyspepsia.
reduction of angiotensin 1 and Causes dry, nonproductive cough,
inhibiting degradation of hyperkalemia. Contraindications:
bradykinin.7 pregnancy. Avoid natural licorice,
avoid salt substitutes. Side effects
increased in African Americans.7
Angiotensin 11 receptor Interfere with renin-angiotensin Nausea. May increase serum
Blockers system without inhibiting potassium, avoid salt substitutes.
degradation of bradykinin.7 Avoid natural licorice, caution
with grapefruit.7
Alpha Adrenergic Blockers Block the vascular muscle N/V, diarrhea, constipation, mouth
response to sympathetic dryness. Avoid natural licorice.7
stimulation; reduce stroke
 volume.7
25. What are the most common nutritional implications of taking hydrochlorothiazide?

This type of medication inhibits the resorption of sodium, chloride and potassium. One of the most
common side effects is fluid and electrolyte imbalance since the medicine works quickly to remove
excess fluids from the body. This imbalance can lead to excessive thirst, muscle cramping, and
involuntary spasms. Low potassium levels can cause lightheadedness, dizziness and irregular
heartbeats. It can also cause constipation from lack of fluid. It can cause an increase in glucose,
triglycerides, calcium, cholesterol and uric acid levels.16

26. Mrs. Langleys physician has decided to prescribe an ACE inhibitor and an HMG-
CoA reductase inhibitor (Zocor). What changes to Mrs. Langleys labs between 6/25 and
3/15, if any, would you attribute to Zocor use?
The ACE inhibitor will decrease the vascular resistance and increase cardio output resulting in a
decrease in BP. This will have no important affect on plasma lipids. HMGCoA reductase
inhibitors play a central role in the production of cholesterol in the liver and work to prevent
diseases such as CVD, diabetes and HTN. On average, these statins can lower LDL cholesterol
and help raise HDL cholesterol.16

27. From the information gathered within the clinical domain, list possible nutrition
problems using the diagnostic terms.

Overweight indicated by high BMI. Excessive energy intake, Excessive fat intake, Excessive
protein intake, Excessive carbohydrate intake, Inadequate fiber intake, and Inadequate
mineral intake (magnesium, potassium, calcium, and zinc). 16

IV. Nutrition Diagnosis (5 points)

28. Select two nutrition problems and complete the PES statement for each.
1. Excessive fat intake related to a high fat diet as evidenced by BP and cholesterol levels.16
2. Not ready for diet changes related to poor food choices as evidenced by the 24-hour recall.16

V. Nutrition Intervention (10 points)

29. When you talk with Mrs. Langley on 3/15, you ask how much weight she would like to
lose. She tells you she would like to weigh 125, which is what she weighed most of her
adult life. Is this reasonable? What would you suggest as a goal for weight loss for Mrs.
Langley? How quickly should Mrs. Langley lose this weight?

I would tell her that for her height, her ideal body weight would be 130 and that anything either
10% above or below that number is healthy. I would want to work on achieving a weight that
lowered her BMI to within the healthy range and then go from there depending on how good she
feels and if the plan she is on is working well for her. I would recommend setting reasonable goals
for her to achieve in small increments and then that way she can feel a sense of accomplishment
with each one. First, I would suggest trying to lose an initial 10 pounds to get her within the healthy
BMI. Then I would want to re-evaluate her and see where her mind set is after each goal is
accomplished and continue.16

30. For each of the PES statements that you have written, establish an ideal goal (based
on the signs and symptoms) and an appropriate intervention (based on the etiology).
1. A goal would be to cut out or substitute the high fat items that she typically loves to eat. The
intervention would include nutrition education about high fat foods and offer lists of flavorful
or beneficial substitutions.16
2. Goals would revolve around her changing her attitude about her conditions and the way her
lifestyle is affecting them. I would want to educate her on why her diet and exercise is so
important in her situation and would try my best to impress the urgency in her making these
changes.16

31. List your major recommendations for dietary substitutions and/or other changes that
would help Mrs. Langley reach her medical nutrition therapy goals, to be consistent with
the DASH diet and sodium intake guidelines.
Her major sources of saturated fat include margarine, butter, milk, chicken, saltine crackers,
ranch salad dressing, donut and ice cream. I would suggest that she cut out her butter and
margarine intake along with majorly decreasing her sweet intake and their portion sizes. She
could also drink fat free milk instead of 2% and use a fat free dressing or substitute it for a
vinaigrette with much less fat. All these changes can dramatically help decrease her saturated fat
levels along with her overall fat intake.16

32. Your appointment with Mrs. Langley on 3/15 is concluded. What would you
want to reevaluate at her next follow-up appointment?
I would want to re-evaluate her whole lipid profile to see if there were any decreases in her fat and
cholesterol levels. I would also like to compare the lab values with another 24 hour recall to see if
she has been following the recommended diet suggestions and give her ideas for areas of
improvement. I would also want to test her blood glucose to see if her risk for CVD has decreased
or not.16
 References
3. Boundless. Systemic Blood Pressure. Systemic Blood Pressure | Boundless Anatomy and
Physiology. https://courses.lumenlearning.com/boundless-ap/chapter/systemic-blood-pressure/.
Accessed October 27, 2017.
4. Arterial Blood Pressure. Image for Cardiovascular Physiology Concepts, Richard E Klabunde PhD.
http://www.cvphysiology.com/Blood%20Pressure/BP002. Accessed October 27, 2017.
5. The Renin-Angiotensin System and Blood Pressure Control. UKRO Funding kidney research today
for a healthier tomorrow. http://ukrocharity.org/kidney-disease/the-renin-angiotensin-system-and-
blood-pressure-control/. Accessed October 27, 2017.
6. The Role of the Nervous System in Blood Pressure - Regulation of Blood Pressure -. Severe
Hypertension .net. http://www.severehypertension.net/hbp/more/the-role-of-the-nervous-system-
in-blood-pressure/. Accessed October 27, 2017.
7. Kivi R. Just the Essentials of Essential Hypertension. Healthline.
https://www.healthline.com/health/essential-hypertension#overview1. Published September 14,
2017. Accessed October 27, 2017.
8. The New York Times. http://www.nytimes.com/health/guides/disease/essential-
hypertension/overview.html. Accessed October 27, 2017.
9. Nelms MN. Nutrition therapy and pathophysiology. Boston, MA: Cengage learning; 2016.
10. What Is Metabolic Syndrome? National Heart Lung and Blood Institute.
https://www.nhlbi.nih.gov/health/health-topics/topics/ms. Published June 22, 2016. Accessed
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11. Nothing
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