CASE STUDY – ISCHEMIC

STROKE
PATIENT DESCRIPTION

 Mrs. R.N. is a 77-year-old woman admitted to the hospital with

right sided hemiparesis and slurred speech.
 Married and lives with her husband, Retired hair dresser
 Her weight is 165 lbs. and is 5’2’’ tall. No prior weights are
available.
 BMI is 30 and falls under obese class I category
 According to Hamwi formula her ideal body weight is 110Lbs.
% of ideal body weight is 150 (Red flag)
 She has a medical history of hypertension and hyperlipidemia
from past ten and two years respectively. She underwent a
hysterectomy ten years ago and does not use alcohol or
tobacco.
PATIENT DESCRIPTION
 She takes captopril 25mg twice daily for treating high blood
pressure, lovastatin 20mg once daily for treating high cholesterol
and triglycerides, multivitamin and calcium 500mg thrice daily at
home.
 Her husband states that his wife has a good appetite and has not
followed any special diet.
 She has been trying to avoid fried foods and stopped adding salt at
the table. She made these changes several years ago and has no
food allergies and previous nutrition therapy
DISEASE INFORMATION
 A stroke is a "brain attack". It occurs when blood flow to an area of brain is cut
off. Brain cells which are deprived of oxygen begin to die. Abilities controlled by
that area of the brain such as memory and muscle control are lost.
 Globally, the incidence of stroke due to ischemia is 68 percent, while the
incidence of hemorrhagic stroke (intracerebral hemorrhage and subarachnoid
hemorrhage combined) is 32 percent. In the United States, the proportion of all
strokes due to ischemia, intracerebral hemorrhage, and subarachnoid hemorrhage
is 87, 10, and 3 percent, respectively.
 Worldwide, stroke is the second most common cause of mortality and the third
most common cause of disability
 A hemorrhagic stroke is either a brain aneurysm burst or a weakened blood vessel
leak.
 Ischemic stroke occurs when a blood vessel carrying blood to the brain is blocked
by a blood clot.
SUSPECTED STROKE- ACT FAST
RISK FACTORS
LABORATORY FINDINGS

Chemistry Reference Range Date:8/12

Cholesterol (mg/dL) 120-199 210ꜛ

HDL-C (mg/dL) >55 F, >45M 40ꜜ

LDL (mg/dL) <130 155ꜛ

LDL/HDL ratio <3.22F, <3.55M 3.875ꜛ

Triglycerides (mg/dL) 35-135 F 198ꜛ

40-160 M
24 HR RECALL
BREAKFAST Orange juice 1 c
Raisin bran -1 c with 6 oz 2% milk
1 banana
8oz coffee with 2 tbsp 2% milk with
sweetener
Chicken tortellini soup (cheese tortellini
LUNCH cooked in chicken broth)- 2c
Saltine crackers-8
Canned pears- 2 halves
6 oz ice tea with sweetener
DINNER Baked chicken (with skin)-4-6 oz breast
Baked potato- 1 medium – with 2 tbsp
margarine
Steamed broccoli- approx.-1 c with 1 tsp
margarine
Canned peaches in juice- 6-8 slices
6 oz ice tea with sweetener
NUTRITIONAL REQUIREMENTS
According to Mifflin St. Jeor equation:
 TER (kcal/d) =1428.79Kcal
 Protein= For stroke 1-1.25g/kg
= 75-93g/day
 Fluid = Based on chronological age method
Age>75years=25ml/kg = 1925ml/day
DIETARY ANALYSIS

 Energy- 1820 Kcal

 Protein- 84g
 Carbohydrate-296g
 Fat-41g
Strengths of the Diet:
 Mrs. R.N. uses baking and steaming as a method of cooking rather than frying to reduce
the fat intake.
 She includes foods which are good sources of potassium such as banana and potato to
reduce blood pressure.
 Does not consume alcohol. Includes fruits in her diet (canned/ juice) and consumes foods
with good sources of fiber and iron.
Weakness of the Diet
 Consumes food made from refined grains such as tortellini and does not include enough
whole grains.
 Her current intake is approximately 5440 mg of sodium and 18g of saturated fat per day.
 High salt foods such as saltine crackers, cheese should be avoided.
 R.N. consumes vegetables but with added fat such as margarine.
 Skim, low fat or 1% fat milk should be consumed instead of 2% milk and avoid cheese
instead use low fat / low sodium options.
 Organ meats should be avoided such as breast chicken with skin and instead choose
healthier options such as skinless poultry, low sodium cold-cuts made with lean meat.
NUTRITION DIAGNOSIS
 Swallowing difficulty related to ischemic stroke as evidenced by
non- normal findings in cranial nerves, (CN VII) muscles of facial
expression, (nerve XII) tongue deviation and the need for NPO.
 Altered nutrition related lab values related to cardiac disease as
evidenced by high total cholesterol 210mg/dl, low HDL 40mg/dl,
high LDL 155mg/dl and high triglycerides 198mg/dl.
 Obesity Class I related to excessive energy intake as evidenced by
BMI 30 and 24hr recall.
Nutrition Intervention
 Start texture modified diet once feasible after consulting with the
speech language pathologist.
 Educate the patient on the Therapeutic Lifestyle Change diet and
provide a total fat intake of 25-35% of total Kcal recommended.
 Motivational interviewing to assist patient in making changes in
food related behaviors.
NUTRITION PRESCRIPTION
 Energy needs (Kcal/kg) = 25-30=1250-1500 Kcal/day
 Protein (gm/kg) = 1-1.25= 50-62.5g/day
 Total fat intake = 25-35% of total Kcal= 42-50g/day
 Total Saturated fat intake = <7% of total Kcal= <11g/day
 Carbohydrate intake = 50-60% of total Kcal= 172-207g/day
 Fluid (ml/kg) = 25=1925ml/day
Current Goals
 Patient to consume greater than 65% of daily meals within 3-5
days once the diet is started.
Nutrition Monitoring and Evaluation
 Will monitor nursing documentation flow sheets for percent
meal intake.
 Lab values warranting change with medical nutrition therapy.
 Will follow and adjust nutrition plan of care as medical
condition requires.
REFERNCES
 American Heart Association, 2018. Retrieved October 15, 2018 from
https://www.strokeassociation.org/STROKEORG/LifeAfterStroke/HealthyLivingAfterStroke/PhysicalAc
tivity/Get-Moving-and-Boost-Your-Brain-Power_UCM_453575_Article.jsp
 American Heart Association, 2018. Retrieved October 15, 2018 from
https://www.strokeassociation.org/STROKEORG/LifeAfterStroke/HealthyLivingAfterStroke/Nutrition/
Nutrition-Tips-for-Stroke-Survivors_UCM_308569_SubHomePage.jsp
 American Heart Association, 2018. Retrieved October 15, 2018 from
http://www.strokeassociation.org/STROKEORG/AboutStroke/About-
Stroke_UCM_308529_SubHomePage.jsp
 American Heart Association, 2018. Retrieved October 15, 2018 from
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Stroke-Risk_UCM_308539_SubHomePage.jsp
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REFERNCES
 National stroke Association, 2018. Retrieved October 13, 2018 from
http://www.stroke.org/understand-stroke/what-stroke
 Nelms, M. N., & Roth, S. L. (2014). Ischemic Stroke. Medical Nutrition Therapy, A case study Approach
(4th ed.). Cengage Learning.
 Nutrition Care Manual, 2018. Retrieved October 12, 2018 from
https://marywood1.marywood.edu:2499/client_ed.cfm?ncm_client_ed_id=98
 Pontes, É. S., Karênina, A., Jordão, D. F., Luiza, F., Heitmann, E., Azevedo, M., … Silva, C. (2017).
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 Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., …
Tirschwell, D. L. (2018). 2018 Guidelines for the Early Management of Patients With Acute Ischemic
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Stroke Association. Stroke, 49(3), e46–e110. https://doi.org/10.1161/STR.0000000000000158
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 Zheng, T., Zhu, X., Liang, H., Huang, H., Yang, J., & Wang, S. (2015). Impact of early enteral nutrition
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