Heart Failure Case Study Name____________Jeremy

Bartel_________
Instructions: Pease type a answers. Submt a paper copy of ths case
study n cass and an eectronc copy of the case study through Backboard.
You may need to ook up terms and abbrevatons ncuded n the case study.
In addton to the questons reated to ths case study, you w need to out
the nutrton documentaton form (Swedsh Medca Center Nutrton
Assessment form). Brng the typed case study wth you to cass on the due.
PRESENTATION OF INESS
A 70-year-od mae presents to the emergency room companng of
breathessness for the past three days. Cardac hstory s postve for a
myocarda nfarcton three years ago foowed by four-vesse coronary artery
bypass surgery. The patent has been asymptomatc snce surgery wth no
compants of chest pan.
Over the ast three months PTA, the patent notes onset of shortness of
breath whe unoadng groceres, wakng stars, and other strenuous ADLs.
Two weeks ago, he was unabe to compete hs day one-me wak at the hgh
schoo track. He noted sweng n hs feet and ankes. Four days PTA he woke
at 2 am short of breath and had to seep n hs recner the rest of the nght.
He has been unabe to ay at n bed at nght snce then and has sept on 3
pows. Yesterday, he became breathess wakng from one room to another.
He presents today wth extreme shortness of breath. He denes chest pan.
PAST !E"ICA HISTOR#
Seep apnea (but he does not ke to wear hs b-pap machne at nght). MI n
2011, CABG x 4 vesse n 2011. SOB PTA for 3 months. Vague hstory of
hyperchoesteroema. Hstory of HTN. Surgca hstory aso postve for
nguna herna repar 15 years pror.
Current !edications
Lptor, Zocor, Coumadn, coreg

Aller$ies
NKDA
Ha%its
Waks one me day unt one week PTA. Smoked 1ppd unt 2011. 30
pack/year hstory. ETOH- 3-4 drnks day. Works 8-12 hours/day n a grocery
store.
Family History
Father ded at 60 - sudden death of unknown cause, no CAD documented.
Mother A&W at 92 wth D|D ony.
Sster ded at 58 wth AMI.
No other sbngs. 2 chdren, A&W.
Social History
Owns and manages own grocery store. Lves wth wfe n own home.
PH#SICA E&A!INATION
BP 170/98
Puse 140, rreg.
Respratons 30 and abored
Temp 99F
Ht: 5'10"
Wt: 210.
Genera: Breathess, moderatey obese mae n acute dstress sttng uprght
companng "I am gong to de. Pease hep me."
HEENT: Normocephac. Eyes, ears, and throat norma.
Neck:. Carotds wthout bruts.
Chest: Scattered rhonch throughout, raes batera one thrd ower bases.
Cough s productve and frothy.
Heart: Tachycarda and rreguar. Grade 3/6 systoc murmur at LSB, S3 gaop
noted.
Abdomen: Lver papabe three centmeters beow rght costa margn. Non-
tender to papaton, +Bowe sounds 4 quadrants.
Extremtes: 4+ pttng edema of ower extremtes. Na beds mnmay
cyanotc, no cubbng. Puses ntact.
Neuroogc: Anxous wth feeng of mpendng doom. No ocazed or sensory
dects. Menta status ntact.
Initial a%oratory "ata
Na 130 (ow), K 3.8 (WNL), BUN 18 (WNL). Cr 1.0 (WNL).
Tota choestero: 270
HDL: 30
LDL: 210
TGY: 160
EKG: Left bunde branch bock. Atra braton wth ventrcuar rate of 140.
CXR: Cardomegay wth dhuse pumonary ntrate consstent wth
pumonary edema.
TREAT!ENT
Pt had ncreasng shortness of breath and was emergenty ntubated, and the
physcan orders were:
1. NPO
2. Propofo-10 m/hr x 24 hours a day
3. dgtas/dgoxn
4. heparn
5. propanoo
6. furosemde
7. 1000 cc tota ud qd ncudng IV
'(ESTIONS
1. What s hs medca hstory coud have contrbuted to hs heart faure?
(4pts)
Three years ago he had a MI and quadrupe bypass surgery. He s
obese, has seep apnea and a hstory of hypertenson.
2. Why mght hs sodum be ow? Woud you recommend a ow sodum
det for hm? Why or why not? (4pts)
He s retanng water as evdenced by the pttng edema n hs ower
extremtes, so he serum sodum eve woud be duted. Snce he has
a hstory of hypertenson, I woud recommend a ow sodum det.
3. If you had addtona nutrton-reated ab vaues such as abumn,
hemogobn and hematocrt, woud you have any concerns nterpretng
them to assess nutrton status?
(4pts)
I woud be concerned that the vaues woud be oh due to the amount
of retaned water n hs body. The vaues woudnt be very vauabe
because of a the water.
4. What are the medcatons he has been prescrbed used for, and what
are the reevant drug/nutrent nteractons of each to be aware of? (7
ponts)
Drug Indcaton Drug/Nutrent
nteractons
Lptor Choestero Lowerng cycosporne, gembroz,
teaprevr,
tpranavr pus rtonavr. Red
yeast rce
Zocor Choestero Lowerng warfarn,
cycosporne, danazo,
gembroz
Coumadn Bood Thnner capectabne, matnb,
mfeprstone,
asprn, asprn-ke drugs
(sacyates), and nonsteroda
ant-nammatory drugs
(NSAIDs such as buprofen,
naproxen, ceecoxb. Vtamn K.
coreg Hypertenson Lowerng ngomod
Propofo Sedatve Other sedatves, vaum,
morphne, narcotc
pan reevers.
dgtas/dgoxn Ant-Heart Dsease No known
heparn Ant-Coaguant Ora
antcoaguants, Pateet nhbtors,
dgtas, tetracycnes, ncotne,
anthstamnes or I.V.
ntrogycern
propanoo Beta bocker Antarrhythmcs, Dgtas,
Cacum Channe Bockers, ACE
Inhbtors, Apha Bockers,
Reserpne, Inotropc Agents,
Isoprotereno and Dobutamne.
Furosemde Duretc There are 133 sgncant
drug
nteractons wth furosemde.
5. Why was he paced on a ud restrcton? (3pt)
The kdneys are keepng ud n the body because they needed more
bood to operate correcty. The heart has been workng reay hard to
keep the ud crcuatng, whch has caused t to fa. There s aso
edema n hs ower body. He needs to absorb some of the ud nto the
body.
6. What needs to be taken nto consderaton when evauatng hs
anthropometrc data? (eg, weght/BMI) What anthropometrc measures
woud you use to assess hs nutrtona status? (2pts)
He s retanng a ot of water, so hs weght woud probaby be oh by
around 10 pounds at east. Athough, he s st consdered obese even
takng oh 10 pounds. I woud use weght and BMI as a measure of hs
nutrtona status. Hs choestero seems to be out of contro, too.
7. Cacuate IBW, %IBW, caore needs, proten needs, ud needs (keep n
mnd ud restrcton). Recommend a nutrton nterventon. Wrte a
nutrton prescrpton. (12pts)
IBW (kg) = heght (cm) - 100 - {|heght(cm) - 150|/2} =
177.8 - 100 - {|177.8 - 150|/2} = 77.8 - 13.9 = 63.9 kg
%IBW = CBW/IBW x 100 = 95 / 63.9 x 100 = 148.6%
RMR = (9.99 x weght) + (6.25 x heght) - (4.92 x age) =
(9.99 x 95) + (6.25 x 177.8) - (4.92 x 70) = 949.05 + 1111.25 - 344.4
= 1715.9 kca
Proten = .8 g/kg to 1 g/kg = 63.9 kg x .8 g/kg = 51.12 g to 63.9 kg x 1
g/kg = 63.9 g
Fud = 25 mL/kg = 63.9 kg x 25 mL/kg = 1597.5 mL
Lmtng sodum and ud ntake t edema essens s necessary. He
needs to be gettng adequate vtamn K and w probaby need a
thamn suppement.
Nutrton Prescrpton = 1700 -1800 kca, 51-64 g proten, 1597 mL
ud.
8. What detary recommendatons woud you make for when he s
reeased? (ncude kca, proten needs and any other recommendatons
) (6ponts)
It s dmcut to eat when norma body functons are takng up so much
energy. Try to eat sma meas throughout the day. Eat ow sodum
foods that ncude penty of fruts and vegetabes. If t s dmcut to
chew, try pureed foods ke soups, and appesauce. You can aso eat
nut butters, ke peanut, amond and sunower, f meat s too dmcut
for you to chew. You need to be gettng 51 g to 64 g of proten per day.
You shoud be eatng at east 1715 caores per day, |ust for the ma|or
functons of the body. You shoud be oosng some weght. The ost
weght shoud be many water weght. If you are ganng weght we
need to ad|ust your food and water ntake. It s mportant to ca us f
you are ganng weght. You need to be drnkng about 1600 mL of
water per day. Pease refran from drnkng any sugary drnks.
9. Complete the Swedish Medical Center Nutrition Assessment form including nutrition
diagnosis (PES) and specific and measurable goals (8 pts).
PES E!cessi"e mineral inta#e (sodium) related to h$pertension as e"idenced b$ heart
failure.
A good goal for this gentleman would be to se"erel$ limit the inta#e of sodium while
getting enough calories e"er$ da$. Calories are going to be difficult to get since his
energ$ is so low.