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CVD Case Study

Charles Bishop, a 68-year-old male with a history of hypertension, atrial fibrillation, congestive heart failure, and hyperlipidemia, presented with difficulty breathing, lower extremity edema, and 12-pound weight gain and was admitted with oxygen saturation of 87% and edema. He consumes 833 calories per day, well below his estimated need of 2200 calories, and has notable muscle and fat loss. He was diagnosed with moderate malnutrition related to inadequate energy intake and a nutrition care plan was created to increase his calorie and protein intake while reducing sodium and maintaining his weight.

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329 views4 pages

CVD Case Study

Charles Bishop, a 68-year-old male with a history of hypertension, atrial fibrillation, congestive heart failure, and hyperlipidemia, presented with difficulty breathing, lower extremity edema, and 12-pound weight gain and was admitted with oxygen saturation of 87% and edema. He consumes 833 calories per day, well below his estimated need of 2200 calories, and has notable muscle and fat loss. He was diagnosed with moderate malnutrition related to inadequate energy intake and a nutrition care plan was created to increase his calorie and protein intake while reducing sodium and maintaining his weight.

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© © All Rights Reserved
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Overview Information: Charles Bishop is a 68-year-old male that presented to the hospital with

complaints of difficulty breathing, lower extremity edema, and 12-pound weight gain. The
patient has since been examined and had an O2 saturation of 87%, orthopnea, generalized
edema and 3+ edema in bilateral lower extremities and was admitted to inpatient care at
General Hospital.

Client History (CH):


Medical hx: Patient has had hypertension for the last 10 years, diagnosed with atrial
fibrillation and congestive heart failure 5 years ago. He has hyperlipidemia. He had been
smoking 1 pack of cigarettes a day for 20 years, but quit smoking 2 years ago. He is a social
drinker only. Immunizations are current with annual flu vaccine.
Family hx: Positive for CAD.
Social hx: Patient lives with his wife. They both retired 3 years ago. He worked as a
school maintenance supervisor. He has three adult children who are very supportive to their
parents.
Surgeries: Patient denies PSH.
Allergies: NKDA
Current Medications/supplements: Lisinopril 5 mg daily, Coreg 3.125 twice a day,
isosorbide dinitrate/ hydralazine hydrochloride one tablet three times a day, spironolactone
12.5 mg daily, Coumadin 2.5 mg PO daily.

Anthropometric Measurements (AD):


Ht.: 72in
Wt.: 180.3lb
UBW/weight hx: 168.2lb, recent weight gain of 12lbs.
BMI: 24.5

Biochemical Data, Medical Test and Procedures (BD):


CMP:
Glucose (high): 122mg/dL Ref range: 70-115mg/dL
BUN: (high): 54mg/dL Ref range: 8-25mg/dL
Creatinine, serum (high): 1.6mg/dL Ref range: 0.6-1.5mg/dL
Sodium, serum (low): 133 mEq/L Ref range: 135-145 mEq/L

CBC with differential:


Hemoglobin (low): 11.3 g/dl Ref range: 13.5-16.5
Hematocrit (low): 30% Ref rance: 41-50
Platelet count (low): 220 Ref range: 100,000 - 450,000
WBC (low): 8.3cells/ml Ref range: 4,500-1000

Lipid profile:
Total cholesterol (high) : 220 mg/dl, Ref Range: <200
HDL cholesterol (low): 32 mg/dl, Ref range: >35
LDL cholesterol (high): 160 mg/dL, ref range <130
Triglycerides (high): 145 mg/dL, ref range: <150

Nutrition-Focused Physical Findings (PD):


Physical appearance: 3+ edema in lower extremities, notable muscle and fat losses.
Clavicle bones are prominent and ribs along the upper chest are visible. Facial muscles and
facial fat pads seem depleted. Arthritic changes to the musculoskeletal system.

Food/Nutrition Related History (FH):

Current diet order: Clear liquid diet


Food and Nutrient Intake from 24hr recall:

Morning:
1 cup black coffee
1 small soft biscuit

Mid-morning:
8oz Ensure supplement

Afternoon:
½ medium grilled cheese sandwich
1 cup tomato soup
4oz applesauce

Evening:
1 cup beef stew

The patient consumed 833 calories on this day, including 107g of carbohydrates, 22g of
protein, 28g of total fat, and 6g of fiber. The patient consumed 2138mg of sodium, 455mg of
potassium, and 95mg of caffeine in this 24-hour diet recall, which was the day prior to
admission to the hospital.

Physical Activity: None, patient reports ADLs limited due to SOB and edema.
Knowledge/Attitudes/Beliefs: The patient stated that he did not have questions,
concerns, anxieties or fears about his condition and/or care at the time of admission.

Comparative Standards/Calculated Needs:

24 cals per kg for patients with HF and malnourishment x 1.2 sedentary factor: ( 76.2 * 24 )*
1.2= 2194
2194 calories with 1.2 basal activity factor for sedentary behavior.
Protein needs: 84g (1.1/kg *76.2)
To maintain a weight of 180.3lbs, the patient should consume 2200 calories per day.
Sodium: <2000mg per day
Fluid needs: 1000ml-2000ml per day

Nutrition Diagnosis:

Moderate chronic disease or condition related malnutrition (NC-4.1.2.1) and inadequate energy
intake (NI-1.2) related to food and nutrition knowledge deficit, low appetite, and sedentary
activity as evidenced by 2138mg of sodium per day, -1361 caloric underconsumption per day,
12lb weight gain, 3+ edema in extremities, and notable muscle and fat losses.

Nutrition Intervention:
Prescription:
-2200 calories per day
-Protein goal of 84g per day
-Less than 2000mg of sodium per day
DASH DIET including:
-6-8 grains per day
-8-10 servings of fruit and vegetables per day
-2-3 dairy servings per day
-Lean meat, poultry and fish: 6 one-ounce servings or fewer a day
-Nuts, seeds and legumes: 4 to 5 servings a week
-Fats and oils: 2 to 3 servings a day
-Sweets: 5 servings or fewer a week
-Low caffeine

Recommend:

1.) Increase energy diet (ND-1.2.2.1)


Goal: Maintain weight of 180.3lbs.
2.) Content related nutrition education (E-1.1)
Goal: Education on DASH diet, help patient learn to identify high sodium foods, while
meeting 84g protein requirement per day and 2200 calorie requirement, and under
2000mg of sodium per day.
3.) Modify schedule of food/fluids (ND-1.3)
Goal: Increase appetite to increase energy intake.

Nutrition Monitoring and Evaluation:


● Indicator: Total energy measured intake in 24 hours (FH-1.1.1.2)
● Criteria: Evidence of 2200 calories per day from 24-hour diet recall with 84g of protein
and <2000mg, daily weights to monitor fluid retention.
● Indicator: Decreased sodium intake (ND-1.2.11.7.2)
● Criteria: Evidence of less than 2000mg of sodium from 24-hour diet recall, distinction
between food sources of high and low sodium, evidence of low-sodium food options,
elimination of high-sodium food options, verbal recall of adaption fo recipes to reduce
sodium content, recall of DASH diet and components.

● Indicator: Weight (AD-1.1.2)


● Criteria: Weight maintenance of 180.3lb as evidenced by daily weights to monitor fluid
retention.

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