NHM 365 HTN Case Study

Transcription

1 Name: Whitney Lundy NHM 365 HTN Case Study This is an individual assignment and is not to be completed as a group. Please type your answers into this document and submit the completed assignment by the due date via the Assignments link on the Course Tools menu. Please answer each question thoroughly. I. Understanding the Disease and Pathophysiology 1. Define blood pressure. Blood pressure is the force exerted by the blood against the inner walls of the blood vessels, measured in millimeters mercury (mmhg). The diameter of the blood vessel significantly affects blood flow; the smaller the diameter, the greater the pressure exerted by the blood. 2. What does the measurement of systolic blood pressure represent (physiologically)? What does diastolic blood pressure represent? Systolic blood pressure is the pressure measured during the contraction phase of the cardiac cycle. Diastolic blood pressure is the pressure measured during the relaxation phase of the cardiac cycle. 3. What are the 3 major regulators of blood pressure? The sympathetic nervous system is partly responsible for short-term control. When the hormone norepinephrine is secreted by the adrenal gland, blood pressure increases. Norepinephrine is a vasoconstrictor, narrowing the blood vessels, increasing resistance to blood flow and thus raising blood pressure. Since the sympathetic and parasympathetic nervous systems, two branches of the autonomic nervous system, work in tandem, the parasympathetic nervous system is also involved in shortterm control. When the vagus nerve is stimulated by an increase in blood pressure, it stimulates the release of acetylcholine. Acetylcholine causes a drop in blood pressure and heart rate. The kidneys are responsible for long-term control of blood pressure. The kidneys regulate sodium and extracellular fluid volume. A decrease in blood pressure, serum sodium, or plasma volume stimulate the release an enzyme called renin from the kidneys. Renin then converts inactive angiotensin into angiotensin I. In the lungs, angiotensin I is converted to angiotensin II by angiotensin converting enzyme. While angiotensin II can act directly upon blood pressure and cause is to rise somewhat, it also stimulates the release of aldosterone. Aldosterone is a powerful vasoconstrictor that can cause significant increases in blood pressure. Aldosterone can also alter the baseline filtering activity of the kidneys on a more long-term scale, resulting in water and salt retention and thus higher blood pressure.

2 4. What causes essential hypertension? According to the Krause text, essential hypertension is hypertension of unknown cause, though it involves complex interactions between gene expression and poor lifestyle factors. 5. When symptoms present themselves, what are the symptoms of hypertension? According to the American Heart Association, hypertension is called the silent killer because it is largely a symptomless condition. Many symptoms long believed to be associated with hypertension, such as headaches, nervousness, sweating, and difficulty sleeping, have no proven correlation to hypertension and are being referred to as myths on the AHA website. Symptoms associated with, though not always caused by, hypertension include blood spots in the eyes, facial flushing, and dizziness. In the case of hypertensive crisis (systolic 180 or diastolic 110), symptoms may include severe headaches, severe anxiety, nosebleeds, and shortness of breath. Hypertensive crisis is a medical emergency that requires immediate medical attention. ngofhighbloodpressure/what-are-the-symptoms-of-high-blood- Pressure_UCM_301871_Article.jsp 6. List the risk factors for developing hypertension. Risk factors include obesity, physical inactivity, stress, smoking, diabetes mellitus, hypercholesterolemia, poor diet, and excessive alcohol intake. Men and non-hispanic blacks are also at increased risk of hypertension. 7. What risk factors does Mrs. Anderson have? Mrs. Anderson is African American. She has a family history of hypertension, resulting in her mother dying of MI. She has high total cholesterol, high LDL levels, and low HDL levels. Mrs. Anderson s diet is poor; she consumes a high number of processed, packaged foods high in fat and sodium, and very few fruits and vegetables. 8. Hypertension is classified in stages. Complete the following table of hypertension classifications. Blood Pressure (mmhg) Category Systolic BP Diastolic BP Normal 120 and 80 Prehypertension and/or Hypertension, Stage and/or Hypertension, Stage and/or Given these criteria, which category would Mrs. Anderson s admitting blood pressure place her in?

3 Mrs. Anderson s blood pressure of 160/100 mmhg places her in the category of Stage 2 Hypertension. 10. How is hypertension treated? A multi-faceted approach is used in the treatment of hypertension. Treatment typically means lifelong management involving lifestyle changes, nutrition therapy, and medications. Lifestyle changes include achieving and/or maintaining a healthy weight, managing stress, being physically active, and quitting smoking. Nutrition therapy for hypertension may involve sodium restriction, reducing alcohol consumption, increasing dietary sources of potassium, calcium and magnesium, and the DASH diet. The DASH diet, when followed properly, can provide necessary intake of calcium, potassium, and magnesium. Medications used to manage hypertension are numerous. They include, but are not limited to, ACE inhibitors, beta-blockers, calcium channel blockers, diuretics, and melatonin. 11. Dr. Thornton indicated in his admitting note that he will rule out metabolic syndrome. What is metabolic syndrome? Metabolic syndrome is a group risk factors that frequently occur together. The risk factors include: high blood pressure, high fasting glucose, high fasting triglyceride levels, low HDL levels, and a waist circumference greater than 35 inches for women or greater than 40 inches for men. At least three of these risk factors need to be present concurrently for diagnosis. Metabolic syndrome significantly increases an individual s risk for type 2 diabetes, heart attack, stroke, coronary heart disease, and atherosclerosis. 12. What factors found in the medical and social history are pertinent for determining Mrs. Anderson s CHD risk? Mrs. Anderson has a family history of uncontrolled hypertension that resulted in her mother s fatal MI. Mrs. Anderson is overweight, and has been diagnosed with Stage 2 hypertension. Her last blood pressure reading was 160/100. Her fasting triglycerides, total cholesterol, and LDL cholesterol are high. Her HDL cholesterol is low. She smoked two packs a day for 30 years until quitting last year. 13. What progression of her disease might Mrs. Anderson experience? Hypertension is a significant risk factor for heart failure. As hypertension progresses, the left ventricle of the heart may become fibrous and hypertrophied, ultimately resulting in failure of the left ventricle. Hypertension may also lead to ischemic heart disease, in which adequate oxygenated blood does not reach the heart. Ischemic heart disease usually results from atherosclerosis; smoking, high blood pressure, and high cholesterol all contribute to atherosclerosis. Mrs. Anderson s patient history and lab results indicate she is at risk of developing atherosclerosis.

4 II. Understanding the Nutrition Therapy 14. What are the most recent recommendations for nutrition therapy in hypertension? Explain the history and rationale of the DASH diet. The current recommendations for nutrition therapy in hypertension involve energy intake, exercise, alcohol consumption, potassium-calcium-magnesium levels, salt restriction, and the DASH diet. Weight loss can positively impact blood pressure and LDL cholesterol levels. Each kilogram of weight lost can result in a reduction of approximately 1 mmhg for both systolic and diastolic blood pressure. Moderate-intensity physical activity most days of the week is recommended as an adjunct therapy for hypertension. Moderate-intensity physical activity is equivalent to minutes of brisk walking. For weight maintenance after weight loss, minutes daily of moderateintensity activity is suggested. Alcohol intake should be limited to no more than one drink per day for women and no more than two drinks per day for men. Potassium, calcium, and magnesium have been shown to have a positive effect on blood pressure. Recommendations for potassium intake for adults is 4.7 grams per day. Recommendations for calcium and magnesium intake are to meet the AI for each. Current sodium recommendations are for young, normotensive adults to consume less than 2400 mg of sodium each day, and for hypertensive or at-risk individuals to consume less than 1500 mg per day. The DASH diet, which stands for Dietary Approaches to Stop Hypertension, was developed to evaluate and compare three eating plans in studies sponsored by the National Heart, Lung, and Blood Institute, or NHLBI. The objective of these studies was to examine the effects of diet on hypertension. The DASH sodium trials compared sodium intake levels of 1500 mg, 2300 mg, and 3300 mg/day, and compared these three eating plans to a typical U.S. diet, for which sodium-restricted eating plans were also created and compared. The DASH diet was proven effective in preventing or treating hypertension, and is considered the ideal eating plan for most adults. The DASH plan not only reasonably limits sodium, refined sugar, total fat and saturated fat, it also focuses on increasing intake of potassium, calcium, magnesium, and fiber. Following the DASH diet can also assist in weight loss efforts, which in turn can help lower blood pressure. The focus on fruits, vegetables, whole grains, and small amounts of lean protein and healthy fats makes this an optimal eating plan for most adults to adopt. 15. What is the rationale for sodium restriction in treatment of hypertension? Is this controversial? Why or why not? Results from the NHLBI-sponsored DASH-Sodium trial showed greater blood pressure benefits for individuals consuming diets of 1500 mg/day, versus 2300 mg/day. The lower-sodium diet also maintained low blood pressure over time, and improved the efficacy of certain blood pressure-lowering medications. Some controversy surrounds sodium restriction; adhering to a diet that limits sodium to less than

5 2000 mg/day is very difficult. Additionally, individual responsiveness to sodium varies. Certain populations appear to be salt-sensitive, meaning their blood pressure seems to respond to changing sodium levels more than so-called salt-resistant individuals. Thus, the magnitude of effect of sodium restriction varies from one individual to another. However, the positive relationship between sodium intake and blood pressure is well-established in current research literature. 16. The most recent recommendations suggest the therapeutic use of stanol esters. What are they, and what is the rationale for their use? Stanols are isolated from soybean or pine tree oil. Once isolated, the stanols are esterified. Stanols can also be found in corn, wheat, peanut oil, and fortified foods. When stanol esters are incorporated into margarines, consuming 2 to 3 grams per day may lower cholesterol up to 20%. These stanol esters appear to lower blood cholesterol by inhibiting the absorption of dietary cholesterol. However, stanol esters also seem to inhibit the absorption of lycopene, α-tocopherol, and β-carotene. III. Nutrition Assessment To receive credit, show your work on all calculations. A. Evaluation of Weight/Body Composition 17. Calculate Mrs. Anderson s BMI. (Note use the metric formula and do not round until you get your final answer. Round your final answer to 1 decimal place.) BMI = kg/m 2 (160lb)(1kg/2.2lb) = 25.9kg/m 2 (66in)(0.0254m/in) What BMI category does this place her in? What are the health implications of this number? Mrs. Anderson s BMI places her in the weight status category of overweight. Being overweight increases Mrs. Anderson s risk of hypertension, heart disease and type 2 diabetes, and elevated cholesterol. The higher her BMI, the greater the associated risk. B. Calculation of Nutrient Requirements 19. Calculate Mrs. Anderson s resting energy needs using the Harris Benedict equation. BEE = (9.563 x kg) + (1.850 x cm) - (4.676 x age) BEE = (9.563 x 72.73kg) + (1.850 x167.64) (4.676 x 54) = BEE = kcal 20. Calculate her total energy needs using an activity factor appropriate for a sedentary individual. Using the TEE equations provided in NHM 363.

6 TEE = BEE x activity factor + TEF (where TEF = BEE x 0.1) TEE = ( x 1.3) = kcal Using the EER prediction equation for overweight and obese women on page 28 of the Krause text. TEE = x age + PA x (11.4 x kg x m) where PA = 1 if sedentary TEE = 448 (7.95 x 54) + 1 x [(11.4 x 72.73kg) + (619 x 1.676m)] TEE = kcal 21. What percentage of her total energy should be from fat? Carbohydrate? Protein? Using these percentages, calculate how many calories she will be getting from each of these macronutrient categories. Acceptable Macronutrient Distribution Ranges for Adults: Carbohydrate 45 65% of energy intake Fat 20 35% of energy intake Protein 10 35% of energy intake Based on 1886 kcal intake Carbohydrate kcal (approx g) Fat kcal (approx g) Protein kcal (approx g) Mrs. Anderson has expressed a desire to lose weight. I assume Mrs. Anderson will initially experience a reduction in weight at a daily intake of kcal, since her 24-hour recall showed an intake of 3000 kcal. C. Intake Domain 22. After assessing Mrs. Anderson s 24-hour recall, identify 3 food choices that could be changed to potentially improve her cardiovascular health. Give possible healthier substitutions for these foods. Considering Mrs. Anderson s lipid profile and hypertensive state, I want to focus on alternatives that reduce the total fat, saturated fat, dietary cholesterol and sodium in her diet. The first two suggested alternatives also reduce Mrs. Anderson s calorie intake, which will benefit her weight loss effort. The first dietary change for Mrs. Anderson to consider concerns her ice cream snack. 2 full cups of butter pecan ice cream contains roughly 720 kcal, 44 grams of total fat, 20 grams of saturated fat, and 120 mg of cholesterol. If Mrs. Anderson replaces the 2 cups of ice cream with 1 cup of chocolate nonfat frozen yogurt, the frozen yogurt provides 200 kcal, 0 grams fat, and 0 mg cholesterol. The second suggestion revolves around her lunch choices. Mrs. Anderson needs to reduce her sodium intake; a canned condensed soup is high in sodium. The can of tomato bisque soup contributes approximately 1200 mg of sodium to Mrs. Anderson s daily total. I suggest Mrs. Anderson try cooking a large batch of minestrone soup at the start of the week, and use this for lunches. Using fresh herbs and a low sodium broth will provide a flavorful soup without excess salt.

7 The third change for Mrs. Anderson to consider is to select an alternative to the ranch dressing on her salad. 3 Tbs of ranch currently contributes 220 kcal, 24 grams of fat, 3 grams of saturated fat and 430 mg of sodium to her daily totals. Switching from a creamy dressing to something as light and simple as a drizzle of olive oil and vinegar can be difficult for many people. If Mrs. Anderson is reluctant to make such a big change, I d like to suggest reducing the amount of ranch she uses, and mixing a small amount of the ranch with a little nonfat sour cream. This will still give her the creamy mouth feel and taste of ranch, but will spare her a significant number of calories, grams of fat, and mg of sodium. D. Clinical Domain 23. In the following table, indicate the normal lab range, the patient s lab values, whether they are high or low, the suspected reason that the lab is abnormal, and what the nutritional implication may be. (For example, if a patient were to have hypernatremia, the possible reason for the abnormality could be dehydration and/or renal dysfunction. In that case an example of a nutritional implication might be to suggest rehydration with a hypotonic solution.) Parameter Normal Patient s Value Value Glucose , 90, 96 Reason for Abnormality Nutrition Implication BUN , 15, 22 Impaired kidney fcn, excessive protein catabolism, excessive dietary protein Creatinine , 1.1, 1.1 Total cholesterol H, 230H, 210H poor diet, inactivity, overweight, smoking, family history HDL-cholesterol >55 (women) 30L, 35L, 38L poor diet, inactivity, overweight, smoking, family history LDL-cholesterol < H, 169H, 147H poor diet, inactivity, overweight, smoking keep protein intake between AMDR for calorie intake, g/day Increase fruit, vegetable, whole grain intake; reduce total and sat fat intake; replace sat fat with monouns fat; increase physical activity; reduce weight to normal BMI Increase fruit, vegetable, whole grain intake; reduce total and sat fat intake; replace sat fat with monouns fat; increase physical activity; reduce weight to normal BMI Increase fruit, vegetable, whole grain intake; reduce total and sat fat

8 Apo A (women) Apo B (women) Triglycerides (women) intake; replace sat fat with monouns fat; increase physical activity; reduce weight to normal BMI 75L, 100L, 110 smoking, low HDL Increase fruit, vegetable, whole grain intake; reduce total and sat fat intake; replace sat fat with monouns fat; increase physical activity; reduce weight to normal 140H, 120, 115 Correspond to elevated LDL-C, diabetes, high fat diet 150H, 130, 125 Poor diet, inactivity, overweight, smoking, hypothyroidism, type 2 diabetes, kidney disease BMI Increase fruit, vegetable, whole grain intake; reduce total and sat fat intake; replace sat fat with monouns fat; increase physical activity; reduce weight to normal BMI Increase fruit, vegetable, whole grain intake; reduce total and sat fat intake; replace sat fat with monouns fat; increase physical activity; reduce weight to normal BMI 24. Interpret Mrs. Anderson s risk of CAD based on her lipid profile. Mrs. Anderson s lipid profile puts her at increased risk of cardiovascular disease. Her lipid profile shows elevated triglycerides, elevated cholesterol, elevated LDL cholesterol, and low HDL cholesterol levels. Additionally, Mrs. Anderson possesses several CAD risk factors, including hypertension, physical inactivity, poor diet, and family history of hypertension and myocardial infarction. 25. What is the significance of apolipoprotein A and apolipoprotein B in determining a person s risk of CAD? Low levels of apolipoprotein A, along with elevated levels of apolipoprotein B, are associated with an increased risk of cardiovascular disease. Low levels of apolipoprotein A and HDL suggest impaired cholesterol clearance from the body. Elevated levels of apolipoprotein B may

9 indicate decreased clearing of LDL cholesterol from the blood, and are often seen in conjunction with elevated LDL levels. 26. Indicate the pharmacological differences among the antihypertensive agents listed below: Medications Mechanism of Action Nutritional Implications/interactions Diuretics Beta-blockers Calcium-channel blockers ACE inhibitors Angiotensin II receptor blockers Alpha-adrenergic blockers Loop: act on the ascending limb of the loop of Henle, inhibiting sodium and chloride reabsorption; Thiazide: act upon distal tubules in the kidneys to inhibit reabsorption of sodium and chloride; Potassium-sparing: compete with aldosterone for intracellular cytoplasmic receptor sites, or directly block sodium channels Inhibit epinephrine/norepinephrinemediated actions may reduce cardiac output and/or renin release from kidneys Reduce contraction of arteries, vasodilation; reduce the force of contraction of the heart; slow conduction of electrical activity of the heart Inhibit angiotensin-converting enzyme to reduce the activity of the renin-angiotensinaldosterone system Block activation of angiotensin II AT1 receptors, causing vasodilation, reducing secretion of vasopressin and production and secretion of aldosterone Block epinephrine/norepinephrine binding on alpha adrenoreceptors Monitor electrolytes; maintain diet high in potassium and magnesium (exc. potassiumsparing diuretics); avoid natural licorice; some req. caution with calcium supplements Maintain prescribed diabetic diet; monitor glucose levels Avoid grapefruit and related citrus; avoid alcohol, which interferes with effects of drug Ensure adequate hydration; caution with high-potassium diet/supplements; avoid salt substitutes; check each agent for specific recommendations regarding ingestion with food Ensure adequate hydration; caution with high-potassium diet/supplements; avoid salt substitutes; avoid natural licorice; avoid grapefruit and related citrus with losartan Avoid alcohol and alcohol products; may increase effects of alcohol

10 27. What are the most common nutritional implications of taking hydrochlorothiazide? Hydrochlorothiazide, a thiazide diuretic, increases urinary excretion of sodium, potassium, and magnesium. Therefore, it is important that a patient taking hydrochlorothiazide maintain a diet high in potassium in magnesium. The DASH diet encourages increased intake of potassium and magnesium. 28. Mrs. Anderson s physician has decided to prescribe an ACE inhibitor and an HMG Co-A reductase inhibitor (Zocor). What changes can be expected in her lipid profile as a result of taking these medications? Zocor, the HMG Co-A reductase inhibitor, is designed to lower LDL cholesterol levels and raise HDL cholesterol levels. The ACE inhibitor should help lower Mrs. Anderson s blood pressure without adversely affecting her lipid profile. 29. What are the pertinent drug-nutrient interactions and medical side effects for nicotinic acid and HMG Co-A reductase inhibitors? Avoid alcohol while taking nicotinic acid. Diabetics should closely monitor glucose levels. Large doses of nicotinic acid may result in hyperuricemia. Side effects include skin flushing and itching, exacerbation of peptic ulcer disease, nausea, vomiting, and diarrhea. Avoid grapefruit and related citrus while taking HMG Co-A reductase inhibitors. Constipation, nausea, gas, diarrhea, dizziness, fainting, and fast or irregular heartbeat may occur with HMG Co-A reductase inhibitors. A significant reduction in coenzyme Q10 may occur, but supplementation is controversial. Patients should maintain a low-fat, low-cholesterol diet to optimize the drug effects. IV. Nutrition Diagnosis and Intervention 30. When you ask Mrs. Anderson how much weight she would like to lose, she tells you she would like to weigh 125#, which is what she weighed for much of her adult life. Is this reasonable? What would you suggest as a weight loss goal for Mrs. Anderson? Mrs. Anderson is interested in a 35 lb loss, which is a 22% reduction in body weight. While a weight of 125 lb would place her at a healthy BMI of 20.2 kg/m 2, I don t think this is a realistic weight loss goal. I would be more comfortable with Mrs. Anderson setting an initial weight loss goal of 15 lbs, which would bring her BMI down to a healthy 23.4 kg/m 2. Once she reaches this first goal of 145 lb, we can set a new weight loss goal if she d like. a. How quickly should she lose this weight? A safe rate of weight loss is 0.5 to 2 pounds per week. I would encourage Mrs. Anderson to initially aim for this range. This rate of weight loss should be feasible with changes to her diet and physical activity level. Creating a calorie deficit of 500 calories per day will result in a 1 pound weight loss per week.

11 31. Select 2 high-priority nutrition problems and write PES statements for each. (Note- be sure to review the NCP module then look at the ADA Problem Statements file or, if you have one, your ADA IDNT Reference Manual prior to writing your PES statements.) Excessive Fat Intake (NI 5.6.2) r/t high intake of commercially prepared and processed foods AEB total cholesterol of 210 mg/dl, LDL cholesterol of 147 mg/dl, HDL cholesterol of 38 mg/dl, and fat intake in excess of 100 grams during 24-hour recall. Excessive Sodium Intake (NI ) r/t high intake of commercially prepared and packaged foods AEB blood pressure of 160/100 and sodium intake in excess of 3300 mg during 24-hour recall.

12 32. For each of the PES statements you have written, establish an ideal goal (goals should be specific and measurable, and related to improving the nutrition diagnosis) an appropriate nutrition-related intervention (based on the etiology), your method for monitoring, and how you will evaluate the success of your intervention. For example: PES Statement (This is the nutrition diagnosis that you wrote in #16) Inadequate energy intake (NI-1.4) related to dementia and poor appetite as evidenced by diet history and recent unintentional weight loss 6% of UBW in 2 months. 1 Goal (What would you like to achieve?) Short-term: Improve caloric intake to meet estimated energy needs of 1800 kcals/day. Long-term: Increase energy intake to 500 kcal>eer to allow for weight gain of 1-2 lbs/week until BMI of 19.0 is reached. Intervention (How will you achieve your goal?) Provide meal assistance to help patient consume meals on tray. Try oral supplements to determine patient preference and evaluate acceptance. If patient enjoys supplement, provide Ensure Plus bid with breakfast and dinner to provide an additional 711 kcal/day. Monitoring (What will you be monitoring to see if your goal is achieved? How often will you monitor this?) Short-term: Monitor trays daily to determine if oral intake improves and if supplement is being consumed. Institute 3- day calorie counts. Long-term: Weigh patient twice weekly. Evaluation (What criteria will you use to determine your intervention successful?) Short-term: Patient drinks beverages and calorie counts indicate pt is meeting or exceeding energy needs. Long-term: Patient demonstrates weight gain of 1-2 lbs/week until goal BMI is reached. PES Statement Goal Intervention Monitoring Evaluation Excessive Fat Intake (NI 5.6.2) r/t high intake of commercially prepared and processed foods AEB total cholesterol of 210 mg/dl, LDL cholesterol of 147 mg/dl, HDL cholesterol of 38 mg/dl, and fat intake in excess of 100 grams during 24-hour recall. Reduce fat intake to meet AMDR for 1886 kcal Educate client on lowerfat alternatives to highfrequency foods Slowly replace processed, packaged foods with whole foods; begin with one swap each day, gradually increase as client feels successful and ready Short-term: Monitor fat intake via daily food logs Long term: Evaluate blood lipid profile every 2 months Short-term: Patient maintains daily fat intake of 42-73g for 1886 kcal diet Long-term: Patient s blood lipid profile shows reduction in total cholesterol and LDL levels, and increase in HDL level

13 Excessive Sodium Intake (NI ) r/t high intake of commercially prepared and packaged foods AEB blood pressure of 160/100 and sodium intake in excess of 3300 mg during 24-hour recall. Adopt DASH diet; Reduce sodium intake to less than 2300 mg daily Educate client on DASH diet guidelines; provide sample meal plans Introduce client to herbs and spices to find saltfree flavors she enjoys; educate her in how to use these when cooking Short-term: Monitor sodium intake via daily food logs Long-term: Monitor blood pressure weekly Short-term: Patient maintains daily sodium intake below 2300 mg Long-term: Patient s blood pressure shows reduction in both systolic and diastolic numbers, ideally below 140/90 Note: for optimal hypertension control, patient should adopt reduced-sodium DASH diet as lifestyle

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