Case Study #6: Hypertension. b. Smoker: Did quite but was an active smoker, smoked 2 packs a day

Transcription

1 Sonia Malhotra November 6, a. Family History of Hypertension Case Study #6: Hypertension b. Smoker: Did quite but was an active smoker, smoked 2 packs a day c. Overweight with a BMI of 26 d. Ethnicity: African American Female e. Diet: high sodium intake, high LDL, low HDL f. Alcohol: 2 beers with dinner (women should consume 1 drink/day) E. Age 14. The DASH diet is the newest recommendation for nutrition therapy of hypertension. The DASH diet focuses on a low saturated fat, low cholesterol, and low total fat intake and limits sodium intake to 2300 mg/day. The diet also recommends an increase in vegetables, whole grains, fruits and low fat dairy options. An increase in potassium, calcium and magnesium has been shown to have an inverse relationship to blood pressure. An increase of calcium, magnesium and potassium will decrease BP. Alcohol should be limited to 2 drinks for men and 1 drink for women a day. Weight loss is also crucial to the DASH diet and decreasing BP. A ten percent weight loss has sustained effects on hypertension, and a 20 lb decrease will result in lowered systolic BP. 16. a. 7% total calories of saturated fat, 25-35% of total calories from fat, Cholesterol less that 200mg per/day B. increase fiber intake to20-30 gm/day C. exercise a minimum of 200kcal/day D. limit sodium to <2400mg/day E. Plant sterols 3.4gm from benicole, synthetic foods like sea weed.

2 18. BMI Calculation Weight = 160 lb = 73 kg Height = 5 6 = 161 cm = 1.61m 72.7kg. / 1.68m 2 = 26 BMI [Classification: Overweight] 19. Health problems related to a BMI of 26 are an increased risk for Type 2 Diabetes, Hypertension, and Cardiovascular disease. 20. Using IBW is more appropriate for this patient s calorie intake. Her IBW is 130 lbs = 59kg and she is 123 % of her IBW. REE = (W) (H) 4.7 (A) REE = (59 kg) +1.9 (161 cm) 4.7 (54) REE = 1273 kcal = 1300 kcal TEE = REE x Activity Factor TEE = 1300 x 1.3 = 1690 kcal =1700 kcal 21. Based on the calculations it is recommended that Mrs. Anderson consume about 1700 calories a day but based on her 24 hr recall she consumes around 3000 calories. I would recommend that Mrs. Anderson reduce her calorie intake to about 2000 calories for the first few months as that is a more realistic goal. Cutting her calories down to 1500 right away would increase her chances of not actually making lifestyle changes, causing frustration and resulting in her giving up on her health. I would recommend her consuming after maybe 4-5 months, as she gets more comfortable with her lifestyle changes and feels that she has more control over her eating habits. By decreasing her daily calorie intake by 200, and continuing to work out Mrs. Andersons can slowly begin loose about 0.5 lbs a week. While it s recommended that a decrease in 500 calories a day will increase weight loss, it is more realistic to decrease calories by 250 and to increase physical activity to about 200 calories. Day 23. Based on information provided on calorieking.com, the data based on the patient s 24hour recall is as follows:

3 Food Item Kcals Total fat (g) Sat Fat (g) Sodium (mg) 1 cup Coffee Instant Oatmeal tsp margarine tsp sugar Frosted Mini Wheat s ½ c 2% Milk cup OJ cup Coffee glazed donut can Tomato Soup 10 Saltines can Diet Coke oz baked Chicken Large baked potato 1 tbsp butter cup carrots tsp sugar tsp butter Dinner salad tbsp ranch dressing 2 beers (reg) c Butter Pecan Ice Cream *Total 3221 kcals 135 grams 54 grams 5104 mg 40% of Kcals 15% of Kcals *total intake does not take into consideration added salt to the chicken, baked potato. No measurements were given on the added salt in diet recall. 24. Mrs. Anderson has a couple of concerns related to her diet intake. Mrs. Andersons excessive calories intake, along with her high intake of fat (40% of Calories), and high intake of saturated fat (15% of calories) are high priority concerns. She consumes an excessive amount t of fat, and sodium through processed foods. Her sodium intake is about 200% of the recommended intake of 2400mg.day.

4 25. Nutrition Problems Include: A. Excessive Sodium Intake (NI ) B. Excessive fat Intake (NI-5.6.2) C. Excessive energy intake (NI-1.5) 27. Mrs. Anderson pt is at high risk of Peripheral Arterial Disease based on her high cholesterol. Her high LDL labs indicate a high risk for atherogenesis and CHD. 38. PES Statement #1: Excessive energy intake as related to calorie intake exceeding 100% of patient s calorie needs as evidenced by an elevated BMI of 26. PES Statement #2: Excessive sodium intake related to intake of processed foods as evidenced by sodium intake being more than 100% of recommended. 40. Mrs. Andersons weight right now is 160 lbs and if she wanted to lose 25 lbs that would make her new goal weight at 135 lbs. The idea of losing 25 lbs is very scary at first, but as a long term goal 25 lbs is achievable. For Mrs. Anderson this is a realistic goal, over a period of 6-12 months. I would recommend that Mrs. Anderson again begin with eating 2000 calories a day in order to ease her into calorie control. Since she consumes over 3000 calories now, a 1500 calorie diet would not be a good place to start and would easily overwhelm her. By starting at 2000 calories and slowly decreasing as she continues to lose weight, it will focus more on lifestyle changes and not quick weight loss. She should carefully be evaluated by an RD every few months in order to make sure she is getting adequate nutrients with her calories. By losing lb a week, Mrs. Andersons weight loss goal would be achievable is 6-12 months. 41. Losing weight is a primary concern for Mrs. Anderson but weight loss should not be done quickly. Losing 1-2 lbs a week is considered be a healthy weight loss. By decreasing her calories it could take Mrs. Andersons anywhere from 6-12 months. This long term weight loss will decrease the pressure and uncomfortable feeling of cutting calories that caused Mrs. Andersons to give up before, and also would allow Mrs. Anderson to consume proper foods that are high in nutrients and contain good fats. 42. PES Statement #1 Goal: To decrease calorie intake. PES Statement #1 Intervention: The patient should be given nutrition education on appropriate calorie control and portion sizes. Mrs., Anderson consumes over 3000 calories a day while her recommended calorie intake is 1700 kcals a day. My educating her on eating less packaged foods (canned soups), and cooking at home Mrs., Anderson can start to control the amount of calories in her food. Also by adding more fruits and vegetables to her diet which are low in calorie and high in fiber can help her feel full longer. One of the most important goals for Mrs. Andersons

5 would be decreasing her intake of ice cream. By consuming only one serving of ice cream and some fruit after dinner, Mrs. Anderson can reduce her calorie intake by 350 calories. PES Statement #2 Goal: To initially decrease sodium intake to 4000 mg/day PES Statement # 2 Intervention: Mrs. Anderson consumes an excess amount of salt, around 5000 mg/day. The recommendation of Sodium intake is <2400 mg/day but it would not be realistic for her. For her it is best to slowly decrease her sodium intake by limiting canned soups and instead making fresh soup at home with salt control. It is also recommended that Mrs. Anderson try to use lower salt dressings for salads. She also is using lots of added salt on her potatoes and chicken. She could substitute other herbs, and seasonings such as black pepper, mint and onion powder to add flavor to her food. Just because she can t use too much salt, does not mean her food needs to be flavorless. 43. Her major sources of saturated fat and cholesterol are from butter, tomato soup, and butter pecan ice cream. I would recommend that Mrs. Andersons switch to healthier fats like Olive Oil. By using olive oil, Mrs. Anderson will be able to decrease her saturated fat intake but still get some flavor for her food. She also consumes high fat tomato bisque. By cooking the soup at home Mrs. Anderson can control the Sodium, and most importantly the saturated fat. She always consumed 4 servings of ice cream in the night. In order to satisfy her sweet tooth, its best for her to look into Fresh Fruit Sorbets or even make them at home. Another substitution would be to use reduced low fat/ fat ice creams at first, and then slowly branch of into eating sorbets, frozen fruits like grapes and even berries.

6 Sonia Malhora October 10, 2011 Case Study Lymphoma is a cancer of the lymphatic cells/nodes of the immune system. 4. Ms. Mitchell s medical plan indicates the use of both chemotherapy and radiation. Chemotherapy: is a drug treatment used to destroy cancer cells; it interrupts the various phase cycles of the cells. It is also a systemic process. Radiation: A localized process of electromagnetic radiation, these charged particles destroys the cancer cells by altering their nuclear material (DNA). The localized treatment is used to control the growth of a tumor. 5. A. Chemotherapy and Radiation affect cells that constantly proliferating like cells of the GI tract, lymph tissue, hair follicle cells, and bone marrow cells. B. Some of the side effects of chemotherapy may include neutropenia, thrombocytopenia, diarrhea, mucositis, and alopecia as references by the book. The symptoms of radiation can vary by the location of the tumor, but common symptoms include based on fatigue, mucositis, dysgeusia, and dry mouth due to salivary gland destruction. 9. Weight in kg: 120 lbs/2.2 = 55 kg Current BMI = 120/ (66)2 x = 19 (healthy) % Usual Body Weight = 120/130 x 100 = 92% Based on these calculations, it would be more appropriate to look into her % UBW to see that the patient has lost about 8% of her UBW in a short period of time. Her BMI is at a healthy range, but the weight loss percent indicates a risk factor. 12. Weight in kg: 120 lbs/2.2 = 55 kg Protein Needs: 55 kg X 1.3 = 72 grams of protein/daily 13. REE and TEE using the Harris Benedict Equation REE: (55 kg) (165 cm) (21) = 1408 TEE: 1408 x 1.3= 1830 Kcal/Kg: 33 Kcals per 1 kg 14. The patient s usual intake: - Estimated Caloric Intake = 1700 kcal and Estimated Protein Intake = 90 g Intakes based on 24 hour recall: -Estimated Caloric Intake = 500 kcal and Estimated Protein Intake = 13 g

7 18. Her reduced intake can be affected by decreased appetite, altered taste and smell. Increased fuel consumption by the tumor including increase in energy expenditure. Hormonal influences and alterations in metabolism. 19. The patient is experiencing excessive night sweats, fever, fatigue and decreased appetite. 20. Involuntary weight loss, inadequate oral food/ beverage intake, increased energy and protein needs. 21. Pre-Albumin, Albumin, Transferrin and Total Protein can be used to determine protein status. A. Chronic changes in protein status can be measured using Albumin as it has a longer half life, and can display lab results over a longer period of time. Acute changes in protein status can be measured by Pre-Albumin because of its shorter half life. B. Based on her medical record, the patients Albumin and total protein labs are available, Albumin would not be a good indicator of her protein status, as her symptoms have not been going on for a long time to be considered chronic C. With her albumin levels being low, it could indicate a protein deficiency. I would request a Pre-Albumin lab in order to get a more accurate protein status. 25. PES # 1: Patient is experiencing Inadequate energy intake related to decreased appetite associated with lymphoma as evidenced by average kcal intake being less than 75% of recommendation. PES # 2: Involuntary weight loss related to increased energy needs associated with lymphoma as evidenced by an 8% weight loss from usual body weight. 26. PES # 1 PES # 2 Goal: increase energy needs to 1830 and protein to 72 grams/day Intervention: focus on the decreased appetite by introducing small frequent meals, and fluids between meals. This should not be done during therapy but instead before or between sessions. Goal: Increase energy needs same as above in order to make patient more nourished for therapy sessions.

8 Intervention: add fortified foods that are high cal/high protein such as (enlive). Use spreadable and edibles for meals, in order to increase protein/calories. Again this process should be done before and inbetween therapy, not during.

9 Sonia Malhotra October 20, 2011 Case Study 23: Diabetes 1. There are multiple differences between type 1 and type 2 diabetes mellitus. The most apparent difference is that type 1 diabetics have a lack of insulin production in their bodies but type 2 patients have insulin resistance in their bodies. 2. One of the common clinical tests used in order to differentiate between type 1 and type 2 diabetes is the auto antibodies testing. Islet cell auto antibodies are present more in type 1 diabetes than in type 2 diabetes. in patients with type 1 diabetes, auto antibodies attack and destroy insulin producing islet beta cells in the pancreas. An excessive amount of islet cell auto antibodies would show a decrease in the number of islet beta cells in the pancreases. 3. Some of the risk factors associates with Mrs. Douglas include her old age, obesity family history, her race (African American) and sedentary lifestyle. 4. The common complications for diabetes include atherosclerosis, microangipathies (destruction of capillaries), neuropathy diseases and hyperglycemia. When adequate insulin is not available in your system, glucose production is stimulated by gluconeogenesis and lipolysis. Ketones are the byproduct by lipolysis, and with excess glucose and ketones in the blood causes osmotic dieresis to occur and cause dehydration and an electrolyte imbalance. The complications of chronic hyperglycemia include the decreased rate of retinopathy, nephropathy and neuropathy and can also create complications in CVD. Atherosclerosis is when hyperglycemia causes all the blood vessels to be prone to endothelial damage, resulting in thickening and decreased flexibility of the vessels resulting in an increase of plaque buildup. In regards to nephropathy, hyperglycemia will change the structure of the blood vessels of the glomerulus. The change on structure of the vessels results in decreased filtering rate, resulting in kidney failure. In Retinopathy, hyperglycemia causes a change in the blood vessels, and excess amounts of sorbitol play an important role in blindness. In the nervous system, the accumulation of excess substances such as sorbitol and glycated proteins result in damage to the cells, disrupting the CNS pathway. This can cause a lack of never function, causing a person to not feel a cut, if that cut or wound goes undetected gangrene can occur, which mostly results in amputations.

10 5. Mrs. Douglas s complications include loss of vision (retinopathy), neuropathy, and dehydration (dry-mucous membranes). 7. Type 2 diabetes can go undetected for years, the symptoms are noticed slowly with this condition and when it is recognized a person can already been experiencing blindness, kidney failure or lose of a limp because of neuropathy. 12. Patients height = 5 Feet = 153 cm or 60 inches Actual Weight= 155 lbs, 71 kg BMI = 155/(60^2) x = A person with a BMI of over 30, is considered to be obese level 1. The health complications include heart disease, high blood pressure, type 2 diabetes, cancer, sleep apnea and depression. 14. By using the Hamwi equation, Mrs. Douglas IBW is 100 pounds but she is 155 pounds instead. That would mean she is 155% of her IBW, I would recommend using her ideal weight in order to determine calories and protein status. REE = (46) (153) 4.7 (71) REE = 1053 kcal TEE = 1053 x 1.3 (stress factor) = 1370 calories 15. Protein needs using IBW 46 x 1.3 = 60 grams of protein/day 16. At this moment a 1200 calorie would help her lose weight, which would help reduce some of her complications and risks associated with obesity and diabetes. 19. Estimation of patient s intake:

11 Kcals = 1600 Protein = 58 grams Fat = 82 grams Carbohydrate = 172 grams 20. The patient is consuming an extra 200 calories, and an excess amount of fat. Her carbohydrate distribution is also inconsistent. 22. The patients Hgb A1C, and pre-prandial/postprandial blood glucose levels should be monitored. 30. PES 1 = Inconsistent carbohydrate intake related to excessive carbohydrate consumption during dinner as evidenced by usual dietary intake of 104 grams of carbohydrates at dinner time. (Recommended is grams/meals). PES 2 = Excessive fat intake as related to high intake of cooking fats as evidenced by diet history and BMI of The patient s overall goal to heal her wound and normalize her blood glucose levels. 33. PES # 1 Ideal goal: To eat consistent amounts of carbohydrates per meal (45-60 grams per meal), Intervention: begin self management monitoring of carbohydrate intake, initiate meal planning in order to create consistent distribution of carbohydrates per day, small frequent meals along with explaining carbohydrates exchanges per patient s educational level. PES # 2 Ideal goal: to decrease fat intake to 30% of 1400 calories (46 grams of fat per day), patients fat intake right now is 46% of 1600 calories (83 grams). Intervention: Modify types of cooking fats in patient s diet, and initiate healthier fats for cooking in order to substitute fat back. Also teach patient about portion control in order to decrease fat intake.

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