MNT in a patient with Congestive Heart Failure

MNT in a patient with Congestive Heart FailureMegan SmithUMD Dietetic InternMay 6, 2015

El CorazonCongestive Heart Failure

Most common signs and symptomsFatigueEdemaShortness of breathChest congestionMd HealthCongestive Heart FailureSystolic Heart failure: Occurs when the heart cannot pump, or eject, blood efficiently out of the heart. Diastolic Heart Failure: Occurs when the heart cannot properly fill with blood.

PixsharkCongestive Heart FailureEtiology most commonly includes:Coronary Artery DiseaseMyocardial InfarctionUncontrolled HypertensionArrythmias, valve problems, drugs,and alcohol can also contribute

Leading PredictorsCoronary artery diseasePoorly controlled blood pressureElevated B natriuretic peptides

So you can see here why a Dietitian is so important to this populationCongestive Heart FailureElectrocardiogramTest that checks for problems with the electrical activity of the heart.Ejection FractionA test that determines how well your heart pumps with each beat.

American Accreditation HealthCare Commission

Emory Health Meet the PatientXX is a 59 year-old Caucasian maleMarried with two daughtersLives at home with wifeEmployed as a physician by a local Baltimore HospitalMedical ConsiderationsDiagnosis: Acute left systolic heart failure with aortic insufficiency. Broadly referred to as CHF.PMH: hypertensionEchocardiogram: Ejection Fraction was 20-25% Signs/Symptoms: Fatigue, loss of appetite, SOBNutrition AssessmentFood/Nutrient Related HistoryDecreased appetite one month PTAEating approx. 50% of meals PTAMD expressed basic understanding of nutrition and wanted to maximize caloric intake prior to surgery. MD is a physician so he understood his disease state MD is on feet all day; in training for a marathon.Nutrition AssessmentHeight=168 cm Weight=194 lbs (88.2 kg) BMI=31UBW=210 lbs;16 pound wt loss, 7% weight change in past monthAnthropometric MeasurementsNutrition AssessmentClient HistoryPMH: hypertension, dyslipidemia, hypercholesteremiaNo surgical history (hx) Employed as a physician as Chief of OrthopedicsDenies family psychiatric hx, alcohol, and drug useNutrition AssessmentNutrition Focused Physical FindingsNo edema present on admissionVital signs stable on admissionSigns & Symptoms on admission: 3 weeks SOB, orthopnea, upper back discomfort, fatigued, lower energy levels during normal work activities, loss of appetite, weight lossNutrition AssessmentBiochemicalBNP levels normal upon admissionBUN slightly elevated: 26 mg/dL on 12/11 XX Labs were not nutritionally significant throughout his stay in the hospital DiagnosisNI-1.2: Inadequate oral intake related to decreased desire to consume sufficient energy 2/2 to CHF symptoms of shortness of breath and fatigue as evidenced by patient report of poor po intake (50% of meals) over last month.

NC-3.2: Unintended weight loss related to decreased appetite 2/2 inadequate oral intake caused by CHF symptoms as evidenced by 15 pound weight loss in past month (7% weight change). InterventionNutrition Prescription

Energy Needs: 1870-2066 kcal (Mifflin St. Jeor)Protein Needs: 65-78 grams (1-1.2 gram/kg)Fluids: 1760-2200 mL InterventionDateDietAverage IntakeNutrition Supplements and IntakeDecember 8thPatient placed on a cardiac diet upon admission25-50%-December 9thCardiac Diet25-50%Ensure Chocolate TID ordered, Patient consumed one Ensure before surgeryDecember 10thNPO at midnight for impending surgery--December 11thNPO--December 12thCLD/FLD50-75%Ensure Clear TID ordered, 1 consumedDecember 13thCardiac diet50-75%Ensure Clear TID ordered, 1 consumedDecember 14thCardiac diet25-50%Ensure Clear TID ordered, 2 consumedDecember 15thCardiac diet25-50%Ensure Chocolate TID ordered, 2 consumedDecember 16thCardiac diet40%Ensure Chocolate TID, 3 consumedMagic Cup x 1/day, consumedDecember 17thCardiac diet, patient discharged today--InterventionRC 1.3 Coordination with other providers: Recommend low sodium, cardiac Diet. Goal: Implement once medically feasible after surgery.

ND-3.1 Medical food supplements: Initiate Ensure Chocolate TID once medically feasible.

RC 1.3 Coordination with other providers: Recommend Ensure Chocolate TID. Goal: Implement once advanced to Clear Liquid Diet after surgery.

RC 1.3 Collaboration with other providers: Patient will maintain current weight throughout hospital stay.

E-1.1 Purpose of Nutrition Education: Prior to discharge educate patient and patient family on importance of adhering to low sodium, cardiac diet after surgery and discharge.

E-1.4 Nutrition relationship to health/disease: Prior to discharge help patient recognize and understand importance of adherence to low sodium cardiac diet in relation to his CHFMonitor/EvaluateFH 1.1.1.1 Energy Intake

FH-1.2.1 Fluid/beverage intake

FH 1.6.2 Sodium Intake

FH 4.1.1 Food and Nutrition Knowledge/Skill

FH 4.1.2 Diagnosis specific food and nutrition knowledgeNutrition ImplicationsSeverity of MDs CHF was reflected in the medical and nutritional therapy. Dietary Approaches to Stop Hypertension (DASH)Implemented to help client make better choices after surgery2000 mg sodium/dayMany CHF patients will require a fluid-modified diet (ND-1.2.8) XX was not experiencing edema or hypernatremiaNutrition ImplicationsSelf-monitoring (C-2.3)Reading nutrition labelsChoosing salt-free additivesReferences Academy of Nutrition and Dietetics. International Dietetics and Nutrition Terminology (IDNT) Reference Manual. Chicago, IL: American Dietetic Association; 2013;

Academy of Nutrition and Dietetics. Nutrition Care Manual.http://www.nutritioncaremanual.org. Accessed several times from December 2014-February 2015. https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5803&lv2=8585&ncm_toc_id=8585&ncm_heading=Nutrition%20Care

Cotugna N, Wolpert S. Sodium Recommendations for Special Populations and the Resulting Implications. Journal of Community Health. 2011; 36: 874-882.

Ejection Fraction picture Emory Health http://www.emoryhealthsciblog.com

Electrocardiogram American Accreditation HealthCare commission-http://www.medicalwordmeanings.com/what-is-electrocardiogram-the-meaning-and-diagram/

Evidence Analysis Library. Academy of Nutrition and Dietetics Website. https://www.andeal.org. Accessed several times from December-February 2015. https://www.andeal.org/topic.cfm?menu=5289&cat=2815

Healthy heart vs. Congested Heart MD Health http://www.md-health.com/Congestive-Heart-Failure.html

Heart El Corazon. http://www.efn.uncor.edu/departamentos/divbioeco/anatocom/Biologia/Los%20Sistemas/Circulatorio/Corazon.htm

Lavid CJ, Ventura HO. Analyzing the Weight of Evidence on the Obesity Paradox and Heart FailureIs there a Limit to the Madness? Congestive Heart Failure. 2013; 19:158-159.

Lennie TA, Moser DK, Biddle MJ, Walsh D. Nutrition Intervention to Decrease Symptoms in Patients with Advanced Heart Failure. Res Nurs Health. 2013; 36(2): 120-145.

Mahan LK. & S. Escott-Stump. 2012. 13th edition of Krauses Food, Nutrition & Diet Therapy. W.B. Saunders Co.: New York. Medical Reference Guide-Complementary and Alternative Medicine Guide. University of Maryland Medical Center. January 2012. http://umm.edu/health/medical/altmed/condition/heart-failure Accessed April 2015.

Riegel B, Moser DK, Anker SD, Appel LJ. State of Science. Promoting Self-Care in Persons with Heart Failure-A Scientific Statement From the American Heart Association.

Systolic/Diastolic HF picture http://pixshark.com/congestive-heart-failure-prevention.htm