MNT in a Patient with Congestive

Heart FailureMegan Smith

UMD Dietetic InternMay 6, 2015

El Corazon

Congestive Heart Failure

Most common signs and symptoms

• Fatigue• Edema• Shortness of

breath• Chest

congestion

Md Health

Congestive Heart Failure

Systolic 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.

Pixshark

Congestive Heart FailureEtiology most commonly includes:• Coronary Artery Disease• Myocardial Infarction• Uncontrolled Hypertension• Arrythmias, valve problems, drugs,and

alcohol can also contribute

Leading Predictors• Coronary artery disease• Poorly controlled blood pressure• Elevated B natriuretic peptides

Congestive Heart Failure

ElectrocardiogramTest 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 Patient

• XX is a 59 year-old Caucasian male• Married with two daughters• Lives at home with wife• Employed as a physician by a local

Baltimore Hospital

Medical Considerations

Diagnosis: Acute left systolic heart failure with aortic insufficiency. Broadly referred to

as CHF.

PMH: hypertension

Echocardiogram: Ejection Fraction was 20-25%

Signs/Symptoms: Fatigue, loss of appetite, SOB

Nutrition AssessmentFood/Nutrient Related History

•Decreased appetite one month PTA•Eating approx. 50% of meals PTA•MD 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 Assessment

•Height=168 cm Weight=194 lbs (88.2 kg) BMI=31

•UBW=210 lbs;16 pound wt loss, 7% weight change in past month

Anthropometric Measurements

Nutrition AssessmentClient History•PMH: hypertension, dyslipidemia,

hypercholesteremia•No surgical history (hx) •Employed as a physician as Chief of Orthopedics

•Denies family psychiatric hx, alcohol, and drug use

Nutrition AssessmentNutrition Focused Physical Findings

•No edema present on admission•Vital signs stable on admission•Signs & Symptoms on admission: 3 weeks SOB, orthopnea, upper back discomfort, fatigued, lower energy levels during normal work activities, loss of appetite, weight loss

Nutrition AssessmentBiochemical

BNP 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).

Intervention

Nutrition Prescription

Energy Needs: 1870-2066 kcal (Mifflin St. Jeor)Protein Needs: 65-78 grams (1-1.2 gram/kg)

Fluids: 1760-2200 mL

InterventionDate Diet Average Intake Nutrition

Supplements and Intake

December 8th Patient placed on a cardiac diet upon admission

25-50% -

December 9th Cardiac Diet 25-50% Ensure Chocolate TID ordered, Patient consumed one Ensure before surgery

December 10th NPO at midnight for impending surgery

- -

December 11th NPO - -

December 12th CLD/FLD 50-75% Ensure Clear TID ordered, 1 consumed

December 13th Cardiac diet 50-75% Ensure Clear TID ordered, 1 consumed

December 14th Cardiac diet 25-50% Ensure Clear TID ordered, 2 consumed

December 15th Cardiac diet 25-50% Ensure Chocolate TID ordered, 2 consumed

December 16th Cardiac diet 40% Ensure Chocolate TID, 3 consumedMagic Cup x 1/day, consumed

December 17th Cardiac 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 CHF

Monitor/Evaluate

FH 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 knowledge

Nutrition Implications•Severity of MD’s CHF was reflected in the medical and nutritional therapy.

•Dietary Approaches to Stop Hypertension (DASH)

• Implemented to help client make better choices after surgery

•2000 mg sodium/day

•Many CHF patients will require a fluid-modified diet (ND-1.2.8)

•XX was not experiencing edema or hypernatremia

Nutrition Implications•Self-monitoring (C-2.3)

•Reading nutrition labels•Choosing salt-free additives

References 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. ϖ 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 Failure—Is 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 Krause’s 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