Megans major case study with table of contents

MEDICAL NUTRITION THERAPY IN PATIENTS WITH ACUTE SYSTOLIC CONGESTIVE HEART FAILURE

Major Case Study

Megan Smith Dietetic Intern University of Maryland, College Park

December 26, 2014

TABLE OF CONTENTS I..................................................................................................................... Executive Summary ..............................................................................................................................................3 Case Report.......................................................................................................................4-8 Hospital Course of Patient...........................................................................................9 Case Discussion....................................................................................................12-15 Appendices...................................................................................................................16-18 Glossary.....................................................................................................................19 References 20

EXECUTIVE SUMMARY Congestive heart failure (CHF) is a result of an inability of the heart to provide adequate blood flow to the rest of the body. Any disease of the heart muscle or vasculature can lead to CHF; which can be acute or chronic in nature. Heart failure can affect either side of the heart or both sides of the heart simultaneously. Systolic heart failure occurs when the heart cannot pump, or eject, blood efficiently out of the heart; diastolic heart failure is when the heart cannot properly fill with blood. The three hallmark symptoms of heart failure include shortness of breath, fatigue, and fluid retention often accompanied by loss of appetite, weight loss, and for some patients, cardiac cachexia. Accurate weight measurement can be complex in patients with CHF due to peripheral and pulmonary fluid retention. Malnutrition, usually related to cardiac cachexia, is a concern for patients with congestive heart failure.

There is an array of research surrounding medical nutritional therapy interventions that should be applied to patients with heart failure. Of this research, sodium reduction is the most highly cited and understood. The literature suggests a low sodium (2,000 mg) diet for patients experiencing moderate to severe heart failure. Other research includes a fluid restricted (2 L) diet for patients with a serum sodium below 130 mEq/L and the avoidance of alcohol; one drink for women and two drinks for men if not contraindicated.

Nutrition counseling and education for heart failure patients varies depending on the severity of the patient’s condition and the specific signs and symptoms that the patient is experiencing. However, a sodium-restricted diet, weight loss, physical activity, and appropriate use of medications are consistently recommended for all patients with CHF. The research clearly shows that collaborative health care team interventions are necessary to implement these lifestyle changes in CHF patients.

CASE REPORT GENERAL INFORMATION XX is a 59-year-old Caucasian male admitted to Union Memorial Hospital in Baltimore, Maryland on December 8, 2014. XX reported that a few weeks ago he developed nasal congestion and a cold followed by progressive shortness of breath, orthopnea, dyspnea and upper back discomfort. He was also fatigued and felt his energy levels were not normal when doing his normal job and activities. Patient also complains of decreased appetite and 15 pound weight loss prior to admission. The patient was diagnosed with congestive heart failure with aortic insufficiency and aortic root aneurysm. Patient was discharged December 19, 2014.

SOCIAL HISTORY Patient is married with two daughters. His wife and youngest daughter have been present during family meetings and nutrition education during patient hospitalization. He and his wife live in a home in the (removed for privacy). Patient is employed as a physician by (removed for privacy). He has Blue Cross Medstar Employee PPO to cover medical and pharmacy needs. Patient denies family psychiatric history, alcohol and illicit drug use.

MEDICAL/SURGICAL DATA Past medical History Past medical history includes hypertension, dyslipidemia, and hypercholesteremia. No history of obstructive lung disease or pneumonia.

Past and Present Surgical Procedures Patient did not have any history of major surgeries. Patient underwent an aortic root replacement during this hospitalization.

Admitting Physical Examination Vital signs were stable with a temperature of 36.4, pulse 87, respirations 16, blood pressure 119/95. Patient complained of progressive shortness of breath, orthopnea, dyspnea and upper back discomfort. Extremities demonstrated no edema. Patient was alert and oriented and in no acute distress.

Laboratory Results Refer to Appendix A for laboratory results during this hospitalization.

Medications Refer to Appendix B for a complete list of in-patient medications. XX expressed that he is compliant with his medications takes at home for his hypertension.

Diagnostic Tests with Results Date

Diagnostic Test

Results

Dec 1

Chest X-ray (done prior to admission) Echocardiogram

Blunt angles and enlarged cardiac silhouette

Electrocardiogram (EKG)

Sinus rhythm at 97 with left ventricular hypertrophy (LVH) and depressed slow-twitch (ST) laterally.

Dec 9

Dec 9

Food Allergies XX has no known food allergies.

Severely depressed ejection fraction 20-25% with severe aortic regurgitation and a severely dilated proximal ascending root with normal right sided filling pressures

NUTRITIONAL HISTORY FROM INITIAL ENCOUNTER Diet History Patient reported a decreased appetite for approximately one month prior to admission, with recent weight loss associated with decreased appetite. Patient reported eating 50% or less of meals prior to hospital admission. XX was still not hungry upon admission but understood the importance of caloric intake and supplementation before surgery.

Weight history Using the Hamwi equation to calculate ideal body weight (IBW) for men, XX’s IBW is 142 pounds. XX’s usual body weight (UBW) is 210 pounds. His body weight upon admission was 194 pounds, yielding a 16-pound weight loss (7% weight change) in the past month, which is considered severe weight loss.

Height 168 cm

Admit Wt 194 lbs (88.2 kg)

IBW/ %IBW 142 lbs (64.5 kg) 137%

UBW/%UBW

BMI

210 lbs (95.4 kg) 92.3 with 7% loss

31 (obese)

Physical Activity Date

Weight (lbs.)

Source of %UBW %IBW Weight 11/8/14 210 Estimated ---148% 12/8/14 194 Measured 92% 136% 12/12/14 190 Measured 91% 133% Patient is an orthopedic surgeon at (removed for privacy) center so he is generally on his feet all day. He is pending surgery on his right great toe because it is deformed and he plans to run a marathon at the age of 60.

Estimated Nutrient Needs Source

Kcal requirements

Protein requirements Fluid requirements

Facility standards

1870 – 2066 kcal

65-78 grams PRO

1760-2200 mL

EAL

1870-2066 kcal (Mifflin St-Jeor; conditional

n/a

RDA – 1 mL/1 kcal

acceptance) Online nutrition care manual

Use of indirect calorimetry best determines needs

1.12-1.37 g/kg (follows EAL guidelines)

1.4-1.9L/day depending on clinical symptoms

Use of Vitamins/Minerals, Oral Liquid Supplements and/or Alternative Supplements Patient denied prior hospitalizations and use of vitamins, minerals, or supplements.

Before his surgery, XX requested oral liquid supplementation to increase caloric intake.

XX reported understanding of the relationship between calories, energy, strength, and health Cultural Attitudes that Influence Dietary Intake Patient did not express cultural or religious food preferences or restrictions.

Past Nutritional Therapy Patient has not had any prior hospitalizations. Past medical nutrition therapy is not applicable. Patient does report that he tries to follow a low sodium diet at home based on his history of hypertension suggesting brief diet education. He reported that he had never talked with an RD about his diet.

Present Nutritional Therapy Date Diet December 8th

December 9th December 10th

Patient placed on a cardiac diet upon admission Cardiac Diet

Average Intake 25-50%

Nutrition Supplements and Intake

25-50%

Ensure Chocolate TID ordered, Patient consumed one Ensure before surgery -

December 11th December 12th

NPO at midnight for impending surgery NPO CLD/FLD

50-75%

December 13th

Cardiac diet

50-75%

December 14th

Cardiac diet

25-50%

-

Ensure Clear TID ordered, 1 consumed Ensure Clear TID ordered, 1 consumed Ensure Clear TID ordered, 2 consumed

December 15th

Cardiac diet

25-50%

December 16th

Cardiac diet

40%

December 17th

Cardiac diet, patient discharged today

-

Ensure Chocolate TID ordered, 2 consumed Ensure Chocolate TID, 3 consumed Magic Cup x 1/day, consumed -

HOSPITAL COURSE OF PATIENT Medical Treatment  Day 1 (12/8/14): XX was admitted to the CVICU with acute left systolic heart failure with aortic insufficiency and CHF. In the Emergency room, the patient had complained of (c/o) three weeks history of progressive shortness of breath (SOB), orthopnea, and upper back discomfort with decreased appetite and poor oral intake over the past month. Pulmonary consult stated the patient’s bicuspid aortic valve and dilated aortic root, were the likely cause of congestive heart failure and cardiomyopathy. Medical Plan: treat CHF with repeat cardiac catheterization to evaluate his coronaries, as well as contrast CT to evaluate aorta.

Diet: Cardiac, eating less than 50% of meals.  Day 2 (12/9/14): Nutrition consulted for weight loss of 11-15 pounds. Diet history taken and poor oral intake noted. Echocardiogram revealed marked dilated left ventricle with diffuse epokinesis and an ejection fraction (EF) of 25%, moderately enlarged left atrium, moderate aortic regurgitation, mild Mitral Regurgitation (MR) with mild mitral annular calcification. Cardiac catheterization demonstrated severely depressed ejection fraction of 20-25%, severe aortic regurgitation, and a severely dilated proximal ascending root with normal right sided filling pressures. Based on testing, the patient was referred for open-heart surgery for an aortic root replacement. Diet: Cardiac during day, NPO after midnight in preparation for surgery on 12/11/14.  Day 3 (12/10/14): Foley placement unsuccessful; patient requested second attempt after sedation. Potential perioperative complications, associated with extensive cardiomyopathy with low ejection fraction (20%) were reviewed with patient and family. MD and family also reviewed the pros and cons of bioprosthetic tissue heart valve versus mechanical valves. The family decision was to proceed with a tissue heart valve replacement. Diet – NPO.  Day 4 (12/11/14): Intubated for procedure. XX underwent aortic root replacement using valve conduit created from 27 mm Mosaic porcine bio prosthetic heart valve and 30 mm Gel weave graft with reimplantation of coronary arteries. DietNPO.

 Day 5 (12/12/14): Post-op day # 1. Diet advanced to a Clear Liquid diet; tolerated well with no choking or coughing. Nutrition follow-up occurred. Diet – Clears plus RD ordered Ensure complete three times per day (TID). No medical note charted on patient.  Day 6 (12/13/14): Post-op day # 2. No patient updates noted in medical chart.

Diet: Cardiac diet with Ensure clear TID.  Day 7 (12/14/14): Post-op day # 3. No patient updates noted in medical chart.

Diet: Cardiac diet with Ensure clear TID.  Day 8 (12/15/14): Post-op day # 4. XX experienced atrial fibrillation in the early morning hours. Pacing wires from surgery were removed today. Some renal insufficiency noted. Liver function tests (LFT) improving. Noted that patient had some confusion over the weekend that has since resolved. Cardiac diet with Ensure Chocolate TID.  Day 9 (12/16/14): Day 9 (12/16/14): Post op day #5. LFT continuing to improve.

Patient is awaiting nephrology consultation and labs to evaluate renal insufficiency further. Nutrition follow-up addressed oral sores with addition of supplement (magic cup) XX’s daughter attended cardiac nutrition education class.

Diet: Cardiac diet with Ensure Chocolate TID.  Day 10 (12/17/14): Post op day #6. Patient was discharged today. Before discharge RD and patient discussed importance of heart-healthy diet after surgery.

No further notes about renal insufficiency. Diet: Cardiac diet with Ensure Chocolate TID.

Nutritional Treatment Nutrition Assessment

Age: 59 Gender: Male UBW: 210 lbs.

Weight: 88 kg or 194 pounds Height: 168 cm or 5 foot 6 inches BMI: 31 (obese)

PMH: hypertension, hypercholesteremia, dyslipidemia

Symptoms: 3 weeks of shortness of breath (SOB), orthopnea, upper back discomfort, poor appetite x 1 month, fatigued, lower energy levels during normal work and activities, loss of appetite, weight loss

Labs (admission): Sodium 142 Potassium 4.4, Chloride 106 BUN 25 (H) Creatinine 0.84 Glucose 105 Calcium 8.5 Magnesium 1.9 Albumin 3.4 (L) WBC 10.0 Hct 41.6, MCV 87.2, Platelet 288 AST 20, ALT 39 Medications: Furosemide, atorvastatin, labetalol Current Diet: Cardiac Diet upon admission, currently NPO due to impending surgery

Diet History: Decreased appetite and variable intake in the past month. Patient reports that he tries to follow a low-sodium diet at home.

Nutrition Diagnosis PES Statements NI-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).

Nutrition Intervention – Nutrition prescription, Interventions with goals Nutrition Prescription Intervention with goals 1870-2066 kcal (Mifflin St Jeor) 65-78 g PRO (1-1.2 gm/kg) 1760-2200 mL Fluids (UMH criteria of 20-25 mL/kg) Low sodium, Cardiac Diet

RC 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 Nutrition Monitoring and Evaluation Indicator

Criteria

FH 1.1.1.1 Energy Intake

Intake of at least 1800 kcal or 75% of tray/snack intake

FH-1.2.1 Fluid/beverage intake

Intake of 2 out of 3 Ensure supplemental drinks per day. No fluid restrictions indicated for this patient.

FH 1.6.2 Sodium Intake

No salt added to meals, snacks, or foods brought in from outside. Patient will state and understand their recommended level of dietary sodium intake upon discharge.

FH 4.1.1 Food and Nutrition Knowledge/Skill

Patient and patient family express verbal understanding of cardiac diet education.

They will be able to distinguish between food sources of high and low sodium and use nutrition labels to limit sodium intake.

FH 4.1.2 Diagnosis specific food and nutrition knowledge

Patient is able to cite one reason why it is important to adhere to a low sodium, healthy-fat diet in relation to his history of hypertension and congestive heart failure.

Patient will be able to define the DASH lifestyle. **Use of Reference (1) CASE DISCUSSION Medical Considerations A properly functioning heart pumps adequate amounts of blood throughout the body to perfuse tissues and meet metabolic demands (7). XX presented to the medical team at UMH with acute left systolic heart failure with aortic insufficiency; broadly referred to as congestive heart failure (CHF). CHF occurs when the heart cannot pump blood to the rest of the body. It has been described as a syndrome in which symptoms define the diagnosis, severity, and determination of treatment effectiveness (6). Progressive heart damage in HF patients can occur through hemodynamic pressure imbalance, volume overload, or an acute myocardial infarction (MI) (7). Compensatory mechanisms by the heart include an increased force of contraction, hypertrophy, frequent pumping, and kidney stimulation.

These mechanisms can help maintain nearly normal blood circulation for a time, but eventually these mechanisms fail (7). Coronary heart disease and hypertension are touted to be the two leading causes of heart failure with prevalence of HF increasing in patients who are also obese (5). Vasoconstriction caused by reduced blood flow to the kidneys is responsible for the hallmark symptoms of HF including: fatigue, shortness of breath, and fluid retention. Other clinical symptoms include confusion, hypoperfusion, and elevated B-natriuretic peptides (7).

XX was experiencing signs of fatigue, loss of appetite, and shortness of breath prior to admission. He also lost 7% of his body weight in one month. Fluid retention, due to sodium and water retention by the kidneys, was not noted in this patient. Upon admission his BUN values were slightly elevated which is expected due to dysfunctioning kidneys.

His other lab values, including his natriuretic peptides (BNP) levels, were normal upon admission. BNP is a hormone produced by the heart that contributes to the elimination of fluids in the body. Elevated BNP levels are indicative of CHF (2). MD did not experience any nutrition related lab changes that were significant.

Hypertension and coronary heart disease (CHD) are the two leading causes of heart failure (5). XXâ&#x20AC;&#x2122;s past medical history of hypertension placed him in this categorical statistic. However, ironically enough, evidence suggests that obese HF patients have lower mortality and hospitalization rates than those HF patients with a normal BMI; a phenomenon, experts refer to as the obesity paradox (8). XX presents with a BMI of 31, a number that categorizes him as obese. Weight loss is contraindicated for a patient such as XX (with a BMI <40 but >20) due to the fact that cardiac cachexia is a major concern for CHF patients (8). More research is needed but it is suggested that patients like XX should be advised to monitor for loss of appetite, unexpected weight loss, and muscle wasting rather than try to lose weight (8). Once symptoms have fully subsided, the patient can meet with an RD and doctor to talk about weight loss options.

Treatment modalities for patients with CHF include improving functional capacity of the heart and lessening progression of the underlying disease (7). Medical management of the disease corresponds to the stage of HF that the patient is experiencing; it can include sodium reduction, exercise, medication, and surgical intervention (7). XX’s family chose the surgical route for XX. XX’s echocardiogram showed that he was experiencing an ejection fraction (EF) of 20-25%. Ejection fraction is the amount of blood the ventricle can pump through the heart at a time. A normal left ventricle ejection fraction (LVEF) is 50-60% and an LVEF of less than 50% is considered to indicate HF of systolic nature (2).

Patients with diastolic HF will not experience a depressed EF due to the heart muscle in this part of the heart being more rigid (2).

Nutritional Therapy XX was admitted with poor appetite and oral intake for one month prior to hospitalization. He said that on a good day he would eat about 50% of his meals, but on average he was eating less than 50%. XX reported his usual body weight as 210 pounds.

Upon admission his weight was 194 pounds, signifying a 7% weight change in the month prior to admission. Although this is a severe amount of weight loss in a month, MD’s recent weight change and other signs and symptoms did not fall under any categories of malnutrition (2). XX did however fall under the criteria for being obese. Based on Mifflin St-Jeor, as per facility standards, his calorie needs were 1870-2066 kilocalories. Energy needs were not restricted due to the fact that HF patients have higher energy expenditure secondary to being in a catabolic state (7). His fluid needs were 1760-2200 mL (20-25 mL/kg). No fluid restrictions were necessary because XX was not experiencing edema and Lasix was prescribed to keep edema from occurring. Thiamine and potassium supplementation is sometimes indicated in patients taking diuretics but this was not necessary for XX. His protein needs were 65-78 gm/kg based on facility standards of 11.2 gm/kg. XX expressed to the RD that he was worried about his recent weight loss and he wanted to maximize his energy consumption before his surgery.

Due to his history of hypertension, XX was placed on a cardiac diet immediately upon admission. After meeting with the RD, an order was placed for three Ensure supplements a day to help maximize energy intake. XX reported to the RD that at home he tried try to follow a diet low in sodium due to his history of hypertension. XX did not express any knowledge of eating a diet lower in saturated and trans-saturated fats or a diet higher in fruits, veggies, and whole grains; both of which would be beneficial to him due to his past medical history (4). XX was made NPO two days after admission due to his open heart surgery. Within a day and a half after his surgery, he was quickly advanced from a CLD, to a FLD, to a cardiac diet. He was not experiencing any chewing or swallowing difficulties. Patient did experience some weight changes in the days following surgery.

These changes were attributed to fluid loss secondary to the patient being on Lasix.

Post-surgery XX was still experiencing a decreased appetite (about 40% meal consumption) and complained of mouth sores that were making it slightly more difficult for him to eat. RD offered magic cup supplement to the patient to help alleviate pain of

sores while still providing calories. Upon discharge, although XX still reported a poor appetite he was deemed stable to return home. XX was counseled on the importance of a heart healthy diet after discharge including ways to reduce sodium intake to less than 2000 mg per day; ways to decrease fat from saturated and trans fat sources, and how to increase fruits, vegetables, and whole grains in the diet. XX reported to RD that he was fully aware of changes he needed to make in his diet once he returned home.

Implications of Findings to the Practice of Dietetics The severity of XX’s CHF was reflected in the medical and nutritional therapy for the patient. According to the Heart Failure Society of America (HFSA) guidelines XX’s level of HF would be scaled as Stage C: Symptomatic. In this stage, “the patient has evidence of structural changes in the heart and experiences symptoms such as shortness of breath, fatigue, and reduced tolerance to activity” (2). XX was experiencing all of these symptoms. Although a standard guideline for CHF patients is a fluid-modified diet (ND1.2.8). XX did not come in with any signs of peripheral or congestive edema, so this nutritional therapy was not necessary for XX. XX’s previous medical history of hypertension caused him to be placed on a cardiac diet immediately upon admission. It also categorized him as a patient who could benefit from the DASH diet. The DASH diet (which is actually a lifestyle, not a diet) is typically recommended for patients with a history of hypertension. These changes are best implemented when hypertension is first diagnosed to help prevent heart failure from occurring; however it is still important to implement after HF and HF surgery to avoid a second occurrence.

DASH diet stands for Dietary Approaches to Stop Hypertension and it emphasizes eating more vegetables, fruits, low-fat dairy, whole grains, fish, poultry, and limiting sodium to 2000 mg per day (2&8). In the case of XX the RD implemented purpose of the nutrition education (E-1.1) and priority modifications (E-1.2) (2). These interventions are necessary to educate XX and his family on how to follow this DASH lifestyle. RD interventions for this patient included education about reducing sodium, increasing fruits, vegetable, and whole grains; decreasing trans and saturated fat in the diet while increasing mono-unsaturated, poly-unsaturated, and omega 3 fatty acids in the diet; reading food labels and checking for sodium and fat levels on the food label, and the importance of getting in the habit of looking at food labels. The RD also counseled the patient on the importance of self-monitoring (C-2.3) with XX and his family. Strategies such as looking up nutrition labels online and reading food labels before cooking and purchasing foods were emphasized with XX and his family to help self monitoring of XX’s sodium intake after being discharged. Self-monitoring strategies to reduce sodium also included using salt-free herbs to season foods when cooking. Coordination of nutrition Care (RC-1), specifically collaboration with other providers (RC-1.4) was also necessary for RD to ensure that patient medications were not having any negative nutritional interactions.

A CHF patient in an acute care setting will require different RD interventions than a CHF patient in an outpatient setting. In the outpatient environment, patients have sought out the help of the RD to prevent the HF from re-occurring. RD Nutrition counseling (C-1,

C-2) techniques are numerous for HF patients in an outpatient setting. Goal setting (C2.2), Cognitive-behavioral theory (C-1.1), and Trans theoretical model/stages of change (C-1.4) are all modes of RD counseling that can be applied to the outpatient HF patient; however, they are not usually indicated for a HF patient in the acute care setting. Due to the progressive nature of the disease, and the large scale of severity in which the disease lies, XX is one of many examples of a HF patient. Although there are ‘typical’ signs and symptoms of the disease, the nutritional therapy targeted at each patient must be individualized according to the patient’s previous medical history, current signs and symptoms, anthropometric data, financial/economic situation, and current social setting and environment. The RD’s role as health care provider for the CHF patient is vast, ever changing and crucial in the prevention of a second occurrence of HF.

APPENDICES Appendix A: Laboratory Results

Lab

Na K Cl CO2 Creatinine Glucose BUN Bili Total Calcium Ionized Ca

Reference Range

12/8

12/9

12/10

12/11

12/11

12/1 1

12/1 1

12/1 1

12/1 1

12/ 11

135-146 mmol/L 3.5-5.3 mmol/L

140

142

-

140

4.8

4.4

-

4.5

136 L 4.1

136 L 4.4

129 L 5.9 H

130 L 6.5 H

128 L 7.0 H

98-107 mmol/L 22-32 mmol/L 0.6-1.1 mg/dl <140 mg/dl 7-20 mg/dl 0.1-1.3 mg/dl 4.4-5.3 mg/dl

106

106

-

105

-

-

-

-

-

13 6 5.

7 H -

24

27

-

29

-

-

-

-

-

-

0.83

0.84

-

0.91

-

-

-

-

-

-

107

105

-

105

109

97

86

104

132

21

25

-

-

-

-

-

-

-

0.6

-

26 H 0.7

10 2 -

-

-

-

-

-

-

-

-

-

-

1.14

1.0 7

0.9 3

1.0 8

1.0 6

8.7

8.5

-

8.8

-

-

-

-

-

0.

90 L -

-

-

-

-

-

-

-

-

-

-

1.9

-

1.9

-

-

-

-

-

-

-

20

-

18

-

-

-

-

-

-

-

39

-

-

-

-

-

-

-

12.5

10

-

-

-

-

-

-

-

-

-

-

46 H 11 H 157

-

-

-

-

-

-

-

-

-

58

-

-

-

-

-

-

-

-

-

84

-

-

-

-

-

-

-

-

-

73

-

-

-

-

-

-

8.1-10.7 mg/dl Phos 2.4-4.7 mg/dl Mg 1.7-2.2 mg/dl AST 15-41 IU/L ALT 17-63 IU/L WBC 4.8-10.8 k/uL Cholestero <200 l mg/dl HDL 60 mg/dl or > LDL 100-129 mg/dL or < 100 mg/dl Triglyceri <150 des mg/dl

Lab

Na K Cl CO2 Creatinine Glucose BUN Bili Total Calcium Ionized Ca Phos Mg AST ALT WBC

Reference Range

12/1 2

12/12

12/13

12/14

12/15

12/16

12/17

135-146 mmol/L 3.5-5.3 mmol/L 98-107 mmol/L 22-32 mmol/L 0.6-1.1 mg/dl <140 mg/dl 7-20 mg/dl 0.1-1.3 mg/dl 4.4-5.3 mg/dl 8.1-10.7 mg/dl 2.4-4.7 mg/dl 1.7-2.2 mg/dl 15-41 IU/L 17-63 IU/L 4.8-10.8 k/uL

147

143

137

134 L

136

137

139

4.6

4.2

4.3

4.6

4.3

4.5

3.9

115 H 27

110 H

105

101

103

102

104

27

26

26

24

28

30

1.16

0.97

0.90

1.58 H

1.47

1.27

1.09

147 H 23 H -

116

116

113

103

94

93

22 H

19

39 H

42 H

36 H

26 H

-

-

1.5 H

1.6 H

1.3

1.1

1.14

-

-

-

-

-

-

7.7 L -

7.6

-

7.8

-

-

-

-

-

-

-

-

-

2.1

-

1.8

-

2.1

-

-

-

-

-

2553 H

686 H

344 H

-

-

-

1933 H

1396H

994 H

13.5 H

-

20.3 H

12.8 H

1237 H 1662 H 15.6 H

10.6

11.7 H

APPENDIX B- MEDICATIONS

In-Patient Medications Medication Function Atorvastatin HMG-CoA reductase (Lipitor) inhibitor that helps lower cholesterol.

Pravastatin Lower cholesterol and triglycerides in the blood.

Docusate

Stool softener

Enoxaparin

Prevents blood clots. Also used to prevent a second heart attack and complications after a heart attack.

Prevents the body from absorbing too much salt.

Treats fluid retention.

Anticoagulant.

Furosemide Heparin

Sodium Chloride Labetalol Senna Famotidine Bisacodyl Dronabinol Dilaudid Phenylephrine

Propofol

Nutritional Implications Diarrhea, constipation, gas, nausea, loss of appetite. Avoid grapefruit juice.

Avoid a diet high in fat. Electrolyte imbalances are possible. Can cause stomach pain.

Take with a full glass of water. May cause bitter taste, bloating, cramping, diarrhea, gas, and throat irritation.

Nausea, diarrhea, fluid retention. Can also cause abnormal liver tests and reduced platelet counts.

Loss of appetite, weight loss, low potassium, low calcium, sore throat, diarrhea, constipation, stomach pain.

Hyperkalemia, hyponatremia, hypertriglyceremia. Vitamin K consumption must be kept consistent to what it was before starting the medication.

Treat or prevent sodium loss. Nausea, vomiting, stomach pain, swelling in the hands, ankles, feet.

Treats high blood pressure.

May hide signs of low blood sugar in diabetic patients. Indigestion, nausea.

Treats constipation.

Can cause electrolyte imbalances, especially hypokalemia. Dehydration, diarrhea, loose stools.

Decreasing the amount of Diarrhea, constipation, vomiting, acid the stomach produces. nausea, abdominal discomfort, dry mouth.

Treats constipation Stomach cramps, stomach discomfort Treats nausea and vomiting. Loss of appetite, diarrhea Can also be used to increase appetite.

Narcotic Constipation, nausea, vomiting, stomach pain, dry mouth.

Decongestant used to treat Loss of appetite nasal and sinus congestion.

Can also be used to treat hypotension.

Slows the activity of the Unusual taste after injection has been brain and nervous system. reported in some patients. Nausea and

Metoprolol

Pantoprazole

Used to help critically ill patients breathe when connected to a ventilator and used to help patients relax before surgery Beta blocker that affects heart and circulation. Used to treat angina and hypertension.

Treats GERD

vomiting.

Rapid weight gain, diarrhea

Nausea, vomiting, gas, constipation

Glossary Bicuspid aortic valve: The aortic valve is a one-way valve between the heart and the aorta, the main artery from the heart that distributes oxygen-rich blood to the body.

Normally, the aortic valve has three small flaps or leaflets that open widely and close securely to regulate blood flow, allowing blood to flow from the heart to the aorta and preventing blood from flowing backwards into the heart.

In bicuspid aortic valve disease (BAVD), the valve has only two leaflets. With this deformity, the valve doesnâ&#x20AC;&#x2122;t function perfectly, but it may function adequately for years without causing symptoms or obvious signs of a problem.

Cardiac Cachexia: unintentional and severe weight loss caused by heart disease.

Heart failure can cause blood to back up into the liver and intestines causing swelling.

This can create a decreased appetite and nausea within the patient. Swollen intestines may not adequately absorb nutrients.

Cardiomyopathy: disease of abnormal heart muscle three types (dilated, hypertrophic, restrictive). Makes it harder for your heart to pump and deliver blood to the rest of body, can lead to heart failure.

Cardiac catherization: catheter is put into a blood vessel and threaded into heart.

Through the catheter tests and treatments can be done Dilation of the aortic root= When the bulb of the aorta swells beyond normal levels, it is called dilation of the aortic root.

Vasoconstriction: narrowing of blood vessels caused by small muscles in the walls of the vessel.

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