MNT in a Patient with Congestive Heart Failure Megan Smith UMD Dietetic Intern May 6, 2015 El CorazonEl 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 Failure Etiology 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 Electrocardiogram Test that checks for problems with the electrical activity of the heart. Ejection Fraction A 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 Assessment Food/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 Assessment Client 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 Assessment Nutrition 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 Assessment Biochemical BNP levels normal upon admission BUN slightly elevated: 26 mg/dL on 12/11 XX L abs were not nutritionally significant throughout his stay in the hospital

Diagnosis 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).

Intervention Nutrition Prescription Energy Needs: kcal (Mifflin St. Jeor) Protein Needs: grams (1-1.2 gram/kg) Fluids: mL

Intervention DateDietAverage IntakeNutrition Supplements and Intake December 8 th Patient placed on a cardiac diet upon admission 25-50%- December 9thCardiac Diet25-50%Ensure Chocolate TID ordered, Patient consumed one Ensure before surgery December 10thNPO at midnight for impending surgery -- December 11thNPO-- December 12thCLD/FLD50-75%Ensure Clear TID ordered, 1 consumed December 13thCardiac diet50-75%Ensure Clear TID ordered, 1 consumed December 14thCardiac diet25-50%Ensure Clear TID ordered, 2 consumed December 15 th Cardiac diet25-50%Ensure Chocolate TID ordered, 2 consumed December 16thCardiac diet40%Ensure Chocolate TID, 3 consumed Magic Cup x 1/day, consumed December 17thCardiac diet, patient discharged today --

Intervention 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

Monitor/Evaluate FH Energy Intake FH Fluid/beverage intake FH Sodium Intake FH Food and Nutrition Knowledge/Skill FH 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®. Accessed several times from December 2014-February ϖ Cotugna N, Wolpert S. Sodium Recommendations for Special Populations and the Resulting Implications. Journal of Community Health. 2011; 36: “Ejection Fraction picture” Emory Health “Electrocardiogram” American Accreditation HealthCare commission- Evidence Analysis Library. Academy of Nutrition and Dietetics Website. Accessed several times from December-February “Healthy heart vs. Congested Heart” MD Health “Heart” El Corazon. 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: 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): Mahan LK. & S. Escott-Stump th 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 Accessed April 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”