Coronary Artery Disease (CAD)

CAD is the most common type of heart disease. In the United States, it is the #1 cause of death for both men and women. Lifestyle changes, medicines, and medical procedures can help prevent or treat CAD. These treatments may reduce the risk of related health problems. CAD happens when the arteries that supply blood to heart muscle become hardened and narrowed. This is due to the buildup of cholesterol and plaque, on the inner walls. This buildup is called atherosclerosis. As it grows, less blood can flow through the arteries. As a result, the heart muscle can’t get the blood or oxygen it needs. This can lead to chest pain (angina) or worse. Most heart attacks happen when a blood clot suddenly cuts off the hearts’ blood supply, causing permanent heart damage.

A patient seen today was admitted in the intesive care unit (ICU) and was referred to the nutrition staff for support in cardiac care.

Background:
The patient experienced a myocardial infarction (MI) and had coronary artery disease (CAD). He was a male, 85 y/o, and admitted for an MI protocol. He was currently on a cardiac diet with no gastric irritants (NGI). NGIs are foods like juices, chili, and black pepper. He was not experiencing shortness of breathe (SOB), nausea, fever, chills, or vomiting.

Anthropometrics:
Ht: 69 in.
CBW: 195# (88.5kg)
BMI: 28.86 (overweight)
IBW: 160# (72.73kg)

Past Medical History (PMH):
• CAD/Cornoary Artery Bypass graft (CABG)
• Deep Veing Thrombosis (DVT)
• Chronic Kidney Disease (CKD)
• Carotid Stenosis
• Hypertension (HTN)
• Peripheral Vascular Disease (PVD)
• Gallbladder Disease
• Microvascular Decompression (MVD)
• Aortic Atherosclerosis
• Renal Neoplasm
• Cholecystitis
• Stable Angina
• Asbestos Exposure
• B-12 Deficiency

Labs:
Glucose: 132 mg/dl (70-109: normal)
Cholesterol: 144 mg/dl (160-200: normal)
TGs: 205 mg/dl (35-160: normal)
HDL: 36.3 mg/dl (40-60: normal)

Assessment:
TLC Diet
• Limit saturated and trans fats
• Limit cholesterol: less than 200 mg/d
• Limit total fats: 25%
• Consume dietary fiber
• Consume more omega-3 fats
• Consume more plant-based meals

Blausen_0259_CoronaryArteryDisease_02

Nasogastric Tube Feedings

A nasogastric (NG) tube is a special tube that carries food and medicine to the stomach through the nose. It can be used for all feedings or for giving your patient/client extra calories. It’s important to take good care of the feeding bag and tubing so that they work properly, as well as the skin around the nostrils so that it does not get irritated.NG tube feedings incorporate a procedure where a thin, plastic tube is inserted through the nostril, down the esophagus, and into the stomach. Once the NG tube is in place, healthcare providers can deliver food and medicine directly to the stomach or remove substances from it.

NG tube feeding has four distinct advantages:

·         Short-term (<4 weeks)

·         Most commonly used

·         Easiest to place (with a prior patient assessment)

·         Least expensive to administer

Nasogastric tubes are used mainly for short-term support in patients who do not have problems like vomiting, GERD, poor gastric emptying, ileus or intestinal obstruction. Nasogastric tubes can be used for longer term support where other enteral access is not possible or could potentially carry a risk. NG tubes are potentially dangerous in patients who cannot swallow correctly and those who need to be nursed. A patient assessment should always be carried out prior to placement of an NG tube. NG tubes are placed by appropriately trained staff like nurses or doctors.

There is a small risk that NG tubes can be misplaced on insertion or move out of position at a later stage. Position of NG tubes should be verified on initial placement and before each use. It is recommended that a pH <5.5 is consistent with gastric placement. If aspirate cannot be obtained or the pH is >5.5 feeding should not begin. The NG tube should be left in place, the patient’s position changed and the aspirate re-tested in 1 hour. The feed itself can increase the pH in the stomach, so aspiration should take place at least 1 hour after the feed has been stopped.

NG tube

Parenteral Nutrition

When a patient cannot eat any or enough food because of an illness or health complication, sometimes other forms of nutrition are required to assist the patient towards better health. The stomach or bowel may not be working normally, or a person may have had surgery to remove part or all of these organs. When this occurs, and a patient or client is unable to eat, nutrition must be supplied in a different way. One method that can be applied is Parenteral Nutrition.

Parenteral Nutrition bypasses the normal digestion in the stomach and bowel. It is a special liquid food mixture given into the blood through an intravenous (IV) catheter (needle in the vein). The mixture contains proteins, carbohydrates, lipids, vitamins and minerals. This special mixture may be called Parenteral Nutrition or Total Parenteral Nutrition (TPN).

A special IV catheter will be placed in a large vein in the chest or arm. It can stay in place for as long as needed. Proper care is required to avoid infection and clotting. Different kinds of catheters may be used. Common types of catheters are Peripherally Inserted Central Catheter (PICC), triple lumen, double lumen, or single lumen catheters, and Ports. Nutrition is given through this large vein. Coordinated care, consisting of doctors, nurses, RDs, and pharmacists, will talk with the patient about the different types of catheters prior to administering anything.

Prior to initiating TPN, a nutrition assessment is necessary to determine nutrient needs and to anticipate any metabolic changes that may occur due to the patient’s underlying condition, medications or concurrent therapies, etc. Important factors to consider when assessing a patient for TPN are:

·         Anthropometric Data: CBW, Wt Hx, IBW

·         Lab Values: Mg levels, Phosphorus levels, TG levels

·         Patient Medical History (PMH): Anatomy resections, ostomies, pre-existing conditions like diabetes or renal failure

·         Diet History: Diet prior to admission, Food/Drug Allergies

·         Medications: Current medications and supplements

TPN_All tube feedings

Diabetic Ketoacidosis (DKA)

As part of my Medical Nutrition Therapy (MNT) rotation, my preceptor has asked me to create a summary sheet of certain illnesses and complications associated with various disease states. One of which, is diabetic ketoacidosis (DKA).

What is DKA?

DKA is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones.
It develops when your body is unable to produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as an alternate fuel. This process produces a buildup of toxic acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.

What causes DKA?

1. Not enough insulin

2. Not enough food

3. Low blood glucose

When cells don’t get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are acids that build up in the blood and appear in the urine when your body doesn’t have enough insulin. They are a warning sign that your diabetes is out of control or that you are getting sick. High levels of ketones can poison the body. When levels get too high, you can develop DKA. DKA may happen to anyone with diabetes, though it is rare in people with type 2. Treatment for DKA usually takes place in the hospital. But you can help prevent it by learning the warning signs and checking your urine and blood regularly. DKA usually develops slowly. But when vomiting occurs, this is life-threatening and can develop in a few hours.

Sugar is a main source of energy for the cells that make up your muscles and other tissues. Normally, sugar enters your cells with the help of insulin. If you don’t have enough insulin in your body, your body won’t be able to use sugar properly for energy. This prompts the release of hormones that break down fat as an alternate fuel. In turn, this process produces toxic acids known as ketones. Excess ketones accumulate in the blood and eventually “spill over” into the urine.

Early symptoms include:

– Polydypsia (increase of thirst)

– Polyuria (frequent urination)

– Hyperglycemia (high blood glucose levels)

– High level of ketones in the urine

– Fatigue, dry skin, nausea, difficulty breathing, fruity odor on the breath (caused from the presence of ketones)

When diagnosing DKA, a healthcare provider should pay close attention to the following lab values:

Blood Glucose: If there isn’t enough insulin in your body to allow sugar to enter your cells, your blood sugar level will rise (hyperglycemia). As your body breaks down fat and protein for energy, your blood sugar level will continue to rise.

Ketone level: When your body breaks down fat and protein for energy, toxic acids known as ketones enter your bloodstream.

Blood acidity: If you have excess ketones in your blood, your blood will become acidic (acidosis). This can alter the normal function of various organs throughout your body.

– Blood electrolyte tests, Urinalysis, Chest X-ray, and an Electrocardiogram (ECG)

The treatment for DKA involves a three-pronged approach:

1. Fluid Replacement: receive fluids, orally or intravenously, until rehydrated. These fluids will replace those that have been lost through excessive urination and dilute the excess sugar in the blood.

2. Electrolyte Replacement: Electrolytes are minerals in your blood that carry an electric charge, such as sodium, potassium and chloride. The absence of insulin can lower the level of several electrolytes in your blood. You’ll receive electrolytes through your veins to help keep your heart, muscles and nerve cells functioning normally.

3. Insulin Therapy: Insulin reverses the processes that cause diabetic ketoacidosis. Along with fluids and electrolytes, you’ll receive insulin therapy — usually through a vein. When your blood sugar level falls below 240 mg/dL (13.3 mmol/L) and your blood is no longer acidic, you may be able to stop intravenous insulin therapy and resume your normal subcutaneous insulin therapy.

Diabetic ketoacidosis is usually triggered by an illness or insulin therapy.

An infection or other illness can cause your body to produce higher levels of certain hormones, such as adrenaline or cortisol. Unfortunately, these hormones work against insulin — sometimes triggering an episode of diabetic ketoacidosis. Pneumonia and urinary tract infections are common culprits.

Missed insulin treatments or inadequate insulin therapy can leave you with too little insulin in your system, triggering an episode of diabetic ketoacidosis.

Other possible triggers of DKA could include:

– Stress

– Physical or emotional stress

– High fever

– Surgery

– Heart attack

– Alcohol or drug abuse, specifically cocaine

While DKA is being treated, there are complications that patients and healthcare providers need to be aware of as well. Complications could include:

Hypoglycemia: Insulin allows sugar to enter your cells. This causes your blood sugar level to drop. If your blood sugar level drops too quickly, you may develop low blood sugar.

Hypokalemia: Fluids and insulin used to treat diabetic ketoacidosis may cause your potassium level to drop too low. A low potassium level can impair the activities of your heart, muscles and nerves.

Cerebral Edema: Adjusting your blood sugar level too quickly can produce swelling in your brain. This complication appears to be more common in children, especially those with newly diagnosed diabetes.

American Diabetes Association- DKA

Mayo Clinic- DKA

DKA3

DKA2

DKA

Setting Goals with Your Team!

No matter what stage of development your team may be at, they’re most effective when the whole group understands and accepts the goals of their assignment. A way to get your team on-board is to allow members to provide feedback on defining and refining project goals. Managers should also provide feedback on establishing and refining these goals. Synergy between team members and managers in establishing project statements will result in achieving these goals, as well. This conversation should normally happen at the initial project meeting, which should also describe team-building goals and information goals.

Effective teams contribute to the achievement of three types of goals throughout the course of a project.

1.      Team-building goals focus on:

          Getting to know each team member. Teams are most effective when they take time to discover each member’s background, skill, work style, etc.

          Learning to work together. Teams need to identify the strengths of each member and set processes in place to work efficiently together.

          Setting ground rules. Members need a common understanding of how the team will conduct itself and what is acceptable and unacceptable behavior. Some of the topics for discussion are meeting attendance, promptness, conversational courtesy, assignments, and breaks.

          Figuring out decision-making processes. A characteristic of ineffective teams is that decisions just seem to happen. Teams need to discuss how decisions will be made to avoid conflicts in the future.

2.      Information goals include:

          Getting updates from team members on progress! Staying connected with your team and making sure everyone is on the same page is important.

          Learning about the tools used to support the team’s various tasks.

          Communicating with stakeholders.

3.      Project goals focus on:

          Understanding the project and each member’s assignment. Teams should be able to ask questions about their tasks and the stakeholders’ expectations.

          Identifying the business needs supported by the goals.

          Understanding the process that will be used. Not only do team members need to understand the overall process, but they also need to understand which steps are their responsibilities.

          Identifying the resources needed. Team members need to discuss resources that might be needed sooner than later in the process. This discussion ensures that necessary resources will be available at their designated times.

          Developing a project plan or outline of how the team will accomplish their goals. Teams need roadmaps. A team leader should discuss the logistics of the project with team members. Breaking the process into smaller steps and assigning duties will help build team collaboration. Team should continue to review and revise these plans as they move toward reaching their goals.

set and reach goal concept