Running head: ISCHEMIC STROKE 1

CASE STUDY REPORT ON MRS. R.N -ISCHEMIC STROKE

SNEHA LAKHOTIA
ND-420
12.06.2018
Marywood University
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Patient Description
Mrs. R.N. is a 77-year-old woman admitted to the hospital with right sided hemiparesis

and slurred speech. R.N. is married and lives with her husband Robert. Children are grown up

and do not live at home. She has been awarded high school diploma and is a retired hair dresser.

She is a European American and speaks English. Her weight is 165 lbs. and her height is 5’2’’.

No prior weights are available. Her BMI is 30 and falls under obese class I category. According

to Hamwi formula her ideal body weight is 110Lbs. % of ideal body weight is 150 (Red flag).

She has a medical history of hypertension and hyperlipidemia from past ten and two years

respectively. She underwent a hysterectomy ten years ago and does not use alcohol or tobacco.

No family history is available at this time. Her husband reports that R.N. takes captopril 25mg

twice daily for treating high blood pressure, lovastatin 20mg once daily for treating high

cholesterol and triglycerides, multivitamin and calcium 500mg thrice daily at home. Her husband

states that his wife has a good appetite and has not followed any special diet. She has been trying

to avoid fried foods and stopped adding salt at the table. She made these changes several years

ago and has no food allergies and previous nutrition therapy (Nelms & Roth, 2014).

Her current diet order is Nil Per Oral (NPO) except medications. Her vital signs are

temperature: 98.8, Pulse:91, Respiratory Rate:19, Blood Pressure: 138/88. At present she is

being given 0.6mg/kg intravenous r-tPA (Tissue plasminogen activator) over one hour with 10%

of total dose given as an initial venous bolus over one minute to help dissolve the blood clot

quickly and restore the blood flow to the brain tissue, acetaminophen 650mg per oral for pain

every 4 to 6 hours, 0.9NS at 75cc/hr. and oxygen at 2 liters/minute via nasal cannula. No

anticoagulants for next 24 hours. Neuro checks are being done every 30mins for 6 hours and then

every hour for next 16 hours (Nelms & Roth, 2014).

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Disease information

A stroke is a "brain attack". It can happen to anyone at any time. It occurs when blood

flow to an area of brain is cut off. When this happens, brain cells which are deprived of oxygen

begin to die. When they die during a stroke, abilities controlled by that area of the brain such as

memory and muscle control are lost.

There are two types of stroke, hemorrhagic and ischemic. Hemorrhagic strokes are less

common, only 15 percent of all strokes are hemorrhagic, but they are responsible for about 40

percent of all stroke deaths. A hemorrhagic stroke is either a brain aneurysm burst or a weakened

blood vessel leak. Blood spills into or around the brain and creates swelling and pressure,

damaging cells and tissue in the brain. There are two types of hemorrhagic stroke called

intracerebral and subarachnoid. Ischemic stroke occurs when a blood vessel carrying blood to the

brain is blocked by a blood clot. This causes blood not to reach the brain. High blood pressure is

the most important risk factor for this type of stroke. Ischemic strokes account for about 87% of

all strokes. An ischemic stroke can occur in two ways i.e. embolic and thrombolytic stroke

(NSA, 2018).

Stroke accounts for 1 of every 19 deaths in the US. It kills someone in the US about

every 3 minutes 45 seconds. When considered separately from other cardiovascular diseases,

stroke ranks No. 5 among all cause of death in the US, killing nearly 133,000 people a year.

From 2005 to 2015, the age-adjusted stroke death rate decreased 21.7 percent, and the actual

number of stroke deaths declined 2.3 percent. Each year, about 795,000 people experience a new

or recurrent stroke. Approximately 610,000 of these are first attacks, and 185,000 are recurrent

attacks. In 2015, stroke deaths accounted for 11.8% of total deaths worldwide, making stroke the

second leading global cause of death behind heart disease (Benjamin et al., 2018).
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Signs and symptoms of stroke are FAST (Facial drooping, Arm weakness, Slurred

speech, Time). Additional symptoms include sudden confusion, trouble speaking, trouble seeing

in one or both eyes, trouble walking, dizziness, loss of balance or coordination and severe

headache with no known cause (AHA, 2018).

High blood pressure, diabetes, smoking, poor diet, lack of physical activity, obesity, high

blood cholesterol, carotid artery disease, peripheral artery disease, atrial fibrillation, sickle cell

disease are modifiable risk factors whereas age, race, gender, family history, prior stroke are

nonmodifiable risk factors. Other factors include geographic location, alcohol and drug abuse,

socioeconomic factors, lack of sleep (AHA, 2018).

According to Serra (2018) suboptimal nutritional status, including an excess caloric

intake, reduced protein intake, and micronutrient deficiencies, particularly the B-vitamins,

vitamin D, and omega 3 fatty acids, may have deleterious effects on metabolic, physical, and

psychological functioning in chronic stroke survivors. Careful evaluation of dietary intake,

especially among those with eating disabilities and preexisting malnutrition, may aid in the

identification of individuals at increased nutritional risk through which early intervention may

benefit recovery and rehabilitation and prevent further complications after stroke.

According to Powers et al (2018) patients with acute stroke who cannot take food and

fluids orally should receive nutrition and hydration via nasogastric, nasoduodenal, or

percutaneous endoscopic gastrostomy tube feedings while undergoing efforts to restore

swallowing. (Zheng et al., 2015) conducted a randomized controlled trial of 146 patients with

acute stroke and dysphagia, among whom 75 were supported with nasogastric nutrition and 71

received family managed nutrition after randomization. It was found that the nasogastric

nutrition group had a better nutritional status and reduced nosocomial infection and mortality
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rates after 21 days compared with patients in the family managed nutrition group. In addition, the

nasogastric nutrition group showed a lower score on the National Institutes of Health Stroke

Scale (NIHSS) than the control group. However, the differences in the scores of the Activities of

Daily Living Barthel index (ADLBI) and the 90-day modified Rankin Scale (mRS) between the

groups were not significant.

Mr. Robert states that his wife woke up in the morning with everything pretty normal, but

midmorning she became dizzy and could not talk or move right side of her body (arm and leg).

Her admitting neurological symptoms were face and arm weakness which is disproportionate to

leg weakness and sensation is impaired on the contralateral side. Dysarthria with tongue

deviation. Cranial nerves III, V, VII, XII are impaired. Motor function tone and strength

diminished. Plantar reflex decreased on right side. Her extremities have reduced strength. Mrs.

RN has undergone non-contrast CT scan, bedside swallowing assessment, endoscopy with

modified barium swallow. Speech language pathologist would determine staged dysphagia diet.

Currently she is NPO.

She is hypertensive (138/88), has hyperlipidemia (high blood cholesterol, low HDL-C,

high LDL, high triglycerides and LDL/HDL ratio) and BMI of 30 (Nelms & Roth, 2014). (Li et

al., 2017) conducted meta-analysis of prospective cohort studies investigating the relationships

between metabolic syndrome and risk of incident stroke. It was found that metabolic syndrome

might be an important risk factor of stroke, particularly among women and those with ischemic

stroke.

Mrs. RN is nutrionally at risk because of dysarthria which may cause dysphagia. (Bahia,

Mourao, & Chun, 2016) conducted a prospective study on 31 patients to determine the

prevalence of dysphagia and communication disorders following stroke, and to identify if

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communication disorders can predict dysphagia. These patients were admitted to the

Otolaryngology-Dysphagia Outpatient Clinic with diagnosis of ischemic or hemorrhagic stroke.

It was found that twenty-five patients presented dysphagia. Aphasia occurred in 32.3% of the

patients; dysarthria in 45.2%. Dysphagia and aphasia co-occurred in 29% of the population;

dysphagia and dysarthria in 45.2%; the three conditions co-occurred in 22.6%. Dysarthria was a

predictor of dysphagia, and it was associated with the presence of oral stage problems.

Right sided weakness and diminished motor function can lead to self-feeding difficulty

in Mrs. RN and impaired ability to prepare meals.(Pontes et al., 2017) conducted an

observational, descriptive, cross sectional study in Brazil among 35 elderly to characterize the

life quality of the elderly swallowing affected by stroke. The Quality of Life Swallowing

Disorders – SWAL-QOL questionnaire was used. It was found that the elderly had low quality of

life, increase in feeding time, oral changes in masticatory capacity, reduced oral sensitivity, as to

the socioeconomic and psychosocial factors that are conditions for food and nutritional status of

the elderly.

According to Powers et al., (2018) patients with acute stroke who cannot take food and

fluids orally should receive nutrition and hydration via nasogastric, nasoduodenal, or

percutaneous endoscopic gastrostomy tube feedings while undergoing efforts to restore

swallowing. (Zheng et al., 2015) conducted a randomized controlled trial of 146 patients with

acute stroke and dysphagia, among whom 75 were supported with nasogastric nutrition and 71

received family managed nutrition after randomization. It was found that the nasogastric

nutrition group had a better nutritional status and reduced nosocomial infection and mortality

rates after 21 days compared with patients in the family managed nutrition group. In addition, the

nasogastric nutrition group showed a lower score on the National Institutes of Health Stroke
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Scale (NIHSS) than the control group. However, the differences in the scores of the Activities of

Daily Living Barthel index (ADLBI) and the 90-day modified Rankin Scale (mRS) between the

groups were not significant.

Laboratory Findings

Her relevant laboratory data in the hospital is as follows:

Chemistry Reference Range Date:8/12

Cholesterol (mg/dL) 120-199 210ꜛ

HDL-C (mg/dL) >55 F, >45M 40ꜜ

LDL (mg/dL) <130 155ꜛ

LDL/HDL ratio <3.22F, <3.55M 3.875ꜛ

Triglycerides (mg/dL) 35-135 F 198ꜛ

40-160 M

Mrs. R.N. has high blood cholesterol, low HDL-C, high LDL, triglycerides and

LDL/HDL ratio resulting in an increased risk for stroke. Large amounts of cholesterol in the

blood can build up and cause blood clots, leading to a stroke. No laboratory data is available over

time to determine any change in findings.

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Analysis of Dietary Intake

According to Mifflin St. Jeor equation:

TER (kcal/d) = 9.99*wt. (kg)+6.25(ht cm)-4.92 (Age)-161

= 9.99*75+6.25 (157)-4.92(77)-16

=1190.66 Kcal/day * 1.2(Activity factor, sedentary) =1428.79Kcal

Protein= For stroke 1-1.25g/kg

= 75-93g/day

Fluid = Based on chronological age method

Age>75years=25ml/kg = 1925ml/day

Strengths of the Diet: Mrs. R.N. uses baking and steaming as a method of cooking

rather than frying to reduce the fat intake. She includes foods high in potassium such as banana

and potato to reduce blood pressure. Does not consume alcohol. Includes fruits in her diet

(canned/ juice) and consumes foods with good sources of fiber and iron.

Weakness of the Diet: Consumes food made from refined grains such as tortellini and

does not include enough whole grains. Her current intake is approximately 5440 mg of sodium

and 18g of saturated fat per day. High salt foods such as saltine crackers, cheese should be

avoided. R.N. consumes vegetables but with added fat such as margarine. Soft or liquid

margarine should be used instead of stick margarine. Consuming whole fruits adds fiber to the

diet rather than in the form of juices. Skim, low fat or 1% fat milk should be consumed instead of

2% milk and avoid cheese instead use low fat / low sodium options. Organ meats should be
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avoided such as breast chicken with skin and instead choose healthier options such as skinless

poultry, low sodium cold-cuts made with lean meat.

Dietary Instructions: Low calorie, Low fat, high fiber and low salt diet is recommended

for Mrs. R.N. Her detailed guidelines are as follows. Grains: Breads and cereals, especially

those made with whole grains such as oats, barley, rye, whole wheat or whole wheat pasta should

be included rather than refined products. Low fat, low sodium crackers, cheese, cottage should

be consumed. Salt: < 300mg of sodium per serving of salt should be consumed. Do not add salt

at the table. Choose carefully when you eat away from home. Ask for low salt or no – salt

options. Herbs and spices add flavor to the meal instead of salt. Fruits and Vegetables: Include

fresh, frozen, or canned vegetables without added fat or salt. Include plenty of fruits and

vegetables, such as broccoli, greens, sweet potatoes, tomatoes, banana, apricots, oranges,

apricots, apple etc. as they add potassium to the diet and helps in reducing blood pressure. Whole

fruits add fiber to the diet rather than juices. Milk: Cheese, cottage cheese, milk, buttermilk

made from nonfat (skim), low-fat, or 1% fat milk should be included in the diet. They add

calcium and potassium that your body needs. Fats and Oils: Eat very little saturated fat and

trans-fat. These types of fat can raise the low-density lipoprotein, or LDL (“bad”), cholesterol in

your blood. Saturated fats are found in foods from animals, such as fatty meats, whole milk,

butter, cream, and other dairy foods made with whole milk. Trans fat is found in foods made

with hydrogenated oils. It may be in fried foods, crackers, chips, and foods made with shortening

or stick margarine. Choose unsaturated fats (heart-healthy fats), such as soybean, canola, olive,

or sunflower oil. Liquid or soft tub margarines can also be included. Keep total amount of fat

that you eat to less than 25% to 35% of the calories that you get from food and drink. Meat and

other protein food: Limit the cholesterol that you get from food to 200 mg of cholesterol per
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day. Foods high in cholesterol include egg yolks, fatty meats, organ meats, shrimp, and dairy

foods. Lean cuts of beef and pork (loin, leg, round, extra lean hamburger), low-sodium cold cuts

made with lean meat or soy protein, skinless poultry can be included in the diet. Include cold-

water, fatty fish (such as salmon, tuna, mackerel, and sardines) twice a week, walnuts, flaxseeds.

These provide omega-3 fats, which are heart-healthy. Fiber: Include 20-30g of fiber in the diet

in the form of whole grains, fruits, vegetables, oatmeal, peas etc. Physical Activity: Be active

30-45 minutes, 5 times per week (NCM, 2018).

Nutrition Care Process

Nutrition Diagnosis

Swallowing difficulty related to ischemic stroke as evidenced by non- normal findings in

cranial nerves, (CN VII) muscles of facial expression, (nerve XII) tongue deviation and the need

for NPO.

Altered nutrition related lab values related to cardiac disease as evidenced by high total

cholesterol 210mg/dl, low HDL 40mg/dl, high LDL 155mg/dl and high triglycerides 198mg/dl.

Obesity Class I related to excessive energy intake as evidenced by BMI 30 and 24hr

recall.

Nutrition Intervention

Start texture modified diet once feasible after consulting with the speech language

pathologist.

Educate the patient on the Therapeutic Lifestyle Change diet and provide a total fat intake

of 25-35% of total Kcal recommended.

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Motivational interviewing to assist patient in making changes in food related behaviors.

Nutrition Prescription

Energy needs (Kcal/kg) = 25-30

Weight used (Energy) = Ideal weight

Kcal/day = 1250-1500

Protein (gm/kg) = 1-1.25

Weight used (Protein) = Ideal weight

Protein (gm/day) = 50-62.5

Total fat intake = 25-35% of total Kcal

Fat (gm/day) = 42-50

Total Saturated fat intake = <7% of total Kcal

Saturated fat intake (gm/day) = <11

Carbohydrate intake = 50-60% of total Kcal

Carbohydrate (gm/day) = 172-207

Fluid (ml/kg) = 25

Weight used (Ideal weight) = 1250ml

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Current Goals

Patient to consume greater than 65% of daily meals within 3-5 days once the diet is

started.

Nutrition Monitoring and Evaluation

Will monitor nursing documentation flow sheets for percent meal intake.

Lab values warranting change with medical nutrition therapy.

Will follow and adjust nutrition plan of care as medical condition requires.
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References

American Heart Association, 2018. Retrieved October 15, 2018 from

https://www.strokeassociation.org/STROKEORG/LifeAfterStroke/HealthyLivingAfterStr

oke/PhysicalActivity/Get-Moving-and-Boost-Your-Brain-

Power_UCM_453575_Article.jsp

American Heart Association, 2018. Retrieved October 15, 2018 from

https://www.strokeassociation.org/STROKEORG/LifeAfterStroke/HealthyLivingAfterStrok

e/Nutrition/Nutrition-Tips-for-Stroke-Survivors_UCM_308569_SubHomePage.jsp

American Heart Association, 2018. Retrieved October 15, 2018 from

http://www.strokeassociation.org/STROKEORG/AboutStroke/About-

Stroke_UCM_308529_SubHomePage.jsp

American Heart Association, 2018. Retrieved October 15, 2018 from

http://www.strokeassociation.org/STROKEORG/AboutStroke/UnderstandingRisk/Understa

nding-Stroke-Risk_UCM_308539_SubHomePage.jsp

Bahia, M. M., Mourao, L. F., & Chun, R. Y. S. (2016). Dysarthria as a predictor of dysphagia

following stroke. Archives of Gastroenterology, 38(2), 155–162.

https://doi.org/10.3233/NRE-161305

Benjamin, E. J., Virani, S. S., Callaway, C. W., Chamberlain, A. M., Chang, A. R., Cheng, S., …

Muntner, P. (2018). Heart Disease and Stroke Statistics-2018 Update: A Report From the

American Heart Association. Circulation, 137(12), e67–e492.

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https://doi.org/10.1161/CIR.0000000000000558

Li, X., Li, X., Lin, H., Fu, X., Lin, W., Li, M., … Gao, Q. (2017). Metabolic syndrome and

stroke: A meta-analysis of prospective cohort studies. Journal of Clinical Neuroscience :

Official Journal of the Neurosurgical Society of Australasia, 40, 34–38.

https://doi.org/10.1016/j.jocn.2017.01.018

National stroke Association, 2018. Retrieved October 13, 2018 from

http://www.stroke.org/understand-stroke/what-stroke

Nelms, M. N., & Roth, S. L. (2014). Ischemic Stroke. Medical Nutrition Therapy, A case study

Approach (4th ed.). Cengage Learning.

Nutrition Care Manual, 2018. Retrieved October 12, 2018 from

https://marywood1.marywood.edu:2499/client_ed.cfm?ncm_client_ed_id=98

Pontes, É. S., Karênina, A., Jordão, D. F., Luiza, F., Heitmann, E., Azevedo, M., … Silva, C.

(2017). Quality of life in swallowing of the elderly patients affected by stroke. Archives of

Gastroenterology, 54(1), 27–32.

Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K.,

… Tirschwell, D. L. (2018). 2018 Guidelines for the Early Management of Patients With

Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart

Association/American Stroke Association. Stroke, 49(3), e46–e110.

https://doi.org/10.1161/STR.0000000000000158

Serra, M. C. (2018). The Importance of Assessing Nutritional Status to Ensure Optimal

Recovery during the Chronic Phase of Stroke. Stroke Research and Treatment, 2018,
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1297846. https://doi.org/10.1155/2018/1297846

Zheng, T., Zhu, X., Liang, H., Huang, H., Yang, J., & Wang, S. (2015). Impact of early enteral

nutrition on short term prognosis after acute stroke. Journal of Clinical Neuroscience :

Official Journal of the Neurosurgical Society of Australasia, 22(9), 1473–1476.

https://doi.org/10.1016/j.jocn.2015.03.028