Case Study: CVA

Maya Yoder
Dietetic Intern Marywood University
Reason for Admission
● Patient arrived in ER by EMS on 2/18 with ℅ AMS and lower extremity edema,
discomfort, and weakness
● She was admitted to 2 Center South (6 days) moved to REH 2/24 (admit date)
● Received an inconclusive arterial study
● Received a CT scan which showed a possible subacute ischemia, no definite
hemorrhagic foci detected (CVA)
● DNR
Patient Information
● Personal:
○ 83 y/o
○ Denies alcohol, tobacco, and illicit drug use
● Medical hx:
○ TIA (2003), T2DM, Afib, osteoarthritis, HLD, HTN, B12 deficiency
● Psycho/social/socioeconomic
○ Lives alone, granddaughter stays with her frequently, feels safe at home
○ Husband deceased
○ Fall risk score 55 (high) - lives alone
● Family hx:
○ Mother: Alzheimer’s
CVA Explained
● Pathophysiology
○ Ischemic / Hemorrhagic
● Ischemic strokes occur when blood flow to the brain is blocked
○ Blockages are caused by fatty deposits from T2DM / heart disease OR blood clotting
○ Brain cells that are deprived of blood will die
● A transient ischemic attack (or TIA) marks a temporary interruption of blood
flow to the brain
○ “mini-stroke” or “warning stroke”
● 87% of all strokes are ischemic
○ Rest is hemorrhagic - blood vessel burst/bleed
CVA Background
● Pathophysiology
○ Subacute ischemia - (time period right after the CVA ~2 weeks)
○ No specific diet: HTN, T2DM, CHF dietary management
● Symptoms
○ BE FAST
○ Lower extremity weakness, edema and discomfort
● Etiology
○ Uncontrolled T2DM, HTN, Heart Disease
● Treatment
○ Severity
○ Type
■ Anticoagulant medications (tPA)
■ Surgery (Carotid endarterectomy)
Risk Factors
● 83 y/o
○ Incidence doubles with each decade after the age of 45
● HTN
● HLD
● T2DM
● Obesity
● Afib (heart disease)
○ Increases risk of stroke five times
● Previous stroke (2003)
Research
● Women are more at risk for strokes than men
○ One in five women have a stroke
○ #4 leading COD in women
○ Every 4 minutes, someone dies of stroke in the U.S
● Most important aspect of a stroke is time
○ 2 million brain cells die every minute
● Every stroke takes about 1.71 years off life expectancy
● Can cause issues with walking, writing and dressing, d/t muscle weakness,
stiffness, and changes in sensation
Current Admission
● Dx on admission:
○ CVA, warfarin coagulopathy, acute kidney failure, E. Coli, UTI
● Prognosis: good (mainly for observation)
● Diagnostic Tests:
○ CT scan of head which detected a subacute ischemia, neurological evaluation Q4 and MRI
recommended, EKG (ECHO), OT, PT, SLP
● Treatment:
○ Given Vit K, started on Protonix, held coumadin temporarily (warfarin)
● Meds:
○ Coumadin*, statin, B12, amoxicillin, multivitamin, protonix (PPI), diltiazem (anti HTN) digoxin,
laxative, amiodarone, insulin (HumaLOG QID), ondansetron, metformin, glucagon
Initial Assessment / NCP
Meds Relevant to Nutrition: Amiodarone,
amoxicillin-clavulanate Atorvastatin, Cyanocobalamin, Digoxin,
dilTIAZem, insulin lispro, magnesium oxide, metFORMIN,
Multivitamin, pantoprazole, Rivaroxaban, docusate-senna,
Reason for Visit: New Admission 2/25 Glucagon, ondansetron
Diet order: Heart Healthy, Carb Controlled
GI: BS+, BM 2/23
Height (centimeters): 153cm
Edema: none
Weight (kilograms): 72.8 2/25
Skin: intact
BMI: 31.14 (obese 1)
Appetite: Fair % Intake: ~50% per observation and pt reports
Pertinent (to Nutrition) Dx: CVA
*Chewing/swallowing: no issues noted
Pertinent (to Nutrition) PMH: HTN, T2DM, OA, PAF, AMS,
HLD, Afib, impaired skin integrity Weight status: wt stable per chart and pt interview

Labs Relevant to Nutrition: Labs (Last four charted values) Comments (Assessment): Pt was pleasant during visit. She
reports a fair appetite and states that she typically consumes
WBC H 15.6 (FEB 25) around 50% of meals. She expressed no nausea or GI issues.
Nutrition education was received well and pt kept packet for
Hgb L 9.5 (FEB 25) further use.

Hct L 29.8 (FEB 25) Nutrition Diagnosis

Plt Cnt H 358 (FEB 25) Inadequate oral intake (NI-2.1) related to decreased appetite
as evidenced by patient interview and 50% meal consumption
*Glucose Random was normal at this time. observation.
NCP Continued
Nutrition Intervention:
Commercial Beverage- Glucerna daily with breakfast
Other- Encouraged PO intakes
Nutrition education on dietary changes to manage hypertension was given and pt understood and was agreeable to information
given.

Nutrition Monitoring and Evaluation

Food and Nutrient: Monitor PO intakes to see >50% meal consumption
Other Goals: Monitor supplement acceptance

Recommendations: Provide Glucerna daily with breakfast to improve PO intakes and promote healing.

Nutrition Risk Classification:

Moderate-
Follow up
Reason For visit: Follow Up 3/02 Relevant (to Nutrition) Meds: SAME

Diet order: Heart Healthy, Carb Controlled GI: BS+, BM 3/02

Weight change (kilograms): 71.6kg, 3/02 Edema: 1+ pitting Bil LL, L&R ankle and pedal

Relevant (to Nutrition) Labs: Labs Skin: intact

WBC H 12.5 (MAR 01) H 15.6 (FEB 25) Appetite: Good % Intake: 50-75% per observation and pt
reports
Hgb L 10.3 (MAR 01) L 9.5 (FEB 25)
Chewing/swallowing: none noted
Hct L 31.5 (MAR 01) L 29.8 (FEB 25)
Comments (Assessment): Pt reports a good appetite and
Plt H 442 (MAR 01) 358 (FEB 25) normally consumes less than 100% of her meals. She reports
no GI issues. Her weight is stable per chart.
Glucose Random H 113 (MAR 01) 96 (FEB 27) H 119 (FEB
25)

- Normal for her

 Follow Up Continued
Nutrition Diagnosis Recommendations: Provide Glucerna daily with
breakfast to promote healing and increase PO
Inadequate oral intake (NI-2.1) related to decreased appetite intakes
as evidenced by patient interview and 50% meal consumption
observation. Nutrition Risk Classification:

Status of Nutrition Diagnosis: Mild -

Improving -

Intervention:

Commercial Beverage- Provide Glucerna daily ** (ordered)

Other- Encouraged PO intakes.

Monitoring and Evaluation

Food and Nutrient: Monitor PO intakes and supplement

acceptance
PES Statements
● Nutrition Diagnosis:
○ 2/25: Inadequate oral intakes (NI-2.1) related to decreased appetite as evidenced
by patient interview and 50% meal consumption observed.
○ 3/02: Inadequate oral intakes (NI-2.1) related to decreased appetite as evidenced
by patient interview and 50% meal consumption observed. (Improving)
Interventions
● Commercial Beverage
○ Provide Glucerna daily with breakfast to promote healing and improve PO
intakes
● Other
○ Encourage PO intakes
○ Provided nutrition education for dietary interventions to manage HTN
Monitoring and Evaluation
● Food and Nutrient
○ Monitor PO intakes to see >50% meal consumption
● Other
○ Monitor supplement acceptance
● Total visits by RDN during stay at WBGH: 2
● Pt was discharged on 3/07 to a rehabilitation facility
○ Prognosis: good
Evaluation of Intakes
● Intakes: 50% upon admission to REH / initial assessment, 50-75% upon FU
● Discharge: consuming 75%
● Level of risk: Moderate upon admission assessment, mild upon FU
● Macronutrient needs:
○ Calories: 25-30kcals/kg
■ ABW: 72.9kg IBW: 46.04kg, DESIRED body weight: 52.76kg
■ X 25 = 1318
■ X 30 = 1582.6 (1600 calories)
○ Protein: 1-1.25g/kg
■ (63) 65g
○ Fluid: 25-30mL/kg
■ 1600mL
● When discharged, follow a heart healthy, carb controlled diet
○ Low fat, low sodium, 60g CHO per meal
Questions?
Resources
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