Carolyn Klempay & Ariana Kulinczenko

Carolyn Klempay & Ariana Kulinczenko

KNH 411 Medical Nutrition Therapy

Matuszak

Ischemic Stroke Case Study #23

I. Understanding the Disease and Pathophysiology

1. Define stroke. Describe the differences between ischemic and hemorrhagic strokes.

A stroke is also known as a cardiovascular accident. This condition occurs when there is a sudden interruption of the blood flow that travels to the brain. The neurons in the brain are deprived of necessary blood, oxygen, and nutrients. The result is an alteration of brain function. In the case of an ischemic stroke, the blood vessels that supply blood to the brain are obstructed. The obstruction may be because of a clot and this classifies the stroke as ischemic. Additionally, when a blood vessel in the brain ruptures, the result is a hemorrhagic stroke. As the walls of blood vessels are weakened due to conditions such as hypertension, there is increased risk of rupturing. In comparison, ischemic strokes are caused from blockages or clots in blood vessels, whereas hemorrhagic strokes occur from a rupture of a blood vessel [Nelms, p.617].

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2. The noncontrast CT confirmed the Mrs. Noland had suffered a lacunar ischemic stroke- NIH Stroke Scale Score of 14. What does Mrs. Noland’s score for the NIH stroke scale indicate?

The NIH Stroke Scale evaluates on a quantitative scale the degree of neurologic dysfunction related to cerebral infarction. The scale scores on a variety of cognitive and physical characteristics such as level of consciousness, responses to questions and commands, various visual and facial abilities, limb mobility, and sensory and language skills. Each attribute is evaluated on various scales and values are totaled to give a final resulting Stroke Score. Mrs. Noland’s score of 14 indicates that she suffered from a moderate stroke. The lower the scores correlate to less severe strokes, so comparatively, the higher scores indicate a more severe stroke [NIH, 2011].

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3. What factors place an individual at risk for stroke?

The risk factors for stroke are categorized as modifiable or unmodifiable. Some risk factors that a patient has no control over include age, gender, and race. Looking specifically at Mrs. Noland’s records, being 77 years old is one of the unmodifiable risk factors that largely affects her risk levels because risk of stroke doubles for each decade after age 55.

Additional risk factors for stroke may be controlled by the patient’s lifestyle. Some of these risk factors are hypertension, cardiovascular disease, diabetes mellitus, dyslipidemia, asymptomatic carotid stenosis, atrial fibrillation, cigarette smoking, physical inactivity, and obesity. Dietary habits play a large part in controlling many of these risk factors and therefore, could be a contributor to stroke risk. Individuals with healthy lifestyle have an 80% lower risk of developing a stroke. The characteristics of a “healthy lifestyle” may be described as not smoking, maintenance of a BMI of 25 kg/m2 or less, participating in at least 30 minutes of physical activity per day, consuming a healthy diet with appropriate balance of nutrients, vitamins, and minerals, and consuming a moderate amount of alcohol, specifically 5-15 grams daily for women and 5-30 grams daily for men [Nelms, p.618].

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4.What specific signs and symptoms noted with Mrs. Noland’s exam and history are consistent with her diagnosis? Which symptoms place Mrs. Noland at nutritional risk? Explain your rationale.

Some signs and symptoms Mrs. Noland was experiencing that are consistent with her diagnosis of Ischemic Stroke are the weakness and partial paralysis she experienced in the right side of her body, including her arm, face, and leg. Dysarthria, difficulty saying words because of problems with muscles related to speaking, and tongue deviations are other symptoms of stroke as well. The sudden dizziness and inability to speak are obvious signs that Mrs. Noland was experiencing a stroke and actions needed to be taken to dissolve the blood clot leading to her brain [Nelms, p.618].

Taking a deeper look into Mrs. Noland’s history and medical records, being at an age of 77 years old, the patient has an increased likelihood of having a stroke with each decade after 55 years old. Additionally, Mrs. Noland has a BMI of 30.0 kg/m2. This places her in the obese range which is another risk factor for developing a stroke. Hypertension is another risk factor of stroke and Mrs. Noland has suffered from this disease for 10 years. Although she regularly takes Catopril, a medication used to treat high blood pressure and reduce stroke risk, upon arrival at the hospital, Mrs. Noland’s blood pressure was 138/88 which is relatively high. Lastly, hyperlipidemia is another stroke risk factor which contributed to Mrs. Noland’s diagnosis [Nelms, p.618].

Mrs. Noland is al nutritional risk because of the dysarthria, tongue deviation, and diminished motor function and strength. These symptoms would prevent Mrs. Noland from consuming food orally and receiving proper nutrition. Additionally, assessment of her swallowing abilities would be another potential contributor to nutritional risk. Through individualized intervention and collaboration between a speech-language pathologist and dietitian, an appropriate staged dysphagia diet could be administered for at least 24 hours to ensure Mrs. Noland is receiving adequate nutrient and fluid quantities [Nelms, p.620].

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5. What is rtPA? Why was it administered?

Recombinant Tissue Plasminogen Activator (rtPA) is beneficial when injected into an individual suffering from an ischemic stroke. This drug is often inserted through a vein in the arm and is useful in breaking through blood clots. If given within four hours and thirty minutes from the start time of the stroke, this medication will dissolve the blood clot that caused the stroke and assist in proper recovery [MayoClinic, 2012]. If the drug is given within three hours of initial stroke onset, the patient has a higher chance to see minimal or no disability outcomes three months after the stroke. The patient is also less likely to require nursing care or rehabilitation services if rtPA is given [Nelms, p.620]. In the case of an extreme emergency, the rtPA may be injected directly into the stroke source rather than passed through the veins for more immediate results [MayoClinic, 2012]. Since the top priority in the treatment of stroke is to eliminate the clot and restore blood flow as quickly as possible, rtPA was administered to encourage these outcomes. Additionally, rtPA was used to minimize potential long-term health detriments and promote optimal stroke recovery.

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II. Understanding the Nutrition Therapy

6. Define dysphagia. What is the primary nutrition implication of dysphagia?

Dysphagia is termed as the inability or difficulty swallowing. This is usually proclaimed as a symptom of a disease. Swallowing is an extremely complicated process of that is controlled by the central nervous system. It requires multiple parts of the brain to be in cohesion, executing multiple involuntary and voluntary muscle contractions. If this area of the brain is damaged from stroke, serious implications are necessary to follow or else the patient will have a slower recovery and post stroke complications. Difficulty swallowing can affect food consumption, cause dehydration, malnutrition and secondary illnesses such as aspiration pneumonia. The primary nutrition implications are weight loss and subsequent development of nutrition deficiencies that result from the inadequate nutrient intake [Nelms, p.355].

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7. Describe the four phases of swallowing [Anatomy & Physiology of Swallowing, 2011].

A. Oral preparation:This phase is when food or liquid is chewed and mechanically manipulated in the mouth for the preparation of swallowing. Movement patterns in this phase depend on the consistency of the material swallowed.

B. Oral transit:This phase is where the tongue propels food or liquid to the back of the mouth. This is the phase that triggers the swallowing response. Once it is pushed to the back of the mouth, the swallowing response begins.

C. Pharyngeal: This phase begins when food or liquid is quickly passed through the pharynx and straight into the esophagus for swallowing.

D. Esophageal: This final phase is where food or liquid from the previous phases passes through the esophagus and moves into the stomach.

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8. The National Dysphagia Diet defines three levels of solid foods and four levels of fluid consistency to be used when planning a diet for someone with dysphagia. Describe each of these levels of diet modifications.

According to the National Dysphagia Diet, there are three levels of solid foods when planning a diet with someone with dysphagia. The first level is pureed. These foods have a pudding-like texture and are very cohesive. They require little to no chewing. Some examples of the pureed level are foods similar to milk and dairy products, applesauce, gravies and sauces. The second level is the mechanically altered level. These foods are very moist and are in semisolid forms that require little chewing. That last level is considered advanced. These include soft foods that require a little more chewing than the previous level. This level is usually presented to patients with improved dysphagia.

Furthermore, there are also four levels of fluid consistency. The first frequently used term for the first level of fluid consistency is ‘thin’, and is 1-50 centiPoise. CentiPoise is a dynamic viscosity measurement. This unit measures the fluids force per unit or internal resistance. The thin consistency includes all liquids, jell-o, sorbet, Italian ice and ice cream. The second level is nectar-like. This is between 51-350 cP. Examples of the nectar phase include an apricot or tomato juice consistency. Honey-like is the third level between 351-1,750 cP. This includes liquids that can still be poured, but slowly. The final and last fluid level is spoon-thick which is greater than 1,750 cP and includes liquids that are spoon-able that will not stay upright when a spoon is held vertically [Dysphagia, 2013].

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9. It is determined that Mrs. Noland’s dysphagia is centered in the esophageal transit phase and she has reduced esophageal peristalsis. Which dysphagia diet level is appropriate to try with Mrs. Noland?

Mrs. Noland’s dysphagia is centered in the esophageal transit phase. This means she is having trouble passing food from the esophagus to the stomach. Mrs. Noland is experiencing reduced esophageal peristalsis, which indicates she cannot handle foods of thick consistencies. In order for food to pass through to the stomach, she will likely need to stick to a pureed and thin liquid diet because liquids have the quickest transit time [Anatomy & Physiology of Swallowing, 2011].

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10. Describe a bedside swallowing assessment. What are the background and training requirements of a speech-language pathologist?

The bedside swallowing assessment was created to provide data for use in diagnosis and treatment planning. The exam has two parts. The first part is the preparatory exam with no swallowing involved. The second part is the initial swallowing exam where the physiology of swallowing is observed. The bedside swallowing exam specifically provides information over the following:

- Location of the patient's dysphagia (oral or pharyngeal)

- The patient's readiness for a radiographic study

- The patient's ability to accept food into the mouth

-The oral reaction to the placement of various tastes, temperatures, and textures in oral cavity

- The presence of any abnormal oral reflexes

- Any particular postural and behavioral needs of the patient that must be observed during the radiographic study

- The Laryngeal Function and if anything may affect airway protection and aspiration during the swallow.

- Coughing status

- Decision on Best Posture

- Best Position of Food in Mouth

- The Oral Sensitivity

- The Best Food Consistency

- Optimum Swallowing Instructions

It is also important to evaluate the following at rest:

-Lips

-Dentition

-Mandible

-Tongue

-Velum and velopharyngeal port

-Valleculae

-Epiglottis

-Hyoid

-Pharynx

-Posterior pharyngeal wall

-Pyriform sinuses

-Larynx (thyroid, cricoid, arytenoid cartilages)

-Trachea

-Upper esophageal sphincter

-Cervical esophagus and spine

The speech-language pathologist evaluates, performs the diagnosis and treats swallowing disorders in the oral-pharyngeal phases. There are numerous requirements a speech pathologist must meet in order to become a professional. A speech pathologist must obtain a master's degree in speech pathology in this field, and it is the minimum requirement for obtaining professional certification and state licensure. Many employers require the Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP) credential offered by the ASHA as well. The training requirements include supervised training and clinical experience through clinics associated with their graduate programs. Students’ training typically provides opportunities to work with children and adults in areas of communication, speech and language development. Other locations that provide training are rehabilitation facilities, schools and other diagnostic and treatment centers. In addition to the master’s degree, the ASHA requires an additional 1,260 hours of full-time postgraduate clinical practice for certification [U.S. Bureau of Labor Statistics, 2013].

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11. Describe a modified barium swallow or fiberoptic endoscopic evaluation of swallowing.

A modified barium swallow is an x-ray examination performed while a person is swallowing barium-coated substances in order to assess the mouth, pharynx and esophagus’ ability to swallow. This procedure may help the doctor track the pathway foods and liquids take during swallowing. A fiberoptic endoscopic evaluation of swallowing is another test used to evaluate the swallowing mechanism. This examination includes the use of vocal tract visualization and imaging to assess the pharyngeal and laryngeal structures. This procedure enables a proper evaluation of the swallowing impairment a patient may be experiencing [Office of the Professions, 1998].

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12. Thickening agents and specialty food products are often used to provide texture changes needed for the dysphagia diet. Describe one of these products and how it may be incorporated into the diet.

Thickening agents are used to provide a thicker texture or consistency to liquids or foods. Generally, thickeners are added to liquids, because thin liquids may move too quickly down the esophagus when swallowed by a patient with dysphagia, and a thicker consistency slows it down. One thickening agent that is commonly used to provide texture changes to a dysphagia diet is starch-based corn flour. This is prescribed in accordance to the prescribed liquid diet from the speech-language pathologist. Corn flour can be incorporated into the diet by adding it to a sauce to make it a thicker consistency. Generally the proportions needed of corn flour to liquid are 1:1. Corn flour is normally used to enhance a liquid to a medium-thick consistency. This method is a safe way to thicken fluids for patients with difficulty swallowing [Dysphagia, 2013].

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III. Nutrition Assessment

13. Mrs. Noland’s usual body weight is approximately 165 lbs. Calculate and interpret her BMI.

Using Mrs. Noland’s current weight of 165 lbs or 75 kg, and her height in meters as 1.58 meters, her BMI is 30.0 kg/m2. This places her in the range of obesity [Nelms, p.249]. Since obesity is one risk factor that contributes to stroke, having a BMI that falls within the obese range is one influential factor as to why Mrs. Noland suffered from a stroke.

BMI = wt (kg) / ht2 (m2)

BMI = 75 kg / (1.58m)2

BMI = 75/2.5

BMI = 30.0 kg/m2

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14. Estimate Mrs. Noland’s energy and protein requirements. Should weight loss or weight gain be included in this estimation? What is you rationale?

Initially, weight maintenance, not weight loss, should be considered while immediately treating Mrs. Noland to ensure she is getting adequate nutrition for optimal healing from the stroke. Eventually, with gradual healing and oral intake abilities, weight loss should be included in Mrs. Noland’s estimation of protein and energy requirements. Her current BMI of 30.0 kg/m2 places her in the obese category so weight loss should be introduced after complete recovery to decrease the risk of suffering a stroke again and to decrease the influence of other risk factors for stroke. The first calculations estimate her current energy and protein requirements at her current weight of 75 kg and physical activity level of low active. The second set of calculations use Mrs. Noland’s adjusted body weight to estimate her calorie and protein needs, again at a low physical activity level.

At her current weight of 75 kg:

TEE for Overweight and Obese Females Aged 19 Years and Older:

TEE = 448 – 7.95 x age (yrs) + PA (1.16 for low active) x (11.4 x weight (kg) + 619 x height (m))

TEE = 448 – 7.95 x 77yrs + 1.16 x (11.4 x 75kg + 619 x 1.58m)

TEE = 1962 kcal = 1,900 kcal – 2,000 kcal

EER for Females 19 Years of Age and Older:

EER = 354 – 6.91 x age (yrs) + PA (1.12 for low active) x ((9.36 x weight (kg) + 726 x height (m))

EER = 354 – 6.91 x 77yrs + 1.12 x (9.36 x 75kg + 726 x 1.58m)

EER = 1893 kcal = 1,800 kcal – 1,900 kcal

Protein Requirements:

1.0 g/kg – 1.2 g/kg

1.0 g x 75 kg = 75 g

1.2 g x 75 kg = 90 g

= 75 g – 90 g protein

At her ADJUSTED weight of 56.4 kg:

Ideal Body Weight: Hamwi Method: 100 + (5 x 2) = 110 lbs

Adjusted body weight = .25 (current wt – ideal wt) + ideal wt

ABW = .25 (165lbs – 110 lbs) + 110lbs

ABW = 124 lbs = 56.4 kg

TEE for Overweight and Obese Females Aged 19 Years and Older:

TEE = 448 – 7.95 x age (yrs) + PA (1.16 for low active) x (11.4 x weight (kg) + 619 x height (m))

TEE = 448 – 7.95 x 77yrs + 1.16 x (11.4 x 56.4kg + 619 x 1.58m)

TEE = 1716 kcal = 1,700 kcal – 1,800 kcal

EER for Females 19 Years of Age and Older:

EER = 354 – 6.91 x age (yrs) + PA (1.12 for low active) x ((9.36 x weight (kg) + 726 x height (m))

EER = 354 – 6.91 x 77yrs + 1.12 x (9.36 x 56.4kg + 726 x 1.58m)

EER = 1698 kcal = 1,600 kcal – 1,700 kcal

Protein Requirements:

1.0 g/kg – 1.2 g/kg