Diana Carrillo-Valle

Case Study 3

1. Per the American Heart Association and American Stroke Society, a stroke can mean a
CNS infarction, ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, or
cerebral venous thrombosis. These strokes deprive the brain and brain cells of nutrients or
oxygen leading to cell death (Nelms & Sucher, 2020, p. 614).
a. Ischemic strokes are characterized by an obstruction to a blood vessel that leads to
zero or reduced blood flow to the brain leading to cell death from lack of nutrients
and oxygen. Ischemic strokes are the most common form of stroke, and they are
mainly caused by fatty deposits obstructing the blood vessel (American Stroke
Association, n.d.).
b. Hemorrhagic strokes are characterized by a blood vessel in the brain rupturing
leading to cell death from lack of nutrients and oxygen. Blood vessels are more
likely to rupture when weakened by hypertension, aneurysms, or other conditions
(Nelms & Sucher, 2020, p. 614).
2. Mrs. Washington was diagnosed with hypertension 10 years ago and hyperlipidemia 2
years ago. Hypertension elevates the risk of a hemorrhagic stroke and hyperlipidemia
elevates the risk of an ischemic stroke. Her current BMI of 33.8, age, and race increase
her risks of both types of strokes. (Nelms & Sucher, 202 p. 615).
3. Signs and symptoms can include, loss of vision or speech, muscle weakness, paralysis, or
change in mental status. The signs depend on where in the brain the stroke occurred. In
the case of Mrs. Washington, she presents with slurred speech, weakness of her right arm
and leg, and impaired sensation of the left leg. She has impaired cranial nerves, and
reduced strength of both sides.
4. tPA, or tissue plasminogen activator is administered to dissolve clots. tPA is a protein
normally produced by the body, but it has been made into a thrombolytic drug to treat
myocardial infarctions and ischemic strokes. Patients who receive tPA within 4.5 hours
of having a stroke are more likely to have little or no disability 3 months after the event.
The goal for tPA administration, is to start it within a 60-minute window of the event.
tPA reduces the chance of the patient needing rehabilitation and nursing home care
(Nelms & Sucher, 2020, p. 616).
5. Mrs. Washington has limited motor function and diminished strength bilaterally. She will
likely have issues grabbing and raising food to her mouth. Her V, VII, and XII cranial
nerves are impaired which means she cannot chew, move her facial muscles, or use her
tongue properly. She will have difficulty chewing and swallowing (National Institutes of
Health, n.d.).
6. Mrs. Washington is not malnourished as evidenced by her prealbumin levels. Her
husband states that she does not add additional salt to her food which does reflect in her
sodium levels. She is consuming excess saturated fats which are causing elevated
triglycerides and cholesterol.
a. Sodium: Her sodium is within a normal range.
b. Cholesterol: Her cholesterol is elevated. This can be due to an unhealthy diet, lack
of exercise, and excess weight (American Heart Association, 2020)
 c. Triglycerides: Her triglycerides are elevated. Similar to cholesterol, the elevated
numbers are due to diet, lack of exercise, and excess weight (U.S. Department of
Health and Human Services, 2022).
d. Prealbumin: Her prealbumin is within a normal range.
7. At her current weight of 185 lbs or 84.1 kg, her BMI is 33.8 and her %UBW is 112%.
8. Her daily requirements are 2102-2523 kcal, 101-168 g protein, and 2523 mL of fluid.
a. Her daily energy needs are estimated to be 25-30 kcal/kg, protein is 1.2-2 g/kg,
and fluid is 30 mL/kg (Arsava et. al, 2018, p. 232; McClave et al, 2016, p. 164).
b. I found two sources for these calculations. The energy and protein requirements
are sourced from ASPEN and the fluid recommendations are sourced from the
Turkish Journal of Neurology. ASPEN sets the guidelines for enteral nutrition in
the United States, so in a clinical setting their guidelines would be followed. I was
unable to find fluid recommendations in the ASPEN guidelines for critical illness,
so I based my fluid calculations on the Turkish Journal of Neurology. They are
similar in energy and protein recommendations; however, the Turkish Journal of
Neurology has a wider range for both energy and protein. I would like to note,
however, that ASPEN had separate recommendations for obese patients, and I did
not opt to follow those because of the chance of hypermetabolic events following
a stroke. (Nelms & Sucher, 2020, p.617).

9. ASPEN critical care guidelines recommend EN within the first 24-48 hours if the patient
is unable to consume adequate oral intake and have a functioning GI system. Based on
this information, I would start Mrs Washington on EN. Stroke patients may experience
hypermetabolic phases and metabolic derangements so by not consuming enough with
modified texture she is at risk of malnutrition without EN. Mrs. Washington’s labs should
be retaken. She is described as somnolent and her lab values should be checked to see if
the lethargy is being caused by a problem with an organ, hydration, or malnutrition and
not just a post stroke complication (Nelms & Sucher, 2020, p. 617).
10. PES:
a. Swallowing difficulty related to ischemic stroke as evidenced by impaired cranial
nerves III, V, VII, and XII, facial weakness, and dysarthria with tongue deviation.
b. Abnormal lab values related to excessive fat intake, chronic hypertension and
hyperlipidemia as evidenced by serum triglycerides of 198 mg/dL, VLDL of 39
mg/dL, LDL of 155 mg/dL, and LDL/HDL ratio of 3.8.
11. Most of cognitive recovery occurs the first 30 days after the stroke so early initiation of
nutrition maximizes recovery. The body needs nutrients for repair and replacement of
damaged systems. Without early initiation of nutrition, the patient has a higher chance of
permanent damage from the stroke (Nelms & Sucher, 2020, p. 617).
12. Mrs. Washington’s diet needs to be heart healthy. Protein should be lean, carbohydrates
should be from whole grains, fruits, and vegetables, and the fats and oils that she
consumes should be unsaturated. Following the DASH diet, she can still have dairy
products, but they should be low fat as dairy has saturated fat. In addition to the texture
modifications, these changes are to be made to improve cholesterol, triglycerides, and
hypertension to prevent another stroke (Nelms & Sucher, 2020, p. 308).
13.
a. I would recommend nasogastric EN. Mrs. Washington has normal GI function but
cannot swallow. The NG tube can be placed at her bedside and does not require
surgery or a pump, therefore less invasive. She is currently somnolent so there is
less risk of tube displacement from her removing it if it were uncomfortable and it
is easy to remove if necessary (Nelms & Sucher, 2020, p. 100).
b. Start Isoplete at 30 mL/hr. Advance 20 mL/hr every 4 hours to goal rate of 90
mL/hr.
Goal of 90mL/hr provides 2160 kcal, 129.6 g protein, 1836 mL free H2O per day.
Add free water flushes of 175 mL every 6 hours to provide additional 700 mL of
free water per day.
14.
a. After modifying diet and incorporating light exercise, pt will have decreased
triglycerides, LDL, and HDL levels, and overall LDL/HDL ratio within one
month and values will continue to improve after one month.
b. Pt will be able to wean from EN pureed foods and extremely thick liquids (to
level 4 modified foods and liquid) after one week.
15.
a. Mrs. Washington should follow the Mediterranean or DASH diets. These diets
consist of vegetables, lean proteins, unsaturated fats, fruits, and whole grains. The
DASH diet goes further than the Mediterranean diet as it has individuals limit
sodium and increase potassium, magnesium, calcium, and fiber. These diets are
considered heart healthy and can prevent stroke as they can help lower cholesterol
and triglyceride levels. Elevated cholesterol and triglycerides, in conjunction with
excess weight, and inactivity can lead to atherosclerosis, which can lead to
hypertension and ultimately a stroke either due to clots in the blood vessels or
damage to the blood vessels from hypertension (Nelms & Sucher, 2020, p. 307-
315).

b. Dinner:
Change fried pork chop to ground turkey or chicken with gravy or as meatloaf.
The meat can be cooked in a pan with 1 tsp vegetable oil.
Keep sweet potato, decrease margarine to 1 tsp, and mash to make sweet potato
mash.
Keep steamed broccoli with 1 tsp margarine (this will make up her max 3 daily
servings of fats and oils).
Replace canned peaches with banana
6 oz iced tea without sweetener and thickened if necessary
(Nelms & Sucher, 2020, p. 364)
American Heart Association. (2020, November 6). Causes of high cholesterol. www.heart.org.
Retrieved April 24, 2022, from https://www.heart.org/en/health-topics/cholesterol/causes-
of-high-cholesterol

American Stroke Association. (n.d.). Ischemic strokes (clots). www.stroke.org. Retrieved April
24, 2022, from https://www.stroke.org/en/about-stroke/types-of-stroke/ischemic-stroke-
clots

Arsava, E. M., Aydoğdu, İ., Güngör, L., Togay Işıkay, C., & Yaka, E. (2018). Nutritional
approach and treatment in patients with stroke, an expert opinion for Turkey. Turkish
Journal Of Neurology, 24(3), 226–242. https://doi.org/10.4274/tnd.92603

McClave, S. A., Taylor, B. E., Martindale, R. G., Warren, M. M., Johnson, D. R., Braunschweig,
C., McCarthy, M. S., Davanos, E., Rice, T. W., Cresci, G. A., Gervasio, J. M., Sacks, G.
S., Roberts, P. R., & Compher, C. (2016). Guidelines for the provision and assessment of
Nutrition Support Therapy in the adult critically ill patient. Journal of Parenteral and
Enteral Nutrition, 40(2), 159–211. https://doi.org/10.1177/0148607115621863

National Institutes of Health. (n.d.). Cranial Nerves. National Cancer Institute. Retrieved April
25, 2022, from https://training.seer.cancer.gov/brain/tumors/anatomy/nerves.html

Nelms, M., & Sucher, K. P. (2020). Nutrition Therapy and Pathophysiology (4th ed.). Cengage.

U.S. Department of Health and Human Services. (2022, April 7). High blood triglycerides.
National Heart Lung and Blood Institute. Retrieved April 25, 2022, from
https://www.nhlbi.nih.gov/health/high-blood-triglycerides