A CASE STUDY ON: Congestive Heart Failure

In partial fulfillment of the requirements of the course: ND 36 - Nutrition Therapy II

For the degree
BACHELOR OF SCIENCE IN NUTRITION AND DIETETICS

Submitted by:
VISMANOS, Jerard

Submitted to:
ASST. PROF. ALVYN KLEIN A. MANA-AY, MPH, MSc, RND

MAY 2023
 Review of Medical Literature

Congestive heart failure can be divided into four functional stages, according to the New York
Heart Association (1964). “Mild, or Class I are people who have heart disease but who are not
constrained in their ability to move around. Regular physical activity does not result in excessive
weariness, palpitations, dyspnea (shortness of breath), or numbness in the arms or legs. Mild,
Class II individuals who have a mild physical activity restriction due to heart illness. When at
rest, they are at ease. Fatigue, palpitations, dyspnea, or anginal discomfort are side effects of
routine exercise. While on the other hand, Moderate, Class III have heart conditions that
significantly restrict their ability to exercise. Congestive heart failure is described as "the state in
which the heart is unable to pump blood at a rate sufficient to satisfy the requirements of the
tissues with function parameters remaining within normal limits" (Denolin, 1983, p. 445). This
condition is frequently accompanied by effort intolerance, fluid retention, and decreased
longevity. Congestive heart failure, often known as heart failure, is currently a significant public
health issue on a global scale. In the majority of developed countries, it is the main cause of
morbidity and mortality. The American Heart Association (2001) estimates that 5 million people
worldwide suffer from heart failure, with roughly 550,000 new cases being identified every year.
In addition, heart failure claims almost 300,000 lives each year. Cardiovascular illnesses are the
leading cause of death in the Philippines, with roughly 77,060 deaths per 100,000 people
attributed to these conditions in 2005, according to the Department of Health. Heart failure
incidence and prevalence are on the rise globally due to population aging and the increasing
pandemic of cardiovascular illnesses in developing countries, which highlights the need of heart
failure prevention. The most frequent principal discharge diagnosis among Medicare
beneficiaries and the third-highest for hospital reimbursements, HF is a significant public health
issue that is linked to high morbidity and mortality among people 65 and older.3 In the single
year of 2007, there were 1.4 million hospitalizations, more than 11 million office visits, and $17
billion in total spending that could be directly attributed to HF alone. The disease's complex
progression and several coexisting conditions frequently have unfavorable effects, the most
costly of which are hospital readmissions. Within 30 days and within 90 days of release, 34%
and 25%, respectively, of patients hospitalised with HF are readmitted. Unplanned HF 30-day
readmission rates from 2009 to 2012 showed a modest decline, according to recent CMS data.

I. Nutritional Implications of the Disease

Case Discussion
 I. Nutrition Assessment Data

A. Client Histoy
Patient X is a 56 years old Filipino man. He has a past medical surgery on his left testicle
which was removed. He is widowed and has an assistant helper for him to help his daily
needs. He is a retired teacher and doesn't have that active lifestyle and good food
choices.It is also stated that he can't shop and cook. He has a heart and liver disease in
his family medical history Patient X also had no known allergies. He doesn't have
medication that is used and he doesn't drink alcohol and use cigarettes. 20 days prior to
admission he has an onset of shortness of breath.

B. Anthropometrics
Patient X's current weight is 61.2 kg and he stands at 1.65m. His BMI is 22 which is
classified as normal range by WHO. He has a presence of edema

C. Biochemical data, medical tests, and procedures

TEST REFERENCE INTERPRETATION

RANGE

Blood UREA H 25.00 mg/dL 9.0-20.0 Above Normal

Nitrogen

Ionized L 0.96 mmol/L 1.05 - 1.32 Below Normal

Calcium

Creatinine H 1.40 mg/dL 0.66 - 1.25 Above Normal

Glycosylated - 6.2 % <6.5 Normal

Hemoglobin

S GPT / ALT - 42.00 U/L <50 Normal

Potassium - 4.00 mmol/L 3.5 - 5.1 Normal

Magnesium - 2.00 mg/dL 1.2 - 2.2 Normal

Sodium - 142.0 mmol/L 137.0 - 145.0 Normal

LIPID PANEL

Cholesterol, H 246.00 mg/dL <200 Above Normal

Total

Triglycerides - 113.00 mg/dL <150 Normal

NON - FASTING SAMPLE

HDL L 34.00 mg/dL 40.0 -60.0 Below Normal

LDL H 189.40 mg/dL <100 Above Normal

VLDL 22.60 mmol/L 20-30 Normal

TC / HDL Ratio H 7.2 - <4.5 Above Normal

The table above shows the labs, medical tests/procedures from the patient.
Blood Uea Nitrogen (BUN) level is elevated (25.00 mg/dL) compared to the reference
range (9.0-20.0 mg/dL). Elevated BUN may indicate impaired kidney function. In terms of
nutrition, it is important to monitor protein intake as excessive protein consumption can
contribute to elevated BUN levels. Adjusting protein intake based on the patient's kidney
function may be necessary. The ionized calcium level is below the reference range (0.96
mmol/L; reference range: 1.05-1.32 mmol/L). Low calcium levels may have implications
for bone health and muscle function. Adequate calcium intake from dietary sources,
such as low-fat dairy products, leafy green vegetables, and fortified foods, should be
encouraged. Calcium supplementation may be considered under the guidance of a
healthcare professional.
 The creatinine level is elevated (1.40 mg/dL) compared to the reference range
(0.66-1.25 mg/dL). Elevated creatinine levels suggest impaired kidney function. In terms
of nutrition, it is important to monitor protein intake and adjust it according to the
patient's kidney function. The HbA1c level is within the target range (6.2%), indicating
reasonably controlled blood glucose levels. It is important to encourage a balanced diet
that includes adequate fiber, whole grains, lean proteins, and controlled carbohydrate
intake to support blood sugar management.

The S GPT/ALT level is slightly elevated (42.00 U/L) compared to the reference
range (<50 U/L). Elevated levels may suggest liver dysfunction. Nutrition interventions
may focus on reducing alcohol consumption (if applicable), avoiding processed foods,
and promoting a diet rich in fruits, vegetables, and whole grains to support liver health.
The potassium, magnesium, and sodium levels are within the reference range, indicating
no significant abnormalities. Maintaining a balanced diet with foods rich in these
electrolytes, such as fruits, vegetables, whole grains, and nuts, is important for overall
health.
Total cholesterol is elevated (246.00 mg/dL) compared to the desirable range
(<200 mg/dL). High cholesterol levels can increase the risk of cardiovascular diseases.
Nutrition interventions should focus on reducing intake of saturated fats and cholesterol
by limiting the consumption of high-fat animal products, fried foods, and processed
snacks. Encourage the consumption of foods high in fiber and omega-3 fatty acids.
Triglyceride levels (113.00 mg/dL) are within the reference range (<150 mg/dL). HDL
cholesterol is below the reference range (34.00 mg/dL; reference range: 40.0-60.0
mg/dL). Higher levels of HDL cholesterol are desirable for cardiovascular health.
D. Nutrition-focused physical findings
The clinical assessment shows that patient X has a past medical surgery on his left
testicular removal. The patient is also having a shortness of breath which is one of the
symptoms for heart disease.

E. Food/nutrition related history

Patient X is taking some moringa powder every morning which can be considered as
healthy. He is on an intermittent diet which he only ate 4 hrs per day which is from
breakfast until lunch.

II. Nutrition Diagnosis

Intake Domain
1. Excessive fat intake (NI 5.5.2) related to knowledge deficit concerning
appropriate amount of dietary fat as evidenced by high in cholesterol, LDL
low in HDL.
2. Limited Food Acceptance related to self limitation of foods/food groups
due to food preference as evidenced by limited food intake inconsistent
with nutrition reference standard for type, variety, or diet quality.
Clinical Domain
1. Altered Nutrition Related Laboratory(NC 2.2) Values related to organ
dysfunction that leads to biochemical changes as evidenced by edema
and shortness of breath.
2. Unintended Weight Gain (NC 3.4) related to conditions causing
unexpected weight gain because of immobility as evidenced by physical
inactivity.
Behavioral Domain
1. Physical Inactivity related to lifestyle change as evidenced by excessive
subcutaneous fat and low muscle mass
III. Nutrition Intervention

The goals for patients with Congestive Heart Disease are as follows: Fluid
restriction: Limiting fluid intake helps reduce the burden on the heart and
alleviate edema. The specific fluid restriction may vary depending on the severity
of CHF and the individual's needs. Typically, it ranges from 1,500 to 2,000
milliliters per day. It's essential to include all sources of fluids consumed,
including beverages and foods with high water content. Also Sodium restriction is
important since restricting sodium (salt) intake is crucial to control fluid
retention. The recommended daily sodium intake for CHF patients is generally
around 1,500 to 2,000 milligrams, although it may be further individualized
based on the patient's condition. It is recommended to avoid adding salt to
meals and limit consumption of processed and packaged foods, as they tend to
be high in sodium. Focus on fresh, whole foods and use herbs and spices to
enhance flavor instead of salt.

a. Nutrition Prescription
A low cholesterol and sodium soft diet is prescribed for patients with heart diseases.
Caloric balance and weight management: Maintaining a healthy weight is important for
managing CHF. Caloric needs should be individualized based on factors such as age,
gender, activity level, and metabolic rate.

II. Nutrition Counseling

RNDs are also trained in the social sciences and understand the psychology of
eating. Appropriate counseling of the patient and the caregiver regarding the nutritional
needs is critical for the treatment of the patient. The counseling of the patient
undergoing CHF is imperative in his behavior change towards being more conscious
about his nutritional status and total wellness and changing his bad habits if there are
any. Aside from changing behavior, nutrition counseling is important for the patient to
understand why his diet is prescribed and how this could help him. Maintaining the
patient’s strength, vitality all depend on his appropriate nutrition

III. Coordination of care

The recovery of the patient is not dependent on one health professional alone
but it is a collaborative of responsibilities between the physicians, nurses, physical
therapists, nutritionist-dietitian, psychologist, and other people who contribute greatly
to his wealth and wellness. The dietitian cannot carry out all the tasks alone but is
responsible for the prescription of diet and menu planning for the patient through the
proper assessment, together with nutrition education and counseling. Physician’s
medical training and basic nutrition education provide them with the tools to recognize
‘at risk’ patients and refer them to trained specialists, such as dietitians, who have the
time, funding, knowledge, and practical skills to provide effective medical nutrition
therapy and elicit behavior change (Sialvera et al. 2017). Nurses ensure that every
patient receives the direct and proper care they need.
Soft Diet
Diet Rx: 2400 kcal; 330g CHO; 90g CHON; 65g FAT
 Breakfast Am Snacks Lunch

1 glass Powdered Milk 1 pc. Pipino (blended) ⅛ Malunggay soup

½ cup squash soup 2 slice piko mangga 1 pc. Chicken meat shredded
1 slice Cassava mashed with 2 tsp jam and jellies ½ tilapia
sugar and margarine 1 pc. Saging nilaga 1 slice pork ham
½ Papaya 1 pc. Boiled camote kahoy ½ cup protein reduced rice
1 pc. Hard boiled mashed egg 1 pc. Chicken meat shredded 8 pcs marie
1 tsp canola oil 2 tsp canola oil 1 ¼ cup mashed boiled
potato
2 tsp canola oil

Reference

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outcomes, and costs of care for congestive heart failure. Ann Intern Med.
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Feltner C, Jones CD, Cené CW, et al. Transitional care interventions to prevent
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