Impact of Nutritional Intervention for Patient with Cerebrovascular Accident and Atrial Fibrillation Secondary to Hypertensive Emergency
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Published
31 January 2024
Keywords:
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cardiovascular disease, diarrhea, dysphagia, malnutrition
Abstract
This case study aims to report on the nutrition management of Cerebrovascular Accidents (CVA) which have a higher risk of malnutrition due to dysphagia, hemiparesis, decreased mobility, and dementia. Mrs. L, a 76-year-old Chinese lady, was less responsive at home. Upon admission, she was diagnosed with hypertensive emergency complicated by CVA, newly diagnosed atrial fibrillation, and End-Stage Renal Disease (ESRD). Her Body Mass Index (BMI) is 22.5 kg/m2, which is underweight for her age. The patient, with abnormal blood results, high blood pressure, and poor Glasgow Coma Scale (GCS) score, was treated with nasogastric enteral feeding and a disease-specific formula for diabetes. Inadequate enteral nutrition infusion related to feeding has yet to optimize as evidenced by intake of 57% of energy and 0.6 g/kg body weight of protein. Mrs. L required 1,442 kcal of energy and 57.7 g of protein (1 g/kg body weight) to meet adequate bodily function and prevent further weight loss. The nasogastric enteral feeding was optimized to 250 mL, seven times daily using the same diabetic formula. Throughout follow ups, although the patient’s dietary intake improved, she experienced episodes of diarrhea. She was also put on a 500 mL fluid restriction per day. Considering those issues, the diseasespecific formula was changed to renal disease formula. The patient then progressed to a soft diet with improved GCS scores and other conditions. This case highlights dysphagia which is the leading cause of malnutrition in stroke patients, associated with poor prognosis, increased mortality, and deteriorated health outcomes, necessitating enteral nutrition support to enhance nutritional status and promote health. It can be concluded that MNT in managing patients with CVA, hypertensive emergency, and underlying diseases of diabetes and ESRD helps to improve the patient’s recovery. The patient's treatment and diet should be optimally adjusted through close monitoring and evaluation
References
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[IPH] Institute for Public Health. 2020. National Health and Morbidity Survey (NHMS) 2019: Non-communicable Diseases, Healthcare Demand, and Health Literacy—Key Findings. Kuala Lumpur (KL): IPH.
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Kuriakose D, Xiao Z. 2020. Pathophysiology and treatment of stroke: Present status and future perspectives. Int J Mol Sci 21(20): 7609. https://doi.org/10.3390/ijms21207609
Lewis SL, Ruff Dirksen S, McLean Heitkemper M, Bucher L, Harding MM. 2014. Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 9th Edition. Missouri (USA): Elsevier.
Locke A, Schneiderhan J, Zick SM. 2018. Diets for health: Goals and guidelines. : Am Fam Physician 97(11):721–728.
MacDonalds E. 2021. Atrial fibrillation pathophysiology [Nursing Student Class Projects]. Ohio (USA): Otterbein University.
Marathe PH, Gao HX, Close KL. 2017. American Diabetes Association Standards of medical care in diabetes 2017. J Diabetes 9(4):320–324. https://doi.org/10.1111/1753-0407.12524
McCance KL, Huether SE, Brashers VL, Rote NS. 2019. Pathophysiology: The Biologic Basis for Disease in Adults and Children. 8th Edition. Amsterdam (NL): Elsevier.
[MoH Malaysia] Ministry of Health Malaysia. 2020. Malaysian Clinical Practice Guidelines for Management of Type 2 Diabetes Mellitus. 6th Edition. Kuala Lumpur (KL): MoH Malaysia.
Musuka TD, Wilton SB, Traboulsi M, Hill MD. 2015. Diagnosis and management of acute ischemic stroke: speed is critical. Can Med Assoc 187(12):887–893. https://doi.org/10.1503/cmaj.140355
Narasimhan R, Patel JM, Velapati SR, Mohamed Elfadil O, Hurt RT, Mundi MS. 2020. The use of calorically dense enteral formulas in adult home enteral nutrition population in a tertiary care center: A retrospective analysis. Int J Acad Med 6(4):294-300. https://www.ijam-web.org/text.asp?2020/6/4/294/304606
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Ojo O, Brooke J. 2016. The use of enteral nutrition in the management of stroke. Nutr 8(12):827. https://doi.org/10.3390/nu8120827
Oh R, Gilani B, Uppaluri KR. 2023. Low carbohydrate diet. https://www.ncbi.nlm.nih.gov/books/NBK537084/ [Accessed 15th September 2023].
Picard K, Barreto Silva MI, Mager D, Richard C. 2020. Dietary potassium intake and risk of chronic kidney disease progression in pre-dialysis patients with chronic kidney disease: A systematic review. Advances in Nutr 11(4):1002–1015. https://doi.org/10.1093/advances/nmaa027
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Winter JE, MacInnis RJ, Wattanapenpaiboon N, Nowson CA. 2014. BMI and all-cause mortality in older adults: A meta-analysis. Am J Clin Nutr 99(4):875–890. https://doi.org/10.3945/ajcn.113.068122
Yoon J, Baek S, Jang Y, Lee CH, Lee ES, Byun H, Oh MK. 2023. Malnutrition and associated factors in acute and subacute stroke patients with dysphagia. Nutr 15(17):3739. https://doi.org/10.3390/nu15173739
[AHA] American Heart Association. 2023. High blood pressure. https://www.heart.org/en/health-topics/high-blood-pressure [Accessed 31st October 2023].
[ASA] American Stroke Association. 2020. Let’s talk about the connection between diabetes and stroke. https://www.stroke.org/-/media/Stroke-Files/Lets-Talk-About-Stroke/Prevention/Lets-Talk-About-the-Connection-Between-Diabetes-and-Stroke.pdf [Accessed 1st November 2023].
Arsava EM, Aydoğdu I, Güngör L, Işıkay CT, Yaka E. 2018. Nutritional approach and treatment in patients with stroke, an expert opinion for Turkey. Turk J Neurol 24:226‒242. https://doi.org/10.4274/tnd.92603
Bossola M, Di Stasio E, Viola A, Cenerelli S, Leo A, Santarelli S, Monteburini T. 2020. Dietary daily sodium intake lower than 1500 mg is associated with inadequately low intake of calorie, protein, iron, zinc and vitamin B1 in patients on chronic hemodialysis. Nutr 12(1):260. https://doi.org/10.3390/nu12010260
Buoite Stella A, Manganotti P. 2022. Enteral nutrition and hydration in patients with acute stroke: Efficacy of an automatic pump system for water administration and flushes-A pilot study. Sens 22(20):8029. https://doi.org/10.3390/s22208029
Buranapin S, Siangruangsang S, Chantapanich V, Hengjeerajarus N. 2014. The comparative study of diabetic specific formula and standard formula on postprandial plasma glucose control in type 2 DM patients. J Med Assoc Thai 97(6):582–588.
Cantone M, Lanza G, Puglisi V, Vinciguerra L, Mandelli J, Fisicaro F, Pennisi M, Bella R, Ciurleo R, Bramanti A. 2021. Hypertensive crisis in acute cerebrovascular diseases presenting at the emergency department: A narrative review. Brain Sci 11(1):70. https://doi.org/10.3390/brainsci11010070
[CDC] Centers for Disease Control and Prevention. 2023. Know your risk for stroke. https://www.cdc.gov/stroke/risk_factors.htm [Accessed 31st October 2023].
Chen R, Ovbiagele B, Feng W. 2016. Diabetes and stroke: Epidemiology, pathophysiology, pharmaceuticals, and outcomes. Am J Med Sci 351(4):380–386. https://doi.org/10.1016/j.amjms.2016.01.011
Damuth E, Mitchell JA, Bartock JL, Roberts BW, Trzeciak S. 2015. Long-term survival of critically ill patients treated with prolonged mechanical ventilation: A systematic review and meta-analysis. Lancet Respir Med 3:544–553. https://doi.org/10.1016/S2213-2600(15)00150-2
Feigin VL. Stark BA, Johnson CO, Roth GA, Bisignano C, Abady GG, Abbasifard M, Abbasi-Kangevari M, Abd-Allah F, Abedi V et al. 2021. Global, regional, and national burden of stroke and its risk factors, 1990–2019: A systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol 20(10):795–820. https://doi.org/10.1016/S1474-4422(21)00252-0
Fiaccadori E, Sabatino A, Barazzoni R, Carrero JJ, Cupisti A, De Waele E, Jonckheer J, Singer P, Cuerda C. 2021. ESPEN guideline on clinical nutrition in hospitalised patients with acute or chronic kidney disease. Clin Nutr 40(4):1644–1668. https://doi.org/10.1016/j.clnu.2021.01.028
Gong L, Wang Y, Shi J. 2021. Enteral nutrition management in stroke patients: A narrative review. Ann Palliat Med 10(10):11191–11202. https://doi.org/10.21037/apm-21-2922
Grant P. 2020. Food gums: Are they safe?. https://pamela-grant.com/blog-ss/food-gums [Accessed 1st November 2023].
Hall JE, Granger JP, Jones DW, Hall ME. 2017. Pathophysiology of hypertension. https://accessmedicine.mhmedical.com/content.aspx?bookid=2046§ionid=176572779 [Accessed 18th September 2023].
Hill AD, Fowler RA, Burns KE, Rose L, Pinto RL, Scales DC. 2017. Long-term outcomes and health care utilization after prolonged mechanical ventilation. Ann Am Thorac Soc 14(3):355–362. https://doi.org/10.1513/AnnalsATS.201610-792OC
Holliday MA, Segar WE. 1957. The maintenance need for water in parenteral fluid therapy. Pediatrics 19:823–832.
Hui C, Tadi P, Patti L. 2022. Ischemic stroke. https://www.ncbi.nlm.nih.gov/books/NBK499997/ [Accessed 18th September 2023].
[IPH] Institute for Public Health. 2020. National Health and Morbidity Survey (NHMS) 2019: Non-communicable Diseases, Healthcare Demand, and Health Literacy—Key Findings. Kuala Lumpur (KL): IPH.
Kelly DM, Ademi Z, Doehner W, Lip GYH, Mark P, Toyoda K, Wong CX, Sarnak M, Cheung M, Herzog CA et al. 2021. Chronic kidney disease and cerebrovascular disease: Consensus and guidance from a KDIGO controversies conference. Stroke 52(7):328–346. https://doi.org/10.1161/STROKEAHA.120.029680
Kuriakose D, Xiao Z. 2020. Pathophysiology and treatment of stroke: Present status and future perspectives. Int J Mol Sci 21(20): 7609. https://doi.org/10.3390/ijms21207609
Lewis SL, Ruff Dirksen S, McLean Heitkemper M, Bucher L, Harding MM. 2014. Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 9th Edition. Missouri (USA): Elsevier.
Locke A, Schneiderhan J, Zick SM. 2018. Diets for health: Goals and guidelines. : Am Fam Physician 97(11):721–728.
MacDonalds E. 2021. Atrial fibrillation pathophysiology [Nursing Student Class Projects]. Ohio (USA): Otterbein University.
Marathe PH, Gao HX, Close KL. 2017. American Diabetes Association Standards of medical care in diabetes 2017. J Diabetes 9(4):320–324. https://doi.org/10.1111/1753-0407.12524
McCance KL, Huether SE, Brashers VL, Rote NS. 2019. Pathophysiology: The Biologic Basis for Disease in Adults and Children. 8th Edition. Amsterdam (NL): Elsevier.
[MoH Malaysia] Ministry of Health Malaysia. 2020. Malaysian Clinical Practice Guidelines for Management of Type 2 Diabetes Mellitus. 6th Edition. Kuala Lumpur (KL): MoH Malaysia.
Musuka TD, Wilton SB, Traboulsi M, Hill MD. 2015. Diagnosis and management of acute ischemic stroke: speed is critical. Can Med Assoc 187(12):887–893. https://doi.org/10.1503/cmaj.140355
Narasimhan R, Patel JM, Velapati SR, Mohamed Elfadil O, Hurt RT, Mundi MS. 2020. The use of calorically dense enteral formulas in adult home enteral nutrition population in a tertiary care center: A retrospective analysis. Int J Acad Med 6(4):294-300. https://www.ijam-web.org/text.asp?2020/6/4/294/304606
[NKF] National Kidney Foundation. 2023. Stage 5 Chronic Kidney Disease (CKD). https://www.kidney.org/atoz/content/stage-5-chronic-kidney-disease-ckd [Accessed 15th September 2023].
Ojo O, Brooke J. 2016. The use of enteral nutrition in the management of stroke. Nutr 8(12):827. https://doi.org/10.3390/nu8120827
Oh R, Gilani B, Uppaluri KR. 2023. Low carbohydrate diet. https://www.ncbi.nlm.nih.gov/books/NBK537084/ [Accessed 15th September 2023].
Picard K, Barreto Silva MI, Mager D, Richard C. 2020. Dietary potassium intake and risk of chronic kidney disease progression in pre-dialysis patients with chronic kidney disease: A systematic review. Advances in Nutr 11(4):1002–1015. https://doi.org/10.1093/advances/nmaa027
Robertson S. 2023. Stroke prognosis. https://www.news-medical.net/health/Stroke-Prognosis.aspx. [Accessed 1st November 2023].
Unnithan AKA, M Das J, Mehta P. 2023. Hemorrhagic stroke. https://www.ncbi.nlm.nih.gov/books/NBK559173/# [Accessed 15th September 2023].
Volkert D, Beck AM, Cederholm T, Cruz-Jentoft A, Goisser S, Hooper L, Kiesswetter E, Maggio M, Raynaud-Simon A, Sieber CC et al. 2019. ESPEN guideline on clinical nutrition and hydration in geriatrics. Clin Nutr 38(1):10–47. https://doi.org/10.1016/j.clnu.2018.05.024
Winter JE, MacInnis RJ, Wattanapenpaiboon N, Nowson CA. 2014. BMI and all-cause mortality in older adults: A meta-analysis. Am J Clin Nutr 99(4):875–890. https://doi.org/10.3945/ajcn.113.068122
Yoon J, Baek S, Jang Y, Lee CH, Lee ES, Byun H, Oh MK. 2023. Malnutrition and associated factors in acute and subacute stroke patients with dysphagia. Nutr 15(17):3739. https://doi.org/10.3390/nu15173739
Authors
RoslanN. I., Ahmad ZamuriA. N., Ab. HamidM. R., & binti BaharudinN. N. (2024). Impact of Nutritional Intervention for Patient with Cerebrovascular Accident and Atrial Fibrillation Secondary to Hypertensive Emergency. Jurnal Gizi Dan Pangan, 19(Supp.1), 53-62. https://doi.org/10.25182/jgp.2024.19.Supp.1.53-62
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