Case Study # 2

Evelyn Rubio N00855431

September 19, 2016
Questions:

1. What is the Dietary Reference Intake (DRI) for Vitamin K? 1

In adults over the age of 20, the average daily vitamin K intake from their diet is
about 90 mcg for woman and 120 mcg for men.

What is the Daily Value (DV) for Vitamin K as listed on food and supplement labels? 1

The daily value for vitamin k as listed on food and supplement labels are 80
micrograms based on a 2,000-calorie intake.

2. Identify sources of Vitamin K, both from diet and synthesis in the body.2

Vitamin K is a fat-soluble vitamin that is absorbed into the intestinal lymph and other
lipids. Bacteria in the large intestine synthesize the main source of vitamin K.
Vitamin K is needed in the process of coagulation and anticoagulation by
synthesizing several proteins. This patient receives most of her vitamin K from green
salad with romaine lettuce, asparagus, spinach, and collard greens.

3. Look up Vitamin K levels of the following sample foods in a food composition table or
database: 1 cup of cooked kale, 1 cup turnip greens, 1 cup raw romaine lettuce, 1 cup raw peeled
cucumber, 1cup cooked turnips.3

I cup of kale= 547 mcg

1 cup of turnip= 138 mcg

1 cup raw romaine lettuce= 48.2 mcg

1 cup raw peeled cucumber= 9.6 mcg

1 cup cooked turnip= 529.3 mcg

How do the Vitamin K levels of these foods compare to the DRI and DV?

1 cup of kale, 1 cup of turnip, and 1 cup of cooked turnip meet the requirements for
DV and DRI.

4. What is the recommended adjustment in Vitamin K intake in patients on warfarin? 4

The recommendation for intake of vitamin K intake in patients on warfarin is to keep

your intake consistent everyday. This is because warfarin interferes with how your
body uses vitamin K. This patient should eat the same amount of greens everyday to
keep that consistency.

What foods should they avoid or limit? 5

Foods you want to limit are kale, green tea, spinach, cranberry juice, chard, Brussels
sprouts, collard greens, and parsley because vitamin K lessens the effectiveness of
warfarin. The key with vitamin k and warfarin is that you do not want to completely
cut out foods with vitamin k, you want to stay consistent with how much vitamin k
you intake.

5. Is it advisable for her to take a multivitamin?

It is advisable to take a multivitamin but only if she is taking it consistently everyday.

How much vitamin K is in a standard once daily multivitamin?6

Many multivitamins do not contains vitamin K. but there is a few multivitamins

contain over 80 mcg of vitamin K. It all depends on what daily multivitamin one is
consuming.

6. How would her periodic use of antibiotics affect her INR? 7

She takes Bactrim periodically for urinary tract infections. This can be dangerous
when using warfarin and Bactrim at the same time. The combinations of these drugs
can increase the risk of bleeding especially in elders, bruising, vomiting, swelling,
blood in urine, blood in stool, dizziness, and weakness. This means you have to
frequently monitor your INR by a doctor since it can cause coagulation to happen at a
slower rate.

7. Describe the effects of herbal supplements such as St. Johns wort on medication action. 8,9

It is recommended not to take warfarin and St. Johns wort at the same time. St.
Johns wort increases the breakdown of warfarin and therefore decreases its
effectiveness. If the effectiveness of warfarin is decreased this than can increase the
risk of blood clotting. When it comes to taking simvastatin, consult a health provider
before combining it with St. Johns wort. St. Johns wort increases the break down of
simvastatin in the body; therefore, it causes simvastatin to become less effective.
Lastly, there is not a known interaction between Bactrim and St. Johns wort but an
interaction may still occur of some sort. One should always consult a doctor when
taking multiple medications.

8. Name other food medication interactions for which she is at risk. 5, 10, 11

Foods you want to limit are kale, green tea, spinach, cranberry juice, chard, Brussels
sprouts, collard greens, and parsley because vitamin K lessens the effectiveness of
warfarin. The key with vitamin k and warfarin is that you do not want to completely
cut out foods with vitamin k, you want to stay consistent with how much vitamin k
you intake. This patient should cease from drinking grapefruit juice. Grapefruit juice
can increase the blood levels of simvastatin. This then can increase the side effects
that come when taking simvastatin such as liver damage, kidney damage, and even
death. Its important to let a doctor know if any symptoms such as weakness, dark
colored urine, joint pain, swelling, skin rashes, loss of appetite, bruising and fatigue
occur. Bactrim only has a bad food interaction with alcohol. It causes unpleasant side
effects such as increase heartbeats, redness under the skin, nausea, vomiting, and a
tingly feeling. This patient has to be aware of these interactions because she needs to
stop consuming alcohol and grape juice.

9. Write a PES statement.12

Her intake of grapefruit juice is related to increase blood levels of simvastatin,

evidence by her multiple bruises on her extremities with no recent trauma and
muscles aches.

What is your intervention?

In this situation, I would have her completely stop drinking grapefruit juice. I would
recommend her to stop drinking orange juice as well because its acidity and substitute
with water.

10. Name a specific intervention(s) that would address her nutrition diagnosis, and specify how
you would monitor their effectiveness.13

She stated how fearful she is of a future stroke and leaving her unable to care for
herself or her husband. Therefore, I would like to monitor her intake of vitamin K
closely since she is also taking warfarin. This has to be monitored closely in order to
prevent a deadly blood clot or a fatal hemorrhage. I would have her consume the
same amount of vitamin k everyday. I would have her weigh out her daily greens and
make sure that she intake the same amount of a daily basis. I would also express my
concerns about this topic to her husband so her husband can hold her accountable for
her health. Lastly, it is a good idea to have her check her INR levels regularly.

In addition to diet and fluid status, what other parameter might you monitor in a HF patient? 14

In addition to diet and fluid state, there are other parameters that need to be
monitored in an HF patient. A recommendation is to weigh yourself every day with
the same scale. If signs of swelling in the feet, belly, or ankles, or showing sign of
retaining water, talk to your doctor. Eliminating sodium from your daily diet is
important for a healthy heart. Other signs you want to be looking out for that can be
done at home are checking your blood pressure, heart rate, and pulse. These sign can
let you know if youve been consuming too much salt or in taking too many fluids.

References:
1. Vitamin K Health Professional Fact Sheet. U.S National Library of Medicine.
https://ods.od.nih.gov/factsheets/vitamink-healthprofessional/. Accessed
September 19, 2016.
2. Vitamin K. Vitamin K.
http://www.vivo.colostate.edu/hbooks/pathphys/misc_topics/vitamink.html.
Accessed September 19, 2016.
3. SELF Nutrition Data. http://nutritiondata.self.com/. Accessed September 19,
2016.
4. Vitamin K and Coumadin - What you need to Know. - Blood Clots. Blood Clots.
https://www.stoptheclot.org/vitamin-k-and-coumadin-what-you-need-toknow.htm. Published April 2015. Accessed September 19, 2016.
5. Thrombophlebitis. Warfarin diet: What foods should I avoid?
http://www.mayoclinic.org/diseases-conditions/thrombophlebitis/expertanswers/warfarin/faq-20058443. Accessed September 19, 2016.
6. Is Vitamin K in Multivitamins? Healthy Eating.
http://healthyeating.sfgate.com/vitamin-k-multivitamins-7130.html. Accessed
September 19, 2016.
7. Bactrim IV and Coumadin Drug Interactions - Drugs.com. Bactrim IV and
Coumadin Drug Interactions - Drugs.com. https://www.drugs.com/druginteractions/bactrim-iv-with-coumadin-2128-3111-2311-1529.html. Accessed
September 20, 2016.
8. St. John's Wort Effectiveness, Safety, and Drug Interactions on RxList. RxList.
http://www.rxlist.com/st_johns_wort-page3/supplements.htm. Accessed
September 22, 2016.
9. Posts about Drugs, Side effects, Conditions and Symptoms - Treato. Treato.
https://treato.com/. Accessed September 22, 2016.
10.Simvastatin and Alcohol / Food Interactions - Drugs.com. Simvastatin and
Alcohol / Food Interactions - Drugs.com. https://www.drugs.com/foodinteractions/simvastatin.html. Accessed September 22, 2016.
11.Bactrim and Alcohol / Food Interactions - Drugs.com. Bactrim and Alcohol /
Food Interactions - Drugs.com. https://www.drugs.com/foodinteractions/sulfamethoxazole-trimethoprim,bactrim.html. Accessed
September 22, 2016.
12.http://blog.kalixhealth.com/author/admin/. IDNT and the Nutrition Care
Process: PART 3-PES Statements. The Official Kalix Blog.
http://blog.kalixhealth.com/idnt-and-the-nutrition-care-process-part-3-pesstatements/. Published September 2014. Accessed September 22, 2016.
13.# BI. Vitamin K & Warfarin. LifeExtension.com.
http://www.lifeextension.com/magazine/2007/6/report_vitamink/page-01.
Accessed September 22, 2016.

14.Heart failure - home monitoring: MedlinePlus Medical Encyclopedia. Heart

failure - home monitoring: MedlinePlus Medical Encyclopedia.
https://medlineplus.gov/ency/patientinstructions/000113.htm. Accessed
September 22, 2016.