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PT: Nutrition Exam 2 > Adult Parenteral Nutrition > Flashcards

Adult Parenteral Nutrition Flashcards

1
Q

Enteral advantages

A
  • less cost
  • more complete nutrient profile
  • fewer complications
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2
Q

Parenteral advantages

A
  • easier admin
  • better patient acceptance
  • more reliable delivery
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3
Q

Contraindications for parenteral nutrition

A
  • functioning and accessible GI tract
  • treatment <7 days anticipated NPO status w/o severe malnutrition
  • prognosis that does not warrant aggressive nutrition support
  • risk exceeds benefits
  • inability to obtain venous access
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4
Q

Indications for parenteral nutrition

A
  • nonfunctioning GI tract
  • inability to tolerate oral feedings
  • patient failed enteral nutrition
  • prognosis warrants aggressive nutrition therapy
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5
Q

T/f benefits should be weight against risks for every potential nutrition candidate

A

True

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6
Q

Conditions warranting use of parenteral nutrition

A
  • preoperative (severely malnourished, NPO >10 days)
  • lower GI obstruction
  • high output GI fistula (>500ml/day)
  • acute IBD
  • short bowel syndrome
  • severe acute pancreatitis
  • critical care
  • cancer
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7
Q

Parenteral nutrition definition

A
  • process of supplying nutrients via IV route

- components in elemental form

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8
Q

What is parenteral nutrition also known as?

A
  • TPN (total parenteral nutrition)

- hyperalimentation

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9
Q

Goal of parenteral nutrition

A

Formulate a safe, clinically appropriate end product

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10
Q

PN protein, CHO and fat

A

AA
Dextrose
Lipid emulsion

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11
Q

PN formula considerations

A
  • central vs peripheral IV access
  • osmolality
  • fluid volume needed
  • concentration of dextrose, AA and lipids
  • addition of MVI, TE
  • pH of solution
  • stability
  • compatibility of nutrient components to meet nutritional needs
  • microbial growth potential of admixture
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12
Q

Central line advantage

A
  • more calories can be delivered

- longer duration of therapy (>10 days to years)

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13
Q

Limitations of central line

A
  • obtaining central access
  • more catheter maintenance
  • more metabolic complications
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14
Q

Peripheral vein uses

A
  • short term therapy (7-10 days)
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15
Q

Peripheral vein advantages

A
  • easy to obtain access
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16
Q

Limitations of peripheral vein

A
  • large electrolyte needs (K strong vascular irritant)
  • nutrient provided (lipids majority)
  • patient tolerance to larger fluid volumes
  • medication compatibilities
  • osmolarity <900mOsm
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17
Q

TPN vs PPN

A
  • TPN: glucose concentration 15-25%, PPN 5-10%
  • Osmolarity TPN: >1300-1800, PPN: <900
  • TPN: large diameter vein (central), PPN: peripheral vein
  • TPN: more concentrated; PPN: large fluid volumes
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18
Q

When a _____ solution is introduced into a small vein with a low blood flow, fluid from the surrounding tissue moves into the vein due to ______

A

Hypertonic

Osmosis

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19
Q

The high concentration in a small vein leads to ______

A

Phlebitis (pain, irritation, inflammation of vein)

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20
Q

Osmolarity limits in peripheral line

A

600-900 mOsm/L

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21
Q

Osmolarity limits in central line

A

> 1800 mOsm/L

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22
Q

Increased osmolarity limits in central line allows for increased concentrations of _____ and ______ to be delivered

A

Dextrose

AA

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23
Q

AA PN osmolarity

A

100 mOsm/1% final concentration/L

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24
Q

Dextrose PN osmolarity

A

50 mOsm/1% final concentraiton/L

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25
Q

Estimating PN osmolarity of dextrose

A

G dextrose/L x 5

% dextrose of solution x 50

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26
Q

Estimating PN osmolarity of protein

A

G protein/L x 10

% AA of solution x 100

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27
Q

Primary energy substrate in PN

A

Carbohydrate

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28
Q

Kcal/g of dextrose monohdyrate

A

3.4 kcal/g

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29
Q

% concentration range of dextrose monohydrate

A

5-70%

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30
Q

Kcal/g of glycerol

A

4.3 kcal/g

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31
Q

Glycerol in PN

A

Pre-manufactured PPN solutions typically

Naturally occurring sugar alcohol

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32
Q

Potential adverse effects of carbohydrates in PN

A
  • increased minute ventilation
  • increased CO2 production
  • increased O2 consumption
  • increased RQ
  • hepatic steatosis
  • hyperglycemia
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33
Q

Source for nitrogen in PN

A

Protein

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34
Q

Kcal/g of protein

A

4 kcal/gm

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35
Q

% concentration of protein

A

3-15%

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36
Q

Standard amino acids

A

Mixture of essential and non-essential AA

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37
Q

Condition specific or modified protein

A
  • renal and liver failure formulations
  • costly
  • not commonly used
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38
Q

Potential adverse effects of protein in PN

A
  • increased renal solute load

- azotemia

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39
Q

20% lipid emulsion kcal/ml

A

2 kcal/mL

40
Q

Potential adverse effects of fat in PN

A
  • egg allergy
  • hypertriglyceridemia
  • decreased cell mediated immunity in immunosuppressed
  • elevated LFTs
41
Q

MVI-13

A
  • limited stability once added to TPN

- contains vitamin K

42
Q

Trace elements in PN

A
  • Zn, Cu, Mn, Cr, Se

- essential to normal metabolism and growth

43
Q

Conditions that require adding trace elements individually

A
  • decreased excretion with biliary disease

- deficiency states may develop with increased metabolic requirements or increased losses

44
Q

Electrolytes uses in PN

A
  • essential nutrients that perform critical physiologic functions and maintain homeostasis
45
Q

Stability of TPN solution is dependent upon compatibility of each _____ and other components of admixture

A

Electrolytes

46
Q

______ forms of electrolytes can affect acid/base balance

A

Salt forms (acetate vs chloride)

47
Q

Electrolyte needs dependent upon

A
  • renal function
  • acid/base balance
  • GI losses
  • medications
48
Q

T/F electrolytes must be individualized

A

True

49
Q

Important electrolytes to add to PN

A

Na, K, P, Mg, Ca

50
Q

Which form of calcium is preferred for PN?

A

Gluconate

51
Q

Why is bicarbonate not used in TPN?

A

Precipitation of Ca and Mg

52
Q

Why is acetate commonly used in TPN?

A

Readily converted endogenously to bicarbonate

53
Q

How is acid/base balance maintained in TPN?

A

Acetate and chloride salts

54
Q

Acetate/chloride in metabolic acidosis

A

Maximize acetate

Minimize Cl

55
Q

Drug shortages and TPN

A
  • occur for variety of components (lipids, AA, electrolytes, MVI)
  • communicate availability
  • prescription may need to be modified
  • if patient risk for deficiency, monitor labs closely
56
Q

Fluid in TPN

A
  • sterile water added to adjust total volume of fluid needed to meet prescribed 24 hour fluid intake
57
Q

T/F individual fluid needs do not need to be considered in every TPN prescription

A

False! Must be considered

58
Q

What considerations must be taken with fluids and TPN?

A
  • other IVF
  • IV drugs
  • blood products being prescribed
59
Q

With fluid levels what do you monitor?

A

BUN

Creatinine

60
Q

T/f the order of admixing can affect overall stability of final product

A

True

61
Q

Stability issues of TPN

A
  • impacted by order components added (esp calcium, P)
  • max cal and P product is 50 (40-45 preferred to prevent precipitation)
  • concentration of AA affects pH
  • temp
  • adequate mixing/agitation
62
Q

2 in 1 admixture

A

Piggyback

-dextrose, AA, electrolytes infused separately from lipids

63
Q

3 in 1 admixture

A

Total nutrient admixture (TNA)

- lipid emulsion admixed with dextrose, AA and electrolytes

64
Q

Advantages of TNA

A
  • decreased nursing time
  • decreased risk of touch contamination, possibly decreased infection risk
  • ease of admin for home TPN patients
  • better lipid utilization
65
Q

Better lipid utilization of TNA

A
  • continuous, slow infusion

- short infusions under 10 hours associated with reticuloendothelial system impairment

66
Q

Disadvantages of TNA

A
  • stability (decreased by lipid)
  • compatibility (decreased amounts of nutrients when lipid present)
  • impaired visual inspection (opaque limits precipitation visualization)
  • filtration
  • TNA may be safely filtered with 1.2um filter (removes large organisms, but not common bacterial contaminants)
67
Q

FDA requires disclosure of _____ content of PN components as all of them contain it

A

Al

68
Q

Where is aluminum highly found?

A

AA solutions
Phosphate salts
Ca gluconate
TE

69
Q

Implications of aluminum

A

Metabolic bone disease
Neurologic dysfunction
Microcytic anemia

70
Q

At risk populations of aluminum

A
  • neonates
  • those with renal dysfunction
  • those on long term PN
71
Q

Symptoms of toxicity of manganese

A
  • HA
  • tremor
  • parkinson like gait dysfunction
72
Q

At risk population of manganese toxicity

A

Cholestatic liver disease

73
Q

Parenteral nutrition monitoring

A
  • labs
  • weight
  • I/Os
  • vital signs
  • Meds
  • changes in medical condition
  • determine readiness to transition to enteral nutrition
74
Q

What labs should you monitor in PN

A
  • serum electrolytes
  • blood glucose
  • triglycerides
  • LFTs
75
Q

TG >250 in PN

A

Consider reducing lipid infusion

76
Q

TG >400 PN

A

Hold lipids

77
Q

Glucose abnormalities of PN

A
  • hyperglycemia (limit glucose)

- hypoglycemia (occurs with sudden discontinuation)

78
Q

What should you check with glucose abnormalities of PN?

A

Assess for new or resolving stress, new or discontinued meds or dextrose containing IVF

79
Q

When can hepatic steatosis occur in PN?

A
  • may occur 1-2 weeks after starting
80
Q

When can cholestasis occur in PN?

A
  • may occur 2-6 weeks after starting
81
Q

Cholestasis indicated by

A

Progressive increase in total bilirubin and alkaline phosphatase

82
Q

Cholestasis occurs due to

A

Lack of intestinal nutrients to stimulate hepatic bile flow, causing disruption or blockage

83
Q

Hepatic steatosis indicated by

A

Elevated LFTs

84
Q

Hepatic steatosis due to

A

Overfeeding of dextrose and lipids

May be due to carnitine or choline deficiency

85
Q

GI atrophy due to

A

Lack of enteral stimulation associated with

  • villus hypoplasia
  • colonic mucosal atrophy
  • decreased gastric function
  • impaired GI immunity
  • bacterial overgrowth
  • bacterial translocation
86
Q

How to prevent GI atrophy in PN?

A

Initiate trophic enteral feeding

87
Q

Acid base disorders in PN due to

A
  • increased renal or GI loss of bicarbonate
  • renal failure
  • ketoacidosis
  • lactic acidosis
  • excessive chloride administration
88
Q

Vascular access issues in PN

A
  • pneumothorax
  • arterial puncture
  • infection
89
Q

What are some complications of PN support?

A
  • glucose abnormalities
  • metabolic bone disease
  • hepatic steatosis
  • cholestasis
  • GI atorphy
  • Acid base disorders
  • vascular access issues
90
Q

Reducing risk of refeeding syndrome

A
  • identify patients at risk
  • correct electrolyte abnormalities BEFORE initiation of nutrition support
  • limit volume initially
  • limit dextrose to 150mg/day initially
  • may need to supplement thiamine
  • GO slow: permissive underfeeding
91
Q

Refeeding syndrome major concern of causing

A

Cardiorespiratory failure

92
Q

Refeeding syndrome can cause

A
  • thiamine deficiency
  • hypophosphatemia
  • hypokalemia
  • salt and water retention
  • hypomagnesemia
  • excessive demands of malnourished heart
93
Q

Permissive underfeeding

A
  • approx 2/3 of needs

- temporary

94
Q

Perfmissive underfeeding used for

A
  • refeeding syndrome
  • hyperglycemia
  • organ failure
  • need for significant fluid restriction
95
Q

Defense against PN complications

A
  • appropriate patient selection
  • do not overfeed
  • monitor fluid/electrolyte/vitamin/mineral status
  • monitor organ function, changes in patient medical status
  • aseptic technique for insertion and site care of IV catheters

PT: Nutrition Exam 2 (10 decks)

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