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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
Estimating PN osmolarity of dextrose
G dextrose/L x 5 | % dextrose of solution x 50
26
Estimating PN osmolarity of protein
G protein/L x 10 | % AA of solution x 100
27
Primary energy substrate in PN
Carbohydrate
28
Kcal/g of dextrose monohdyrate
3.4 kcal/g
29
% concentration range of dextrose monohydrate
5-70%
30
Kcal/g of glycerol
4.3 kcal/g
31
Glycerol in PN
Pre-manufactured PPN solutions typically | Naturally occurring sugar alcohol
32
Potential adverse effects of carbohydrates in PN
- increased minute ventilation - increased CO2 production - increased O2 consumption - increased RQ - hepatic steatosis - hyperglycemia
33
Source for nitrogen in PN
Protein
34
Kcal/g of protein
4 kcal/gm
35
% concentration of protein
3-15%
36
Standard amino acids
Mixture of essential and non-essential AA
37
Condition specific or modified protein
- renal and liver failure formulations - costly - not commonly used
38
Potential adverse effects of protein in PN
- increased renal solute load | - azotemia
39
20% lipid emulsion kcal/ml
2 kcal/mL
40
Potential adverse effects of fat in PN
- egg allergy - hypertriglyceridemia - decreased cell mediated immunity in immunosuppressed - elevated LFTs
41
MVI-13
- limited stability once added to TPN | - contains vitamin K
42
Trace elements in PN
- Zn, Cu, Mn, Cr, Se | - essential to normal metabolism and growth
43
Conditions that require adding trace elements individually
- decreased excretion with biliary disease | - deficiency states may develop with increased metabolic requirements or increased losses
44
Electrolytes uses in PN
- essential nutrients that perform critical physiologic functions and maintain homeostasis
45
Stability of TPN solution is dependent upon compatibility of each _____ and other components of admixture
Electrolytes
46
______ forms of electrolytes can affect acid/base balance
Salt forms (acetate vs chloride)
47
Electrolyte needs dependent upon
- renal function - acid/base balance - GI losses - medications
48
T/F electrolytes must be individualized
True
49
Important electrolytes to add to PN
Na, K, P, Mg, Ca
50
Which form of calcium is preferred for PN?
Gluconate
51
Why is bicarbonate not used in TPN?
Precipitation of Ca and Mg
52
Why is acetate commonly used in TPN?
Readily converted endogenously to bicarbonate
53
How is acid/base balance maintained in TPN?
Acetate and chloride salts
54
Acetate/chloride in metabolic acidosis
Maximize acetate | Minimize Cl
55
Drug shortages and TPN
- 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
Fluid in TPN
- sterile water added to adjust total volume of fluid needed to meet prescribed 24 hour fluid intake
57
T/F individual fluid needs do not need to be considered in every TPN prescription
False! Must be considered
58
What considerations must be taken with fluids and TPN?
- other IVF - IV drugs - blood products being prescribed
59
With fluid levels what do you monitor?
BUN | Creatinine
60
T/f the order of admixing can affect overall stability of final product
True
61
Stability issues of TPN
- 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
2 in 1 admixture
Piggyback | -dextrose, AA, electrolytes infused separately from lipids
63
3 in 1 admixture
Total nutrient admixture (TNA) | - lipid emulsion admixed with dextrose, AA and electrolytes
64
Advantages of TNA
- decreased nursing time - decreased risk of touch contamination, possibly decreased infection risk - ease of admin for home TPN patients - better lipid utilization
65
Better lipid utilization of TNA
- continuous, slow infusion | - short infusions under 10 hours associated with reticuloendothelial system impairment
66
Disadvantages of TNA
- 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
FDA requires disclosure of _____ content of PN components as all of them contain it
Al
68
Where is aluminum highly found?
AA solutions Phosphate salts Ca gluconate TE
69
Implications of aluminum
Metabolic bone disease Neurologic dysfunction Microcytic anemia
70
At risk populations of aluminum
- neonates - those with renal dysfunction - those on long term PN
71
Symptoms of toxicity of manganese
- HA - tremor - parkinson like gait dysfunction
72
At risk population of manganese toxicity
Cholestatic liver disease
73
Parenteral nutrition monitoring
- labs - weight - I/Os - vital signs - Meds - changes in medical condition - determine readiness to transition to enteral nutrition
74
What labs should you monitor in PN
- serum electrolytes - blood glucose - triglycerides - LFTs
75
TG >250 in PN
Consider reducing lipid infusion
76
TG >400 PN
Hold lipids
77
Glucose abnormalities of PN
- hyperglycemia (limit glucose) | - hypoglycemia (occurs with sudden discontinuation)
78
What should you check with glucose abnormalities of PN?
Assess for new or resolving stress, new or discontinued meds or dextrose containing IVF
79
When can hepatic steatosis occur in PN?
- may occur 1-2 weeks after starting
80
When can cholestasis occur in PN?
- may occur 2-6 weeks after starting
81
Cholestasis indicated by
Progressive increase in total bilirubin and alkaline phosphatase
82
Cholestasis occurs due to
Lack of intestinal nutrients to stimulate hepatic bile flow, causing disruption or blockage
83
Hepatic steatosis indicated by
Elevated LFTs
84
Hepatic steatosis due to
Overfeeding of dextrose and lipids | May be due to carnitine or choline deficiency
85
GI atrophy due to
Lack of enteral stimulation associated with - villus hypoplasia - colonic mucosal atrophy - decreased gastric function - impaired GI immunity - bacterial overgrowth - bacterial translocation
86
How to prevent GI atrophy in PN?
Initiate trophic enteral feeding
87
Acid base disorders in PN due to
- increased renal or GI loss of bicarbonate - renal failure - ketoacidosis - lactic acidosis - excessive chloride administration
88
Vascular access issues in PN
- pneumothorax - arterial puncture - infection
89
What are some complications of PN support?
- glucose abnormalities - metabolic bone disease - hepatic steatosis - cholestasis - GI atorphy - Acid base disorders - vascular access issues
90
Reducing risk of refeeding syndrome
- 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
Refeeding syndrome major concern of causing
Cardiorespiratory failure
92
Refeeding syndrome can cause
- thiamine deficiency - hypophosphatemia - hypokalemia - salt and water retention - hypomagnesemia - excessive demands of malnourished heart
93
Permissive underfeeding
- approx 2/3 of needs | - temporary
94
Perfmissive underfeeding used for
- refeeding syndrome - hyperglycemia - organ failure - need for significant fluid restriction
95
Defense against PN complications
- 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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