Exam 3 Flashcards

Question

enteral feeding access devices jejunostomy J-tube ``` indication: placement: advantages: disadvantages: crushed meds?: ```

Answer 1

enteral feeding access devices indication: long term, impaired GE, aspiration placement: surgical advantages: earlier feeding, comfort, reduced aspiration disadvantages: procedure risk, smaller tube, site complications, NO BOLUS FEEDS crushed meds?:NO

Answer 2

standard formulas are recommended for most patients how we choose a formula typically is based on how much protein a pt. needs if pt has other issues (volume intolerance, impaired digestion, renal disease, stress/trauma etc.,) may warrant specialty formula

Answer 3

may contribute to aspiration, requires holding feeds and impacts delivery of nutrition ways to be monitored for intolerance: 1. gastric volume residuals (GVR) volume rmeinig in stomach over a given interval * not a god indicator 2. symptoms of intolerance * better than grr prevention/maanagement: *heep head of bead at 30-40 degrees * minimize opioids * correct fluid and electrolyte abdnormaliities * continuous rather than bolus feeding * post pyloric feeding * prokinetic agents: metaclopromide, erythromycin

Answer 4

1.DIARRHEA 2. intestinal ischemia * risks: neonates, critically ill, immunosuppressed, juejenal feeding, hyperosmolar feeds * prvention: delay feeding until fully volume resuscitated * iniitiate with is0-asmolor fiber free formula * monitor for SS, esp. if previous tolerating feeds 3. Metabolic: glucose, fluid electrolytes, macros andmicronutrient perturbations (alterations) 4. mechanical: * feeding tube occlusion: flushing maintains potency * malposition: * nasopulminar intubation 5. infectious a. aspirarion b. sinusitis c. exit site infections of gastric tube d. intra-abdominal

Answer 5

Fluid/weights: daily Glucose: q1-6hr electrolytes: daily-TIW visceral proteins: 1-2x/week CBC, PT/PTT: 1-2x/week Protein turnover: weekly GI intolerance: daily up to every 4 hours

Answer 6

1. med ordered by provider 2. oder reviewed by nurse or pharmaist 3. medication prepared by nurse or pharmacist 4. medication administered by nurse

Answer 7

access site: *may affect absorption of drug med dosage form: *liquid vs tablet. NOT CR and enteric coated tabs physical incompatibilities prevention and management of tube occlusions proper administration techniques

Answer 8

oral preffered. crush immediate release tablets administer multiple meds seperately, with water flushes done between each medication, flushingg w. at least 15-30 ml of water before and after medication do not crush enteric coated tablets

Answer 9

Precipitating factor- Object drug-nutrient: carbamezapine decreases biotin status drug-nutrient status: quetiapine causes weight gain drug metabolic status: capecitabine causes hypertriglyceridemia nutrition status-drug: obesity lowers ertapenem levels nutrient-drug: vitamin D reduces atorvastatin levels food component-drug: protein reduces levodopa absorption food-drug: grapefruit increases simvastatin concentrations

Answer 10

1. atovaquone 2. azalea antifungals (fluconazole, posazonazole and voriconazole) 3. linezolid 4. metronidazole 5. h2 receptor blockers 6. levetiracetam 7. pantoprazole 8. tacrolimus

Answer 11

1. phenytoin * reduced absorption requiring substantially higher doses * managed by escalating dose, holding feeds 2 hours before/after admin(not reliable), dilution of suspension, use of IV formulation enterally

Answer 12

improved bioavailability w. slow gastric emptying *1:1 dilution w. water and rigorous tube flushing

Answer 13

reduced bioavailability bind multi-valent cations give 2 hours before or 4 hours after antacids (calcium, magnesium)

Answer 14

amiodarone: absorption is improved with food. make sure it is administered in stomach digoxin: soluble fiber reduces digoxin absorption . reduced bioavailability

Answer 15

levothyroxine : absorption best in fasting state continuous enteral foods reduce efficacy

Answer 16

admin. with alkaline solution or as one of the powder formulations

Answer 17

must increase dose for warfarin due to protein content of the feeds monitor pt/inr closely-especially when feeds are DC'd

Answer 18

1. poor viability 2. can clog tube 3. binds phosphate

Answer 19

*rivaroxaban *apixaban *dabigatran: DO NOT CRUSH edoxaban

Answer 20

malabsorption, medications, alcohol, hemodialysis and hyperthyroidism

Answer 21

1.thiamine, riboflavin, niacin, biotin, pantothenic acid energy releasing 2. vit. b6, b12, folate: * hematopoeisis

Answer 22

fat soluble vit. A,D,E,K greater potential for toxicity

Answer 23

RDA= recommended dietary allowance AI: adequate intake EAR= estimated average requirement: average daily intake estimated t meet the requirements of 50% of healthy individuals uL=tolerable upper intake level (max amount)

Answer 24

requirements are increased with high carb consumption: deficiency in alcoholics

Answer 25

increased requirements during periods of metabolic stress. isolated deficiencies are rare

Answer 26

called Pellagra characterized by the 3 d's dermatitis diarrhea dementia treat agressively with high doses

Answer 27

levadopa and high doses >5 mg/day phenobarbital, phenytoin

Answer 28

older>50 yrs have decreased absorption macro-lyritic anemia can cause irreversible nerve damage

Answer 29

pregnant patients require supplementation to prevent neural tube defects

Answer 30

scurvy defect in collagen synthesis difficulty in healing wounds

Answer 31

ascites portal hypertension vatical bleeding spontaneous bacterial peritonitis hepatic encephallopathy Hepatorenal syndrome

Answer 32

used for dosage adjustments 1. bilirubin: Score 1: 1-2 Score 2: 2-3 score 3: >3 2.albumin: Score 1: >3.5 Score 2: 2.8-3.5 score 3: <2.8 3. Acsites: Score 1: none Score 2: mild score 3: moderate 4.PT (prothrombin time Score 1: 1-4 Score 2:4-6 score 3:>6 Grade A:<7 points Grade B: 7-9 points Grade C: 10-15 points

Answer 33

staging cirrhosis. also used for transplant considerations meld score=3.78[in serum bilirubin (mg/dL)]+11.2[ln INR] + 9.57[ln serum creatinine (mg/dL)]+6.43

Answer 34

Patho: as a result of portal hypertension. increase sinusoidal pressure->causes back up of blood flow to sphlanic vessels around gi track. body produces NO PE: full, tense, bulging abdomen abdominal paracentesis * removes fluid: therapeutic and * SAAG>/=1.1 g/dL indicates portal hen from cirrhosis * can be used to see abc in peritoneum, dx of SBP * note: paracentesis should not be avoided even if pt has low platelets or increased pt/INR

Answer 35

non pharm: * Na+ restriction *NOT FLUID RESTRICT: because circulating intravascular volume is low due to moving into extravaasculr space ``` pharm: 1)aldosterone antagonists: RAAS (counter RAAS system activation due to body sensing decreased circulating volume a)sprinolactone 50-100 mg up to 400 mg causes k+, sooooo.. paired with b)loop diuretics: to prevent hyperkalemia 40 mg RATIO: 100mg/40mg * do not give thiazide diuretics: because they worsen already hyponatremia in cirrhosis ``` what if a pt is not tolerating diuretic therapy, bp is low * HOLDING THRESHOLD IS systolic bp<90 * add midodrine (vasoconstrictor in periphery and raises bp inorder to tolerate diuresis) *large volume paracentesis (4-8L) ever 2 weeks -> can cause decreased bp even more -> increased SCr(due to organ hypoperfusion) to combat that, if removing greater than 5L, give 8g IV 25% albumin(hypertonic) for q L of fluid removed ****$$, short tpx t1/2, but could reduce mortality TIPS procedure: Transjugular intrahepatic portosystemic shunt *refractory ascites pts intolerant of large volume paracentesis *also used for refractory vatical bleeding *shunt bypasses liver providing immediate relief for the high pressure portal vein *increases ammonia-> cases increased hepatic encephalopathy

Answer 36

define: difference in pressures btw portal vein and inferior vena cava dx: SAAG >/=1.1 compliacations: * variceal bleeding - > causes 1/3 of cirrhotic death * ascites (as mentioned b4) goals: prevent vatical enlargementt and bleeding (NOT to prevent variceal development) treatment only used in confirmed varies through EGD

Answer 37

goals: prevent vatical enlargementt and bleeding (NOT to prevent variceal development) treatment only used in confirmed varies through EGD pharm: *non selective beta blockers *propanolol, nadolol, carvedilol *b1 blockade: reduce HR, reduce CO-> reduces portal pressure b2 blockade: causes sphlannic vasodilation, so blockade will vasoconstrict *propanolol: 20-40 bid *nadolol: 20-40 mg daily *carvedilol: 3.125 mg bid titrate up needs to resting HR ~60- bpm ``` holding parameters: decreaes/hold dose *systolic BP<90 or DBP<60 *HR<60 *hepatorenal syndrome (HRS) *refractory ascites *SBP ```

Answer 38

define: gastric and esophageal varies form as a result of shunting of blood away. varices: abnormally dilated vessels. as total pressure increases increases risk for rupture and bleeding big risk of variceal bleeding: SBP

Answer 39

supportive care measures * IV fluids * PRBC * hgb ~8 g/dL octeotride IV: somatostatin analog. moa: inhibits glucagon->causes vasoconstriction of sphlancnic circulation EVL: endoscopic variceal ligation (rubber banding) :squeezes off varies-> with EGD best results when octreotide IV and evl occur together SBP prophylaxis: 7 DAY CEFTRIAXONE iv *if octreotide IV+evl doesn't work and bleeding persists, consider TIPS once bleed stabilizes: *non selective BB

Answer 40

bacterial infection of the ascitic fluid caused by enteric gram _(E. Coli) Dx: * fever, malaise, increased WBC, pain/tenderness in abdomen * paracentesis: absolute polymorphonucleated leukocyte count>/=250 mm^3 * take WBC x PMN= absolute PMN cel count * +bacterial culture (the culture might come back neg., but pt are still treated

Answer 41

prophylaxis: * IV cetriaxone, (or ciprafloxacin) for 7 days * indefinitE sap ppt: a. previous hx of sbp b. ascitic protein <1.5 + other criteria * Ciprofolax 750 mg weekly (in guidelines), but more practical -> 250-500 mg daily * bactrim Double strength (DS) 5 days a week (guideline) more practical 1 tab daily ``` active: for absolute PMN>/=250 *3rd gen ceph *cephotaxime *ceftriaxone (more widely available) *cipro if true PCN allergy ``` if specific org. is identified, can streamline therapy within 48-72 hrs of starting IV abx Duration: 5 days *IV albumin 25%: 1.5g/kg on day 1 + 1g/kg on day 3 indicated for pts with Scr>1, BUN>30, OR bilirubin >4. *reduces mortality

Answer 42

# define: accumulations of toxins from declining hepatic function and portal-systemic blood flow shunting toxins: ammonia results in altered mental status *NOTE: ammonia levels don't determine severity. elevated ammonia indicated yes they have hepatic encephalopathy. don't need to keep checking ammonia levels when treating

Answer 43

1. remove precipitating factors * meds: opioids, benzos, 2. dietary protein: switch pt to dairy or vegetable protein sources because less likely to cause BBB 3. ammonia in GI tract * Lactulose- nonabsoprbale disaccharides * but bacteria ferments this, decreases colonic ph with acid production, causes bowel movement where NH34 GETS trapped in bowel. * eliminated fecally acute hepatoencephalopathy * PO lactulose 25 mL q1-2h until have atlas 2 loose/watery stools * enema : 300 mL retention enema, retin for 1 hour q 6-12 hours Prevention HE: * after active treatment: * give lactulose 15-60mLq 6-12 hours (2-3 soft BM/day) other therapies: Rifaximin (Xifaxen) *abx: reduce bacteria that produce ammonia acute dose: 40 mg po q8h maintenance: 550 mg po BID *ADD ON, NOT SUBSTITUTION. almost all trial pts used this in combo

Answer 44

sphelncnic vasodilation secondary to portal HTN, causing reduced intravascular volume, causing reduced renal perfusion * very high mortality rate * sort of last stage of cirrhosis dx: * cirhosis with ascites * Scr: >/= 0.3 mg/dL in 48hrs or >/=50% increase in baseline in last 7 days * no improvement in scrabble after 2 days of diuretic d/c + iv albumin 1g/kg/day

Answer 45

* ultimately liver transplant * iv NORPEPINEHRINE+ iv albumin 1g/kg/day response to therapy: Scr decrease to < 1.5mg/dl or return within 0.3 mg/dL of baseline over a max of 2 weeks. if after 4 days of therapy he scr remains the same, d/c therapy

Answer 46

*impact dugs that have high first pass effect ex: propanolol morphine coreg (carvedilol) increased in bioavailability decrease doses to compensate

Answer 47

decreased metabolic activity effects phase I (cyp) metabolism more often than phase II solution: use agents that undergo phase II metabolic. more than phase I when possible ex: benzos diazepam: has more cyp lorazepam: more phase II

Answer 48

heavily protein bound drugs have more unbound drug- > more tpx effect ex: phenytoin: decrease dose if needed to compensate

Answer 49

decreased renal function in the setting of increased Scr increased tpx response: increase BB permeability of opioids benzos (decrease dose to compensate)