MNT for Neurological Disorders (part 3) Flashcards
A ___ ____ ____ is caused by a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain
Traumatic brain injury
What groups of people are at the highest risk for traumatic brain injury?
-Infants/children: 0-4 years
-Elderly individuals
-Teenagers: 15-19 years
-Military personnel
-People who experience homelessness
-People who are in correctional and intentional facilities
-Survivors of intimate partner violence
The ____ ____ ____ evaluates the level of consciousness by response to verbal and painful stimuli
Glasgow Coma Scale (GCS)
A GCS score of ___-___ indicates a mild TBI
13-15
A GSC score of ___-___ indicates moderate TBI
9-12
A GCS of ___-___ indicates severe TBI
3-8
____ posture results from damage to one or both corticospinal tracts; in this posture, arms are adducted and flexed, with the wrists and fingers flexed on the chest; the legs are stiffly extended and internally rotated with plantar flexion of the feet
Decorticate
_____ posture results from damage to the upper brain stem; in this posture, arms are abducted and extended, with the wrists pronated and the fingers flexed; the legs are stiffly extended, with plantar flexion of the feet
Decerebrate
What are two ways to classify TBI?
-Open head injury (penetrating trauma) vs closed head injury (blunt trauma)
-Primary vs secondary
____ and ____ are types of bruises
Contusions and hematomas
What are examples of types of hematomas?
-Epidural hematoma
-Subdural hematoma
-Intracerebral hematoma
Contusions and hematomas are ____ ____ ____
Observable brain lesions
Damage caused by contusions and hematomas results from…
-Compression against the skull at the point of impact
-Rebound effect (damage to front and back of the brain due to movement of head)
____ are the most common type of TBI
Concussions
Concussions are caused by a ____ or ____ to the head or a hit to the body causing the head and brain to move rapidly back and forth
Blow or jolt
Concussions create ____ changes in the brain, sometimes stretching and damaging brain cells
Chemical
Concussions may cause a brief loss of consciousness for less than ___ hours
6
A ____ ____ ____ is an injury to neuronal axons caused by stretching and shearing forces
Diffuse axonal injury
A diffuse axonal injury results from…
-Acceleration/deceleration
-Rotational injuries
With diffuse axonal injury, ___ ___ may be torn
Nerve fibers
Diffuse axonal injuries can range from ____ to ____ to ___
Mild to moderate to severe
With diffuse axonal injury, loss of consciousness usually lasts for ___ ___ or more
6 hours
Diffuse axonal injury can result in severe ___ and ____ deficits
Cognitive and affective
What are some manifestations and complications of TBI?
-Metabolic response to stress
-Loss of consciousness
-Altered mental status
-Altered memory, attention, and mood
-Paresis
-Seizures
-Increased intracranial pressure
-Dysphagia
-Visual and hearing impairment
-Aphasia
-Headache
-Dizziness
-Hyperglycemia
-Fluid and electrolyte imbalances
-GI complications
____ ____ ____ is the hypermetabolic, catabolic response to acute injury
Metabolic stress response
Tissue injury stimulates the release of…
-Glucagon
-Cortisol
-Catecholamines
-Cytokines
-Aldosterone and antidiuretic hormone
The net effect of the metabolic stress response is greater availability of substrates for metabolically active tissue via increased glycogenolysis and gluconeogenesis, leading to…
-Muscle catabolism
-Lipolysis
-Fluid and sodium retention
Increased intracranial pressure is caused by…
-Hemorrhage
-Cerebral edema
Increased intracranial pressure causes secondary brain injury by…
-Compression of tissue
-Herniation
What types of medications may be used to manage increased intracranial pressure?
-Diuretics
-Pentobarbital (powerful sedative)
Pentobarbital reduces ____ ____
Cerebral metabolism
Side effects of increased intracranial pressure:
-Decreased GI motility
-Decreased gastric emptying
Management of increased intracranial pressure include…
-Drainage of cerebrospinal fluid
-Positioning to increase venous drainage: elevate HOB to 30 degrees (reverse Trendelenburg position)
-Fluid restriction
Hyperglycemia may be caused by…
-Metabolic stress
-Infection
-Medication
Syndrome of inappropriate antidiuretic hormone causes…
-Fluid retention
-Hyponatremia
____ ____ caused decreased secretion of antidiuretic hormone (opposite of SIADH)
Diabetes Insipidus
Diabetes Insipidus causes…
-Increased urinary output
-Dehydration
What are two possible GI complications of TBI?
-Stress Ulcers (AKA Cushing ulcer)
-Delayed gastric emptying
Delayed gastric emptying may be due to…
-Damage to vagus nerve
-Meds: pentobarbital, morphine
People with TBI are at a high risk for ____
Malnutrition
The goals of MNT for people with TBI:
-Lessen catabolism
-Prevent malnutrition
-Provide nutrition via the best route as soon as possible
It is difficult to accurately assess someone’s nutrition status in the ____ ____
Acute period
Why would it be difficult to assess nutrition status in the acute period?
-May be unable to obtain a diet history
-Fluid retention may distort anthropometrics
What should be included in the nutrition assessment for someone with a TBI?
-Diagnosis/current medical status
-Medical history
-Food-drug interactions
-Psychosocial history
-Nutrition/diet history
-Anthropometrics
-Nutrition-focused physical exam
-Biochemical data
-GI function
-Intake and output records
Food drug interactions for Mannitol (loop diuretic used for cerebral edema):
-Monitor for hypokalemia
-Monitor for hypomagnesemia
-Monitor for hypovolemia
-Monitor for hyperglycemia
Food-drug interactions for Barbituates:
-May reduce energy requirements
Food-drug interactions for Propofol (10% lipid emulsion):
-Provides 1.1 kcal/mL
Food-drug interactions with Phenytoin (Dilantin):
-Decreased absorption if on continuous enteral nutrition
-Hold EN for 1-2 hours before and after drug adminstration
Energy needs vary widely from ____-____% of predicated REE
100-200%
On average, energy requirements are ___-___% of estimated REE
120-160%
What factors increase energy needs in someone with TBI?
-Infections
-Posturing
-Seizures
What factors decrease energy needs in someone with TBI?
-Sedatives
-Barbituates
The highest energy needs are seen in patients with a Glasgow Coma Scale score of ___-___ due to posturing
4-5
The lowest energy needs are seen in patients who…
-Have brain death
-Are on barbituates or musculoskeletal blockers
If someone is in a Pentobarbital coma, their energy needs are ___-___% of their REE
100-120%
It is best to use ____ _____ to determine energy requirements
Indirect calorimetry
The ideal ____ to estimate energy expenditure for TBI patients has not been established
Equation
What calculations are often used to determine someone’s energy needs with TBI?
-140% of REE
-25-30 kcal/kg
(must individualize based on clinical course)
We should ensure someone is getting adequate ___-___ ____ to spare protein
Non-protein calories
We also need to be careful to avoid ____ patients with TBI
Overfeeding
People with TBI have high protein needs due to…
-Catabolism/increased urinary nitrogen excretion
-Healing
Protein requirements for someone with TBI:
1.5-2.5 g/kg
What are some things to consider when determining fluid needs for someone with TBI?
-Increased intracranial pressure
-Additional sources of fluid
-Sources of fluid loss
-Fever
-Constipation
If someone has syndrome of inappropriate antidiuretic hormone, they would need a fluid ____
Restriction
If someone has Diabetes Insipidus, they may need fluid ____
Replacement
Exact requirements for micronutrients in someone with a TBI are unknown, but we should provide at least ____% of DRI
100
What are some things to consider when determining micronutrient requirements for someone with TBI?
-Wound healing
-Food-drug interactions
-Losses
We should provide nutrition in appropriate form as soon as _____ _____
Hemodynamically stable
We should also avoid prolonged _____ status
NPO
For those on enteral nutrition, initiate early enteral nutrition within ____-____ hours post-injury
24-48
Many patients require enteral nutrition support due to…
-Decreased level of consciousness
-Intubation
-Severe dysphagia or aspiration risk
What are some things to consider when initiating enteral nutrition?
-Short vs long-term feeding
-Tube location
What are some risks of enteral nutrition?
-Delayed gastric emptying
-High risk for aspiration
___-___ feeding may be best for those with TBI
Post-pyloric
If someone is critically ill, they should have ____ ____ of enteral nutrition
Continuous adminstration
People with TBI should also receive a ____ ____ tube feed formula
High protein
What may indicate a concentrated tube feed formula?
-Syndrome of inappropriate antidiuretic hormone
-Increased intracranial pressure
We should consider the use of ___-___ formulas that contain omega-3 fatty acids and extra arginine for patients with TBI
Immune-modulating
Patients who are ____ are not suitable for oral intake
Lethargic
A ____ evaluation should be done prior to initiation of oral diet
Swallowing
When transitioning from tube feeding to oral feeding, consider ___ ___ ___
Cyclic tube feeding
Once someone has transitioned to oral intake, we should monitor for…
-Dysphagia
-Ability to feed self
-GI complaints
-Adequacy of intake
Considerations for oral intake:
-Nutrient-dense meals and supplements
-Small, frequent meals
-May need texture alterations and thickened liquids
