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864 > Nutrition II > Flashcards

Nutrition II Flashcards

1
Q

Complications – PN

Mechanical (catheter-related)
– Clotting of line
– Displacement

Infectious
– Catheter-related ___
– Solution contamination
– Bacterial translocation

A

sepsis

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2
Q

Bacterial Translocation

___ -dependent passage of bacteria or endotoxins from the ___ to extra-intestinal sites

___ organisms cause systemic infections
- Pneumonia
- Central line infections
- Abscesses
- Multi-organ dysfunction syndrome (MODS)

A

time
GI tract
Enteric

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3
Q

Complications – PN (cont.)

Metabolic
- Electrolyte imbalances
- Fluid imbalance
- Hyper- and hypo ___
– Liver function abnormalities:
* Steatosis (fatty liver)
* Intrahepatic cholestasis
* Cholelithiasis

A

glycemia

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4
Q

Baseline Monitoring – PN

Baseline
- CMP, Mg, Phos, Ca
- Hepatic function panel
- ___ / ___
- PT/INR

Q4-6H
- Finger sticks for ___
* Correct elevated glucose concentrations with insulin via
infusions and/or sliding scale
- Residuals, distention, vomiting, ___

A
  • Prealbumin/CRP
  • glucose
  • aspiration
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5
Q

Ongoing Monitoring – PN

Daily
- Vital signs
- Intake/Output (stools)
- ___ (electrolytes, glucose, BUN/SCr)
- Feeding tube placement and patency
- May decrease frequency when stable

A

CMP

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6
Q

Ongoing Monitoring – PN

Twice Weekly
- Weight
- CBC
- Mg, Phos, Ca, ___ / ___
- ICU setting -> increase to ___

A
  • prealbumin/CRP
  • daily
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7
Q

Ongoing Monitoring – PN

Weekly
- Albumin, transferrin, nitrogen balance
- Liver function tests (alk phos, AST, ALT, LDH, bilirubin)
- ___
- PT/INR
- ___ ___ /Indirect Calorimetry

A

TG
Respiratory Quotient (RQ)

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8
Q

Refeeding Syndrome

  • Constellation of fluid, micronutrient,
    electrolyte, and vitamin ___
  • Occurs within first few days of feeding a ___ patient
  • Potentially life threatening
A

imbalances
starved

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9
Q

Clinical Findings of Refeeding Syndrome

  • Hypo ___ , hypo ___ , hypo ___
  • ___ distress
  • Paresthesias
  • Tetany
  • Cardiac ___
  • Hemolytic ___
A
  • hypophosphatemia, hypomagnesemia, hypokalemia
  • respiratory
  • arrhythmias
  • anemia
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10
Q

Risk Factors for Refeeding

  • Rapid feeding, excessive ___ infusion
  • Low BMI (less than __ - __ kg/m2)
  • Excessive weight loss
  • Insufficient caloric intake
  • Low levels of ___ , ___ , or ___ prior to feeding
  • Loss of subcutaneous fat or muscle mass
  • High-risk comorbidities: ___ , anorexia nervosa, ___
A
  • dextrose
  • 16-18.5
  • K, Phos, Mag
  • alcoholism, Marasmus
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11
Q

Prevention of Refeeding Syndrome

Replete ___ before initiating feeds

Initiation recommendations (Day #1):
- Limit carbohydrates (dextrose) to ___ - ___ gm
- Limit fluids to ___ mL/day
- Provide adequate amounts of ___
- Provide approximately ___% of total caloric needs
- Advance calories/dextrose by 20-33% of goal every 1-2 days as tolerated
- Give ___ 100 mg daily x5-7 days

A

electrolytes
- 100-150
- 800
- electrolytes
- 50%
- thiamine

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12
Q

Essential Fatty Acid (EFA)

Requirements

  • Estimated to be __ - __% of daily calories
  • EFAs include __ and __ acids
A

4-10%
linoleic, linolenic

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13
Q

Essential Fatty Acid Deficiency (EFAD)

Mechanism:
- Continuous infusion of hypertonic dextrose will increase circulating insulin levels
- Inhibits ___ and fatty acid mobilization

Clinical onset:
- Several weeks on a fat-free PN regimen ( __ - __ days)

Symptoms:
- Dry scaly skin, brittle hair, lack of luster

A

lipolysis
10-14

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14
Q

Prevention of EFAD

Recommended minimum requirement is to provide approximately __ % of caloric intake as lipids

Prevention:
- Provide at least 500 mL of 10% fat emulsion over at least 3-5 hours __ weekly
– OR –
- Provide at least 250 mL of 20% fat emulsion over at least 5-9 hours __ weekly

A
  • 4%
  • twice
  • twice
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15
Q

EN indications

“If the gut works, use it.”
* Oral consumption inadequate
* Oral consumption ___ :
– ___ obstruction
– Head and ___ surgery
– Dysphagia
– Trauma
– Cerebrovascular accident
– Dementia

A
  • contraindicated
  • esophageal
  • neck
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16
Q

Advantages - EN

Provides GI ___
- Decreased chance for bacterial ___
- Stimulates biliary flow through biliary tract

Avoids risks associated with IVs
- Non-invasive tube placement at the bedside
- Line ___ , pneumothorax, etc.

More ___ than PN

Bolus feeds are more physiologic than continuous

Less stringent protocol for administration

Less expensive (depending on the formula)

A
  • stimulation
  • translocation
  • infections
  • physiologic
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17
Q

EN - decreased bacterial translocation

Time-dependent passage of bacteria or
endotoxins from GI tract to extra-intestinal
sites

Enteric organisms cause systemic infections
– Pneumonia
– Central line infections
– Abscesses
– Multi-organ dysfunction syndrome (MODS)

___ infectious morbidity and mortality w/ EN

A

decreased

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18
Q

Contraindications to EN

Mechanical obstruction
- Hernia, tumors, adhesions, scar tissue, etc.

Non-mechanical obstruction – ___
- No peristalsis, decreased perfusion, post-op, etc.

Intractable vomiting
Severe malabsorption
Severe GI hemorrhage
Certain types of __
- High output, proximal small bowel

A

ileus
fistulas

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19
Q

Routes of Administration – EN

___ (NG) / Orogastric (OG)
Nasojejunal (NJ) / Orojejunal (OJ)
- Dobhoff®
- Cortrak® / Corpak®

___ ; Percutaneous endoscopic gastrostomy (PEG)
- Surgical placement

___ ; PEG/PEJ

A

Nasogastric
gastronomy
jejunostomy

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20
Q

Determining Route of Access

Risk of aspiration
- If low risk – may utilize ___
- If high risk – ___ (post-pyloric) is preferred

Tolerance
- Vomiting – use ___
- Gastric residuals – use ___

Duration of therapy
- Long term – consider ___ or ___

A
  • gastric
  • jejunal
  • jejunal
  • jejunal
  • PEG or PEJ
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21
Q

Bolus

Mimics ___

Administer > 200 mL formula over 5-10 min
- Maximum volume 300 – 400 mL

Used primarily for patients with ___
- Nursing facilities
- Ambulatory settings

Advantages
- More convenient for patients
- Requires minimal equipment (syringe)
- Less medication interactions

Disadvantages
- Cannot feed into ___
- Higher risk of ___ and intestinal side effects?

A
  • meal
  • gastrostomy
  • small bowel
  • aspiration
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22
Q

Intermittent

Administer > 200 mL formula over 20-30 minutes (gravity drip)
- __ - __ feedings per day

Advantage
- Helps __

Disadvantage
- More equipment required (requires use of reservoir bottle or bag)

A
  • 4-8
  • tolerance
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23
Q

Continuous Infusion

  • Administer continuously over 12-24 hours/day
  • Requires use of infusion pump
  • Preferred method when feeding into the ___

Advantages
- Lower risk of gastric distention and ___
- Better tolerated by the patient

Disadvantages
- Problematic for ___ administration
- Requires infusion ___

A
  • jejunum
  • medication
  • pump
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24
Q

Trickle or Trophic

___ continuous infusion at 10 – 30 mL/hr

Advantages
- Prevent mucosal ___ and bacterial __
- May shorten time on ___ and decrease mortality

Disadvantage
– Difficult to achieve sufficient ___ delivery

A
  • slow
  • atrophy, translocation
    venetilator
    calorie
25
Q

Initiation & Advancement of Tube Feeding

  • Initiate full strength at __ mL/h
  • Advance 25 mL/h q 4-6 hrs as tolerated up to goal rate
  • Check ___ q 4-6 hrs
  • May hold for > 500 mL
  • Dilution of formula has limited benefit (not recommended)
A
  • 25
  • residuals
26
Q

Cyclic

  • Administer over __ - __ hours/day
  • Often infused ___

Advantage
- increased ___ for the patient

A
  • 8-20
  • overnight
  • independence
27
Q

EN – ICU Initiation Points

Achieve > __ - __ % goal calories within
first week (if not, consider PN)
- Do not initiate if ___ unstable (concern for intestinal ___ )
- Bowel sounds or flatus not needed for
initiation
- EN promotes gut ___

A
  • 50-60
  • hemodynamically
  • ischemia
  • motility
28
Q

NPO Times

Minimize holding times
- Inadequate nutrient delivery
- May stimulate ___ development

Patients undergoing frequent surgical
procedures have ___ infections when
EN is not stopped for each procedure

A
  • ileus
  • fewer
29
Q

Immune-modulating Contents (Impact 1.5)

  • ___ : T lymphocyte function
  • ___ : Antioxidant, immune support, and nitrogen retention
  • ___ : Reduced inflammation,
    arrhythmia incidence, ARDS, and
    sepsis
  • ___: Selenium, ascorbic acid, and
    vitamin E
A
  • arginine
  • glutamine
  • omega-3 fatty acids
  • antioxidants
30
Q

Immune-modulating Formulation (Impact 1.5)

  • Target Patient Populations: Major elective surgery, ___ , ___ , head or neck cancer, mechanically ___
  • Use w/ Caution: Severe ___
  • Benefits: Reduced time on ventilator, infectious morbidity, length of hospital stay
A
  • trauma, burn, ventilated
  • sepsis
31
Q

EN Nutrient Composition

Protein
- Intact protein
* Requires complete digestion into smaller peptides
- Partially digested (peptide-based)
* ___ ; may be beneficial for pts with malabsorption, diarrhea

Fat
- Long-chain fatty acids
- ___ -chain fatty acids
* More water soluble; rapid hydrolysis, little or no
pancreatic lipase for absorption

Carbohydrates
– ___ polymers primarily used for tube feeding formulas
– Simple glucose used for oral supplements (higher in osmolality)

A
  • Elemental
  • medium-chain
  • Glucose
32
Q

Adjunctive Therapies- modular supplements

Pro-Stat
- 2 Tbsp (30 mL)
- __ g protein
- 72 kcal
- 3 g CHO

A

15 g

33
Q

Adjunctive Therapies - glutamine

  • May reduce hospital and ICU length of stay
  • Reduces mortality in ___ patients
  • No systemic effect when given by ___ route
  • Will help maintain gut integrity
  • 0.3 – 0.5 g/kg/day divided in 2 – 3 doses
  • Do not supplement if already receiving glutamine via an immune-modulating formula (i.e., ___ )
A
  • burn
  • enteral
  • Impact 1.5
34
Q

Adjunctive Therapies - Probiotics

Microorganisms conferring potential health benefits to host:
- Inhibit pathogenic bacterial growth
- Block pathogen attachment
- Eliminate toxins
- Enhance host inflammatory response

Clinical efficacy data are mixed/lacking

May increase complications (e.g., ___ )

A

diarrhea

35
Q

Vitamins and Trace Elements

  • Used for antioxidant effects and/or repletion
  • Vitamin E and vitamin C
  • Trace elements (Selenium, zinc, copper, chromium, manganese)
  • Beneficial in most ICU patients
  • Emphasis on ___ , ___ , and ___ ___
  • Consider organ dysfunction as previously discussed
A
  • burn, trauma, and mechanically ventilated
36
Q

Complications - GI

  • High gastric ___
  • ___
  • Nausea/vomiting or ___ motility
  • Consider prokinetic medications
  • Metoclopramide, erythromycin may be given

Abdominal distention
- Diarrhea
- Check meds, formula

Constipation
– Check meds

A
  • residuals
  • aspiration
  • decreasd
37
Q

High Gastric Residuals

Lower cut offs do not protect patient from complications

Residuals
- < ___ mL: do not hold unless intolerance signs
- 200 to 500 mL: implement risk reduction measures to avoid ___
- Cutoffs may vary by site

A
  • 500
  • aspiration
38
Q

Aspiration Risk Reduction

  • Elevate ___ 30-45 degrees
  • Administer as ___ infusion
  • Change to post-pyloric delivery
  • Consider ___ drugs or narcotic
    antagonists
A
  • HOB
  • continuous
  • prokinetic
39
Q

Decreased Motility: Consider Prokinetic Agents

  • ___ 10 mg IV/PO/feeding tube QID
  • ___ base 250 – 500 mg PO/feeding tube TID or 3 mg/kg IV Q8hr
  • ___ 8 mg via feeding tube QID
  • ___ weight-based dosing IV x1
A
  • metoclopramide
  • erythromycin
  • naloxone
  • methylnaltrexone
40
Q

Diarrhea

Formula
- Change to soluble ___ -containing or small ___ formulations
- Suspect Clostridium difficile colitis
- Consider other infectious etiologies

Evaluate medications:
- ____ medications
– Liquid formulations with sorbitol
– ___ regimen
– ___ ___ antibiotics

A
  • fiber, peptide
  • hyperosmolar
  • bowel
  • broad sprectrum
41
Q

Hyperosmolar Medications

≥ ___ mOsm/kg

A

3000

42
Q

Medications with Sorbitol

A
43
Q

Complications - Metabolic

Hyper- or hypoglycemia
- Check meds, ___ regimen
- Stress
- Infection

Overhydration; dehydration
- Monitor fluid status

Electrolyte imbalance
- ___ is most common

A
  • insulin
  • hyponatremia
44
Q

Glycemic Control in ICU

Goal blood glucose (BG)
- ≤ ___ mg/dL

NICE-SUGAR Study
- ____ mortality with tight glycemic control
- Higher rate of hypoglycemia with tight control

A
  • 180
  • increased
45
Q

Complications - Mechanical

  • ___ of feeding tube
  • Tube ___ (abdominal X-ray “KUB”)

Rhinitis
- Reposition daily
- Use smaller bore tube
- Change from NG to ___

Sinusitis

A
  • clogging
  • malposition
  • OG
46
Q

Complications - Medication Related

  • ___ feeding tubes
  • Drug-tube feed ___
A
  • clogged
  • interactions
47
Q

General Guidelines for Medication

Delivery via Enteral Feeding Tubes

  • ___ medications are preferred whenever possible.
  • If using oral dosage forms, crush the tablet to a fine powder (or empty capsule contents) and mix in water.
  • Do not crush ___ -released or ___ coated formulations!!
  • Administer each medication separately.
  • Ensure adequate flushing with water between each medication.
  • Dilute ___ medications or those irritating to the gastric mucosa in at least 30 mL of water before administering
A
  • liquid
  • sustained, enteric
  • hypertonic
48
Q

Liquid Medications Preferred

Avoid ___ formulations due to risk of clogging tube:
– Syrups
– Mineral oil
– Granules

Can sometimes crush tablets or open
capsules
- Dilute in __ - __ mL of sterile water

A

viscous
15-30

49
Q

Unclogging the Tube

  • 1 ___ tab + 1 ___ cap + 10 mL warm sterile water
  • place slurry into feeding tube
  • clamp tube for 15-30 min
  • flush when complete
A
  • sodium bicarb
  • pancreatic enzyme
50
Q

Drug/Tube Feed Interactions

antibiotics (4)
anti-retrovirals (3)
other (4)

hold tube feed
- wait ___ hour

Give med
- wait ___ hours

Resume feed

A
  • 1
  • 2
51
Q

Monitoring – Gastrointestinal

  • Gastric ___
  • Emesis
  • Check q __ - __ hrs
  • ___ daily (frequency, volume)
  • Bloating/distention
  • Bronchial/tracheal aspirate
A
  • residuals
  • 4-6
  • stools
52
Q

Monitoring – Metabolic

  • I/Os; bowel movements
  • ___ : 2-3 times per week
  • Serum electrolytes, glucose, BUN/SCr [CMP]: ___ until stable -> twice weekly -> weekly
  • Mg, Phos, Ca, triglycerides, LFTs: ___
  • Albumin, prealbumin/CRP, nitrogen balance: ___
A
  • weight
  • daily
  • weekly
  • weekly
53
Q

Monitoring – Mechanical

  • Feeding tube ___
  • Feeding tube __
A
  • placement
  • patency
54
Q

Special Considerations and Disease States

Acute Renal Failure
- Use a normal EN formula unless electrolyte profile dictates otherwise

Hemodialysis/Continuous Renal Replacement Therapy
- CRRT: ___ protein requirement to prevent nitrogen deficit (max 2.5 g/kg/day)
- HD: 0.8-1.2 g/kg/day protein
- Loss of ___ micronutrients ( ___ , ___ , ___ )
– ___ accumulates due to it being cleared renally (falsely high)

A
  • increased
  • water-soluble, selenium, zinc, thiamine
  • prealbumin
  • falsely
55
Q

Special Considerations and Disease States

Hepatic Failure
- Traditional nutritional assessment tools are ___ due to presence of ascites, intravascular volume depletion, edema, portal hypertension, and hypo-albuminemia
- Standard enteral formulations for most liver disease patients
- ___ ___ ___ ___ formulations (BCAA) for encephalopathic patients refractory to other treatments

A
  • inaccurate
  • Branched chain amino acid
56
Q

Special Considerations and Disease States

Pulmonary Failure

Fluid- ___ , calorically dense formulations
- ___ - ___ kcal/mL
- Monitor ___ closely
- Component of adenosine triphosphate (ATP) and 2,3-disphosphoglycerate (2,3-DPG):
essential for normal ___ function

A
  • restriction
  • 1.5-2.0
  • phosphate
  • diaphragmatic
57
Q

Special Considerations and Disease States

Acute Pancreatitis

Metabolic changes
– ↑ protein ___
- inability of exogenous glucose to inhibit ___
– ↑ energy expenditure
– ↑ ___ resistance
– ↑ dependence on ___ oxidation for energy

EN vs. PN
– Recovery and resumption of oral intake often occurs within 3-7 days, not requiring __

A
  • catabolism
  • gluconeogenesis
  • insuline
  • fatty acid
  • PN
58
Q

Special Considerations and Disease States

Acute Pancreatitis (cont.)

Protein requirements
- ___ - ___ g/kg/day
- Consider adding ___

Glucose
- Safe, same maximum as other patients

Lipid infusions
- Safe if ___ levels are within normal limits -> monitor closely

Parenteral nutrition does NOT affect ___ secretion and function

A
  • 1.2-1.5
  • glutamine
  • TG
  • pancreatic
59
Q

Special Considerations and Disease States

Burn

Metabolic changes
– ↑ basal metabolic rate and ___ loss
- Glycolysis, proteolysis, lipolysis

Nutritional requirements
- High in protein ( __ - __ g/kg/day) and calories
- ___ feeding with EN

Supplements
- Adult multivitamin
- If TBSA >10%: Ascorbic acid, Zinc, Vitamin E, Selenium
- If TBSA >20%: oxandrolone/growth hormones
- Vitamin D (if deficient); Vitamin A (if on corticosteroids)

A
  • nitrogen
  • 2-2.5
  • early

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