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CNSC > Parenteral Nutrition > Flashcards

Parenteral Nutrition Flashcards

1
Q

mOsm/g of Dex
mOsm/g of AA
mOsm/g of electrolytes

A

Dex: 5
AA: 10
Electrolytes: 1 per mEq

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2
Q

PPN Dex and AA g amounts

A

Dex: 150-300
AA: 50-100

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3
Q

PPN Requirements (4)

A

At least 5 days
Up to 2 weeks
Good peripheral access
Able to tolerate large volume (2.5-3L)

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4
Q

3 downsides PPN

A

May cause phlebitis
Hyperosmolar
May require frequent IV rotation sites

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5
Q

Midline is recommended if PPN needed >6 days d/t

A

Length

Decreased probably of dislodging

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6
Q

Contradictions to PPN (5)

A 
Significant malnutrition
Severe metabolic stress
Large fluid/electrolyte needs
Fluid restriction
Renal/liver compromise
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7
Q

Hypocaloric PN may improve ______

A

N balance

But little data >30 days

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8
Q

Permissive underfeeding

A

80% of needs

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9
Q

Recommendations for PN in post-op wound healing

A

Start within 5-10 days if unable PO/EN

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10
Q 
PN with caution when 
BUN >
Glc >
Osomalrity >
Na >
K <
Hcl > or <
Phos
A 
BUN > 100
Glc > 300
Osmolarity > 350
Na > 150
K < 3
Hcl > 115 or < 85
Phos < 2

Need to be hemodynamically stable

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11
Q

When to start TPN

A

Well-nourished not at risk (even critically ill) - after 7 days
Critically ill at high risk - consider earlier

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12
Q

Critically Ill labs monitor daily vs weekly

A 
Daily:
Electrolytes + Cl, BUN, Cr, CO2
Glucose
Weight
I/O

Weekly:
CBC
Clotting labs
TAGs, Liver labs

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13
Q

Stable monitor labs weekly vs 1-2x/week vs 2-3x/week

A

Weekly:
CBC, Clotting labs, TAG

1-2x/week:
Electrolytes

2-3x/week
Weight

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14
Q

Why no bowel rest in pancreatitis?

A

Important to maintain GI integrity to prevent further complications
Add glutamine if NPO?

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15
Q

Critical Illness: PN if all 3 factors

A
  1. Malnourished at baseline
  2. Unable to do EN for >7-10 days
  3. Hemodynamically stable

Also indicated for paralytic ileus, acute GI bleeding, or complete bowel obstruction

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16
Q

Home PN use caution with (6)

A 
DM
CHF
Pulmonary disorder
Severe malnutrition
Hyperemesis gravidarum 
Electrolyte disorders
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17
Q

Dextrose concentration >10% reserved for central administration d/t propensity to cause

A

Thrombophlebitis in peripheral veins

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18
Q

Glycerol/Glycerin kcal/kg and use

A

4.3 kcal/kg, Peripheral

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19
Q

Protein generally assumed to be __% Nitrogen

A

16%

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20
Q

Modified AA formula

A

High in BCAA, low in aromatic AA
Limited indication for use
Maybe hepatic encephalopathy (high aromatic may alter mental status)
Theory BCAA may also benefit stress/trauma

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21
Q

SMOF lipids composition, good for, associated with

A

Soy Mct Olive Fish
Oleic acid and decreased omega 6
Good for: Can’t tolerate soy, carnitine deficiency
Associated with decreased liver changes and antioxidant preservation

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22
Q

ILE contains ___ phospholipid emulsifier

A

Egg

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23
Q

ILE infusion goal

A

< or equal to 0.11 g/kg/h

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24
Q

Fat overload syndrome

A

Headache, seizure, fever, jaundice, hepatosplenomegaly, abd pain, shock

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25
Q

Goal EER for lipids and g/kg/d

A

Less than or equal to 60%
2.5 g/kg/d
Can limit to 1 g/kg/d d/t high omega 6

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26
Q

Preferred form of magnesium and calcium in PN

A

Mag sulfate and Ca gluconate

Less likely to provide chemical incompatibility

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27
Q

Avoid Calcium _____ in PN

A

Ca Chloride

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28
Q

PN electrolyte requirements

A 
Na: 1-2 mEq/kg
K: 1-2 mEq/kg
Ca: 10-15 mEq/kg
Mag: 8-20 mEq/kg
Phos: 20-40 mmmol
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29
Q

TNA advantages (6)

A

More efficient, cost effective, convenient
Less manipulation and risk contamination
Slower bacterial growth

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30
Q

TNA Disadvantages (8)

A

Need pore size filter 1.2 um
Less stable, less compatible for Ca Glu and Na/K Phos, less daily catheter lifespan
More prone to separation , increased risk of catheter occlusion
Low pH of AA may destabilize lipid
Opacity (difficult to see)

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31
Q

If using true peripheral vein, _____ and ___ should be low

A

Cal and K concentration

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32
Q

In TNA, desired concentration of dex and AA to prevent destabilization

A

Dex >10%
AA >4%
ILE >2%

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33
Q

ILE hang time for 2-in-1

A

12 hours

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34
Q

Benefits of ACDs vs Disadvantages

A

Easily tailored to meet needs
More efficient
Decreased risk touch contamination
Shelf stable

Not appropriate for all pts
Electrolytes, AA and Dex standardized

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35
Q

Stability and examples

A

Degradation of nutrient that changes characteristics; Ability to maintain integrity/activity

Ex: Milliard reaction between IV dex and lysine -> brown discoloration
Ex: Light degradation

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36
Q

Factors effect ILE emulsion stability (2)

A

Alters electrical charge between fat droplets:
pH <5
Addition of electrolyte salts

Low pH also degrades egg emulsifiers

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37
Q

Physical sign of emulsion destabilization

A

Yellow oil streaks or amber layer on top

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38
Q

What increase CaPhos solubility? Downside?

A

Cysteine HCl

Lowers pH

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39
Q

Factors increase Ca/Phos precipitation (4)

A

High Ca amount
High Phos amount (including Phos in AA)
CaCl
High temperature

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40
Q

Factors increase Ca/Phos solubility (3)

A

High amount AA
High amount dextrose
Low pH

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41
Q

Increased risk aluminum toxicity (4)

A

Renal dysfunction
Iron deficiency
Pediatric
Long term PN

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42
Q

Size filter removes precipitates

A

5 um

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43
Q

Use ____ size filter for AA/dex 2-in-1

A

0.22 um

Retain microorganisms, but they are also effective in trapping precipitates found in dextrose–amino acid PN

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44
Q

Use ___ for TNA and ILE added to 2-in-1 via Y connector

A

1.2 um

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45
Q

Time for new in line filter change

A

24 hours for TNA and 2-in-1

10-12 hours for ILE only

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46
Q

ILE in TNA can hang 24 hours because

A

Lower pH of TNA inhibits bacterial growth

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47
Q

If micron filter occludes…

A

Don’t remove

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48
Q

Usual dextrose administration rate and maximum rate

A

3 mg/kg/min

Max liver can oxidize: 5 mg/kg/min

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49
Q

Fluid restriction PN, calculate in order:

A
  1. AA 2. Fat 3. Dex

Fat first to maximize kcal with available fluid

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50
Q

Preferred access for PN/Central access

A

SVC - main venous return to heart

Rate of blood flow rapidly dilutes

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51
Q

CVC Cuff

A

Attaches to CVC and acts as anchor and mechanical barrier

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52
Q

Dacron cuff

A

Subcutaneous tissue

Tunneled cath

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53
Q

Collagen cuff

A

Attach to cath at insertion, ions exert antimicrobial activity

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54
Q

Groshong cath

A

VAD with pressure sensitive 3 way valve - eliminate the need for daily heparin flush and cath clamping before disconnecting

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55
Q

PVC catheter increases risk for ___ and ____

A

Thrombus and phlebitis

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56
Q

Peripheral vs CVC tip placement

A

Peripheral: Just outside SVS or IVC (inferior vena cava)
CVC: distal SVS, IVC or R atrium

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57
Q

Peripheral access

A

Peripheral : Hand/lower arm

Midline : Above elbow/antecubital fossa in cephalic or basilic vein

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58
Q

Must immediately remove peripheral catheter if

A

Infiltrate or complication is suspected

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59
Q

Midline and peripheral lines not for ___ or ___

A

osmolarity >900 or dex >10%

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60
Q

Midline only for ___ weeks and not for ___

A

2-4 weeks, not for central access

61
Q

Nontunneled PICC: time, complication risk, downside

A

Weeks to months
Low risk
Limited ability for self care/ADL

Most common acute care short term

62
Q

Percutaneous central catheter (CVC or PICC) nontunneled: location, time, infection risk, downside

A

Jug, subclavian, femoral
7-14 days
High risk infection
Not for home care

63
Q

Jugular (cuff or non/tunneled or not): Benefit, Downside

A

Can preserve subclavian for HD pts

Can easily dislodge

64
Q

Tunneled, Cuffed catheter: Site, time, benefits

A

Jugular or subclavian
Long term
Easy self care, coverable, Limited risk bacteria

65
Q

TIVAD: Site, Benefits, Downside

A

Peripheral, jugular, subclavian
Long term
More cosmetic, only need care when accessed
Expensive

66
Q

Translumbar/hepatic/collateral

A

Only when all others cant

67
Q

Phlebitis symptoms

A

Pain, ethythema/redness, tender, palpable cord

68
Q

Dwell time temporary cath

A

5-7 days

69
Q

Guidewire exchange can replace malfunctioning catheter if ___

A

No infection

However higher rate of infection if do exchange over guidewire

70
Q

Midline can ____ risk infection and risk for phlebitis d/t ____

A

Decrease

Less changing

71
Q

What to do with dislodged PICC

A

Do not advance

Can exchange over guidewire if no infection

72
Q

Contraindications to new CVAD

A

Sudden deterioration
New unexplained fever
WBC <1000/mL
If platelet count <50000, give platelets within 2 hours

73
Q

Immediate complications of CVAD placement; What reduces risk?

A

Pneumothorax, air embolus, arterial puncture, arrythmia (if too far into atrium)
Cutdown approach

74
Q

Clean access sites with (3)

A

CHG
70% alcohol
10% povidone iodine

Dry before dressing with sterile gauze or transparent dressing

75
Q

Routine use of antibiotic ointment not recommended because

A

Changes normal bacteria, increase risk resistant bacteria

76
Q

Hub

A

End of VAD connects to med tube/cap

77
Q

Access VAD for ____ prior to each infusion and ____ after

Why

A

Blood return; flush with NS after
Ensures patency
Decrease risk precipitation/occlusion

78
Q

Access VAD for ____ prior to each infusion and ____ after

Why

A

Blood return; flush with NS after
Ensures patency
Decrease risk precipitation/occlusion

79
Q

How to flush VAD

A

Use single use of locking solution
Use 10 mL syringe
Never forcibly flush

80
Q

What is locking

A

Instilling antiseptic solution following routine flush
Usually dwell
Helps prevent infection an clot formation

81
Q

Ethanol lock solution: Properties, Treats, what catheter

A

Bacterial/fungicidal properties
Treat CRBSI
Only use silicone catheters

82
Q

Signs and sources CRBSI

A

WBC >10500, fever, chills, tachycardia, N/V, hypotension
Tender, swelling, redness, exudate

Skin, hands/devices, seeding, infusate

83
Q

Remove catheter for which infections

A

S aureus and fungus

84
Q

Noninfectious complications (6)

A 
PE 
Air embolus
Cardiac tamponade
Cath migration
Nerve injury
Occlusion
85
Q

Primary type of catheter dysfunction

A

Thrombotic occlusion

86
Q

Catheter patency

A

Ability infuse via resistance and ability aspirate blood

87
Q

Volume of flush solution should be

A

Twice volume of catheter

88
Q

Intraluminal occlusion: Sign, Type

A

Resistance both infuse and aspirate

Drug/lipid precipitate

89
Q

How to clear lipid occlusion

A

70% ethyl alcohol

90
Q

How to clear Ca/Phos precipitate

A

0.1 HCl

91
Q

How to clear med occlusion

A

Na bicarb

92
Q

Fibrin Sheath - distal cath tip: what is, Sign, how to clear

A

Reaction to injury
Inability to aspirate
Thrombolytic
Endovascular cath stripping

93
Q

Vessel/pericath thrombosis: Sign, how to clear

A

Resistance both infuse and aspirate
Thrombolytic agent
Endovascular stenting

94
Q

Mechanical occlusion: Sign, Cause, How to fix

A

Resistance both infuse and aspirate
External clamp, cath kink, occluded port needle, constricting suture

Rectify closed clamp, tight suture, or cath malposition

95
Q

Symptoms venous thrombus/vascular obstruction

A 
Neck vein distention 
Edema
Tingling/pain
Tight throat
Venous chest pattern
96
Q

Thrombolytic clear CVAD occlusion

A

Alteplase

97
Q

What to do for exit site infection

A

Only remove is systemic treatment fails or pt is septic

98
Q

Disease states at increased risk for metabolic bone disease (4)

A

Crohns, cancer (altered Ca and Vit D, chemo), SBS (ca wasting), hyperthryroidism

99
Q

Cholestasis indicated by

A

Bilirubin >2 mg/dL

100
Q

How is Manganese excreted

A

Bile

101
Q

Reduce risk of catheter-related infection? (3)

A

Max barrier technique
Adequate training
Clean insertion site with 2% chlorohexidine prep

102
Q

If suspect occlusion, (5)

A
  1. Obtain s/s of cath malfunction
  2. Check function and patency
  3. Check for mech obstruction (clamp/kink/sutures tight/needle if there) and postural changes
  4. Assess pt flushing/infusing/aspirating techniques
  5. Assess site
103
Q

Max PN macro components recommended

A

30-40 mL/kg/d fluid
7 g/kg/d CHO
2.5 g/kg/d fat
2 g/kg/d protein

104
Q

Malassezia furfur and at risk (2)

A

Yeast, superficial infection of skin

Most often premies and those with ILE

105
Q

Thrombosis symptoms

A

Inflammation, edema, pain, dilated vein

106
Q

Long term PN monitoring (week, month, 3-6 mo, 6 mo)

A

Weekly then decrease when stable: BMP/Mag/Phos
Monthly then decrease when stable: CBC, Liver fxn INR
3-6 months: Iron, Vitamin D
6 month: Zn, Cu, Selenium, Mn

107
Q

Excess CHO complications

A

Hepatic steatosis

Increased CO2 production

108
Q

Initiate PN at

A

1/2 needs
150-200 g dextrose
1st 24 hours

109
Q

Add insulin to PN initial

A

0.05-0.1 units/g dex

110
Q

Insulin is ___ effective in chromium deficiency

A

Less

111
Q

Prevent EFAD

A

1-2% linoleic
0.5% alpha linolenic
or 250 mL 20% (or 500 mL 10%) 2x week

112
Q

How fast can EFAD occur in fat-free PN for adults

A

1-3 weeks

113
Q

OK to hold ILE in critically for 1st week d/t

A

Soy based ILE may be immunosuppressive

114
Q

Hyperlipidemia may cause ()

A

Decreased immune response, altered hemodynamics, increased risk pancreatitis

ILE - <30% or over 8-10 hours

115
Q

Use ILE in pancreatitis

A

Safe if TAGS <400

116
Q

Causes azotemia

A

Dehydration, excess protein, inadequate nonprotein energy

Hepatic/renal insuffiency increased risk d/t decreased ability to eliminate urea

117
Q

Causes azotemia

A

Dehydration, excess protein, inadequate nonprotein energy

Hepatic/renal insuffiency increased risk d/t decreased ability to eliminate urea

118
Q

Thiamine/Folic acid supplementation in PN

A

50-100 mg thiamin and 1 mg folic acid for 5-7 days

119
Q

Be careful of vitamin A in

A

Liver and renal failure

120
Q

HD patients may need more ____ d/t losses from HD

A

Water soluble vitamins

121
Q

Ration MVI in shortage

A

50% or give 3x/week

If not available, give vitamin C, thiamin, folic acid, pyridoxine

122
Q

Trace elements concern for toxicity in hepatobiliary disease

A

Manganese and Copper

123
Q

When is refeeding most concern

A

2-5 days

Increased demand for Phos for ATP and uptake with insulin

124
Q

Steatosis in PN

A

Fat accumulation d/t excess energy stimulating insulin which promotes lipogenesis and inhibits FA oxidation
Mostly adults
Can happen within 2 weeks

125
Q

Cholestasis in PN (PNAC) cause

A

Impaired bile secretion or obstruction
AA play a role
Mostly children
Bili > 2 mg/dL

126
Q

Gallbladder stasis in PN

A

Impaired bile flow/contractility d/t lack of Gi stimulation leading to gallstones/sludge

127
Q

Little to no fat can also cause ____ d/t excess CHO and EFAD

A

Steatosis

128
Q

Carnitine deficiency is associated with developing and concern in which population

A

steatosis, encephalopathy
Infants, renal failure

Supplementing may help mobilize fat stores and prevent it in neonates

129
Q

Ursodiol is and treats

A

Form of bile acid that treats cholestasis

130
Q

Osteomalacia

A

Softening of bones d/t vitamin D deficiency

131
Q

Risks for bone loss (12)

A 
Cushing disease, hyperthyroid, amenorrhea
Crohns, SBS, Malabsorption, Roux en Y
Cancer
Bed rest, Spinal cord injury
Alcohol abuse
Anorexia
132
Q

Meds increase risk for bone loss (7)

A

Corticosteroids, Heparin, Coumadin, Levothyroxine, Phenytoin, Phenobarbital, Methotrexate

133
Q

Increase Ca loss in long term PN d/t (4)

A

Inadequate Phos
High protein
Chronic metabolic acidosis
Cyclic PN

134
Q

___ (2) can suppress PTH

A

Mag deficiency and excess vitamin D

135
Q

Copper deficiency can cause

A

Osteoporosis

136
Q

Prevent/treat osteoporosis in PN (8)

A 
Avoid high protein/sodium
Supp Ca and Phos
Treat acidosis
Adequate Mag and Copper
Minimize almuinum
Avoid heparin
Avoid smoking
Limit alcohol/caffeine
137
Q

Which medication is incompatible with PN

A

Octreotide

138
Q

What cause a high risk for PN and medication precipitate?

A

pH of each differ significantly

PN pH 5.0-6.5

139
Q

What to do for pinch off syndrome

A

Remove it

140
Q

Amount of divalent cations that compromise TNA stability

A

> 20 mEq

141
Q

Tunneled Cath examples and purpose

A

Hickman, Groshong, Powerline, Broviac

Reduced risk infection and removal

142
Q

Creaming TPN

A

Translucent band surface emulsion

Lipid particles destabilized but not safety concern usually

143
Q

Specific TPN Medicare coverage (3)

A

Calories outside 20-35 range
Protein outside 0.8-1.5 range
Lipid >1500 g month

144
Q

Mural thrombus

A

Clot or buildup on vessel

145
Q

The most common route of infection for a tunneled central venous catheter (CVC) is

A

contamination of the catheter hub

146
Q

Chronic metabolic acidosis increases risk for

A

Ca loss

147
Q

Tx CRBSI

A

catheter salvage with 70% ethanol lock + systemic antibiotic therapy

148
Q

High nutrition risk NRS and NUTRIC score

A

NRS 2002 ≥5 or

NUTRIC score ≥5

149
Q

Free Water Deficit =

A

TBW × [1 – (140/Serum Sodium)]

CNSC (7 decks)

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