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CNSC Exam > PN Overview > Flashcards

PN Overview Flashcards

1
Q

for a pregnant patient with hyperemesis gravidarium presenting with fluid/electrolyte imbalances, ketonuria and dehydration, what would be the first line of therapy

A

IV fluid, additional B vitamins such as B12 and B6 as well as thiamine

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2
Q

for a patient with severe hyperemesis gravidarum with little to no po intake, what should be supplemented to prevent Wernicke’s encephalopathy and neural tube defects

A

Thiamine

Folic Acid

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3
Q

what is the second line of therapy for hyperemesis gravidarum

A

hold oral intake, start antiemetic

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4
Q

if a patient with hyperemesis gravidarum is unable to take oral feedings after 24-48 hours of supportive therapy (IV fluid, anti emetic, vitamins) what should be started as far as nutrition support

A

enteral feedings

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5
Q

when should PN be considered for hyperemesis gravidarum

A

if a patient fails EN due to exacerbated nausea, vomiting, diarrhea, significant gastric residuals or tube displacement, and clinically significant weight loss >5% of body weight

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6
Q

Rapid IV infusion of potassium phosphate can cause

A

thrombophlebitis

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7
Q

infusion rates of IV phosphate should not exceed ___mmol/hr because it can cause ________ and metastatic ___ deposition/organ dysfunction

A

7 mmol/hr
thrombophlebitis
calcium phosphate deposition

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8
Q

the most common complication associated with PN

A

hyperglycemia

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9
Q

hyperglycemia is the most common complication associated with PN due to

A

stress associated hyperglycemia in sepsis/acutely ill causing insulin resistance, increased gluconeogenesis, glycogenolysis and suppressed insulin secretion

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10
Q

what is the glycemic BG target for the majority of critically ill patients

A

140-180mg/dL (American Association of Clinical Endocrinologists and American Diabetes Association)

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11
Q

a target BG below ____ is not recommended in the ICU due to the adverse effects of hypoglycemia

A

<110mg/dL

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12
Q

What is the preferred approach for subcutaneous insulin administration in the hospitalized adult patient with diabetes mellitus

A

basal, bolus insulin.

(basal insulin is given for hepatic glucose output and bolus insulin regularly scheduled is used for meal times) as well as correctional insulin

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13
Q

what form of glutamine supplementation improves physical compatibility and stability for admix in PN solutions

A

glutamine dipeptide (L-alanyl, Lglutamine, Glycl L glutamine)

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14
Q

___glutamine supplementation is more beneficial than enteral supplementation

A

parenteral

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15
Q

IV glutamine supplements are _____ available in the U.S.

A

not

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16
Q

free ____ is unstable in PN solutions

A

glutamine

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17
Q

a critically ill obese patient with a BMI of 33.4

should be recommended for this range of calories/body weight/day per SCCM and ASPEN

A

11-14 kg/ABW/day

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18
Q

for all classes of obesity where BMI >30 kg/m2, the goal PN regiment shouldn’t exceed ___ to ___ total energy requirements as measured by indirect calorimetry

A

65-70%

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19
Q

If indirect calorimetry isn’t available, the weight based equation of _______ should be used for patients with a BMI of 30-50 kg/m2 to predict energy needs

A

11-14 kcal/kg/ABW

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20
Q

If IC isn’t available, the weight based equation of ___ should be used for patients with a BMI >50 kg/m2 to predict energy needs

A

22-25 IBW

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21
Q

protein should be provided in a range > or equal to ____ g/kg _____ a day for patients with a BMI of 30-40 kg/m2

A

2.0 g/kg IBW day

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22
Q

protein should be provided in a range up to ____g/kg ____ a day for patients with a BMI greater than or equal to 40

A

2.5 g/kg IBW /day

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23
Q

the majority of PN complications that increase PN Prescription errors happen when

A

inadequate knowledge of PN therapy, certain pt characteristics related to PN such as renal function, calculation of PN doses are incorrect, specialized PN dosage formulation characteristics and lack of knowledge of prescribing nomenclature

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24
Q

According to ASPEN , what is the best way to express dextrose content on the PN label to avoid misinterpretation

A

total grams within 24 hours (ie 255 grams/day)

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25
Q

On the PN label, PN ingredients are ordered in ____ for adults and ______ for pediatrics and neonates

A

amounts per day for adults

amounts per kg for neonates/peds

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26
Q

On the PN label, macronutrients should be expressed in

A

grams per day

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27
Q

On the PN label, micronutrients should be measured in

A

mEq,mmol,mcg,mg per day (units)

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28
Q

Mandatory items on a PN ORDER FORM per ASPEN

A 
patient identifiers (birthdate or age)
patient allergies
Height, Weight
Diagnosis (es)/ indication for PN
Administration route/venous access device (periph vs. central)
Prescriber contact info
order date/time
administration date/time
volume infusion rate
infusion schedule (continuous vs cyclic)
type of formulation (TNA vs 2 in1 + ILE) 
PN ingredients (amt per day or per kg)
electrolytes in complete salt form 
full generic name for each ingredient
joint commission approved abbreviations
dose of vitamins, trace elements, on nutrients medication
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29
Q

electrolytes on the PN order form and label should be expressed in

A

complete salt form

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30
Q

Mandatory inpatient PN label should contain

A 
electrolytes in complete salt forms
2 patient identifiers
patient location
dosing weight in kg
administration date and time
route of administration
prescribed volume
overfill volume
infusion rate in mL/hr
duration of infusion (continuous or cycled)
size of the in line filer
all ingredients with barcode
same sequence as PN order
name of institution or pharmacy
contact info for above
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31
Q

if ILE is hung separately, the mandatory PN label should also contain

A 
2 patient identifiers
patient location
patient dosing weight in kg
administration time/date
route of administration
prescribed amount of ILE
volume of ILE
infusion rate
duration of infusion
complete name of the ILE
beyond use date and time, name of the institution/pharmacy with contact#
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32
Q

A patient’s PN order is 2400mL, 300 grams of dextrose, 90 grams of protein and 225mL of IL20%. How many total kcals and grams of fat are provided

A 
1830 kcal and 45 grams of fat
300 g dextrose x 3.4 kcal = 1020 kcal
90g protein x 4 kcal = 360 kcal
225mL IL20% x 2kcal/mL = 450 kcal
450kcal of lipid /10 kcal = 45 grams
1020 + 360 +450 = 1830
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33
Q

A patient who weighs 75 kg is getting 2: in 1 PN with piggy back ILE 20% at 65mL/hr. with 117 grams of protein, 273 grams of dextrose. What is the total daily caloric content per kg of body weight

A

117 g protein x 4 kcal = 468 kcal
273 g dextrose x 3.4 kcal = 928 kcal
250mL x 2kcal= 500 kcal
468+928+500 kcal = 1896 kcal/75 kg = 25.3 g/kg

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34
Q

A critically ill obese patient has a BMI >33.4 kg/m2, how much protein is recommended per SCCM and ASPEN

A

greater than or equal to 2.0 g/kg IBW

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35
Q

Which of the following is an indication to start PN

high output fistula, Chron’s disease, pancreatitis, hyperemesis gravidarum

A

high output fistula

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36
Q

When is PN indicated in severe burn patients

A

when EN is contraindicated or unlikely to meet nutritional needs. Studies have found that use of PN in burn patients has been associated with increased mortality

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37
Q

The routine use of preoperative PN is indicated for patients with a non functioning GI tract who are ____ to decrease perioperative complications

A

severely malnourished when used for >7 days pre op

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38
Q

An adult patient with an abdominal tumor resulting in an unresolved SBO for over 7 days is a candidate for PN true or false

A

true

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39
Q

Any adult with a GI obstruction that precludes oral intake for at least 1 week is a candidate for PN true or false

A

true

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40
Q

Palliative use of nutrition support in terminal ill patients is ______ indicated

A

rarely

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41
Q

patients who are scheduled for surgery and are _______ are recommended for PN if PN can continue for 7-10 days

A

severely malnourished

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42
Q

When should PN be used in Chron’s

A

only after failure to tolerate EN (studies have found no advantage of PN over the use of EN)

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43
Q

EN should only be used in patients with Chron’s requiring

A

nutrition support therapy

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44
Q

peri operative specialized nutrition support is indicated in patients with IBD who are ___ and surgery can be safely postponed

A

severely malnourished

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45
Q

In a TNA ILE is stable at room temperature for ______ and stable refrigerated for ________

A 
24 hours (room temp)
9 days  (refrigerated)
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46
Q

Prolonged exposure to light of an ILE can cause

A

degradation

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47
Q

ILE is most stable at a pH of ____ and adding _____ can cause instability

A

6-9 pH

acidic dextrose

48
Q

ILE administration via Piggy Back separate from dextrose and protein has a max hang time of

A

12 hours

49
Q

ILE administration via piggy back separate from dextrose and protein tubing/filters should be changed

A

with each new infusion

50
Q

_____ micron filters should be used to stop fat emboli, air emboli, microorganisms, or particulate matter from the patient

A

1.2 micron

51
Q

what is the most appropriate distal catheter tip placement at a peripherally inserted central catheter

A

superior vena cava

52
Q

a catheter inserted via peripheral vein (cephalic or basilic) whose distal tip lies in the vena cava

A

PICC line

53
Q

central or peripheral access is defined by

A

position of the distal tip

54
Q

disadvantages of PICC lines

A

limited self care ability
limited mobility
high rate of malposition or coiling
long lines increase risk of occlusion

55
Q

advantages of PICC lines

A

NO risk of pneumothorax of puncture of carotid/subclavian arteries
NO repeated skin punctures
comes in single, double or triple lumens

56
Q

When is it most appropriate to start a PN infusion in a patient with a new central venous catheter inserted at the bedside without fluoroscopy

A

AFTER chest x-ray confirms correct cath tip placement

57
Q

one of the most common complication(s) of central venous catheters inserted at the bedside

A

misplacement/pneumothorax

58
Q

fluoroscopy for central line insertion allows

A

immediate repositioning of catheter tip

59
Q

The CDC recommends to ______ routinely replace CVC’s, PICCs, HD catheters or pulmonary artery catheters to prevent catheter related infections

A

NOT

DON’T Recommend to routinely replace

60
Q

The CDC recommends ______ remove the CVC/PICC based on fever alone

A

DON’T remove the line based on fever alone

61
Q

______ should be used to determine appropriateness of catheter removal if infection is evidenced from another site or non infectious cause

A

clinical judgement

62
Q

Catheter insertion over a guidewire during bacteremia should ______ due to a source of infection/colonization of the skin to the insertion site

A

SHOULD NOT BE DONE

63
Q

Which of the following additives has the greatest risk of destabilizing a lipid injectable emulsion in a total nutrient admixture (TNA) (sodium chloride, calcium acetate, iron dextran or potassium phosphate)

A

iron dextran

64
Q

Phase separation and liberation from free oil from the destabilization of TNAs can result over time with an excess of ____ added to a formula

A

cations

65
Q

The ____ the cation valence, the greater the destabilizing power of a TNA with oil (ILE)

A

greater the valence, the more disruptive

66
Q

A PICC line should only be removed if

A

it is suspected or known to be the source of infection

67
Q

the LEAST favorable place for a PN catheter is

A

femoral

68
Q

Evidenced based interventions for patients with IV catheters that should be implemented together for the best outcomes is known as

A

the institute for health care improvement central line bundle

69
Q

what are the two principles of the central line bundle

A
  1. optimal cath selection

2. avoid of CV access in places at high risk for infection (femoral catheters, when alternative access is available

70
Q

what are the max percentages of dextrose and amino acids appropriate for peripheral PN

A

10% dextrose

3% amino acids

71
Q

osmolarity up to _______ mOsm/L can be safely infused peripherally

A

900 mOsm/L

72
Q

high concentrations of ____ increases calcium phosphorous precipitation in PN

A

amino acids

73
Q

the increase of temperature of PN bags increases the dissociation of ____ salts

A

calcium

74
Q

storage of PN in the refrigerator decreases the risk of _____ precipitation

A

calcium phosphate

75
Q

when compounding PN, always add _____ first then ______

A

PHOS FIRST

then calcium

76
Q

what type of parenteral amino acids should be used in a hospitalized adult with acute kidney injury requiring PN (standard, branched chain , essential amino acids, or renal specialty amino acids

A

standard

77
Q

patients with acute renal insufficiency have a decreased ability to synthesize ____ amino acids, no research has proven the benefit of branched chain amino acids or renal specialty formulas to be more beneficial than the standard

A

non essential amino acids

78
Q

Branched Chain Amino Acid PN formulations are the most appropriate for

A

a cirrhotic patient with chronic encephalopathy who is intolerant of standard protein sources, despite optimal pharmacotherapy

79
Q

APSEN recommends the use of _______ amino acid formulas for critically ill patients with acute and chronic liver disease

A

standard amino acid formulations

80
Q

Failure to provide linoleic and alpha linolenic acids with PN will most likely result in

A

essential fatty acid deficiency

81
Q

to prevent EFAD in adults, provide at least ___ to____ total calories as linoleic and ____ to _____ of alpha linoleic acid. In infants provide at least ___ to ___ g/kg/day of lipids to prevent EFAD

A

2-4% total calories linoleic acid

  1. 25-0.5% total calories alpha linoleic acid
  2. 5 to 1 gram/kg/day
82
Q

what is a lipid injectable emulsion produced by the transesterification of fatty acids to form a composite triglyceride molecule?

A

a structured lipid

83
Q

what is the purpose of using a structured lipid for an injectable lipid emulsion

A

to slow the rate or release and utilization of medium chain fatty acids

84
Q

in a patient with hepatobiliary disease, which trace elements should be withheld or require a dose reduction when prescribing PN

A

manganese and copper due to impaired excretion in liver disease

85
Q

what parts of PN are a major source of aluminum exposure 2/2 contamination of raw materials and byproducts

A

calcium salts, phosphate salts, calcium gluconate and potassium phosphate

86
Q

The FDA mandates all manufacturers to measure and report the maximum content of ______ in their products

A

aluminum

87
Q

per the FDA, large volume PN products should contain less than _____ mcg/L of aluminum

A

25 mcg/L

88
Q

per the FDA, small volume PN products should label the amount of aluminum________

A

at the time of product expiration

89
Q

a long term PN patient begins to experience Parkinson’s like symptoms; which trace element toxicity is most likely to present these symptoms

A

manganese

90
Q

excess manganese accumulates in the _____ when not excreted through bile appropriately

A

the brain

91
Q

What are the Parkinson’s like symptoms from hypermagnesemia

A

rigidity
involuntary movement
tremors

92
Q

what patients are at risk for manganese toxicity

A

patients who are on TPN and have liver failure and elevated LFT’s because bile excretion is limited

93
Q

patients with chronic liver disease should get ____ free TPN

A

manganese free

94
Q

when compared to the DRIs for fat soluble vitamins given orally, the DRIs for parenterally administered fat soluble vitamins are ____ even though the amounts in PN are higher than PO. Fat soluble vitamin needs increase 2/2 malnutrition & metabolic changes from chronic illness. No toxicities have been reported

A

equal

95
Q

when compared to the DRIs for water soluble vitamins given orally, the DRI’s for parenterally administered water soluble vitamins are

A

higher

96
Q

PN water soluble doses are 2-2.5x____ than the RDA or AI 2/2 increased requirements from malnutrition, baseline vitamin deficiencies, increased urinary excretion of water soluble vitamins when used IV (rare toxicity)

A

greater than

97
Q

according to the United States Pharmacopeia (USP) chapter 797, a PN solution prepared from 8.5% amino acid with electrolytes, 70% dextrose with MVI, trace elements and famotidine added would be classified as ____ risk

A

medium (Compounding of PN using manual or automated devices during which there are multiple injections, detachments, and attachments of nutrient source products to the device or machine to deliver all nutritional components to a final sterile container)

98
Q

according to the United States Pharmacopeia (USP) chapter 797, PN solutions are categorized as low, medium and high risk corresponding with the probability of

A

microbial contamination, chemical or physical contamination

99
Q

according to the United States Pharmacopeia (USP) chapter 797, PN high risk solutions involve

A

NONSTERILEE ingredients and devices

100
Q

Automated Computed Devices for compound TPN are _____ error free

A

NOT ERROR FREE, errors can still occur

101
Q

Error rates of ACD devices compared to manual compounding are ____% and ___% respectively

A

22% ACD

39% Manual

102
Q

There should be established ____ limit warnings and _____ based limits in the pharmacy and ACD systems

A

dose limit warnings

weight based limits

103
Q

_____ should develop monitoring and surveillance plans for PN compounding

A

pharmacies

104
Q

when is manual compounding appropriate to use over ACD’s when preparing PN

A
  1. when the volume of PN are less than the ACD can accurately provide
  2. when chemical interactions between PN components cannot be mitigated by sequencing
  3. conservation during drug shortages
105
Q

_______ all healthcare providers should have the ability to override soft and hard limit alerts from ACDs

A

NOT ALL

106
Q

the preparation of compounded sterile preparations (CSPs) for all patient populations should be _____ for each population, with ________ strategies

A

separate, separate

107
Q

a translucent band at the surface of the emulsion separate from the remaining TNA dispersion is called

A

creaming

108
Q

when TNA has creaming, this is the ____ phase of an emulsion and the lipid droplets are preserved. Light creaming is a _____ occurrence and _____ spose a significant risk unless in extreme cases

A

Initial phase
common occurrences
Doesn’t (little clinical risk)

109
Q

when a TNA develops yellow/brown oil droplets near or at the TNA surface, marbling/streaking of oil all throughout the TNA or a continuous layer of yellow brown liquid at the surface of TNA this is known as

A

Cracking (terminal state of emulsion destabilization)

110
Q

Cracking of a TNA solution is the _____ phase of emulsion destabilization and can cause a ____ risk of clinical danger

A

terminal phase of emulsion destabilization

high risk of clinical danger

111
Q

what complication is most likely to occur when transitioning a critically ill patient from PN to EN and why. how can this be limited?

A

hyperglycemia because there may be an overlap in excess nutrients given when transitioning. This can be limited by keeping GIR < 4 mg/kg/min

112
Q

rapid infusion of IV Na or KPhos may result in ____ from an abrupt decrease in ________

A

tetany from abrupt decrease in serum calcium

113
Q

potassium phosphate in PN is _____ in nature, acid base wise

A

acidic/acidifying

114
Q

while getting PN, your patient develops metabolic acidosis. What serum electrolyte level needs to be monitored most closely

A

potassium

115
Q

during metabolic acidosis and tissue catabolism, there is an extracellular shift in ____ to maintain electroneutrality. Correcting metabolic acidosis will treat this.

A

potassium

116
Q

what is considered the most serious complication of significant hyperphosphatemia?

A

soft tissue and vascular complications 2/2 calcification when serum calcium multiplied by serum phos exceeds >55mg/DL

CNSC Exam (32 decks)

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