Previous Exam Questions Flashcards
1
Q
Intracellular ion?
A
Potassium
2
Q
Extracellular Ion?
A
Sodium (Na)
3
Q
Osmolarity of dextrose?
A
1g =5 mOsm
4
Q
Osmolarity of Amino Acids?
A
1g = 10 mOsm
5
Q
What decreases the GRADE of research articles?
A
Score may be decreased because of problem with Bias, constistency, precision, directness
6
Q
GRADE I
A
Large randomized trials with clear cut results; low risk of false positive and or false negative error
7
Q
GRADE II
A
Small randomized trials with uncertain results; moderate risk of false-positive and/or false negative error
8
Q
Grade III
A
Nonrandomized cohort with contemporaneous controls
9
Q
Level IV
A
nonrandomized cohort with historical controls
10
Q
Level V
A
Case series, uncontrolled studies, and expert opinion
11
Q
Types of research
A
Retrospective, Descriptive, Qualitative, Experimental
12
Q
Retrosepective research
A
uses information already collected
13
Q
Descriptive Research
A
analysis of data to make a hypothesis
14
Q
Qualitative Research
A
Obtaining data through open ended and conversational communication
15
Q
Experimental Research
A
uses scientific method to determine cause/effect
16
Q
Insulin Dosing
A
Regular insulin is the only type of insulin added to the TPN bag, Only addd 60-80% of IV insulin needs to PN. If patient is not in the ICU, start with 0.1 unit of insulin/gram of dextrose or 10 units per 100gm of dextrose (ex: for 200gm or dextrose, add only 20units of inuslin), detrose in PN should not ben increased until BG is less than 200. Can increase insulin by adding 2/3 of insulin needed from the day before or adding 5 units per 10 grams of carb.
Insulin function decreases in TPN, will stick to tubing
17
Q
Respiratory quotient of fat metabolism
A
0.7
18
Q
Respiratory quotient of protein
A
0.82
19
Q
Respiratory quotient of mixed
A
0.85
20
Q
Respiratory quotient of carbohydrate
A
1.0
21
Q
Respiratory quotient greater than 1.0
A
lipogenesis, overfeeding likely going on
22
Q
What to do during IV vitamin shortages
A
Reserve for patients receiving soley PN or have a clinical need for IV MVI
Consider using oral MVI if able
Provide x3 week or reduce by 50%
If a 13 vitamin product cannot be obtained, obtain a 12 vitamin product and supplement K outside (150mcg/day or 5-10mg/week)
Give B1 (thiamine), folate (B9), B6, vitamin C daily if absolute shortage
Using pediatric MVI for adults is not recommended because it could lead to shortage of pediatric product
Adult MVI should not be administered to peds
Monitor for signs of deficiency of vitamins
23
Q
Lipid limit for critical care PN
A
No more than 1gm/kg/day
24
Q
Phenoytoin requires supplementation of which micronutrient and how long should EN be held?
A
Folate
Can bind to tubing or EN formulation, Hold EN 1 hr before and 2 hrs after dose
25
Filter size needed for 3:1 TPN formulation
1.2-um filter
26
Filter size needed for a 2:1 TPN formulation?
0.22-um filter
27
Are antibiotics used for line care?
Do not use antibiotics for line care as there is concern for multidrug resistance
28
Line insertion bundle and what it entails
Hand hygiene, maximal barrier precautions, (mask, gloves, gown, cap, and body drape), CHG skin antisepsis, optimal catheter site selection and daily review of line necessity with prompt removal of unnecessary lines
29
Grade level for nutrition support education material
5th or 6th grade
30
Niacin
used for cardiovascular disease to treat HLD but can cause flushing
Pellagra = 3 D’s - diarrhea, dermatitis, dementia
31
Erythromycin can cause which deficiency?
Erythromycin can cause hypokalemia and hypomagnesemia
32
What happens with aging?
Functional age-related changes in the GI tract may include an altered GI motility, such as delayed gastric emptying. The changes may include altered sensory response; decreased muscle mass, strength, or pressure; decreased secretions. The absorption of certain nutrients, such as calcium, iron, vitamin D, and others may be reduced. With aging, liver values of vitamin A remain stable, which may mean that, despite decreasing dietary intake, absorption of the vitamin increases.
Decreased colonic tone
Decreased small intestinal absorption
Decreased absorption of calcium, iron vitamin D
Causes of malnutrition: Chronic disease, poor oral health, loss of taste/smell, polypharmacy, social isolation, dementia, sarcopenia, loss of functional capacity, inability to procure, prepare and consume food
33
What micronutrients need to be supplemented on dialysis?
May need to supplement vitamin C, folic acid, B6 may be needed with HD
Supplementation of water soluble vitamins is recommended for all dialysis patients
34
What risk is TPN and how long can it be stored in the refrigerator for?
TPN is medium risk and can be stored for 9 days in fridge
35
Hang time for Open EN feeding system?
Open container: 8-12hrs
36
Hang time for Closed EN feeding System?
24-48 hrs
37
Hang time for reconstituted EN feeding system?
4 hrs, formula can be refrigerated after opening for 24 hrs, feeding bags changed every 24 hrs
38
Hang time for breast milk?
4 hrs
39
Best way to prevent calcium oxalate stones?
Low fat, oxalate restricted diet, calcium supplementation, adequate hydration
40
Vitmin A toxicity can cause
bone fractures
41
Diarrhea causes which acid/base disorder?
Metabolic acidosis
42
Symptoms of manganese toxicity
parkinson’s like symptoms and tested with MRI
43
Which micronutrient is not compatible with 3:1 TPN?
iron
44
3:1 TPN cannot see changes due to being
opaque
45
Which micronutrient deficiency causes cardiomyopathy?
Selenium
46
Pediatric Fluid calculation
100ml/kg for the 1st 10kg, 50ml/kg for 2nd 10kg, 20ml/kg for the next kg
47
When to stop EN/PN when taking oral intake (% of calories being met)
66% or 3/4 of needs
48
Home nutrition support requires a ____?
telephone
49
How long should you hold EN for carbamazepine?
2 hrs before and after administration
50
Glucose target for hospitalized patients?
140-180
51
Where is iron and vitamin B12 absorbed
Iron = duodenum
B12 = ileum
52
How often should a CMP be checked for a stable TPN patient?
Monthly
53
Independent variable
what is being studied or able to be changed, the “cause”
54
Dependent variable
what is being changed due to the study, the “effect”, this is what is being measured, reaction that is studied
55
4 Principles of Ethics
Autonomy, Beneficence, Justice, Maleficence
56
Autonomy:
right to self determination (ie with advanced directives this allows the person to maintain autonomy even after they are unable to verbalize their wishes)
57
Beneficence
fundamental obligation of healthcare workers to seek good for the patient above all other priorities
58
Justice
fairness, access to all resources
59
Maleficence
do no harm principle, in medicine we need to minimize and relieve needless suffering and pain
60
DPOA
form that lists patient wishes when pt is too sick to speak for themselves
61
Peripheral access is not appropriate for PN solutions that have greater than ___ dextrose and ___ mOsm/L
10% ; 900
62
Tunneled cuffed catheter
Needs a small procedure to be removed
63
Line that needs needle access
port
64
ANH and Terminal Illness
is it palliative or painful to not have access to food and water when dying?
A common fallacy in terminally ill patients is that dehydration is thought to be an uncomfortable state. At the end of life, patients rarely complain of thirst, and aggressive artificial nutrition and hydration (ANH) can be more harmful and can produce life-threatening symptoms. Decreased nutritional intake stimulates increased production of endorphins and dehydration leads to increased dynorphin levels. Both endorphins and dynorphins are natural analgesics and may increase comfort levels. Numerous studies report that patients who are dying predominately have electrolyte values that run in the normal range.
65
ANH and Dementia
a patient’s expected survival time affects the evaluation of the benefits vs burdons and risks of the procedure. Factors to consider before placement of a long term tube is the patient’s prior wishes for medical therapies (if known before advanced dementia), the length of time the feeding tube may be required, the patient’s medical condition, and expected survival time. There is lack of evidenced that EN improves morbidity and decreases mortality in advanced dementia.
66
Vegetative state
In early stages, clinicians are cautioned against the premature forgoing of ANH in these patients soley based on neurologic status. Need accurate dx and reassessment of the patient’s neurolog status (Persistent Vegetative State vs Minimally Conscious State). Clinicians need to provide information to surrogate about PEG tube long-term outcomes or a patient in a PVS. Decisions to forgo PEGs in the early vegetative state may be premature, particularly if the dx of PVS is not confirmed. In these cases, a time limited trial of EN may be warranted, along with frank discussions with the surrogate decision maker, other family members, and significant others regarding specific goals and expectations
67
How to best prevent oxalate stones
Avoid High protein diet
Avoid High green leafy veg
Calcium supplementation - correct answer
High dose vitamin C—this is def wrong
Include high calcium food or calcium citrate supplement with meals to bind oxalate and alkaliniaxe the urine
Consume a low oxalate diet
68
Biliary draining electrolyte losses
Sodium, Potassium, Chloride, Bicarb
69
Respiratory acidosis
Increase in CO2, compensatory increase in HCO3
Causes: head injury, pulmonary abnormalities, PNA, Guillian-Barre, hypoventilation, overfeeding, caused by decreased effective alveolar ventilation
70
Respiratory Alkalosis
Decrease in CO2, compensatory decrease in HCO3
Causes: anxiety, pain , hyperventilation
71
Metabolic Acidosis
Decrease in HCO3, compensatory decreased in CO2
Caused by inability of kidneys to excrete H or the loss of bicarb from diarrhea or fistula, can also happen with SIBO or short gut
Causes: Diarrhea, fistula output
72
Metabolic Alkalosis:
Increase in HCO3, compensatory increase in CO2
Caused by loss of gastric acid (HCl) dt vomiting or NG suction or loss of volume/chloride from diuretics, normally kidneys can compensate so for this to happen some degree of renal function is present
Causes: diuretic therapy, NG suctioning, N/V
73
Max LIR
0.11 gm/kg/hr
74
DIR caluclation
Gm Dextrose / wt in kg/ 1.44
75
Triglyceride level for adults and peds to remove lipids
Adults: 400
Peds: 200
76
Six Sigma
a process improvement workflow, includes define, measure, analyze, improve, control
Goal is to reduce failure of quality until it is no longer cost-effective to pursue further reduction
Goal is not to fix all failures
77
Plan/Do/Study/Act (PDSA)
Quality improvement problem solving model
The Plan/Do/Study/Act (PDSA) cycle is a quality improvement problem-solving model. The process begins with a planning phase, followed by the implementation of a process improvement (the “do” phase). The study process measures the results of the improvement effort. During the “act” phase, the team will determine if changes made should be permanent and includes standardization and documentation of the processes.
Method for improving strategies, defines a problem/barriers to track progress, study the plan and summarize data, act to implement changes
Create a plan, execute the plan and document problems/barriers and track progress, study the plan and summarize data, act to implement changes
78
Prosthetic device act
EN/PN may be covered under the prosthetic device act which is a benefit of medicare part B, requires the permanent dysfunction of a body organ and must be needed for 3+ months
79
Vitamin D toxicity can contribute to
metabolic bone disease
80
TPN taper 1-2 hrs to prevent
hypoglycemia
81
What is a closed feeding system and what are the benefits?
Sterile container of prefilled formula that is ready to administer to the patient and is spiked with an administration set
Less manipulation
Less human/environmental contact
Decreased risk of bacterial contamination
Fewer steps in administration, this saving time and resources
82
What is an open feeding system?
Involve cartons/cans poured into feeding bags or syringe before delivery to the patient
83
Hang time for lipids
Time for lipids in PN
TNA: 24 hrs
Alone 12 hrs
Can store in fridge for 9 days
84
Cracking of lipids
Cracking is expiring, bad, dont use, brown and yellow
2: yellow-brown oil droplets at or near the TNA surface.
3: a continuous layer of yellow-brown liquid at the surface of the TNA.
4: marbling or streaking of the oil throughout the TNA.
85
Creaming of lipids
translucent layer on top
1: a translucent band at the surface of the emulsion separate from the remaining TNA dispersion.
86
Common cause of N/V in long term EN
Gastic outlet obstruction
87
Manganese toxicity
- Long term TPN patients are high risk
- Manganese can cause parkinson like symptoms, affects the brain
- Can be monitored with MRI
88
Iron in regards to PN
- Not added to TPN due to compatability concerns, deficiency is common
- Iron dextran can be added to 2:1 solutions but cannot be added to TNA
89
Which trace elements should be removed in liver disease or hyperbilirubinemia?
Manganese and copper
90
Fluid needs for different age groups
18-55: 35 ml/kg
55-75: 30ml/kg
>75: 25 ml/kg
91
Enteral formula free water estimations
1 kcal/ml: 85% free water
1.5 kcal/ml: 78% free water
2 kcal/ml: 69-72% free water
92
ASPEN feeding guidelines: BMI 30-50
11-14 kcal/kg ABW
>2gm/kg IBW
93
Aspen Feeding guidelines: BMI >50
22-25 kcal/kg IBW
Protein 2-2.5 kgm/kg IBW
94
When should PN be discontined?
when pt has reliable EN intake, can tolerate solid foods. Consider reduction to 50% and continue to increase EN/PO intake to “acceptable” limit before DC
95
Nitrogen Balance
Gold standard to determine if protein intake is adequate
80% of nitrogen is lost to urine
Nitrogen Output (g/day)= [Urinary Urea nitrogen (mg/100mL) x Urinary volume (L/day)] x .2(urine nitrogen) + 2 g
Nitrogen is 16% of protein losses
Nitrogen output (g/day) = urinary urea nitrogen (gm/100mL) x urinary volume (L/day) / 100 + 20% of urinary losses + 2g (estimated other nitrogen from skin, GI losses)
I.e.: Enteral nutrition provides 136gm protein (21.8g Nitrogen), Urine output was 2920ml, and urine nitrogen was 16g. Therefore 21.8 - [16 +3.2 (20% for other urinary losses) + 2] = 0.6 nitrogen equilibrium
To get the gm Nitrogen multiply the gm protein from EN by 0.16 (ie 136 x 0.16 = 21.8 g Nitrogen)
96
Majority of fat digestion occurs in the
Duodenum - due to excretion of pancreatic lipase
97
What is the best intervention for a community dwelling elderly patient who is homebound?
Meals on Wheels
98
What is the hallmark sign of frailty?
Sarcopenia
99
An older adult without IV access requires strict bowel rest and PN for 6 weeks. Which of the following vascular access devices should be employed?
A . PICC
100
75 year old man is admitted tot he hospital with aspiration PNA, was deemed unsafe for an oral diet, and is now experiencing aspiration while receiving continues EN via NGT. Which of the following long term feeding options would be most appropriate?
PEJ
101
An older adult nursing home resident with a history of constipation has a newly placed PEG tube. Which of the following formulas would most likely be the best choice?
Standard 1kcal/ml formula with fiber
102
Enteral nutrition formulas supplemented with fiber are often used in the older adult patient population to prevent constipation. Which of the following considerations is most important it this type of formula is chosen?
Provision of adequate water
103
Patient receiving PN has HIgh ileostomy output. Which of the following changes to the PN prescription is most appropriate?
Increase sodium and increase fluid volume
104
Subjective Global assessment
Method of assessing nutritional status in a variety of patient populations. It intigrates 5 historical (weight, dietary intake, GI symptoms, functional status, metabolic demand) and four physical exam parameters (subcutaneous fat loss, muscle wasting, edema, ascites) to define nutrition status.
105
Which of the following are examples of conditionally indispensable amino acids?
Glutamine and arginine - conditionally indispensable amino acids are synthesized from other amino acids under normal conditions but require dietary source in order to meet increase needs by metabolic stress
106
Best method for energy requirements in the critically ill
Indirect calorimetry (IC)
107
Respiratory Quotient calculation
CO2 produced / O2 consumed
108
Primary fuel for colonocytes
Short Chain Fatty Acids
109
Which of the following is associated with adaption to starvation?
Increased lipid oxidation and Decrease in urinary nitrogen losses
110
How much vitamin K is in the standard IV MVI
150 mcg
111
Glycemic target for critically ill patient?
140-180
112
In patients with severe acute pancreatitis, the use of enteral nutrition via NJT rather than PN is associated with
Decreased risk of infectious complications, maintained equal nitrogen balance, and had reduced incidence of hyperglycemia
113
What medications can be infused with PN?
H2 antagonist
114
Fibrin sheath
a layer of fibrin that develops around the outside of a central venous catheter secondary to aggregation of fibrin from the presence of a central venous catheter within a vein
115
Mural thrombus
develops when fibrin build up inside the vein causes the vascular access device to adhere to the vessel wall
116
Intraluminal thrombus
a clot within the catheter lumen and is caused by inadequate flushing and blood reflux
117
Fibrin tail
fibrin build up on the CVC tip that will allow for infusion through the CVC but will inhibit withdrawal of blood
118
0.1N Hydrochloric acid is most effective for clearing catheter occlusions due to precipitation of
Calcium- phosphate
0.1N Hydrochloric acid has been reported effective in clearing catheters with crystalline occlusions because its acidic pH is favorable for calcium and phosphate solubility and acidic medications such as vancomycin
119
Sodium bicarbonate 1 mEq/ml has been anecdotally effective for
Occlusions due to precipitates associated with medications in the high pH range such as tobramycin and phenytoin
120
70% ethanol is the most effective solvent for
lipid residue
121
Thrombotic catheter occlusion
Related to fibrin sheath of fibrin sleeve, develops when fibrin adheres to the external surfaces of the catheter
122
Nonthrombotic catheter occlusion
result from mechanical obstructions (catheter migration or malpositioning), drug or mineral precipitates, or lipid deposits
123
Evidenced based intervention for reducing the risk of central venous catheter related infections?
Research supports the following recommendations a primary interventions for reducing the risks of CVC-related infections
- Using maximal barrier technique during catheter insertion
- Cleansing insertion sites with 2% chlorhexidine preparation
- Education and training of health care personnel
*** Administering antibiotics has NOT been shown to be effective in reducing the rates of CVC-related infections
124
How to calculate osmolarity
Add the mOsm of Amino acids and dextrose. Divide the total mOsm by the volume of PPN
125
ASPEN PN Safety Consensus Recommendations for the inpatient PN label EXCEPT
The PN label should include the following:
- Two patient identifiers
- patient location or address
- dosing weight in metric units,
- administration date and time,
- beyond use date and time,
- route of administration (central versus peripheral),
- prescribed volume and overfill volume,
- infusion rate in mL/h, duration of infusion (continuous versus cyclic),
- size of in-line filter (1.2 or 0.22 micron),
- completer name of all ingredients, barcode,
- all ingredients shall be listed in the same sequence and same units of measure as PN order, name of institution or pharmacy, and institution or pharmacy contact information (including telephone number).
- If ILE is to be infused separately, the ILE label should include: two patient identifiers, patient location or address, dosing weight, administration date and time, route of administration (central versus peripheral), prescribed about of ILE and volume required to deliver that amount, infusion rate in mL/h, duration of infusion (not longer than 12 hours), complete name of ILE, beyond use date and time, name of institution or pharmacy, and institution or pharmacy telephone number.
126
What metabolic changes are caused by starvation?
Lipolysis
Catabolism of endogenous substrate including fat stored in adipose tissue (lypolysis) is common in stress and starvation related malnutrition. Hypoglycemia and ketosis are also seen in starvation related malnutrition. Hypermetabolism and hyperglycmia are signs of stress related malnutrition.
127
Which of the following is NOT appropriate to tell a family regarding nutrition at the end of life?
1: Dying patients rarely feel hungry or thirsty
2: Fewer calories are needed at the end of life
3: The experience of eating remains unchanged at the end of life
4: Patients should not be made to feel guilty if they do not wish to eat
3: The experience of eating remains unchanged at the end of life
It is important for family members to be educated regarding the process of decreased food/fluid intake during the dying process. As illness advances, nutritional needs change and fewer calories are needed. The experience of eating can change from a pleasant one to a distressing one for a patient as the disease process alters the patient's desire to eat. Dying patients rarely feel hungry or thirsty because the natural process of dying shuts down normal functions. Patients should not be made to feel guilty if they do not try to eat. Diminished food and fluid intake are natural parts of the dying process.
