3- nutrition

Question 1

tube feeds uses

Answer 1

for any patient requiring to be NPO for 1-2 wk, consider tube feeding to maintain the integrity of the intestines and bacteria and an easier transition back to oral feeding

Question 2

tube feeds contraindications

Answer 2

bowel obstruction, bowel perforation, bowel ischemia, pancreatitis, and sometimes perioperative bowel; for delayed gastric emptying,

Question 3

Indirect calorimetry

Answer 3

process that calculates heat that the patient produces by measuring either the production of carbon dioxide and nitrogen waste or from the consumption of oxygen; calculates the REE

Question 4

Resting energy expenditure (REE)

Answer 4

energy used at rest; correlates with lean body mass; accounts for 75-95% of TEE;

Question 5

basal energy expenditure (BEE)

Answer 5

similar but more restrictive

66.5 + [13.8 x kg] + [5 x cm] – [6.8 – yr] x stress factor

Question 6

Respiratory quotient (RQ)

Answer 6

ratio of CO2 eliminated (VCO2) over O2 consumed (VO2); used in calorimetry since it correlates with the metabolism of food and can be used to determine which substance is being utilized

Question 7

RQ for carbs, proteins, fats

Answer 7

carbs have an RQ of 1.0,
protein 0.8,
fat 0.7;

Question 8

what can increase RQ

Answer 8

hyperventilation (↑ CO2 elimination), metabolic acidosis (buffering acid generates CO2 → ↑ CO2 elimination), overfeeding (↑ lipogenesis

Question 9

What enteral formula and goal rate would you order and why?

Answer 9

Unless fluid restricted or with malabsorption, use 1 kcal/ml in isotonic, polymeric, lactrose-free solution; usually have 12-20% kcal protein, 45-60% kcal carbs, 30-40% kcal fat

Question 10

Protein needs increase in which state and decrease in what state to prevent uremia and encephalopathy

Answer 10

inc- anabolic states

dec- renal and hepatic failure

0. 6 -0.8 g = renal failure and not on dialysis
1. 8 g = healthy individual
2. 0-1.2 = g fever, infection
3. 3-1.5 = g wound healing, trauma, surgery, repletion

Question 11

If you need more protein without exceeding calories, what should you do

Answer 11

decrease feeding volume and add supplemental powder

Question 12

Explain why the patient’s PCO2 decreased with the change in the enteral formula and goal rate.

Answer 12

CO2 production declines as energy intake more closely matches the patient’s ability to utilize calories and avoid lipogenesis

Question 13

High gastric residuals are most common in

Answer 13

diabetics and head trauma;

associated with regurgitation and thus aspiration in patients unable to protect their airway

Question 14

high gastric residual goal

Answer 14

should be less than hourly goal rate (150 ml if goal rate is 75 ml/hr)

Question 15

treatment for high gastric residual

Answer 15

continuous infusion rather than boluses; elevate head of bed to 30-45 degrees during feeding and after for 1 hr; use isotonic formula

place jejunal tube if unsuccessful

Question 16

How would you reassess the patient’s nutritional status during hospitalization course?

Answer 16

Repeat indirect calorimetry for present REE and RQ, reassess stress factors;
prealbumin (half life 1-2 days) is better than albumin (halflife 21 days);
24 hr urine nitrogen collection for nitrogen balance study

Question 17

Parentral nutrition is indicated in

Answer 17

in hemodynamic instability, significant arrhythmias, significant abdominal distention, and ischemic bowel

Question 18

describe pertinent nutritional support monitoring parameters

Answer 18

Monitor for fluid overload, ↑ or ↓ BP, electrolyte imbalance, glucose, triglycerides, LFTs, H/H, strength and activity

Question 19

refeeding syn

Answer 19

– starvation is associated with muscle wasting and ↓ Phos; with refeeding, insulin isreleased causing uptake of glucose, phos, water and other components into ells and stimulates anabolic protein synthesis; this causes further ↓ in Phos and may cause cardiac, respiratory, and neuromuscular dysfunction; K and Mag are also driven into cells causing low serum levels; together this can cause arrhythmias and death; monitor for hyperglycemia and hypokalemic metabolic alkalosis

Question 20

Describe how to transition TPN patient to enteral support

Answer 20

Give less than full salt, fluid, and caloric need and advance slowly; increase feeding while slowly decreasing TPN

Patient may have difficulty swallowing from intubation; may need to place an NG; do not place hyperosmolar solutions such as medications in tube feeding

Question 21

refeeding syn

Answer 21

– starvation is associated with muscle wasting and ↓ Phos; with refeeding, insulin isreleased causing uptake of glucose, phos, water and other components into ells and stimulates anabolic protein synthesis; this causes further ↓ in Phos and may cause cardiac, respiratory, and neuromuscular dysfunction; K and Mag are also driven into cells causing low serum levels; together this can cause arrhythmias and death; monitor for hyperglycemia and hypokalemic metabolic alkalosis

Question 22

Describe how to transition this patient to enteral support when it is appropriate.

Answer 22

Give less than full salt, fluid, and caloric need and advance slowly; increase feeding while slowly decreasing TPN

Patient may have difficulty swallowing from intubation; may need to place an NG; do not place hyperosmolar solutions such as medications in tube feeding

Question 23

What are some of the other complications that this patient can have because of her shortened bowel and what is basic mechanism?

Answer 23

PUD- incr. hormones to inc gastric acid

Gallstones- dec. reabsorption of bile acids in ileum

Kidney stones- Ca bound to unabsorbed fatty acids–> oxalate»calcium

drunken state syn.

Question 24

Drunken state syndrome

Answer 24

unabsorbed carbs ferment in colon
→ d-lactate is produced and absorbed
→ slurred speech, ataxia, altered affect;

treat with lower carb diet