Calculations III

Question 1

Enteral nutrition (EN):

Answer 1

Uses the GI tract

• if the GI tract is working then, enteral nutrition is preferred.

Question 2

Parenteral nutrition (PN):

also referred to as TPN “total parenteral nutrition”

Answer 2

Delivered into a vein through a peripheral or central line.
parenteral nutrition (PN) requires a filter due to the risk of a precipitate.
They are classified as High-alert medications by the ISMP.

1) peripheral line-

2) central line- allows for a higher osmolarity and wider variation in pH.
ex. PICC line, Hickman line, Broviac line, Groshong line

• delivers calories into a vein through a peripheral or central line.

Question 3

Calorie Sources:

Carbohydrates:
Enteral route-
parenteral route-

Fat:
Enteral route-
Parenteral route-

Protein:
Enteral route-
Parenteral route-

Answer 3

Carbohydrates:

Enteral route- 4 kcal/gram
parenteral route- 3.4 kcal/gram ex. dextrose

Fat:

Enteral route- 9 kcal/gram
Parenteral route- kcal/mL (Product-specific)
- propafal
- clevidipine
“ when we give fat as a energy source parenterally, the energy kcals is determined by the volume”

Protein:
Enteral route- 4 kcal/gram
Parenteral route- 4 kcal/gram

Question 4

Calories Provided from macronutrient: Given (PN) parenterally

dextrose monohydrate

Answer 4

dextrose monohydrate = 3.4 kcal/gram

Question 5

Calories Provided from macronutrient: Given (PN) parenterally

glycerol/glycerin

Answer 5

glycerol/glycerin = 4.3 kcal/gram

Question 6

Calories Provided from macronutrient: Given (PN) parenterally

injectable lipid emulsion (ILE) 10%

Answer 6

ILE 10% = 1.1 kcal/mL

Question 7

Calories Provided from macronutrient: Given (PN) parenterally

injectable lipid emulsion (ILE) 20%
(Intralipid, Smoflipid)

Answer 7

ILE 20% = 2 kcal/mL

Question 8

Calories Provided from macronutrient: Given (PN) parenterally

injectable lipid emulsion (ILE) 30%

Answer 8

ILE 30% = 3 kcal/mL

Question 9

Calories Provided from macronutrient: Given (PN) parenterally

Amino Acid solutions
(Aminosyn, FreAmine,)

Answer 9

Amino Acid solutions = 4 kcal/gram

Question 10

Parenteral Nutrition is an option for patients who are not able to receive adequate nutrition via the GI tract for more than > 5 days.

Question 12

Determining Fluid Needs:

Fluid requirements are determined first when designing a PN regimen.

When weight is greater > than 20kg: Use equation:

Answer 12

Fluid requirement = 1500mL + [(20mL) x (weight in kg - 20)]

Use patients total body weight in calculations unless told otherwise.

Question 13

(NPC) non-protein calories

Question 13

Determining Caloric Needs:

(BEE) Basal Energy Expenditure: “basically doing nothing else”
- is the energy expenditure in the resting state.
How much energy it takes you to lie in a bed and breath.

(TEE) Total Energy Expenditure:
- is a measure of the BEE plus excess metabolic demands as a result of stress, the thermal effects of feeding and energy expenditure from activity.

TEE equation =

Answer 13

TEE = BEE x activity factor x stress factor

Question 14

Protein is used to either repair or build muscle cells or as an energy source.

Answer 14

ambulatory, non-hospitalized (non-stressed): 0.8-1g/kg/day

Hospitalized or malnourished: 1.2 - 2g/kg/day

Question 15

Nitrogen Balance:

Nitrogen intake =

Answer 15

grams of protein intake / 6.25

Question 16

There is ________ grams of Nitrogen for each __________ gram of protein.

Answer 16

There is 1 gram of nitrogen for each 6.25 grams of protein.

Question 17

Non-Protein Calories (NPC) to Nitrogen Ratio (N):

Determined by dividing the grams of total non-protein calories (dextrose + lipids) by the nitrogen.

Desirable NPC:N ratios are:

_______ the most severely stressed patients
_______ severely stressed patients
_______ unstressed patient

Answer 17

80:1 the most severely stressed patients
100:1 severely stressed patients
150:1 unstressed patient

“ex. so there should be 80kcal from non-protein sources per 1 gram of nitrogen”

Question 18

Branded amino acid solutions commonly used for PN include:

Amiosyn
FreAmine
Travasol
TrophAmine
Clinisol

Question 19

Carbohydrates:

__________ is the primary energy source.

Answer 19

Glucose

Question 20

carbohydrates from food or in (EN) enteral nutrition formulas provide _____________

Answer 20

4 kcal/gram

Question 21

carbohydrates in (PN) parenteral nutrition “dextrose” provide ______________

Answer 21

3.4 kcal/gram

Question 22

Occasionally, glycerol is used as an alternative to dextrose monohydrate in patients with impaired insulin secretion.

Glycerol in (PN) provides ___________ kcal/gram

Answer 22

4.3 kcal/gram

Question 23

FAT:

In (EN) enteral formulations, fat provides ___________ kcal/gram

Answer 23

9 kcal/gram

Question 24

In (PN) parenteral formulations, fat provides __________ kcal/mL

Answer 24

depends on fat component of product

ex. a 10% (ILE) injectable lipid emulsion provides 1.1 kcal/mL

Question 25

Intralipid, Smoflipid (20% only)

Answer 25

(ILE) injectable lipid emulsions

Question 26

If Lipids are given once weekly, divide the total calories by 7 to determine the daily amount of fat the patient receives
Lipid emulsions can not be filtered through 0.22 micron filters; __________ micron filters must be used.

Answer 26

1.2

Question 27

Some medications are formulated in a lipid emulsion:

Answer 27

propofol

clevidipine

Question 28

Electrolytes in (PN) parenteral nutrition:

_______1____ is the principal extracellular cation.

_____2______ is the principal intracellular cation.

_____1____ may need to be reduced in renal disease or cardiovascular disease, including hypertension.

_____2____ may need to be reduced in renal or cardiovascular disease.

Answer 28

1) sodium

2) potassium

Question 29

sodium (Na) comes in many different concentrations:

normal saline =

1/2 normal saline =

Answer 29

normal saline = 0.9%

1/2 normal saline = 0.45%

Question 30

Hypertonic saline (greater than 0.9%) is dangerous if used incorrectly.

Question 31

Sodium can be added to (PN) parenteral nutrition as either:

1)
2)
3)

Answer 31

1) sodium chloride (NaCl)
2) sodium acetate (NaC2H3O2)
3) sodium phosphate (NaPO4)

Question 32

If acidosis is present, which sodium formulation should be used?

Answer 32

sodium acetate

” sodium acetate is converted to sodium bicarbonate and may help correct the acidosis”.

Question 33

Normal reference range for Na:

Answer 33

135-145 mEq/L

Question 34

Normal reference range for K:

Answer 34

3.5 - 5 mEq/L

potassium is eliminated renally, so if patients develop kidney disease then potassium will creep up and elevate. Something to monitor.

Question 35

Potassium (K) can be provided in what forms?

1)
2)
3)

Answer 35

1) potassium chloride (KCl)
2) potassium phosphate (KPO4, KPhos)
3) potassium acetate (KC2H3O2)

“same salt forms as sodium”

Question 36

Normal reference range for phosphate (PO4):

Answer 36

2.3-4.7 mg/dL

Question 37

Phosphate (PO4) can be provided by which forms?

1)
2)

But with these two formulations, they DO NOT provide equivalent amounts of phosphate.

Also too Note: (PN) parenteral nutrition orders for phosphate should be written in mmol of phosphate.

Answer 37

1) sodium phosphate
2) potassium phosphate

Question 38

Calcium (Ca), total reference range: ______1_______

Calcium (Ca), ionized reference range:__2_____

Answer 38

1) 8.5-10.5 mg/dL or mEq/L

2) 4.5-5.1 mg/dL or mEq/L

Question 39

The normal serum Calcium level is __________.

Almost half of serum calcium is bound to _________.

So if albumin levels are low, then the measured serum calcium concentration will falsely report _________

Answer 39

8.5-10.5 mg/dL or mEq/L

albumin

low.

Question 40

If albumin is low (______1____), then the calcium level must be corrected with the equation _____2____.

Answer 40

1) albumin < 3.5g/dL

2) Ca corrected (mg/dL) = (calcium reported (serum)) + [(4 - albumin) x 0.8]

Question 41

What is the normal reference range for albumin:

Answer 41

3.5-5 (g/dL)