Mine Flashcards

Question

Ursodial facilitates absorption of

Answer 1

Fat Can dissolve some gall stones and treat primary cholangitis

Answer 2

Primarily in upper small intestine

Answer 3

Primarily jejunum

Answer 4

Primarily in proximal small intestine primarily in jejunum

Answer 5

Pancreatic exocrine insufficiency PERT may help

Answer 6

Hyperglycemia Chromium potentiates action of insulin

Answer 7

think "Broom" Increases stool weight and bulk and increase regularity of bowel movements Foods High in Insoluble Fiber: Whole Wheat Products Wheat Bran: Vegetables: Many common vegetables contribute insoluble fiber, such as:Green beans, Cauliflower, Broccoli, Carrots Fruits with Edible Skins: Apples, pears, and berries consumed with their skins on

Answer 8

Water soluble Do not require bile salts or pancreatic enzymes for absorption Transported directly to liver Excess can cause GI upset

Answer 9

Majority in duodenum

Answer 10

TBW= 80 kg x 60% = 48 Liters ECF= 1/3 x 48 =16 Intravascular space is 1/4 of the ECF. SO 16 x 1/4 =4 liters

Answer 11

With all segments of small bowel and colon in continuity - jejunoileocolonic anastomosis

Answer 12

End jejunostomy - likely needs PN

Answer 13

Enzymes such as cellulase or endoscopic intervention Do not use meat tenderizer that contains papain

Answer 14

Dry scaly rash Impaired wound healing Increased infections & immune dysfunction Treatment: give 100 grams weekly of SO-ILE; 20% ILE formulation, 250 mL 2x weekly, or 500 mL x1 weekly

Answer 15

protein carbs and fat including omega 3 and omega 6

Answer 16

Lipid transport and metabolism Investigated as tx for hepatic steatosis. PN does not contain

Answer 17

Low potassium Normal gastric fluid is 10’mEq/L of K Also hyponatremia and hypochloremia And can cause metabolic alkalosis

Answer 18

D : diuretics A: adenoma / colonic adenoma m: misc: bulimia excessive upper GI losses p: post hypercapnia (build up of co2 in copd) E: emesis n: NG output

Answer 19

Uses body surface area

Answer 20

Can cause mucosal atrophy It is the principle metabolic fuel for intestinal cells

Answer 21

Considered therapeutic for wound healing and immune function Controversial for critically ill septic patient

Answer 22

Calcium gluconate Used for symptomatic pts with ECG changes

Answer 23

Diarrhea bloating and flatulence after sugar intake

Answer 24

80% Nitrogen intake = 24 hour protein intake (g/day) / 6.25 Nutrition output = 24 UUN (grams) + 20% UUN + 2 grams

Answer 25

Wounds fistulas ostomy stool and urine output

Answer 26

Hyperkalemia - trimethoprim can induce hyperkalemia by impairing renal K excretion

Answer 27

Pancreatic lipase, cholesterol ester hydrolase and phospholipase

Answer 28

Soft tissue calcification

Answer 29

Osteomalacia Bone pain Tetany Low Ca

Answer 30

Takes place in small intestine

Answer 31

Enterohepatic circulation

Answer 32

Zinc deficiency, chronic ETOH use, changes in jejunal pH, impaired bile secretion

Answer 33

Is storage form of carbs in the body Stored primarily in liver and skeletal muscle

Answer 34

Conditionally essential AA and primary source of fuel for enterocytes

Answer 35

Sodium glucose transporter 1

Answer 36

Plasma selenium level Erythrocyte selenium concentration Plasma glutathione peroxidase

Answer 37

Metastatic calcification of non skeletal tissues When ca/phos product exceeds 55 mg2/dL Also causes secondary hyper parathyroidism and renal osteodystrophy

Answer 38

Metabolic acidosis Diarrhea induces GI losses of bicarb and can cause metabolic acidosis (with normal anion gap)

Answer 39

14-20 days albumin is a negative acute phase response - decreases in times of stress/inflammation

Answer 40

Fluid restrict Sodium restrict 1.5g/kg/d protein Max concentration PN

Answer 41

Increased urinary sodium - sodium wasting , causing labs notable for hyponatremia Inappropriate release of ANTIDIURETIC HORMONE. Result is increased total body water and dilutional hypontremia

Answer 42

Fluid restriction and increased sodium intake

Answer 43

How well kidneys are concentrating urine Increased = dehydration, kidney disease, DI, SIADH decreased= excessive fluid intake, CHF, adrenal insufficiency , diluted urine

Answer 44

Will be increased as well as urinary sodium Due to excessive water reabsorpton

Answer 45

Loop diuretics or vasopressin2 receptor agonists

Answer 46

Pallor Fatigue Microcytic anemia

Answer 47

PKU - deficiency of phenylalanine hydroxylase enzyme

Answer 48

Can lead to copper deficiency

Answer 49

Liver disease - excreted via bile *same with manganese

Answer 50

Reliability of urinary urea nitrogen therefore cannot calculate nitrogen balance

Answer 51

Riboflavin def Also includes hyperemia of oral mucosa, angular stomatitis, glossitis or magenta tongue

Answer 52

Macrocytic or megaloblastic anemia

Answer 53

300-600 cm

Answer 54

Likely require PN and hydration

Answer 55

Lactic acidosis Needed for metabolism of CHO AND conversion of pyruvate to acetylcoA Without thiamine, Cho metabolism at risk for lactic acid fermentation

Answer 56

0.7 is fat 0.82 is protein 0.85 is mixed 1 is carbs

Answer 57

Carnitine def

Answer 58

Folic acid Hyperhomocysteinemia can increase risk of coronary atherosclerosis folic acid B6 and B12 can reduce plasma levels

Answer 59

Jejunum / proximal bowel; duodenum and proximal jejunum Bc ileal compensation and adaptation

Answer 60

Zinc Can be used in patients not improving on lactulose and rifaximin therapy

Answer 61

Arginine Cysteine Glutamine Glycine Proline Tyrosine

Answer 62

Increased volume and increased sodium Na concentration of ileal output can be as high as 120’meq/l

Answer 63

30 day mortality

Answer 64

Lactated ringers - 130 meq/l na, 109 meq/l chloride, 4 meql/ potassium, 28 meq/l lactate, 2.7 meq/l calcium

Answer 65

Increased lipid oxidation

Answer 66

Hypoglycemia and ketosis

Answer 67

Hyperglycemia and hyper metabolism

Answer 68

Microcytic hypochromic copper and iron = microcytic anemia

Answer 69

Macrocytic anemia

Answer 70

Microcytic hypochromic

Answer 71

30’ml/kg

Answer 72

Duodenum and proximal jejunum

Answer 73

TBI ASPEN cautions against use in ICU

Answer 74

Ileocecal valve and colon May allow life without PN even with less than 60 cm of small bowel remaining

Answer 75

iso-osmolar, diluted juice with sodium. ideal range is 90-120 mEq/L sodium concentration. i.e isotonic IVF. recipe- 1/2 tsp salt + 32 oz water + 2 tbsp sugar

Answer 76

24-48 hr hang time, decreased risk of microbial contamination

Answer 77

foul smelling drainage, peristomal infection most common

Answer 78

66%-75% or 2/3-3/4 needs

Answer 79

d/c or reduce narcotic meds, use low fat/low fiber formula and or isotonic formula (1-1.2kcal/mL), room temperature formula, reduce rate of TF infusion

Answer 80

Cdiff should be ruled out in any pt receiving abx prior to ordering antidiarheal medication, these meds are not indicated with pt who have Cdiff

Answer 81

no longer recommended to assess aspiration

Answer 82

water - if water does not workk, an enzymatic declogging kit or mechanical device for clearing tubes may be used

Answer 83

regular insulin *Short acting* may minimize incidence of hypoglycemia when initiating EN, as titration and tolerance of EN is unpredictable at first

Answer 84

basal/bolus insulin

Answer 85

full strength formula, 40-50 mL/hr advanced to goal rate within 1-2 days. bolus feeds can then be advanced by volumes of 60-120 mL every 8 to 12 hours until goal volume reached

Answer 86

initiate a bowel regimen other strategies- obtain image to r/o abdominal etiology, reduce narcotics or anticholinergic meds, fiber*but may incr gas*, providing additional free water

Answer 87

volume based feeding protocol FEED ME and PEP UP protocols have been used w/ positive outcomes small bowel feeding is superior to gastric feeding in terms of nutrient delivery, however, can still be interrupted during the day and likely not as effective as volume based feeding

Answer 88

the most common symptom when nutrition/hydration withheld is dry mouth- ellivated with good mouth care, ice chips, hard candy EN and hydration do not always ensure comfort - feeding even small amounts can prevent ketonemia and prolong sense of hunger, IVF in these pts can also increase discomfort and respiratory distress

Answer 89

cyclic- 8-20 hours nocturnal- supplement intake and promote unobstructed day activity; would benefit stroke pt in rehab

Answer 90

90-120 mEq/L

Answer 91

hemodynamically unstable pt risk of refeeding should not delay initiation of EN

Answer 92

pt who is s/p stroke on inpatient medical unit, pt with head and neck trauma admitted to ICU, sedated pt s/p tracheostomy *ideal- pt who is alert and cooperate, as passage of feeding tube may be facilitated by concurrent pt swallowing to decr risk of entering respiratory system

Answer 93

Jejunostomy - closes quickly direct jejunostomy tube requires surgical, endoscopic, or fluouroscopic replacement NG/ND can be replaced by RN or medical provider bed side gastrostomy tube is priority, however if standard tube not immediately available, comparable sized Foley or red rubber catheter can be used to keep stomach open

Answer 94

sorbitol content of liquid meds as little as 10-20 g of sorbitol can lead to diarrhea

Answer 95

administer each med separately, followed by 15-30 mL water flush enteric coating, controlled release, and sustained release meds should not be crushed and given via EAD

Answer 96

decreased LOC, >70 years of age, GERD, delayed gastric emptying, supine position, vomiting, bolus feeds, mechnical ventilation, poor oral care

Answer 97

cauterization with silver nitrate trimmed with scissors then treated w silver nitrate topical steroids may also be given

Answer 98

jejunostomy feeding

Answer 99

flush EAD with 30 mL water every 4 hours with continuous feeding also before and after intermittent feedings, and after each GRV measurement

Answer 100

patients own throat, lungs, and stomach can occur both exogenously through feeding tube equipment and endogenously via retrograde contamination from pt own infected secretions there is a correlation between prolonged enteral hang time and bacterial contamination no need for routine cultures in uncomplicated enterally fed pt

Answer 101

referral to physician or surgeon who placed tube - c/f buried bumper syndrome, infection, pressure necrosis

Answer 102

240 mL delivered over 45 min, five times per day 240-720 mL over 20-60 minutes -4-6 x day

Answer 103

240-480 mL delivered over 4-15 min via gravity or syringe, at least 3 hours between feeds

Answer 104

fecal impaction

Answer 105

every 24 hrs and disposable feeding sets should not be reused

Answer 106

formula supply for 8-12 hrs

Answer 107

pt info, EN formula name, delivery route and access device, admin method including rate/volume

Answer 108

used when HOB elevation of 30-45 degrees is contraindicated supine (laying on back) and HOB tilted down below feet

Answer 109

ALL PATIENTS as nutrition screen does not always identify malnutrition

Answer 110

continuous

Answer 111

CHO - taste better most enteral products for PO intake are 40-60 percent kcal from carbs,, 15-25% protein, and 15-35% from fat also usually have a blend of soluble and insoluble fiber

Answer 112

high fiber formula *increase in accumulation of formula sediment in the inner lumen of the EAD is seen more often with high fiber orrr high protein formulas

Answer 113

fiber containing formulas, small diameter tubes, silicone tubes rather than polyurethane, checking GRVS, improper med administration

Answer 114

electromagnetic placement highly accurate

Answer 115

lack of adequate hydration, inadequate or excessive fiber intakm prolonged bed rest/minimal physical activity, use of narcotics

Answer 116

oral care twice daily, HOB 30-45 degrees, post pyloric tube placement

Answer 117

1-2 hour taper or 50% rate reduction to prevent rebound hypoglycemia

Answer 118

when catheter is compressed between first rib and clavicle leads to intermittent occlusion of infusion and increased risk of catheter fracture change in arm position can relieve occlusion - Hallmark sign if catheter tears, tx is removal and replacement

Answer 119

0.1N hydrochloric acid *note this can be associated w/ fever, phlebitis, sepsis

Answer 120

sodium bicarb 1 mEq/L solution

Answer 121

70% ethanol

Answer 122

hepatic steatosis, as excess CHO deposits in liver as fat also can increase CO2 production

Answer 123

chronic complication of PN -from potential aluminum contamination, inadequate Ca provision, Mg and Copper def, also both vitamin D toxicity and def can lead to bone loss

Answer 124

during insertion process- hand hygeine, cleaning site with 0.5-2% chlorhexedine/70% alcohol preparation, use max barrier precautions

Answer 125

fibrin sheath - usually allows meds and PN to infuse but aspirating blood difficult

Answer 126

catheter related blood stream infection *often present with no redness or purulence

Answer 127

tenderness, erthyema, induration from catheter site along subcutaneous tract of a tunneled catheter

Answer 128

erythema or induration within 2 cm of cath exit site, abscense of concomitant blood stream infection and without purulence

Answer 129

inflammation of vessel wall as well as erythema and pain near cath insertion site or along the affected vein

Answer 130

cholestasis *elevated Alk Phos, GGT, conjugated bili usually indicate cholestasis or biliary obstruction elevated direct bili; >2 mg/dL

Answer 131

hepatic steatosis - overfeeding with 43 kcal/kg

Answer 132

neomycin (antiobiotic) can cause partial villious atrophy and steatorhea lab markers are poor indicators in cirrhosis anthropometrics are also poor d/t ascites muscle and fat wasting is common

Answer 133

usually with moderate elevations of aminotransferases, usually c/b overfeeding

Answer 134

characterized by impaired biliary secretion elevated conjugated (direct) bilirubin is common lab manifestation in this population

Answer 135

complication of PN d/t lack of enteral stimulation

Answer 136

dyspnea, seizures, cardiac arrthymias -electrolyte abormalites- low Phos, Mg, K, sodium retention uusually in early phase d/t excessive sodium and fluid intake--leads to pulmonary edema, cardiac decompensation

Answer 137

Increase sodium and increase fluid BUN/Cr ration of >/=20:1 indicates volume depletion

Answer 138

increase chloride:acetate ratio Bicarb 34 is high (22-26) pH of 7.49 indicates alkalosis (7.35-7.45) PCO2 is normal (34-45)

Answer 139

brain Parkinson like sx pt with impaired biliary secretion / liver diseases are at risk for toxicity bc manganese is excreted via bile can be visualized via brain MRI or monitor whole blood manganese levels since 60-80% of it is contained in red blood cells

Answer 140

topical antibiotic ointment if no purulence or clinical signs of sepsis present

Answer 141

increase acetate (bicarb) or decrease chloride metabolic acidosis likely r/t AKI pH indicates acidosis (7.35-7.45) PCO2 is normal (35-45) Bicarb is low (22-26) -- so decreased chloride:acetate ratio

Answer 142

hypomagnesemia

Answer 143

3- excess acetate salts; metabolic alkalosis other causes of metabolic alkalosis- NG suctioning, volume depletion, diuretic use *excess chloride, diarrhea, acute renal failure are common causes of metabolic ACIDOSIS

Answer 144

early initiation of EN to improve bile flow

Answer 145

malnutrition, hepatic dysfunction, renal insufficiency

Answer 146

pancreatitis, obesity, sepsis

Answer 147

longer half life=higher incidence of severe hypoglycemia

Answer 148

superior vena cava syndrome

Answer 149

chest pain, ear ache, jaw pain, swelling of arm, shoulder, neck or face on ipsilateral catheter side, or leaking at the exit or insertion site

Answer 150

pain, swelling, erythema, induration along the subcutaneous tract of a tunneled catheter

Answer 151

complication of subclavian tunneled central catheters, with intermittent or permanent occlusion related to postural changes

Answer 152

SOB, dyspnea, cough, cyanosis of face, neck, shoulder, arms, distended check or neck veins

Answer 153

respiratory acidosis (incr CO2 production), elevated TG (fatty liver), elevated BG suggested feeding range= 12-25 kcal/kg

Answer 154

Hyperglycemia from dextrose = pt receiving more than recommended dose, GIR of 6.2 mg/kg/min Other components are WNL (0.56 g/kg ILE, 1.5 g/kg protein, 33 mL/kg fluid) Ideal GIR range is 4-5 mg/kg/min

Answer 155

catheter related central venous thrombosis central venous catheters can cause endothelial trauma and inflammation which lead to venous thrombosis

Answer 156

thrombotic catheter occlusion, and develops when fibrin adheres to external surfaces of the catheter

Answer 157

reduce AA content of PN solution *most important contributer to MBD is a negative calcium balance.

Answer 158

excessive Ca and inadequate Phos supplementation, excessive protein in PN solution, cyclic PN infusions, chronic metabolic acidosis Hyper parathyroidism; Pth pulls Ca out of bone and into blood and kidneys try to excrete via urine Too much vit D Loop diuretic like lasix

Answer 159

decreased Ca intake and or increased Ca urinary excretion

Answer 160

prolonged use of SO-ILE - proinflammatory and contain toxic phytosterols, which may impair bile flow reduce risk by= cycling PN, supplementing with enteral feeds, adding Ursodiol to stimulate bile flow, use alternative ILE that contain olive oil/fish oil with higher omega3:omega6 ratio- can reduce LFTs

Answer 161

catheter related infections

Answer 162

glucose checks every 2-6 hrs, max GIR of 5 mg/kg/min, start dextrose at 100-150 g/day to reduce hyperglycemia and refeeding

Answer 163

allows body to oxidize fat and results in lower insulin levels, improves liver enzymes

Answer 164

essential carrier molecule in fatty acid metabolism, added as Levocarnitine in TPN, can help with elevated TG

Answer 165

Thiamine - involved in energy metabolism usually depleted in times of malnutrition, weight loss, chronic alcoholism. supplementation of 100-200 mg before feeding or before introduction of dextrose containing IVs. Continue supp for 5-7 days or longer depending on pt nutrition status.

Answer 166

systematic approach to determine cause and prevent unnesessary cath removals/replacements. for ex= determine if occlusion is relieved via postural changes, remove dressing and check for kinks in tubing, review recent flushing techniques, check patency and blood aspiration, assess for signs of edema, redness, pain, dilated vessels

Answer 167

pt safety event of an unexpected occurence involving death or serious physical injury or the risk thereof need for immediate investigation or response ex= pneumothorax after placement of CVC

Answer 168

hypertriglyceridema; >400 mg/dL pancreatitis, fat overload syndrome, hypercoagulation, decr immune function, hepatic injury, pulmonary compromise, infection risk

Answer 169

contamination of catheter hub most common cause of infections for CVADs or implantable devices, with intraluminal colonization

Answer 170

dual energy x ray absorptiometry, urinary phos concentrations, quantitative ultrasounds NOT serum calcium concentrations

Answer 171

thrombotic catheter occlusion

Answer 172

mechanical obstructions, drug or mineral precipitates, lipid deposits

Answer 173

Alteplase 2 mg/2mL - cathflow only FDA approved thrombolytic agent for CVAD occlusions

Answer 174

1 gram = 10 mOsm add all PN components together and divide by total volume

Answer 175

1 gram = 5 mOsm add all together and divide by total volume

Answer 176

Volume=3000 mL 75 grams AA x 10 = 750 mOsm 210 grams Dex x 5= 1050 mOsm = 1800 mOsm total 1800 mOsm / 3000 mL = 600 mOsm/L

Answer 177

subclavian vein >>> less risk of infections compared to jugular or femoral placement external jugular NOT preferred, internal jugular and femoral placement have high risk of infection

Answer 178

NOT recommended - encourages resistant flora

Answer 179

manganese toxicity early phase = weakness, anorexia, headache, apathy late phase = Parkinson like sx toxicity may occur in pt on long term therapy supplemented by multiple trace elements. cholestasis and biliary obstruction also increase risk of toxicity; as more than 90% of manganese is excreted via bile into feces

Answer 180

Pt experiencing respiratory acidosis as evidenced by decreased pH, and elevated PCO2. He is also receiving 45 kcal/kg. Most appropriate nutrition intervention is to decrease calories. Overfeeding can lead to hypercapnia, excessive CO2 production

Answer 181

aluminum contamination *highest in PN calcium and Phos salts, trace minerals, and vitamins in PN solutions Renal insufficient patients at highest risk for toxicity due to impaired renal aluminum excretion causes osteomalacia by impairing calcium bone fixation, inhibiting conversion of 25H Vitamin D to active form, reduced PTH secretion

Answer 182

pt has permanent condition or disorder (defined as >90 days) that impairs food from reaching small bowel, or disease of small bowel impairs digestion or absorption of adequate nutrition I.e - dysphagia dx not covered= malnutrition, anorexia, dementia

Answer 183

disease of small intestine or exocrine glands that significantly impair nutrient absorption, or motility disorders of GI tract which results in severe nutrient absorption i.e=need for bowel rest x 3 months

Answer 184

loss of taste and altered smell, night blindness (as zinc def can lead to vit A def), gonadal hypofunction, dermatitis if severe, alopecia, growth retardation

Answer 185

must document failure of enteral feeding trial (doesnt need to say how long) or explain why enteral feeding tube is not an option

Answer 186

teach back method

Answer 187

access to telephone, electricity, sanitary water, refrigeration

Answer 188

10 times more

Answer 189

pt being fed via jejunal tube

Answer 190

sole source of nutrition 25-30 kcal/kg

Answer 191

midline - peripheral

Answer 192

iron - not included in TNA d/t compatibility iron dextran can be added to 2-in-1, after given test to evaluate tolerance/allergy. serum iron and ferritin levels should be routinely monitored (every 1-3 weeks) to prevent iron overload

Answer 193

education, training, evaluation of pt/caregiver competency

Answer 194

no known reliable indicator role in glucose, protein, lipid metabolism, potentiates action of insulin. pregnancy and t2DM can lead to excess chromium excretion; if def is suspected, can treat hyperglycemic pt with chromium and observe for resolution of sx, lab detection very difficult

Answer 195

renal failure or iron deficiency anemia majority of aluminum in bloodstream is bound to protein, primarily transferrin, and cannot be excreted=excessive exposure to aluminum accumulation sx neither specific or sensitive

Answer 196

6th grade reading level, broad principles in plain language clear graphics and typography design

Answer 197

gastric outlet obstruction also- too rapid of a bolus administration, feeding tube migration, excessive feeding volume, gastroparesis

Answer 198

formula delivery, equipment and supplies delivery, infusion nursing care

Answer 199

inadequate flushing

Answer 200

use largest tube bore that is feasible, flush tubes before and after intermittent feeds or at standard intervals for continuous feeds, before and after meds, limit GRV checks

Answer 201

all pts on PN for >1 year should be recommended for a dual-energy x ray (DXA) scan absorptiometry

Answer 202

weekly at first for 4 weeks or until labs are stable once stable, can be increased to monthly

Answer 203

Medicare criteria

Answer 204

every 6 months a micronutrient assessment should be obtained

Answer 205

tubing, syringes, equipment not always formula

Answer 206

B12 def symptoms anemia, leukopenia,foot numbness, gait difficulty

Answer 207

12 hours at home 8 hours in hospital

Answer 208

peristomal infection

Answer 209

DM and renal disease

Answer 210

7.35-7.45 measures H+ concentration - acid base status of blood

Answer 211

35-45 this is the respiratory component of acid base regulation regulated by the lungs, acidic component

Answer 212

less base than necessary aka acidosis present

Answer 213

more base (HCo3) than necessary = alkalosis present

Answer 214

primary problem is low PCO2, high pH (>7.45) -move in opposite directions- patient is blowing off too much PCO2 respiratory rate quickens, hyperventilation causes: pain, anxiety, fever, stimulated respiration (I.e. ventilator)

Answer 215

primary problem is high PCO2, and a low pH (<7.35) aka acidic -move in opposite directions- compensatory response is increase in HC0O3, respiratory rate has slowed down (hypoventilation) so there is retention of CO2 and causes a buildup of acid causes: COPD, stroke, cardiac arrest, airway obstruction, depressed RR, overfeeding

Answer 216

result from disturbances in plasma HCO3 (bicarbonate//base component) regulated by kidneys

Answer 217

primary problem is low HCO3 (bicarb) and low pH = so the body is in an ACIDIC state -move in same way- causes: severe diarrhea, laxatives, renal failure, DKA, CKD hyperkalemia is common HCO3 also decreases as GFR rises, so this is common in CKD too compensatory response: lungs will hyperventilate, increase RR, to blow off CO2

Answer 218

pH is low HCO3 is low

Answer 219

compensatory response that acts to minimize pH changes produced by the primary disorder also called COMPENSATION -for example, when lungs are causing acidosis, the kidneys will step in and retain HCO3

Answer 220

there is alkalosis = elevated pH, and decreased PCO2 the kidneys will then increase HCO3 (base) excretion

Answer 221

there is acidosis= decr pH, elevated PCO2 the kidneys will retain HCO3 (base) and lose H+ anions

Answer 222

there is alkalosis = >pH, >HCO3 and high bicarb the lungs will retain CO2 (acid)

Answer 223

there is acidosis =

Answer 224

metabolic acidosis = decreased pH, decreased HCO3 present = more acid present the lungs will lose acid (CO2) and breathe it off aka hyperventilation leading to a decrease in PCO2 lab

Answer 225

presence of one primary acid-base disorder PCO2 and HCO3 move in same direction

Answer 226

simultaneous occurence of two or more primary disorders; 2 simple acid-base disorders at the same time pCO2 and HCO3 move in opposite direction= mixed acid base disorder example - high output fistula presenting with respiratory failure example - DKA presenting with PNA

Answer 227

decreased pH due to increased PCO2 (acid) so the kidneys will decrease bicarbonate (HCO3) excretion to increase HCO3 levels

Answer 228

acute airway disorders that cause HYPOVENTILATION = build up of CO2 - airway obstruction, asthma/COPD exacerbation acute CNS depression (drug overdose, head trauma, stroke, infections) acute neuromuscular disorders (guillian barre, spinal cord injury) meds (opioids, sedatives, neuromuscular blockers) acute respiratory disorders (PNA, pulmonary edema, embolus, hemothorax, pneumothorax)

Answer 229

asthma, COPD, emphysema, OSA, myasthenia gravis, spinal cord injury, MS, hypothyroidism

Answer 230

indentify/treat underlying cause ventilator support, respiratory treatments, antimicrobial therapy as needed, antidotes for overdoses, d/c offending meds, avoid alkali therapy - bc this does not treat the underlying cause

Answer 231

alkalosis d/t lungs = >pH, breathing off too much PCO2 this means there is hyperventilation - breathing all of the acid off, making the blood basic the kidneys will then excrete bicarbonate (HCo3) and increase levels of H+

Answer 232

HYPERVENTILATION CNS disorders - anxiety/panic attack, infections, head traumas, cancer hypoxia, elevated altitude pneumonia, pulmonary edema, embolism, hyperventilation, interstitial fibrosis mechanical ventilation - improper settings medications - xanthine derivatives, nicotine, catecholemines, salicylates pregnancy - progesterone leads to incr ventilation cirrhosis sepsis renal insuffiency - impaired compensation

Answer 233

identify/treat underlying cause d/c offending meds if present ventilator support respiratory suppresants- decr ventilation reassurance for anxiety antimicrobial therapy as approproate; PNA

Answer 234

normal or elevated anion gap Anion Gap Basics • It’s a simple blood calculation to figure out where the acid is coming from. • Anion gap = (Sodium) – (Chloride + Bicarbonate) • Normal anion gap ≈ 8–12 (depending on lab).

Answer 235

lungs will hyperventilate

Answer 236

AG = Na - (Cl + HCO3) =

Answer 237

hypo-albuminemia can falsely decrease the anion gap so you have to correct AG *Corrected AG = AG + 2.5 x (4.5 - measured albumin)

Answer 238

normal = 3-11 increased AG = incresed unmeasured anions (PO4, SO4, albumin, ketones) Non-AG = bicarb losses from the ECF are replaced by chloride (every 1 mEq/L increase in Cl should result in 1 mEq/L decrease in HCO3) decreased AG = decreased unmeasured anions (when albumin is low)

Answer 239

U=urinary diversion; loss of bicarb S=small bowel (pancreatic/biliary) fistula; loss of bicarb E= excessive chloride (IVF/PN) D= diarrhea; loss of bicarb C= CKD/carbonic anyhydrase inhibitors (diamox or acetazolimide) decr renal bicarb absorption A= aldosterone or adrenal insufficiency R=renal tubular acidosis; decr renal bicarb absorption

Answer 240

increase levels of acid in the body G= glycols - ethylene and propylene O= oxoproline (acetaminophen;chronic use) L= lactic acidosis (most common; d/t hypoperfusion/sepsis) D=D-lactate acidosis (small bowel bacteria overgrowth), undigested CHO in colon M= methanol toxicity A= aspirin toxicity R=renal failure K=ketoacidosis; DKA and starvation

Answer 241

identity/treat underlying cause antidiarrhea/antisecretory meds to d/c GI losses of bicarb d/c chloride (acid) based fluids adjust PN to have higher acetate (bicarb/base) :chloride ratio fluid resus - insulin for DKA or antimicrobials for sepsis bicarb replacement(oral or IV) antimicrobials for bacterial overgrowth

Answer 242

saline resistant (urine chloride >10 mEq/L) and saline responsive (urine chloride <10 mEq/L)

Answer 243

primary problem is high HCO3 (bicarb) and increased pH (>7.45) -causes; excessive loss off H+ (acid) from kidney or stomach, ingestion or administration of bicarb rich fluids, loss of fluid containing chloride (Acid) *persistent vomiting, NGT output, diuretics DAMPEN lungs compensate by= increase PCO2= lungs will do this by decreasing respiratory rate/hypoventilation, retain CO2 to increase acid levels Metabolic alkalosis --> lungs hypoventilate

Answer 244

Metabolic alkalosis. Caused by losing too much acid or having too much base in blood D=diuretics; loops and thiazides A=adenoma (secrete chloride and K) M=miscellaneous aka bulimia (Excessive upper GI losses) P=post hypercapnia (build up of CO2 as in COPD) and incr PCO2 E=emesis N=NG suction/losses

Answer 245

Saline resistant = saline won’t fix A= alkali ingestion B= beta hydroxylase deficiency E= exogenous steroids L= licorice ingestion C=Cushing's syndrome H=hyperaldosteronism; enhanced H+ secretion/losses the higher the urine chloride, the greater the shift of H+ into cells or increase in H+ secretion

Answer 246

indentify/treat underlying cause volume replacement d/c acetate (bicarb) based fluids; change to chloride based salts adjust PN to have higher chloride:acetate ratio antiemetics, acid suppressive therapy for emesis or high NG output K replacement when K is low acetazolamide; can cause metabolic acidosis, so can help with this , instead of lasix give diamox spironolactone hydrochloric acid=severe/rare cases

Answer 247

NG output pulmonary embolism= respiratory problem septic shock= high lactic acid/lactate buildup d/t tissue hypofunction, so likely metabolic acidosis w/ AG morphine overdose= leads to decr resp rate, so likely acute resp acidosis

Answer 248

use acetate salts instead of chloride salts when low HCO3 present (acidosis) acetate is converted to bicarbonate in the liver ; HCO3 additives are incompatible in PN solutions Excess CHO can lead to increased PCO2 production, difficult weaning from the vent Excess Cl salts can cause non-AG metabolic acidosis Albumin is largest source of unmeasured anions in the blood; can falsely effect AG

Answer 249

metabolic alkalosis - pH >7.45, HCO3 (bicarb) is also elevated. what is the source= GI losses of chloride rich fluids - vomiting, NG tube what would the compensation response be? = lungs will retain CO2, decr resp rate (hypovent) how to treat = fluid resus, replete K, give isotonic fluids

Answer 250

0.45%NaCl (1/2 normal saline) + 10-20 mEq/L KCL Stomach fluid: ~60 mEq Na, 130 mEq Cl, 15 mEq K, 0 mEq HCO3

Answer 251

60 mEq Na, 40 mEq Cl, 30 mEq K, 0 mEq HCO3

Answer 252

140 mEq Na, 80 mEq Cl, 5 mEq K, 0 mEq HCo3

Answer 253

140 mEq Na, 75 mEq Cl, 5 mEq K, 115 mEq HCO3

Answer 254

145 mEq Na, 100 mEq Cl, 5 mEq K, 35 mEq HCO3

Answer 255

140 mEq Na, 104 mEq Cl, 5 mEq K, 30 mEq HCO3

Answer 256

high output = anything >500 ml/d primary disorder=metabolic acidosis; low pH and low bicarb (HCO3) cause = ECF output with high bicarbonate losses; now he is acidic expected compensation; lungs will increase RR, breathe off CO2 treat= change NS to a balanced crystaloid like LR or PLasmalyte

Answer 257

balanced crystalloid; LR, Plasmalyte bicarb or acetate-based custom fluid *pancreas, bile, ileum= all contain bicarb and ~140-145 mEq/L Na, 75-100 mEq/L Cl, 5 mEq/l K, ~30-115 mEq/L bicarb *highest bicarb in pancreatic fluid

Answer 258

pH and HCO3 are low = metabolic acidosis cause= loss of bicarb from ileal conduit, receiving NS IVF expected compensation= lungs will incr RR, to breathe off CO2 (acid) how would you treat= change IVF to balanced crystalloid, bicarb containing IVF

Answer 259

invasive bladder cancer surgery complication- metabolic acidosis; normal/non anion gap hyperchloremic, U in the USEDCAR mnemonic experiences= excess losses of bicarb and sodium, increased absorption of ammonium,hydrogen, and chloride *know common to have loss of bicarb and Na

Answer 260

Crohn's, UC, and colitis indeterminant

Answer 261

transmural unpredicatable small bowel involvement - rectal sparing fistulas, granulomas, lesions, 25-30% have no bleeding

Answer 262

mucosal disease, starts from rectum up, colonic involvement only, bleeding very common, pain when defecating

Answer 263

features of both crohns and UC 10% of cases

Answer 264

folate metabolism

Answer 265

protein metabolism

Answer 266

alters mineral and protein metabolism

Answer 267

Vitamin D, B12, vitamin C and vitamin A Zinc, Selenium Calcium, Magnesium, Iron

Answer 268

IBD = significant nutritional risk - bowel rest with PN not superior to EN unless high output fistula or high grade SBO present - Elemental formulas not better than polymeric - CD fistula treated with PN may close but high rate of recurrence -peri operative PN is appropriate if malnourished

Answer 269

IV supplementation is required to maintain health and or growth vs intestinal insuffiency; doesn't require IV supplementation but still+reduction of gut absorptive function

Answer 270

patients with <200 cm of functional small bowel 2 subgroups - colon in/not in continuity - possible reconnection - total colectomy

Answer 271

operative report at time of surgery, or radiologically via opsiometer

Answer 272

1. duodenostomy or jejunoileal anastomosis with <35 cm residual bowel 2. Jejunocolic or ileocolic anastomosis with <60 cm remaining bowel 3. end jejunostomy with <115 cm remaining bowel

Answer 273

Carbs, Fats, Proteins Calcium, Magnesium, Trace Elements, Vitamins

Answer 274

water, electrolytes

Answer 275

small bowel - ~7 L (max 12 L) colon - ~1.4 L (max 5 L)

Answer 276

pt will still have good absorption unless >75% resected good ileal adaptation preserves absorption of B12 and bile salts normal intestinal transit peptide YY is present least common type of SBS

Answer 277

adequate absorption if >/=60 cm of jejunum to colon remaining malabsorption of B12 and bile salts Poor jejunal adaptation rapid transit- reduced peptide YY small bowel bacterial overgrowth

Answer 278

>/=100 cm of small bowel to avoid TPN large fluid losses, malabsorption, poor jejunal adaptation, acid hypersecretion, rapid gastric emptying, rapid intestinal transit, most challenging

Answer 279

acid hypersecretion - decr activation of pancreatic enzymes rapid intestinal transit - no time to mix food in intestine decreased peptide YY loss of surface area bacterial overgrowth bile acid wasting

Answer 280

loperamide, codeine, diphenoxylate-atripine

Answer 281

catabolic state, up to 150% REE, 35 kcal/kg, 1-1.5 g/kg protein +MCT, pancreatic enzymes mild-likely just need IVF and adv PO as toleranced mod/severe- start EN via NG, or NJ if NG poorly tolerated; likely benefit from semielemental formula for acute pancreatitis decr B12 and increase malabsorption of fat soluble vitamins, lower levels of antioxidants, insulin dependent diabetes APACHE and Ranson are 2 criteria to determine severity of pancreatitis

Answer 282

chronic pancreatitis CF Schwachman syndrome (short stature, nutropenia, anemia, PI, thrombocytopenia)

Answer 283

acute -wacth for hypocalcemia (25%) alcoholic - thiamine, folate, mg, zinc, Selenium, b12 chronic - B12 and ADEK, evaluate fat metabolism, TG, steatorrhea PI - focus on growth and weight gain for children- assess nutrient needs, may have increased energy needs

Answer 284

metabolic organ regulates protein and energy metabolsim vitamin storage and activation detoxifies and excretes waste products

Answer 285

abstain from alcohol corticosteroids nutrition - MCT EN as affective as steroids, PN may be beneficial on liver function, no published studies for EN vs PN

Answer 286

severity of malnutrition correlates with severity of liver disease frequently underdiagnosed

Answer 287

25-35 kcal/kg (ICU), normal needs if stable 1-1.2 g/Kg protein, up to 2 g/kg if malnourished/renal function is up Zinc can help in hepatic encephalopathy; cofactor for ammonia break down metabolic dysfunction-associated steatotic liver disease- new term for non alcoholic fatty liver disease

Answer 288

need late night snack to reduce - increased fat oxidation, catabolism of protein cirrhosis is a catabolic state cirhotic patients utilize fat as fuel more; increased ketone production

Answer 289

REE measured with indirect calorimetry general estimates: 25-30 kcal/kg ascites increases REE by 10% use actual, ideal, or dry weight 1-1.2 g/kg protein, or 1.5 g/kg if malnourished high complex carbs frequent small meals and bedtime snacks MVI with Ca, Znc, Mg

Answer 290

STAMP, STRONGkids, PYMS

Answer 291

37-42 weeks

Answer 292

low birth weight - <2500 g very low birth weight - <1500 g -> almost always on PN, no electrolytes at first, peripheral calcium can cause skin damage, start GIR 5-6, goal 8-12, target BG 120-150, treat hyperglycemia by decreasing GIR, not starting insulin, watch TG if >1000 g birth weight, max lipid 3g/kg extremely low - <1000 g micronate - < 750 g

Answer 293

birth weight <10%ile on intrauterine growth curve or birth weight / length below -2 SDS for gestational age - causes: pregnancy induced HTN, maternal malnutrition, maternal substance abuse, chromosomal abnormalities *infant can be low body weight but full term

Answer 294

birth weight >90%ile on intrauterine growth chart -causes: maternal diabetes (most common), genetic predisposition, miscalculation of due date

Answer 295

metabolic acidosis and azotemia azotemia- build up of nitrogen containing waste; BUN>100

Answer 296

free water

Answer 297

increased nutrient needs PERT - max of 2500 units of lipase/kg/meal or 10,000 units lipase/kg/day high calorie diet - 110-200% of DRIs supplement fat soluble vitamins-ADEK in water miscible form supplement salt for infants - 1/8 tsp day from 0-6 months, or 1/4 tsp day >6 months

Answer 298

liquid gold macronutrient content - 20 kcal/oz, 0.9-1.4 g/protein per 100 mL, 3.5-3.9 g fat/100 mL varies

Answer 299

third trimester *this is why neonate/premie formulas include incr Ca, Phos, Zinc for bone growth

Answer 300

10% more viscous than standard, wont work with antacid meds indicated for babies with severe GER

Answer 301

4. formula high in MCT

Answer 302

all infants *except galactosemia*

Answer 303

galactosemia

Answer 304

exclusively breast fed - 400 units/day breast fed and formula - assess and supplement accordingly formula fed - no supplementation if daily volume of formula consumed meets needs

Answer 305

prophylactic supplementation in all new borns

Answer 306

breast fed w/o supplementation dark skin birth prior to 32 weeks gestation recent immigration from developing country, where they live (is it sunny/cold/cloudy?) at risk conditions -malabsorption, epilepsy/cerebral palsy *phenobarbitol*

Answer 307

c/f breast fed infant if mother is vegan possible concern for IF infants/children

Answer 308

fortify in breast fed infants by 4-6 months, as their endogenous supply is depleted commercial formulas contain iron may need supplementation in times of malabsorption

Answer 309

no need to supplement from birth to 6 months after 6 months may need supplementation based on water supply -well water will need flouride ex: 0.25 mg/d for 6 month-3 years of age if water contains < 0.3 ppm

Answer 310

cows milk *low in iron, low in vitamin C & E, low in essential fatty acids, high renal solute load

Answer 311

inability to consume <60-80% of nutrient needs for >5 days in children over 1 year of age or >3 days in children less than 1 year

Answer 312

orogastric tube

Answer 313

if it is evident that full PO feeds or EN goals are not going to be met, start PN: infants: within 1-3 days children/adolescents: 4-5 days critical illness: not recommended within 24 hr of PICU admission, start of PN depends on intake of EN and overall nutritional status

Answer 314

pediatric: 0.15 g/kg/hour adults: 0.11 g/kg/hour

Answer 315

use for cholestasis (d bili > 2 mg/dL) dosage is 1 g/kg/day Omegaven

Answer 316

soy based - 0.5 g/kg/day for infants/children multi oil based -30% of calories

Answer 317

fat emulsion should run over 12 hrs if possible. if not possible, infusion should be completed in 24 hrs with 2 separate doses of no more than 12 hrs hang time each

Answer 318

2-in-1 neonates/infants receive IV fat emulsion separate from dex and AA

Answer 319

dex: 40-60% kcal fat: 20-40% kcal >60% from fat will cause ketosis protein: based on g/kg, type of AA solution differs from birth to 1 year and after 1 year

Answer 320

taurine is added pH is lower higher levels of tyrosine, histadine lower - phenylalanine, methionine, glycine

Answer 321

manganese And copper-also excreted via bile

Answer 322

reduce/change lipids- soy to SMOF or SMOF to omegaven cycle TPN GIR within range adjust trace elements

Answer 323

<1 kg: 1.5 mL/day <3 kg: 3.25 mL/day 3 kg-11 years: 5 mL/day >11 years: 10 mL/day of adult formulation

Answer 324

carnitine - as Levocarnitine transports LCT along membrane low levels of carnitine associated with elevated TG, elevated alk phos

Answer 325

Conditionally essential. cysteine added to preterm/infant PN to reduce the pH and increase calcium/Phos solubility

Answer 326

PN components with lowest aluminum amount should be used to reduce exposure in pediatrics FDA recommends <5 mcg/kg/day

Answer 327

urine sodium

Answer 328

neonate is first 28 days of life preterm: <37 weeks GA term: >/= 37 weeks GA

Answer 329

small for gestational age - <10%ile large of gestational age- >90%ile appropriate for gestational age -10th-90th%ile

Answer 330

1. VLBW who cannot be adequately fed enterally 2. premature neonates with severe respiratory distress syndrome 3. neonatal congenital defects (volvulus, meconium ileus, atresia, gastrochesis, hirshprungs, enteric fistula, diaphragmatic hernia)

Answer 331

VLBW - ideally within first few hours of life, use starter/vanilla/base PN LBW premature- within 24-48 hrs and continue until adequate EN established

Answer 332

provides immediate protein for extremely premature infant often contains dex (5-10%) and AA (3-4%), can also contain heparin, calcium, MVI

Answer 333

75-120 mL/kg/day

Answer 334

60-120 mL/kg/day

Answer 335

decreased fluid requirements for first 48 hrs of life to allow natural diuresis (70-90mL/kg) increased fluid for: increased insensible losses, provision of optimal nutrition (140-160 mL/kg/d for full enteral nutrition)

Answer 336

PN is part of maintenance fluids PN total volume = (total 24 hr fluid goal - fluids from drips - ILE - EN feeds)

Answer 337

special formulations metabolized to ammonia-> converted to urea->eliminated in urine high AA can incr ammonia in bloodstream d/t immature urea cycle activity, can result in incr BUN and organic acids formation

Answer 338

BG guidelines not the same in neonates tolerance of GIR is indicated by glucose screening values of 60-150 mg/dL with negative to trace amounts of glucose in urine GIR 10-14 mg/kg/min, max 14-18

Answer 339

EFAD can happen very quickly - minimal fat stores smallest neonates become deficient in 3-7 days provided as either 10%, 20%, or 30% emulsions

Answer 340

first 24 hrs neonates receive no electrolytes - D10W after first 24 hrs, can add sodium - D10 0.2%NS

Answer 341

extremely important to prevent MBD preterm infants lost out on accrual during 3rd trimester

Answer 342

1.7 : 1 mg:mg or 1.3 mol : 1 mol

Answer 343

<2.5 kg = 2 mL/kg/day >/= 2.5 kg = 5 mL/day

Answer 344

precursor of glutathione antioxidant allows for reduction of methionine added at 40 mg per gram of AA lowers pH- improve Ca:Phos solubility not required if providing at least 3g/kg/day

Answer 345

quaternary amine recquired for transport of LCT across mitochondrial membrane for oxidation premature infants are at risk for def d/t limited reserves supplementation required in premature infants <32-34 weeks gestational age

Answer 346

cofactor of lipoprotein lipase: enhances lipid clearance only in NICU PN, recommended dose: 0.25-1 unit/mL of PN remains patency of catheter, reduces vein irritation

Answer 347

mother with HIV/AIDS if mother not on anti-retroviral (ART), needs to have undetectable levels if a mothers med could cause harm to infant if passes through human milk

Answer 348

recommended feeding method for virtually all infants gold standard AAP recs exclusively breast feed for first 6 months of life supplement after 6 months with formula and additional foods

Answer 349

donor milk

Answer 350

not all created equally recommend fortification for BW < 1500 g human milk based - prolacta cows milk based hydrolyzed and Elemental formulas

Answer 351

0.5 mL PVS, Fe and folic acid (depends on weight), 200 IU vitamin D

Answer 352

Iron (depends on weight) and vitamin D

Answer 353

poly vi sol - depends on weight

Answer 354

You can fix it by giving saline - These patients are usually low on fluids and low on chloride. - Giving them saline helps correct the alkalosis. Cause: •Vomiting (losing stomach acid and chloride) •Diuretics (pee out too much salt and water) •Dehydration Think: “They’re DRY and SALTY — just give them saline!”

Answer 355

Meaning: Giving saltwater won’t fix it. • These patients aren’t low on fluids, or their problem is hormonal, not just salt loss. • You have to fix the underlying disease, not just rehydrate them. Causes: •Hyperaldosteronism (body makes too much aldosterone, which keeps pushing out acid and potassium) •Cushing’s syndrome •Severe low potassium Think: “They’re HORMONALLY MESSED UP — saline alone won’t help.”

Answer 356

Anion gap is normal. •Problem isn’t new acids — it’s losing bicarbonate or gaining chloride. •Chloride usually rises to “replace” the lost bicarbonate (hence sometimes called hyperchloremic acidosis). Causes you’ll see: •Diarrhea (lose bicarb through your gut) •Renal tubular acidosis (kidneys fail to reabsorb bicarb) •Certain IV fluids (like normal saline overload) Simple memory tip: Losing base, not gaining bad acid

Answer 357

Anion gap is HIGH (>12–16+). •There are extra acids in the blood that shouldn’t be there. •These acids eat up bicarbonate while they flood the blood. Causes you’ll see: (Use the famous mnemonic: MUDPILES) • Methanol (antifreeze poisoning) • Uremia (kidney failure) • Diabetic ketoacidosis (DKA) • Propylene glycol (another toxic alcohol) • Isoniazid or Iron overdose • Lactic acidosis (shock, sepsis) • Ethylene glycol (antifreeze again) • Salicylates (aspirin overdose) Simple memory tip: “Too much poison acid.”

Answer 358

4.3 kcal/kg - used in IVF shortages

Answer 359

Clinamix -1 and 2 liter dual chamber -dextrose with or without Ca -amino acids with or without lytes Kabiven -3 chamber, 4 sizes avail -need to be activated by pharmacy , limited amounts of protein and lytes, need to add MVI and trace minerals

Answer 360

1.2 micron filter

Answer 361

phosphate (from phospholipid) around 1.5 mmol/100 mL and vitamin K from soy and or olive oil

Answer 362

central and peripheral PN 30% only for central -TNA only

Answer 363

SMOF or Omegaven

Answer 364

soy and egg alllergies can test prior to admin for allergy

Answer 365

PNAC - PN associated cholestasis d bili >2 dosed 1 g/kg day max 1.2 micron filter

Answer 366

1.2 micron filter

Answer 367

leakage of intravenous (IV) fluids, medications, or PN administered through the same line, out of the vein and into the surrounding tissues. Causes: catheter dislodgement or perforation of the vein wall, fragile veins, improper insertion technique, increased venous pressure.

Answer 368

can lead to a range of local complications, including: pain, swelling, redness, and blistering. Tissue damage, ranging from irritation to necrosis, depending on the osmolarity and vesicant properties of the fluid or medication. delayed medication or nutrient delivery. *Identifying patients at higher risk for extravasation (e.g., those with fragile veins, altered mental status who may dislodge lines)

Answer 369

a blood clot that forms inside a blood vessel, obstructing the flow of blood. it can occur within the vein where the catheter is placed or within the catheter itself. Causing a partial or complete occlusion of the IV catheter, resulting in difficulty infusing or aspirating. Local symptoms such as pain, swelling, and redness along the vein. More serious complications like deep vein thrombosis (DVT) or catheter-related bloodstream infections (CRBSI).

Answer 370

causes -damage to the inner lining of the vein during insertion, slow or turbulent blood flow around the catheter, presence of the foreign body (catheter) itself, which can activate the coagulation cascade. pt's with a hypercoagulable states, those with a history of DVT, hypercoagulable conditions, or certain medical conditions

Answer 371

TNAs maintain final concentrations of amino acid ≥4%, monohydrated dextrose ≥10%, and injectable lipid emulsion ≥2% are more likely to remain stable for up to 30 hr at room temperature orrrr for 9 days refrigerated followed by 24 hr at room temperature

Answer 372

no, it can increase risk of central vein thrombosis.

Answer 373

ASPEN recommends using a 1.2 micron in-line filter for administration of total nutrient admixtures (TNAs), dextrose-amino acid admixtures and lipid injectable emulsion (ILE). For TNAs, place the filter as close to the catheter hub as possible. For dextrose-amino acid admixtures, place below the Y-site where the dextrose-amino acid admixture and the ILE co-infuse

Answer 374

1. Starvation-related malnutrition: Chronic starvation without inflammation (eg, anorexia nervosa). 2. Chronic disease-related malnutrition: Inflammation is chronic and of mild to moderate degree (eg, organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity) 3. Acute disease or injury-related malnutrition: Inflammation is acute and of severe degree (eg, major infection burns,trauma, closed head injury).2

Answer 375

** Involuntary weight loss of 10% of usual body weight within 6 months or 5% within 1 month ** Involuntary loss of 10 lb within 6 months ** Body mass index (BMI) less than 18.5 kg/m2 ** Increased metabolic requirements ** Inadequate nutrition intake, including not receiving food or nutrition products for more than 7 days

Answer 376

** Weight for length, weight for height, or sex less than 10th percentile (–1.28 z score) ** BMI for age or sex less than 5th percentile (–1.64 z score) ** Increased metabolic requirements ** Impaired ability to ingest or tolerate oral feeding Documented inadequate provision of or tolerance to nutrients ** Inadequate weight gain or a significant decrease in usual growth percentile

Answer 377

High Risk ** Preterm less than 28 weeks at birth ** Extremely low birth weight less than 1000 g ** Infant establishing feeds after episode of NEC or GI perforation ** severe congenital gastrointestinal malformations (eg, gastroschisis) Moderate Risk ** Preterm 28th–31st weeks, otherwise well ** Intrauterine growth restriction (weight less than 9th percentile) ** Very low birth weight 1000–1500 g ** Illness or congenital anomaly that may compromise feeding

Answer 378

Global Recommendations 5A: Individualize the selection of vascular access device (VAD) for PN administration based on an evaluation of the risks and benefits of the device, clinical factors, and psychosocial considerations. 5B: Choose the smallest device with the fewest number of lumens necessary for the patient’s needs. 5C: Dedicate 1 lumen of the VAD for PN administration when possible. 5D: Position the tip of the central venous access device (CVAD) in the lower third of the superior vena cava near the junction with the right atrium. 5E: Confirm optimal position of the CVAD tip prior to initiating PN

Answer 379

Use peripheral PN only for short-term purposes, no more than 10–14 days, as supplemental PN or as a bridge therapy during transition periods, where oral intake or EN is suboptimal or clinical circumstances do not justify placing a CVAD. 6B: Estimate the osmolarity of peripheral PN formulations. 6C: Maintain an upper limit of 900 mOsm/L for the peripheral PN formulations.

Answer 380

8A: Consider preoperative PN in severely malnourished patients unable to tolerate sufficient oral intake or EN. 8B: Reserve postoperative PN for severely malnourished patients unable to tolerate EN for more than 7 days, unless initiated preoperatively. Neonate and Pediatric 8C: Consider preoperative and postoperative PN in malnourished neonates and children who are unable to tolerate oral intake or EN.

Answer 381

High GI losses, decubitus ulcers, wounds, burns consider additional 10-15 mmol/day

Answer 382

via bile hold or remove for cholestasis

Answer 383

burns, malabsorptive states, critical illness consider additional 20-40 mcg/day

Answer 384

kidneys consider holding or decreasing in renal failure

Answer 385

cardiomyopathy

Answer 386

glucose intolerance

Answer 387

not well documented

Answer 388

anemia (microcytic), dipigmentation of hair, neurologic abnormalities

Answer 389

Dextrose: ~50% kcal, or 60-85% of non protein calories (most PN's will have 150-350 g/day) Protein: g/kg as appropriate, can initiate at goal caution with azotemia (BUN >100 mg/dL) Fat: 15-30% kcal, do not exceed 2.5 g/kg/day]]

Answer 390

Acute liver failure Also known as fulminant hepatic failure. During this, glycogen stores are rapidly depleted and insulin’s metabolism is impaired. Oral intake also usually reduced

Answer 391

Iron Blood products are typically recruited before stem cell trans plant and can lead to iron overload

Answer 392

A proximal high output The higher the fistula occurs in the GI tract , the greater the output and higher risk of metabolic derangements. As seen in proximal high out put fistulas. High output = >500 mL/d.

Answer 393

Fiber containing EN Opposite for distal ileal or colonic low output fistulas— those require low fiber or fiber free EN, and site should be as high up as possible to increase surface area of absorption

Answer 394

Azotemia Med leads to increased urine output and lyte abnormalitie. Specifically low K and Mg due to increased K and Mg excretion. Loop diuretics can lead to azotemia due to volume depletion

Answer 395

EFAD profiles have been shown to improve in patients with CF AFTER lung transplant Usually, EFAD signs are uncommon in patients with CF. usually causes poor growth and poor pulmonary function. Sometimes omega 3 can be used in management of CF, however mixed results from trials.

Answer 396

Proximal jejunum

Answer 397

Respiratory acidosis

Answer 398

B metabolic alkalosis

Answer 399

Answer: C. Metabolic acidosis

Answer 400

Answer: B. Bicarbonate

Answer 401

Loss of gastric acid (H⁺) increases blood bicarbonate levels And causes metabolic alkalosis

Answer 402

Loss of bicarbonate (HCO₃⁻) from intestinal secretions Causes Metabolic acidosis (non-anion gap)

Answer 403

Zinc supplementation at risk populations = older adults, postoperative GI surgery , liver disease, renal disease, malabsorptive conditions Plasma and urinary zinc have been confirmed as the most reliable biomarkers of zinc status in healthy populations. However, plasma zinc should be interpreted with caution in patients with low albumin, inflammation or hemodilution. Pt with wounds who are deficient or shown to be losing zinc in wound exudates (negative pressure therapy) may benefit from supplementation. Supplementation for all patients with wounds is not recommended due to the risks of copper deficiency and adverse effects on wound healing with zinc toxicity. Clinical manifestations of zinc deficiency are evident at plasma levels < 33 mcg/dL If signs of zinc deficiency such as alopecia and skin rash are noted on nutrition focused physical exam it is most likely a deficiency is prese Treatment for zinc deficiency in adults is typically 220 mg zinc sulfate (50 mg elemental zinc) twice daily for a total of 100 mg elemental zinc per day. Oral replacement will generally alleviate all clinical manifestations within 1-2 weeks.

Answer 404

Thiamin = this deficiency is more common in heart failure patients than the general population Mechanisms include decreased intake, poor absorption (due to cardiac cachexia and splanchnic congestion), increased urinary excretion with diuretics , altered thiamin metabolism. High dose loop diuretics ( urosemide) are thought to be the most important factor contributing to thiamin deficiency. Furosemide causes thiamin deficiency due to increased urinary thiamin excretion Clinical trials in patients with CHF have shown that thiamine supplementation increases systolic, diastolic and central venous pressures with a decline in heart rate and increase in LVEF.

Answer 405

COPPER Nutritional deficiencies of iron, vitamin B12, folate, copper, thiamin and zinc have all been described after gastric bypass surgery. B12 was normal, but when deficient can also cause anemia, neurological and psychiatric symptoms including numbness, paresthesia and memory disturbance. Thiamin deficiency can lead to neuropathy such as beriberi or Wernicke ’s encephalopathy but not anemia. Zinc deficiency can lead to pica, dysgeusia, hair loss and skin lesions, not anemia. Copper deficiency though rare, can present with anemia (microcytic, normocytic, or macrocytic) and also neutropenia. In addition, it can manifest as myelopathy and peripheral neuropathy.

Answer 406

30-35 kcal/kg IBW daily with >= 1.5 g protein per kg body weight Energy needs will vary with the individual, but energy requirements are usually estimated at 1.3 - 1.5 x basal energy expenditure (BEE), or approximately 30 to 35 kcal per kilogram IBW. Protein intake should be aimed at 1.5 - 2.0 g per kilogram IBW during the first 1 to 3 months after transplantation.

Answer 407

hyperkalemia Cyclosporine or tacrolimus, commonly used after solid organ transplantation for immune suppression, can frequently cause nutrient disorders such as hyperkalemia, hypomagnesemia, hyperglycemia, and hypercholesterolemia, and has a direct effect on the renin-angiotensin-aldosterone system contributing to altered potassium homeostasis. Tacrolimus and cyclosporine also affect the renal tubular excretion of potassium

Answer 408

1-1.2 g/kg

Answer 409

delayed weaning from the vent prolonged underfeeding of patients with chronic respiratory disease may lead to deficits in lean body mass that may increase mortality. Patients with COPD frequently have an increased REE secondary to their disease, although the exact etiology of this hypermetabolism is not fully understood. Accumulation of an energy deficit throughout a hospitalization has been associated with a greater risk of increased length of stay, complications, infections, days on antibiotics, and time on mechanical ventilation.

Answer 410

= famotidine NOT octreotide since it is recent surgery Histamine 2-receptor antagonists/famotidine and octreotide can be added to PN solutions; however, octreotide may impair small intestinal adaptation if used in the early phase following significant resection of the bowel. Omeprazole or a Proton pump inhibitor are effective antisecretory agents but cannot be added to parenteral nutrition. Clonidine can only be taken by oral route or patch.

Answer 411

continuous IV insulin In the critical care setting, continuous intravenous insulin infusion has been shown to be the best method for achieving glycemic targets and allows for off cycles during the 24-hour period when enteral feeding is discontinued.

Answer 412

11 - 14 Kcal/kg actual body weight BMI is >30 kg/m2, the goal of the parenteral and enteral regimen should not exceed 65% to 70% of target energy requirements as measured by indirect calorimetry. If indirect calorimetry is unavailable then 11 - 14 Kcal/kg of actual body weight is recommended for individuals with a BMI 30 - 50 kg/m2. For individuals with a BMI > 50 kg/m2 the recommendation is 22 - 25 kcal/kg of ideal body weight.

Answer 413

PICC is defined as a catheter inserted via peripheral vein whose distal tip lies in the lower third of the superior vena cava or the cavoatrial junction. The cephalic or basilic veins are often used as the insertion site for PICCs. Central or peripheral access is not defined by the initial point of entry into the vascular system but rather by the position of the distal catheter tip. Central lines are defined as catheters with the distal tip in either the superior or inferior vena cava. Therefore, by definition, a PICC is used as central venous access.

Answer 414

difference is the type of fluid or medication that leaks out of the vein into the surrounding tissue Infiltration: when a non-vesicant solution or medication leaks into the surrounding tissue. non-vesicant does not typically cause significant tissue damage or irritation. Common examples of non-vesicant fluids = normal saline, dextrose solutions, and some non-irritating antibiotics. Extravasation: when a vesicant solution or medication leaks into the surrounding tissue. this vesicant can cause significant tissue damage, blistering, or even necrosis (tissue death). Examples = certain chemotherapy drugs, vasopressors (like norepinephrine), and some electrolyte solutions (like calcium chloride).

Answer 415

blood cot alteplase=Thrombolytic agent

Answer 416

Sodium: 135-145 Potassium: 3.5-5 Chloride: 98-108 CO2: 23-30 Calcium: 9-10.5, or 8.5-10.5 Phosphorus: 2.5-4.5 Magnesium: 1.7-2.4

Answer 417

highest in chloride (130 mEq), and H+ ions -aka ACID- decent amount of sodium (60 mEq), and highest in potassium (15 mEq), NO BICARB!

Answer 418

sodium; ~140-145 mEq/L chloride; 75-104 mEq/L K; 5 mEq/L and ileum, bile, pancreas contain bicarb. highest fluid in bicarb is pancreas; 115 mEq/L

Answer 419

can lead to too much flouride, fluorosis, or impair bone growth

Answer 420

human maternal milk/donor milk can decreas risk of NEC or sepsis minimal enteral feeding is not recommended anymore probiotics are not widely used for treatment of NEC

Answer 421

increases kcals, but also increase osmolarity. want to keep it <400 mOsm/L to prevent renal solute load, malabsorption, poor tolerance AAP recs max osmolarity if 450 mOsm/L for infant formulas

Answer 422

intense inflammatory state, highly catabolic body oxidizes lipid as fuel glucose production increased / glucose uptake decreased hyperglycemia and insulin resistance is common energy expenditure increases at first, tapers after ~21 days feed high protein

Answer 423

AKI = 20-30 kcal/kg can require increased protein anuric: 1-1.2L fluid/d Oliguric: fluid as tolerated CKD= 30-35 kcal/kg protein 1 g/kg appropriate PD= 30-35 kcalk/kg - subtract dextrose absorbed via dialystate 25-35 kcal/kg for outpatient PD, 1-1.2 g/kg stable PD outpatient

Answer 424

respiratory acid/base disorders, fix the respiratory issue

Answer 425

Pathophysiology: Normal serum osmolality with low measured sodium due to laboratory artifact. • Causes: • Hyperlipidemia • Hyperproteinemia (e.g., multiple myeloma) • Clinical Features: Typically asymptomatic; discrepancy between serum sodium and osmolality. • Management: No specific treatment; address underlying cause. Hypertonic Hyponatremia • Pathophysiology: Increased serum osmolality due to the presence of osmotically active substances drawing water into the ECF, diluting sodium concentration. • Causes: • Hyperglycemia • Mannitol administration • Clinical Features: Symptoms related to underlying cause; signs of hyponatremia may be present. • Management: Treat underlying cause (e.g., insulin for hyperglycemia); correct sodium levels cautiously.

Answer 426

Steatosis = fat buildup * elevated liver enzymes Cholestasis = bile flow obstruction * elevated alk phos, elevated bilirubin Feature Hepatic Steatosis (Fatty Liver) Cholestasis (Bile Flow Blockage) Cause Fat buildup in liver cells Impaired bile flow (inside or outside liver) Common Triggers Alcohol, obesity, TPN, meds Gallstones, liver disease, TPN, sepsis Main Lab Finding Elevated AST & ALT High Alk Phos & Direct Bilirubin Symptoms Often none; fatigue, RUQ pain Jaundice, dark urine, pale stool, itching Reversible? Often yes (with lifestyle change) Depends on cause (some reversible) Risk if Untreated Fibrosis → cirrhosis Liver damage, fat-soluble vit def, infection

Answer 427

occurs when both sodium and water are lost, but more sodium is lost than water, leading to a low serum sodium concentration. Depletion of ECF volume Cause; Renal losses, diuretics, GI fistula output, excessive sweating, burns, wounds/drains, SAH and cerebral salt wasting Urine sodium concentratio < 20 meq/l Urine osm > serum osm Clinical Features: Signs of volume depletion such as hypotension, tachycardia, dry mucous membranes, and decreased skin turgor. Management: Volume repletion with isotonic saline to restore ECF volume and suppress antidiuretic hormone (ADH) secretion. Give isotonic fluids to expand ECF

Answer 428

Total body water increases while total body sodium remains normal, leading to dilutional hyponatremia without signs of volume overload. Usually due to excess anti diuretic hormone Also due to medications, central nervous system disorders, pulmonary diseases, or malignancies. • Endocrine disorders: Hypothyroidism, adrenal insufficiency. • Primary polydipsia: Excessive water intake. • Low solute intake: “Tea and toast” diet, beer potomania. SIADH (Syndrome of Inappropriate Antidiuretic Hormone): Patients can be euvolemic despite having low sodium, because the excess water is evenly distributed. SIADH- usually from brain/CNS injury or malignancy, head trauma, lung Ca, pneumonia, can also be psychogenic High urine sodium and high urine osmolarity Urine osm > serum osm Clinical Features: Typically asymptomatic or mild symptoms; no signs of volume depletion or overload. • Management: Address underlying cause, fluid restriction, salt tabs, and in some cases, administration of vasopressin receptor antagonist or loop diuretic Often present with normal Blood pressure, heart rate, and tissue perfusion /// No signs of fluid retention (like edema) or fluid loss (like dry mucous membranes)

Answer 429

Fluid OVERLOAD • Pathophysiology: Both sodium and water content increase, but water retention >>>> sodium retention, leading to edema and dilutional hyponatremia. Fluid retention, 3rd spacing Causes: end organ damage, heart failure / ESRD / ESLD / ascites, nephrotic syndrome Tx: fluid AND sodium restriction Think ascites- we limit fluid and Na for treatment Clinical Features: Signs of fluid overload such as peripheral edema, ascites, and pulmonary congestion. • Management: Fluid and sodium restriction, diuretics, and treatment of the underlying condition

Answer 430

If low, increase by 50% of prior day provision If trending down but still WNL, increase by 25% of prior day provision

Answer 431

A standard 10% amino acid stock solution provides 1 g AA per 10 ml. Dextrose and lipid each require 0.5 ml per kcal. Each g dextrose provides 3.4 kcal and each g lipid provides 10 kcal. 105 grams x 10 mL/g = 1050 mL 280 grams Dex = 952 kcal x 0.5 kcal/mL =476 mL 40 g lipids x 10 kcal/g = 400 kcal x 0.5 kcal/mL = 200 mL 200+476+1050= 1726 mL

Answer 432

8 meq Each 8 meq of magnesium repletion should increase serum magnesium by 0.1 mg/dL

Answer 433

Each 10 mEq of potassium repletion should increase serum K+ by 0.1 mmol/L

Answer 434

Answer: a. Albuterol Albuterol and insulin can both shift potassium into cells within 60 minutes. Dextrose is administered with insulin to prevent hypoglycemia. Calcium gluconate is given concurrently for cardioprotection. Both Kayexalate and Lokelma take > 60 minutes to take effect and are not first line treatment for acute hyperkalemia.

Answer 435

Answer: b. Hypovolemic hypotonic hyponatremia Because the patient was experiencing diarrhea, the patient is hypovolemic with sodium losses exceeding fluid losses. Euvolemic hypotonic hyponatremia is more commonly seen in SIADH, head trauma or malignancy. Normal sodium I/O but retaining water/ normal fluid volume in the body hypervolemic hypotonic hyponatremia is more common in end-organ failure. Hypertonic hyponatremia is seen in hyperglycemia, HHNK (hyperglycemic hyperosmolar non-ketotic syndrome) also called psuedohyponatremia

Answer 436

Answer: d. Lactated Ringers (LR) Normal Saline and Lactated Ringers are both isotonic. NSS is most appropriate for resuscitation. LR is most similar to blood plasma and appropriate for acute trauma and surgery. D5W is indicated for increased free water needs following resuscitation. ½ NS is used in DKA and hypernatremia but contraindicated in acute trauma, burns and liver failure.

Answer 437

B normal saline

Answer 438

Answer: b. Phosphorus Phosphorus is a component of ATP and critical in energy utilization. Hypophosphatemia is a hallmark of refeeding syndrome due to AP demand. Neurologic dysfunction can result from phosphorus deficiency.

Answer 439

Answer: c. Choline Choline is not included in PN and must be repleted enterally. Choline is not an amino acid- it is a water soluble vitamin

Answer 440

Arginine Arginine is important in immune function and wound healing. Carnitine is required for transformation of long-chain fatty acids. Choline is essential to membrane structure. Glutamine is necessary for colonic health.

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