Misc Flashcards
1
Q
___ thrombosis is caused by fibrin buildup within the blood vessel adhering to a CVC
A
Mural
The thrombus is almost “hugging” the wall
2
Q
CVC thrombosis is characterized by what physical symptoms?
A
Arm, shoulder and neck swelling
3
Q
What is “pinch off syndrome?”
A
When the catheter is compressed between the first rib and clavicle. Can cause occlusion, and more dangerously: risk of catheter fracture - and therefore needs to be replacement immediately
4
Q
What are the physical symptoms of “superior vena cava syndrome”?
A
Characterized by shortness of breath, dyspnea, cough, cyanosis and distended veins in neck.
5
Q
What is an intraluminal thrombus?
A
Blood refluxes into the catheter lumen
6
Q
What clears precipitates that are acidic (vancomycin)?
A
0.1 N HCL
7
Q
What clears calcium phos precipitates?
A
0.1 N HCL
8
Q
What clears lipid precipitate from a central line?
A
70% ethanol (EtOH)
9
Q
What clears alkaline drug precipitate (such as tobramycin, phenytoin)?
A
Sodium bicarb (Na HCO3)
10
Q
What is the most compatible form or iron in PN? What type of PN can this iron NOT be added to?
A
Iron dextran, cannot be added to a 3-in-1 (only a 2-in-1)
11
Q
Rapid IV infusion of KPO4 may result in what?
A
Thrombophlebitis
12
Q
Rapid infusion of ___ or ___ phosphate may result in tetancy due to abrupt decrease in serum ___ concentrations
A
Sodium or potassium phosphate
Calcium
13
Q
Infusion of phosphate > 7mmol/hour increases risk of ___ and ___
A
Thrombophlebitis
Metastatic CaPO4 deposition (resulting in potential organ dysfunction)
14
Q
What is the primary factor causing steatosis?
A
Excess energy intake (particularly excess carb)
15
Q
What may lead to gallbladder sludge/stone formation in long term PN patients?
A
Lack of gut stimulation
16
Q
PN associated cholestasis is an impairment of ___ secretion or ___ obstruction
A
bile, biliary duct
17
Q
What is the suspected cause of PN-associated cholestasis? What can be done to treat it?
A
Overfeeding of dextrose and/or FAT in PN
Avoid overfeeding, reduce lipid, stimulate the gut
18
Q
What is the difference between PN_associated steatosis vs. cholestasis?
A
Steatosis is characterized by the accumulation of fat within liver cells, while cholestasis involves impaired bile flow
19
Q
What are the 4 strategies that can help manage PN-associated liver disease?
A
- Lower dextrose or ILE
- Cycle
- Maximize enteral intake
- Prevent/treat bacterial overgrowth
- Ursodiol, cholestyramine
20
Q
Peripheral PN is ___ mOsm/L
A
<900
21
Q
Central PN is ___ mOsm/L
A
> 900
22
Q
Optimal glucose infusion rate is ___ mg/kg/min (stressed, hospitalized) - however maximum for adults is ___ g/kg/day
A
3-5
Max = 7
23
Q
To prevent EFAD, patients need at least ___ g weekly (of a SOY based ILE)
A
100
- Give 20% ILE 250 mL twice weekly or 500 mL weekly
24
Q
What are the 6 strategies to prevent/manage MBD in long term PN patients?
A
- Evaluate protein, phosphorus, calcium, sodium dosing
- Treat chronic metabolic acidosis
- Maintain Mg++ and copper intake
- Minimize aluminum contamination
- Encourage weight bearing exercise
- Reduce caffeine and limit alcohol intake
25
Amino Acids
* Final concentration < ___%
Dextrose
* Final concentration < ___%
ILE
* Final concentration < ___%
4, 10, 2
26
What would be a sign of 2-in-1 PN destabilization?
Able to see solid precipitates
27
What are the 4 types of destabilization in 3-in-1 PN?
1. Cracking
2. Creaming
3. Coalescence
4 Aggregation
All related to the instability of LIPID
28
What 2 types of PN destabilization make PN unsafe to use?
Coalescence and cracking
29
What type of PN destabilization would this scenario suggest:
-yellow-brown oil droplets at or near the TNA surface
-continuous layer of yellow-brown liquid at the surface of the TNA
-marbling or streaking of the oil throughout the TNA
Cracking
30
What type of PN destabilization would this scenario suggest:
A translucent band at the surface of the emulsion separate from the remaining TNA dispersion.
Creaming
31
What type of PN destabilization would this scenario suggest:
No obvious separation, but droplet size increases.
Coalescence
32
What type of PN destabilization would this scenario suggest:
May appear cloudy or flocculated (clumped), depending on severity.
Aggregation
33
What are the 4 symptoms associated with EFAD?
1. Scaly dermatitis
2. Alopecia
3. Poor wound healing
4. Thrombocytopenia
34
What is the equation for total body water for an adult male?
Body weight x 0.6
35
What is the equation for total body water for an adult female?
Body weight x 0.5
36
What is the equation for total body water for an elderly male?
Body weight x 0.5
37
What is the equation for total body water for an elderly female?
Body weight x 0.4
38
Name 4 conditions that increase fluid needs?
1. Hyperventilation
2. Sweating
3. Fever
4. Hyperthyroidism
39
What is the equation for calculating free water deficit?
(TBW = 0.6 x body weight in kg) x [(Serum sodium - 140) / 140]
Ex: 60 kg with serum sodium of 154
-60 x 0.6 = 36
-154-140 = 14/140 = 0.1
-36 x 0.1 = *3.6 L free water deficit*
40
Rapid sodium correction can cause what?
Osmotic myelinolysis
correct no more than 1/2 per day
41
Calculation for sodium deficit?
Na required = (Desired sodium - measured sodium) x TBW
42
Calculation for corrected calcium?
[0.8 x (4 - albumin)] + serum calcium
43
Insensible loss is about ___mL per day
500
44
What is hyponatremia in the immediate post-op period best treated with?
Fluid restriction
45
How long should you wait to recheck potassium after repletion?
2 hours
46
What electrolytes are in the ECF in high concentrations?
Sodium
47
What electrolytes are in the ICF in high concentrations?
Potassium!! Mg/Phos concentrations are higher in the ICF than the ECF
48
Urea = ___% of urine nitrogen losses
80%
49
1 kg is ___ lbs
2.2
50
1 inch is ___ cm
2.54
51
1 oz is ___mL
30
52
GIR calculation
[(grams dextrose x 1000) / weight in kg] / 1440
53
Insulin sensitivity factor (lispro)
CF = 1800 / units of insulin needed daily
CF = mg/dL drop in blood glucose per 1 unit of insulin
54
Insulin sensitivity factor (Regular)
CF = 1500/units of insulin needed daily
CF = mg/dL drop in blood glucose per 1 unit of insulin
55
Adjusted gestational age
Current/actual age + weeks baby was born at
Ex:
-Currently 8 weeks old, born at 32 weeks
-Adj age = 40 weeks
56
Corrected age
1). Determine how many weeks premature (40 weeks - number of weeks baby was born at = correction factor)
Then can determine corrected age
2). Current/actual age - correction factor = corrected age
Ex:
-Currently 16 weeks old, born at 32 weeks
-40 weeks - born at 32 weeks = 8 weeks correction factor
-Currently 16 weeks - 8 weeks premature = 8 weeks corrected age
57
Fluid needs for an infant >20 kg
1500mL + 20mL for each kg >20
58
Fluid needs for an infant 10-20 kg
1000mL + 50mL for each kg >10
59
Fluid needs for an infant 1-10 kg
100mL per kg
60
Osmolarity of PN
[(grams AA x 10) + (grams dextrose x 5) + (mEq lytes x 1)] / liters of volume
61
Anion gap
Na - (Cl+HCO3)
62
Normal anion gap is ___, but can range between ___-___.
9
3-11
63
Nitrogen balance
(Grams of protein / 6.25) - (UUN+4)
64
Corrected sodium for glucose
Serum sodium + [0.016 (serum glucose - 100)]
65
Free water deficit (hypernatremia)
TBW x [1 - (140 / serum sodium)]
Note: TBW = weight x 0.6
66
Sodium deficit (hyponatremia)
TBW x (140 - serum sodium)
67
Corrected calcium
[0.8 (4 - albumin)] + serum calcium
68
Enteral formulas contain ___% water by volume
70-85%
69
USP 797: ___ risk compounding: involves only transfer, measuring and mixing with closed/sealed packaging systems.
Ex: re-constitution of single dose power with sterile water
Low
70
USP 797: ___ risk compounding: involves multiple injections, detachments/attachments to deliver all components to a final sterile container
Ex: standard PN compounding
Ex: PN solution prepared from 8.5% amino acid solution with electrolytes, 70% dextrose, trace elements and famotidine added
Medium
71
USP 797: ___ risk compounding: involves non sterile ingredients/devices prior to terminal sterilization
Ex: previously compounded L-glutamine supplemented in PN formulation
High
72
List the 4 major symptoms of riboflavin deficiency?
1. Cheilosis
2. Hyperemia and edema of pharyngeal and oral mucosa
3. Angular stomatitis
4. Glossitis (magenta tongue).
73
Vitamin D deficiency is most often characterized by what?
A loss of bone density.
74
Studies have shown that what 3 micronutrient supplementations can reduce plasma homocysteine concentrations?
Folic acid, vitamin B6, and vitamin B12
75
What are the benefits of having colon in continuity?
1. Colon has critical roles in fluid and nutrient absorption. Therefore, patients lacking a colon are at greater risk of dehydration.
2. Colon is capable of salvaging calories through anaerobic bacterial fermentation of undigested carbohydrates into absorbable short-chain fatty acids (SCFAs)
76
Resections of the proximal bowel, including the duodenum and proximal jejunum, are generally ___ tolerated because of ileal compensation and adaptation.
better
77
It is particularly important to limit the amounts of aluminum contaminants in PN solutions in what 2 patient populations?
1. Premature neonates
2. Patients with significant renal dysfunction
78
Aluminum toxicity is treated with ___, an agent that chelates aluminum.
Deferoxamine
79
___ toxicity can result in abnormalities of hematopoietic, bone, and neurologic functions.
Aluminum
80
The result of SIADH is an increase in total body water which causes a dilutional hyponatremia. Increased ___ concentrations and ___ are seen in the *urine* due to excessive water reabsorption.
Sodium, osmolality
81
The sodium content of ileostomy output can be as high as ___ mEq/liter
120
82
During fasting, fuel oxidation gradually shifts from ___ to mainly ___ as the oxidative source.
Carbohydrates, lipids
83
During fasting, ____ increases and provides the body with fatty acids.
Lipolysis
84
As a consequence of increased fatty acid oxidation, terminal ___ oxidation is decreased.
Glucose
85
Hypoglycemia and ketosis are characteristic of ___.
Starvation
86
Hypermetabolism and hyperglycemia are characteristic of what type of malnutrition?
Stress-related
87
Catabolism of endogenous substrate including fat stored in adipose tissue (lipolysis) is common in which types of malnutrition?
Acute illness/injury-related malnutrition and social/environmental related malnutrition
88
ASPEN guidelines recommend the use of ___ in trauma and TBI
Arginine
89
What is Fanconi syndrome?
Fanconi syndrome is a disorder of the kidneys where substances that should be reabsorbed back into the bloodstream are instead excreted in the urine.
90
What acid:base disorder would be associated with hypophosphatemia?
respiratory and metabolic ALKALOSIS
91
12 symptoms of copper deficiency:
1. Microcytic hypochromic anemia
2. Sensory ataxia
3. Lower extremity spasticity
4. Paresthesia in extremities
5. Leukopenia
6. Neutropenia
7. Hypercholesterolemia
8. Increased erythrocyte turnover
9. Decreased ceruloplasmin
10. Erythrocyte copper/zinc superoxide dismutase (SOD)
11. Abnormal EKG patterns
12. Myeloneuropathy.
Summary: 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.
92
The ___ equation, when using actual body weight with an activity factor, have demonstrated greater accuracy with healthy obese and non-obese people
Mifflin-St. Jeor
93
What equations are associated with estimating needs in critically ill patients?
The Ireton-Jones and Penn State equations
94
Name the 4 major symptoms of vitamin D deficiency.
1. Muscle weakness
2. Fatigue
3. Bone pain
4. Depression.
95
Name the 3 major symptoms of Vitamin E deficiency.
1. Numbness/tingling
2. Muscle weakness
3. Impaired coordination.
96
Name the 3 major symptoms of iron deficiency.
1. Pallor
2. Fatigue
3. Microcytic anemia
97
In metabolic acidosis: for every 0.1 decrease in pH, potassium will increase by ___ mEq per liter generally.
0.6
98
For all classes of obesity where BMI is >30 kg/m2, the goal of the parenteral and enteral regimen should not exceed ___% to ___% of target energy requirements as measured by indirect calorimetry.
65-70%
99
For those with a BMI of 30-40, protein should be provided in a range greater than or equal to ___ g/kg ___ body weight/day
2, ideal
100
For those with a BMI >40, protein needs are ___ g/kg ___ body weight/day
2.4, ideal
101
If indirect calorimetry is not available, calculate energy needs for those with a BMI 30-50 using the weight based equation 11–14 kcal/kg ___ body weight/day for patients with BMI 30-50 kg/m2 and 22–25 kcal/kg ideal body weight/day for patients with BMI > 50 kg/m2 is recommended.
11-14, actual
102
If indirect calorimetry is not available, calculate energy needs for those with a BMI >50 using the weight based equation ___ kcal/kg ___ body weight/day
22-25 IBW
103
Two or more oils mixed together (like SMOF) is called a ___ mixture
physical
104
The risk of thrombophlebitis increases by day ___
4
105
To prevent EFAD, ___% of daily energy requirements should be derived from linoleic acid and about ___% of energy from alpha-linolenic acid.
2-4%
0.25-0.5%
106
To prevent EFAD, ___mL of a ___% ILE should be given once per week. This can be broken up in a few ways.
500 mL of a 20% ILE given once a week
Can be 500mL of 10% ILE OR 250mL of a 20% ILE - twice weekly
107
A PICC may be more prone to occlusion because of what?
Longer catheter
108
Name the 3 major symptoms of late-phase Manganese toxicity
Parkinson disease-like symptoms:
1. tremor
2. involuntary movements
3. rigidity.
Early toxicity symptoms include: weakness, anorexia, headache, and apathy
109
Stress-associated hyperglycemia in acutely ill and septic patients often develops as a result of insulin resistance, ___ gluconeogenesis and glycogenolysis, and ___ insulin
secretion.
Increased, suppressed
110
Hyperemesis gravidium treatment
1. Initial management generally starts with basic interventions of small, frequent meals comprised of low-fat, high-carbohydrate foods and the avoidance of trigger foods and foods with strong odors.
2. Supplemental vitamin B6, ginger, and acupressure.
3. Combined vitamin B6/doxylamine, antihistamines, dopamine antagonists, serotonin antagonists, and IV fluids with or without diazepam.
4. The last line of therapy would be corticosteroids, EN (or PN in severe cases), gabapentin, or transdermal clonidine
111
Common causes of hypertonic hyponatremia include what 3 things?
1. hyperglycemia
2. infusion of hypertonic fluids (with little or no sodium)
3. medications (e.g. mannitol)
112
The estimated initial amount of insulin to add to PN for a diabetic is ___ unit insulin/gm dextrose, increased daily to achieve glycemic goals by adding ___ of previous days sliding scale insulin
0.05-0.1
2/3
113
Selenium deficiency is associated with Keshan disease (a type of ___) and increased ___ injury
cardiomyopathy, oxidative
114
A patient with a CVAD presents with arm, shoulder, or neck swelling, limb, jaw, or ear pain, and dilated collateral veins over the arm, neck or chest. These are hallmark symptoms of what?
Catheter related central venous thrombosis
Central venous catheters cause endothelial trauma and inflammation which can lead to venous thrombosis.
115
When would it be recommended to exchange the catheter over guide wire?
If catheter removal is indicated and:
-other IV access is unavailable
-or, if the patient is at increased risk for bleeding due to hypocoagulability
116
When would systemic antimicrobial treatment be appropriate in a CVAD patient with concern for infection?
Used in the presence of purulent drainage from the catheter exit site or if topical treatment is unsuccessful.
117
When should a CVAD be removed?
The catheter should be removed if systemic antimicrobial treatment fails or if the patient has clinical signs of sepsis.
118
___ can be characterized by pain, swelling, erythema, or induration along the subcutaneous tract of a tunneled catheter
Tunnel infection
119
___ are characterized by erythema or induration within 2 cm of the catheter exit site, in the absence of concomitant blood stream infection and without purulence.
Exit site infections
120
___ is characterized by inflammation of the vessel wall as well as erythema and pain near the catheter insertion site or along the affected vein.
Catheter-related phlebitis
121
Regarding PNALD: abnormalities in aminotransferases are indicative of ___, whereas abnormalities in conjugated/direct bilirubin are indicative of ___.
Hepatocellular steatosis
Cholestasis
122
Lipid should be removed from PN when triglycerides are over___ mg/dL in neonates
200
123
Ascites is considered a relative contraindication to percutaneous endoscopic gastrostomy (PEG) placement because of the increased risk of complications such as ___.
peritonitis
124
For individuals over the age of 65, some experts discourage the use of energy-based formulas and instead recommend ___ with a minimum of 1500mL per day.
30mL/kg
125
___ formulas may lead to fluid overload in patients with severe cardiac issues or kidney disease
Weight based
126
What might weighted TF tips help with?
Might help reduce chance of post-pyloric tubes curling back into the stomach.
127
Alpha-2 adrenergic agonists, such as clonidine, have been shown to have significant ___ effects
Antimotility
often prolonging intestinal transit time.
128
___ is routinely used in standard infant formula to mimic the carbohydrate found in human milk
Lactose
129
Elemental infant formulas use ___ solids as the carbohydrate source which also do not contain lactose.
Corn syrup
130
What is the most common symptom when feeding/fluids are withheld at EOL?
Dry mouth, which is easily alleviated with good mouth care
131
What might happen if a short term feeding tube is not exchanged every 4-6 months.
Sinusitis, skin breakdown and fistulae.
132
Replacement of a jejunostomy tube requires ___ verification with ___ medium
radiographic, contrast
133
Who can place a PEG/G-tube?
The first replacement of a gastrostomy or percutaneous endoscopic gastrostomy tube should be performed by the physician who inserted the tube. After that, it is appropriate for trained nurses to replace these tubes.
134
Administration sets used for ___ should be di(2-ethylhexyl) phthalate (DEHP) free and bisphenol A (BPA) free.
Human breast milk
135
Do you need gloves when preparing human breast milk?
Yes
136
Electromagnetic placement device for nasogastric tubes shows a real-time perspective of the tube tip location with a ___localization.
3-dimensional
137
Electromagnetic placement device for nasogastric tubes follows the tip placement relative to the lower ___
esophageal sphincter
138
When would the reverse Trendelenberg position be appropriate?
When elevated backrest is contraindicated to elevate HOB (head of bed).
139
The instilling of air into gastric feeding tubes is useful for increasing ___ when drawing GRV from small bore feeding tubes.
negative pressure
140
Normal or high GFR is > ___ mL/min, whereas ESRD is < ___ mL/min
90, 15
141
Stool output greater than ___ mL/day for 2 consecutive days should be evaluated with intervention started to reduce the risk of volume depletion and electrolyte deficiencies
500
142
___, used to treat bile salt malabsorption, can be used with antidiarrheal agents for patients who have undergone extensive bowel resection
Cholestyramine
143
A BMI of 30-34.9 is considered ___in HD patients. A BMI less than 23 and hypoalbuminemia (< 3.2g/dL) are strong predictors of ___in HD patients
protective, mortality
144
What are the 4 major symptoms of zinc deficiency
1. Alopecia
2. Skin rash
3. Pica
4. Dysgeusia
145
Supplementation of ___ and ___ reduces osteopenia in patients on long-term steroids
calcium and vitamin D
146
What are the 5 associated risk factors of MBD in patient's with inflammatory bowel disease?
1. Malnutrition
2. Vitamin D deficiency
3. Corticosteroid therapy
4. Magnesium deficiency
5. Chronic inflammation
147
What 2 toxicities/elevated labs and 1 deficiency are common in patient's with MBD, IBD and on long term PN?
Toxicity = Hypercalciuria, aluminum toxicity
Deficiency = magnesium
148
Fiber containing enteral nutrition may be possible in patients with what type of distal fistulas?
1. low output (< 500mL/d)
2. esophageal, gastric, duodenal, or proximal jejunal fistulas
3. distal enteral access
149
What type of formula should be used to minimize fistula output in distal ileal or colonic fistulas?
Fiber free
150
Iron overload may adversely affect the outcome of a stem cell transplant by increasing the likelihood of acute ___disease, blood and fungal infections, and sinusoidal obstruction syndrome of the ___.
GVHD, liver
151
Hypoglycemia is a significant complication of acute liver failure, also known as ___hepatic failure
Fulminant
152
What type of formula should be considered in pregnancy (for constipation)?
Fiber-containing
153
Isotonic vs. polymeric formula
Many standard formulas are both isotonic (osmolality close to that of blood plasma, ~300 mOsm/kg) and polymeric, making them suitable for a wide range of patients starting enteral nutrition.
154
Use of ___should be reserved for patients with large volume stool losses in whom fluid and electrolyte management is problematic and should be avoided in the early adaptation stage.
octreotide
155
Iron and calcium are absorbed in the ___. Folic acid is absorbed in the proximal ___. Vitamin B12 is absorbed in the distal ___.
Duodenum, jejunum, ileum
156
What are the 4 risk factors for oxalate stone formation (facilitated in the kidneys of SBS patients)?
1. excess oxalates
2. dehydration
3. metabolic acidosis
4. hypomagnesemia.
157
Both strategies, trophic or full nutrition by EN, have ___ outcomes during the first week of hospitalization
similar
158
Can proton pump inhibitors be added to PN?
No
are effective antisecretory agents but cannot be added to parenteral nutrition
159
Can histamine 2-receptor antagonists be added to PN solutions?
Yes
160
Can octreotide be added to PN solutions?
Yes
161
What are the indications for using Glutamine?
ASPEN does NOT recommend glutamine use in either enteral or parenteral regimens.
The effect of glutamine appears to depend on route of delivery, amount of glutamine delivered, population (medical ICU, surgical ICU, trauma, TBI, mixed ICU), baseline glutamine levels and other confounding factors found in nutrition research (ie other nutrients delivered and additional aspects of medical care).
162
Low plasma glutamine levels at admission to the ICU is an independent risk factor for ___.
Mortality
163
___ also acts as a vasodilator and reduces the afterload on the heart, improving cardiac function.
Thiamin
164
The inflammation following a traumatic injury provokes a release of what 3 systemic catabolic hormones?
1. epinephrine
2. glucagon
3. cortisol.
165
The inflammatory hormones (epinephrine, glucagon, cortisol) contribute to what 4 metabolic processes?
1. Glycogenolysis
2. Gluconeogenesis
3. Proteolysis
4. Free fatty acid release
166
Cyclosporine or tacrolimus Can cause what 4 nutrient/electrolyte disorders?
1. Hyperkalemia
2. Hypomagnesemia
3. Hyperglycemia
4. Hypercholesterolemia
167
Protein needs for PD?
1.0 - 1.2
168
What are the 6 main nutritional deficiencies after gastric bypass surgery.
1. Iron
2. Vitamin B12
3. Folate
4. Copper
5. Thiamine
6. Zinc
169
What are the 4 major signs of B12 deficiency?
1. Anemia
Neurological and psychiatric symptoms
2. Numbness
3. Paresthesia
4. Memory disturbance
170
Beriberi or Wernicke ’s encephalopathy are ___ disorders caused by thiamine deficiency
Neuropathy
171
Cardiologists prescribe digoxin for arrhythmias and coronary heart disease and pair this medication with diuretics in some patient populations.
Digoxin is a water-soluble drug that is eliminated solely via renal excretion. Renal insufficiency, hypokalemia, hypomagnesemia, hypercalcemia, and advanced age are risk factors associated with digoxin toxicity
Potassium and magnesium depletion sensitizes the myocardium to digoxin, leading to toxicity despite therapeutic concentrations. These electrolyte abnormalities also cause arrhythmias.
172
An older adult receiving digoxin and parenteral nutrition who is experiencing signs of digoxin toxicity should be assessed for
Hypokalemia
173
Functional disability, falls, and decreased bone density, in addition to glucose intolerance, and decreased heat and cold tolerance have been linked to ___.
Sarcopenia
174
Decreased physical activity, malnutrition, increased cytokine activity, oxidative stress, and abnormalities in growth hormone (decreased growth hormone production) have been implicated in the etiology of ___.
sarcopenia
175
There is a 35% reduction in hepatic blood flow in the elderly accompanied by reduced hepatic volume. As a result, drug metabolism, particularly ___metabolism, may be considerably reduced.
first-pass
176
Water lost from the skin and lungs is considered insensible and can account for up to ___mL of fluid loss per day under normal conditions of body and ambient temperature.
1000
177
According to National Kidney Foundation's Kidney Disease Outcomes Quality Initiative Guidelines (KDOQI), calorie needs for stable and acutely ill patients on maintenance HD are ___ kcal/kg for those under 65-years of age and ___-____ kcal/kg for those older than 65-years of age.
35
30-35
178
A diagnosis of frailty can be made when 3 or more additional criteria are met which include:
1. unintentional weight loss (10 pounds in past 1 year)
2. self-reported exhaustion, weakness (hand-grip strength)
3. slow walking speed, and low physical activity
179
A Do Not Resuscitate (DNR) or Do Not Attempt Resuscitation (DNAR) order is not a contraindication to the provision of AANH in any state.
180
It is recommended that patients with cirrhosis receive ___-___ g protein/kg/d to prevent muscle catabolism and promote gluconeogenesis.
1-1.5
181
Protein should not be restricted in cirrhotic patients with hepatic encephalopathy as it may increase protein breakdown. The only exception would be in critically ill patients with severe acute liver failure, at risk for ___ edema.
In this case, protein intake may be withheld for 24-48 hours until liver function improves.
cerebral
182
Advance directives are documents that allow individuals to document their treatment preferences and identify a surrogate or proxy decision maker to act in the patient's state when he or she loses the ability to make decisions.
In the absence of an advanced directive, where evidence of an incompetent person's previously expressed wish not to be kept alive by medical technologies meets state evidentiary standards, the exercise of that choice by a surrogate decision-maker must also be honored.
183
According to the 2018 NIS, 59.5% of hospitalized patients older than 65 years were discharged with malnutrition coded as a diagnosis. The average length of stay of 9 days for patients with malnutrition.
184
Older adults have increased metabolic complications associated with PN therapy due to ___ resistance, impaired ___and __functions and ___ deficiencies.
Insulin, cardiac, renal, micronutrient
185
Although decreased urination, tube clogging, tube leaking and skin problems at tube site are all commonly reported patient complications of home EN, decreased urination has been found to be the most common complication in a group of elderly patients receiving home enteral nutrition.
Decreased urination likely indicates inadequate fluid intake while on enteral feeding and the potential for dehydration and risk for acute kidney injury. In the extra-cellular fluid volume depleted patient, the urine becomes concentrated and contains very little Na+ consequent to renal conservation of salt and water. In the dehydrated patient, although urine is concentrated (due to water absorption in the distal tubule), urinary Na+ is not decreased. In fact, hypernatremia in a dehydrated patient can augment renal natriuresis by mechanisms that appear to be independent of changes in atrial natriuretic peptide.
186
The ___ is one of the most widely used tools to measure health-related quality of life.
Short Form-36
187
Regular alcohol intake can affect absorption and/or utilization of what vitamin/minerals (hint: 9)
-B6
-B12
-B9
-C
-A
-D
-E
-Iron
-Zinc
188
The ___ ADL tool measures activities of daily living
Katz
189
___ IADL tool measures instrumental activities of daily living.
Lawton-Brody's
190
The ___ is a tool used to measure functional independence in rehabilitation settings.
FIM
191
Thiazide or thiazide-like diuretics are the most common causative agent associated with diuretic-induced hyponatremia. Thiazide diuretics act solely in the distal tubules, and do not interfere with urinary concentration and the ability of antidiuretic hormone to promote water retention.
In comparison, loop diuretics (e.g. furosemide) can actually diminish anti-diuretic hormone-induced free water absorption and treat hyponatremia in syndrome of inappropriate antidiuretic hormone.
192
Activities of daily living, used to assess an older adult's functional status, are classified into three levels:
1. basic activities of daily living (BADLs) = self-care tasks (grooming, maintaining continence)
2. instrumental or intermediate activities of daily living (IADLs) = maintain an independent household (taking medications)
3. advanced activities of daily living (AADLs) = fulfill societal, community, and family roles as well as participate in recreational or occupational tasks such as exercising.
193
Autonomy is an ethical principle based on respecting and upholding the patient's right to self-determination. The principle of autonomy should guide the health care team in making a decision for an incompetent individual who has an advance directive regarding artificial nutrition and hydration.
194
If an advance directive is not available, the principles of beneficence and nonmaleficence are more central. Beneficence is defined as an ethical principle whereby health care providers actively seek the good of the patient above all other priorities.
195
Nonmaleficence, "to do no harm" relates to health care providers actively seeking to prevent, minimize and relieve needless suffering and pain to avoid harming the patient.
196
Justice is related to the fair distribution of resources.
197
Sarcopenia and frailty's age-related decline in muscle strength may affect the smaller striated muscles of the head and neck, therefore contributing to dysphagia and aspiration.
198
Without vitamin D binding to VDRs, PTH production is ___; stimulation of muscle fibers is ___causing muscle weakness; renin activity is ___resulting in hypertension; and there is a potential for hyperlipidemia given the need for vitamin D in lipid cell membranes formation.
PTH increased
Muscle fiber decreased
Renin increased
199
In older adults, within the intestines there is decreased absorption of carbohydrate, protein, triglyceride, folate, vitamins B12 and D, and calcium while there is increased absorption of vitamins A and C and cholesterol.
200
The Minimum Data Set (MDS) is completed by members of the interprofessional team who use it to assess all aspects of clinical status and facilitate problem identification (“triggers”) in residents of long-term care facilities.
The nutrition component of this assessment is found under section ___ and assesses a resident's ability to maintain adequate nutrition and hydration. This section covers height and weight, weight changes, swallowing disorders, and nutrition approaches, including the use of mechanically altered and therapeutic diets, and artificial nutrition and hydration.
K
201
The Care Area Assessment (CAA) investigates “trigger” areas identified through the MDS to determine if further planning and intervention is required. Combined, the MDS and CAA form the ___, a screening and assessment tool mandated for use in certified long-term care facilities by the Center for Medicare and Medicaid (CMS). This tool provides an interdisciplinary framework for resident assessments and the identification of problems. Problems identified are then required to have individualized care plans.
Residential Assessment Instrument (RAI)
202
Patients with iron deficiency anemia may present with what symptoms?
-Fatigue
-Headache
-Pallor
-Reduced work performance
-Impaired behavioral and intellectual performance
-Impaired ability to maintain body temperature
203
Iron dextran, the preferable form to add to PN, may be added only after the patient has been given a test dose to evaluate tolerance and avoid anaphylactic reactions
204
Serum iron and ferritin levels should be monitored routinely every ___-___ months if a repletion dose is added to the PN solution to prevent iron overload
1 to 3
205
___ of the gastric mucosa is caused by excessive tension between the external and internal bolster which leads to erosion and bleeding.
Ulceration
206
Colocutaneous ___ occur when the colon is inadvertently punctured during placement. It is extremely rare.
fistulas
207
For home PN patients: laboratory tests should be done on a weekly basis for ___ weeks or until values are stable. Once they are deemed stable, laboratory monitoring may be incrementally shifted to once a month, or a less-frequent schedule may be used depending on patient situation and plan of care.
Ongoing monthly to bimonthly follow-up should continue unless there is a change in clinical condition necessitating more frequent monitoring on an individual, case-by-case basis.
4
208
Manufacturers of large volume, small volume, and pharmacy bulk packages of components for PN must label each with the amount of aluminum anticipated to be in the product when the product ___.
The amount on the label has been shown to be approximately ___ times more than what was actually measured in a PN bag prepared according to a patient's prescription.
Pharmacies are not required to list the aluminum content on each patient's PN bag. The clinical manifestations of aluminum toxicity (neurological, hepatic, hematologic, and skeletal) are neither specific nor sensitive for aluminum toxicity. The etiology of parenteral nutrition-associated bone disease is multifactorial and aluminum toxicity is only one of many potential contributors.
Expires
10
209
Chromium potentiates the action of insulin and has a role in glucose, protein, and lipid metabolism.
Pregnancy and type 2 diabetes can potentially lead to increased urinary excretion of chromium.
If deficiency is suspected, treating hyperglycemic patients with chromium supplementation and observing for resolution of symptoms empirically is the best way to determine if the patient was chromium deficient. There are no known reliable indicators of chromium status and levels in the blood are present in extremely low concentration making detection difficult.
210
Estimation of manganese in ___ is the preferred of monitoring manganese status as they correlate well with MRI abnormalities.
whole blood
211
Patients should be taught to clean carefully under external bolsters to remove debris and check for excessive pressure. Routine use of antibiotic ointments is not advised, and dressings at the tube insertion site are not necessary unless there is drainage.
212
There is no known microbial resistance to ethanol.
A 70% ethanol lock (ELT) solution removes the luminal biofilm inside VADs in which microorganisms are harbored. They can detach from the biofilm and seed the bloodstream causing central line associated bloodstream infection. ELT should be considered to prevent recurrent infections.
Ethanol is incompatible with heparin.
213
Medicare reimbursement for home and community-based professional nutrition education services provided by a registered dietitian covers patients with diabetes, non-dialysis kidney disease, and those who have had a kidney transplant within the past ___ months.
36
214
The 3 types of VADs approved for HPN administration include:
(1) tunneled central venous catheters
(2) implanted ports
(3) peripherally inserted central catheters.
Note: Midline catheters provide peripheral and not central venous access, and are short-term VADs typically used for therapies lasting 2-4 weeks.
215
Designing education materials for patients should go beyond the written words and their readability.
Using plain language should focus not only on writing but also the role of clear graphic and typographic design, information design and document design.
“A communication is in plain language if its wording, structure, and design are so clear that the intended audience can easily find what they need, understand what they find, and use that information.”
216
Pancreatic lipase, cholesterol ester hydrolase, and phospholipase are all ___ enzymes involved in fat digestion.
These enzymes hydrolyze triglycerides, phospholipids, cholesterol esters, and fat-soluble vitamins in the ___.
The role of bile salts in fat digestion is to act as ___.
Pancreatic
Duodenum
Emulsifiers
217
Glucose and galactose are transported from the intestinal lumen into the enterocyte via the ___.
The transport process requires energy provided by hydrolysis of ATP and is, therefore, called an active transport system.
Two molecules of sodium are cotransported with one molecule of glucose or galactose.
SGLT-1
218
Presence of fat in the distal ileum produces an inhibitor feedback effect called the “ileal brake,” which ___ gastric emptying and intestinal transit.
slows
219
Some types of fiber are fermented by bacteria in the ___ into short-chain fatty acids.
colon
220
In the EDEN study comparing trophic and full feedings found NO difference in the first week of ICU in ventilator days, 60 day mortality or infectious complications.
Enteral nutrition has many benefits and has been shown to preserve gut integrity & immune function, provide gut prophylaxis against GI bleeding and modulate stress in the critically ill patient.
221
Chromium potentiates the action of insulin and is important in glucose, protein and lipid metabolism.
Chromium deficiency impairs glucose and amino acid use which may result in hyperglycemia.
222
The ___ is a key organ for protein metabolism because of its high capacity for uptake and metabolism of amino acids.
About 57% of the amino acids extracted by the liver are either oxidized or used to synthesize plasma proteins.
Liver
223
MCTs are hydrolyzed and pass through the ___ directly into the portal circulation.
enterocytes
224
MCTs are ___ soluble
Water
225
Phytobezoars treatment can include enzymatic therapy such as cellulase with lavage and endoscopic intervention.
Case studies have shown oral cola and acetylcysteine infusions to be effective.
Meat tenderizer that contains papain has also been reported in the literature but is not recommended as it damages normal tissue which can lead to peptic ulcer disease, esophagitis and gastritis.
Long-term prokinetic therapy can treat and prevent bezoar formation.
In refractory cases surgery offers a definitive solution.
226
Signs of vitamin D toxicity include:
-confusion
-psychosis
-tremor
-hypercalcemia
-hypercalciuria.
Soft tissue calcification may occur with long-term toxicity in lungs and cardiovasculature.
227
Hypocalcemia, osteomalacia, tetany, and osteoporosis are seen with vitamin D ____.
Deficiency
228
The acute phase response to injury and infection suppresses iron ___.
Clinically, serum iron levels are ___, while serum ferritin levels are ___.
Transport
Decreased, increased
229
Pellagra, or niacin deficiency disease, is rare in developed nations. It presents as the “three D's”: dermatitis, diarrhea, and dementia. THose with malabsorptive disorders are at risk (ie alcohol)
230
the majority of fat digestion occurs in the duodenum by pancreatic lipase.
231
The overwhelming majority of enteral dietary lipids (approximately 90%) are ingested in the form of triglycerides. Bile acids are detergent-like derivatives of cholesterol produced by the liver, which aid in triglyceride emulsification and the formation of micelles in the small intestine. This emulsification process and micelle formation makes triglycerides and fatty esters available for hydrolysis by intestinal lipases and esterases. Fatty acids of up to 10 carbons in length and glycerol can be absorbed directly via the villi of the intestinal mucosa. However, long-chain triglycerides require bile salts for both enzymatic digestion and formation of micelles.
232
Decreased protein provisions are indicated in uremic status & low intake of protein in combination with a hypocaloric diet may worsen mortality in obese patients
233
Water, the most abundant substance in the body, constitutes approximately 50% to 60% of body weight. Total body water (TBW) is a function not only of weight, age, and gender but also of the relative amount of body fat. Of all body tissues, adipose tissue is the least hydrated. Thus, individuals with more body fat have proportionally less TBW content. TBW is distributed among two main compartments: intracellular (ICF) and extracellular (ECF). Transcellular fluid compartments (TCF) make up approximately 3 percent. Approximately two-thirds is contained in the ICF, and the remaining one-third is in the ECF. One-fourth of the ECF is the intravascular space and three-fourths is in the interstitial space. Calculations for this patient are: TBW: (80 x 0.6) = 48 L; Extracellular fluid: (1/3 x 48) = 16 L; Intravascular space: (1/4 x 16) = 4 L.
234
Mitochondria are organelles found in most eukaryotes whose primary function is to generate ATP via oxidative phosphorylation, the major source of cellular energy. Fatty acids are broken down by various tissues to produce energy. Fatty acids are transported into the mitochondria membrane and through the beta-oxidation pathway the fatty acid is degraded and released as ATP. Fatty acid (and/or lipid) oxidation releases substantially more energy than does oxidation of carbohydrate. Adipocytes store energy as fat. Red blood cells do not contain mitochondria in their cytoplasm and rely on the metabolic pathway of glycolysis for ATP for energy.
235
Dietary folate is converted to monoglutamate by jejunal enzymes for entry into the intestinal cell. It undergoes further reduction before entry into the portal circulation for reabsorption via enterohepatic circulation. Zinc deficiency, chronic alcohol consumption, changes in jejunal luminal pH and impaired bile secretion may limit folate absorption.
236
The average nitrogen content of protein was determined to be 16%. The total grams of protein multiplied by 0.16 or divided by 6.25 will determine the nitrogen content of protein in a PN solution.
237
Serum albumin is a visceral (hepatic) protein and has a half-life of 14-20 days. The half-lives of retinol-binding protein, prealbumin, and transferrin are approximately 12 hours, 2-3 days, and 8-10 days, respectively. Serum levels of these proteins were traditionally used as nutritional markers but are now recognized more as inflammatory markers.
238
Some amino acids administered in higher amounts may have therapeutic effects. Arginine is a semi-essential amino acid that has demonstrated importance in immune function and wound healing. Few studies have focused on chronic wounds and arginine's effectiveness to enhance wound healing. Supplementation with arginine in the critically ill septic patient population remains controversial.
239
The AMDR is defined as the percent of energy intake associated with reduced risk of chronic disease while providing adequate amounts of essential nutrients. AMDR has been set for carbohydrate, protein, and fat including Omega-3 and Omega-6 fatty acids. The tolerable upper intake level is the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population. The EAR is defined as the average daily nutrient intake level estimated to meet half the needs of healthy individuals in a particular life stage and gender group.
240
Because of the profound lean body mass loss that is associated with critical illness, protein needs are elevated. The current recommendation for stressed trauma patients is that 20-25% of total nutrient intake be provided as protein. This equates to roughly 1.5-2g/kg/day. Exceptions include intensive care unit patients receiving continuous renal replacement therapy and those with a BMI >30 kg/m2 should receive 2-2.5 g/kg/day.
The Swinamer Equation uses body surface area in addition to physiological variables to predict resting metabolic rate (RMR). This equation has been found to predict RMR in about 55% of patients. Mifflin-St. Jeor Equation and Harris-Benedict Equation use weight, height, and age; Ireton-Jones Equation uses weight, height, age, sex, as well as trauma, and burn.
241
The Swinamer Equation uses body surface area in addition to physiological variables to predict resting metabolic rate (RMR). This equation has been found to predict RMR in about 55% of patients. Mifflin-St. Jeor Equation and Harris-Benedict Equation use weight, height, and age; Ireton-Jones Equation uses weight, height, age, sex, as well as trauma, and burn.
