MNT in Critical Care Flashcards
(133 cards)
1
Q
The metabolic response to stress can occur due to responses in: (4)
A
Sepsis
Trauma
Burns
Surgery
2
Q
_________ is a infection, and could be bacterial, viral, caused by a parasite, or any microbial infection
A
Sepsis
3
Q
What differentiates sepsis from a localized infection?
A
It’s very widespread (affects the whole body), infection gets into the bloodstream and spreads throughout the body
4
Q
T/F: metabolic response to stress can occur from emotional trauma
A
False, its a response to physical trauma
5
Q
What are examples of physical trauma?
A
Car accident, sports injury, major injury from an accident
6
Q
T/F: a metabolic response to stress occurs only in response to severe burns
A
True
7
Q
T/F: metabolic response to stress can occur in response to minor surgery
A
False, it only occurs in response to major surgery that happen in multiple organs
8
Q
A result of metabolic response to stress is the _____________ of lean body mass
A
catabolism
9
Q
What are TWO signs of catabolism of lean body mass?
A
- Negative nitrogen balance
- Muscle wasting
10
Q
There are _____ phases of metabolic response to stress
A
two
11
Q
The first phase of MRS (metabolic response to stress) is ______ phase, which occurs ___________ after injury.
A
Ebb, immediately
12
Q
Ebb phase is characterized by: (6)
A
Hypovolemia
Shock
Tissue hypoxia
↓ Oxygen consumption
↓ Cardiac output
↓ Body temp
13
Q
Hypovalemia is low blood _____
A
volume
14
Q
Tissue hypoxia is a ______ profusion of the tissues with oxygen
A
decrease
15
Q
The second phase of MRS is called the _____ phase
A
Flow
16
Q
When EMT (Kelly) arrives, the first thing they provide is _____ and _____
A
oxygen and fluids
17
Q
Why is it important to provide fluids to a person with MRS?
A
Due to hypovalemia, we want to get their blood volume and pressure back up.
18
Q
Why is it important to provide oxygen to a patient with MRS?
A
because of tissue hypoxia, we want to increase oxygen levels
19
Q
Flow phase occurs _______ fluid resuscitation and oxygen
A
after
20
Q
What occurs during flow phase? (4)
A
↑ Oxygen consumption
↑ Cardiac output
↑ Body temp
Release of pro-inflammatory cytokines
21
Q
What hormones are released during stress response? (5)
A
Catecholamines
Glucagon
Cortisol
Aldosterone
Antidiuretic hormone
22
Q
Which hormone contributes to the increase in metabolic rate?
A
Catecholamines
23
Q
Which of the following hormones includes the glycogen breakdown in liver AND muscle
a. Catecholamines
b. Glucagon
c. Cortisol
d. Aldosterone
A
a. Catecholamines. glucagon is only involved with glycogen breakdown in liver.
24
Q
which two hormones are responsible for glycogen breakdown in liver, glucose production from amino acids, and release of fatty acids from adipose tissue?
a. glucagon and cortisol
b. catecholamines and aldosterone
c. glucagon and catecholamines
d. cortisol and aldosterone
A
c. glucagon and catecholamines
25
Which hormone is involved with glucagon secretion from pancreas?
catecholamines
26
What are examples of catecholamines?
epinephrine and norepinephrine, fight or flight response
27
Which hormone has more of an effect on blood sugar?
glucagon
28
cortisols biggest affect on the body is _______ breakdown
protein
29
what is the metabolic effect of cortisol? (4)
protein degradation, enhancement of glucagon's action on liver glycogen, glucose production from amino acids, release of fatty acids from adipose tissue
30
__________ is the hormone that affects sodium reabsorption in kidneys
aldosterone
31
_______ is the hormone that affects water reabsorption in kidneys
antidiuretic hormone
32
The metabolic response to starvation is ____metabolism
hypometabolism, decrease in energy
33
During starvation the body slows down, resulting in _____ blood sugar, and muscle _____
low, wasting
34
T/F: the metabolic response is different between stress and starvation, with stress resulting in muscle hypertrophy and starvation resulting in muscle wasting
False, stress leads to an increase in blood sugar, hypermetabolism, and muscle wasting. Starvation results in low blood sugar, hypometabolism, and muscle wasting. Both result in muscle wasting but through different mechanisms.
35
What causes muscle wasting in starvation and stress?
for starvation: muscle is broken down for fuel
for stress: muscle is broken down as a result of inflammation
36
ketosis occurs more in _________
starvation
37
there is a high release of _____ in both stress and starvation
glucagon
38
Why is glucagon high in starvation?
glucagon increases to correct low blood sugar
39
glucagon also releases _____ from adipocytes which can be converted in the liver to _____
FFA → Ketones
40
In starvation we have a lot more ______ because we're relying on ____ for fuel
ketosis, fat
41
In stress the body is using _____, ____, and ____
glucose, fat, and protein
42
In both starvation and stress you have ______, and _______ occurring, but in starvation there is more _____ occurring
glycogenolysis, gluconeogenesis, ketosis
43
What two methods allow the body to produce glucose for the brain to utilize?
gluconeogenesis and cori cycle
44
In starvation, insulin ______ and glucagon _____
insulin decreases, glucagon increases
45
What does a lower respiratory quotient tell us? (Hint: starvation has a lower respiratory quotient then stress)
lower fuel sources
Starvation (0.6-0.7) → converting fat to fuel
Stress (0.8-0.9) → Mixed, using multiple fuel sources
46
Proteolysis is ______ in stress whereas ketone production is _______ in starvation
higher, higher
47
Sepsis can cause _____ but also be caused by it.
SIRS → system inflammatory response syndrome
48
After critical injury, _____ may sometimes precede and be the cause of SIRS
shock
49
Initially with Sepsis or SIRS, a persons body temp will ______ to fight infection, but if infection takes over the body temp will ______
increase, decrease
50
Initially with Sepsis or SIRS, a persons WBC will ______ to fight infection, but if infection takes over the body, it _______ WBC
increase, suppresses
51
Exposure to shock may lead to ______ or multiple organ failure
MODS → multiple organ dysfunction syndrome
52
________ and ______ BP / blood flow are symptoms of MODS
Edema, low BP
53
The first organ to fail in MODS is the ______
lungs
54
________ can fail as a result to shock/SIRS, which can lead to hypoperfusion into the gut.
Intestines
55
What is hypoperfusion?
decreased blood and oxygen flow to the gut
56
Hypoperfusion can lead to ______, which is described as the GI tract being paralyzed. This is typically ________
ileum, temporary
57
If someone has an ______ you can not feed them (not even PN or EN)
ileus
58
Once ileus goes away, we want to start ________ right away to restore gut function and reduce bacterial translocation
EN feeding
59
Not feeding the gut bacterium on the villous epithelium can lead to ____ ____ which can lead to bacteria and intact nutrients (unbound glucose) can be absorbed into the blood stream.
open junction
60
In a pt recovering from ileus, what can be provided early to prevent open junction?
EN
61
T/F: In SIRS, PN is preferred over EN due to decreased risk of infection and stress response
False, EN is preferred over PN due to decreased risk of infection and stress response
62
T/F: some PN lipids are pro-inflammatory
true, can exacerbate the stress response in individuals with SIRS
63
RD's in an _____ care system are focused primarily on _________
acute, malnutrition
64
A person on a ventilator in ICU is usually on a sedative or unconscious, therefore RD's are unable to obtain:
What can an RD do?
diet history, height/weight, allergies
Ask family/friends. Tape measure for height, beds have scale (take into account for excess weight, i.e. bedding/tubes)
65
weight of a person in ICU is affected by:
fluid resuscitation
66
pre albumin and albumin will typically be _____ in a person in ICU due to inflammation and fluids
low
67
T/F: the recommended BG levels for a pt in ICU should be less than 100.
False, not realistic. A good BG level for critical care is 140-180 mg/dL
68
When making a nutrition assessment in the ICU, a RD should assess ______ nutrition status
prior
69
Why is it important to avoid overfeeding a pt that is starved or stressed?
to prevent refeeding syndrome
70
In refeeding syndrome _______ moves into cells from oxidation which causes electrolytes to shift into intracellular space
glucose
71
What can occur as a result of refeeding syndrome
electrolyte imbalance → hypokalemia, hypophosphatemia, hypomagnesemia
72
_________ should be monitored every single day to prevent overfeeding
electrolytes
73
Another issue with overfeeding may contribute to ______ overload
fluid → rapid weight gain
74
Overfeeding may also contribute to ____ which can worsen blood glucose levels
hyperglycemia
75
Overfeeding may make it _______ to wean from the vent due to _____ CO2
difficult, high
76
Lastly, overfeeding may contribute to __________
fatty liver → hepatic steatosis
77
The gold standard for determining energy need for SIRS and MODS is using _______ _______
indirect calorimetry
78
How do we measure using indirect calorimetry
Metabolic carts - pt puts face mask and it measures their VCO2 & VO2. A formula can be used to determine their indirect calorimetry.
79
Non-vent energy needs for SIRS and MODS?
25-30 kcal/kg/d
80
Vent energy needs for SIRS and MODS
20-25 kcal/kg/d
81
What is unique about the Penn State Equation
the equation can determine energy needs (for SIRS and MODS) but you can actually enter the ventilation setting from the ventilator for a better measurement
82
Why higher calories in non-ventilated patients than ventilated patients
↑ calories = ↑ CO2 production, want to avoid overfeeding if on vent because they won't be able to ween from the vent
83
If using Penn State equation or kcal/kg/d estimates, a RD should use the persons _____ weight
dry, or best estimate
84
Multiple studies suggest ___________ feeding for obese patients with SIRS or MODS
hypo caloric - underfeeding
85
For BMI of 30-50 the kcals/kg/d lowers to:
11-14
86
T/F: a patient with a BMI greater than 50 with SIRS should consume 22-25 kcals/kg/d of their current body weight
False, they should consume 22-25 kcals/kd/day of their IBW
87
Protein needs depend on: (3)
baseline nutrition status, degree of injury, and losses
88
The protein needs of normal BMI ranges and for pt with BMI > 30 is:
Normal BMI: 1.2-2 g/kg/d
BMI > 30: 2-2.5 g/kg/d of IBW
89
_____ is an amino acid that is beneficial for the immune system, but it is also a preferred fuel source for the enterocytes and the colonocytes (GI function)
glutamine
90
______ is an amino acid that helps prevent lean body mass losses, so for pt with muscle wasting
Arginine, however it is contraindicated in Sepsis
91
Why is arginine contraindicated in sepsis?
precursor for nitric oxide, which dilates the blood vessel (vasodilator)
92
Why are BCAA's recommended?
They can be absorbed into muscle without need of liver, and they can act as a direct fuel source
93
_________ fatty acids is recommended for its anti-inflammatory effects
Omega-3
94
____ if NPO with good intestinal function and __ if EN is contraindicated or if NPO > 7 days
EN, PN
95
Short term tubes include:
Any of the nasal tubes: nasogastric tube, nasoduodenal tube, nasojejunal tube
96
Why do we only want to do nasointeric (ends in the intestines) tubes short-term?
causes inflammation and erosion to the nose, esophagus, throat
97
IF we know the pt needs feeding for more than 2 weeks then we want to use a _________ tube
ostomy, surgically created opening
98
________ parenteral nutrition is accessed via inferior vena cava, a central catheter where nutrients can be directed into the bloodstream.
total
99
In TPN what can be included in the formula?
Dextrose, amino acids, and lipids (all three macronutrients) and micronutrients
100
_______ parental nutrition is accessed via the arm which is susceptible to osmolality concerns.
Peripheral
101
What is PPN limited to?
Only dextrose and amino acids (no lipids), limited to the amount of dextrose
102
T/F: PPN can be a long term solution
False, because limited dextrose and no lipids, not a full nutrition diet
103
What's a PICC line?
Peripherally Inserted Central Catheter, entered in arm but the tip enters the vena cava where nutrients get delivered (hence the name central).
104
Which of the following is more likely to be used for longer term?
a. TPN
b. PPN
c. PICC
d. Naso tubes
c. PICC, can be used for weeks or months.
105
T/F: If a pt is NPO for less than 7 days and is adequately nourished they don't need nutrition support
True, they need a dextrose containing IVF
106
T/F: A patient is NPO and not receiving adequate nutrition, but the doctor plans for them to resume normal eating in 5 days. Nutrition support is not necessary in this case.
False, if BMI <18.5 or > 10% wt loss then pt needs to begin nutrition support even if less than 7 days to oral feeding.
107
When should nutrition support be required regardless of nutrition status?
over 7 days if NPO
108
No nutrition support if pt is not ________ stable
hemodynamically
109
What does hemodynamically stable mean?
A patient has stable blood circulation -- their blood pressure, heart rate, and overall cardiovascular function are within normal ranges, indicating that vital organs are getting enough blood and oxygen.
110
Anything that renders the GI tract not functional is when you would want to do ___
PN
111
T/F: RDs are responsible for making the PN nutrition bags
False, they calculate the dextrose, amino acid, and lipid needs and work with a pharmacist who then makes the bags
112
T/F: for tube feeding, RD's are responsible for determining the type of formulas and rate
True, determine how many mL per hour and their fluid protein, lipid and carb needs.
113
Often times fluid needs aren't met in tube feeding so the RD must determine how many ______ the pt needs
water flushes, how much and how often
114
What should be monitored in EN? (5)
-heart rate
-blood pressure
-mean arterial pressure (MAP)
-use of pressers - dopamine, epi, norepinephrine (raise blood pressure) - higher dose means not hemodynamically stable.
-oxygen saturation
(main two is MAP and use of pressers)
115
When should EN start?
24-48 hours of Icu admission, advanced to goal during next 48-72 hrs
116
What is the goal calories during first week with EN?
50-65%
117
What is the main concern for RD's in EN
monitoring for tolerance:
- pain/ distension
- Gastric residual volume (GRV)
- aspiration
- passage of flatus/stool
118
What volume in gastric residual volume requires the team to withhold tube feeding?
> 150-250 mL, however some research suggest GRV does not indicate tolerance, benefits of tube feeding outweighs any other issues.
119
Aspen reports to not withhold tube feeding for high gastric residual volumes. However most nurses will push to stop tube feeding. What should the RD do?
Advocate for the patient, present the research and most recent data findings. Current research: stop tube feeding if GRV exceeds 500 mL.
120
What can be done for a pt on EN experiencing aspiration?
Elevate the heads of the beds (30 degrees), decrease the rate of tube feeding, place tube in jejunum, or give Reglan which is a pro-motility medication
121
In many cases diarrhea is not caused by tube feeding but because of:
medications are the number one cause of diarrhea
122
What can be done for a pt with diarrhea during EN
Anti-diarrheal medication, switch current medications, probiotics, switch formula or add soluble fiber
123
Formula selection in immune-modulating for GI surgery, trauma, and burns contain: (4)
arginine (except if sepsis), glutamine, antioxidants, omega-3
124
Formulas for improved tolerance (EN) include: (4)
elemental, low-fat, low-fiber, hypo-osmolar
125
Appropriate candidates for PN include: (5)
- impaired GI absorption (ileus)
- bowel obstruction
- need for bowel rest
- motility disorders
- enteral access not possible
126
When should PN be initiated for well-nourished, moderately malnourished, or severely malnourished pts?
- well nourished: 7 days
- moderately malnourished: 3-5 days
- severe malnourished: ASAP
127
When should supplemental PN be considered?
7-10 days if not meeting 60% of needs with EN
128
What is the medical management of major burns? (4)
- fluid & electrolyte repletion
- wound care
- ROM exercises
- warm environment
129
If a patient has burns covering less than 20% of their Total Body Surface Area (TBSA), they should be placed on a diet that is:
- High-kcal (calorie) – to meet increased energy needs for healing
- High-protein – to support tissue repair and prevent muscle breakdown
- High-fluid – to replace fluid losses due to the burn and prevent dehydration
130
T/F: a pt with major burns most likely needs nutrition support
True, they experience increased energy expenditure and protein catabolism and may need to consume a large amount of calories.
131
What is the MNT for major burns?
- use indirect calorimetry and increase by 10-30%
- Milner formula
- prevent > 10% weight loss from UBW
132
A major burn pt may need 1.5-2 g/kg/d but this depends on:
Nitrogen balance → Measures if the patient is losing or gaining protein (muscle/tissue breakdown vs. rebuilding).
PAB (Prealbumin) → A lab marker used to monitor protein status and response to nutrition support. Low PAB may suggest protein deficiency or inflammation.
133
What micronutrients are important for major burn victims?
Vitamin C → collagen synthesis
Zinc → protein synthesis
