MW Flashcards by Frances Dion

Osmolarity of PN/TPN:

(grams amino acid x ___) + (grams dextrose x ___) + (mEq lytes x ___) / volume in liters

If it is a 3-in-1: + grams lipid x ____

Grams AA: 10
Grams dextrose: x5
mEq electrolytes x 1

Grams lipid x .71

How well did you know this?

Not at all

Perfectly

____ is a conditionally essential amino acid in neonates/preemies - often added to PN. It ___ the solubility of CaPO4 and ___ pH of the solution

Cysteine
Increases
Lowers

How well did you know this?

Not at all

Perfectly

Who is responsible for the safe compounding of PN?

USP 797

How well did you know this?

Not at all

Perfectly

Cisplatin may cause what electrolyte abnormality?

Low magnesium (and potentially secondary hypokalemia and hypocalcemia)

How well did you know this?

Not at all

Perfectly

What element contributes to PN/TPN osmolarity the MOST?

Amino acids

How well did you know this?

Not at all

Perfectly

What 3 trace elements in PN are associated with toxicity?

Copper, manganese, chromium

How well did you know this?

Not at all

Perfectly

What 2 deficiencies are associated with valproic acid?

Carnitine
Vitamin D

How well did you know this?

Not at all

Perfectly

Calorie needs for ICU patient with BMI >50

22-25 kcal/kg of IBW

How well did you know this?

Not at all

Perfectly

What type of anemia is associated with iron and copper deficiency?

Microcytic hypochromic

How well did you know this?

Not at all

Perfectly

What type(s) of anemia could be associated with copper deficiency?

Could be microcytic, normocytic or macrocytic

How well did you know this?

Not at all

Perfectly

What type of anemia is associated with B12 and folate deficiency?

Megaloblastic or macrocytic

How well did you know this?

Not at all

Perfectly

What type of anemia is associated with inflammation?

Microcytic

How well did you know this?

Not at all

Perfectly

What is the adult Holliday Seger equation? At what age is this equation appropriate to use?

1500 x (weight in kg - 20)

Appropriate for those >65 years old

How well did you know this?

Not at all

Perfectly

What is the pediatric Holliday Seger equation? What age would this equation not be appropriate to use?

(1000mL for the first 10 kg) + (500mL for the second 10 kg) + (20mL for the remaining kg)

Not appropriate for <14 days old

How well did you know this?

Not at all

Perfectly

What are the general fluid requirements for adults?

30-40 mL per kg

How well did you know this?

Not at all

Perfectly

Fluid Needs

18-55 years old: ___
55-75 years old: ___
>75 years old: ___
Fluid restriction: ___

35
30
25
25

How well did you know this?

Not at all

Perfectly

What type of medication can be crushed and given via tube?

Immediate release

How well did you know this?

Not at all

Perfectly

What type of medications CANNOT be crushed and given via tube?

Enteric or film coated medications may the tube to clog. Extended or modified release medications should not be crushed.

How well did you know this?

Not at all

Perfectly

How many days should 100mg thiamine be given for significant refeeding risk?

5-7 days

How well did you know this?

Not at all

Perfectly

What happens to thiamine levels in pregnancy?

Decreased thiamine levels seen in pregnancy

How well did you know this?

Not at all

Perfectly

Thaimine deficiency can occur in PN (that has had MVI held) within ___-___ weeks

3-4 weeks

How well did you know this?

Not at all

Perfectly

___ can lead to reduced thiamine in cardiac cells - which may lead to wet beriberi

Digoxin

How well did you know this?

Not at all

Perfectly

Name the outcomes of thiamine deficiency

Wernickes
Wet and dry beriberi
Lactic acidosis

How well did you know this?

Not at all

Perfectly

What are some symptoms of Wernicke’s?

Opthalmoplegia, nystagmus

How well did you know this?

Not at all

Perfectly

What is the treatment for hyperemesis gravidium?

The first treatment for hyperemesis gravidium should be to address fluid and electrolyte abnormalities

What is the most common electrolyte abnormality with refeeding?

Hypophosphatemia

How does refeeding affect sodium?

Causes sodium retention in early refeeding

What are the physical symptoms associated with hypophosphatemia (in refeeding)?

Respiratory failure, seizures

What are the physical symptoms associated with hypokalemia (in refeeding)?

Cardiac arrythmias, muscle weakness, muscle cramping

What are the physical symptoms associated with sodium retention (in refeeding)?

Pulmonary edema, cardiac decompression

What is alpha significance error?

Probability of making a type 1 error (i.e. probability of rejecting the null hypothesis when it actually true)

In the statement: "does fever affect temperature?" What is the independent and what is the dependent variable?

Independent = Fever Dependent = Temperature

What medications require tube feeds to be held around administration? How long should tube feeds be held?

Phenytoin Warfarin Carbamazepine Fluroquinolones (i.e. cipro) Should be held up to 2 hours before and after medication administration

How long is recommended for a CVC to stay in place?

5-7 day dwell time In chart: 7-14 days

How long is recommended for a PICC to stay in place?

Weeks to months

How long is recommended for a tunneled line to stay in place?

Years

How long is recommended for a port to stay in place?

Months to years, >6 weeks

What is the most appropriate CVAD for a long-term PN patient?

Single lumen tunneled catheter

What type of central access has the LOWEST risk of CRBSI?

Port

What are the 3 sites of CVC placement?

Internal jugular, subclavian and femoral

What type of catheter is an IJ? How long should it stay in place?

CVC, intended for short term

What is the preferred site for CVC placement?

Subclavian, reduced infection risk

What is the LEAST preferred site for CVC placement

Femoral

What type of CVAD would be most appropriate for an acute care setting?

CVC

What type of CVAD would be appropriate for both the acute care setting AND the home setting?

PICC

What type of CVAD would be appropriate for a patient who may require hemodialysis?

Internal jugular CVC

What type(s) of CVAD requires an OR to place?

Tunneled line, port

When can the dressings/sutures of a tunneled line be removed?

After 1 month

What are the benefits of a tunneled line?

Lower infection risk, easy self care

What type of CVAD is associated with pneumothorax?

Tunneled CVC

How would you confirm the placement of a CVAD?

Fluoroscopy during placement at bedside OR confirmed with xray

What is a disadvantage of a PICC line?

Difficult self care

What type of small bowel resection is the most poorly tolerated?

Ileal resection

Those who have had their ileum resection would be at risk for what deficiencies?

B12 Bile salts Vitamin E Vitamin C

Patients with >100cm of terminal ileum resected are at higher risk of ___ malabsorption and ___.

Bile salt, steatorrhea

Ileal resection predisposes patients to ___

SIBO

What is the most commonly affected site of Crohn's?

The terminal ileum

What is the best IVF for short bowel syndrome?

Normal saline

What are some associated diseases that are secondary to SBS?

MBD, SIBO, D-lactic acidosis, renal dysfunction, oxalate nephropathy, acid-peptic disease

Name the 3 medications associated with SBS

1. Gattex 2. Octreotide 3. PPI/H2

SBS is typically defined <___cm without colon or <___cm with colon

<100cm without colon or <50cm with colon

To avoid TPN, patients need at least ___ cm of small bowel WITH colon in continuity

To avoid TPN, patients need at least ___ cm of small bowel WITH jejunocolonic anastomosis (presence of ileo-cecal valve)

To avoid TPN, patients need at least ___ cm of small bowel with end jejunostomy

100

Tube feeds are NOT appropriate with <___cm of small bowel

Tube feeds would be appropriate for someone with SBS and colon in continuity if there's at least ___cm of small bowel remaining

Tube feeds would be appropriate for someone with SBS with an end jejunostomy if there's at least ___cm of small bowel remaining

100

What considerations should be made with providing tube feeds to someone with SBS?

It is NOT recommended to feed into the jejunum Slow, continuous feeds

What deficiencies are present in someone with SBS? (hint: 7)

1. B12 2. Fat soluble vitamins 3. Essential fatty acids 4. Zinc/selenium (stool losses) 5. Electrolyte abnormalities 6. Dehydration 7. Iron (if on long-term PN)

What type of SBS patient would be at risk for oxalate nephrolithias? How would oxalate levels be managed in these patients?

Only when colon is in continuity. Should be on low oxalate diet. Additionally, eat foods high in calcium (or calcium supplements) to help bind oxalate.

What are some PO diet recommendations for SBS?

Reduce simple sugars, choose complex carbohydrates Liberal sodium Increase soluble fiber if >3L of stool

What type of fluid would a patient with SBS require (end jejunostomy)?

Isotonic

An ORS intended for a patient with SBS and end-jejunostomy should include what?

Glucose and sodium (90-120 mEq of sodium per liter) Isotonic fluid

Metabolic acidosis is characterized by ___ pH and ___ HCO3

Low, low

Metabolic alkalosis is characterized by ___ pH and ___ HCO3

High, high

Respiratory acidosis is characterized by ___ pH and ___ CO2

Low, high

Respiratory alkalosis is characterized by ___ pH and ___ CO2

High, low

What is the compensatory response to metabolic acidosis?

Hyperventilation (blow off more acid/CO2)

What is the compensatory response to metabolic alkalosis?

Hypoventilation (retain acid/CO2)

What is the compensatory response to respiratory acidosis?

Kidneys retain HCO3 (to balance acid)

What is the compensatory response to respiratory alkalosis?

Kidneys excrete HCO3 (to lower pH)

How would you correct metabolic acidosis in TPN?

Decrease chloride

How would you correct metabolic alkalosis in TPN?

Decrease acetate

How would you correct respiratory acidosis in TPN?

Avoid overfeeding

How would you correct respiratory alkalosis in TPN?

None

A normal range for pH is ___-___

7.35-7.45

A normal range for CO2 is ___-___

35-45

A normal range for HCO3 is ___-___

22-26

Home EN/PN is covered under what?

Medicare part B - prosthetic device act

"Test of permanence" of home EN/PN is ___ days. Permanence does not exclude the possibility of improvement.

90 days

Home EN/PN must fit into a defined ___ category to be covered by medicare.

Benefit

Home EN/PN must be ____ and ____ for the treatment of illness or improve the ___ of the malformed body part.

Reasonable, necessary, function

Home EN/PN must provide sufficient nutrients to maintain ___, ___, and commensurate with overall ___ status.

Weight, strength, health

Medicare will cover home EN when it is the ___ source of nutrition

Sole

Home EN must provide ___-___ kcals/kg to be approved for medicare coverage.

20-35

When would a tube feed pump be covered by medicare?

Only with intolerance or contraindication to bolus feeds. Examples include: reflux, aspiration, dumping syndrome, glycemic control, circulatory overload, slow infusion rate, jejunal feed

When would tube feeds not be covered by medicare?

With a functioning GI tract (malnutrition, dementia, anorexia). Supplemental feeds. Enteral formula is not covered.

What documentation is required for medicare coverage of home PN? (hint: 4 major requirements)

1. Diagnosed non-functioning GI tract (disease impairing absorption or significant motility issue) 2. EN was considered, tried/failed or would worsen GI symptoms. 3. Need for >90 days 4. Meets 100% needs (supplemental not usually covered)

Medicare will often cover home PN if there's evidence of ___ malabsorption

Fat

Name the acid-base disorder: Diarrhea

Metabolic acidosis

Name the acid-base disorder: AKI

Metabolic acidosis

Name the acid-base disorder: Excess chloride in PN

Metabolic acidosis

Name the acid-base disorder: SBS

Metabolic acidosis

Name the acid-base disorder: Uncontrolled diabetes (diabetic ketoacidosis)

Metabolic acidosis

Name the acid-base disorder: Chronic diuretic use

Metabolic alkalosis

Name the acid-base disorder: Excess vomiting or NG output

Metabolic alkalosis

Name the acid-base disorder: Excess acetate in PN

Metabolic alkalosis

Name the acid-base disorder: Disorders of altered ventilatory control (ex: COPD)

Respiratory acidosis

Name the acid-base disorder: Sedation

Respiratory acidosis

Name the acid-base disorder: Respiratory muscle weakness

Respiratory acidosis

Name the acid-base disorder: Hyperventilation (anxiety, sepsis, fever, pain)

Respiratory alkalosis

Acidosis can lead to an ___ in potassium

increase

Alkalosis can lead to a ___ in potassium

decrease