Parenteral Nutrition: Initiation and Management Flashcards by Leslie Najera

What are the 7 indications for PN?

Patients severely malnourished (unable to take oral products for > 7 days OR enteral products)
Severe pancreatitis
Small or large bowel obstruction
Pregnant (severe N/V)
Head injury patients who have no enteral access or GI dysfunction
Severe inflammatory bowel disease exacerbated by oral or enteral nutrition
Extensive bowel surgery causing malabsoprtion

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Give two examples of severe inflammatory bowel disease?

Chron’s disease

- Ulcerative colitis

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Give an example of an extensive bowel surgery?

Short bowel syndrome

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How is IBW for females calculated?

IBW = 45.5 + 2.3 (height (in) - 60)

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How is IBW for males calculated?

IBW = 50 + 2.3 (height (in) -60)

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(T/F) - Obesity is considered 130% above IBW

TRUE

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(T/F) - Severely malnourished is considered less than 80%

FALSE - less than 70%

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(T/F) - In PN, you will use Adj. BW when a patient is obese to solve calculations

FALSE - IBW will be used even if the patient is obese

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(T/F) - In PN, you will use Act. BW when a patient is malnourished to solve calculations

TRUE

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How is Adj. BW calculated?

Adj. BW = IBW + 0.25(Act. BW - IBW)

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How is the body mass index (BMI) calculated?

BMI = weight (kg) / height (m^2)

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What is the range of an overweight BMI - also known as Grade I obesity?

25 - 29.9 kg/m^2

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(T/F) - The normal weight BMI is 20 - 24.9 kg/m^2

TRUE

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What is the range for a Grade II obese BMI?

30 - 40 kg/m^2

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(T/F) - The Grade III obese scale is > 40 kg/m^2

TRUE

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For obese patients, what is their goal for kcal/kg?

22 kcal/kg of their IBW

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For obese patients, what is their protein gm/kg goal?

2 gm/kg of their IBW

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What are the fluid requirements for adults with normal renal function?

2500 - 3500 mL/day

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What are the fluid requirements for adults with insufficient renal function?

500 - 1500 mL/day

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What type of insulin can be added to PN bags to control glucose levels?

Regular insulin

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What is the initial dose of insulin?

0.1 units/gm of dextrose

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(T/F) - Insulin is usually added to PN bags to prevent hyperglycemia and reduce cost for patient

FALSE - it’s not added usually because of the risk of hypoglycemia and a high cost

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How much should IV fat consist of in total calories?

1 - 4%

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Why is IVFE (IV fat emulsion) given to nearly all patient?

To prevent essential fatty acid deficiency

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What are the two main essential fatty acids? Are they produced within the body or need to be given from the environment?

- Linolenic acid and Alpha-linolenic acid | - They are given from the environment (food)

How should IVFE preparations be given? What filter size should be used?

- In-line IV filter | - A 1.2 micrometer filter size

(T/F) - Lipids cannot be given as a separate peripheral IV infusion (piggyback)

FALSE - Lipids can be given as a piggyback and MUST not exceed 12 hours

Are there any contraindications for IVFE?

Yes, egg allergy patients - IVFE are stabalized with egg phospholipids

What is propofol?

A sedative agent that is manufactured as a 10% lipid emulsion

(T/F) - Propofol does not require to measure the kcal if administered in a patient who is malnourished

FALSE - it needs to be taken into account since it contains lipids in its formulation

At what concentration does dextrose have to be in order for total nutrition admixtures (TNAs) to be stable?

> 10% of the final concentration

At what concentration does amino acids have to be in order for TNAs to be stable?

> 4% of the final concentration

At what concentration do lipids have to be in order for TNAs to be stable?

> 2% of the final concentration

(T/F) - Sodium can be given in a PN when it's clinically needed (use clinical judgement)

TRUE

In which patients should sodium be avoided in? (3 types)

- Iatrogenic fluid overload - End-stage liver disease - Congestive heart failure

In which patients should sodium be given to? (4 types)

- High ileostomy output - High pancreatic fitula output - Large nasogastric fluid output - Large small bowel losses

Sodium content in PN should not exceed how much?

154 mEq/L

(T/F) - Potassium cannot be given in a PN, even if a patient needs it

FALSE - It can be given in a PN but clinicians need to use their clinical judgement

(T/F) - Potassium is generally influenced by acid-base status

TRUE

What happens to potassium serum levels when a patient is metabolic acidic? Does it increase or decrease?

Increase (hyperkalemia)

What happens to potassium serum levels when a patient is metabolic alkalotic? Does it increase or decrease?

Decrease (hypokalemia)

What is the recommended parenteral daily intake of calcium?

10 mEq OR 200 mg/day

In which patients should low amounts of calcium be given? (3 types)

- Hyperparathyroidism - Hypophosphatemia - Metastatic cancer

How do you calculate corrected Ca 2+?

Corrected Ca 2+ = measured calcium + 0.8(4 - albumin)

What is the recommended parenteral daily intake of magnesium?

10 mEq OR 120 mg/day

The amount of calcium and magnesium should not exceed what number in a 3-in-1 formulation?

20 mEq/L

Which disease states require a larger dose of magnesium? (2 types)

- Short bowel syndrome | - Alcoholism

What is the recommended parenteral daily intake of phosphorus?

30 mmol OR 100 mg/day

(T/F) - Omission of PN can induce life-threatening hypophosphatemia within a week in normal renal function patients

TRUE

What disease states are associated with hypophosphatemia? (4 types)

- Alcohol abuse - Thermal injury - Refeeding syndrome - Trauma

If a patient has metabolic acidosis, which salts would you use?

Acetate salts

If a patient has metabolic alkalosis, which salts would you use?

Chloride salts

(T/F) - ONLY sodium bicarbonate should not be used in PN formulas

FALSE - sodium bicarbonate AND calcium chloride should not be used in PN formulas

There are 5 trace elements that can be added once a day -- what are the names?

- Zinc - Chromium - Selenium - Manganese - Copper

What should be done with the trace elements in patients with small/large bowel fluid loses?

Provide a zinc supplement of 5-10 mg/day (if needed) with the Trace element cocktail

What should be withheld in patients with hepatic cholestasis? Why?

- Copper and Manganese | - Excreted through bile

(T/F) - Not every PN should contain MVI

FALSE - every PN should contain MVI

How many products are available in the US that contain MVI? What are the names?

- 2 products | - MVI-Adult and Infuvite Adult

Should iron be added to the TNA formulation? Why or why not?

No, it's not generally stable in TNAs

What is preferable, PNs given in central lines or peripheral lines?

In central lines, unless the formulated product is needed to be given peripherally

Name 4 types of central lines

- PICC - Hickman - Port-A-Cath - Lines in which the tip of the catheter is positioned in the superior vena cava

How can you minimize vein damage from administering hypertonic solutions?

By administering PN through a large diameter central vein

Why is administering PN through a large-diameter central vein going to help minimize vein damage? (2 reasons)

Because of rapid blood flow and PN will be diluted quickly

If PN is given peripherally, would the solution be hypertonic or less hypertonic?

Less hypertonic

What must the osmolality be for PPN (peripheral parenteral nutrition)?

700 - 900 mOsmol/L

Is PPN given for short-term or long-term?

Short-term

What are some limitations of PPN? (2 limitations)

- Limits concentrations of nutrients (osmolality) | - Fluid overload is possible

In which patients is PPN not recommended to? (3 types)

- Long-term PN - Fluid restriction - Severe under nutrition

What should be checked in a patient before discontinuing PN?

Make sure patient is consuming 50% or more of an oral diet that contains at least 60 gm of protetin/day

(T/F) - Abruptly discontinuing PN is recommended in several patients

FALSE - It is not recommended in any patient because it could cause a rebound hypoglycemia

How will a patient be discontinued PN if they're not receiving continuous enteral feedings? (2 steps)

- Decrease 50% of PN rate q 2 hours | - If PN is < 25 mL/hr, discontinue PN

Parenteral Nutrition: Initiation and Management Flashcards

(71 cards)