MNT II Final Exam

Organs involved in compensatory acid base reactions

Kidneys

lungs

Respiratory acidosis compensatory response

Kidneys increased bicarbonate absorption

Respiratory alkalosis compensatory response

kidneys excrete bicarbonate

Metabolic acidosis compensatory response

Lungs increase respiration

Metabolic alkalosis compensatory response

Lungs decrease respiration

Is CO2 acidic or basic

acidic

Is HCO3 acidic or basic

basic

ROME meaning

Respiratory Opposite Metabolic Equal

Respiratory alkalosis

PH increases

PCO2 decrease

Respiratory acidosis

low pH, high PCO2

Metabolic alkalosis

high pH, high HCO3

Metabolic acidosis

low pH, low HCO3

Normal body ph

7.35-7.45

Rule on deciding wether or not to use enteral or parenteral nutrition

If the gut works, use it

If you had a client that is a new tube feeder and the RD is meeting with them, what are questions that would be appropriate

-how many times do you usually eat in a day

-how often do you eat

-would you be okay/bothered by night feedings

If you at a dietitian and you get sent to look at a tube feeder what are some questions for a doctor

-are they NPO

-how long have they been in the tube feeding

-special medical conditions

-anthropometric

-is the feeding bolus on continuous

-are they mobile

Volatile vs nonvolatile

Volatile can become gas and eliminated by the lungs

nonvolatile cannot become gas and are eliminated by the kidneys

Indirect measure of acidity

CO2

Acid

Substances that give up or donate H+ ions

Bases

Substances that can accept or receive H+

Alkalemia

Accumulation of a base or loss of acid

Acidemia

Accumulation of acid or loss of base

Buffers

Reacta with free H+ in order to maintain acid-base equilibrium

Foods and PH

1. Meats-cause more acid production

2. fruits/vegetables- cause more alkaline production

First defense in acid base imbalance

The lungs

Acidosis renal response chart

1. H+ secretion- up

2. H+ excretion-up

3. HCO3- reabsorption and addition of new HCO3 to plasma -up

4: HCO3 excretion-normal

5. PH of urine-acidic

6. compensatory change in plasma PH-alkalinzation towards normal

Alkalosis renal response chart

1. H+ secretion-down

2. H+ excretion-down

3. HCO3- reabsorption and addition of new HCO3 to plasma-down

4. HCO3- excretion-up

5. PH of urine-alkaline

6. compensatory change in plasma PH-acidification toward normal

If a patient has acidosis, how could you anticipate their CO2 level to be

CO2 would be increased, hypoventilation, bicarbonate is lowered

Authority for enteral and parenteral nutrition

ASPEN

True or false: because enteral feedings are mostly water, no more water is needed than the formula

False

true or false: if a patient is receiving enteral feedings, they will automatically be NPO

False

Percentage of body water in people

-50% of males

-60% of females

-75% of newborns

-less than 50% in people older than 65

As body fat increases

Water decreases

As muscle increases

Water increases

Osmotic pressure

-helps the cell maintain shape

-hypertonic-dehydrated cell

-hypotonic-over hydrates cell

-isotonic-perfectly hydrated

Extracellular

Outside the cell

Intracellular

Inside the cell

intrasvascular

Inside the vessel

Transcellular

Secreted in the organs

During normal processes where do nutrients go once they have left the GI

-the liver, them to the heart (through the hepatic vein), then to the body

-parenteral nutrition bypasses this and goes straight to the heart

Conditions where CPN may be indicated

Ileus

non stop vomiting

obstruction

GI bleeding

Osmolality of CPN and PPN

1. periferal-less than 900 mOsm

2. Central-can be more than 900 mOsm

how to calculate osmolarity

1. Mg of dextrose x 5

2. G protein x 10

3. add 300-400 for vitamins and minerals

sum of all of these

What is the main goal for enteral over parenteral nutrition

Maintaining gut

Two reasons research supports enteral nutrition

-protects the gut

-costs less

-less labor intensive for staff

-less stress in patient

Explain the difference in continuous and bolus feedings

Continuous feedings are done a little at a time all day and all night

bolus feedings are a greater quantity of formula delivered every few hours (typically used for more mobile people)

Time frame over which a bolus is delivered

15 minutes

follow with 30ml flushes before and after

How much formula is usually in a bolus

250-500ml

basic types of enteral feedings

1. Polymerized/standard

2. hydrolyzed-for tubes in the lower GI

3. Modular-have specific ingredients to meet special needs

4. fiber containing-reduces diarrhea

5. disease specific-kidney disease, diabetes etc

What does RSL stand for

Renal solute load

What is renal solute load

The amount of nitrogenous waste and minerals that must be excreted by the kidney. Proteins and electrolytes increase the RSL.

Normal free water content for the standard formulas

Nutrient dense formulas contain less water

1kcal-84% water

1.2-81% water

1.5-76% water

1.7-73% water

2kcal-70% water

How water content changes with gender

Men have less water content than women

Osmolality vs. Osmolarity

osmolality- osmols per kg of solvent

osmolarity- osmols per liter of solvent

Which is more accurate, Osmolality or Osmolality

Osmolality

Normal body Osmolality

275-295

higher means dehydrated

lower means over hydrated

What regulates fluid and electrolytes in the body

-osmotic and hydrostatic pressure

-thirst

-renal

-hormonal influence (RAAS)

-electrolyte regulation

Which organ is involved in thirst

Hypothalamus

Renal: when blood volume increases...

Renal hydrostatic pressure in the kidneys increases resulting in large amounts of fluid moving to the renal tubes to be excreted

Vasopressin (_antidiuretic)

Triggered by:

-increased Osmolality of ECF

-RAAS system

stimulates the reabsorption of fluid in the tubule of the kidney which increases blood volume and lowers Osmolality

The RAAS system is an intricate system of hormones from the

Kidneys

liver and lungs

A decrease in blood volume causes

-the hormone renin to be released from the kidneys

-renin stimulates the conversion of angiotensinogen to angiotensin I then to angiotensin II

-the increase in this stimulates the release of aldosterone from the adrenal cortex

-this influences the kidney to retain sodium

-when level of sodium increases the increased osmotic pressure pulls fluid back into the blood and the blood volume increases

Aldosterone hormone

Impacts potassium

high potassium causes the adrenal glands to release aldosterone and this results in increased excretion of potassium by the kidneys

Hypovolemia

decreased blood volume

Hypervolemia

increased blood volume

Assessment of Acid-Base Balance

1. Assess PH

2. assess PCO2

3. assess serum HCO3

Respiratory acidosis is characterized by

-reduced PH

-elevated PCO2

-variable increase in HCO3

almost always results from decreased effective alveolar ventilation , not an increase in CO2

Respiratory alkalosis is characterized by

-elevated PH

-Decreased PCO2

-variable reduction in serum HCO3

occurs when alveolar ventilation is increased beyond the level necessary to eliminate metabolically produced CO2

Common causes of metabolic alkalosis

Loss of acid

vomiting

nasogatric suctioning

hypokalemia

excessive base

intravenous therapy

blood transfusion

excessive or chronic use of antacid

GI loss

nasogastric suction

renal loss diuretic therapy

excessive bicarbonate administration

Metabolic acidosis

1. Normal anion gap

-gastrointestinal loss of HCO3

-renal loss of HCO3

-inges to on of ammonium chloride or parental nutrition containing chloride salt

2. increased anion gap

-increased production of endogenous acid (lactic acidosis, ketoacudisis, inborn errors)

-renal Failure

-ingestion of salicylates, methanol, ethanol

What are some factors that need to be assessed after deciding on EN

How to establish access to GI

Patients DX

Length of therapy

aspiration

GI anatomy

gastric and intestinal function

Steps for tube feeding

1. Estimate needs of patient

2. select appropriate tube feeding formula

3. determine how much formula is required

4. divide the amount of formula by 24 hours

5. calculate the energy protein and fluid load

6. establish free water flushes

Indications for using EN

1. EN

-inadequate intake 7-14 days

-coma

-cannot meet requirements

Risks of EN

-aspiration

-tune malpositioning

-referring syndrome

-medication related complications

-fluid imbalance

-infection

-agitation

EN contraindications

-obstruction

-GI bleeding

-uncontrollable vomiting or diarrhea

-pancreatitis

-inability to gain access

Patients who may need 2kcal formulas

Patients with restricted fluid intake

renal

cardiac

pulmonary issues

What are residuals

Content remaining in the stomach from tube feeding

How do you monitor tolerance-what are symptoms to look for to indicate intolerance

Monitor hydration status and adequacy of nutrition support

bad symptoms:

nausea

cramping

constipation

aspiration

How do you progress a patient?

Determined by tolerance

goal is to meet 25-50% of their needs the first day

80% in 24-48 hours

What are some things the RD would need to check for in the patients listed above

1. Sufficiency of nutrient intake

2. electrolytes, BUN, creatinine, blood glucose

3. Mg, phos, calcium, nitrogen balance

4. liver Fx, Tg

5. weight

6. vital signs

7. hydration status

What is refeeding syndrome?

When body rapidly changes from catabolic to anabolic metabolism

If an RD is asked to check a residual related to enteral feedings what is that referring to and what is a high value

Excess is >100-150ml

Which type of formula would be used if the clients GI has full use

Standard

Which type of formula would be used if the tube is in the duodenum and why

Hydrolyzed formulas because the tube bypasses certain parts of the stomach/digestive processes

What is the purpose of elevating the head of the bed for tube feeders

Prevent aspiration

Standard formula contains ____% protein, a high protein formula contains ____ % calories from protein

10-15% for standard

up to 25% for high calorie

A low protein formula is usually needed for

People with renal or liver disease

A typical standard formula contains about __% kcal from carbohydrates

50

List two ways to assess hydration status in tube fed patients

Urine output

skin integrity

List 5 parameters that should be monitored for people receiving nutrition support

1. Sufficiency of nutrient intake

2. electrolytes, BUN, creatinine, blood glucose

3. Mg, phosphorus, calcium, nitrogen balance

4. liver Fx tests, TG

5. vital signs

6. hydration status

Oxygen

Received from cellular metabolism and expired as waste products.

Metabolized

Process where metabolic fuels such as CHO, Pro, and Lipid use O2 and produce CO2.

Lung disease

One in every 6 deaths in America is related to this, making it the 3rd leading cause of death.

Pharynx

Part of the gut and respiratory system that carries both food and air.

Pulmonary system

Includes the upper and lower respiratory tracts and their respective organs.

Upper respiratory tract

Includes the nose, nasal cavity, front and maxillary sinuses, larynx, and trachea.

Lower respiratory tract

Includes the lungs, bronchi, and alveoli.

Trachea

Air enters the lungs through this structure, which divides into the right and left bronchi.

Bronchi

Divides into smaller bronchioles which end in small air sacs called alveoli.

Alveoli

Small air sacs embedded with millions of capillaries responsible for the exchange of O2 and CO2.