Exam 2 - Practive

Loop diuretics increase excretion of

• Potassium

• Magnesium

• Sodium

Potassium sparing diuretics _______ potassium excretion

decrease

Discuss the drug nutrient concerns with long-term corticosteroid adminsitration

• Increase risk for osteoporosis as it promotess loss of lean body mass and bone

• Causes sodium and water retention

• Enhances excretiton of potassium and calcium

• Impairs calcium absorption

• Can increase appetite and contribute to hyperglycemia

• May increase needs for K, Ca, A, D, C, and protein

Patients prescribed with coumadin/ warfarin should..

consume more foods high in Vit K

Patients on phenytoin and continuous enteral feedings must..

have enteral feedings held 1-2 hours before and after medication administration

Ritalin _____ appetite

decreases

What are some foods high in Vit K

• Spinach

• Kale

• Swiss Chard

• NOT bananas

Weight gain is associated with what medications

• Predisone

• Megace

• Insulin

Weight loss is associated with what medication

Lasix

What is a major constituent of the body accounting for _____% of Body Weight in adults

50-60%

List the three main compartments of which total body water is distributed

• Intracellular

• Extracellular

• Transcellular

How much volume would 1L of isotonic IVF solution (0.9% NaCl) distribute to intravasular space

Infusion 1L water with 0.9% NaCl (isotonic), 1000mL remains in ECF with 25% in intravascular (250mL)

D5W (5% dextrose) is considered a

hypotonic solution

Albumin is an important molecule involved in maintaining oncotic pressure and thereby preventing the movement of water into the

interstitial space

Important hormones that regulate fluid balance:

• ADH (antidiuretic hormone)

• Aldosterone

• Atrial Natriuretic peptide

• Renin

• Angiorensin

Carol is an 80yo female in the ICU with CHF. She is 5’2” and 110#. What would best align with her fluid requirements

1250mL/ day

What can contribute to fluid balance

• Diarrhea

• Nasogasric output

• Vomiting

• Urine output

• Wound drainage

Normal range for arterial blood pH is

7.34-7.45

The major extracellular osmole or cation which acts to hold water in the extracellular space is

sodium

Acid-base balance is maintained by

• Kidneys

• Lungs

• Buffering systems

Any substance that releases hydrogen ions in a solution is considered

Acid

Any substance that accepts hydrogen ions in a solution is considered

Base

If hypernatremia is the result of free water loss, fluid deficit is determined by using a simple equation incorporating the patient’s weight and serum sodium. Calculate fluid deficit for the following case: Mr. Mendoza weighs 75kg. His serum sodium is 148. Calculate fluid deficit. What is his total fluid deficit. Include your work

• Male: (0.6 x wt in kg) x (serum Na - 140) / serum Na = Fluid deficit

• Female: (0.5 x wt in kg) x (serum Na - 140/ serum Na = Fluid deficit

• (0.6x75) x (148-140)/148 = 45 x 8/148 = 45 x 0.054 = 2.43 = Fluid Deficit 2.4L

Joe Smith's nutrition prescription = 2100 kcal, 95 g pro, 2100 ml fluid. Which of the following rates would best meet his energy/protein needs at goal enteral nutrition if on continuous feedings. (Osmolite 1.2: 1.2 kcals/mL, 55.5 grams of protein/liter; 82% free water, 0 gm fiber and meets or exceeds RDIs for micronutrients in 1200 mL)

Osmolite 1.2 at 75mL/ hr x 24hrs

What is the gold standard for determining proper positioning of feeding tubes placed at bedside (For example, this would be critical to assure proper placement of a nasoenteric tube prior to use)

Radiographic confirmation

Joe Smith is a new admit to your hospital unit. He was receiving night feeds of Osmolite 1.5 at 85 ml per hour x 14 hours (7 pm to 9 am) via j-tube at home.  In addition he was receiving 120 ml water flushes every 4 hours. Calculate energy, protein, fluid delivery on this enteral regimen. (Osmolite 1.5: 1.5 kcals/mL, 62.7 gms of protein/liter; 76% free water, 0 gm fiber and meets or exceeds RDIs for micronutrients in 1000 mL)

• 1190 mL

• 1785 kcal

• 75 g pro

• 1624 ml total water with flush

Tube feedings are typically held before and after administration of which medication

Phenytoin (Dilantin)

What is associated with the occurrence of diarrhea in tube fed patients

• Sorbitol containing preparations

• Antibiotic use

• Magnesium containing preparations

• Laxatives

To reduce pulmonary aspirations during enteral feedings is recommended that HOB be elevated 

>30-45 degrees

To reduce occlusion and maintain patency of feeding tube it is recommended to

• Flush with water before and after medication delivery

• Flush with water before and after tube feeding formula boluses

• Flush with a minimum of 30mL water q 4 hours during continuous feedings

Early enteral nutrition (EEN) has been associated with reduced infectious complications, length of stay, and even mortality in critically ill patients. In which patient population might ENN be contraindicated

Patients that are hemodynamically unstable with increasing pressor requirement and MAP <60

JD is in the ICU on mechanical ventilation. Her fluid needs are 2200mL/ day. If her TF at goal is providing 1020mL if free water how much additional water flush should be ordered so that IVF can be tapered off

~200mL every 4hrs

List 5 benefits of early enteral nutrition

• Preservation of gut integrity

• Shorter/ decreased LOS

• Reduced risk of infection

• Faster achievement of nutritional goals

• Reduced reliance on PN

In patients with refeeding syndrome, what electrolytes are critical to monitor before and during start of nutrition support

• Phosphate

• Potassium

• Magnesium

JS in the neuro unit at your acute care facility. He has severe dysphagia and is NPO on continuous TF. He is being discharged to a rehab in 3 days and you would like to transition him to bolus feedings to prepare him for d/c. He has a PEG in place for feedings. Nutrition Prescription: 2000 kcal, 78g pro, 2200 mL water. Select at TF from the TF order sheet used in class and calculate a goal bolus regimen for JS. Include water flushes to meet fluid needs and any modulars if indicated. Write a TF order including initiation and advancement.

• Formula: Osmolite 1.5 via PEG, bolus feed

• Goal: 270mL five times daily at 6am, 10am, 2pm, 6pm, 10pm

• Water: Flush 100mL before and 120mL after each bolus

• Start 120mL bolus x1, if tolerated advance by 120-150mL to reach 270mL by 24 hrs

• Modulars: none needed

Fluid status can be assessed by evaluating:

• Input and Output

• Assessment of mucous membranes

• Evaluatoin of skin turgor

Enteral nutrition, when intdicated, is preferred over parenteral nutrition for what reason?

Maintenance of gut integrity

A patient receiving continuous nasojejunal feedings has developed significant diarrhea.  Which of the following is the most appropriate initial action for the management of this patient?

Review the patient’s medication administration record

What is associated with sarcopenia?

• Age

• Sedentary lifestyle

• Obesity

• Endocrine abnormalities

What are indications for enteral nutrition?

• Dysphagia

• Vegetative state

• MAP >60

• Anorexia

What is a potential tube placement site for long-term enteral feedings?

• Percutaneous endoscopically-placed gastrostomy

• Jejunostomy

• NOT nasoduodenal

What are complications of enteral nutrition support

• Aspiration

• Diarrhea

• Constipation

NG stands for

Nasogastric

ND stands for

Nasoduodenal

NJ stands for

Nasojejunal

G-Tube stands for

Gastronomy

J-Tube stands for

Jejunsotomy

PEG stands for

Percutaneous Endoscopically-Placed Gastronomy

JEG stands for

Percutaneous Endoscopically-Placed Jejunostomy

What formula is considered a diabetic formulation?

Glucerna

Scott, a 68 y.o. male, will be undergoing surgery for a knee replacement tomorrow. During your nutrition assessment, you noted that Scott is 5’8” and weighs 210 lbs (stable). Due to knee problems he has difficulty walking, even to the mailbox. Which of the following might you suspect based on this information?

Scott may have sarcopenia obesity

M.R. is an 85 y.o. female who had a CVA with hemiparesis (paralysis).  She has had and has failed her swallow evaluation. The speech therapist is recommending she remain NPO.  Which nutrition support modality, if needed, would best accommodate her needs?

PEG

What nutrition support infusion method can be used when feeding in the small bowel?

Continuous feeding

At what nutritional oral intake level should nutrition support be discontinued?

Greater than 60%

11. Today is day 2 of enteral nutrition via a NG tube for Jenna. Based on the following information, what would you determine the problem to be?

Ht: 5’ 7”           Current Wt:  129 lbs.              Usual Wt:  120 lbs.           MAP: 65

Labs: Sodium: 134 (135-145)     Potassium: 3.2 (3.5-5.5)        Chloride: 101 (99-112)

Bicarb: 26 (22-29)                       fasting glucose: 91 (65-99)    BUN: 13 (8-24)  

Creatinine: 0.7 (0.6-1.1)              Albumin: 2.9 (3.5-5.5)            WBC: 13 (4-11)  

Ca++: 7.8 (8.5-10)                       Phosphorus: 1.2 (2.5-4.5)     Magnesium 1.0 (1.5-2.5)   

Refeeding syndrome

A person who is edentulous has

no teeth

What is a feature of elderly people and water metabolism

They do not feel thirsty or recognize dryness of the mouth

 John is 60 years old and has been experiencing numbness in his hands for the past 3 months. His doctor suspects that John is not producing enough hydrochloric acid and intrinsic factor and encourages him to eat more foods containing vitamin B12. What is wrong with this suggestion?

Because John is not producing intrinsic factor, he cannot efficiently utilize vitamin B12 from natural sources and would need a vitamin B12 supplement

A patient has just been placed on Warfarin and the physician has asked you to meet with them for nutrition counseling. Which of the following would you recommend?

Keep daily vitamin K intake constant

What factors affect the absorption of an orally administered drug?

• GI motility

• Drug concentration

• Drug solubility

Patients receiving loop or thiazide diuretics have increased _________ needs

Potassium

John has been prescribed Prednisone, a corticosteroid, and is worried about some of the drug’s side effects.  Which of the following should he consider?

Protein, calcium, and vitamin D supplements if oral intake is inadequate

Oncotic pressure controls fluid movement via

albumin concentration

Contraindication to EN include

• Total bowel obstruction

• High output fistula

• MAPs less than 60 or escalating pressor requirements

Management of malnourished patients at risk of refeeding should include

• Daily monitoring of BMP, Mg. Phos with initiation of NS

• Monitoring of Daily monitoring of BMP, Mg. Phos before initiation of NS

• Thiamine provision of 100 mg daily for 5 days

One indication for use of immune enhanced formulas include

Trauma /Traumatic Brain Injury

Your patient has a pH of 7.25 and has been having intractable diarrhea. The patient likely has:

Metabolic acidosis