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Nutrition
| Question | Answer |
|---|---|
| Essential Proteins | Histidine, Isoleucine, Leucine, Lysine, Methionine, Phenyalanine, Threonine, tryptophan and Valine |
| What protein supplementation is required for critical illness | Glutamine |
| Alpha linolenic acid | DHA and EPA omega 3's |
| Linoleic acid | arachadonic acid omega 6 |
| What is GALT? | Gut Associated Lymphoid Tissue ( highest amount in ileum) host defense |
| What is required to absorb vitamin b12 | Intrinsic factor secreted by the stomach binds b12 and allows absorbtion |
| What is the site of absorption of most nutrient particles? | The Jejunum |
| What cells secrete insulin and glucagon | Endocrine pancreatic Beta cells |
| What are the metabolic fates of proteins? | 1. Protein synthesis ( the body makes them into useable AA's) 2.Deamination conversion into urea and NH3 3.Transamination: Ketoacids (carbon skeletons) |
| What are the metabolic fates of Lipids? | 1. Beta oxidation 2. stored as triglycerides in adipose tissue |
| What are the metabolic fates of carbohydrates? | 1. Glycolysis- oxidation: 1 the conversion to ATP for immediate use or 2.FA to be stored in adipose tissue 3. Glycogenesis: stored in liver and skel muscle 3. |
| Growth hormone | GI Hormone that is secreted by the pituitary and acts on adipose and muscle tissue to increase muscle growth |
| EPI/ NOR epi and cortisol | secreted from adrenals, acts to break down muscle |
| When can dysphagia occur? | 24-48 hours after intubation post stroke speech therapist will do a barium swallowing test to determine |
| What is a MBS? | modified barium swallowing test where different types and consistencies of food are mixed with barium to see what the patient can swallow |
| How many Kcal/Kg/day do we feed a normal healthy patient? | 25kcal/kg/day |
| how many Kcal/Kg/day do we feed a patient under moderate stress? | 30 Kcal/Kg/day |
| How many Kcal/Kg/day do we feed a patient with a major trauma? | 35 Kcal/Kg/day |
| How many Kcal/Kg/day do we feed a burn victim? | 40 Kcal/Kg/day |
| How many Kcal/Kg/day do we feed an obese patient? | 11/14 Kcal/Kg/day |
| How much fat do we feed a patient per day | <30% of total Kcal per day |
| How much fiber do we feed per day? | 20-35 grams per day |
| how much water do we need per day | 35 ml/kg/day |
| Non-inflammatory term for malnutrition? | starvation |
| Inflammatory terms for malnutrition | acute and chronic disease related |
| Marasmus malnutrition | severe calorie deficit malnutrition |
| Kwashiorkor malnutrition | Severe protein deficiency malnutrition |
| Starvation related malnutrition types and response | anorexia and bulimia; responds to nutrition, non-inflammatory |
| Linoleic acid deficiency: Pn Deficiency | scaly rash, increased infection and decreased wound healing |
| Vitamin A deficiency | Night blindness, dry hair and pruritis |
| Vitamin A toxicity | peeling skin, alopecia, gingivitis and jaundice absent yellow eyes |
| Vitamin d functions | calcium absorbtion and regulation |
| Vitamin D deficiency | RICKETS, osteomalacia and muscle weakness |
| Vitamin E function | Antioxidant and normal RBC function |
| Vitamin E deficiency | ANEMIA, muscle weakness and hemolysis |
| Vitamin E toxicity | increased bleeding and bruising and decreased platelet aggregation |
| Vitamin K functions | Synthesis of clotting factors |
| Vitamin K deficiency | Increased bleeding and bruising |
| Vitamin K toxicity | Jaundice |
| Vitamin B1 | Thiamine |
| Vitamin B1 functions | nucleic acid synthesis and carbohydrate metabolism |
| Vitamin B1 deficiency | Beriberi and Wernicke-Korsakov syndrome |
| Vitamin B2 | Riboflavin |
| Vitamin B2(riboflavin) functions | energy production, niacin synthesis and antioxidant |
| Vitamin B2 (riboflavin) deficiency | mucositis, cheilosis, photophobia and burning eyes |
| Vitamin B3 | Niacin |
| Vitamin B3 (niacin) functions | coenzyme in energy production |
| Vitamin B3 (niacin) deficiency | Pellagra and Casal's necklace |
| Vitamin B3 ( niacin) toxicity | Flushing and Liver damage at chronic high doses |
| Vitamin B5 | Pantothenic acid |
| Vitamin B5 (pantothenic acid) functions | synthesis of cholesterol and steroid hormones |
| Vitamin B6 | Pyridoxine |
| Vitamin B6 (pyridoxine) functions | Synthesis of neurotransmitters Synthesis of niacin from tryptophan Hemoglobin synthesis and function |
| Vitamin B6 (pyridoxine) deficiency | mycrocytic anemia neuropathy seizures |
| Vitamin B6 (pyridoxine) toxicity | neuropaties |
| Vitamin B9 | Folic acid |
| Vitamin B9 (folic acid) functions | synthesis of methionine from homocysteine and RBC formation |
| Vitamin B9 (folic acid) deficiency | Neural tube defects glossitis (swelling of the tongue) stomatitis macrocytic anemia |
| Vitamin B12 | Cyanocobalamin |
| Vitamin b12 (Cyanocobalamin) functions | nervous system cellular division and growth |
| Vitamin B12 (Cyanocobalamin) deficiency | PERNICIOUS ANEMIA glossitis peripheral neuropathy Focal neurological deficits |
| Biotin functions | Cofactor in carbohydrate metabolism |
| Vitamin C functions | collagen synthesis, norepinephrine synthesis, carnitine synthesis, antioxidant |
| Vitamin C deficiency | Scurvy, poor wound healing and keratosis of hair follicle |
| Vitamin C toxicity | kidney stones stomach cramping and diarrhea |
| Chromium Functions | Promotes normal function of insulin |
| Chromium toxicities | Insulin resistance(hyperglycemia) Increased LDL peripheral neuropathies |
| Copper functions | enzyme catalyst, melanin production and iron metabolism |
| Copper deficiency | microcytic anemia, neutropenia, decreased hair and skin pigmentation |
| copper toxicity | kidney and liver failure |
| Iodine function | Thyroid hormone |
| Iodine deficiency | Goiter and hypothyroidism |
| Iodine toxicity | hyperthyroidism and parotitis |
| Manganese functions | cartilage synthesis and metabolism of fats and proteins |
| manganese deficiency | bone malformation, infertility and seizures |
| Manganese toxicity | parkinsonism difficulty concentrating |
| Selenium functions | enzymatic processes and activation of T3 |
| Selenium deficiency | muscle pain and weakness cardiomyopathy and hypothyroidism |
| Selenium toxicity | brittle hair and nails, hair loss and death |
| Zinc functions | Various enzymatic processes Sense of taste and smell Immune function Growth and development |
| Zinc deficiency | Decreased sense of taste and smell Impaired wound healing Dermatitis |
| Zinc toxicity | metallic taste, N |
| Refeeding syndrome | occurs when feeding after starvation, insulin increases drives ions intracellular = shut down of organs and possibly death |
| JNC requirement for assessment of nutrition | all hospitalized patients within 24 hours |
| Prealbumin | Carrier protein for thyroid hormone Sensitive to short-term changes in inflammation and protein nutrition (t½ is 2-3 days) |
| Nitrogen balance | Direct marker of protein gain/loss Indirect marker of metabolic rate g of protein per day/ 6.25) – (UUN + 2 |
| Ways to kill or seriously harm patients with nutrition | Risk for refeeding syndrome – no electrolytes Renal impairment – too many electrolytes Fluid overload – no fluid restrictions Parenteral nutrition Exceeding Ca-Phos solubility Exceeding osmolarity max Exceeding dextrose-rate max All pts, no monitor |
| Harris benedict equation for REE | overestimates in modern populations Underestimates in hospitalized patients |
| Mifflin St. Jeor equation | More accurate in obesity NOT accurate in critical care patients |
| Ireton jones equation | Most accurate in critically ill patients Do not use in healthy or moderately stressed patients |
| estimated Kcal requirement for all patients except obese | 25 kcal/KG actual body weight/day |
| Estimated Kcal requirement for obese patients | 11-14 Kcal/Kg actual body weight /day |
| How many Kcal per gram in each: protein, fat and carb | Prot=4 Kcal/g Carb= 4 Kcal/g Fat = 9 Kcal/g |
| How many Kcal in D5 dextrose | 0.17 Kcal/ml |
| How many Kcal of fat in propofol | 1.1 Kcal/ml |
| How many kcal in dextrose PN | 3.4 Kcal/G |
| How many Kcal in IVFE | 10%= 11 Kcal/g 20-30%= 10 Kcal/g |
| How many total ml to be provided qday of fluid via PN | 35ml/kg |
| formula to determine glucose infusion rate | glucose in mg(grams 1000)/patient weight in kg/ minutes of administration (1440 for 24 hours, 720 for 12 hours...) |
| what must the glucose infusion rate be below to be acceptable? | <5 mg/kg/min |
| formula for final concentration of macronutrients | total grams of carb/total volume in ml total grams of protein/total volume in ml total grams of fat/ total volume in ml |
| Formula for osmolarity | Total grams of protein/total volume in liters x factor 10 plus total grams of carbs/total vol in liters x 5 plus total grams of fat/total volume in liters x 1.5 |
| what number must the total osmolarity be under to be given peripherally? | <900 |
| Contraindications for enteral nutrition | severe short bowel <100 cm severe GIB gi obstruction illeus |
| when to start EN | non critically ill within 7 days critically ill within 24-48 hours |
| short term methods of entry for EN | oral and nasal |
| long term methods of entry for EN | gastric and jejunal or duodenal distal from trietz point |
| closed system EN delivery method | bottle containing sterile formula, can hang 24-36 hours used for continuous feeds |
| continuous feeds and who to give them to | feeding at a constant rate over 24 hours, preferred in critically ill, intubated, risk of re-feeding, unable to tolerate bolus, poor glycemic control and j-tube atients |
| bolus feeding | mimics natural feeding, given via syringe or can over 20-60 QID |
| cyclic feeding | continuous feeds given <24 hours to promote daytime eating |
| trophic feeding | delivers low rate< 30 ml/h to stimulate intestinal feeding, used in newborns and adults intolerable of goal EN rate |
| Regulation formula for EN | considered medical food, not subject to strict claim and labeling regulations |
| polymeric/standard EN | closest to real food, contains macro nutrients in original form |
| monomeric/hydrolyzed/elemental EN | eliminates need to digest all nutrients, partially or completely predigested macronutrients. |
| frequency and rate of continuous EN feeds | 20/50 ml/hr goal 50-60 ml/hr, advance 10 ml q4 until at goal |
| frequency and rate of bolus feeds | start 125 ml per feed advance 125 ml/feed until at goal of 725 ml per feed |
| when to check residuals | q4h |
| what volume of residuals will initiate a change and what is the change | >250 consider prokinetic >500 hold 4 hours then if >250 consider prokinetic |
| Safe practices for enteral feeding | A=aseptic technique L=label enteral equipment E=elevate head of bed 30' R=Right patient, right formula, right tube T=trace all lines and tubing back to patient |
| safe practices for enteral medications | A=ask the pharmacist about interactions... W=water only for admin and flushing A=administer medications individually R=Right patient, Right med, Right dose E=establish evidence based protocols |
| enteral misconnections | wrong tube for EN or EM, always trace to patient |
| common problem medications with EN | warfarin, levo, phenytoin and FQ's |
| what does basic PN not contain? | Iron, fiber, glutamine or phytochemicals |
| contraindications for PN | Hemodynamic instability, working gut, acid base imbalance and electrolyte imbalance |
| PICC line Vs Central line for PN administration | PICC risk of extravasation and phlebitis short term<2 weeks and <900 mosmol to be administered and < 10 % dextrose |
| things that affect the solubility, stability and compatibility of PN | ph, light, temperature, concentration of admixture ingredients and medications |
| types of CHO used in PN | dextrose or glycerol (glycerin) |
| concentrations of amino acids in PN | standard 3.5-10% concentrated 15-20% pediatric 6-10% |
| contents of AA in PN | > BCAA, less phenylalanine and methionine and lower PH |
| what protein is missing from PN | L-cysteine, must supplement |
| TPN electrolytes | come in salts or combo salts, must be added to custom PN bags |
| how to give NA ions in tpn | In salt form with phosphorus until PH dose reached then based on acid base if acidotic give remainder as acetate if alkalotic give as chloride |
| Preferred method of calcium combination | calcium gluconate |
| Phosphate | increase if refeeding possible decrease in renal insufficiency |
| How to keep ca and Ph soluble | lower PH, add l-cysteine, use ca gluconate, administer separately keep product <55 MEQ, use high conc of AA |
| acetate and chloride | no requirements, use to maintain acid base balance |
| trace elements for TPN | zinc, copper, manganese, chromium and selenium Selenium not found in pediatric TE supplement |
| aluminum contamination in PN toxicities | can lead to osteomalacia and encephalopathy microcytic anemia; all concerns with long term TPN |
| Order of mixing when making a compounded PN | 1. dextrose, AA's and sterile water 2. Phosphate 3. electrolytes 4. Trace elements then agitate 5. calcium then agitate and inspect for particles 6. IVFE, inspect for phase separation 7. Vitamins |
| compounded PN storage parameters | store in fridge, good for 30 hours at room temp and 7 days in fridge avoid extreme light |
| IVEF: Creaming | separation of TG to top of the bag |
| IVEF: aggregation | clumping of TG particles |
| IVEF: coalescence | clumping of TG particle into large fat globules |
| IVEF: crackling | separation of oil and water phases |
| Hang time for PN | TPN: change q 24H 2:1 can hang 72 hours IVFE <12 hours |
| how to calculate a cycle for tpn | 50% of goal for first and last hours, then total volume / total middle hours plus the added 50% for first and last hours, EG goal 1800 = 1800/11 = 164 164 /2 = 82 so 163x 10plus 82x2 = 1804 |
| Filter sizes for PN | TPN or 3:1 1.2 micrometer 2:1 .22 Micrometer, catches bacteria will clog with IVFE IVFE alone+ not filtered |
| dextrose rates | min 1mg/kg/min MAX 5MG/KG/MIN 10-14 in peds |
| some PN adverse effects | steatohepatitis (fatty liver), infection, occlusion, bone disease hypo/per glycemia and hypertriglyceridemia |
| preventing hyperglycemia in TPN | administer 1 unit of insulin/ 10G CHO, if diabetic make it 1.5-2 units/G CHO |
| Fatty liver signs and prevention | elevated ast/alt 3x uln, prevent by not exceeding 30% IVFE, don't overfeed, reduce CHO rate, Cycle PN |
| Disease specific: Diabetes Mellitus | Kcal: decrease CHO: not restricted may require insulin PROT: limit if nephropathy w/o dialysis FAT: limit sat fat to <7% Fluids/lytes: no recommendations Micro: do not supplement antioxidants give MVI |
| Disease specific: Renal failure | Kcal: same, increase if stressed CHO: same as normal Prot: same if not dialysis Increase If dialysis Fat:sat fat <7% |
| organization responsible for all obesity information | national heart, lung and blood institute at NIH |
| formula for BMI | height in inches X weight in KG (ABW) all time 703 |
| classification for overweight | 25-29 bmi |
| classification for obese | 30-34.9 stage 1 35-39.9 stage 2 >40 extremely obese stage 3 |
| comorbidities for obese:cardiac | HTN, stroke, HF and CAD |
| comorbidities for obese: metabolic | DLD, DM, insulin resistance, polycystic ovarian syndrome and menstrual irregularities |
| Comorbidities for obese: respiratory | COPD, sleep apnea, asthma and pulmonary HTN |
| waist circumpherences for obese | men >40 inches women >35 inches |
| risk factors for obesity related diseases | 3 or more of the following Cigarette smoking HTN High LDL, low HDL DM family history of CHD AGE men>45 women >50 |
| goal intake of calories for obesity to lose weight | women 100-1200 men 1200-1500 may be higher in very obese |
| Orlistat (ALLI)MOA | pancreatic lipase inhibitor reduces fat absorbtion |
| Orlistat ADR | fecal urgency, spotting, can be helped by increase of fiber |
| Orlistat CI | pregnancy |
| Orlistat interactions | supplement MVI and interacts with Warfarin |
| Apidex, suprenza (Phentermine) | sympathomimetic, adrs similar to amphetamine, increased HR, tremor, insomnia, palpitations, blood pressure^ dry mouth |
| Apidex, suprenza (Phentermine CI) | maoi's w/in 14 days, Preg, breast feeding, HTN, glaucoma, h/x substance abuse, CVD and hyperthyroidism |
| Qysmia (Phentermine/ topirimate) | all similar to phentermine alone but added topirimate |
| Bontril (Phendimetrazine) | similar to phentermine in everyway, add flushing to ADR. |
| Tenuate (Diethylproprion) | similar to phentermine in everyway |
| Belviq (Lorcaserin)MOA | %HT-2 agonist produces early satiety |
| Belviq (lorcaserin) ADR's | HA, dizziness, dry mouth constipation and hypoglycemia |
| Belviq (lorcaserin) CI | Pregnancy and concomitant use of ergot derivatives |
| Bitter orange evidence and moa | this med not proven effective yet sympathomimetic appetite suppressant |
| Bitter orange ADR | MI, stroke seizure |
| Bitter orange CI/warnings | Preg, cardio problems, avoid with drugs that extend QT wave |
| Chitosan | reduces fat absorption, good evidence, can cause gas, stinky stool, loose stool. works like orlistat so avoid combo. avoid in shellfish allergies |
| Raspberry ketones | appetite suppressant, proven in animals only, can increase BP, tachycardia and palpitations, CI in prego |
| DHEA MOA | endogenous adrenal hormone thought to be decreased in obesity |
| DHEA evidence | good evidence |
| DHEA ADR's | gynocomastea, masculinization, increased BP and Blood glucose |
| DHEA CI/ warnings | Prego, risk or current prostate, ovarian or breast cancers |
| HOODIA | appetite suppressant, unclear evidence, CI prego |
| Pyruvate | evidence unclear,Increases metabolism, ADR's bloating, diarrhea, gas. CI in prego and cardiomyopathy |
| HCG | good evidence |
| lapband | creates a pouch to reduce volume consumed |
| biliopancreatic diversion | creates malabsorbtion by decreasing intestine available toabsorb |
| rous en Y bypass | reduces stomach size and reroutes past the duodenum |
| supplementation for bypass patients | Vitamin B12, ≥ 350 mcg/day PO Vitamin D 400-800 IU/day PO Elemental iron 40-65 mg/day PO Calcium citrate 1200-2000 mg/day PO Folic acid 400 mcg/day Multivitamins 1-2 tablets/day PO |
| infant developmental milestones | 6 months: sits unsupported 9 months: immature pincer grasp |
| growth charts to use in children | WHO chart: <2 CDC chart: 2-20 |
| frequency of breast feeding of infants | 8-12 times qday 10-15 minutes per breast |
| Deficits in weight for age are called what? | Underweight |
| Deficits in length for age are called what? | Stunting |
| Deficits in weight for length are called what? | Wasting |
| When does Sids most often occur? | Ages 1-5 |
| Similac go n grow is what kind of formula? | traditional and soy |
| Enfamil prosobee is what kind of formula? | Soy |
| pregestimil lipil is what kind of formula? | semi elemental |
| Neocate infant formula is what kind of formula? | Elemental |
| when calculating nutrition for infants and kids what do we calculate? | Kcal and protein only |
| what is the tend for Kcal needs as kids age | decreases as they age |
| what is the trend for kids for protein as they age | Increases as they age 1-20 |
Created by:
btrain67
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