MNT 3 exam
7. What criteria is used in diagnosis of SIRS, sepsis...?
A. SIRS: the body's response to an infectious or noninfectious insult. a. Fever: temperature above 98.6 b. Tachycardia: heart rate over 100 c. Tachypnea: breathing over 20 breaths per minute d. WBC: leukocytosis B. Sepsis: infection (itis) and know where it is C. Severe Sepsis: organ(s) are starting to fail (acute respiratory distress syndrome, altered mental status, multiple organ dysfunction system) D. Septic shock: want to make heart beat harder (make it easier for blood to get through)
what are the risk factors for hypertension
Risk factors for hypertension: a. Overweight/obesity b. Diet (excessive salt intake, too little potassium, vitamin D, magnesium, and calcium, excessive alcohol intake) c. Smoking d. Lack of exercise e. Stress f. Race/ethnicity g. Genetics h. Aging i. Certain chronic diseases (diabetes, kidney disease, sleep apnea, hypercholesterolemia, atherosclerosis)
At least how much protein should be provided by the diet of a patient who receives hemodialysis three times per week? a. 0.8 g/kg of body weight b. 1 g/kg of body weight c. 2 g/kg of body weight d. 1.2 g/kg of body weight
a. 0.8 g/kg of body weight b. 1 g/kg of body weight c. 2 g/kg of body weight d. 1.2 g/kg of body weight*
12. What is max lipid infusion rate
a. 10% = 1.1 kcal/ml, 20% = 2 kcal/ml or 10kcal/g**, 30% = 2.9 kcal/ml b. Should not exceed 2 g of lipid/kg of body weight per day**, 1g/kg for ICU **RD exam questions
12. A tube feeding ran from 6PM till 6AM, providing 1800 calories, at 1.5 calories/cc. How many cc/hour were given? a. 100 b. 125 c. 210 d. 65
a. 100* b. 125 c. 210 d. 65 1800 kcal / 12 hrs = 150 ml/hr / 1.5 kcals = 100 cc/ hr
10. In a PN mixture, what volume of the amino acid solutions listed would come closest to providing 185 calories? a. 1000 ml of 8.5% amino acids b. 850 ml of 5.5% amino acids c. 500 ml of 7.0% amino acids d. 500 ml of 10% amino acids
a. 1000 ml of 8.5% amino acids b. 850 ml of 5.5% amino acids* c. 500 ml of 7.0% amino acids d. 500 ml of 10% amino acids 1000 ml X 8.5% amino acids = 85 g X 4kcal/g = 340 kcal 850 ml X 5.5% amino acids = 46 g x 4kcal/g = 187 kcal 500 ml X 7.0% amino acids = 35 g X 4kcal/g = 140 kcal
what is peripheral parental nutrition
b. Peripheral parenteral nutrition (PPN) . catheter in small vein, typically the arm 1. short term 2. can't tolerate concentrated solutions c. PN access . Peripheral access 1. up to 800-900 mOsm/kg 2. principal complication is thrombophlebitis (inflammatory process that causes a blood clot to form and block one or more veins) 3. extended dwell catheter: 3 to 6 weeks ii. Short- term central access 1. Percutaneous non-tunneled catheters iii. Long- term central access 1. peripherally inserted central catheter
what is the role of fat for decreasing the risk of CVD
b. Substitute mono or polyunsaturated fat for saturated fat in the diet to lower LDL cholesterol
5. What are the different types of PN access and what are short term, long term options
central parenteral nutrition (CPN), paripheral parenteral nutrition (PPN),
what are all the lipoproteins responsible for transporting TG adn exogenous dietary fat (TAG)
chylomicrons VLDLs LDLs HDLs Apoliporotiens
what is ACTH's- role in sepsis
d. ACTH: Adrenocorticotropic hormone is a hormone produced in the anterior pituitary gland in the brain- needed for the adrenal gland to work properly and help the body react to stress i. ACTH stimulates the release of cortisol from the cortex of the adrenal gland ii. role in sepsis- significantly lower levels of ACTH in critically ill patients
what is continuous pump
d. Continuous pump i. slow rate infusion pump over 16-24 hours ii. avoid abrupt cessation and rebound hypoglycemia iii. for critically ill patients (can't tolerate very much food at one time) 1. KRAUSE BOOK SAYS - Increase incrementally over 2 or 3 days to reach goal rate (I interpret this to means goal kcal....) 2. I see goal volume day 1 - DNS tutorial rec goal volume day 1
what is HDL and what do they carry in the blood,( ie TAG (exogenous dietary fat), cholesterol...)
d. HDL → Contains more protein than other lipoproteins, serve as a reservoir of the apolipoproteins that direct lipid metabolism
10. What is the role of nuts for decreasing CVD
d. Nuts → Lowers risk of coronary heart disease. Lowers total cholesterol and LDL when consumed in moderation as part of a diet (fiber, prebiotics, good MUFA/PUFA ratio, antioxidants, specifically polyphenolic compounds)
what is a Percutaneous endoscopic jejunostomy (pej)
d. Percutaneous endoscopic jejunostomy i. preferred for longer than 3 to 4 weeks ii. similar to the PEG, except the tube has to be placed into the intestine (jejunum) instead of the stomach iii. PEJ is considered harder to maintain, long term, and used less often than a PEG
what is the role of wine/grape juice for decreasing CVD
e. Purple grape juice/wine → contains antioxidants specifically polyphenic compounds. . Inhibits oxidation of LDL i. Inhibits the stickiness of platelets that lead to blood clotting ii. Promotes the relaxation of blood vessel walls (dilation)
what is the role of garlic for decreasing CVD
f. Garlic contains sulfur compounds . Prevents platelet stickiness i. inhibits constriction of arteries ii. reduces LDL oxidation iii. Prevents high BP iv. Reduces blood lipids
8. Know these a. Nephritic syndrome
i. Acute glomerulonephritis - inflammation of the capillary loops of the glomerulus. ii. Occurs after streptococcus infections iii. Symptoms 1. Hematuria! 2. Hypertension 3. Mild loss of renal function iv. I've seen this maybe once in 20yrs.... v. May reverse or progress to ESRD vi. nephritic syndrome involves the loss of a lot of blood.
3. What is: a. Embolism
i. Blockage-causing piece of material inside the blood vessel ii. Embolus may be a blood clot (thrombus), a fat globule (fat embolism), a bubble of air or other gas (gas embolism) or foreign material.
b. what is Angina
i. Chest pain caused by reduced blood flow to the heart. Beginning stages of atherosclerosis. this is the beginning stages of atherosclerosis . it goes angina unstable angina then myocardial infarct
10. Know these types of dialysis when and where you do them and what fluid restriction they have (slide 23-27) a. HD (Hemodialysis)
i. Dialyzer ii. Time commitment, 3x's a week iii. Lots of time to provide MNT! iv. used on people whose status is stage 4 CKD v. 750-1500 cc/d fluid requirement vi.
e. What does a chylomicron carry?
i. Formed in GIT endothelial lining, transport exogenous dietary fat (TAG) from the diet and cholesterol in the liver
4. a. What are interleukin-1, interleukin-6, and tumor necrosis factor
i. Inflammatory cytokines 1. Cytokines are a large group of proteins, peptides or glycoproteins that are secreted by specific cells of the immune system. Cytokines are a category of signaling molecules that mediate and regulate immunity, inflammation and hematopoiesis 2. Cytokines interact with cells of the immune system in order to regulate the body's response to disease and infection, as well as mediate normal cellular processes in the body.
d. What are normal, decreased and elevated levels of HDL
i. Low → < 40 ii. High → > 60
b. What are normal, decreased and elevated levels of TAG or serum triglycerides
i. Normal → < 150 ii. Borderline → 150-199 iii. High → 200-499 iv. Very high → > 500
e. Ischemic stroke
i. Occurs when an artery that supplies blood to the brain is blocked by a blood clot or fatty buildup, called plaque.
c. What are normal, decreased and elevated levels of LDL
i. Optimal → < 100 ii. Near optimal → 100-129 iii. Borderline → 130-159 iv. High → 160-189 v. Very high → > 190 or 240
c. what is Transient ischemic attack
i. Stroke that lasts only a few minutes. Occurs when the blood supply to part of the brain is briefly blocked.
8. Be able to calculate mL, calories, free water, protein of enteral tube feeds - from the enteral handout on HuskyCT a. mL:
i. What is the administration rate of enteral feeding if the patient is receiving 1800 ml of a 1 cal/ml solution daily? 1. 1800 ml/ 24 hr = 75 ml/hr b. Calories: c. Free water: . How much free water is in 1.5 liters of an enteral feeding that has 1.5 calories per cc? Use HHC formulary card. Most 1.5kcal/mL formulas have similar free water %. Use Impact Peptide to determine the answer. 1. 1500 ml volume X .77 = 1155 ml free water OR 2. 1500 ml volume X 770 ml H2O per liter in Impact Peptide / 1000 mL = 1155 ml free water 3. 1ml/kcal a. 1500 ml volume - 1155 ml free water = 345 ml free H2) flush b. BUT this feeding is 1.5 calories per cc so do...... i. 1500 ml volume X 1.5 kcal/ml = 2250 kcal ii. 2250 kcal - 1155 ml free water = 1095 ml free H2O flush d. Protein: . A patient receives 1800ml of a 1 cal/cc formula with 44 grams protein per liter. How much protein will he receive? 1. 1.8 L X 44g/L = 72.9 g protein
d. what is Hemorrhagic stroke
i. When blood from an artery begins bleeding into the brain.
What are LDLs?
low density lipoproteins (bad cholesterol) c. LDL → Primary cholesterol carrier in the blood, formed by breakdown of VLDL
3. What are the dietary tubes?
nasogastric, nasojejunal, precutaneous endoscopic gastrostomy (peg or G tube), precutaneous endoscopic jejunostomy (PEJ)
12. What is in the dialysate used in peritoneal dialysis (CAPD)? Why do we care? (slide25- 26)
• Dialysis solution comes in 1.5 percent, 2.5 percent, and 4.25 percent dextrose concentrations. • Mostly I see 1.5% or 2% dextrose • A typical prescription for CAPD requires three or four exchanges during the day and one long—usually 8 to 10 hours (overnight dwell time) as the patient sleeps. • Each exchange is 2L. • So total of 5 times a day = 10L • 10,000mL x 2% dex = 200g dex x 3.4 = 680kcal x 75% is the average of what is absorbed thru the peritoneum = 510kcal a day of glucose which can lead to hypertriglyceridemia, DM and obesity due to the large volume of glucose in the fluid. • In total you can have a range of 500-1200 additional calories to the diet per day
13. Why are CKD pts anemic? (slide 48)
• Hypoproliferative, normochromic anemia of chronic renal failure • Fatigue • Inability of kidney to produce erythropoietin (EPO) • Synthetic or Recombinant human erythropoietin (EPO) • Oral iron: do not take with phosphate binders; avoid high doses of vitamin C (stones) • Monitor iron status using serum ferritin (but not when acutely stressed)
9. How much free water is in 1.5 liters of an enteral feeding that has 1.5 calories per cc? Use HHC formulary card. Most 1.5kcal/mL formulas have similar free water %. Use Impact Peptide to determine the answer. a. 1155mL b. 1057 mL c. 926 mL d. 801 mL
a. 1155mL* b. 1057 mL c. 926 mL d. 801 mL 1500 ml X .77 = 1155 ml free water 1mL/kcal 1500 ml - 1155 ml free water = 345 ml free H20 Flush 1500 ml X 1.5 kcal/ ml = 2250 kcal 2250 kcal - 1155 free water = 1095 ml free H2O Flush 770 ml free water (77%)
4. Closed enteral nutrition systems can hang for? a. 12 hours b. 24 - 48 hours c. 12 - 24 hours d. unlimited because the container is closed
a. 12 hours b. 24 - 48 hours* c. 12 - 24 hours d. unlimited because the container is closed
11. How much additional water would a 68 kg patient need when receiving 2400 ml of a standard 1kcal/Ml formula, 85% free water, was given daily? a. 125 ml b. 360 ml c. 155 ml d. 270 ml
a. 125 ml b. 360 ml* c. 155 ml d. 270 ml 2400 ml X 0.85 free water = 2040 2400 ml - 2040 = 360 ml
5. A 60 KG female receives 2700 calories on PN. The calorie to nitrogen ratio is 150:1. How many grams of nitrogen is she getting? a. 14 b. 16 c. 18 d. 20
a. 14 b. 16 c. 18* d. 20 2700 kcals/ 150 = 18 grams nitrogen
6. Two liters of a 5% dextrose solution provide how many calories? a. 170 b. 340 c. 212 d. 195
a. 170 b. 340* c. 212 d. 195 2000 ml (0.05 dextrose) X 3.4 = 340 kcal
17. What is the administration rate of enteral feeding if the patient is receiving 1800 ml of a 1 cal/ml solution daily? a. 180 ml per hour b. 105 ml per hour c. 90 ml per hour d. 75 ml per hour
a. 180 ml per hour b. 105 ml per hour c. 90 ml per hour d. 75 ml per hour* 1800 ml / 24 hr = 75 ml/ hr
8. What is a guide for calculating water needs with tube feedings? a. 1mL water / 0.5 calories b. 1mL water / 1.0 calories c. 1mL water / 2.0 calories d. 1mL water/ 3.0 calories
a. 1mL water / 0.5 calories b. 1mL water / 1.0 calories* c. 1mL water / 2.0 calories d. 1mL water/ 3.0 calories
7. The maximum hang time for open enteral systems is: a. 2 hours b. 4 hours c. 6 hours d. 8 hours
a. 2 hours b. 4 hours c. 6 hours d. 8 hours*
14. An infant requires 340 calories/24 hours. How many ounces of 20 kcal/oz formula should be given every 6 hours? a. 2 oz b. 3 oz c. 3.5 oz d. 4.25 oz
a. 2 oz b. 3 oz c. 3.5 oz d. 4.25 oz* 340 kcals / 4 = 85 kcals per 6 hours 85 kcal / 20 kcal/oz = 4.25 oz
18. A patient weighing 104kg is placed on a 1.5 cal/ml formula with 75% free water, 54 grams protein/L. He needs 3000 calories per day. How much formula should he receive daily to meet his caloric needs? a. 2000 m b. 3000 ml c. 2275 ml d. 2575 ml
a. 2000 m* b. 3000 ml c. 2275 ml d. 2575 ml 3000 cal/ 1.5 cal/ml = 2000 ml 2000 ml = 2L X 54 = 108 g
13. Infuse a peripheral- solution at a maximum rate of how many mOsm/L? a. 300 b. 900 c. 1400 d. 2000
a. 300 b. 900* c. 1400 d. 2000
16. A patient receives 1800ml of a 1 cal/cc formula with 44 grams protein per liter. How much protein will he receive? a. 44 b. 79 c. 65 d. 88
a. 44 b. 79* c. 65 d. 88 1.8 L X 44 g/ L = 79.2 g protein
21. A sedated ventilated patient receives 25 cc of Propofol per hour. How many calories will be provided from the medication? a. 500 b. 660 c. 720 d. 785
a. 500 b. 660* c. 720 d. 785
2. How many calories are in 300 ml of a 5% dextrose solution?` a. 51 b. 60 c. 15 d. 200
a. 51* b. 60 c. 15 d. 200 300 ml X 5% = 15 g dextrose X 3.4 kcal/gram dextrose = 51 kcal
20. Referring to the above patient, how much additional water should be provided q4' a. 520 ml b. 250 ml c. 785 ml d. 640 ml
a. 520 ml b. 250 ml* c. 785 ml d. 640 ml 2000 ml X .75 = 1500 ml 1500 ml / 6 times a day = 250 ml
19. Referring to the patient above, how much protein will he receive? a. 64 g b. 108 g c. 146 g d. 150 g
a. 64 g b. 108 g* c. 146 g d. 150 g 2000 ml = 2L X 54 = 108 g
Enteral/ Parenteral Nutrition Support Questions 1. How many grams of protein would you receive on a 1500 calorie diet which is 20% protein? a. 70 b. 75 c. 64 d. 300
a. 70 b. 75* c. 64 d. 300 1500 kcal X 20% = 300 kcal protein/ 4 kcal/ gram = 75 g protein
3. How many calories are in 1.5 liters of a 25% dextrose solution? a. 850 b. 1275 c. 1000 d. 1500
a. 850 b. 1275* c. 1000 d. 1500 1.5 liter = 1500 ml (.25 dextrose) X 3.4 dextrose = 1275 kcals
13. What happens in heart failure?
a. A previous myocardial infarction, valve defect, or increased work demand on the heart from hypertension all can damage the heart. This damage results in a decreased ability of the heart to pump adequately. i. If left side failure, blood seeps back to the lungs (causes lung congestion, CHF, pulmonary edema) ii. If right side failure, blood seeps back to the periphery (causes abdominal edema/ascites - lower body)
5. What is, where does it originate what does it do:(slide 4 and 5)
a. ADH i. sympathetic nervous system is short term control of BP. This is ADH remember: increased secretion of ADH causes more water to be reabsorbed in the kidney; decreased ADH secretion allows more water to be excreted. b. renin . comes from the kidney and helps regulates blood pressure. is also known as a angiotensinogenase because it converts angiotensinogen that is secreted from the liver and converts it into angiotensinogen 1 which could be taken up by the liver c. angiotensin . secreted by the liver it is a peptide hormone that causes vasoconstriction and an increase in blood pressure there are different forms of angiotensin d. angiotensin 1 . the angiotensin that is secreted by the liver is in contact with renin and creates angiotensin 1. angiotensin 1 is uptaken by the lungs where the angiotensin converting enzyme resides which converts angiotensin 1 to angiotensin 2. e. angiotensin 2 . is secreted by lungs and stimulates the release of aldosterone from the adrenal cortex f. aldosterone . is a hormone secreted by the adrenal gland or the adrenal cortex to promote sodium retention and potassium excretion by the kidneys, vasoconstriction by the arteries
12. 3 ways you can get increased BP
a. ADH release from high sodium diet b. Damaged kidneys (keeps secreting renin) c. Atherosclerosis
16. What is the brain hormone called that increased or decreased blood volume (hint it has 2 names)
a. Antidiuretic hormone (ADH) also called Vasopressin
what is the role of antioxidants for decreasing the risk of CVD
a. Antioxidants are part of the defense system of the body protecting against free radical damage. Donate an electron to a free radical without becoming free radical themselves. Dietary antioxidants that are not produced in the body come from food.
What is atherosclerosis?
a. Atherosclerosis is an inflammatory response with damage to the arteries that results in build-up of plaque that is composed of cholesterol, calcium, and clotting factors. plaque and break free and block blood flow where it stops
The RDN is teaching a client with CKD about necessary food changes that he must now make due to the progression of his disease. He needs to limit his potassium now and give up eating which of the following? a. Baked Potatoes b. Bell peppers c. Carrots d. Green beans
a. Baked Potatoes* b. Bell peppers c. Carrots d. Green beans
4. Which of the following decreases in congestive heart failure? a. Beta-natriuretic peptide b. Ejection fraction c. Cardiac remodeling d. Interleukin-1
a. Beta-natriuretic peptide b. Ejection fraction* c. Cardiac remodeling d. Interleukin-1
what is bolus feeding
a. Bolus feeding i. type of feeding method using a syringe to deliver formula through a person's feeding tube 1. about 250-400 ml of formula every 4-6 hours via syringe or funnel (allows you to have more freedom in between meals) 2. for medically stable patients
RENAL 1. Protein level for CKD, PD, HD pts (found slide 32)
a. CKD stage 4 (chronic kidney disease)- .8g/kg; avoid high protein intake >1.3g/kg b. PD (peritoneal dialysis)- 1.2-1.3g/kg c. HD (hemodialysis)- 1.2g/kg (stable), 1.2-1.3g/kg acutely ill or PEW
The most common renal stones contain: a. Calcium b. uric acid c. phytate. d. struvite.
a. Calcium* b. uric acid c. phytate. d. struvite.
what is central parenteral nutrition (CPN)
a. Central parenteral nutrition (CPN) i. catheter in large, high- blood-flow vein such as superior vena cava
9. Be able to calculate continuous, nocturnal, bolus EN options - the practice questions cover all of this
a. Continuous: b. Nocturnal: c. Bolus:
17. What is secreted from the kidneys and what does it impact
a. Damaged kidneys keep secreting renin causing HTN from activation of RAAS system b. When the diameter of a blood vessel is decreased by atherosclerosis, there is increased resistance and an increase in BP
Which of the following guidelines should be followed by a patient who has a history of calcium containing kidney stones? a. Decrease fluid intake to keep urine output to less than 1 L/day. b. Increase vitamin C supplements c. Increase fluid intake to maintain urinary output at or above 2 L/day. d. Use sodium bicarbonate to alkalize urine.
a. Decrease fluid intake to keep urine output to less than 1 L/day. b. Increase vitamin C supplements c. Increase fluid intake to maintain urinary output at or above 2 L/day.* d. Use sodium bicarbonate to alkalize urine.
11. What is the effect of pulmonary disease on a patient's energy requirements? a. Decreased need for energy because of loss of lean body mass b. Increased need for energy because of increased work of breathing c. Decreased need for energy because of a lack of physical activity d. Decreased need for energy because of starvation
a. Decreased need for energy because of loss of lean body mass b. Increased need for energy because of increased work of breathing* c. Decreased need for energy because of a lack of physical activity d. Decreased need for energy because of starvation
4. What is a. Myocardial infarction
(heart attack) i. Myocardial = muscular component of the heart ii. Infart = stoppage in a vessel iii. ischemic = lack of oxygen iv. 50% die within the first 2 hours, so the first couple hours is most critical
what are the most common renal/kidney stones
-calcium is the most common kidney stone overall -uric acid is more common in men than in women -struvite is more common in women with UTI infections
b. what is Platelet
. Blood cells that help your body form clots to stop bleeding
b. when and where and what fluid restriction PD (peritoneal dialysis) has
. Continuous ambulatory peritoneal dialysis (CAPD) i. Glucose absorption is an issue for some ii. Advantages over hemodialysis, can do at home or overnight iii.
c. what is Aneurysm
. Enlargement of an artery caused by weakness in the arterial wall
c. when where and what fluid restriction for CRRT (continuous renal replacement therapy)
. Hemofiltration i. Removal of solutes, fluids, or both ii. Hydration status must be monitored iii. Advantages in acute care situations, used in unstable pts iv. CRRT typically is used when patients develop anasarca (extreme generalized edema) or elevated blood pressure and are unable to excrete fluid or uremic wastes. v. It is the therapy chosen when periodic hemodialysis is to be avoided because rapid removal of fluid and wastes may put the kidney into a less active state causing decreased blood flow to the kidney and a delay in regaining of kidney function. vi. Mainly used on pts that aren't stable enough for HD, the equipment is only available at select hospitals. d.
d. what is Thrombus (blood clot)
. Made up of platelets and fibrin proteins i. When you have an irregular heartbeat (atrial fibrillation) or have hypercoagulability state (some cancers), or have damage to an artery or vein, a thrombus can form: 1. The thrombus can rupture, are called embolus/emboli, they block blood flow where they stop and kill the tissue that now doesn't receive O2.
b. what is Nephrotic syndrome
. Main causes i. Diabetes mellitus ii. Systemic lupus erythematosus iii. Amyloidosis iv. Causes damage to glomerular system v. Large protein losses in the urine lead to hypoalbuminemia vi. Proteinuria (>3.5g in 24hrs) vii. Edema viii. Hypercholesterolemia ix. Elevated LDL, VLDL and lipoprotein(a) x. And malnutrition! xi. nephrotic syndrome involves the loss of a lot of protein,
22. Your patient is on D12 AA 4% @ 75mL/' how many calories does this provide in one day and how many grams of protein is in this?
D12 AA 4% @75mL/hr 75 ml/hr X 24 hr = 1800 ml 1800 ml x 0.12 (D12) = 216 g dextrose 216 g dextrose X 3.4 g/kcal = 734 kcal 1800 ml x 0.04 (AA) = 72 g protein 72 g protein x 4.0 g/kcal = 288 kcal Total kcal = 1022 kcals 72 grams protein Estimated Needs: 80 kg, 25-30 kcal/kg - 2000 kcals/ kg Protein 1.2- 1.5 kcal/kg - 120 grams protein Fluid 1ml/ kcal - 2000 ml 2000 ml/ 24 hr = 83.3 ml/ hr (round to 85) 85 ml/ hr X 24 hr = 2040 kcals 200 g dextrose X 3.4 g/kcal = 680 kcal 120 g AA X 4.0 g/kcal = 480 kcal Total kcal = 1160 kcal Give all volume and protein day 1. Give 200 g dextrose day 1. Extra 150 g of dextrose per day to advance to goal (with diabetes advance 100 g per day (maybe add insulin)) TPN order: Day 1 TPN continuously. @ 85 ml/hr, 120 g AA, 200 g of dextrose providing 1160 kcals, 1.5 g protein/ kg based on adult weight of 80 kg. Advance day 2 by 150 grams of dextrose 350 per day 1670 kcals, 21 kcal/kg. Day 2: 2000 kcal - 1160 kcal = 840 kcals dextrose to meet needs 840 kcals / 3.4 g/kcal = 247 g dextrose goal to meet needs Max 150 grams dextrose day 2 (150 grams X 3.4 kcal/kg = 510 kcal dextrose) 97 grams dextrose day 3 (247 dextrose goal - 150 dextrose day 2 = 97 grams leftover)
18. How do diuretics work? Any nutritional concerns?
Hint yes a. Water pills b. Decreases blood volume by increasing urinary output (to help lower the amount of sodium and water in the blood); inhibits renal sodium and water reabsorption decreases blood volume c. Lasix (Furosemide) → loses potassium d. Aldactone (Spironolactone) → potassium sparing e. Thiamine and potassium supplementation as needed to compensate for losses in patients on some diuretics.
3. What is the gut barrier function? What promotes what decreases?
a. Definition: intestinal epithelium is a single layer of cells lining the gut lumen and has two critical functions i. acts as a barrier to prevent passage of harmful intraluminal entities including foreign antigens, microorganisms and their toxins ii. acts as a selective filter allowing the translocation of essential dietary nutrients, electrolytes, and water from the intestinal lumen into circulation b. Proposed benefits of enteral versus parenteral function i. better GI barrier function ii. preserved GI immunity iii. attenuate (reduce) catabolic response iv. better blood glucose control v. decreased rates of infection
6. Calculate calories from dextrose, protein, 20% fat, propofol
a. Dextrose: i. How many calories are in 300 ml of a 5% dextrose solution? 1. 300 ml X 0.05 dextrose = 15 g dextrose X 3.4 kcal/ gram dextrose = 51 kcal dextrose ii. How many calories are in 1.5 liters of a 25% dextrose solution? 1. 1500 ml X 0.25 dextrose = 375 g dextrose X 3.4 kcal/gram dextrose = 1,275 kcal dextrose iii. Two liters of a 5% dextrose solution provide how many calories? 1. 2000 ml X 0.05 dextrose = 100 g dextrose X 3.4 kcal/gram = 340 kcal dextrose b. Protein: i. How many grams of protein would you receive on a 1500 calorie diet which is 20% protein? 1. 1500 kcal X .20 protein = 300 kcal protein / 4 gram/kcal protein = 75 g protein c. 20% fat: d. Propofol: i. A sedated ventilated patient receives 25 cc of Propofol per hour. How many calories will be provided from the medication?
10. What term refers to rapid breathing? a. Dyspnea b. Hemoptysis c. Tachypnea d. Aspiration
a. Dyspnea b. Hemoptysis c. Tachypnea* d. Aspiration
7. What is hormone sensitive lipase where is it found what does it do?
a. Enzyme responsible for release of free fatty acids from adipose tissue. Plays an important role in providing the major source of energy for most tissues. b. Found in brown adipose tissue. Activation of this lipase leads to breakdown of triglycerides already stored in brown fat.
11. What is GIR, what is max for critically and non critically ill adult pts
a. GIR (glucose infusion rate) is expressed in terms of milligrams of glucose per kilogram of body weight per minute (mg dextrose /kg/min) b. measures how quickly the patient receives carbohydrates i. GIR=mg dex/kg/min; maximum rate should not exceed 6 mg/kg/min, ≤ 4-5 mg/kg/min in the critically ill. RD exam question
6. What is Glucagon role in sepsis
a. Glucagon: hormone formed in the pancreas which promotes the breakdown of glycogen to glucose in the liver. i. role in sepsis-transient increase in blood glucose concentration (hyperglycemia) in critically ill patients
11. What is normal BP, what is HTN?
a. Hypertension → Persistent high arterial blood pressure, >2 measurements b. Normal BP → Less than 120/80 mm Hg
8. What is the correct diagnosis for a client who frequently eats in restaurants and has the following laboratory findings: blood pressure level, 135/86 mm Hg; total cholesterol, 256 mg/dl; LDL cholesterol, 192 mg/dl; and HDL cholesterol, 34 mg/dl? a. Limited access to food b. Excessive oral food/beverage intake c. Impaired ability to prepare foods/meals d. Altered nutrition-related laboratory values
a. Limited access to food b. Excessive oral food/beverage intake c. Impaired ability to prepare foods/meals d. Altered nutrition-related laboratory values*
9. What are the main diet meal patterns that are recommendations for CVD?
a. Mediterranean diet b. DASH diet c. Therapeutic Lifestyle Changes (TLC) US Dietary Guidelines
What is a nasogastric tube?
a. Nasogastric i. carries food and medicine to the stomach through the nose ii. short term- up to 3 or 4 weeks iii. normal GI function iv. bolus, intermittent, or continuous infusions
Which kidney condition is associated with hematuria? a. Nephritic syndrome b. Nephrotic syndrome c. Pyelonephritis d. Renal tubular acidosis
a. Nephritic syndrome* b. Nephrotic syndrome c. Pyelonephritis d. Renal tubular acidosis
CVD, HTN, HF 1. What are risks of CVD? Modifiable and non modifiable
a. Non-modifiable i. Increasing age, male gender, family history of premature heart disease b. Modifiable . Atherogenic diet (high in sugar, processed foods and low in fruits, vegetables, and whole grains), high blood LDL cholesterol, low blood HDL cholesterol, hypertension, diabetes, obesity (abdominal obesity), physical inactivity, cigarette smoking
19. What is BNP - Beta-natriuretic peptide
a. Normal is <100 b. High is > 400
9. Which of the following disease states may require a fluid restriction? a. Obesity b. Congestive heart failure c. Myocardial Infarction d. Asthma
a. Obesity b. Congestive heart failure* c. Myocardial Infarction d. Asthma
14. What is ejection fraction?
a. Percentage of blood that is pumped out of your heart during each beat. b. Decreases in congestive heart failure
8. What is lipoprotein lipase? Where is it found what does it do?
a. Plays an important role in breaking down fat in the form of triglycerides, which are carried from various organs to the blood by lipoproteins. b. Enzyme found primarily on the surface of cells that line the tiny blood vessels within muscles and in fatty (adipose) tissue.
3. Which of the following is NOT one of the recommendations of the US Dietary guidelines? a. Reduction of dietary cholesterol b. Reduction of added sugars c. Increase in dietary fiber d. Appropriate calories
a. Reduction of dietary cholesterol* b. Reduction of added sugars c. Increase in dietary fiber d. Appropriate calories
5. Which mineral has been shown to improve (lower) blood pressure when consumed in adequate amounts? a. Sodium b. Magnesium c. Potassium d. Chloride
a. Sodium b. Magnesium* c. Potassium (biggest one)* d. Chloride
Renal Questions Intake of which of the following nutrients is generally NOT decreased in the nutrition therapy of patients with ESRD? a. Sodium b. Phosphorus c. Calcium d. Potassium
a. Sodium b. Phosphorus c. Calcium* d. Potassium
Which of the following blood parameters is associated with uremia? a. Sodium greater than 145 mEq/L b. Blood urea nitrogen greater than 100 mg/dl c. Creatinine level between 0.6 and 1.5 mg/dl d. eKt/V greater than 1.2
a. Sodium greater than 145 mEq/L b. Blood urea nitrogen greater than 100 mg/dl* c. Creatinine level between 0.6 and 1.5 mg/dl d. eKt/V greater than 1.2
2. Difference between stress vs starvation?
a. Stress: hypermetabolic state- stress causes accelerated energy expenditure, glucose production, glucose cycling in liver and muscle i. Hyperglycemia can occur either from insulin resistance or excess glucose production via gluconeogenesis ii. muscle breakdown acceleration b. Starvation: decreased energy expenditure, use of alternative fuels, decreased protein wasting, stored glycogen used in 24 hours i. Late starvation = fatty acids, ketones, and glycerol provide energy for all tissues except brain, nervous system and RBCs
15. How is BP controlled by brain and by RAAS
a. The brain receives info from baroreceptors i. If BP is low, pituitary releases ADH (antidiuretic hormone) aka vasopressin, which is a vasoconstrictor, which helps to increase BP ii. ADH also signals to the kidneys to retain H20. b. If you have high sodium in blood from the diet → increases osmolality. It also triggers the release of ADH to tell the kidneys to retain water and this increases BP c. The kidneys also have baroreceptors . Kidney detects low BP and renin is released, which activates angiotensin 1. Angiotensin 1 goes thru lungs and ACE activates 1 to angiotensin 2. Angiotensin 2 is a vasoconstrictor. i. Angiotensin 2 also activates aldosterone in the adrenals which signals the kidneys to retain sodium and water, leading to an increase in BP.
6. What are normal, decreased and elevated levels of total cholesterol
a. Total cholesterol i. Desirable → < 200 ii. Borderline → 200-239 iii. High → > 240
What are VLDLs?
a. VLDL → Formed in the liver, transports endogenous TAG
6. Which of the following causes blood pressure to increase? a. Vasodilation b. Decreased cardiac output c. Increased peripheral resistance from atherosclerosis
a. Vasodilation b. Decreased cardiac output c. Increased peripheral resistance from atherosclerosis*
10. Be able to calculate volume, calories and protein from PN formulas - the practice questions cover all of this
a. Volume: b. Calories: c. Protein: i. In a PN mixture, what volume of the amino acid solutions listed would come closest to providing 185 calories? 1. 1000 ml X 8.5% amino acids = 85 g X 4kcal/g = 340 kcal 2. 850 ml X 5.5% amino acids = 46 g x 4kcal/g = 187 kcal 3. 500 ml X 7.0% amino acids = 35 g X 4kcal/g = 140 kcal
3. Sources of oxalate(slide 10)
a. beans, spinach,beets, nuts and nut butter
2. What is MNT for calcium kidney stones (slide 9-11)
a. calcium- is the most common kidney stone overall i. The following foods should be avoided (contain more than 10 mg oxalate/serving): Beans, (wax, green) Spinach, Nuts and nut butters, beets ii. Striking the right balance is important for calcium. iii. 1000mg for adults 19-70, 1200mg 71+ iv. Too little calcium is a risk factor for calcium oxalate stones because there is not enough calcium going through your digestive tract to bind with oxalate and prevent its absorption. This could lead to high urine oxalate. v. Too much calcium, more than your body can use, is a risk factor for calcium stones because it could cause you to excrete excessive calcium into your urine. vi. A low fat diet (less than 50 grams per day) should be followed for individuals with fat loss in their stool. vii. Remember oxalate is a byproduct of GIT metabolism. After oxalate is formed, it normally combines with calcium to be excreted in the stool. When large amounts of unabsorbed fat are available (e.g. from fat malabsorption, ileal resections), calcium preferentially binds to fat instead of oxalate. This leaves oxalate available to be easily reabsorbed by the colon and ends up in the urinary tract. viii. Drink 2 ½ to 3 liters of fluid per day, this will lower the concentration of oxalates, >2L urine/d ix. Avoid excessive supplementation (more than 1-2 grams/day) of vitamin C as oxalate is derived from vitamin C metabolism too.
2. Which of the following lipoproteins carries triglyceride from the intestine's endothelial cells to the plasma? a. chylomicrons b. IDL c. LDL d. HDL
a. chylomicrons* b. IDL c. LDL d. HDL
During which stage of chronic kidney disease does the National Kidney Foundation (NKF) recommend that a protein intake of 0.8 g/kg/day be initiated? a. for acute kidney injury b. when HD is started c. for CKD stage 4
a. for acute kidney injury b. when HD is started c. for CKD stage 4*
6. What is GFR
a. glomerular filtration rate. the rate at which the kidneys filter out fluid and is measured by creatinine per unit.
15. A patient on parenteral nutrition is to be transitioned to enteral feeding. He should receive: a. half-strength enteral feeding initially b. half-strength, then 3/4 strength enteral feeding c. half-strength enteral feeding with a low osmolality d. full strength enteral feeding starting at a low rate
a. half-strength enteral feeding initially b. half-strength, then 3/4 strength enteral feeding c. half-strength enteral feeding with a low osmolality d. full strength enteral feeding starting at a low rate*
SEPSIS 1. What are key metabolic and respiratory stress changes in the body (carbs, protein, fat)
a. increased Glycogenolysis- glycogenolysis : process by which glycogen, the primary carbohydrate stored in the liver and muscle cells of animals, is broken down into glucose to provide immediate energy and to maintain blood glucose levels during fasting b. increased Gluconeogenesis- gluconeogenesis: pathway used by the body to create glucose from other molecules and an important pathway that allows the body to store needed energy for the brain in the form of glucose c. increased Lipolysis: process by which fats are broken down in our bodies through enzymes and water, or hydrolysis. Lipolysis occurs in our adipose tissue stores, which are the fatty tissues that cushion and line our bodies and organs d. Negative nitrogen balance: associated with burns, serious tissue injuries, fevers, hyperthyroidism, wasting diseases, and during periods of fasting. This means that the amount of nitrogen excreted from the body is greater than the amount of nitrogen ingested.
The primary cause of anemia that presents in chronic renal failure is a. lack of heme and nonheme iron intake. b. loss of iron through the diseased kidney. c. deficiency of the hormone erythropoietin. d. loss of blood through dialysis.
a. lack of heme and nonheme iron intake. b. loss of iron through the diseased kidney. c. deficiency of the hormone erythropoietin.* d. loss of blood through dialysis.
Practice Questions: CVD, HTN, HF 1. CVD is the leading cause of death in the United States in a. men only. b. women only. c. African American women but not White women. d. men and women.
a. men only. b. women only. c. African American women but not White women. d. men and women.*
ENTERAL PARENTERAL 1. What is refeeding syndrome
a. metabolic abnormalities when a malnourished person begins feeding, after a period of starvation or limited intake b. caused by overly aggressive parenteral nutrition, specifically carbohydrate c. potentially lethal d. cardiac and pulmonary complications from fluid overload e. monitor serum magnesium, potassium, and phosphorus f. start with 50% of goal parenteral nutrition in those at risk i. on 1st day provide 50% kcals or 15 kcal/kg, limit dextrose to 100-200 g/d, provide protein up to 1.5g/kg ii. advance slowly over 3-5 days until goal iii. supplement with additional thiamine, 100 mg (for carbohydrate metabolism)
5. What is Multiple organ dysfunction syndrome (MODS)
a. progressive, potentially reversible dysfunction of two or more organ systems following acute, life- threatening disruption of systemic homeostasis i. leading cause of mortality among patients requiring ICU care
7. Diuretics work to lower blood pressure by a. promoting vasodilation. b. decreasing blood volume. c. increasing sodium retention.
a. promoting vasodilation. b. decreasing blood volume.* c. increasing sodium retention.
2. Who gets PN nutrition?
a. provision of nutrients directly into bloodstream intravenously b. reserved for nonfunctional or severely diminished small bowel
The rennin-angiotensin mechanism a. regulates calcium and phosphorus balance. b. regulates blood pressure. c. is the first function of the kidney to deteriorate in AFI. d. is responsible for the production of EPO.
a. regulates calcium and phosphorus balance. b. regulates blood pressure.* c. is the first function of the kidney to deteriorate in AFI. d. is responsible for the production of EPO.
4. What is RAAS
a. renin angiotensin aldosterone system b. RAAS is long term control of blood pressure
4. What are complications of nasoenteric feeding tubes.
a. sinusitis (sore throat and epistaxis- acute hemorrhage from the nostril, nasal cavity or nasopharynx) b. nausea and vomiting c. medication related complications d. More serious complications: i. luminal perforation ii. pulmonary injury iii. aspiration iv. tube malpositioning or dislodgement v. refeeding syndrome
2. What causes atherosclerosis?
b. Causes include: i. High cholesterol, high blood pressure, inflammation, obesity, diabetes, smoking. The damage causes build-up of plaque.
what is Cortisol role in sepsis,
b. Cortisol: steroid hormone that regulates a wide range of processes throughout the body, including metabolism and the immune response. It is a very important role in helping the body respond to stress. i. role in sepsis- increase in cortisol levels during sepsis
what is gravity drip
b. Gravity drip i. way to deliver formula through a feeding tube. Formula flows out of the bag and into the tube by gravity. This method is slower than feeding with a syringe and uses a roller clamp on the bag's tubing to control the rate. 1. allows you to have more freedom in between meals, this method is slower than feeding with a syringe
what is a nasojejunal tube
b. Nasojejunal i. carries food and medicine to the jejunum of the small intestine through the nose ii. short term- up to 3 or 4 weeks iii. gastric motility disorders, esophageal reflux, or persistent nausea and vomiting, less aspiration risk
what is the MNT for uric acid kidney stones
b. uric acid- is more common in men than in women. gout or chemo can increase risk . Reduce urine acidity i. Sometimes, only medication can address acidic urine effectively. Allopurinol, sodium bicarb or citrate or magnesium ii. Increase intake of fruits and vegetables iii. potassium will alkalinize your urine. iv. Pure lemon juice (not lemonade) and lime juice are very rich in citric acid. You may try using 2 ounces of lemon or lime juice diluted in water or other beverage twice daily. v. Reduce amount of acid and purine rich foods: vi. cheese, meats, fish, and poultry. vii. Organ meats, water fowl, game meats, and some seafood (anchovies, sardines, herring) are especially high in purines. viii. Make 2 or more days a week "non-meat" days (you may use dairy and eat non-meat protein foods like beans). ix. Limit yourself to one serving per day of meat, fish, poultry or seafood. x. Acid/Alkaline diet?
7. What are the different tube or parenteral or enteral feeding methods? fix this when i figure it out
bolus feeding, gravity drip, cyclic pump, continuous pump.
what are the outcomes of developed atherosclerosis cardiovascular disease (ASCVD)
c. Can cause: . Coronary heart disease, coronary artery disease (angina, myocardial infarction) i. Cerebrovascular accident (CVA) or transient ischemic attack (TIA) ii. Peripheral vascular/arterial disease (PVD/PAD) iii. Aneurysms
what is cyclic pump
c. Cyclic pump i. alternative to continuous feeding. It is given a faster rate over a shorter period of time. Given at the same time each day for the same amount of time. 1. 8 to 12 hours per day, usually at night 2. higher rate and more concentrated solution 3. 1st and last hr at ½ rate then off and check POC glucose (FS) ii. for medically stable patients
what is Epinephrine role in sepsis
c. Epinephrine: commonly known as adrenaline, is a hormone secreted by the medulla of the adrenal glands i. strong emotions such as fear or anger cause epinephrine to be released into the bloodstream, which causes an increase in heart rate, muscle strength, blood pressure and sugar metabolism ii. role in sepsis- epinephrine is low in critically ill people 1. norepinephrine is the first choice vasopressor to correct hypotension in septic shock
what is the role of soluble fiber for decreasing the risk of CVD
c. Fiber → i. Soluble (viscous fiber) → dissolve in water, form gels and are easily digested by bacteria in the lower intestine. Think oatmeal... gel, found in legumes and fruit 1. Reduces total and LDL cholesterol 2. Reduces CHD risk ii. Insoluble fiber → does not dissolve in water and does not form gels and are less readily fermented. Mostly found in grains and vegetables. 1. Feeds microbiome 2. Many are sources of prebiotics
what is a Percutaneous endoscopic gastrostomy (PEG or g tube)
c. Percutaneous endoscopic gastrostomy (PEG or g tube) i. surgical procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach. PEG allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus ii. for patients who have difficulty swallowing, problems with their appetite or an inability to take adequate nutrition through the mouth
what is the MNT for struvite kidney stones
c. struvite- mostly in women with urinary UTIs
what are the different types of kidney/renal stones
calcium, uric acid, struvite
d. What are Acute phase proteins?
i. class of proteins whose plasma concentrations increase (positive acute-phase proteins) or decrease (negative acute-phase proteins) in response to inflammation ii. in response to injury, local inflammatory cells secrete a number of cytokines into the bloodstream, most notable of which are interleukin 1, interleukin 6, and tumor necrosis factor. The liver responds by producing many acute-phase reactants and the production of other proteins are reduced (negative acute-phase proteins). Increased acute- phase proteins from the liver may also contribute to the promotion of sepsis. 1. positive acute-phase respondents: a. C- reactive protein, serum amyloid, haptoglobin 2. negative acute- phase respondents: . albumin, transferrin, retinol- binding protein
b. What are Catecholamines?
i. hormones made by your adrenal glands, which are located on top of your kidneys 1. ex: dopamine, norepinephrine and epinephrine 2. the adrenal glands send catecholamines into your blood when physically or emotionally stressed (regulate physiological functions such as heartbeat and breathing rate)
c. What is Cortisol?
i. steroid hormone that regulates a wide range of processes throughout the body, including metabolism and the immune response. It is a very important role in helping the body respond to stress. 1. helps control blood sugar levels, regulate metabolism, help reduce inflammation, and assist with memory formulation
What are IDLs?
intermediate densities lipoprotiens b. IDL → Transports TAG and cholesterol
14. Know a few high Na, potassium and phosphorus foods, what are normal lab values for these
• NA o found in processed foods, burgers, pizza, soup, meat, rice, vegetables o most dialysis pt's are restricted to 2g/day o DRI is 1.5g/day o 1g of sodium per 100g is 2.5g of salt • phosphorus o 1300mg/day for men and 1000mg/day for women o DRI 700mg/day o • potassium o restriction for dialysis pt's 2g/day o DRI is 4.7g/day o potassium is surprisingly found in meat and salt substitutes o potassium is most common in fruits in vegetables o o o o o Food, Standard Amount Potassium (mg) Sweet potato, baked, 1 potato (146 g) 694 Tomato paste, ¼ cup 664 Beet greens, cooked, ½ cup 655 Potato, baked, flesh, 1 potato (156 g) 610 White beans, canned, ½ cup 595 Yogurt, plain, non-fat, 8-oz container 579 Tomato puree, ½ cup 549 Clams, canned, 3 oz 534 Yogurt, plain, low-fat, 8-oz container 531
What is apolipoprotein?
•Apolipoproteins: are proteins! And carry lipids in the blood and control the metabolism of the lipoprotein molecule