1. Therapeutics IV Tutoring Nutrition Lisa Hayes lhayes3@uthsc.edu April 16 th 2016

2. Outline Nutrition Support – Renal Failure Nutrition Support – Hepatic Failure Nutrition Support – Geriatrics Nutrition Support – Obesity Drug Nutrient Interactions

3. Which formula is more appropriate for a patient with CKD on HD? A – concentrated, polymeric, nutritionally complete B – concentrated, low-protein, low/no electrolyte C – concentrated, low-protein, moderate electrolyte

4. Unfortunately, you miscalculated the number of dextrose calories to be provided to patient CG. CG has been receiving twice the daily recommended amount. What will likely happen to their RQ? A – RQ will remain unchanged B – RQ will increase C – RQ will decrease

5. Which of the following is the best indicator for acute changes in nutritional status? A – albumin B – prealbumin C – transferrin

6. Which of the following is not a way to manage hyperglycemia associated with TPN administration? A – Add long-acting insulin to TPN bag B – start patient on sliding scale insulin C – decrease dextrose concentration of bag D – start patient on insulin drip

7. What can be done when elevated gastric residuals are noted in a patient on EN? A – half the rate of EN B – metoclopramide 20mg IV q12 hours C – erythromycin 50mg IV q6hours x 48hours D – change to PN

8. How would you treat hyperglycemia associated with EN? A – add regular insulin to EN formula B – look for other sources of dextrose in patient’s regimen and eliminate C – consider long-acting insulin D – change to high-carb formula E – B and C

9. LF is a patient who you are monitoring TPN for. Her SCR has jumped from 1.1 to 1.7 overnight. She is in AKI. Based on this information. What would be an appropriate energy and protein requirement for her TPN? A – 1.2 BEE, 1.5g/kg protein B – 25kcal/kg/day; 2g/kg/day protein C – 30kcal/kg/day; 1.2g/kg/day protein

10. What mineral/electrolyte is often held prior to the start of dialysis in HD patients? A – potassium B – phosphorus C – selenium D – multivitamin

11. RD has cirrhosis secondary to alcohol use. He currently has Stage III hepatic encephalopathy despite lactulose administration. EN is to be started. What should be recommended to the team? A – protein restrict at 0.5g/kg/day B – use 30-35kcal/kg/day C – transition to BCAA formulation if moves to stage 4 D- no recommendations

12. Hyperglycemia associated with cirrhosis is due to which of the following dysregulations? A – decreased glucagon, increased insulin resistance B – decreased insulin concentrations but increased glucagon C – increased glucagon + increased insulin resistance

13. WC arrives to the ED in a severe stupor. It is determined that he is drunk. He will be admitted for observation as it is possible he has aspirated during his episode. Before administering nutrition, what should you recommend to the team? A – intubation to protect airway B – thiamine C – vitamin D D – vitamin C

14. FT is a patient admitted to the TSICU at UTMC s/p MVC with multiple traumas. He is 115kg. Hgt: 6ft. IBW: 78kg. Determine the number of calories and protein appropriate for his TPN. Enteral nutrition not indicated at this time due to severe bowel injury and open abdominal wounds. A – 1950kcal/day + 156g/day protein B – 2875kcal/day + 230g/day protein C – 1950kcal/day + 230g/day protein D – 2875kcal/day + 156g/day protein

15. If hypocaloric feeding is chosen, it is ok to limit protein and fat also. True False

16. Determine if the following patient is classified as “frail”. FC is a 81year old female who has generalized weakness, typically spends her days at home and does not enjoy traveling outside her home, she reports exhaustion on physical activity, and shuffles at a slow speed as she ambulates. A – yes frail B – no not frail

17. CV is a patient diagnosed with dementia. He is malnourished and the team would like to recommend tube feeds. What should you tell them? A – Recommend cycling at night B – avoid TFs due to risk of aspiration in demented patients, recc assisted hand feeding C – change to PN

18. BH is a 87y/o patient with severe pancreatitis. The medicine wishes to start her on TPN since she has not eaten in 7 days. Which of the following calculations would be most appropriate for a calorie calculation? Weight: 60kg IBW: 54kg A – 25kcal/kg/day B – 1.2 x BEE C – 1.5 x BEE D – 35 kcal/kg/day

19. How much protein should be added to BH’s TPN? Additional information: it was determined today she has a Stage III ulcer on her buttocks due to poor turning and nursing care at her SNF. A – 1g/kg/day B – 1.2g/kg/day C – 1.4g/kg/day D – 2g/kg/day

20. Which electrolyte abnormality is common due to aging? A – B12 deficiency secondary to atropic gastritis B – increased calcium levels due to super therapeutic dosing of supplements C – increased sodium due to increased water losses

21. VF is a patient on EN who is also receiving all his medication via tube. Medications include metoprolol tabs, lisinopril tabs, furosemide tabs, APAP elixir, nexium powder. He is experiencing severe diarrhea. What would you recommend to the medicine team? A – check stool for Cdiff B – consider changing APAP to tabs C – add peptobismol D – change nexium powder to suspension

22. Hyponatremia can be associated with which of the following drugs? A – Prozac B – Tegretol C – Paroxetine D – all of the above

23. B12 deficiency is common with which of the following drugs? A – Omeprazole B – Metformin C – Glimepiride D – A + B

24. The addition of grapefruit juice to the administration of many drugs (felodipine, buspirone, CSA, CBZ) can cause which of the following by interacting with the 3A4 system? A – decreased concentrations of drug B – increased concentrations of drug

25. BR is a patient admitted to your unit on chronic phenytoin therapy secondary to epilepsy. However, he has failed his barium swallow test and is on EN + all meds per tube. BR is taking phenytoin suspension 200mg TID. What do you recommend about the administration of his phenytoin? A – Hold EN 2 hours before and after each dose. No change in EN rate. B – Hold EN 1 hour before and after each dose. Increase EN rate to give total dose over 18 hours. C – Hold EN only before doses. No change in EN rate. D - Hold EN 1 hour before and after each dose. Decrease EN rate.

26. In an unfortunate turn of events, BR has develop a DVT and needs to be anticoagulated. The attending wishes to use coumadin. What should you recommend about the administration of the coumadin in regards to tube feeds? A – no need to change or hold EN B – hold EN 2 hours before and after dose C – hold EN 1 hour before and after dose D – increase coumadin dose 10% to account for interaction, no holding of EN

27. A patient, NH, has the following formula for their TPN. Calculate the number of dextrose calories that come from their TPN. 240g dextrose, 40g lipid, 140g protein. A – 960kcal B – 2400 kcal C – 816kcal D – 840kcal

28. How many calories come from fat? What percentage of daily calories is this? (reminder: 240g dextrose, 40g lipid, 140g protein. ) A – 400kcal; 15% B – 400kcal; 22.5% C – 136kal; 4% D - 136kcal; 8%

29. THANKS! lhayes3@uthsc.edu