18 - Critically Ill

Question 1

Critically ill is assoc w state of…

Answer 1

catabolic stress characterized by

• systemic inflammation
• multipl-orgn dysfnctn
• prolonged hospitalitn
• disproportnt mortality

Question 2

nutrition support aids in

Answer 2

• metab response to stress
• prevent oxidative cellular injury
• decr exaggerated immune response
• reduce infectious morbidity
• reduve ventilator dependency
• decr protein catabolism

Question 3

disruption in homeostasis elicits a…

Answer 3

body wide stress response

• characterized by hormonal + inflammatory/metab changes for healing
• ebb + flow

Question 4

ebb + flow phase of stress response

Answer 4

1 initial shock/ebb
2 catabolic flow
3 anabolic flow

Question 5

initial shock or ebb

Answer 5

hemodynamic instability

-24-48 hr

Question 6

initial shock or ebb characteristics

Answer 6

• shock
• hypo vol
• low perfusn
• low CO, O consumption, temp
• high HR, gluc, acute phase proteins
• activated immune systm

Question 7

initial shock or ebb Tx

Answer 7

• restore blood flow to organs
• maintain oxygenation
• stop bleed
• replace fluids

Question 8

Catabolic Flow

Answer 8

metabolic instability + catabolism

• 3-10 days
• spike in circulatory hormones (fight/flight)
• promotes breakdown of stored nutrients (glycogen>glucose, muscle>amino acids, fat>fatty acids)

Question 9

Catabolic Flow

characteristics

Answer 9

• insulin resistance
• high CO, O consumptn, temp, BMR, total body protein catabolism
• length of phase depends on severity or whether complications develop*

Question 10

positive/negative nitrogen balance

Answer 10

+ protein synth

- protein catabolism/breakdwn

Question 11

Catabolic Flow

Nutrition goals

Answer 11

• fluid/electro balance
• minimize body protein catabolism
• meet caloric protein
• micronutrient needs

Question 12

Anabolic Flow Phase

characteristic + nutrition needs

Answer 12

• [+] nitrogen balance> protein synth

- needs calories, protein, nutrients for anabolism

Question 13

hormone response includes….

Answer 13

• catecholamines, glucagon, + cortisol»> release stored macros to meet incr demands, hyperglycemia,
• excess cortisol is damaging when prolonged»> inhibits protein synth even when intake is high, promotes insulin resistance, suppress immune response
• aldosterone + antidiuretic> maintain blood volume

Question 14

acute phase response

Answer 14

quick inflammatory response to destroy infectious agents, prevent further damage, promote healing

Question 15

inflammation causes increase in positive acute proteins such as… and decrease in negative acute proteins such as…

Answer 15

• c-reactive protein

- albumin, prealbumin, transferrin

Question 16

cytokines

Answer 16

• more than 100 types of proteins involved in immune response
• responsible for regulating acute-phase proteins
• produce changs in other cells that cause accelerated catabolism> anorexia, fever, lethargy, wt loss

Question 17

prolonged or exaggerated inflammatory response is compensated by…

Answer 17

• increasing the ANTIinflammatory response to counter
• disproportionate shift towards ANTIinflammtn can lead to endothelial damage, organ failure, immune suppression, metab abnormalities, + loss of body mass
• weakened immune system is unable to destroy pathogens> immunocompromised

Question 18

sepsis

Answer 18

abnormal systemic host response to infection

• causes life-threatening organ dysfunction
• primary cause of death fr infectn

Question 19

septic shock

Answer 19

underlying circulatory + cellular metabolism abnormalities are severe enough to substantially incr risk f death

Question 20

why is there malnutrition w inflammatory response?

Answer 20

hypermetabolism + catabolism quickly deplete protein stores

Question 21

nutrition support

Answer 21

via enteral tubes or parenteral catheters

Question 22

an oral intake that meets __% of client’s needs from days 3-7 is considered adequate

Answer 22

70%

Question 23

if enteral feed is indicated, it should be initiated as soon as…

Answer 23

fluid resuscitation is complete + client is hemodynamically stable
-preferably w/in 24-48 hr

Question 24

polymeric enteral formula

Answer 24

intact macros

-1-1.5 cal/mL

Question 25

enteral formula for obese

Answer 25

low-caloric density formula - reduced nonprotein calorie-to-nitrogen ratio - less cals fr fat + carb than protein

Question 26

enteral formula for surgical ICU, or severe trauma

Answer 26

immune-modulating formula that provides arginine, fish oil, glutamine

Question 27

disease specific formula

Answer 27

no benefit for critically ill

Question 28

weight based calories

Answer 28

BMI<30: 25-30 cal/kg BMI 30-50: 11-14 cal/kg BMI>50: 22-25 cal/kg

Question 29

protein intake based on BMI

Answer 29

<30: 1.2-2 g/kg 30-40: 2 g/kg >40: 2.5 g/kg ** higher amounts may be needed for certain illnesses like burns

Question 30

supplemental enteral glutamine

Answer 30

not recommended to be added | -no benefits

Question 31

supplemental vitamins + minerals

Answer 31

``` antioxidant vit (E + C) trace minerals (selenium, zinc, copper) ``` esp w burns, trauma, + pt that needs mechanical ventilation

Question 32

formula for clients with persistent diarrhea

Answer 32

fiber containing formula or semi-elemental formula or soluble fiber supplement

Question 33

indirect calorimetry

Answer 33

analysis of O2 + CO2 of inspired + expired air - gold standard for determining cal needs - not done routinely bc limited availability + costly

Question 34

how often should calorie calculation should be reevaluated?

Answer 34

more than once a week

Question 35

how to avoid overfeeding

Answer 35

early full EN + PN should not be given to critically ill -should be achieved w/in 3-7 days * unless severely malnourished or high nutrition risk, then advance to goal quickly over 24-48 hr - --monitor for refeeding syndrome

Question 36

monitor malnourished clients such as ...... for refeeding syndrome

Answer 36

- alcoholic - chronic undernutrition - morbid obesity w massive wt loss - prolonged fasting - long-term use of simple IV hydratn - cardiac/cancer cachexia

Question 37

sudden availability of carb stimulates...

Answer 37

- insulin secretion | - incr need for thiamin + minerals involved in carb metab

Question 38

thiamin deficiency can cause..

Answer 38

acidosis, hyper vent, neurologic impairments

Question 39

initial provision of ___% of calculated cals is reasonable in msot young or well nourished clients

Answer 39

100-70%

Question 40

extubation care

Answer 40

- oral intake is commonly inadequate right after bc pain, anorexia, GI upset, etc - monitor oral intake closely - small frequent high cal + protein - nutrient dense - oral or EN supplements may be needed

Question 41

protein is for..

Answer 41

- replace lean body mass lost fr catabolic phase - restore blood vol + plasma proteins - replace loss fr immobility - meet incr need for tissue replare - resistance to infection

Question 42

calories is for...

Answer 42

- spare protein | - restore norm wt

Question 43

vitamin c is for

Answer 43

- capillary formation - tissue synth - wound healing thru collagen formation - antibody formation

Question 44

thiamin, niacin, riboflavin is for

Answer 44

increased metab rate

Question 45

folic acid + B12 is for

Answer 45

- cell prolif> tissue synth - maturation of RBC - impaired folic acid synth or impaired b12 absorptn fr some abx

Question 46

vit A is for

Answer 46

- immune functn - protein synth - cell differentiatn - epithelial cells

Question 47

vit K is for

Answer 47

- blood clotting | - impaired intestinal synth bc abc

Question 48

zinc is for

Answer 48

- protein synth - wound heal - norm lymph + phagocyte response