Answers to Self-Assessment Questions - ACCP

More documents

Recommendations

Info

unless the patient does not tolerate a trial of nasojejunal feedings. Answer B (nasogastric feedings) is incorrect because nasogastric feedings empty into the duodenum and thus stimulate the pancreas, resulting in pain. Answer C (PN through a peripheral venous catheter) is incorrect for two reasons. First, the patient has not had a trial of nasojejunal feedings, and secondly, peripheral PN is impractical at home because peripheral venous catheters often need to be replaced every 1–2 days, resulting in significant nursing effort and decreasing quality of life for the patient. 1. McClave SA. Nutrition support in acute pancreatitis. Gastroenterol Clin North Am 2007;36:65–74. 2. McClave SA, Chang WK, Dhaliwal R, Heyland DK. Nutrition support in acute pancreatitis: a systematic review of the literature. JPEN J Parenter Enteral Nutr 2006;30:143–56. 3. ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN 2002;26(1 Suppl):1SA– 138SA. 22. Answer: B R.C. is a 40-year-old who underwent bowel resection secondary to mesenteric artery thrombosis, leaving him with short bowel syndrome (SBS). He will require home PN probably for the rest of his life. The most appropriate access for R.C. is Answer B (a tunneled CVAD with the tip in the superior vena cava). Either an implanted line, a percutaneously inserted central catheter (PICC), or an implanted port with the tip in the superior vena cava is appropriate for all patients receiving home PN. A patient receiving home PN also needs a CVAD that is reasonably resistant to accidental dislodgement. These CVADs are placed under the skin, and some have a cuff that makes them more resistant to dislodgement. Answer A (a percutaneous subclavian CVAD) is incorrect because these catheters are prone to being dislodged, which may result in significant bleeding. Answer C (a femoral CVAD with the tip located distal to the bifurcation of the iliac veins) is incorrect because femoral catheters increase the risk of infection, and most intravenous CVADs are too short to reach the superior vena cava from a femoral approach. Answer D (a peripheral venous catheter) is incorrect because these catheters are intended for short-term use only, and R.C. will need an intravenous catheter for the rest of his life. 1. ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN 2002;26(1 Suppl):1SA– 138SA. 2. Siepler J. Principles and strategies for monitoring home parenteral nutrition. Nutr Clin Pract 2007;22:340–50. 23. Answer: C A 45-year-old woman required a massive bowel resection and duodenocolostomy after a motor vehicle accident. The first step in the process of discharging a patient home on PN is to discuss the need for home PN with a discharge planner (Answer C); thus Answer C is correct. Finding a physician willing to manage the patient’s PN at home (Answer A) is incorrect. Although finding a physician experienced in home PN is desirable, if funding has not been ensured, it is unlikely that she will be able to pay for her PN. Answer B (find a home care provider to make the PN) will need to Gastroenterology and Nutrition Answers 40 be accomplished before discharge; however, this answer is incorrect because it is not the first step in the process. The home PN provider will need funding information before accepting the patient. Training the patient and her family in CVAD care and PN administration (Answer D) is another important step in the process, but it is not the first step, making Answer D incorrect. 1. Messing B, Joly F. Guidelines for management of home parenteral support in adult chronic intestinal failure patients. Gastroenterology 2006:130:S43–S51. 2. Siepler J. Principles and strategies for monitoring home parenteral nutrition. Nutr Clin Pract 2007;22:340–50. 3. Howard L. Home parenteral nutrition: survival, cost, and quality of life. Gastroenterology 2006;130:S52–S59. 24. Answer: D Reimbursement for home PN by most insurance plans is provided based on the patient meeting certain criteria. Answer D (the patient is unable to maintain body mass because of intestinal failure) is the condition that most correctly identifies a patient for whom home PN will be reimbursed. Answer A (the patient is unable to maintain body mass because of malabsorption of oral nutrients) is incorrect because a trial of tube feedings with a predigested enteral formulation has not been attempted. Inability to eat or refusal to have tube feedings (Answer B) is not an indication for home PN that would be reimbursed by most insurance companies, making Answer B incorrect. Answer C (inability to eat because of a terminal illness with a life expectancy of 1 month) is incorrect because a patient with a terminal illness and 1-month life expectancy is generally not considered an acceptable candidate for home PN. However, controversy does exist because some data suggest that patients in this condition may have an improved quality of life with nutrition support. Most experts in the field of nutrition support, however, feel that the risk of complications with home PN, including increased infections, may actually decrease quality of life and hasten a patient’s death. 1. Siepler J. Principles and strategies for monitoring home parenteral nutrition. Nutr Clin Prac 2007;22:340–50. 2. Kovacevich DS, Frederick A, Kelly D, Nishikawa RA, Young L. Standards for specialized nutrition support: home care patients. Nutr Clin Prac 2005;20:579–90. 3. Messing B, Joly F. Guidelines for management of home parenteral support in adult chronic intestinal failure patients. Gastroenterology 2006:130:S43–S51. 25. Answer: C Before a patient can be discharged to receive PN in the home, electricity, a refrigerator, and a telephone (Answer C) must be in the home. The PN solutions will be delivered for a 7–14 day period. These solutions must be refrigerated until use. A telephone is necessary to be able to communicate with the medical provider, home health nurses, and the home PN provider. Thus, Answer C is the correct answer. Answer B (transportation to a laboratory for weekly blood draws) is incorrect because laboratory samples can be drawn in the home by the home care nurse. Daily nursing care in the home to initiate and discontinue the PN infusion (Answer A) is impractical and not supported by third-party payers. The patient or a caregiver must be trained to administer Pharmacotherapy Self-Assessment Program, 6th Edition
the PN solution daily. Having a caregiver, other than the patient, to care for the CVAD and manage the PN infusion (Answer D) would be helpful for all patients, but it is not necessary before discharge because most patients can do these functions; thus Answer D is not the best answer. 1. Siepler J. Principles and strategies for monitoring home parenteral nutrition. Nutr Clin Prac 2007;22:340–50. 2. Kovacevich DS, Frederick A, Kelly D, Nishikawa RA, Young L. Standards for specialized nutrition support: home care patients. Nutr Clin Pract. 2005;20:579–9. 26. Answer: B A patient with Crohn’s disease and SBS has a tunneled CVAD for home PN. She has a temperature of 104°F (40°C) for several days. The most likely cause of her fever is a CVAD-associated infection (Answer B); thus, Answer B is the correct answer. Answer A (Crohn’s disease–related hyperthermia) is possible, but in a patient receiving home PN through a CVAD, infection is more likely to explain her fever; thus, Answer A is incorrect. Answer C (a systemic viral infection) is also possible, but a CVAD-associated infection is more likely with the high fever. Answer D (hypersensitivity reaction to the fat emulsion in the PN) is incorrect because the patient has been receiving home PN for several years. 1. Siepler J. Principles and strategies for monitoring home parenteral nutrition. Nutr Clin Prac 2007;22:340–50. 2. Yildizeli B, Lacin T, Batirel HF, Yuksel M. Complications and management of long-term central venous access CVADs and ports. J Vasc Access 2004;5:174–8. 27. Answer: D A 45-year-old man (weight 75 kg, height 165 cm ) with SBS (150 cm small bowel and the entire colon remaining) is receiving 2200 calories only 2 days/week. Answer D (his PN infusion should be weaned to 1 day/week) is the correct answer. He has had stable weight gain for 3 years, is well hydrated, and does not need additional hydration on the days that he does not receive a PN infusion. Thus, a trial of weaning his PN to 1 day/week is appropriate. Both Answer A (referral to an intestinal rehabilitation program) and Answer B (referral to an intestinal transplant program) are incorrect because it appears that he will be able to wean off PN without additional assistance; his bowel length is long enough, and he has been able to wean to only two PN infusions weekly. It would be desirable to attempt to wean him off PN first before referral to a rehabilitation or transplantation program. Answer C (his PN should be changed to a daily infusion of 630 kcal) is incorrect because he is doing well with hydration using his current twice weekly regimen, so there is no need to go back to a daily infusion. 1. Siepler J. Principles and strategies for monitoring home parenteral nutrition. Nutr Clin Prac 2007;22:340–50. 2. Messing B, Joly F. Guidelines for management of home parenteral support in adult chronic intestinal failure patients. Gastroenterology 2006:130:S43–S51. 3. Jeppesen PB, Mortensen PB. Intestinal failure defined by measurements of intestinal energy and wet weight absorption. Gut 2000;46:701–6. 28. Answer: C A 34-year-old with Crohn’s disease and SBS (25 cm residual small bowel) had a dual-energy x-ray absorptiometry (DEXA) scan with T scores reported as lumbosacral spine −3.2 and right femoral neck −3.0. This patient has osteoporosis with a significant risk of fracture; thus the best treatment for her is to start pamidronate 60 mg intravenously every month (Answer C). Answer A (start alendronate oral solution 7.5 mg daily) is not the best answer because alendronate in either the tablet or liquid dosage form is likely to be inadequately absorbed in this patient with severe SBS. Answer B (discontinue methylprednisolone) is incorrect because rapidly discontinuing her corticosteroid treatment is not advisable as it may result in a flare of her Crohn’s disease. Answer D (do nothing) is not the best course of action because she will require PN for her lifetime, and her osteoporosis likely will continue to worsen without treatment. 1. Buchman AL, Moukarzel A. Metabolic bone disease associated with total parenteral nutrition. Clin Nutr 2000;19:217–31. 2. Hurley DL, McMahon M. Long term parenteral nutrition and metabolic bone disease. Endocrinol Metab Clin North Am 1990;19:113–31. 29. Answer: A A patient receiving home PN is having difficulty aspirating blood from her CVAD for routine laboratory testing. The CVAD flushes easily, and she reports no problems with the PN infusion. This difficulty in withdrawing blood from the CVAD likely is caused by a thrombus “flap” that allows infusion of fluid through the CVAD but obstructs the CVAD lumen when negative pressure is applied in the process of aspirating blood. Answer A (instill alteplase in the CVAD to attempt to clear the obstruction) is the correct answer. Answer B (do nothing) is incorrect because this withdrawal occlusion can progress to complete occlusion and should be addressed at this time. Answer C (instill ethanol 70% to dissolve the probable lipid occlusion) is incorrect because the most likely problem is a thrombus occlusion, not a lipid occlusion, because the catheter still flushes well. A lipid plug usually causes a complete occlusion, not just withdrawal occlusion. Answer D (have the CVAD removed) is incorrect because alteplase will likely correct the problem, avoiding CVAD removal. 1. Gould JR, Carlos HW, Skinner WL. Groshong CVAD associated subclavian CVAD thrombosis. Am J Med 1993;95:419–23. 2. Bern MM, Lokich JJ, Wallach SR, Bothe A Jr, Benotti PN, Arkin CF, et al. Very low doses of warfarin can prevent thrombosis in central venous CVADs. A randomized prospective trial. Ann Int Med 1990;112:4213–28. 30. Answer: D The most likely cause of W.H.’s weight loss is dehydration, probably from an increase in his stool output. Before any changes in his therapy are made, he should be questioned to determine if his stool output has increased during the past week. Answer A (increase the protein and carbohydrate in his PN formulation to stimulate weight gain) and Answer B (increase the intravenous fat component of his PN formulation to stimulate weight gain) assume that his weight loss is caused by suboptimal calorie intake. Pharmacotherapy Self-Assessment Program, 6th Edition 41 Gastroenterology and Nutrition Answers
Page 1 and 2: Answers to Self-Assessment Question
Page 3 and 4: 8. Answer: A J.G. is receiving prop
Page 5: during continuous venovenous hemodi
Page 9 and 10: 34. Answer: D T.O. is obese (i.e.,
Page 11 and 12: 1. Consensus recommendations from t
Page 13 and 14: (Answer D) occurs more often in pat
Page 15 and 16: Dietary Supplements 61. Answer: B I
Page 17 and 18: level. Exclusion of conventional vi
Page 19 and 20: claimed effect size in GAIT was an

Answers to Self-Assessment Questions - ACCP

Create successful ePaper yourself

Delete template?

Save as template?