Nutritional Support NS2P2 Exam3

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Nutritional Support NS2P2 Exam3
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NS2 NSP2 Nutrition Michelle Exam3
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Nutriton Paternal TPN PICC
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  1. **The Digestive System
    • -30 foot system
    • Breaks down ingested food
    • Prepares food for absorption
    • Provides body with water
    • Eliminates waste

    • => Organs include:
    • The gastrointestinal tract

    Accessory organs: Liver, Gallbladder, Exocrine pancreas-secretes digestive enzyme

    FYI: Enocrine pancreas- secrets insulin and other hormones directly into bloodstream
  2. **Digestion & Absorbtion
    • =>Mouth
    • Saliva produces enzymes (amylase)
    • Breaks down starches while still in mouth

    • =>Stomach
    • Hydrochloric acid and pepsin break down food fibers and proteins


    • **Absorption
    • =>Small intestine
    • Pancreatic enzymes, intestinal enzymes, and bile salts
    • Protein is broken down into amino acids, peptides
    • Fats broken down into fatty acids and monoglycerides

    =>Water, vitamins, and electrolytes absorbed here
  3. **Nutrition
    Protein
    Carbohydrates
    Lipids
    Vitamins
    • =>Essential nutrients-required for cells to function properly
    • Protein-major structural unit of cell !! decrease in protien causes a decrease in intestinal mass-leading to decreased ability to absorb nutrients-so low protein causes malabsorbtion;

    Carbohydrates like glucoses and dextrose; break down of statrch and provides energy used by cells so we can produce atp; when deficient in glucose, your body will switch over to metabolizing fats (not good state to be in)

    Lipids (fats)-lipid deficiency causes breaks down adipose tissue and body produces ketones causing DKA; we need fats to live. Cell membrane is made of phospholipids

    Vitamins-need to be in diet; essential for normal cellular function, most not made in body, come from diet, Vit D is made in body Minerals

    • =>Patients need good nutrition for normal cellular metabolism
    • tissue building- skin issues(protein) and repair
    • ability to fight infection
  4. **Malnutrition
    Defined as any disorder of nutritional status (deficit, excess, or imbalance of nutrients); seen in 30-50% of hospitalized patient

    Under-nutrition: Deficiency of nutrients; public health threat especially in developing country; can occur in US with low socioeconomic

    Over-nutrition: Excess of nutrients. Linked to variety of chronic disorders. -encourage activity
  5. **Malnutrion: Who’s at Risk?
    Older adults mostly due to the following factors

    Economic –biggest risk factor for lack of fixed income and tend to buy fresh ingredients and desire to cook ("why cook if it's just me? So just a piece of toast.")

    Psychosocial-loneliness and socialized isolation; especially for med-- if wife passed used to cook men oftet won’t bother to cook themselves a nutritious meal

    Functional limitations: lack of dexterity and neuropathic issues the disable them fro preparing themselves good meal (can't chop with knives). Limits sensation, And cognitive requirments for planning and preparing feeling

    Physiological-annorexia; nausea vomiting dysphagia

    • incidence in long term care is 35-50%
    • Hospital pts for 65 yr or older: 60%

    • =>People of all ages with:
    • GI disorders
    • Chronic disease or malignancies
    • Lower socioeconomic status: Decreased access and quality of food
    • Alcohol/drug abuse
    • COPD: SOB so you don't eat a lot.
    • Cancer: depressed appetite and malnurtiron
  6. **Malnutrion: Why Should We Care?
    Causes increased morbidity and mortality in hospitalized patients are increased with Longer recovery time- which costs more money

    Impaired immune response-sick

    Anemia

    Delayed wound healing

    Impaired organ function
  7. **Starvation Process
    1. Body depletes carbohydrates first then uses reserves from liver and muscle but initially spares protein

    2. Gluconeogenesis in liver: Amino acid converted from protein and now made into glucose, Called being in negative nitrogen balance (Defined as increased rate of protein breakdown vs. protein synthesis. Nitrogen excretion exceeds nitrogen intake)

    3. Body fat is mobilized: within 5-9 days of malnutrion; body is still trying to spare protein

    4. Fat stores are depleted and body proteins used for energy 4-6 weeks

    5. Protein depletion causes liver function to be impaired and synthesis of protein decreases. If there's no protein, then liver can't make albumin!!

    7 Decreased oncotic pressure leads to edema and electrolyte/fluid shifts --ascites.

    8 Failure of the sodium-potassium exchange pump can lead to life-threatening electrolyte imbalances=HYPERkalemia that can cause arrythmias. Potassium cannot get into the cell.


    • 9 Continued organ dysfunction can eventually lead to death )
    • marasnus: form of severe malnutrion characterized as energy deficiency; body weight is reduced to 60% of normal bodyweight for that age; like severly anorexic!
  8. **Protein-Caloric Malnutrition (PCM) & Manifestations
    Most common form of UNDER nutrition

    • =>Primary
    • Poor eating habits: Ingesting food deficient in protein, vitamins, minerals

    • =>Secondary
    • Alteration or defect in ingestion, digestion, absorption, or metabolism;
    • Due to GI obstruction, surgical procedures, cancer, malabsorption syndromes, drugs, infectious diseases
    • Long-term facility population has 23-85% PCM rate; they don't like the food

    • **Clinical Manifestations
    • Integumentary- dry, scaly skin, alopecia, rashes
    • GI- glossitis (like ID anemia), mouth ulcerations, dental caries, ascites, bowel changes
    • MS- decreased mass of small intestine leads to malnutriont, weakness, “wasted” appearance
    • CNS- confusion, irritability, tremor, syncope
  9. **Diagnostic Studies for PCM
    H&P

    • =>Laboratory Studies
    • Albumin, Prealbumin-low

    CBC-low hand hh due to low production; generalized anemia

    And lymphocytes might be decreased

    BMP (basic metabolic panel)-elevated potassium , bun elevated because urea is byproduct of protein metabolism and increased during starvation

    • =>Measurements
    • Height, weight
    • BMI (<18.5)-considered malnurished
    • Body fat %
  10. **Albumin and Prealbumin
    • =>Significance:Made in the liver60% of total protein in the body
    • Contributes to osmotic pressure within the vascular space; holds the fluid in vessels
    • Transports drugs, hormones, and enzymes in the blood--hitch ride with albumin
    • Decreased albumin indicated decreased liver functioning

    • =>Serum Albumin (3.5-5.0 g/dl)
    • Half-life of 20 to 22 days
    • so if you're having ACUTE malnutrion, the serum albumin is still going to be normal
    • Poor indicator of acute changes in nutrition-because change won’ take place for about a month

    • =>Pre-serum albumin (20-50mg/dl)
    • Half-life of 2 days
    • BETTER Indicator of acute changes, however may reflect other conditions- but it can change with other infection with trauma and infection and inflammation
  11. **Nursing Diagnoses (Malnutrition)
    -Nurses are responsible for nutrional screening done within 24 hours of admission, per Joint Commison

    • Imbalanced nutrition, <LBR
    • Deficient fluid volume
    • Self-care deficit (feeding)
    • Risk for Impaired Skin Integrity
    • Risk for Infection
    • Activity Intolerance
    • Constipation/Diarrhea
  12. **Supplemental Nutrition (Broad Goals)
    • Oral supplementation-prefered route
    • Enteral feeding
    • Parenteral feeding
    • -functioning GI, abosorbtion? and how long the nutriitional support is gonna be needed

    • **Supplemental Nutrition: Broad Goals
    • To meet the patient’s nutritional needs and to allow for growth of new body tissue
    • Maintain positive nitrogen balance
    • Protein intake msut be greater than use protein use of the body
  13. **Oral Supplementation
    • Start with well-balanced diet; Modify as needed
    • Add high-calorie supplements and high protien.
    • Snacks 3 times/day between meals

    • =>Consider commercial prepared products-just supplements not meant as meal replacements
    • Ensure
    • Isoca
    • lBoost
  14. **Enteral Feeding
    Used for pt with functioning GI tract but unable to take in enough oral nurishment

    • =>Nutrition provided through GI tract via tube
    • NGT < 4 wks (SHORT TERM ONLY).-because of eroding tissue down nose and throat
    • GT or JT for > 4 wks. (Long term)

    • -check residual with G tubes NOT J TUBES; jejunum has no reservoirs to hold the feeding, slower rate and constantly absorbed. BUT DO CHECK PLACEMENT.
    • -PEG "Percutaneous endoscopic Gastrostomy"

    • =>Enteral feeding delivery options
    • Continuous infusion pump (60mls/every hour, change bag usually Q4H)
    • Intermittent bolus with syringe-mostly done in home settings; pour down syrine from cans(in home setting 3x a day like a meal)
    • Cyclic intermittent with pump- feeding done only at night; sometimes just to boost nutrition at night-during day can eat food po if can swallow
  15. **Nasogastric Tube
    -contraindication: Facial trauma, facial fractures. DON"T PUT DOWN NG tube because can go INTO THE BRAIN o: Esophageal varices or easily bruised vessels usually seen in alcholic cirrosis pts--they may have strictures (scar tissue). Pts with GERD, more erosions. Alkaline ingestion can cause erosion of esophagus.

    Must have intact, unobstructed GI tract

    Lower risk, cost procedure

    • -Insertion: tuck chin and swallow water. Sedation: makes it more difficult, can go into lungs. Signs: coughin and O2 stat falls--pull it out.
    • -Bubbles in waterInitial placement verified by XR

    • =>Monitor tube patency and position
    • Monitor tube length-tape up nose, check ever 4 hours.
    • Residuals q4Flush q4 and prn
    • Check with air bolus or pH strip
    • Aspiration precautions-HEAD OF BED UP TO AT LEAST 30 DEGREES
  16. **Gastrostomy Tube
    • Placed surgically, radiologically, endoscopically--when required more than 4 weeks.
    • Percutaneous endoscopic gastrostomy (PEG)

    • =>Monitor tube patency, position
    • Monitor tube length
    • Residuals q4
    • Flush q4 and PRN
    • =>Aspiration precautions: HOB at 30-45 degrees
    • Turn off the feedings 30 mins before putting the head down so stomach has chance to empty
  17. **Jejunostomy Tube
    Indicated for patients with high aspiration risk, delayed gastric emptying, gastric dysfunction, reflux

    Placement confirmed via XR (with all tubes)

    Monitor tube length

    Residual checks unnecessary

    Diabetes: gastroparesis: stomach doesn't have enough parastalisis to get the food down, so food just sits there.
  18. **PEG Tube Insertion: PUSH & Pull methods
    Doctor orders for: esophageal cancer, oral surgery, stroeke, trauma, burns, anorexia, inflammation of pancrease, inflammatory bowel affecting the small intestine

    Before procedure: IV sedative, local anesthetic on abdomen-most common: pull method: Lighted endoscope down throat with camera. Needle inserted into stomach's skin, then use endoscope to locate needle inside stomach and encricle with wire snare. The doctor passes a thin wire through the NEEDLE into stomach, use endoscope to pull the wire out and have it come OUT of the mouth. Then he will attach PEG feeding tube to wire outside of mouth, then pull wire from stomach's side so that feeding tube will eventually come from the inside of the stomach to the outside so the tip shows, bumper is secured.

    => Push method: Pushing the PEG tube into the stomach with the wire.

    • After procedure: IV fluids for 1-2 days.
    • Once evidence that digestive tract is functioning; clear liquids willbe provided then formula. :)
  19. **G Tube Care and Maintenance
    • -allows food and medications directly into stomach
    • -prevent weight loss, minmize risk of aspiration
    • -ALS or truma pts-oral intake encouraged even after G tube insertion
    • -Before G tube insertion: NPO from midnight. -Clean skin around tab for first 5 days after insertion, use qtip and clorhexidine, then dip in betadine (once daily)

    -in shower: clean with mild soap and water, don't take bath, gauze only necessary if you have drainage from stoma. Wash hands throughly before any tube checks. S/S infection: fever, redness, tenderness, any discolored foul smelling discharge.Secure free tube with tape, check mark. Don't pull tubes, can disolodge! Amount of water used to anchor device.

    -Feed by syringe or by gravity. sit in upright for feeding and 30 mins after feeding.

    -Shake formula well. Check for expiration date. Close roller camp on feeding side. Pour into bag, hang above head level. Open rollerclamp to start feeding. Flush with water.

    -don't mix meds with feeding formula.
  20. **FEEDING PROCEDURE
  21. **GIVING MEDS PROCEDURE
  22. **GIVING MEDS PROCEDURE
  23. **Potential Complications G Tubes
    Aspiration: turn it off when HOB down, microaspiration--asthma and pneumonia usually in crtically ill

    Skin irritation: monitor for redness, swelling

    Tube displacement: length, assess if there's any orders for sending to xray if dislodged,

    Enteral feeding misconnection-trace tubes back to where it's going

    Reglan: if they're having high residuals, which increases gastric emptying, to remove feeding from their system
  24. **Parenteral (IV) Nutrition
    Utilized when patient cannot tolerate enteral feeding-used when patient has malabsorbtion issues and nutrition can’t be taken through gi tract; bypasses this whole system

    "TPN" is tailored to each pt: consists of doctor, nurse, pharmacist, nutritionlist

    -25-30 calories/kg/day: formula for assessing caloric intake.

    In contrast, If a TPN bag gives someone everything they need for 24 hours, vs. a liter bag of D5 or D5 Lactated ringers, only gives then 170 calories (not longterm)

    -avg adult needs: 1200-1500 caolories a day (laying in bed-non-active)

    Delivered intravenously Highly concentrated, hypertonic solution

    Calories supplied from dextrose and fat emulsion

    Also provides amino acids, vitamins, electrolytes, minerals, trace elements. Can add insulin, H2 blockers, sometimes heparin
  25. **TPN: Total parenteral nutrition (TPN)
    is a hypertonic intravenous (IV) bolus solution thatprovides complete nutrition to a client who does not have a functioning gastrointestinal(GI) tract or needs additional nutritional supplementation (burns). The purpose of TPNadministration is to prevent or correct nutritional deficiencies and minimize the adverseeffects of malnourishment.

    TPN administration is usually through a central line, such as a nontunneled triplelumen catheter or a single- or double-lumen peripherally inserted central line (PICC).

    • TPN contains complete nutrition, including calories (through a high concentration
    • – 20 to 50% – of dextrose), lipids/essential fatty acids, protein, electrolytes, vitamins,and trace elements. Standard IV bolus therapy is typically ≤ 700 calories a day.


    Partial parenteral nutrition or peripheral parenteral nutrition (PPN) is lesshypertonic and intended for short-term use in a large peripheral vein. Usual dextroseconcentration is 10% or less. Risks include phlebitis
  26. **TPN Care: Ongoing Care
    • ■The flow rate is gradually increased and gradually decreased to allow body adjustment (usually no more than a 10% hourly increase in rate).
    • ☐Never abruptly stop TPN. Speeding up/slowing down the rate iscontraindicated. An abrupt rate changes can alter glucose levelssignificantly.
    • ■Monitor the client’s vital signs every 4 to 8 hr.
    • ■Follow sterile procedures to minimize the risk of sepsis.

    ☐TPN solution is prepared by the pharmacy using aseptic technique with alaminar flow hood.

    ☐Change tubing and solution bag (even if not empty) every 24 hr.

    ☐A filter is used on the IV bolus line (to collect particles from the solution).

    • ☐Do not use the line for other IV bolus solutions (prevents contaminationand interruption of the flow)
    • Do not add anything to the solution due to risks of contamination andincompatibility.

    ☐Use sterile procedures, including a mask, when changing the central line dressing (per facility procedure).

    => Interventions

    • ■Check capillary glucose every 4 to 6 hr for at least the first 24 hr.
    • ☐Clients receiving TPN frequently need supplemental Regular insulin untilthe pancreas can increase its endogenous production of insulin.
    • ☐Keep dextrose 10% in water at the bedside in case the solution is unexpectedly ruined or the next bag is not available. This will minimize therisk of hypoglycemia with abrupt changes in dextrose concentrations.

    ☐Older adult clients have an increased incidence of glucose intolerance
  27. **Indications for PN
    • Chronic diarrhea and/or vomiting: nutrients aren't in the system long enough to be absorbed
    • Complicated surgery or traumaGI obstruction
    • GI tract anomalies and fistulae
    • Severe malabsorption
    • Short Bowel syndrome: after multiple resections of the bowelpts usually go from PN to Enteral nutrion if they're getting better

    • =>Specific conditions
    • ☐ Chronic pancreatitis
    • ☐Diffuse peritonitis
    • ☐Short bowel syndrome
    • ☐Gastric paresis from diabetes mellitus
    • ☐Severe burns◯Client Presentation

    • ■Basic guidelines regarding when to initiate TPN
    • ☐A weight loss of 7% body weight and NPO for 7-10 days or more
    • ☐A hypermetabolic state
  28. **Composition of PN
    • =>Calories
    • Dextrose- 20 percent peripheral line max - up to 50% max central line= highly concentrated
    • -Provides 3.4 kcal/gram

    • =>Proteins
    • Form of amino acids
    • 2.5-8.5% of the solution; can vary with type of pt: renal or liver failure

    • =>Electrolytes, vitamins and essential trace elements: calc, mg, potassium and sodium
    • -water sol vitamines given in excess due to rapid admin which increases excretions (B&C)
    • Fat soluble: ADB&K (you can overdose)
    • -looks yellow b/c of multivitamins

    • =>Additional additives sometimes
    • -albumin
    • Regular insulin
    • H2 blockers
  29. **ATI Info: Components of Parenteral Nutrition Solutions
    =>PN includes amino acids, dextrose, electrolytes, vitamins, and trace elements in sterile water.

    • => Carbohydrate or dextrose solutions are available in concentrations of 5% for PPN and up to 70%for TPN.
    • ◯ A higher concentration of dextrose is often prescribed for a client on fluid restrictions.
    • ◯ A lower-dextrose concentration may be used to help control hyperglycemia.

    =>Electrolytes, vitamins, and trace elements are essential for normal body functions. The amounts addedare dependent upon the client’s blood chemistry values, and physical assessment findings are used todetermine the quantity of electrolytes. Additional vitamin K may be added to the PN solution.

    • =>Lipids (fats) are available in concentrations of 10%, 20%, and 30%. Lipids are a significant source ofcalories and are used to correct or prevent essential fatty acid deficiency.
    • ◯ Lipid emulsions can be added to the PN solution, administered piggyback, or given intermittently.
    • ◯IV lipids are contraindicated for clients who have hyperlipidemia, severe hepatic disease, or anallergy to soybean oil, eggs, or safflower oil.
    • ◯ Lipid emulsion provides the needed calories when dextrose concentration must be reduced due tofluid restrictions.
    • ◯lipid emulsion provides the calories without increasing the osmolality of the PN solution.

    • => Protein is provided as a mixture of essential and nonessential amino acids and is available inconcentrations of 3% to 5%.
    • ◯ Protein should provide 3.5% to 20% of the total concentration of the PN solution.
    • ◯ The client’s estimated requirements and liver and kidney function determine the amount ofprotein provided.

    =>Two medications, insulin and heparin, may be added to the PN solution by pharmacy services. Insulin may be added to reduce the potential for hyperglycemia, and heparin may be added to preventfibrin buildup on the catheter tip. Administering any IV medication through a PN IV line or portis contraindicated.
  30. **Intravenous Fat Emulsion: Lipids
     Overfeeding?
    Given concurrently with TPN below filter BUT LIPIDS NEVER FILTERED

    -500 mL bag of 20% lipids can provide 1000 calories; made from egg phospholipids

    10-20% solutions

    Provide essential fatty acids and another source of non-protein energy (1 to 2 Cal/ml)

    Check allergy

    Infuse slowly to avoid N/V; ramp up and wean off slow

    Never mix tpn with blood or meds

    usually given over 12-24 hours.

    => overfeeding syndrome: too much TPN: hyperglycemia, fatty liver, hypertriglycerides, excess CO2 production.
  31. Peripheral VS. Central PN:
    • => Peripheral Parenteral Nutrition (PPN)
    • Peripheral line – PPN
    • -always need large bore: 20 gauge and above (10, 18,16)
    • -nutritional support is short term,Infused by a large peripheral vein of arms
    • Concentration of dextrose up to 20%
    • But usually 10%
    • -placed in large veins of arms, thrombophlebitis is high incidence--very irritating b/c hypotonic!

    • =>Central Parenteral Nutrition
    • Central line – CPN (includes PICC)
    • Infused by large central vein
    • Concentration of dextrose up to 50%
    • Subclavian or Jugular Veins-lie in superior vena cava
  32. **PICC Line
    Placed in basilic or cephalic vein and advanced into central circulation

    Can be placed by RN who has special training

    Advantages: ease of placement, cost, and limited complications

    X-ray to confirm placement

    PICC Line InsertionCatheter Placement
  33. **Administration Considerations PN
    • PN solutions are prepared by Rx under strict asepsis (high risk of bacteria)
    • Do not add to PN solution after

    Solutions must be kept refrigerated and are good for 24 hours at room temp. Every 24 hours: chainge everything-tubing and bag. Room temp.

    Check the recipe!

    Administer using dedicated tubing and a filter and change with each bag

    dedicated line, always Use infusion pump

    IF YOU RUN OUT: Hang Dextroseof the same percentage! D20 by itself to replace finished bag. Don't slow down rate b/c hypoglycemic.
  34. **Complications of PN
    • Hyperglycemia-
    • NUMBER ONE. Goal: BG <150.
    • Gradually increase rate for 24-48 hours
    • Blood glucose check q4-6
    • Administer insulin per sliding scale
    • Do not stop or discontinue PN abruptly--> May be risk cause hypoglycemia

    Fluid overload: assess lungs for crackles, monitor I&O

    =>Electrolyte imbalance

    • =>Refeeding Syndrome
    • Occur at any time in malnutrition pt that's been put on aggressive nutritional support
    • When delivery of glucose icnreases circulatory glucose--pancrease puts on soo much insulin and rapid intake of glucose, potassium, phosphate and magnesuium. Serum levels will fall. Hypokalemia. Hypophosphatemia (HALLMARK SIGN OF REFEEDING SYNDROM)

    • Electrolyte disturbances, especially hypophosphatemia(halmark signs of refeeding syndrome)
    • Cardiac, respiratory, neuro complications

    • =>Infection-major risk in central lines
    • Suspect catheter if no other cause can be identified
    • Catheter or blood cultures
    • To assess they pull catheter out and cut off tip to get lab culture to find out what it is to treat
    • High dextrose levels is a great feeding ground for bacteria

    =>Fatty liver and liver failure- poorly understood, may be due to intralipids..unknown. Just monitor.

    • =>Bacterial translocation(causes intestinal atrophy because intestines being bybassed and not being used anymore; promoted bacteria to travel to lymph nodes..and to other parts of the body.
    • GI tract feeding preferred over IV.
  35. **Catheter Complications of PN
    Pneumothorax-colapsesd lung

    Hemothorax-blood in pleural space

    Catheter misplacement-need chest xray to verify placement before you put anything through line

    Air embolism-caused by air to come into system through central line

    Phlebitis and thromboembolism: solutions are irritating to vein. Foreign objects in body, make platelets stick to it..

    Infection: concentrated glucose is a medium for bactera. Assess central lite site insertion for redness, and change the STERILE dressing Q72H.Do NOT use TPN line for other IV bolus fluids and medications (repeated access increases the risk for infection). **TPN can mean CPN or PPN :)
  36. **Critical Thinking Situation
    The physician has ordered TPN 2000ml (20% dextrose solution) with 10 units regular insulin to run in over 24 hrs.What are the nursing responsibilities when a patient is receiving TPN? 

    The patient has developed an infection and has IVPB antibiotics ordered, what should you do?
    -check tubing and blood sugar Monitor and filter tpn , always start slowly until reach ordered dose , and strict aseptic technique, dedicated line, accuchecks Q4.

    The patient has developed an infection and has IVPB antibiotics ordered, what should you do?


    start new IV line unless they have double lumen picc lines.sterile dressing changes for picc line done 24 hours after insertion, then 3-7 days after.
  37. **When teaching the older adult about nutritional needs during aging, the nurse emphasizes that 

    a) The need for all nutrients decreases as one ages

    b) Fewer calories, but the same amount of protein are required as one ages  

    c) Fats, carbohydrates, and protein should be decreased, but vitamin and mineral intake should be increased

    d) High-calorie oral supplements should be taken between meals to ensure that recommended nutrient needs are met
    a) The need for all nutrients decreases as one ages

    b) Fewer calories, but the same amount of protein are required as one ages (THIS- because metabolism is decreased)

    c) Fats, carbohydrates, and protein should be decreased, but vitamin and mineral intake should be increased


    d) High-calorie oral supplements should be taken between meals to ensure that recommended nutrient needs are met

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