# A 19-year-old patient with anorexia nervosa is admitted for medical stabilization with a BMI of 13. The team is starting nutritional rehabilitation. Which interventions should the nurse include to recognize and prevent refeeding syndrome? Select all that apply.

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> category: PSI

## Question

A 19-year-old patient with anorexia nervosa is admitted for medical stabilization with a BMI of 13. The team is starting nutritional rehabilitation. Which interventions should the nurse include to recognize and prevent refeeding syndrome? Select all that apply.

1

Begin nutrition at a low caloric load and advance gradually over several days while monitoring tolerance.

2

Aim for rapid restoration of pre-illness body weight in the first week to reverse the patient's low BMI.

3

Check daily fingerstick glucose and serum phosphate, potassium, and magnesium during the first week.

4

Replace phosphate, potassium, magnesium, and thiamine before and during the first days of refeeding.

5

Monitor electrocardiogram and assess for clinical signs of cardiac failure (edema, dyspnea, tachycardia) during early refeeding.

## Explanation

Refeeding syndrome is the metabolic and clinical consequence of carbohydrate reintroduction in a chronically malnourished patient. The carbohydrate surge releases insulin, which drives intracellular shift of phosphate, potassium, and magnesium and can produce hypophosphatemia, hypokalemia, hypomagnesemia, and thiamine depletion within days. Resulting cardiac, neuromuscular, hematologic, and respiratory dysfunction can be fatal. Correct interventions: (1) start low and advance slowly, (2) replace electrolytes and thiamine prophylactically, (4) monitor ECG and watch for cardiac failure during early refeeding, (5) check daily phosphate, potassium, magnesium, and glucose. Choice 2 is incorrect — rapid weight restoration in the first week precipitates refeeding syndrome; the goal is medical stability first, with weight restoration over weeks.

## In-depth explanation

Refeeding syndrome occurs when carbohydrate reintroduction in a chronically malnourished patient triggers an insulin surge that drives intracellular shift of phosphate, potassium, and magnesium and depletes thiamine. Hallmark labs are hypophosphatemia, hypokalemia, and hypomagnesemia. Within days the resulting cardiac, respiratory, neuromuscular, and hematologic dysfunction can be fatal. The "start low, go slow" approach uses 5–10 kcal/kg/day initially in the highest-risk patients (BMI <14 or prolonged starvation), advancing gradually over 4–7 days. Prophylactic replacement of phosphate, potassium, magnesium, and thiamine BEFORE and during the first days of nutritional support is required even if baseline labs are normal; thiamine 100–300 mg/day prevents Wernicke encephalopathy. Daily monitoring of phosphate, potassium, magnesium, glucose, and weight during the first week is essential.

## Clinical scenario

A **19-year-old patient with anorexia nervosa** is admitted for **medical stabilization** with **BMI 13**. Nutritional rehabilitation is starting and the team plans to prevent and recognize refeeding syndrome.

## Key concepts

- **Refeeding Syndrome** — Metabolic and clinical syndrome triggered by carbohydrate reintroduction in chronically malnourished patients. Insulin surge drives intracellular shift of phosphate, potassium, and magnesium and depletes thiamine. Hallmark labs: hypophosphatemia, hypokalemia, hypomagnesemia. Can cause fatal cardiac, respiratory, neuromuscular, and hematologic failure within days.
- **Start Low, Go Slow** — Initial caloric load is typically 5–10 kcal/kg/day in highest-risk patients (BMI <14, prolonged starvation), advanced gradually over 4–7 days. Faster advancement triggers refeeding syndrome.
- **Prophylactic Replacement** — Replace phosphate, potassium, magnesium, and thiamine BEFORE and during the first days of nutritional support, even if baseline labs are normal. Thiamine 100–300 mg/day prevents Wernicke encephalopathy. Daily monitoring of phosphate, potassium, magnesium, glucose, and weight during the first week.

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