Total Parenteral Nutrition

(see pre-printed orders)

Purpose of TPN:
TPN is the intravenous administration of essential nutrients and is initiated when the GI tract does not provide for adequate ingestion, digestion and absorption.

A general indication is anticipation of undernutrition (< 50% of metabolic needs) for > 7 days. TPN is given before and after treatment to severely undernourished patients who cannot ingest large volumes of oral feedings and are being prepared for surgery, radiation therapy, or chemotherapy.

Components of TPN
TPN may include a combination of sugar and carbohydrates (for energy), proteins (for muscle strength), lipids (fat), electrolytes, and trace elements. A TPN solution may contain all or some of these substances, depending on clients condition.

 Nutritional content: TPN requires water (30 to 40 mL/kg/day), energy (30 to 60 kcal/kg/day, depending on energy expenditure), amino acids (1 to 2.0 g/kg/day, depending on the degree of catabolism), essential fatty acids, vitamins, and minerals

 Fluid. Fluid is an essential component of parenteral nutrition. Calories. Carbohydrate. Glucose is the main source Protein. This is delivered as a synthetic crystalline amino acid solution. Adverse effects of excess protein include a rise in urea and ammonia Intralipid. An oil-in-water emulsion derived from egg phospholipid, soyabean and glycerol. Minerals. Sodium, potassium, chloride, calcium, magnesium and phosphorus levels need to be closely monitored Trace Elements. Zinc, copper, manganese, selenium, fluorine and iodine are provided in a number of commercial TPN preparations. Vitamins. The daily requirements for both water and fat soluble vitamins can be provided in TPN

 When hanging TPN, confirm the TPN bag label with the original order form Standardized Bag Prescribing
Solutions may be modified based on laboratory results, underlying disorders, hypermetabolism, or other factors.

Lipids: Commercially available lipid emulsions are often added to supply essential fatty acids and triglycerides; 20 to 30% of total calories is usually supplied as lipids.

TPN Administration
Before you administer TPN, look at the solution closely. It should be clear and free of floating material. Gently squeeze the bag or observe the solution container to make sure there are no leaks. Do not use the solution if it is discolored, if it contains particles, or if the bag or container leaks.

Tubing/Line: Because of high infection risk and compatibility issues, TPN is infused only through a dedicated lumen. CDC Guidelines state, Designate one port exclusively for TPN if a multi-lumen catheter is used to administer parenteral nutrition. Label the lumen used for TPN to ensure that it is not used for other medications/fluids.

 Because TPN solutions are concentrated and can cause thrombosis of peripheral veins, a central venous catheter is usually required The solution is started slowly at 50% of the calculated requirements usually 1st 24hrs Insulin: The amount of regular insulin given (added directly to the TPN solution) depends on the blood glucose level

 TPN lines shall be used exclusively to administer TPN/PPN and shall not be accessed for any other reason (e.g., blood draws, piggybacking meds or other fluids) compatible medication is sometimes piggybacked with TPN (check policy) PPN may be infused through a peripheral or central VAD.

 TPN with or without lipid admixture administration sets changed Q48hrs (check policy) Filters for TPN (check policy) Filtration is aimed at filtering out particulate matter and microbes from infusates. (changed Q24hrs check policy) Lipid administration sets changed Q24hrs.

 Patients receiving TPN shall have their intake and output, blood glucose, and weight monitored according to physician order, or at least daily. A weaning period is necessary for all TPN infusions (does not include PPN). If TPN runs out, is not available, or the TPN line becomes dysfunctional, D10W shall be infused at the previously ordered TPN rate (check policy) A blood glucose level shall be checked 1 hour after D10W is started

 Weigh patient every Monday/Wednesday/Frida y or as ordered. Prep all TPN connections with alcohol vigorously for 5-10 seconds prior to entering Connect filter to the end of the TPN tubing, below the pump; change filter daily. Infuse TPN via infusion pump.

Monitoring
Progress should be followed on a flowchart. An interdisciplinary nutrition team, if available, should monitor the patient. Weight, CBC, electrolytes, and BUN should be monitored often (eg, daily for inpatients). Blood glucose should be monitored q 6 h until stable. Fluid intake and output should be monitored continuously. When the patient becomes stable, blood tests can be done much less often LABS: Monitor:
Na, K, Cl, HCO3, BUN, CR, Gluc, Mg, PO4, AST, ALT, alkaline phosphatase, triglycerides.

 LABS: Monitor:
Na, K, Cl, HCO3, BUN, CR, Gluc, Mg, PO4, AST, ALT, alkaline phosphatase, triglycerides. Liver function tests should be done. Protime Plasma proteins (eg, serum albumin)

(See individual facility protocol for lab and frequency)

Signs of infection
symptoms of a catheter-related infection tenderness warmth irritation drainage redness swelling pain

 PATIENT/CAREGIVER

Explain rationale for TPN therapy. Instruct patient/caregiver to report: loose, wet or soiled IV dressing pain at IV site redness/swelling of IV site

The following symptoms may occur with TPN administration

fever or chills stomach pain difficulty breathing rapid weight gain or loss increased urination upset stomach vomiting confusion or memory loss muscle weakness, twitching, or cramps swelling of the hands, feet, or legs thirst fatigue changes in heartbeat tingling in the hands or feet jumpy reflexes convulsions or seizures

Complications of TPN Therapy

Glucose abnormalities are common. Hyperglycemia can be avoided by monitoring blood glucose often Abnormalities of serum electrolytes and minerals should be corrected by modifying subsequent infusionsVolume overload (suggested by > 1 kg/day weight gain) may occur when high daily energy requirements require large fluid volumes. Metabolic bone disease, or bone demineralization (osteoporosis or osteomalacia), develops in some patients receiving TPN for > 3 mo. The mechanism is unknown Adverse reactions to lipid emulsions (eg, dyspnea, cutaneous allergic reactions, nausea, headache, back pain, sweating, dizziness) are

 Hepatic complications include liver dysfunction, painful hepatomegaly, and hyperammonemia Gallbladder complications include cholelithiasis, gallbladder sludge, and cholecystitis

Central Line Dressing Change

Central Line Dressing Change

Central Venous Access Device: Dressing Change:
permanent tunneled long-term (Hickman, Broviac, Groshong) temporary non-tunneled single/multilumen (Arrow, Hohn, Cook) accessed subcutaneous implanted ports non-tunneled long-term (PICC)

(See individual facility protocols)

At least every four (4) days for transparent dressings (Tegaderm, Sorbaview, and Opsite) At least every other day or three times per week, (usually Monday, Wednesday and Friday), for any gauze dressing.

An immediate dressing change is required for a wet, soiled or loose dressing. An occlusive dressing must be intact at all times. Do not reinforce loose dressings with tape; the dressing must be changed. Gauze may be added for patients who are diaphoretic or when there is bleeding or oozing at the catheter insertion site.

 Assess site and change dressing within 24 hours of catheter placement. For patients admitted with existing catheters, dressing change and site care must be done within 24 hours of hospital admission.

**Please see individual facility

STEPS KEY POINTS

1. Explain procedure to patient/caregiver. 2. Perform hand hygiene and put on clean gloves. Place patient in supine position with head turned away from dressing site. 3. Remove dressing carefully and discard with gloves.
2. For Bone Marrow Patients, refer to Infection Control Manual for "Recommended Procedures for Managing Indwelling IV Catheters

STEPS KEY POINTS

Never use scissors when removing the dressing. 4. Observe the site for redness, swelling or discharge, and integrity of any sutures.
2. For Bone Marrow Patients, refer to Infection Control Manual for "Recommended Procedures for Managing Indwelling IV Catheters 4. Report signs of infection to MD.

 5. Repeat hand hygiene. --Alcohol-based foam may be used. 6. Open the sterile dressing change kit --Mask patient if indicated 7. Put on mask. 8. Put on sterile gloves.

9. Use first alcohol swab stick to cleanse the skin around the catheter or needle insertion site. Use firm circular motion beginning at the insertion site and moving outward. X3, Include the entire area to be covered by the dressing. 2-3 inches. (apply friction and pressure)

 10. Repeat cleansing in the same manner with second alcohol swab. 11. Use third swab stick to cleanse any catheter or tubing that will be covered by the sterile dressing. Allow to dry.

 12. Use chlorhexidine applicator to cleanse skin around catheter or needle insertion site. Use firm circular motion beginning at the insertion site and moving outward to include entire area to be covered by the dressing

--Chlorhexidine should not be used for patients < 2 months of age or chlorhexidineallergic patients. 13. Allow chlorhexidine to air dry (at least 30 seconds, may take up to 2 minutes).

 14. Apply transparent (Tegaderm, Sorbaview, Opsite) occlusive dressing and change weekly. Must change immediately if wet, soiled or loose. --May use gauze dressing (gauze and tape or Mefix or transparent dressing over sterile 2 X 2 gauze) as an alternative only if patient has an allergy to the transparent occlusive dressing.

Change at least every other day or three times per week, (usually Monday, Wednesday and Friday). May use 2 x 2 gauze, folded, under port needle to prevent rocking. 15. Pleat transparent dressing around the tubing to insure occlusive dressing. 16. Change catheter cap

 16. Remove gloves. 17. Anchor catheter with tape to skin. --This helps prevent tension on insertion site and accidental dislodgement of catheter.

18. Label dressing with date and nurses initials.

 DOCUMENTATION: Record on Client Care Record, flowsheet or electronic record: procedure site observations patients tolerance patient instruction/understanding.