Transcript Nutritional Support NUR 267 Pharm

Nutritional Support
NUR 171 Pharm
Why TPN?
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Physical Exam
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Hair/nails/skin
Eyes
Oral cavity
Heart
Abdomen
Bones/joints
Neuro
Other Indices
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Nitrogen Balance
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Measures loss/gain of protein
Positive nitrogen balance is “anabolic state”
showing a gain in body protein for the day
Negative nitrogen balance shows a “catabolic
state” with a net low of protein…tissue is
breaking down faster than it can be replaced
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Body uses glucose (converted from protein) for energy
E.g., fever, starvation, surgery, burns, disease
Nutritional Requirements
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Carbohydrates
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In IV is glucose
Provides energy
Spares protein
Stored as glycogen
Calories will vary depending on pt’s needs
Dextrose increases metabolic rate…raises
their ventilatory requirements
>20% dextrose into CVC
Nutritional Requirements
(Con’t)
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Fats
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Provides twice as many energy calories per
gram as either protein or carb
Needed for cell membranes
Prevents essential fatty acid deficiency
Regulates cholesterol metabolism
S/s of deficiency is alopecia, delayed wound
healing, decreased immunity, platelet
dysfunction, susceptibility to infection
See Table 15-4 for lipid emulsions
Nutritional Requirements
(Con’t)
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Proteins
Promotes tissue growth/repair of body
cells
 A component in scar tissue, antibodies
 Amino acids basic units of protein
 Requirements for healthy adults
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 0.8
g/kg/d
 Critical states 1.2 to 2.5 g/kg/d
Other Nutrients
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Electrolytes
May be in the solution or added
 Includes potassium, magnesium,
calcium, sodium chloride, phosphorus,
chloride
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Vitamins
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Fat/water soluble
Trace elements
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Zinc, selenium, nickel, iron, iodine
Parenteral Nutrition
Additives
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Insulin
Due to the high glucose
concentration
 Only “regular” insulin added IV
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Heparin
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1000 to 3000u/L may be added to
decrease potential formation of a
fibrin clot
Histamine inhibitors
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Pepcid, Reglan, Zantac to alleviate
stress ulcers
Nutritional Support
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Indications for TPN
A 10% deficit in pre-illness weight
 Inability to take oral food/fluids within 7
days post-op, hypercatabolic situations
 Fistulas, renal failure, hepatic failure
 Ingestion of food is impaired
 Prolonged pre/post-op period
 Intake not sufficient to be anabolic
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Peripheral Parenteral
Nutrition
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PPN
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Used short-term (up to two weeks)
Patients that cannot tolerate enteral
feeding
Patients that cannot have CVC access
Dextrose is <20%
Advantages
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Increases calorie/fat source
Disadvantages
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May cause phlebitis
Does not increase weight
Total Parental Nutrition
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CV access can be used for a prolonged
period of time
Achieves tissue synthesis, repair,
growth
Advantages
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20-70% dextrose as a calorie source
Restores nitrogen balance
Allows bowel to rest
Improves tolerance to surgery
Nutritionally complete
TPN (con’t)
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Disadvantages
May require a surgical procedure to
insert a catheter
 May cause metabolic complications
 Fat emulsions in severely stressed pts.
May not be used effectively
 Risk of pneumothorax with CVC insertion
procedure
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Complications of TPN
Pneumothorax
 Air Embolism
 Vein thrombosis
 Catheter malposition
 Hyper/hypo glycemia
 Potential for infection
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Standards of Practice
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Implementation/Monitoring standards
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Formula will be sterile and properly stored
No additives to existing bag
Patients/families need education of home care
Monitor lab values
Weigh patient daily
Serum albumin levels
Check creatinine levels
Blood sugars every 6 hours
Home Health Care
Teach asepsis with equipment, TPN,
dressings, accessing line
 Instruct patient to report any
malfunction with equipment or
complications with TPN
 Assess ability to continue with TPN
 Check if storage space available at
home
 Give verbal/written instructions
 Emergency intervention
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General Guidelines
One cath lumen for TPN only
 Same bag not to infuse past 24 hrs
 Hang D10W if bag empty and new TPN
not available
 Remove from fridge an hour prior to
hanging
 Start first bag slowly…
 Use infusion pump
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Guidelines (con’t)
Monitor patient’s weight daily
 Strict I&O
 Chem panel drawn every 3 days
 Assess oral and enteral intake prior to
d/c
 Wean off TPN to prevent
hypoglycemia
 Check accuchecks as ordered (e.g.,
q6h)
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Nursing Diagnoses
Altered nutrition
 Altered health maintenance
 Altered tissue perfusion
 Potential for infection
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