Transcript 1e4cb96be631de9

TPN
Total Parenteral
Nutrition
Outlines
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Definition
Indication.
Types of parenteral Nutrition
TPN Solution Content
Equipment
Administration
Montoring.
Nursing skills
TPN
• TPN therapy is the abbreviation for Total
Parenteral Nutrition.
• TPN therapy is the delivery of all essential
nutrients required by the body through the blood
stream.
• (TPN) is a method of feeding that bypasses the
gastrointestinal tract. Fluids are given into a vein
to provide most of the necessary nutrients the
body needs. The method is used when a person
cannot or should not receive feedings or fluids
by mouth.
Indication
• Trauma to the GIT.
• Pre-operative malnutrition. BMI less than 15.
• Post-opertaive complication delying Enteral
feeding.
• Malabsorption as in cancer pt., radiotherapy,
chemotherapy.
• hyper metabolic rate as in sever trauma,
burn, sepsis….
• Nausea, vomitind syndrom relates to CNS.
Types of parenteral Nutrition
Type
Uses
TPN by
C.V.P ,
internal or
external
Jagular Catheter
► Nutritionally complete.
► High hypertonic solution.
TPN by
Periphereral
Catheter
► Nutritionally complete. for short
time. 2 wks or less.
► Provide up to 2000 C/ day.
► Not used in nutritional depleted pt.
► Not used in volume restricted pt.
► Maintain adequate nutrition status.
► As effective as re-assume bowel
function and oral feeding after few
days.
► Provide large calories and
nutrients need.
► When need 2 wks or more
Nutrition
► used in nutritional depleted pt
► Improve tolerance of surgery.
Lipid emulsion
► May interfere with
immune mechanisms.
► In pt. with respiratory
compromise, reduce co2
build up.
►In pt. with respiratory
compromise, reduce co2
build up
TPN Solution 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),
• Glucose ,usually D50W or D20W, (25- 35%)
• Lipids (10-20%)
• Essential fatty acids
• Electrolytes
• Minerals
• Vitamins
TPN Content Value
Basic Adult Daily Requirements for Total Parenteral Nutrition
Nutrient
Amount
Water (/kg body wt/day)
30–40 mL
Energy* (/kg body wt/day)
Medical patient
30 kcal
Postoperative patient
30–45 kcal
Hypercatabolic patient
45–60 kcal
Amino acids (/kg body wt/day)
Medical patient
1.0 g
Postoperative patient
2.0 g
Hypercatabolic patient
3.0 g
Minerals
Vitamins
*Requirements for energy increase by 12% per 1° C of fever.
Equipment
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Strict aseptic technique.
Central venous cath.
Triple / double lumen, Hickman or C.V.
Sub Xylocaine  numbing
Betadine.
4x4’s guaze.
Heparin lock solution.
Syringes to flush.
IV fluid & line and caps & Pumps.
Stitch to secure.
Transparent obsite.
CXR for placement .
Health care team
A variety of members of the health care team
may be involved in the decisions to order
parenteral nutrition and in the care required
to administer it. These include:
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physicians
pharmacists
dieticians
nurses
administration:
• Because the central venous catheter needs to remain in place
for a long time, strict sterile technique must be used during
insertion and maintenance.
• The TPN line should not be used for any other purpose.
• External tubing should be changed q 24 h with the first bag
of the day.
• In-line filters have not been shown to decrease complications.
• Dressings should be kept sterile and are usually changed q
48 h using strict sterile techniques.
• The solution is started slowly at 50% of the calculated
requirements, using 5% dextrose to make up the
balance of fluid requirements.
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The amount of regular insulin given (added directly to
the TPN solution) depends on the plasma glucose level;
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if the level is normal and the final solution contains 25%
dextrose, the usual starting dose is 5 to 10 units of
regular insulin/L of TPN fluid.
Monitoring
Suggested
monitoring
schedule
Baseline
Acute patient
Stable patient
Blood
chemistry
Yes
2 - 3 times/week
Weekly
Lytes, BUN,
creatinine
Yes
Daily
1-2
times/week
Triglycerides
Yes
Weekly
Weekly
CBC w/diff
Yes
Weekly
Weekly
PT, PTT
Yes
Weekly
Weekly
Glucose
3 times/day
3 times/day
until <200
consistently
3 times/day
until <200
consistently
Weight
Yes
Daily
2-3
times/week
• If possible, blood tests should not be done
during glucose infusion.
• Physical examination; Obesity and the
Metabolic Syndrome: Body composition
analysis.
Complications
• Mechanical:
Pneumothorax, hemothorax, air embolism, catheter misplacement,
thromboembolism.
• Infection:
Prevent by using aseptic tech. During insertion & post care. Use in
line filter, Chg. Tubing q new bag.
• Metabolic:
Hyperglycemia –rarely hypoglycemia.
• Others:
Fluid Imbalances
Electrolyte Imbalances
Acid-base Imbalances (acidosis)
Fluid over-load  Pulmonary edema, CHF.
DO
• Refrigerate the TPN solution until 30 minutes before
using it
• Avoid infusing it immediately after refrigeration.
• Check the bag against the order for the correct
patient name, formula components, and expiration
date.
• Explain the procedure to the patient.
• Use a filter to administer TPN solution. Initiate
therapy at a rate of 40 to 50 ml/hour, then increase
the rate by 25 ml/hour every 6 hours (as tolerated)
until reaching the desired infusion rate. Infuse TPN at
a constant rate.
• Every 24 hours, change both the bag and the
tubing.
• Be sure to clamp the central line (to prevent air
from entering the catheter and causing an
embolism).
• Check the venous access site for redness and
drainage and monitor the patient for signs and
symptoms of sepsis. Using aseptic technique,
change the dressing every 48 hours or whenever
it becomes soiled or loose.
DO NOT
• Don't store TPN solution at room temperature, which
would promote bacterial growth.
• Don't allow a bag of TPN solution to hang longer than 24
hours.
• Don't add medication to a TPN bag, piggyback anything
into a TPN line, or administer other medications through
the same lumen as TPN solution.
• Don't administer TPN solution that has a brown layer,
which indicates that the lipids have separated from the
solution.
Nursing Care, Skills
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Daily Weight.
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Prevent infection, air embolism.
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Maintain fluid & electrolyte balance.
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Encourage ambulation, ADL’s & comfort.
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Educate patient & family.
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NPO  stress.
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Dressing change.
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No meds backed into TPN
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No blood drawn from TPN port
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Always chart port being used
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Always on Infusion Pump!!!!
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TPN order checked against label, checked by 2
RN’s & signed
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Gradually rate increased when beginning
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When discontinuing- gradual decreasing
Discontinuing Central Line
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MD ORDER!
Suture removal kit
Sterile gloves
Remove suture, pull out in one motion
Hold pressure sterile gauze
Sterile dressing – check for drainage
PRN culture cath tip.
After care
Patients who have been receiving parenteral
nutrition for more than a few days, and have
been given permission to start eating again,
should reintroduce foods gradually.
This will give the digestive tract time to start
functioning again.
References
• Wikipedia , last modified on 15 January 2010 .
• McConnell, Edwina A "Administering total
parenteral nutrition". Nursing. FindArticles.com.
31 Mar, 2010.
• Copyright Springhouse Corporation Nov 2001
Provided by ProQuest Information and Learning
Company.
• http://findarticles.com/p/articles/mi_qa3689/is_20
0111/ai_n8997797.
• Bare, B. & Smeltzer, S. (2004\0: Medical
Surgical Nursing. Loppincott.
• Alexander, M., et al . (2007). 3rd Ed. Nursing
Practice. The Adult. Churchill Livingstone.
• Hardine, S., Kaplow, R. (2008). Critical Nursing
Optimal Outcomes. Jones Bartelett Publisher.