Home Parenteral Nutrition Flashcards
Indications for home PN
GI length/function Intestinal failure (chron's , short bowel ) Short term loss of GI function (radiation enteritis from CA tx) Temporary/permanent failure of EN feedings
Is a patient with ESRD an indicator for the need of home PN
no
in a patient with a small bowel resection, home PN will be covered if TPN is needed for longer than ___ days and if
90 days 2 feet (60 cm)
in order to be covered for HPN, the diagnosis of _______ is critical to document
nonfunctional GI tract
In order to be considered for HPN coverage a patient must have been shown to trial and fail
enteral feeding (motility disturbance, short bowel >5 feet lost, mild malabsorption, regional enteritis, enter cutaneous fistula w/ inability to feed distally)
in order for Medicare to pay for home PN the MD must document
the need for PN based on the patient’s condition for 90 + days, anything less is NOT considered long and indefinite duration
for a home PN patient, there should be enough supplies for a ___,___, or ___ day supply
3,7,14 days
why can’t a 30 day supply of PN bags be provided to a home PN patient
not allowed by compounding guidelines
what is one of the main key concepts for discharge teaching for a home PN patient
learning the signs/symptoms of hypoglycemia/hyperglycemia
what factors contribute to quality of life in HPN patients
- the severity of their underlying dz
- frequency/magnitude and duration of sx
- effect of sx on functional status
- a person’s perception of health
in a home PN patient displaying signs of metabolic bone disease, the following adjustment would be the most appropriate
decrease the protein content, it will cause more calcium losses
in a home PN patient displaying signs of liver impairment, the most appropriate course of action would be to
decrease carbs and fat content
in addition to quality of life, cycling PN may provide __ in home PN patients
decreased risk of hepatic complications
____ can lead to metabolic bone disease, a possible complication of home PN
chronic metabolic acidosis
_____ increases the risk for hypercalciuria in home PN patients
excess dietary protein. Increased phosphate in the blood enhances calcium reabsorption by the renal tubule and won’t be urinated out. The urine will become concentrated with calcium
_____ing PN may increase renal losses s of calcium
cycling
a ____ to obtain a blood specimen during a lab draw can cause psuedohyperkalemia 2/2 hemoconstriction/hemostasis
tourniquet
as part of CMS documentation, documentation of inability to tolerating nutrition via the enteral route must include less than ____ feet of small bowel remaining beyond the ________, GI losses greater than____% of oral intake (2.5-3L/day), bowel rest for at least _____ days, calorie necessity of ____ to _____ kcal/kg/day, ____ to _____g/kg of protein a day, and lipids greater than _____ grams a month
- < 50 feet
- ligament of Treitz
- 50%
- 90 days
- 25-30 kcal/kg
- 0.8-1.5 g/kg/day
- > 1500 g /month
what materials/environmental necessities are REQUIRED for home TPN
- home or cell phone for medical emergencies
- back up BATTERY
- area for supplies storage
- electricity and running water
- refridgeration
is a back up generator required for home PN
no
who are considered high risk home PN patients
infants, patients on dialysis, diabetics, IV drug abuse, fluid/electrolyte or acid base disorders, refeed risk
high risk HPN patients require more
monitoring/clinical assessment
what does Medicare/Medicaid require in regards to length of time for insurance coverage
90 days, 3 months
Following initial certification of parenteral nutrition by Medicare, after what length of time is recertification required?
6 months(180 days)
Enteral tube feeding must be trialed and attempted or shown to fail or explain why it isn’t an option prior to starting
PN
under medicare guidelines, enteral infusion pumps are covered only with documentation of
- not tolerative gravity feeding
- gravity feeding contraindicated: reflux, aspiration, dumping syndrome, glycemic control, circulatory overload, slow infusion rate, or jejunal feedings
serum conjugated bilirubin level is elevated in an adult patient with short bowel syndrome. The pt has been getting a 12 hour cycle of 3 in 1 TPN solution. The clinicians initial plan may include
evaluating for possible overfeeding of dextrose and or IVFE
a condition of impaired secretion of bile or frank biliary obstruction in children/ LTPN adult patients is known as
Parenteral Nutrition Associated Cholestasis (PNAC)
symptoms of PNAC include
elevated alk phos
elevated GGT
elevated conjugated/direct bilirubin with or without jaundice
increase manganese/copper (potentially)
what is the proposed main cause of parenteral nutrition associated cholestasis
overfeeding of dextrose or IVFE
there is no commercially available form of ______ and no proven benefits of helping with PNAC
choline
only add carnitine to PN where there is __________ and it is not shown to help with ____________
a true deficiency detected
PNAC
which trace element is most likely to occur in LTPN patients after 3-6 months of therapy
Iron Deficiency
Fe deficiency is common in LTPN patients becuase
iron is not a component of PN to avoid potential microbial growth and damaging oxidative reactions
IV iron should only be considered when
there is an identified iron deficiency and oral iron cannot be used
what are the symptoms of iron deficiency
fatigue, headache, pallor, impaired behavior, unable to maintain body temperature
iron is not compatible in which type of PN solution
TNA 3 in 1 TPN 2/2 the IVFE
IV / parenteral iron can be added to this type of PN _______ but only when __________ ________ is given as a test dose for tolerance and to rule out a(n) _________
2: in 1 PN, iron dextran, anaphylactic reaction
when IV iron is added to 2 in 1 PN solutions, how often should serum iron and ferritin levels be monitored
every 1-3 months to prevent Fe overload
Medicare approved indications for HPN includes which of the following: supplement to EN, ESRD, long term loss of GI function, or delayed gastric emptying
long term loss of GI function
a patient’s condition is considered to be long and indefinite when the duration is documented as ____ days
90 days, 3 months
what defines good quality of life in HPN patients
the patient enjoys life, is happy, satisfied with life.
_________ depends on a patients physical health, psychological well being, social and cognitive function and outlook on their illness/treatment
Quality of Life
long term PN patients may develop metabolic bone disease if they have
pre existing disease malabsorption metabolic acidosis steroid treatment calcium, phos, mag imbalances vitamin D deficiency
all patients on PN for greater than 1 year should be recommended for ______ to screen for metabolic bone disease
DEXA
what is a key concept that should be included in post discharge teaching regimen for a HPN patient
signs and symptoms of complications and who to notify
patients who maintain stability in their personal lives (employment, family support, financial support) adjust better to
life with HPN
cosmetic look of a VAD is a concern for many HPN patients, true or false
true
adjusting to HPN is easier for patients who
structure HPN around their specific lifestyles
patients with _____ or ____ are at a higher risk for developing aluminum toxicity in long term PN
iron deficiency anemia (transferrin binds to aluminum to eliminate)
Renal disease: aluminum is excreted by the kidneys
a majority of aluminum is bound to ______
transferrin
clinical manifestations of aluminum toxicity are
neruologic hepatic hematologic skeletal non-specific non sensitive
many components of PN have an affinity for ___ which makes LTPN patients at high risk for toxicity
aluminum
70% ethanol locks removes the _____ from the inside of VAD’s in which microorganisms are harbored.
biofilm
70% ethanol locks are _____ with heparin
incompatible
Ethanol locks should not be used on a venous access device made out of this material as it can degrade it
polyurethane
True or false; 70% ethanol lock solutions have been known to provide microbial resistance
FALSE
the ______ provides education, self help, research, an annual summer conference and online education materials
Oley Foundation
