Lecture 01 Total Parenteral Nutrition (TPN)

Question 1

What are indications for TPN? (7)

Answer 1

1. [*] Used to meet nutritional needs of patients who cannot ingest, absorb, or digest essential nutrients via the gastrointestinal tract. You will always have a nutritional consult.
2. [*] Patients moderately to severely malnourished, negative nitrogen balance
3. [*] Impaired GI tract: Ileus, surgery, fistulas, short “gut” bowel syndrome
4. [*] Acute pancreatitis or gastro-intestinal bleeding
5. [*] Acute episodes/exacerbations of Crohn’s Disease
6. [*] Severe burns, trauma, liver or renal disease
7. [*] Radiation enteritis and terminal illness

Question 2

What are TPN Components? (10)

Answer 2

1. [*] Amino acids
2. [*] Glucose
3. [*] Fat emulsion (lipids/intralipids)
4. [*] Vitamins
5. [*] Electrolytes
6. [*] Minerals
7. [*] Trace elements
8. [*] Water
9. [*] Glucose concentration (10% for adults; generally 15 – 25% depending on condition of patient and what tolerated)
10. [*] Lipids may be combined with TPN solution or infused separately

Question 3

How should TPN be adminstered if:
Gluclose concentration >10%

Answer 3

Via the central or PICC line

Question 4

What are some general guidelines to TPN infusion? (10)

Answer 4

1. [*] TPN infusions administered via a “dedicated port” of a central line
2. [*] TPN is “custom” mix & reconstituted in pharmacy under strict, aseptic technique
3. [*] Administered via an infusion pump over usually 24 hours, however can be cyclic
4. [*] TPN, lipids and tubing changed every 24 hours
5. [*] TPN is administered with in line micron filter (special intravenous tubing). Lipids are not filtered.
6. No medications are added to TPN solution bags by nurses EVER.
7. [*] TPN and lipids are infused as a closed system and no other intravenous medications or solutions are “piggy backed” or secondary medications infused into the TPN IV tubing
8. [*] All TPN infusions, IV tubing and central line access are performed using meticulous, strict, aseptic technique
9. [*] TPN kept refrigerated until 30 minutes prior to being infused
10. [*] If TPN infusion is unavailable for any reason, IV solution of Dextrose 10% & Water (D10W) infused until TPN solution available (to prevent rebound hypoglycemia)

Question 5

What kind of tubing is needed to adminster dextrose/amino acid solution?

Answer 5

IV tubing with 0.2 micron filter

Question 6

What are some guidlines to lipid infusion? (2)

Answer 6

1. Lipids can be a separate infusion and does not refrigeration, and can ve admin via PIC
2. Lipids do not need filtered IV tubing and a filter shouldn’t be used.

Question 7

What are should you monitor for during TPN infusion?

Answer 7

1. Signs of hyperglycemia
2. Monitor for possible infection at central access line
3. Monitor for signs/symptoms of infection/sepsis

Question 8

What are things you shouldn’t do with TPN? (4)

Answer 8

1. [*] Don’t store TPN solution at room temp - high glucose concentration and warmth promote bacterial growth
2. [*] Don’t add any medications or anything to TPN bag on unit
3. [*] Do not administer medications as a secondary infusion to the TPN
4. [*] Do not administer other medications through the same central catheter lumen as TPN solution

Question 9

what is the TPN procedure?(4)

Answer 9

1. [*] Examine solution for turbidity, precipitation, cloudiness. Examine container for any holes or cracks. If present, do not use solution
2. [*] Prior to hanging solution:
   [*] RN checks pharmacy label and prescriber order form for:
   [*] Patient name and medical record number or birth date
   [*] Solution contents (every line)
   [*] Expiration date and time
   [*] Signs off parenteral nutrition order
3. [*] Prime IV tubing and hang solution on infusion pump using sterile technique
4. [*] Connect primed needleless tubing to patient’s IV catheter
5. [*] Date and time solutions hung and date and time tubing(s)

Question 10

Preventing infection is No.1 priority with pts with central lines receiving TPN.

What are symptoms of a systematic infection?

Answer 10

1. Fever, shakes, chills,
2. lethargy
3. glucose greater tahn 200 mg/dl
4. Increase WBC

Question 11

What would infection look like at a catheter site? (4)

Answer 11

1. purulent drainage
2. edema
3. erythema
4. tenderness

Question 12

TPN can cause unstable BG.

What would be considered hyperglycemia?
What are causes?
Treatment?

Answer 12

Hyperglycemia is glucose > 200 mg/dl

Causes:
Rapid infusion of TPN
Infection/Sepsis
Medication induced
Co existin diabetes mellitus

Treat by:
Obtain and monitor bg as ordered. Admin regular insulin per sliding scale order.

Question 13

TPN can cause unstable bg.

What would define hypoglycemia?

Causes?

Treatments?

Answer 13

Hypoglycemia : glucose < 60 mg/dl

Causes:
Abrupt decrease in rate
Abrupt discontinuation of TPN

Monitor bg as ordered.
Administer Dextrose 10% and water per order or 50% dextrose solution per prescriber order.

Monitor infusion rate

Question 14

TPN may lead to risk of fluid volume overload.

What do you monitor?

What do you maintain?

Answer 14

Monitor symptoms of fluid volume overload:
Tachycardia, hypotension, distended neck veins, weight gain, crackles on lung auscultation

Maintain strick intake and ouput of liquids, take daily weights

Question 15

TPN may lead to fluid volume deficiet:
Monitor?

Maintain? (How to measure volume)

Answer 15

Decreased urine output, patient verbalized feeling of thrist, decreased skin turgo, tacycardia, orthstatic hypotension

Maintain strict intake and output, daily weights

Question 16

TPN can lead to risk for electrolyte imbalance

Monitor for what?

Maintain?

Answer 16

Monitor: muscle weakness, lethargy, cramps, muscle twitching, cardiac rhythm changes

Monitor any abnomral serum electrolytes levels to prescriber

Question 17

TPN may lead to hypertriglyceridemia (elevated triglycerides) complications:

What precautions steps should be taken? (3)

Answer 17

1. Only infuse lipids as ordered
2. Obtain bseline and weekly serum triglyceride levels or per prescriber orders
3. Use caution when administering medications that are lipd based i.e Propofol