TPNTotal

Parenteral Nutrition

Outlines

• 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 UsesLipid emulsion

TPN by

C.V.P,

internal or external

Jagular Catheter

► Nutritionally complete.

► High hypertonic solution.

► Provide large calories and nutrients need.

► When need 2 wks or more Nutrition

► used in nutritional depleted pt

► Improve tolerance of surgery.

► May interfere with immune mechanisms.

► In pt. with respiratory compromise, reduce co2 build up.

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.

►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

Basic Adult Daily Requirements for Total Parenteral Nutrition

Nutrient Amount

Water (/kg body wt/day)30–40 mL

Energy* (/kg body wt/day)

Medical patient30 kcal

Postoperative patient30–45 kcal

Hypercatabolic patient45–60 kcal

Amino acids (/kg body wt/day)

Medical patient1.0 g

Postoperative patient2.0 g

Hypercatabolic patient3.0 g

Minerals

Vitamins

*Requirements for energy increase by 12% per 1° C of fever.

TPN Content Value

Equipment• 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:

• 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.

• The amount of regular insulin given (added directly to

the TPN solution) depends on the plasma glucose level;

• 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.

MonitoringSuggested 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.

• 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.

DO

• 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.

• Daily Weight.

• Prevent infection, air embolism.

• Maintain fluid & electrolyte balance.

• Encourage ambulation, ADL’s & comfort.

• Educate patient & family.

• NPO stress.

• Dressing change.

Nursing Care, Skills

• No meds backed into TPN

• No blood drawn from TPN port

• Always chart port being used

• Always on Infusion Pump!!!!

• TPN order checked against label, checked by 2

RN’s & signed

• Gradually rate increased when beginning

• When discontinuing- gradual decreasing

Discontinuing Central Line

• 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 Copyright Springhouse Corporation Nov 2001

Provided by ProQuest Information and Learning Provided by ProQuest Information and Learning Company. Company.

• http://findarticles.com/p/articles/mi_qa3689/is_200111/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.