tpn total parenteral nutrition. outlines definition indication. types of parenteral nutrition tpn...
TRANSCRIPT
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.