TPN Inductivo Without Pics

8/3/2019 TPN Inductivo Without Pics

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A N N E C H R I S T I N E R . I N D U C T I V O , R N

TOTAL PARENTERALNUTRITION

ASSOCIATION OF NURSING SERVICEADMINISTRATORSOF THE PHILIPPINES, INC. (ANSAP)

Our Lady of the Pillar Medical Center

in cooperation with


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Justthe facts

y This lecture will help youunderstand anddealwithtotal parenteral nutrition (TPN).

yWe will focus on: howto identify patients who would benefit from TPNwhateach TPN componentis andhow TPN is

delivered

howto recognize & prevent complications associated

with TPN howto care for a patientreceiving TPN, and

the promotion ofnutritional health


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Common components of TPN solutions

ydextrose 50% inwater (D50W)y amino acidsy electrolytesCalciumChlorideMagnesiumPhosphorusPotassiumSodium

y vitaminsFolic acidVitamin B

Vitamin CVitamin DVitamin K

y other additives

AcetateMicronutrientsAmino acids


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Who needs TPN?

y Patients who cant meettheirnutritional needs by oral andenteral feedings mayrequire I.V. nutritional supplement orTPN. Generally, thistreatmentis prescribed for any patient

who cant absorb nutrients from the GI tract for morethan10 days.

y Morespecific indicationsinclude:o debilitating illness lasting longerthan 2 weekso loss of 10% or more of pre-illness weighto serum albumin below 3.5 g/dlo excessivenitrogen loss from woundinfection, fistulas, or

abscesseso renal orhepatic failureo nonfunction ofthe GI tract lasting for 5 to 7 days


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TPN triggers

y Commonillnesses ortreatmentsthat cantriggertheneed for TPNincludeinflammatory bowel disease, ulcerative colitis, bowelobstruction orresection, radiationenteritis, severediarrhea or

vomiting, AIDS, chemotherapy, andsevere pancreatitis, all of whichhinder a patients abilityto absorb nutrients.

y

In addition, patients may benefit from TPN after majorsurgery oriftheyhave a high metabolic ratedueto sepsis, trauma, or burns ofmorethan 40% oftotal bodysurface area.

y Infants with congenital or acquireddisorders mayneed TPN topromote proper growth anddevelopment.

y TPN has limitedvalue for well-nourished patients whose GI tracts

arehealthy or will most likelyresumenormal function within 10days. Thetreatment also may beinappropriate for a patient with apoor prognosis or whentherisks of TPN outweighits benefits.


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Todays TPN trends

y Thetrend oftodaysnutritional supplementationisto individualize TPN formulasdepending onthepatientsspecific needs.

yAs a result, standard TPN mixtures are becomingless popular.

y Nutritional supportteams consisting ofnurses,doctors, pharmacists, anddietitians assess,prescribe for, and monitor patientsreceiving TPN.


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Lipid Emulsions

arethickemulsions ofseveral essential fatty acids

assistin woundhealing, inthe production ofred blood cells,andin prostaglandinsynthesis.

are givenin conjunction with TPN or may be given alonethrough a peripheral or centralvenous line.

should be given cautiouslyin patients with liverdisease,pulmonarydisease, anemia, coagulationdisorders, or anypatient atrisk fordeveloping a fatembolism.

should be avoidedin patients who have conditionsthatdisruptnormal fat metabolism, such as pathologic hyperlipidemia,lipidnephrosis, and acute pancreatitis. Makesureto reportadversereactionsto thedoctorso the TPN regimen may bechanged asneeded.


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Adversereactionsto lipidemulsions

y Immediate orearly adversereactionsto lipidemulsionsinclude: dyspnea cyanosis

nausea orvomiting headache flushing ordiaphoresis lethargy orsyncope

chest and back pain

slight pressure overtheeyes irritation atthesite hypercoagulability thrombocytopenia.


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Adversereactionsto lipidemulsions

y Delayed complications associated with

prolonged administrationinclude:

hepatomegaly splenomegaly

jaundice

blooddyscrasias

fatty liversyndrome


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Parenteral Nutrition

y Administration of Parenteral Nutrition requires aneasily placed, well tolerated centralvenous accessdevice (CVAD) that can beused forextended periods

oftime.y I.V. Nurse Therapists areresponsible forthedaily

care and areheld accountable for preventing andminimizing the manydevice-related complications.


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Howto infuse TPN

y TPN, a hypertonic solution, may beup to sixtimesthe concentration of blood, whichmakesthesolutiontoo irritating for aperipheralvein.

y TPN must beinfusedthrough a centralvein.y TPN may beinfused aroundthe clock or for a

part ofthedayy

Asterile catheter made of polyurethane,polyvinyl chloride, orsiliconerubber (silastic)isinsertedinthesubclavian orjugularvein.


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Why go peripheral?

yA peripherallyinserted central catheter, avariationof centralvenoustherapy, can beused fortherapylasting 3 months or more. The catheterisinsertedthroughthe basilic or cephalicvein andthreaded

so thatthetip liesinthesuperiorvena cava.y The patient generallyexperiences lessdiscomfort

with a peripheral catheter, especiallyifhe canmove aroundeasily. Movementstimulates bloodflow anddecreasestherisk of phlebitis.

y Peripherallyinserted central catheters are fastbecoming the preferred choice forintermediate-term therapy, both athome andinthehospital.


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Complications

y Signs andsymptoms ofelectrolyteimbalances caused by TPNadministrationinclude abdominal cramps, lethargy, confusion,malaise, muscle weakness, tetany, convulsions, and cardiacarrhythmias. Acid-baseimbalances can also occurdueto thepatients condition orthe TPN content. Look forthese othercomplications:

y congestive heart failure (CHF) or pulmonaryedema, both of whichmay occur from fluid andelectrolyte administration and can leadtotachycardia, lethargy, confusion, weakness, and labored breathing

y hyperglycemia as a result ofdextroseinfusing too quickly, aconditionthat mayrequire an adjustmentinthe patientsinsulindosage

y adversereactionsto medications addedto TPN forexample,addedinsulin can causehypoglycemia, which canresultinconfusion, restlessness, lethargy, pallor, andtachycardia.


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Nurses Duties and Responsibilitiesin Parenteral Nutrition

Constant assessment andrapidinterventionare critical for patientsreceiving TPN. Whencaring for a patient on TPN, youll wanttotakethese actions:


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Assess and monitor

y Carefully monitor patientsreceiving TPN to detectearlysigns of complications, such as metabolic problems, CHF,pulmonaryedema, or allergic reactions. Adjustthe TPNregimen asneeded.

y Assessthe patientsnutritional status, and weighthepatient atthesametimeeach morning afterhevoids, insimilar clothing, and onthesamescale. Weight gain mayindicate fluid overload. A patientshouldnt gain morethan3 lb (1.4 kg) a week.

y Assess for peripheral and pulmonaryedema.

y Monitorserum glucose levelsevery 6 hoursinitially, thenonce a day. Stay alert forsigns ofthirst and polyuria,symptoms ofhyperglycemia. Periodically confirm serumglucose meterreadings with laboratorytests.


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Assess and monitor

y Monitor forsigns andsymptoms of glucose metabolismdisturbance, fluid andelectrolyteimbalances, andnutritional problems. Some patients mayrequireinsulinaddeddirectlyto the TPN fortheduration oftreatment.

y Monitorelectrolyte and protein levelsdaily at first, andthentwice a week forserum albumin. Albumin levels maydrop initially astreatmentrestoreshydration.

y Checkrenal function by monitoring BUN and creatininelevels; increases mayindicateexcess amino acidintake.

y Assessnitrogen balance with 24-hoururine collection.y Assess liver function with liver functiontests, bilirubin,

triglyceride, and cholesterol levels. Abnormalvalues mayindicateintolerance.


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Assess and monitor

y In mostinstitutions, central lines andperipherallyinserted central cathetersrequirean order and a patient-consent form. Only anRN specializing ininserting those linesshouldobtainthe form. (SeeTeaching aboutTPN.) Teaching about TPN

Besureto coverthesetopics with your patientto evaluatehis learning: explanation of TPN anditsspecific use forthe patient adversereactions or catheter complications and whento reportthem basic care of a TPN line maintenance ofequipment.

y Obtain a chest X-rayto checkthe catheterplacement afterinsertion.


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Infuse properly

y Reviewthe patientsserum chemistry andnutritionalstudies, and alertthedoctor of abnormal results, whichmayindicatethatthe TPN fluid concentration oringredients mayneedto be adjustedto meetthe patientsspecific needs.

y Avoid an adversereaction bystarting TPN slowly about1,000 calories over 24 hours andincreasing gradually.Continually monitorthe patients cardiac andrespiratorystatus. When a patientisseverely malnourished, startingTPN maysparkrefeeding syndrome, whichincludes a rapid

drop in potassium, magnesium, and phosphorus levels. Toavoid compromising cardiac function, initiate feedingslowly and monitorthe patientselectrolyte levels closelyuntil theystabilize.


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Infuse properly

y Becausethe TPN solutionishighin glucose, starttheinfusionslowly. Doing so will allowthe patients pancreatic

beta cellsto adaptto the glucose byincreasing insulinoutput. Withinthe first 3 to 5 days of TPN, thetypical adultcantolerate about 3 L ofsolution a day withoutsuffering an

adversereaction.y Occasionally a patient mayreact adverselyto specific

ingredientsinthe TPN solution. Protein mayneedto bereducedif BUN and creatinine levels areelevated.

y Alertthedoctorif TPN needsto bestopped and glucose

given orally or I.V. The patientsdiagnosis and pre-existingphysical conditionneedto be considered whendeterminingthe composition and amount ofelectrolytesused fortheTPN solution.


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Setup

y Use aninfusion pump forrate control.y Flush central lines according to protocol.y Ifusing a single-lumen centralvenous line, dont

usethe line for blood and blood products, or give abolusinjection, administersimultaneous I.V.solutions, measurethe centralvenous pressure, ordraw blood for lab tests

y Never add medicationsto a TPN solution

container. Dontuse a three-waystopcockunlessabsolutelynecessary; add-ondevicesincreasetherisk ofinfection.

y Explaintheinsertion procedureto the patient.


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Monitorduring theinfusion

y Recordvital signs at leastevery 4 hours.Temperatureelevationis one oftheearliestsignsof catheter-relatedsepsis.

yAssessthe patientdaily. Measure armcircumference andskinfold thickness overthetriceps, if ordered.

y Perform site care anddressing changes at least

threetimes a week (once a week fortransparentsemipermeable dressings), or wheneverthedressing becomes wet, soiled, ornonocclusive. Usestrict aseptic technique.


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yMonitor for anddocumentsigns ofinflammation andinfection.Documenting TPNWhendocumenting about TPN, youll wantto include

these points:

adversereactions or catheter complications

signs ofinflammation orinfection at I.V. site

nursing interventions andthe patientsresponsetime anddate of administrationset changes

specific dietaryintake.


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y Changethe I.V. administrationset according toyour facilitys policy, and alwaysuse aseptictechnique. Changes of I.V. administrationsets are

usuallydoneevery 24 hours for TPN.y Do not allow TPN solutionsto hang for morethan

24 hours.

y The TPN solutionshould be clear. If yousee

particulate matter, cloudiness, or an oily layerinthe bag when preparing to hang a TPN solution,returnthe bag to the pharmacy.


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Followup

y Provideemotional support, especiallyifeating isrestricteddueto the patients condition.provide frequent mouth care.

yWhile weaning the patient from TPN, documenthisdietaryintake andtotal calorie and proteinintake. Use percentages whenrecording foodintake.


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Followup

yWhendiscontinuing TPN, decreasetheinfusionslowly, depending on current glucoseintake.Slowlydecreasing theinfusion minimizestheriskofhyperinsulinemia andresulting hypoglycemia.

Weaning usuallytakes place over 24 to 48 hoursbut can be completedin 4 to 6 hoursifthe patientreceivessufficient oral or I.V. carbohydrates.

y Report any adversereactionsto thedoctorpromptly.

y Prepare your patient forhome care.yAccuratelydocument all aspects of care, according

to your facilitys policy.


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QuickQuiz

1. The patient most likelyto benefit fromTPN is:

A. a well-nourished patient whose GI tractwill resumenormal function within 10days

B. a patient with a chronic, intractable

conditionC. a patient with a nonfunctioning GI tract

lasting 5 to 7 days


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QuickQuiz

2. When a severely malnourished patientstartsreceiving TPN, his lab testsshowa rapiddrop in potassium, magnesium,

and phosphorus levels. The findingsindicate:

A. fluidshock

B. refeeding syndromeC. hypovolemia


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QuickQuiz

3. Thetype of I.V. catheterrecommended forTPN expectedto last months or yearsisthe:

A. silastic catheter

B. polyvinyl chloride catheter

C. metal-winged catheter


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QuickQuiz

4. When preparing to hang a TPNsolution, yousee an oily layerinthebag. Youshould:

A. gently agitatethesolutionto dispersethecontents.

B. hang thesolution; the oily layer willdisperseintime.

C. returnthesolutionto the pharmacy


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QuickQuiz

5. Site care anddressing changes for apatient with TPN should be

performed at least:A. once a week

B. threetimes a week

C. everyday


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QuickQuiz

6. Infusions of lipidemulsions areuseful for promoting:

A. wound cleaning

B. coagulationin bleeding disorders.

C. a reductionininflammation frompancreatitis.


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QuickQuiz

7. Thetip of a peripherallyinsertedcentral catheterisusually placedinthe:

A. right atriumB. internaljugularvein

C. superiorvena cava


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