{"id":3715,"date":"2015-06-22T23:26:58","date_gmt":"2015-06-22T23:26:58","guid":{"rendered":"http:\/\/opentextbc.ca\/clinicalskills\/?post_type=chapter&#038;p=3715"},"modified":"2021-05-20T22:05:43","modified_gmt":"2021-05-20T22:05:43","slug":"8-8","status":"publish","type":"chapter","link":"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/8-8\/","title":{"raw":"8.8 Total Parenteral Nutrition (TPN)","rendered":"8.8 Total Parenteral Nutrition (TPN)"},"content":{"raw":"<strong>Total parenteral nutrition (TPN)<\/strong>, also known as\u00a0parenteral nutrition (PN) is a form of nutritional support given completely via the bloodstream, intravenously with an IV pump. TPN administers proteins, carbohydrates, fats, vitamins, and minerals. It aims to prevent and restore nutritional deficits, allowing bowel rest while supplying adequate caloric intake and essential nutrients, and removing antigenic mucosal stimuli (Perry et al., 2014).\r\n\r\nTPN may be short-term or long-term nutritional therapy, and may be administered on acute medical floors as well as in critical care areas. The caloric requirements of each patient are individualized according to the degree of stress, organ failure, and percentage of ideal body weight.\u00a0TPN is used with patients who cannot orally ingest or digest nutrition (Triantafillidis &amp; Papalois, 2014). TPN may be administered as peripheral parenteral nutrition (PPN) or via a central line, depending on the components and osmolality. Central veins are usually the veins of choice because there is less\u00a0risk of thrombophlebitis and vessel damage (Chowdary &amp; Reddy, 2010). According to\u00a0Chowdary &amp; Reddy (2010), candidates for TPN are:\r\n<ul class=\"unordered\">\r\n \t<li>\r\n<div>Patients with paralyzed or nonfunctional GI tract, or conditions that require bowel rest, such as small bowel obstruction, ulcerative colitis, or pancreatitis<\/div><\/li>\r\n \t<li>\r\n<div>Patients who have had\u00a0nothing by mouth (NPO) for seven\u00a0days or longer<\/div><\/li>\r\n \t<li>Critically ill patients<\/li>\r\n \t<li>\r\n<div>Babies with an immature gastrointestinal system or congenital malformations<\/div><\/li>\r\n \t<li>Patients with chronic or extreme malnutrition, or chronic diarrhea or vomiting with a need for surgery or chemotherapy<\/li>\r\n \t<li>Patients in hyperbolic states, such as burns, sepsis, or trauma<\/li>\r\n<\/ul>\r\nTPN is made up of two components: amino acid\/dextrose solution and a lipid emulsion solution (see Figure 8.9). It is ordered by a physician, in consultation with a dietitian, depending on the patient's metabolic needs, clinical history, and blood work. The amino acid\/dextrose solution is usually in a large volume bag (1,000 to 2,000 ml), and can be standard or custom-made. It is often yellow in colour due to the multivitamins it contains. The ingredients listed on the bag must be confirmed by the health care provider hanging the IV bag.\u00a0The solution may also include medication, such as insulin and heparin. The amino acid\/dextrose solution is reviewed and adjusted each day based on the patient's blood work. Lipid emulsions are prepared in 100 to\u00a0250 ml bags or glass bottles and contain the essential fatty acids that are milky in appearance. At times, the lipid emulsion may be added to the amino acid\/dextrose solution. It is then called<em> 3 in 1<\/em> or <em>total nutrition admixture<\/em> (Perry et al., 2014).\r\n\r\nTPN is prepared by a pharmacy, where the calories are calculated\u00a0using a formula, and is usually mixed for a 24-hour continuous infusion to prevent vascular trauma and metabolic instability (North York Hospital, 2013).\u00a0TPN\u00a0orders should be reviewed each day, so that changes in electrolytes or\u00a0the acid-base balance can be addressed appropriately without wasting costly TPN solutions (Chowdary &amp; Reddy, 2010).\r\n\r\n[caption id=\"attachment_6806\" align=\"aligncenter\" width=\"300\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-060.jpg\"><img class=\"wp-image-6806 size-medium\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-060-300x300.jpg\" alt=\"Oct 2, 2015 060\" width=\"300\" height=\"300\" \/><\/a> Figure 8.9 Types of TPN (amino acids and lipids)[\/caption]\r\n\r\n[caption id=\"attachment_6807\" align=\"aligncenter\" width=\"300\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061.jpg\"><img class=\"size-medium wp-image-6807\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061-300x80.jpg\" alt=\"TPN tubing with special filter\" width=\"300\" height=\"80\" \/><\/a> Figure 8.10 TPN tubing with special filter[\/caption]\r\n\r\nTPN is not compatible with any other type of IV solution or medication and must be administered by itself. TPN must be administered using an EID (IV pump), and requires special IV filter tubing (see Figure 8.10) for the amino acids and lipid emulsion to reduce the risk of particles entering the patient. Agency policy may allow amino acids and lipid emulsions to be infused together above the filters. TPN tubing will not have any access ports and must be changed according to agency policy. Always review agency policy on setup and equipment required to infuse TPN.\r\n\r\nA physician may order a total fluid intake (TFI) for the amount of fluid to be infused per hour to prevent fluid overload in patients receiving TPN. It is important to keep track of all the fluids infusing (IV fluids, IV medications, and TPN) in order to avoid fluid overload (Perry et al., 2014).\u00a0Do not abruptly discontinue TPN (especially in patients who are on insulin) because this may lead to hypoglycemia. If for whatever reason the TPN solution runs out while awaiting another bag, hang D5W at the same rate of infusion while waiting for the new TPN bag to arrive (North York Hospital, 2013). Do not obtain blood samples or central venous pressure readings from the\u00a0same port as TPN infusions.\u00a0To prevent severe electrolyte and other metabolic abnormalities, the infusion rate of TPN is increased gradually, starting at a rate of no more than 50% of the energy requirements (Mehanna, Nankivell, Moledina, &amp; Travis, 2009).\r\n<h2>Complications Related to TPN<\/h2>\r\nThere are many complications related to the administration of TPN (Perry et al., 2014). Table 8.8 lists potential complications, rationale, and interventions.\r\n<table style=\"height: 571px;\" border=\"1px solid rgb(0, 0, 0)\" width=\"100%\"><caption>Table 8.8 TPN Complications, Rationale, and Interventions<\/caption>\r\n<tbody>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">\r\n<p style=\"text-align: center;\"><b>Complication<\/b><\/p>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">\r\n<p style=\"text-align: center;\"><strong>\u00a0Rationale and Interventions<\/strong><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Catheter-related bloodstream infection (CR-BSI), also known as sepsis<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">CR-BSI, which starts at the hub connection, is the spread of bacteria through the bloodstream. There's an increased risk of CR-BSI with TPN, due to the high dextrose concentration of TPN. Symptoms include tachycardia, hypotension, elevated or decreased temperature, increased breathing, decreased urine output, and disorientation.\r\n\r\nInterventions: Strict adherence to aseptic technique with insertion, care, and maintenance; avoid hyperglycemia to prevent infection complications; closely monitor vital signs and temperature. IV antibiotic therapy is required. Monitor white blood cell count and patient for malaise. Replace IV tubing frequently as per agency policy (usually every 24 hours).<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Localized infection at exit or entry site<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Due to poor aseptic technique during insertion, care, or maintenance of central line or peripheral line\r\n\r\nInterventions: Apply strict aseptic technique during insertion, care, and maintenance. Frequently assess CVC site for redness, tenderness, or drainage. Notify health care provider of any signs and symptoms of infection.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Pneumothorax<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">A pneumothorax occurs when the tip of the catheter enters the pleural space during insertion, causing the lung to collapse. Symptoms include sudden chest pain, difficulty breathing, decreased breath sounds, cessation of normal chest movement on affected side, and\u00a0tachycardia.\r\n\r\nInterventions: Apply oxygen, notify physician. Patient will require removal of central line and possible chest tube insertion.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Air embolism<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">An air embolism may occur if IV tubing disconnects and is open to air, or if part of catheter system is open or removed without being clamped. Symptoms include sudden respiratory distress, decreased oxygen saturation levels, shortness of breath, coughing, chest pain, and decreased blood pressure.\r\n\r\nInterventions: Make sure all connections are clamped and closed. Clamp catheter, position patient in left Trendelenburg position, call health care provider, and administer oxygen as needed.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Hyperglycemia<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Related to sudden increase in glucose after recent malnourished state.\u00a0After starvation, glucose intake suppresses gluconeogenesis by leading to the release of insulin and the suppression of glycogen. Excessive glucose may lead to hyperglycemia, with osmotic diuresis, dehydration, metabolic acidosis, and ketoacidosis. Excess glucose also leads to lipogenesis (again caused by insulin stimulation). This may cause fatty liver, increased CO<sub>2<\/sub> production, hypercapnea, and respiratory failure.\r\n\r\nInterventions: Monitor blood sugar frequently QID (four times per day), then less frequently when blood sugars are stable. Follow agency policy for glucose monitoring with TPN. Be alert to changes in dextrose levels in amino acids and the addition\/removal of insulin to TPN solution.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Refeeding syndrome<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\"><strong>Refeeding syndrome<\/strong> is caused by rapid refeeding after a period of malnutrition, which leads to metabolic and hormonal changes characterized by electrolyte shifts (decreased phosphate, magnesium, and potassium in serum levels) that may lead to widespread cellular dysfunction. Phosphorus, potassium, magnesium, glucose, vitamin, sodium, nitrogen, and fluid imbalances can be life-threatening.\u00a0High-risk patients include the chronically undernourished and those with little intake for more than 10 days. Patients with dysphagia are at higher risk. The syndrome usually occurs 24 to 48 hours after refeeding has started. The shift of water, glucose, potassium, phosphate, and magnesium back into the cells may lead to muscle weakness, respiratory failure, paralysis, coma, cranial nerve palsies, and rebound hypoglycemia.\r\n\r\nInterventions: Rate of TPN should be based on the severity of undernourishment for moderate- to high-risk patients. TPN should be initiated slowly\u00a0and titrated up for four to seven\u00a0days. All patients require close monitoring of electrolytes (daily for one week, then usually three times\/week). Always follow agency policy. Blood work may be more frequent depending on the severity of the malnourishment.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Fluid excess or pulmonary edema<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Signs and symptoms include fine crackles in lower lung fields or throughout lung fields, hypoxia (decreased\u00a0O<sub>2<\/sub> sats).\r\n\r\nInterventions: Notify primary health care provider regarding change in condition. Patient may require IV medication, such as Lasix to remove excess fluids. A decrease or discontinuation of IV fluids may also occur. Raise head of bed to enhance breathing and apply O<sub>2<\/sub> for oxygen saturation less than 92% or as per agency protocol. Monitor intake and output. Pulmonary edema may be more common in the elderly, young, and patients with renal or cardiac conditions.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Data source:\u00a0Chowdary &amp; Reddy, 2010; Mehanna et al., 2009;\u00a0O'Connor, Hanly, Francis, Keane, &amp; McNamara, 2013; Perry et al., 2014<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nA patient on TPN must have blood work monitored closely to prevent the complications of refeeding syndrome. Blood work may be ordered as often as every six hours upon initiation of TPN. Most hospitals will have a TPN protocol to follow for blood work. Common blood work includes CBC (complete blood count), electrolytes (with special attention to magnesium, potassium, and phosphate), liver enzymes (total and direct bilirubin, alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase [ALP], gamma-glutamyl transferase [GGT], total protein, albumin), and renal function tests (creatinine and urea). Compare daily values to baseline values, and investigate and report any rapid changes in any values (Chowdary &amp; Reddy, 2010; Perry et al., 2014).\u00a0Table 8.9 outlines a plan of care when a patient is receiving TPN.\r\n<a id=\"table8.9\"><\/a>\r\n<table style=\"height: 571px;\" border=\"1px solid rgb(0, 0, 0)\" width=\"100%\"><caption>Table 8.9 Assessment of a Patient with TPN<\/caption>\r\n<tbody>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">\r\n<p style=\"text-align: center;\"><b>Assessment<\/b><\/p>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">\r\n<p style=\"text-align: center;\"><strong>\u00a0Additional Information<\/strong><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">CVC\/peripheral IV line<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Intravenous line should remain patent, free from infection.\r\n\r\nDextrose in TPN increases risk of infection. Assess for signs and symptoms of infections at site (redness, tenderness, discharge) and systemically (fever, increased WBC, malaise). Dressing should be dry and intact.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Daily or biweekly weights<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Monitor for evidence of edema or fluid overload.\u00a0Over time, measurements will reflect weight loss\/gain from caloric intake or fluid retention.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Capillary or serum blood glucose levels<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">QID (4 times a day) capillary blood glucose initially to monitor glycemic control, then reduce monitoring when blood sugars are stable or as per agency policy. May be done more frequently if glycemic control is difficult. Indicates metabolic tolerance to dextrose in TPN solution and patient\u2019s glycemic status.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Monitor intake and output<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Monitor and record every eight\u00a0hours or as per agency policy. Monitor for signs and symptoms of fluid overload (excessive weight gain) by completing a cardiovascular and respiratory assessment. Assess intakes such as IV (intravenous fluids), PO (oral intake), NG (nasogastric tube feeds).\u00a0Assess outputs:\u00a0NG (removed gastric content through the nasogastic tube), fistula drainage, BM (liquid bowel movements), colostomy\/ileostomy drainage, closed suction drainage devices (Penrose or Jackson-Pratt drainage) and chest tube drainage.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Daily to weekly blood work<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Review lab values for increases and decreases out of normal range. Lab values include CBC, electrolytes,\u00a0calcium, magnesium, phosphorus, potassium, glucose, albumin, BUN (blood urea nitrogen), creatinine, triglycerides, and transferrin.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Mouth care<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Most patients will be NPO. Proper oral care is required as per agency policy. Some patients may have a diet order.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Vital signs<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Vital signs are more frequently monitored initially in patients with TPN.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Data source: BCIT, 2015a; Perry et al., 2014<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nTPN may be administered in the hospital or in a\u00a0home setting. Generally, patients receiving TPN are quite ill and may require a lengthy stay in the hospital. The administration of TPN must follow strict adherence to aseptic technique, and includes being alert for complications, as many of the patients will have altered defence mechanisms and complex conditions (Perry et al., 2014). To administer TPN, follow the steps in Checklist 76.\r\n<table style=\"border-color: #000000; width: 100%;\" border=\"1px solid rgb(0, 0, 0)\"><caption><a id=\"checklist76\"><\/a>Checklist 76: TPN Administration<\/caption>\r\n<tbody>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 75px; text-align: center;\" colspan=\"4\">\r\n<h5 style=\"text-align: center;\"><span style=\"color: #000000;\">Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 75px;\" colspan=\"4\">\r\n<h5><span style=\"color: #333333;\">Safety considerations:\u00a0<\/span><\/h5>\r\n<ul>\r\n \t<li>Compare the patient\u2019s baseline vital signs; electrolyte, glucose, and triglyceride levels; weight; and fluid intake and output with treatment values, and investigate any rapid change in such values.<\/li>\r\n \t<li>To identify signs of infection early, be aware of the patient\u2019s recent temperature range.<\/li>\r\n \t<li>Use strict aseptic technique when caring for central venous catheters and PICC lines.<\/li>\r\n \t<li>Do not use TPN solution if it has coalesced, as evidenced by formation of a thick, dense layer of fat droplets on its surface. If the solution appears abnormal in any way, request a replacement from the pharmacy.<\/li>\r\n \t<li>Never try to catch up with a delayed infusion.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 250px; text-align: center;\" colspan=\"2\">\r\n<h4 style=\"text-align: center;\">Steps<\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000; width: 250px; text-align: center;\" colspan=\"2\">\r\n<h4 style=\"text-align: center;\">\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">1. Review physician's orders and compare to MAR and content label on TPN solution bag and for rate of infusion. Each component of the TPN solution must be verified with the physician's orders.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">Check date and time of last TPN tubing change,\u00a0lab values, and expiry date of TPN to\u00a0prevent medication error.\r\n\r\nAssess CVC, WBC, and patient for malaise.\r\n\r\nMedications may be added to the TPN.\r\n\r\nEnsure the rate of infusion is verified in the doctor\u2019s order each time new TPN bag is initiated.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">2. Collect supplies, prepare TPN solution, and prime IV tubing with filter as per agency protocol. TPN requires special IV\u00a0tubing with a filter.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">Generally, new TPN tubing is required every 24 hours to prevent catheter-related bacteremia. Follow agency policy.\r\n\r\nEnsure tubing is primed correctly to prevent air embolism.\r\n\r\n[caption id=\"attachment_6807\" align=\"aligncenter\" width=\"206\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061.jpg\"><img class=\" wp-image-6807\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061-300x80.jpg\" alt=\"TPN tubing with special filter\" width=\"206\" height=\"55\" \/><\/a> TPN tubing with special filter[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">3. &lt;a href=\"\/clinicalskills\/chapter\/1-6-hand-hygiene\/\"&gt;Perform hand hygiene, identify yourself, and identify patient using two patient identifiers. Compare the MAR to the patient's wristband. Explain the procedure to the patient.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">Hand hygiene prevents the spread of microorganisms.\r\n\r\nProper identification prevents patient errors.\r\n\r\n[caption id=\"attachment_6460\" align=\"aligncenter\" width=\"212\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-029.jpg\"><img class=\"wp-image-6460\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-029-300x163.jpg\" alt=\"Identify patient with two identifiers\" width=\"212\" height=\"115\" \/><\/a> Compare MAR to patient wristband[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">4.\u00a0Complete all safety checks for CVC as per agency policy.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">This adheres to safety policies related to central line care.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">5. If changing TPN solution, pause EID and remove old TPN administration set. Disinfect connections and change IV tubing as per agency policy.\r\n\r\nIf starting TPN for the first time, flush and disinfect CVC lumens as per agency policy.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">Change TPN IV tubing as per agency policy. Use strict aseptic technique with IV changes as patients with high dextrose solutions are at greater risk of developing infections.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">6. Insert new TPN solution and IV tubing into EID.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">EID must be used with all TPN administration.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">7. Start TPN infusion rate as per physician orders.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">Prevents medication errors.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">8. Discard old supplies as per agency protocol, and perform hand hygiene.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">These steps prevent the spread of microorganisms.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">9. Monitor for signs and symptoms of complications related to TPN.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">See Table 8.8 for list of complications related to TPN.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">10. Complete daily assessments and monitoring for patient on TPN as per agency policy.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">See daily and weekly assessments in Table 8.9. Flow rate may be monitored hourly.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">11. Document the procedure in the patient chart as per agency policy.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">Note time when TPN bag is hung, number of bags, and rate of infusion, assessment of CVC site and verification of patency, status of dressing, vital signs and weight, client tolerance to TPN, client response to therapy, and understanding of instructions.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"4\">Data source: North York Hospital, 2013; Perry et al., 2014<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<div class=\"textbox textbox--exercises\"><header class=\"textbox__header\">\r\n<p class=\"textbox__title\">Critical Thinking Exercises<\/p>\r\n\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n<ol>\r\n \t<li>Describe refeeding syndrome and state one method to reduce the risk of refeeding syndrome.<\/li>\r\n \t<li>A patient receiving TPN for the past 48 hours has developed malaise and hypotension. What potential complication are these signs and symptoms related to?<\/li>\r\n<\/ol>\r\n<\/div>\r\n<\/div>\r\n<h1>Additional Videos<\/h1>\r\n<h3><a id=\"video8.7\"><\/a>Video 8.7<\/h3>\r\n<div class=\"textbox shaded\" style=\"text-align: center;\">Watch a video\u00a0<a href=\"https:\/\/barabus.tru.ca\/nursing\/cvad_with_valves.html\"><em>CVAD Care and Maintenance\u2014Lumens with Valves<\/em><\/a>\u00a0by\u00a0<a href=\"\/clinicalskills\/back-matter\/appendix-3\/\">Ren\u00e9e Anderson &amp; Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\r\n<h3><a id=\"video8.8\"><\/a>Video 8.8<\/h3>\r\n<div class=\"textbox shaded\" style=\"text-align: center;\">Watch a video\u00a0<a href=\"https:\/\/barabus.tru.ca\/nursing\/cvad_without_valves.html\"><em>CVAD Care and Maintenance\u2014Lumens without Valves<\/em><\/a>\u00a0by\u00a0<a href=\"\/clinicalskills\/back-matter\/appendix-3\/\">Ren\u00e9e Anderson &amp; Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>","rendered":"<p><strong>Total parenteral nutrition (TPN)<\/strong>, also known as\u00a0parenteral nutrition (PN) is a form of nutritional support given completely via the bloodstream, intravenously with an IV pump. TPN administers proteins, carbohydrates, fats, vitamins, and minerals. It aims to prevent and restore nutritional deficits, allowing bowel rest while supplying adequate caloric intake and essential nutrients, and removing antigenic mucosal stimuli (Perry et al., 2014).<\/p>\n<p>TPN may be short-term or long-term nutritional therapy, and may be administered on acute medical floors as well as in critical care areas. The caloric requirements of each patient are individualized according to the degree of stress, organ failure, and percentage of ideal body weight.\u00a0TPN is used with patients who cannot orally ingest or digest nutrition (Triantafillidis &amp; Papalois, 2014). TPN may be administered as peripheral parenteral nutrition (PPN) or via a central line, depending on the components and osmolality. Central veins are usually the veins of choice because there is less\u00a0risk of thrombophlebitis and vessel damage (Chowdary &amp; Reddy, 2010). According to\u00a0Chowdary &amp; Reddy (2010), candidates for TPN are:<\/p>\n<ul class=\"unordered\">\n<li>\n<div>Patients with paralyzed or nonfunctional GI tract, or conditions that require bowel rest, such as small bowel obstruction, ulcerative colitis, or pancreatitis<\/div>\n<\/li>\n<li>\n<div>Patients who have had\u00a0nothing by mouth (NPO) for seven\u00a0days or longer<\/div>\n<\/li>\n<li>Critically ill patients<\/li>\n<li>\n<div>Babies with an immature gastrointestinal system or congenital malformations<\/div>\n<\/li>\n<li>Patients with chronic or extreme malnutrition, or chronic diarrhea or vomiting with a need for surgery or chemotherapy<\/li>\n<li>Patients in hyperbolic states, such as burns, sepsis, or trauma<\/li>\n<\/ul>\n<p>TPN is made up of two components: amino acid\/dextrose solution and a lipid emulsion solution (see Figure 8.9). It is ordered by a physician, in consultation with a dietitian, depending on the patient&#8217;s metabolic needs, clinical history, and blood work. The amino acid\/dextrose solution is usually in a large volume bag (1,000 to 2,000 ml), and can be standard or custom-made. It is often yellow in colour due to the multivitamins it contains. The ingredients listed on the bag must be confirmed by the health care provider hanging the IV bag.\u00a0The solution may also include medication, such as insulin and heparin. The amino acid\/dextrose solution is reviewed and adjusted each day based on the patient&#8217;s blood work. Lipid emulsions are prepared in 100 to\u00a0250 ml bags or glass bottles and contain the essential fatty acids that are milky in appearance. At times, the lipid emulsion may be added to the amino acid\/dextrose solution. It is then called<em> 3 in 1<\/em> or <em>total nutrition admixture<\/em> (Perry et al., 2014).<\/p>\n<p>TPN is prepared by a pharmacy, where the calories are calculated\u00a0using a formula, and is usually mixed for a 24-hour continuous infusion to prevent vascular trauma and metabolic instability (North York Hospital, 2013).\u00a0TPN\u00a0orders should be reviewed each day, so that changes in electrolytes or\u00a0the acid-base balance can be addressed appropriately without wasting costly TPN solutions (Chowdary &amp; Reddy, 2010).<\/p>\n<figure id=\"attachment_6806\" aria-describedby=\"caption-attachment-6806\" style=\"width: 300px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-060.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6806 size-medium\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-060-300x300.jpg\" alt=\"Oct 2, 2015 060\" width=\"300\" height=\"300\" srcset=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-060-300x300.jpg 300w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-060-150x150.jpg 150w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-060-65x65.jpg 65w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-060-225x225.jpg 225w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-060-350x350.jpg 350w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-060.jpg 1024w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-6806\" class=\"wp-caption-text\">Figure 8.9 Types of TPN (amino acids and lipids)<\/figcaption><\/figure>\n<figure id=\"attachment_6807\" aria-describedby=\"caption-attachment-6807\" style=\"width: 300px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6807\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061-300x80.jpg\" alt=\"TPN tubing with special filter\" width=\"300\" height=\"80\" srcset=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061-300x80.jpg 300w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061.jpg 1024w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061-65x17.jpg 65w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061-225x60.jpg 225w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061-350x93.jpg 350w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-6807\" class=\"wp-caption-text\">Figure 8.10 TPN tubing with special filter<\/figcaption><\/figure>\n<p>TPN is not compatible with any other type of IV solution or medication and must be administered by itself. TPN must be administered using an EID (IV pump), and requires special IV filter tubing (see Figure 8.10) for the amino acids and lipid emulsion to reduce the risk of particles entering the patient. Agency policy may allow amino acids and lipid emulsions to be infused together above the filters. TPN tubing will not have any access ports and must be changed according to agency policy. Always review agency policy on setup and equipment required to infuse TPN.<\/p>\n<p>A physician may order a total fluid intake (TFI) for the amount of fluid to be infused per hour to prevent fluid overload in patients receiving TPN. It is important to keep track of all the fluids infusing (IV fluids, IV medications, and TPN) in order to avoid fluid overload (Perry et al., 2014).\u00a0Do not abruptly discontinue TPN (especially in patients who are on insulin) because this may lead to hypoglycemia. If for whatever reason the TPN solution runs out while awaiting another bag, hang D5W at the same rate of infusion while waiting for the new TPN bag to arrive (North York Hospital, 2013). Do not obtain blood samples or central venous pressure readings from the\u00a0same port as TPN infusions.\u00a0To prevent severe electrolyte and other metabolic abnormalities, the infusion rate of TPN is increased gradually, starting at a rate of no more than 50% of the energy requirements (Mehanna, Nankivell, Moledina, &amp; Travis, 2009).<\/p>\n<h2>Complications Related to TPN<\/h2>\n<p>There are many complications related to the administration of TPN (Perry et al., 2014). Table 8.8 lists potential complications, rationale, and interventions.<\/p>\n<table style=\"height: 571px; width: 100%;\">\n<caption>Table 8.8 TPN Complications, Rationale, and Interventions<\/caption>\n<tbody>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">\n<p style=\"text-align: center;\"><b>Complication<\/b><\/p>\n<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">\n<p style=\"text-align: center;\"><strong>\u00a0Rationale and Interventions<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Catheter-related bloodstream infection (CR-BSI), also known as sepsis<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">CR-BSI, which starts at the hub connection, is the spread of bacteria through the bloodstream. There&#8217;s an increased risk of CR-BSI with TPN, due to the high dextrose concentration of TPN. Symptoms include tachycardia, hypotension, elevated or decreased temperature, increased breathing, decreased urine output, and disorientation.<\/p>\n<p>Interventions: Strict adherence to aseptic technique with insertion, care, and maintenance; avoid hyperglycemia to prevent infection complications; closely monitor vital signs and temperature. IV antibiotic therapy is required. Monitor white blood cell count and patient for malaise. Replace IV tubing frequently as per agency policy (usually every 24 hours).<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Localized infection at exit or entry site<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Due to poor aseptic technique during insertion, care, or maintenance of central line or peripheral line<\/p>\n<p>Interventions: Apply strict aseptic technique during insertion, care, and maintenance. Frequently assess CVC site for redness, tenderness, or drainage. Notify health care provider of any signs and symptoms of infection.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Pneumothorax<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">A pneumothorax occurs when the tip of the catheter enters the pleural space during insertion, causing the lung to collapse. Symptoms include sudden chest pain, difficulty breathing, decreased breath sounds, cessation of normal chest movement on affected side, and\u00a0tachycardia.<\/p>\n<p>Interventions: Apply oxygen, notify physician. Patient will require removal of central line and possible chest tube insertion.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Air embolism<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">An air embolism may occur if IV tubing disconnects and is open to air, or if part of catheter system is open or removed without being clamped. Symptoms include sudden respiratory distress, decreased oxygen saturation levels, shortness of breath, coughing, chest pain, and decreased blood pressure.<\/p>\n<p>Interventions: Make sure all connections are clamped and closed. Clamp catheter, position patient in left Trendelenburg position, call health care provider, and administer oxygen as needed.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Hyperglycemia<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Related to sudden increase in glucose after recent malnourished state.\u00a0After starvation, glucose intake suppresses gluconeogenesis by leading to the release of insulin and the suppression of glycogen. Excessive glucose may lead to hyperglycemia, with osmotic diuresis, dehydration, metabolic acidosis, and ketoacidosis. Excess glucose also leads to lipogenesis (again caused by insulin stimulation). This may cause fatty liver, increased CO<sub>2<\/sub> production, hypercapnea, and respiratory failure.<\/p>\n<p>Interventions: Monitor blood sugar frequently QID (four times per day), then less frequently when blood sugars are stable. Follow agency policy for glucose monitoring with TPN. Be alert to changes in dextrose levels in amino acids and the addition\/removal of insulin to TPN solution.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Refeeding syndrome<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\"><strong>Refeeding syndrome<\/strong> is caused by rapid refeeding after a period of malnutrition, which leads to metabolic and hormonal changes characterized by electrolyte shifts (decreased phosphate, magnesium, and potassium in serum levels) that may lead to widespread cellular dysfunction. Phosphorus, potassium, magnesium, glucose, vitamin, sodium, nitrogen, and fluid imbalances can be life-threatening.\u00a0High-risk patients include the chronically undernourished and those with little intake for more than 10 days. Patients with dysphagia are at higher risk. The syndrome usually occurs 24 to 48 hours after refeeding has started. The shift of water, glucose, potassium, phosphate, and magnesium back into the cells may lead to muscle weakness, respiratory failure, paralysis, coma, cranial nerve palsies, and rebound hypoglycemia.<\/p>\n<p>Interventions: Rate of TPN should be based on the severity of undernourishment for moderate- to high-risk patients. TPN should be initiated slowly\u00a0and titrated up for four to seven\u00a0days. All patients require close monitoring of electrolytes (daily for one week, then usually three times\/week). Always follow agency policy. Blood work may be more frequent depending on the severity of the malnourishment.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Fluid excess or pulmonary edema<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Signs and symptoms include fine crackles in lower lung fields or throughout lung fields, hypoxia (decreased\u00a0O<sub>2<\/sub> sats).<\/p>\n<p>Interventions: Notify primary health care provider regarding change in condition. Patient may require IV medication, such as Lasix to remove excess fluids. A decrease or discontinuation of IV fluids may also occur. Raise head of bed to enhance breathing and apply O<sub>2<\/sub> for oxygen saturation less than 92% or as per agency protocol. Monitor intake and output. Pulmonary edema may be more common in the elderly, young, and patients with renal or cardiac conditions.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Data source:\u00a0Chowdary &amp; Reddy, 2010; Mehanna et al., 2009;\u00a0O&#8217;Connor, Hanly, Francis, Keane, &amp; McNamara, 2013; Perry et al., 2014<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>A patient on TPN must have blood work monitored closely to prevent the complications of refeeding syndrome. Blood work may be ordered as often as every six hours upon initiation of TPN. Most hospitals will have a TPN protocol to follow for blood work. Common blood work includes CBC (complete blood count), electrolytes (with special attention to magnesium, potassium, and phosphate), liver enzymes (total and direct bilirubin, alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase [ALP], gamma-glutamyl transferase [GGT], total protein, albumin), and renal function tests (creatinine and urea). Compare daily values to baseline values, and investigate and report any rapid changes in any values (Chowdary &amp; Reddy, 2010; Perry et al., 2014).\u00a0Table 8.9 outlines a plan of care when a patient is receiving TPN.<br \/>\n<a id=\"table8.9\"><\/a><\/p>\n<table style=\"height: 571px; width: 100%;\">\n<caption>Table 8.9 Assessment of a Patient with TPN<\/caption>\n<tbody>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">\n<p style=\"text-align: center;\"><b>Assessment<\/b><\/p>\n<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">\n<p style=\"text-align: center;\"><strong>\u00a0Additional Information<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">CVC\/peripheral IV line<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Intravenous line should remain patent, free from infection.<\/p>\n<p>Dextrose in TPN increases risk of infection. Assess for signs and symptoms of infections at site (redness, tenderness, discharge) and systemically (fever, increased WBC, malaise). Dressing should be dry and intact.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Daily or biweekly weights<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Monitor for evidence of edema or fluid overload.\u00a0Over time, measurements will reflect weight loss\/gain from caloric intake or fluid retention.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Capillary or serum blood glucose levels<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">QID (4 times a day) capillary blood glucose initially to monitor glycemic control, then reduce monitoring when blood sugars are stable or as per agency policy. May be done more frequently if glycemic control is difficult. Indicates metabolic tolerance to dextrose in TPN solution and patient\u2019s glycemic status.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Monitor intake and output<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Monitor and record every eight\u00a0hours or as per agency policy. Monitor for signs and symptoms of fluid overload (excessive weight gain) by completing a cardiovascular and respiratory assessment. Assess intakes such as IV (intravenous fluids), PO (oral intake), NG (nasogastric tube feeds).\u00a0Assess outputs:\u00a0NG (removed gastric content through the nasogastic tube), fistula drainage, BM (liquid bowel movements), colostomy\/ileostomy drainage, closed suction drainage devices (Penrose or Jackson-Pratt drainage) and chest tube drainage.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Daily to weekly blood work<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Review lab values for increases and decreases out of normal range. Lab values include CBC, electrolytes,\u00a0calcium, magnesium, phosphorus, potassium, glucose, albumin, BUN (blood urea nitrogen), creatinine, triglycerides, and transferrin.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Mouth care<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Most patients will be NPO. Proper oral care is required as per agency policy. Some patients may have a diet order.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Vital signs<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Vital signs are more frequently monitored initially in patients with TPN.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Data source: BCIT, 2015a; Perry et al., 2014<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>TPN may be administered in the hospital or in a\u00a0home setting. Generally, patients receiving TPN are quite ill and may require a lengthy stay in the hospital. The administration of TPN must follow strict adherence to aseptic technique, and includes being alert for complications, as many of the patients will have altered defence mechanisms and complex conditions (Perry et al., 2014). To administer TPN, follow the steps in Checklist 76.<\/p>\n<table style=\"border-color: #000000; width: 100%;\">\n<caption><a id=\"checklist76\"><\/a>Checklist 76: TPN Administration<\/caption>\n<tbody>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 75px; text-align: center;\" colspan=\"4\">\n<h5 style=\"text-align: center;\"><span style=\"color: #000000;\">Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 75px;\" colspan=\"4\">\n<h5><span style=\"color: #333333;\">Safety considerations:\u00a0<\/span><\/h5>\n<ul>\n<li>Compare the patient\u2019s baseline vital signs; electrolyte, glucose, and triglyceride levels; weight; and fluid intake and output with treatment values, and investigate any rapid change in such values.<\/li>\n<li>To identify signs of infection early, be aware of the patient\u2019s recent temperature range.<\/li>\n<li>Use strict aseptic technique when caring for central venous catheters and PICC lines.<\/li>\n<li>Do not use TPN solution if it has coalesced, as evidenced by formation of a thick, dense layer of fat droplets on its surface. If the solution appears abnormal in any way, request a replacement from the pharmacy.<\/li>\n<li>Never try to catch up with a delayed infusion.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 250px; text-align: center;\" colspan=\"2\">\n<h4 style=\"text-align: center;\">Steps<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000; width: 250px; text-align: center;\" colspan=\"2\">\n<h4 style=\"text-align: center;\">\u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">1. Review physician&#8217;s orders and compare to MAR and content label on TPN solution bag and for rate of infusion. Each component of the TPN solution must be verified with the physician&#8217;s orders.<\/td>\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">Check date and time of last TPN tubing change,\u00a0lab values, and expiry date of TPN to\u00a0prevent medication error.<\/p>\n<p>Assess CVC, WBC, and patient for malaise.<\/p>\n<p>Medications may be added to the TPN.<\/p>\n<p>Ensure the rate of infusion is verified in the doctor\u2019s order each time new TPN bag is initiated.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">2. Collect supplies, prepare TPN solution, and prime IV tubing with filter as per agency protocol. TPN requires special IV\u00a0tubing with a filter.<\/td>\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">Generally, new TPN tubing is required every 24 hours to prevent catheter-related bacteremia. Follow agency policy.<\/p>\n<p>Ensure tubing is primed correctly to prevent air embolism.<\/p>\n<figure id=\"attachment_6807\" aria-describedby=\"caption-attachment-6807\" style=\"width: 206px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6807\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061-300x80.jpg\" alt=\"TPN tubing with special filter\" width=\"206\" height=\"55\" srcset=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061-300x80.jpg 300w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061.jpg 1024w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061-65x17.jpg 65w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061-225x60.jpg 225w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-061-350x93.jpg 350w\" sizes=\"auto, (max-width: 206px) 100vw, 206px\" \/><\/a><figcaption id=\"caption-attachment-6807\" class=\"wp-caption-text\">TPN tubing with special filter<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">3. &lt;a href=&#8221;\/clinicalskills\/chapter\/1-6-hand-hygiene\/&#8221;&gt;Perform hand hygiene, identify yourself, and identify patient using two patient identifiers. Compare the MAR to the patient&#8217;s wristband. Explain the procedure to the patient.<\/td>\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">Hand hygiene prevents the spread of microorganisms.<\/p>\n<p>Proper identification prevents patient errors.<\/p>\n<figure id=\"attachment_6460\" aria-describedby=\"caption-attachment-6460\" style=\"width: 212px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-029.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6460\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-029-300x163.jpg\" alt=\"Identify patient with two identifiers\" width=\"212\" height=\"115\" srcset=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-029-300x163.jpg 300w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-029.jpg 1024w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-029-65x35.jpg 65w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-029-225x122.jpg 225w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-029-350x190.jpg 350w\" sizes=\"auto, (max-width: 212px) 100vw, 212px\" \/><\/a><figcaption id=\"caption-attachment-6460\" class=\"wp-caption-text\">Compare MAR to patient wristband<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">4.\u00a0Complete all safety checks for CVC as per agency policy.<\/td>\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">This adheres to safety policies related to central line care.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">5. If changing TPN solution, pause EID and remove old TPN administration set. Disinfect connections and change IV tubing as per agency policy.<\/p>\n<p>If starting TPN for the first time, flush and disinfect CVC lumens as per agency policy.<\/td>\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">Change TPN IV tubing as per agency policy. Use strict aseptic technique with IV changes as patients with high dextrose solutions are at greater risk of developing infections.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">6. Insert new TPN solution and IV tubing into EID.<\/td>\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">EID must be used with all TPN administration.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">7. Start TPN infusion rate as per physician orders.<\/td>\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">Prevents medication errors.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">8. Discard old supplies as per agency protocol, and perform hand hygiene.<\/td>\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">These steps prevent the spread of microorganisms.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">9. Monitor for signs and symptoms of complications related to TPN.<\/td>\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">See Table 8.8 for list of complications related to TPN.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">10. Complete daily assessments and monitoring for patient on TPN as per agency policy.<\/td>\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">See daily and weekly assessments in Table 8.9. Flow rate may be monitored hourly.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">11. Document the procedure in the patient chart as per agency policy.<\/td>\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">Note time when TPN bag is hung, number of bags, and rate of infusion, assessment of CVC site and verification of patency, status of dressing, vital signs and weight, client tolerance to TPN, client response to therapy, and understanding of instructions.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"4\">Data source: North York Hospital, 2013; Perry et al., 2014<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div class=\"textbox textbox--exercises\">\n<header class=\"textbox__header\">\n<p class=\"textbox__title\">Critical Thinking Exercises<\/p>\n<\/header>\n<div class=\"textbox__content\">\n<ol>\n<li>Describe refeeding syndrome and state one method to reduce the risk of refeeding syndrome.<\/li>\n<li>A patient receiving TPN for the past 48 hours has developed malaise and hypotension. What potential complication are these signs and symptoms related to?<\/li>\n<\/ol>\n<\/div>\n<\/div>\n<h1>Additional Videos<\/h1>\n<h3><a id=\"video8.7\"><\/a>Video 8.7<\/h3>\n<div class=\"textbox shaded\" style=\"text-align: center;\">Watch a video\u00a0<a href=\"https:\/\/barabus.tru.ca\/nursing\/cvad_with_valves.html\"><em>CVAD Care and Maintenance\u2014Lumens with Valves<\/em><\/a>\u00a0by\u00a0<a href=\"\/clinicalskills\/back-matter\/appendix-3\/\">Ren\u00e9e Anderson &amp; Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\n<h3><a id=\"video8.8\"><\/a>Video 8.8<\/h3>\n<div class=\"textbox shaded\" style=\"text-align: center;\">Watch a video\u00a0<a href=\"https:\/\/barabus.tru.ca\/nursing\/cvad_without_valves.html\"><em>CVAD Care and Maintenance\u2014Lumens without Valves<\/em><\/a>\u00a0by\u00a0<a href=\"\/clinicalskills\/back-matter\/appendix-3\/\">Ren\u00e9e Anderson &amp; Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\n","protected":false},"author":5,"menu_order":8,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-3715","chapter","type-chapter","status-publish","hentry"],"part":3534,"_links":{"self":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/3715","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/users\/5"}],"version-history":[{"count":29,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/3715\/revisions"}],"predecessor-version":[{"id":10170,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/3715\/revisions\/10170"}],"part":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/parts\/3534"}],"metadata":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/3715\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/media?parent=3715"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapter-type?post=3715"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/contributor?post=3715"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/license?post=3715"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}