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TPN — Transcript

by Trinity Pullam · 2,537 words · 382 segments · language en · Watch on YouTube

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0:06this PowerPoint will be discussing Total
0:08pereral Nutrition also referred to as
0:13tpn when we're looking at tpn we use it
0:16to replace interal intake in patients
0:18who can't ingest food nutrients through
0:20their GI track this tpn will provide
0:23calories protein fatty acids by the
0:25intravascular route to support life and
0:27it's going to maintain growth and
0:29development
0:37so who needs tpn tpn is needed in people
0:40with severe malnutrition individuals
0:43with Burns if they've had GI trauma
0:45prolong pancreatitis prolong ptic ilas
0:49cancer of the GI tract GI obstruction
0:52typically someone who is unable to eat
0:55via the GI track for longer than 5 to
0:57seven days they need to be considered
0:59for TP in this can be given in almost
1:02any location anywhere from the Intensive
1:04Care Unit Med surge unit long-term care
1:06facility or even the
1:13home so we use tpn when there is no
1:16other nutritional alternative other
1:18forms of administering nutrition such as
1:21the oral route or gastrointestinal tube
1:24need to be initiated first this is very
1:26very
1:28important
1:32so we know poor nutrition means if we
1:34have poor nutrition we know that we have
1:36poor wound healing we have an increased
1:38risk of um infection we have decreased
1:41production of white blood cells and red
1:43blood cells we have increased edema and
1:45skin breakdown and so all of this can go
1:48on if a person goes without food for
1:51more than five to seven days we need to
1:53really be considering our nutritional
1:55status of our
1:58patient so just some little facts um
2:01less than 600 calories per day when this
2:04happens a person will break down their
2:05own tissue the heart walk and thin
2:08you'll have decreased respiratory muscle
2:10function organs begin to atrophy we'll
2:13start to see decreased alumin production
2:16we'll see decreased glar filtration rate
2:18and the intestinal Bill decrease in size
2:20and numbered so if a person is able to
2:23eat but can't eat enough of course again
2:26poor nutrition will result um you can
2:28see a person that is already it become
2:31truly truly more compromised if these
2:34things
2:36occur so just a little bit of math and
2:39there's some note Pages for your
2:40enjoyment just to let you know that one
2:43liter of D5W only has Believe It or Not
2:46170 calories and a lot of us would like
2:49to think that it has much
2:54more this is an example of a bag of tpn
2:58um tpn Solutions have a variety of looks
3:00so just be aware of that and that's of
3:02course depending on the company that
3:04used to package the solution um min mini
3:07look like the picture that's on your
3:08screen they're usually one liter bag and
3:11on the Note Pages you're going to see
3:13that um what type of ingredients that a
3:17standard tpn formula would contain so
3:20everywhere from the amount of aminin
3:22it's got a lot of dextr in it some
3:24electrolytes some
3:26multivitamins now I need you to know
3:27that tpn is very very expensive
3:29expensive so we want to be careful with
3:31this and not let it hang past the
3:33expiration date and not let it um
3:36actually expire because a a bag of tpn
3:39can actually cost several hundred dollar
3:42so that that becomes very very important
3:44always be sure to check the expiration
3:46date on the bag because we don't want to
3:48hang one that expired because there's a
3:50lot of glucose in it and we know that
3:51the glucose the sugar is really a medium
3:54for bacterial
3:58growth
4:04a common additive to tpn is regular
4:06insulin youi patients have a very
4:09difficult time tolerating this 24-hour
4:11day high concentration glucose solution
4:14because what happens is the patient's
4:15pancreas must continually secrete
4:17insulin in order to utilize the glucose
4:19in the solution and to keep the blood
4:21glucose within normal range if a patient
4:24becomes hypoglycemic during the time
4:26they're receiving tpn insulin is going
4:28to be ordered and be are um and added to
4:31the solution in the pharmacy
4:32Additionally the patient's going to be
4:34placed probably on a sliding skill
4:35insulin based on their blood glucose AC
4:38Che values if the patient on tpn is NPO
4:41and this is fairly typical of patients
4:43receiving tpn their blood glucose CHS
4:45are usually ordered every six hours
4:47instead of before meals and at bedtime
4:50they would try to do this as if they
4:51were actually
4:58eating
5:05there is a um great risk for infection
5:08so this slide is just basically showing
5:10you how tpn is prepared under laminer
5:12airflow hood and this is to decrease the
5:14chance of contamination because there's
5:16very very high risk of infection when
5:18you're giving tpn now just for your
5:21information there is also a periperal
5:23form of Parental nutrition and it is
5:25actually called peripheral parental
5:27nutrition and or PPN
5:30this is used if the patient does not
5:32have a central Venus access device and
5:34for whatever reason it is and PPN can
5:38actually be used through a peripheral IV
5:41line and so just want to to let you
5:44understand
5:55that remember whenever it's possible all
5:58efforts should be made um to use the gut
6:00for feeding because tpn has a greater
6:03risk of complication especially
6:05infection over interal feedings and Tube
6:10feedings so what are your goals of tpn
6:13obviously to improve nutritional status
6:15to establish a positive nitrogen balance
6:18to preserve muscle mass to promote
6:20weight gain and to support healing so
6:22just the the basics that that make a lot
6:24of sense to
6:27you as a Remer we need to give tpn it's
6:32it must be administered through a
6:33central Venus access device or what we
6:35call a cvad um this is just an example
6:38of a triple Lumen catheter any of the
6:40ports can be used for TPM um the other
6:43ports can be used for other medications
6:46antibiotics blood products so on and so
6:48forth the reason the central line is
6:50necessary is because the high osmolarity
6:52concentration of the solution if you
6:55gave the solution through a pural IV you
6:57would um cause irritation in in that
6:59line fitis would occur in your patient
7:02so very important to remember this
7:11component um sometimes tpn is given
7:14through a tunnel catheter these
7:16catheters are generally placed for
7:18long-term use and the patient may even
7:19go home with these of course a tunnel
7:22catheter is more difficult to insert but
7:23less likely to be the source of systemic
7:25infection so and these of course can
7:27come in double intol as well
7:36this is a example of lipids lipids are
7:39commonly used as part of the regimen
7:42with
7:42tpn um if we go back to the former
7:45slides and we look at the components of
7:48the tpn solution we're going to see that
7:51of course something is missing and what
7:53is missing is fat we all have to have
7:55fat in our not to survive a very long
7:58time and what I lipids can do is they
8:01can provide approximately one calorie
8:03per CC and lipids are the only solution
8:06that can be piggybacked into tpn without
8:08a specific doctor's order now before
8:11hanging the lipids you need to look
8:12closely at the solution it should have a
8:15homogeneous look it really will look
8:18like milk make sure it doesn't have an
8:20oily layer on top now you will run the
8:23lipids through the secondary line while
8:25the tpn primary line is going you want
8:28to make sure they're no filters no
8:31filters below the lipid drip chamber
8:34because if this is so the filter will
8:36Clogg always run the solutions
8:38concurrent you never want to stop tpn
8:41abruptly because hypog hypoglycemia can
8:44result and I've got some slides and I'll
8:46tell you a little more on that later
8:48patients can have an allergic reaction
8:50to the lipids so you must always always
8:54always monitor for an aaxis when you're
8:56administering lipids the lipids may
8:58contain sweet beans a SE flower oil and
9:01egg yolks all of which we know can cause
9:03allergic reactions in certain
9:05individuals so what you do is you begin
9:08by taking and recording your Baseline
9:10bottles you're going to hang the 500 CC
9:12bottle of lipids and run the lipids at a
9:14rate of one cc per minute which is of
9:17course 60 CC's per hour on the infusion
9:19pump you want to use a larger filter
9:22than normal because the lipid particles
9:24are too large and would actually clog in
9:27the smaller
9:28filter you then you'll check your Vital
9:30Signs every 10 to 15 minutes times three
9:33and then at the end of 30 minutes uh if
9:35vital signs are compared to Baseline you
9:37will increase that rate to 83 CC's per
9:39hour in a patient that can tolerate this
9:42and that solution runs over six hours so
9:45um lipids can also run via periperal
9:47line and Light
9:58tpn
10:00now some facilities use a solution that
10:02comines the tpn and the lipids and this
10:04is a picture where both are in one bag
10:08so just kind of to let you understand
10:10that philosophy when we mix these
10:12together one bag it decreases the chance
10:14of bacterial contamination when lipids
10:17are piggyback of force into the tpn
10:19because anytime you break the IV line
10:21you run the risk of
10:28contamination
10:30just a picture of a three in one mixture
10:33being infused note the infusion pump tpn
10:36and lipid should always be delivered
10:38with an IV pump because we want to
10:40maintain a constant drip rate which will
10:42help prevent hypoglycemia and
10:50hyperium so let's talk about the body's
10:52response to the high glucose load let's
10:55talk about hypoglycemia when tpn is
10:58initiated we're going to do ACU checks
11:01at least every six hours for The First
11:0348 hours and then depending on the
11:05patient response these can be
11:07discontinued or may have to be continued
11:09and monitored so tpn is going to be
11:11given by an infusion pump and we're
11:13going to start slowly and we're going to
11:15build up to a rate that fits the
11:17patient's needs so example tpn usually
11:20begins at 50 CC's per hour and then
11:23maybe increased to 75 to 100 to 125 and
11:28to even 15 D per hour over time some
11:31patients of course may never go past 50
11:33CC's an hour if they have trouble
11:34handling the excess flood volume and
11:37then other patients easily tolerate the
11:38150 cc per hour what we do by starting
11:42slowly is we allow the body to adjust
11:44the glucose load so the pancreas can
11:46begin to release the appropriate amount
11:48of insulin to keep the blood glucose
11:50controlled remember the body may have
11:53difficulty adjusting to the constant
11:54glucose infusion so watch carefully for
11:57signs of hypoglycemia such as of course
11:59polyura confusion Lethy dehydration on
12:03and on and on certainly not everyone
12:05becomes hypoglycemic from tpn it is a
12:07very common side
12:11effect okay we can have an opposite
12:13problem with a blood clue POS called
12:15hypoglycemia
12:18obviously um why does this happen the
12:21patient may develop hypoglycemia at the
12:22fusion rate suddenly drops so an example
12:26might be the pump accidentally gets
12:27turned off the ey the infiltrates of
12:30course um that can't happen because why
12:33IV is not going to infiltrate because
12:35you're giving it through a central line
12:38or what if we get ready to hang the next
12:40bag of tpn and realize the patient bag's
12:43not available somebody forgot to ordered
12:45from Pharmacy or Pharmacy forgot to send
12:47it or there's something wrong with the
12:49bag when you get it and so now you don't
12:51have your tpn so it suddenly stop um we
12:54can't just go to the pixus and get
12:56another bag and if we hang
12:59um normal saline or or just even D5W the
13:04patient's going to suddenly get
13:06hypoglycemic because remember the
13:08pancreas has been secreting insulin like
13:10a madman and suddenly we have no glucose
13:12to match the insulin
13:14secretion and so um what's going to
13:16happen then is your blood glucose is
13:18going to drop dramatically this is one
13:20reason why we run tpn on an infusion
13:23pump maintaining constant rate and this
13:26this really helps stop those glucose
13:27changes
13:29now when the tpn is ready to be DCd
13:31we're going to always taper it down over
13:33a period of time so that the endogenous
13:36insulin production can slow down before
13:38the tpn is stopped so remember that if
13:42by some chance you your patient's
13:45receiving
13:46tpn and there's the bags run dry you
13:50will hang a bag of
13:52d10 you'll call um this will be in the
13:55pixus system that's the highest glucose
13:57concentration that we have about
13:58available on the floor you're going to
14:00call the pharmacy stat explain the
14:02situation so that they can quickly get a
14:04bag hung and during this time frame
14:06you're going to need to really closely
14:08watch for signs and symptoms of
14:09hypoglycemia in your
14:21patient we've mentioned a little bit
14:24about infection being a very big concern
14:27um we want to know that of course we
14:29know glucose is an excellent medium for
14:31bacterial growth we will do dressing
14:33changes according to hospital policy we
14:35don't want to break the IV line for
14:37anything um other than the lipid
14:38infusions and of course when we're using
14:41TPM the dressing will be changed every
14:4424 hours as always make sure the Central
14:47Line dressing is intact if anything um
14:50is wrong with that you'll will do a
14:52sterile dressing
14:54change don't let a b bag hang longer
14:56than 24 hours because all these viously
14:59that would be a great medium for
15:00bacterial growth remember that these are
15:02mixed in Pharmacy under Lam or air flow
15:04Hood to decrease the chance of infection
15:06and we have to continue that dilligence
15:08on the nursing unit we need to watch our
15:11patients for signs and symptoms of
15:12sepsis this would in include fever
15:15decrease blood pressure changeing mental
15:17status and look for infection at the
15:19catheter
15:27site
15:31some other stuff that we want to think
15:32about take tpn out of the bag um one
15:36hour before hanging always check the
15:39label um oral hygiene is very very
15:42important in all patients but even more
15:44so in individuals receiving
15:47tpn cold tpn um need we need to hang tpn
15:51of course at room temperature while we
15:52talk about taking out the refrigerator
15:54because cold tpn can cause basil spasm
15:57chest pain and hypothermia do not put
15:59the bag in the microwave or run it under
16:01hot water because these actions cause
16:03contamination and of course remember
16:05room temperature tpn is
16:20best
16:21documentation um obviously careful
16:24documentation of Ino and daily weight
16:27keep track of this we need to know that
16:29tpn is effective we want them to least
16:32be maintaining their weight and in some
16:33instances the goal is actually even to
16:35gain one to two pounds per week it just
16:37depends on the goal for the patient um
16:41in your
16:42documentation we want to be sure that we
16:46look at um when we hang it and how long
16:49that the TPA a TPA I'm sorry tpn has
16:52been
16:55hanging

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