Nutritional Support NUR 171 Pharm

Why TPN? Physical Exam Hair/nails/skin Eyes Oral cavity Heart Abdomen Bones/joints Neuro

Other Indices Nitrogen Balance Measures loss/gain of protein Positive nitrogen balance is “anabolic state” showing a gain in body protein for the day Negative nitrogen balance shows a “catabolic state” with a net low of protein…tissue is breaking down faster than it can be replaced Body uses glucose (converted from protein) for energy E.g., fever, starvation, surgery, burns, disease

Nutritional Requirements Carbohydrates In IV is glucose Provides energy Spares protein Stored as glycogen Calories will vary depending on pt’s needs Dextrose increases metabolic rate…raises their ventilatory requirements >20% dextrose into CVC

Nutritional Requirements (Con’t) Fats Provides twice as many energy calories per gram as either protein or carb Needed for cell membranes Prevents essential fatty acid deficiency Regulates cholesterol metabolism S/s of deficiency is alopecia, delayed wound healing, decreased immunity, platelet dysfunction, susceptibility to infection See Table 15-4 for lipid emulsions

Nutritional Requirements (Con’t) Proteins Promotes tissue growth/repair of body cells A component in scar tissue, antibodies Amino acids basic units of protein Requirements for healthy adults 0.8 g/kg/d Critical states 1.2 to 2.5 g/kg/d

Other Nutrients Electrolytes May be in the solution or added Includes potassium, magnesium, calcium, sodium chloride, phosphorus, chloride Vitamins Fat/water soluble Trace elements Zinc, selenium, nickel, iron, iodine

Parenteral Nutrition Additives Insulin Due to the high glucose concentration Only “regular” insulin added IV Heparin 1000 to 3000u/L may be added to decrease potential formation of a fibrin clot Histamine inhibitors Pepcid, Reglan, Zantac to alleviate stress ulcers

Nutritional Support Indications for TPN A 10% deficit in pre-illness weight Inability to take oral food/fluids within 7 days post-op, hypercatabolic situations Fistulas, renal failure, hepatic failure Ingestion of food is impaired Prolonged pre/post-op period Intake not sufficient to be anabolic

Peripheral Parenteral Nutrition PPN Used short-term (up to two weeks) Patients that cannot tolerate enteral feeding Patients that cannot have CVC access Dextrose is <20% Advantages Increases calorie/fat source Disadvantages May cause phlebitis Does not increase weight

Total Parental Nutrition CV access can be used for a prolonged period of time Achieves tissue synthesis, repair, growth Advantages 20-70% dextrose as a calorie source Restores nitrogen balance Allows bowel to rest Improves tolerance to surgery Nutritionally complete

TPN (con’t) Disadvantages May require a surgical procedure to insert a catheter May cause metabolic complications Fat emulsions in severely stressed pts. May not be used effectively Risk of pneumothorax with CVC insertion procedure

Complications of TPN Pneumothorax Air Embolism Vein thrombosis Catheter malposition Hyper/hypo glycemia Potential for infection

Standards of Practice Implementation/Monitoring standards Formula will be sterile and properly stored No additives to existing bag Patients/families need education of home care Monitor lab values Weigh patient daily Serum albumin levels Check creatinine levels Blood sugars every 6 hours

Home Health Care Teach asepsis with equipment, TPN, dressings, accessing line Instruct patient to report any malfunction with equipment or complications with TPN Assess ability to continue with TPN Check if storage space available at home Give verbal/written instructions Emergency intervention

General Guidelines One cath lumen for TPN only Same bag not to infuse past 24 hrs Hang D 10 W if bag empty and new TPN not available Remove from fridge an hour prior to hanging Start first bag slowly… Use infusion pump

Guidelines (con’t) Monitor patient’s weight daily Strict I&O Chem panel drawn every 3 days Assess oral and enteral intake prior to d/c Wean off TPN to prevent hypoglycemia Check accuchecks as ordered (e.g., q6h)

Nursing Diagnoses Altered nutrition Altered health maintenance Altered tissue perfusion Potential for infection