What exactly is Total Parenteral Nutrition? Known as intravenous or IV nutrition feeding, TPN facilitates the absorption of required nutrients into the body through its veins. While healthy individuals get their nutrition through the digestive tract, TPN supplies all the nutritional requirements that human beings need daily. Partial parenteral nutrition, on the other hand, supplies only part of the daily nutritional requirements – often supplementing oral intake. Show
TPN typically contains a good amount of water, energy expenditure, amino acids, essential minerals, vitamins, and fatty acids. That said, TPN mixtures are best recommended by doctors as they would know best the right mixture of protein, carbohydrates, fat vitamins, and glucose for the patient. Because TPN can be administered at home (besides the hospital), understanding the ins and outs of the medical care can help you provide better support for a loved one who might be needing it. Who needs TPN?Begin by understanding the type of patients who end up requiring TPN. TPN is not only administered to adults but children as well. A better way of recognising who needs TPN would be to assess their medical background and history. When all or part of an individual’s digestive system fails to function normally, TPN becomes a need. Often, it is due to a gastrointestinal disorder that the patient struggles with swallowing food, having it move through the digestive system, and absorb the nutrients found in the food. Patients with disorders that necessitate complete bowel rest also need TPN. What’s surprising is, TPN is highly common among children and adolescents. More often than not, these children have short bowel syndrome – an outcome of intestinal diseases like microvillus inclusion disease or malfunctioning of the small intestines. Administration of TPN | How do you do it?Because it is a specialised form of nutritional support, TPN must be administered carefully in clean, sterile environments. TPN is usually administered into a vein through a peripherally inserted central catheter, but it can also be done through a central line. If TPN is done at home, we recommend having qualified nurses that can offer support and recognise infections when they arise. What are the side effects of TPN?Some of the common side effects of TPN include mouth sores, changes in the skin, and poor night vision. If you experience less common side effects like fever, chills, and swelling in your hands, legs, and feet – it is advisable to contact your doctor for advice. Seek caregiving services from our JagaProsDo you need additional support in caring for a loved one? Medical or non-medical, the financial and emotional weight of caregiving on a full-time basis can be challenging. With our home care services, you can entrust in our expertise and partner with our nurses to provide your loved one with manageable day-to-day life. For more information on acquiring support for loved ones, read more here. Find out more about Jaga-Me and our services here. Parenteral nutrition is by definition given IV. Partial parenteral nutrition supplies only part of daily nutritional requirements, supplementing oral intake. Many hospitalized patients are given dextrose or amino acid solutions by this method. Total parenteral nutrition (TPN) supplies all daily nutritional requirements. TPN can be used in the hospital or at home. Because TPN solutions are concentrated and can cause thrombosis of peripheral veins, a central venous catheter is usually required.
TPN may be the only feasible option for patients who do not have a functioning GI tract or who have disorders requiring complete bowel rest, such as the following:
Children who need TPN may have different fluid requirements and need more energy (up to 120 kcal/kg/day) and amino acids (up to 2.5 or 3.5 g/kg/day).  Basic TPN solutions are prepared using sterile techniques, usually in liter batches according to standard formulas. Normally, 2 L/day of the standard solution is needed. Solutions may be modified based on laboratory results, underlying disorders, hypermetabolism, or other factors. Most calories are supplied as carbohydrate. Typically, about 4 to 5 mg/kg/minute of dextrose is given. Standard solutions contain up to about 25% dextrose, but the amount and concentration depend on other factors, such as metabolic needs and the proportion of caloric needs that are supplied by lipids. Commercially available lipid emulsions are often added to supply essential fatty acids and triglycerides; 20 to 30% of total calories are usually supplied as lipids. However, withholding lipids and their calories may help obese patients mobilize endogenous fat stores, increasing insulin sensitivity. Many TPN solutions are commonly used. Electrolytes can be added to meet the patient’s needs. TPN solutions vary depending on other disorders present and patient age, as for the following:
Because the central venous catheter needs to remain in place for a long time, strict sterile technique must be used during insertion and maintenance of the TPN line. The TPN line should not be used for any other purpose. External tubing should be changed every 24 hours with the first bag of the day. In-line filters have not been shown to decrease complications. Dressings should be kept sterile and are usually changed every 48 hours using strict sterile techniques. If TPN is given outside the hospital, patients must be taught to recognize symptoms of infection, and qualified home nursing must be arranged. The solution is started slowly at 50% of the calculated requirements, using 5% dextrose to make up the balance of fluid requirements. Energy and nitrogen should be given simultaneously. The amount of regular insulin given (added directly to the TPN solution) depends on the plasma glucose level; if the level is normal and the final solution contains 25% dextrose, the usual starting dose is 5 to 10 units of regular insulin/L of TPN fluid. Progress of patients with a TPN line should be followed on a flowchart. An interdisciplinary nutrition team, if available, should monitor patients. Complete blood count should be obtained. Weight, electrolytes, and blood urea nitrogen should be monitored often (eg, daily for inpatients). Plasma glucose should be monitored every 6 hours until patients and glucose levels become stable. Fluid intake and output should be monitored continuously. When patients become stable, blood tests can be done less often. Liver tests should be done. Plasma proteins (eg, serum albumin, possibly transthyretin or retinol-binding protein), prothrombin time, plasma and urine osmolality, and calcium, magnesium, and phosphate should be measured twice/week. Changes in transthyretin and retinol-binding protein reflect overall clinical status rather than nutritional status alone. If possible, blood tests should not be done during glucose infusion. Catheter-related sepsis rates have decreased since the introduction of guidelines that emphasize sterile techniques for catheter insertion and skin care around the insertion site. The increasing use of dedicated teams of physicians and nurses who specialize in various procedures including catheter insertion also has accounted for a decrease in catheter-related infection rates. Glucose abnormalities (hyperglycemia or hypoglycemia) or liver dysfunction occurs in > 90% of patients. Glucose abnormalities are common. Hyperglycemia can be avoided by monitoring plasma glucose often, adjusting the insulin dose in the TPN solution, and giving subcutaneous insulin as needed. Hypoglycemia can be precipitated by suddenly stopping constant concentrated dextrose infusions. Treatment depends on the degree of hypoglycemia. Short-term hypoglycemia may be reversed with 50% dextrose IV; more prolonged hypoglycemia may require infusion of 5 or 10% dextrose for 24 hours before resuming TPN via the central venous catheter. Hepatic complications include liver dysfunction, painful hepatomegaly, and hyperammonemia. They can develop at any age but are most common among infants, particularly premature ones (whose liver is immature).
If infants develop any hepatic complication, limiting amino acids to 1.0 g/kg/day may be necessary. Abnormalities of serum electrolytes and minerals should be corrected by modifying subsequent infusions or, if correction is urgently required, by beginning appropriate peripheral vein infusions. Vitamin and mineral deficiencies are rare when solutions are given correctly. Elevated blood urea nitrogen may reflect dehydration, which can be corrected by giving free water as 5% dextrose via a peripheral vein. Volume overload (suggested by > 1 kg/day weight gain) may occur when patients have high daily energy requirements and thus require large fluid volumes. Metabolic bone disease, or bone demineralization (osteoporosis or osteomalacia), develops in some patients given TPN for > 3 months. The mechanism is unknown. Advanced disease can cause severe periarticular, lower-extremity, and back pain. Adverse reactions to lipid emulsions (eg, dyspnea, cutaneous allergic reactions, nausea, headache, back pain, sweating, dizziness) are uncommon but may occur early, particularly if lipids are given at > 1.0 kcal/kg/hour. Temporary hyperlipidemia may occur, particularly in patients with kidney or liver failure; treatment is usually not required. Delayed adverse reactions to lipid emulsions include hepatomegaly, mild elevation of liver enzymes, splenomegaly, thrombocytopenia, leukopenia, and, especially in premature infants with respiratory distress syndrome, pulmonary function abnormalities. Temporarily or permanently slowing or stopping lipid emulsion infusion may prevent or minimize these adverse reactions. Gallbladder complications include cholelithiasis, gallbladder sludge, and cholecystitis. These complications can be caused or worsened by prolonged gallbladder stasis. Stimulating contraction by providing about 20 to 30% of calories as fat and stopping glucose infusion several hours a day is helpful. Oral or enteral intake also helps. Treatment with metronidazole, ursodeoxycholic acid, phenobarbital, or cholecystokinin helps some patients with cholestasis.
Click here for Patient Education How do you care for a TPN?Store the TPN solution in the refrigerator when you are not using it. Let the solution warm to room temperature before you use it. You can do this by placing the TPN bag on a clean table or kitchen counter for 2 to 3 hours before you use it. Never microwave the solution.
What is the nurse's responsibilities in administering TPN?Educate client on the need for and use of TPN. Apply knowledge of nursing procedures and psychomotor skills when caring for a client receiving TPN. Apply knowledge of client pathophysiology and mathematics to TPN interventions. Administer parenteral nutrition and evaluate client response (e.g., TPN)
What nursing measures must be carried out when a patient is receiving total parenteral nutrition?The RN caring for the patient having TPN must:
Measure and record the patient's Blood Glucose Level (BGL) four times a day (QID) on commencement of TPN, then daily when BGLs are stable (as determined by the patient's treating team).
What interventions should the nurse include in the plan of care for a client receiving TPN?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.
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