Weight, complete blood count, 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 much less often. Liver tests should be done. 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. Full nutritional assessment including BMI calculation Physical examination Undernutrition is a form of malnutrition. Malnutrition also includes overnutrition. Undernutrition can result from inadequate ingestion of nutrients, malabsorption, impaired metabolism, loss Complications include cardiovascular disorders particularly in people with excess abdominal fat , diabetes mellitus If blind percutaneous placement 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 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. 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. Liver dysfunction may be transient, evidenced by increased transaminases, bilirubin, and alkaline phosphatase; it commonly occurs when TPN is started. Delayed or persistent elevations may result from excess amino acids.
Pathogenesis is unknown, but cholestasis and inflammation may contribute. Progressive fibrosis occasionally develops. There will be disruptions, but with the help and support of your home infusion company and the Intestinal Care Center, you should try to minimize them as much as possible. Maintaining a sense of normalcy is important for both you and your child, no matter how old he or she is.
While your child is on TPN, he or she can do many, if not most, of the same things that other children of the same age can do. Many limitations will depend on why your child needs TPN- or on his or her underlying disease or problem - and its affect on how well your child feels in general. As long as your child feels well, encourage him or her to stay as active as possible and to continue doing normal activities for his or her age.
Activities to avoid are swimming and contact sports. Things like soccer, gymnastics, baseball, and riding bikes are safe and may be fun for your child. If you ever have any doubts or questions about the safety of participating in an activity, be sure to call your nurse at the Intestinal Care Center. Being on TPN may be the most difficult mentally for teenagers. They may be more concerned about their body image and being able to live a "normal" teenage life. They may disconnect their TPN before they should or sometimes not do it at all.
It is important to try to recognize if this is happening so you can address the problem with the help of the Intestinal Care Center. It may be especially helpful for teens to get in contact with other kids who are on TPN. IT may also be helpful for you to get in touch with other families who have a child on TPN.
The nutrition support team can help you get in touch with other parents and children who are on TPN and who may be dealing with and going through the same things you are. There are also support groups available for families and the children who are on TPN. The Oley Foundation is on such example. The Oley foundation is a national, non-profit organization. It provides information, outreach services, and emotional support for persons on TPN, their families and caregivers.
Before your child leaves the hospital after being put on TPN, a clinical nurse specialist or educator in nutrition support will give you detailed instructions and help you prepare for returning home. He or she will teach you how to administer TPN, how to take care of the equipment, how to recognize a problem and what to do in case of an emergency. Depending on your child's age, he or she may also may be involved in the learning process. The more involved your child is, the better.
Taking an active role in treatment can help your child feel like he or she has some control over his or her medical condition. Your child may be more likely to comply with instructions and medications if he or she is involved and active in his or her own care. The time when your child first goes on TPN will probably be the most difficult as you learn a new routine, and how to take care of your child's TPN needs.
You may have trouble at first and become easily frustrated. Just like with anything, as time goes on and with practice, total parenteral nutrition will probably get easier for both you and your child.
It will just become another part of your family's daily routine. Once you and your child return home from the hospital, you will usually do your child's TPN infusion at night while he or she is sleeping. This will minimize daily disruption and your child will not have to deal with tubes and pumps during the day.
Remember to call your home infusion company or the Intestinal Care Center with any questions, doubt, worries, problems, or concerns. They are there to help you and your child. It is important to be able to recognize the signs ans symptoms of infection.
Before your child leaves the hospital on TPN, you will learn what the signs and symptoms of infection are. Call your child's clinical nurse specialist or doctor immediately if he or she has a fever or experiences any of the following at their catheter site:.
TPN increases the risk of having liver disease and damage. Infants and yound child on TPN are more at risk for liver disease than older children and adults. The organs of infants and younger children are still developing. They are not as capable of handling the burden and strain that TPN puts on them. Children who are on TPN for a long time are also more at risk than those who are on TPN temporarily or for a short time.
Some children who require an intestinal transplant may also receive a liver transplant at the same time due to liver disease associated with their use of TPN. Table 8. 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. Localized infection at exit or entry site Due to poor aseptic technique during insertion, care, or maintenance of central line or peripheral line. 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. Pneumothorax 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 tachycardia.
Interventions: Apply oxygen, notify physician. Patient will require removal of central line and possible chest tube insertion. Air embolism 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. 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. Hyperglycemia Related to sudden increase in glucose after recent malnourished state. After 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 2 production, hypercapnea, and respiratory failure. 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. Refeeding syndrome Refeeding syndrome 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.
High-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.
Interventions: Rate of TPN should be based on the severity of undernourishment for moderate- to high-risk patients. TPN should be initiated slowly and titrated up for four to seven days. Always follow agency policy. Blood work may be more frequent depending on the severity of the malnourishment. Figure 8. Pulling back the syringe to the prescribed dose of medication. Figure 9. Pushing syringe into the medication vial. Figure Pulling back plunger to fill the syringe with medication.
Removing the divider in the middle of the TPN bag. Removing protective covering from spike tip of the administration set. Inserting tip of the administration set into spike port of TPN bag. Squeezing the chamber of the administration set. Removing the protective cap from TPN tubing. Your pump will sound an alarm when your infusion is done. Your nurse will teach you how to do this and give you the supplies you will need.
You have now finished giving yourself TPN. Throw away all the disposable materials in the garbage. If you have any questions, ask your healthcare provider. If you have any questions or concerns, call your healthcare provider at
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