Read Total Parenteral Nutrition (TPN) Initiation text version

INITIATION [to be done prior to the start of Total Parenteral Nutrition (TPN) therapy] 1. CVAD placement then stat portable chest x-ray for verification of catheter tip placement if not done within the past 24 hours. If catheter is repositioned, a repeat chest x-ray must be done to verify placement. Placement must be in the superior vena cava before the catheter is used for infusing TPN. Registered dietitian to assess patient's calorie and protein needs LABORATORY: Baseline labs to be completed TPN-10 panel Hepatic Function panel (HFP) Triglycerides CBC Protime Prealbumin

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4. After verification obtained, start TPN per Nutrition: Total Parenteral Nutrition Protocol # 966.75 DAILY MONITORING 5. 6. 7. 8. 9. TPN prescriber will order TPN and labs, as needed Daily weight before 7:00 AM and accurate I & O every shift Notify TPN prescriber of any critical lab values Pharmacist to monitor patient's progress daily Notify Physician if clotted line or leakage from catheter or insertion site

STANDARD GUIDELINES DURING TPN THERAPY 10. 11. 12. 13. 14. 15. Infusion rate must be constant for continuous TPN orders. A volumetric pump must be used. Do not increase or decrease the rate by more than 10% of the ordered rate. For cyclic TPN orders, wean on and wean off, as per order. After continuous TPN therapy is initiated, if TPN is unavailable, infuse 10% dextrose in water (D10W) at the same rate as the TPN solution until the TPN is available Site dressing changes per Central Venous Access Device (Non-Tunneled) Dressing Change Protocol # 910.00 Culture catheter tip when removed if infection suspected. Request C & S and hold culture for 72 hours. (Place tip in culture tube and deliver to lab STAT) At termination of TPN, discontinue associated laboratory tests, glucose monitoring, and have prescriber review GLUCOSE MANAGEMENT: Obtain fingerstick blood glucose every 4 hours for first 24 hours, then every 6 hours. If on insulin infusion, check blood glucose per insulin infusion protocol. As an alternate for neutropenic or thrombocytopenic patients, use line draw for blood glucose instead of fingerstick blood glucose

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(09/01/11) Revision I



STANDARD GUIDELINES DURING TPN THERAPY (Continued) 15. GLUCOSE MANAGEMENT: (Continued) ­ Please select appropriate treatment option Initiate Glycemic Control- Insulin Infusion Physician Order #824 Initiate Glycemic Control- Subcutaneous Addendum Physician Order #825 Glucose Correction Scale Subcutaneous Regular Insulin: Provider to check dosing level · If fingerstick blood glucose greater than 180 mg/dL times 3 consecutive checks increase correction insulin scale to next higher dose. Based on Previous Day Total Insulin Dose Low Dose for Total Daily Medium Dose for Dose less than Total Daily Dose 40 Units/Day 40-80 Units/Day 2 units 3 units 4 units 6 units 6 units 9 units 8 units 12 units 10 units 15 units High Dose for Total Daily Dose greater than 80 Units/Day 4 units 8 units 11 units 15 units 18 units

Blood Glucose (mg/dL) 150-200 201-250 251-300 301-350 Greater than 350 (Notify Physician)

HYPOGLYCEMIA PROTOCOL (Blood glucose less than 70 mg/dL): · · · · · If patient awake and able to take PO ­ give 4 oz of clear regular soda (i.e. Sprite) If patient awake and unable to take PO ­ give 25 ml (1/2 amp) 50% dextrose in water (D50W) IV push If patient obtunded (due to hypoglycemia) ­ give 50 ml (1 amp) 50% dextrose in water (D50W) IV push Recheck blood glucose in 15 minutes. If blood glucose less than 70 mg/dL, repeat above treatment. Recheck blood glucose every 30 minutes until greater than or equal to 80 mg/dL. If glucose remains less than 70 mg/dl after 2 doses of soda/dextrose, then notify provider.

NOTE: These orders should be reviewed by the attending physician, appropriately modified for the individual patient, dated, timed and signed below.


TIME PRESCRIBER'S SIGNATURE Another brand of drug, identical in form and content, may be dispensed unless checked.


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Total Parenteral Nutrition (TPN) Initiation

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