TPN

There are two basic guidelines regarding when to initiate TPN. What are they?

- A weight loss of 7% body weight and NPO for 5 days or more - A hypermetabolic state

What are the benefits to having a PICC line route for TPN? (name two)

- Access to central vein - Can accommodate hypertonic fluids - Lower risk of phlebitis than PPN - Easier to insert than central line

Potential indications for TPN include any condition that: (name two)

- Affects the ability to absorb nutrition. - Has a prolonged recovery. - Creates a hypermetabolic state. - Creates a chronic malnutrition.

TPN contains complete nutrition, this includes...

- Calories (in a high concentration [20% to 50%] of dextrose) - Lipids/essential fatty acids - Protein - Electrolytes - Vitamins - Trace elements.

Patients receiving PN

...

True or False? The PN patient should receive lipid emulsions every day.

False!

True or False? IV lipids are hypertonic.

False!

True or False? Up to about 90 g/day of protein can be supplied via PPN.

True!

True or False? When nutrient needs are high and the patient must be on parenteral nutrition for a long period of time, TPN is the appropriate choice.

True!

A nurse is caring for a cient who is receiving enteral tube feedings. The client requires 2000 cal / day to meet his caloric needs. The tube feeding prescribed provides 2 cal / mL. How many mL/hr should the nurse set the pump to administer the tube feeding within 24 hr? (round to nearest whole number)

42 mL 2000 calories / 2 calories per mL = 1000 calories 1000 / 24 = 41.66

TPN standard IV bolus therapy is typically less than or equal to _____ calories/day.

700

A nurse is caring for a client who is receiving TPN solution. It has been 24 hr since the current bag of solution was hung, and 400 mL remains to infuse. Which of the following is the appropriate action for the nurse to take? A. Remove the current bag and hang a new bag. B. Infuse the remaining solution at the current rate and then hang a new bag. C. Increase the infusion rate so the remaining solution is administered within the hour and hang a new bag. D. Remove the current bag and hang a bag of lactated Ringer's solution.

A. CORRECT: The current bag of TPN should not hang more than 24 hr due to the risk of infection.

A nurse is caring for a client who is receiving TPN solution. It has been 24hrs since the current bag of solution was hung, and 400 mL remains to infuse. Which of the following is the appropriate nursing action to take? A. Remove current bag, hang new one B. Infuse remaining solution at current rate and hang new bag C. Increase infusion rate so remaining solution is administered within the hour and hang a new bag D. Remove the current bag and hang a bag of lactated ringer's solution

A. The current bag of TPN should not hang more than 24 hrs due to the risk of infection

What is the maximum lipid tolerance (in grams) for a patient who weighs 70 kg? A. 125 g B. 175 g C. 250 g D. 375 g

B. 175 g Maximum fat-emulsion amount should not exceed a dose of 2.5g/kg/day and should be administered slowly over 12 hours 2.5 x 70 = 175

250 mL of a 10% lipid emulsion provides _______ kcalories. A. 250 kcals. B. 275 kcals. C. 500 kcals. D. 550 kcals.

B. 275 kcals 10% solution = 1.1 kcal / mL 250 x 1.1 = 275

Which of the following assessments is considered priority in the care of a patient who has recently begun receiving parenteral nutrition (PN)? A. Skin integrity and bowel sounds B. Electrolyte levels and daily weights C. Auscultation of the chest and tests of blood coagulability D. Peripheral vascular assessment and level of consciousness

B. Electrolyte levels and daily weights The use of PN necessitates frequent and thorough assessments. Key focuses of these assessments include daily weights and close monitoring of electrolyte levels. Assessments of bowel sounds, integument, peripheral vascular system, LOC, chest sounds, and blood coagulation may be variously performed, but close monitoring of fluid and electrolyte balance supersedes these in importance.

The complication that can arise when a hypertonic solution is introduced to a small vein is: A. infarction. B. thrombosis. C. sepsis. D. dehydration.

B. thrombosis.

250 mL of a 20% lipid emulsion provides _______ kcalories. A. 250 kcals. B. 275 kcals. C. 500 kcals. D. 550 kcals.

C. 500 kcals. 20% solution = 2 kcal / mL 250 x 2 = 500

The nurse is caring for a patient admitted to the hospital for asthma who weighs 186 lb (84.5 kg). During dietary counseling, the patient asks the nurse how much protein he should ingest each day. How many grams of protein does the nurse recommend should be included in the diet based on the patient's current weight? A. 24 B. 41 C. 68 D. 93

C. 68 Correct The daily intake of protein should be between 0.8 and 1 g/kg of body weight. Thus this patient should take in between 68 and 84 g of protein per day in the diet. **From PPT notes: Protein should be provided at the rate of 1 to 1.5 g/kg/day depending on the patient's needs.**

Excessive lipid administration may suppress which body system? A. Digestive B. Respiratory C. Immune D. Endocrine

C. Immune

Lipid solutions could be a potential source of Vitamin K. In which pharmacological therapy could that be contraindicated?

Could pose a problem in the patient on anticoagulants.

TPN administration regime whereby nutrients are infused at night, but not during the day.

Cyclic TPN

The digestive tract is used as the route for nutrient delivery whenever possible to prevent: A. thrombosis and cardiac arrest. B. diarrhea and sepsis. C. hunger and constipation. D. GI atrophy and sepsis.

D. GI atrophy and sepsis.

Parenteral nutrition is administered A. intramuscularly. B. into the stomach. C. into the small intestine. D. into the circulatory system.

D. Into the circulatory system

The purpose(s) of lipid emulsion in PN therapy is/are to: A. Provide kcalories. B. provide essential fatty acids. C. provide essential amino acids. D. two of the above. E. all of the above.

D. two of the above. - Provide kcalories. - provide essential fatty acids.

Partial Parenteral Nutrition (PPN) is: Hypertonic or Isotonic?

Isotonic

This kind of solution is one in which its effective osmole concentration is the same as the solute concentration of a cell. It has approximately the same osmolality of the comparison solution.

Isotonic *I*sotonic stays where *I* put it Hyp*o*tonic goes *o*ut of the vessel Hyp*e*rtonic *e*nters the vessel

PPN does not need to be tapered off. Why?

It uses more dilute solution with less dextrose.

Partial Parenteral Nutrition (PPN) is: Administered into a large or small peripheral vein?

Large

Is it okay to put additives into lipid solutions?

No - do not mix!

Potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (whether enterally or parenterally).

Refeeding Syndrome

Pt receiving IV Fat Emulsion therapy should have which levels monitored?

Serum Triglycerides

Partial Parenteral Nutrition (PPN) is: Intended for long or short term use?

Short-Term

What should the nurse observe for when a patient switches from continuous TPN to cyclic TPN?

Signs of: Glucose Overload Fluid Imbalance

If fat emulsions are infused separately from PN solution, is it delivered rapidly or slowly?

Slowly

How long should a fat emulsion infusion run for?

Slowly over 12 hours

Which needs to be tapered slowly, TPN or PPN?

TPN

What materials are used to administer TPN?

A central line, such as a tunneled triple lumen catheter or a single- or double-lumen peripherally inserted central (PICC) line

A weight gain of greater than _______ lb(s). per day indicates fluid retention. A. 0.5 B. 1.0 B. 1.5 D. 2.0

A. 0.5

What is the hallmark biochemical feature of refeeding syndrome?

Hypophosphataemia

What are some reasons for administering parenteral nutrition?

- Client's GI tract does not function - Client cannot consume sufficient nutrients via GI tract

Total parenteral nutrition (TPN) is a _______ , __ ______ solution.

- Hypertonic - IV Bolus

What lab values do you want to monitor in the patient who may have refeeding syndrome?

- Phosphorous - Magnesium - Potassium - Glucose

What is the primary purpose of TPN?

- To meet the patient's nutritional needs - To allow growth of new body tissue (protein)

You need at least ____% of kcals from lipids to prevent Essential Fatty Acid Deficiency.

10%

PPN is appropriate for caloric needs that are no more than how many calories per day?

2000 - 2500

The nurse is responsible to ensure that PN solution is discontinued and replaced with a new solution if that bag is not empty after how long?

24 hours

To decrease the risk of overfeeding, an energy intake of how many kcals/kg/day are recommended in a non-obese patient?

25 - 30

A nurse is planning care for a client who has a new prescription for TPN. Which of the following interventions should be included? (select all that apply) A. Obtain CBS 4xday B. Give meds through secondary port on TPN tubing C. Monitor VS three times during 12 hr shift D. Change TPN tubing every 24 hrs E. Ensure a daily aPTT is obtained

A, C, D - Client is at risk of hyperglycemia - VS recommended to assess for fluid overload - Tubing in TPN should be changed every 24hrs.

With TPN infusion initiation, _______ liter(s) of solution is/are infused the first day, then the infusion is increased by _______ liter(s) a day until the desired volume is reached. A. 1; 1. B. 1; 2. C. 2; 1 D. 0.5; 0.5

A. 1; 1.

A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should be included in the plan of care? (Select all that apply.) A. Obtain a capillary blood glucose four times daily. B. Administer prescribed medications through a secondary port on the TPN IV tubing. C. Monitor vital signs three times during the 12-hr shift. D. Change the TPN IV tubing every 24 hr. E. Ensure a daily aPTT is obtained.

A. CORRECT: The client is at risk for hyperglycemia during the administration of TPN and may require supplemental insulin. C. CORRECT: Vital signs are recommended every 4 to 8 hr to assess for fluid volume excess and infection. D. CORRECT: It is recommended to change the IV tubing that is used to administer TPN every 24 hr.

Which of the following methods should be used to confirm the placement of a patient's newly-inserted nasogastric (NG) feeding tube? A. X-ray B. Aspiration C. Air auscultation D. Measurement of external length

A. X-ray It is imperative to ensure that an NG tube is situated in the GI tract rather than the patient's lungs. When an NG tube has been recently inserted, it is important to confirm this placement with an x-ray that will identify the tube's radiopaque tip.

A potential complication associated with the sudden cessation of the TPN infusion is: A. rebound hypoglycemia B. pneumothorax C. kidney failure D. nutritional recovery syndrome

A. rebound hypoglycemia

A patient who has suffered severe burns in a motor vehicle accident will soon be started on parenteral nutrition (PN). Which of the following principles should guide the nurse's administration of the patient's nutrition? A. Administration of PN requires clean technique. B. Central PN requires rapid dilution in a large volume of blood. C. Peripheral PN delivery is preferred over the use of a central line. D. Only water-soluble medications may be added to the PN by the nurse.

B. Central PN requires rapid dilution in a large volume of blood. Central PN is hypertonic and requires rapid dilution in a large volume of blood. Because PN is an excellent medium for microbial growth, aseptic technique is necessary during administration. Administration through a central line is preferred over the use of peripheral PN and no medications may be added to PN by the nurse.

A patient with dysphagia from a stroke is receiving enteral feedings through a percutaneous endoscopic gastrostomy (PEG). Which of the following interventions should the nurse integrate into this patient's care? A. Flush the tube with 30 ml of normal saline every 4 hours. B. Flush the tube before and after feedings if the patient's feedings are intermittent. C. Flush the PEG with 100 ml of sterile water before and after medication administration. D. To prevent fluid overload, avoid flushing when the patient is receiving continuous feeding.

B. Flush the tube before and after feedings if the patient's feedings are intermittent. The nurse should flush feeding tubes with 30 ml of water (not normal saline) every 4 hours during continuous feeding or before and after intermittent feeding. Flushes of 100 ml are excessive and may cause fluid overload in the patient.

The nurse recognizes that the majority of patients' caloric needs should come from which of the following sources? A. Fats B. Proteins C. Polysaccharides D. Monosaccharides

C. Polysaccharides Polysaccharides are the complex carbohydrates that are contained in the breads and grains that form the base of the food pyramid. - Carbs should constitute between 45% and 65% of caloric needs - 20% to 35% from fats - 10% to 35% from proteins.

The nurse is reviewing the laboratory test results for a 70-year-old patient with lung cancer. The patient was admitted with a diagnosis of malnutrition. Serum albumin level is 4.0 g/dl and prealbumin is 10 mg/dl. The nurse should draw which of the following conclusions? A. The albumin level is normal, and therefore the patient does not have protein malnutrition. B. The albumin level is increased, which is a common finding in patients with cancer who have malnutrition. C. Both the serum albumin and prealbumin levels are reduced, consistent with the admitting diagnosis of malnutrition. D. Although the serum albumin level is normal, the prealbumin level more accurately reflects the patient's nutritional status.

D. Although the serum albumin level is normal, the prealbumin level more accurately reflects the patient's nutritional status. Serum albumin has a half-life of approximately 20 to 22 days; therefore the serum level may lag behind actual protein changes by more than 2 weeks and is therefore not a good indicator of acute changes in nutritional status. Prealbumin has a half-life of 2 days and is a better indicator of recent or current nutritional status.

Why is the TPN infusion started slowly? A. To prevent fluid overload. B. So the body has time to adapt to the glucose load. C. So the body has time to adapt to the hypotonic solution. D. So the body has time to adapt to the protein load. E. A and B only. F. A, B and D only.

E. A and B only.

3. Medical conditions for which TPN may be indicated include: A. AIDS-related enteropathy. B. cardiovascular disease. C. acute pancreatitis D. bowel infarction E. all of the above. F. A, C and D only.

F. A, C and D only.

Contraindications for lipid emulsions include: A. Diabetes mellitus. B. Acute pancreatitis with hyperlipidemia. C. Severe egg allergy. D. Hyperlipidemia. E. B and D only. F. B, C and D only.

F. B, C and D only.

True or False? If, for some reason, the infusion must be stopped for a period of time, the rate should be increased upon commencement of the infusion to "catch up" so that the day's kcalorie and protein needs can be met.

False!

True or False? Pneumothorax is caused by a sudden cessation of TPN infusion.

False!

True or False? The maximum kcalories tolerated with PPN is about 1000 kcal/day?

False!

True or False? With PPN, nutrients are supplied to the superior vena cava.

False!

True or False? With cyclic TPN, the patient receives the infusion 24 hours a day.

False!

This kind of solution is one with a higher concentration of solutes outside the cell than inside the cell. It has a higher osmolality than the comparison solution.

Hypertonic Hyp*e*rtonic *e*nters the vessel *I*sotonic stays where *I* put it Hyp*o*tonic goes *o*ut of the vessel

This kind of solution has a lower concentration of solutes outside the cell than inside the cell. It has a lower osmolality than the comparison solution.

Hypotonic Hyp*o*tonic goes *o*ut of the vessel *I*sotonic stays where *I* put it Hyp*e*rtonic *e*nters the vessel

TPN does need to be tapered off. Why?

To prevent hypoglycemia

True or False? In monitoring the TPN patient, fluid input/output should be recorded every day.

True!

True or False? Cyclic TPN reduces the risk of hepatotoxicity and allows essential fatty acids to be released from body stores.

True!

True or False? Lipids are often hung separately, or piggyback into EN?

True!

True or False? Protein, carbohydrates, and vitamin/minerals contribute to solution osmolarity.

True!