TOTAL PARENTERAL NUTRITION - TPN (HYPERALIMENTATION)

MEANING OF TOTAL PARENTAL NUTRITION: TPN bypasses the normal way the body digests food in the stomach. It supplies the fuels the body needs directly into the blood stream through a central IV line. The body needs three kinds of fuelcarbohydrates, protein and fat. Carbohydrates provide calories to the body. They supply most of the energy or fuel the body needs to run. The main energy source in TPN is dextrose (sugar). Protein is made up of amino acids, which are the building blocks of life. The body uses protein to build muscle, repair tissue, fight infections and carry nutrients through the body. Fat or Lipids are another source of calories and energy. Fat also helps carry vitamins in the blood stream. Fat supports and protects some of your organs and insulates your body against heat loss. Fat is white in color.TPN also contains other nutrients, such as vitamins and minerals, electrolytes and water. Vitamins added to the TPN provide the needed daily amounts of vitamins A, B, C, D, E and K. It is the vitamins that are added to the TPN mixture that turns it yellow. The body also needs minerals. These minerals are zinc, copper, chromium, manganese and selenium. The vitamins and minerals in the TPN are needed for the bodys growth and good health. Electrolytes are important for bone, nerve, organ and muscle function. Electrolytes, such as calcium, potassium, phosphorus, magnesium, sodium, chloride and acetate, are also added to the TPN mixture. Water is a vital part of TPN. It prevents patients from becoming dehydrated (too little fluid). The amount of water in the TPN is based on your childs height and weight. Continued Staff members will use blood tests to check the balance of all the TPN parts. The most critical of these tests is the chemistry test that your child will have during each clinic visit. The TPN mixture may be changed, based on your childs needs and the blood test results. PURPOSE:

To sustain life and promote growth in patients whose gastrointestinal function is altered to such an extent that adequate oral intake is prevented for an extended period of time. INDICATIONS: The indications for TPN in children are similar to the indications in adults, i.e., if the G.I. tract cannot be used as a route of administration for nutrition, then parenteral nutrition may be indicated. One big difference vs adults is that due to fewer body stores and a higher caloric daily requirement, children are started on hyperalimentation sooner than adults. Generally, the smaller or younger the child is, the sooner (s)he needs appropriate nutritional intake. Indications: 1. Congenital or acquired anomalies if the G.I. tract: gastroschisis, bowel fistulas, intestinal obstruction, atresias, short gut syndrome. NOTE: "Short gut syndrome" or "short bowel syndrome" is a condition which is present after a significant amount of intestine has been surgically removed. Often these patients are dependent upon lifetime parenteral nutrition. 2. Chronic or recurrent diarrhea: malabsorption syndrome, inflammatory bowel disease. 3. Preterm infants 4. Malnutrition (i.e. TPN as a supplement in certain diseases in which adequate caloric intake is not being achieved via the oral route: cystic fibrosis, cancer, anorexia nervosa, hypermetabolic states, e.g., burns). 5. Patient who are NPO (or who will be NPO) for sufficient periods of time to cause a significant decrease in caloric intake (e.g., post-operative patients) PROCEDURE: 1. Explains procedure to patient and instructs how to perform Valsalva maneuver. Washes hands or uses hand sanitizer. 2. Aseptically connects tubing to TPN and primes. 3. Washes hands with chlorhexidine or uses hand sanitizer and dons 4. Changes dressing and tubing: 5. Preps catheter site with chlorhexidine gluconate 4%/Chloraprep One Step/povidone iodine. 6. When the patient is alert, instructs patient to perform Valsalva maneuver while replacing tubing. 7. Places dressing, either sterile gauze and tape, or Semipermeable transparent dressing over insertion site, labels and initials with date and time.

8. Sets infusion device on prescribed setting for fluid administration. 9. Disposes of contaminated articles in contaminated trash. 10. Removes gloves and washes hands. Documents in the patients medical record: Appearance of catheter insertion site, skin color, edema, drainage, etc. Date and time the dressing/tubing was changed. Bag number, rate of delivery, time hung. Patients tolerance to procedure. NURSING CONSIDERATIONS FOR TPN 1. Verify central line placement after initial insertion via chest (radiograph) prior to beginning TPN infusion; pneumothorax or hemothorax is a risk with central lineplacement. 2. Check vital signs (including blood pressure) at least every 6 hours after initiating infusion. 3. Check central line insertion site frequently for signs of infection (infection is a common complication when a central line is used and may lead to sepsis). 4. Follow agency policy regarding frequency of dressing changes and procedure. 5. Change IV line setup every 24 hours. (TPN fluids are an excellent medium forbacterial growth 6. Do not administer IV piggyback or direct IV push medications through or draw blood samples from the TPN line. Only lipids may be piggybacked carefully through the TPN line beyond the in -line filter. 7. Monitor blood glucose every 6 hours; administer sliding scale insulin as ordered. 8. Weigh patient daily. (High glucose content of TPN can cause an osmotic diuresis and lead to dehydration.) 9. Order TPN solutions from the pharmacy in a timely manner; remove the next container from the refrigerator an hour before needed to prevent central infusion of cold solutions. 10. When a new container of TPN is needed, but is not available, follow agency policy to maintain the ordered fluid delivery rate with D10W until the TPN is available. (High glucose content of fluid stimulates release of insulin, which may cause hypoglycemia if fluids are discontinued abruptly. 11. Do not attempt to catch up on fluids if rate inadvertently slows 12. Discontinue TPN solution gradually at the end of therapy to prevent hypoglycemia. 13. Monitor lab values. (Liver complications, electrolyte imbalances, and pH changes are possible.)

COMPLICATIONS OF TOTAL PARENTERAL NUTRITION Total parenteral nutrition gives many people without the use of their intestines a chance at long, productive lives. Still, patients receiving TPN are always at risk of complications from the procedure. Complications may include:

Clotting (thrombosis) in central access veins Frequent infections in the central-vein access lines Inflammation of the gallbladder (cholecystitis) Bone disease (osteoporosis) TPN-induced liver damage or liver failure Hypergycemia

TPN-induced liver failure occurs more often in children than adults. Some people who receive long-term TPN may develop social problems because TPN can severely limit their everyday activities. REFERENCES: 1. Swearingen, P. (2007) Swearingen: Manual of Medical Surgical Nursing Care (6th ed) Mosby: Missouri. 2. Fundamentals of Nursing Made Incredibly Easy (2007) Lippincott, Williams, Wilkins: Ambler, Pennsylvania.