A patient on TPN must have blood work monitored closely to prevent the complications of refeeding syndrome. Blood work may be ordered as often as every six hours upon initiation of TPN. Most hospitals will have a TPN protocol to follow for blood work.
Full Answer
Do blood glucose levels predict hospital mortality and complications during TPN?
Our study indicates that blood glucose values before and within 24 h of initiation of TPN are better predictors of hospital mortality and complications than the mean blood glucose during the entire duration of TPN.
How often should blood tests be performed on patients on TPN?
When a patient is initially placed on TPN, lab and vital signs are usually performed much more frequently. Once the patient is stable blood tests can be performed less often. A suggested monitoring schedule is shown below.
What causes TPN to raise blood sugar levels?
Reasons for Elevations. Blood glucose levels can also be increased if too many calories are provided in the TPN from carbohydrates. The dextrose grams should be limited to 150 grams per day to start.
What is the normal blood sugar level before TPN?
The mean blood glucose level before TPN was 123.2 ± 33 mg/dl and increased to a mean blood glucose of 146 ± 44 mg/dl within 24 h of TPN and remained elevated (147 ± 40 mg/dl) during days 2–10 of TPN infusion ( P < 0.01 from baseline). The overall hospital mortality was 27.2%.
How often should blood glucose be checked with TPN?
QID (4 times a day) capillary blood glucose initially to monitor glycemic control, then reduce monitoring when blood sugars are stable or as per agency policy. May be done more frequently if glycemic control is difficult.
Why is it important to check blood glucose levels while on TPN?
Our study indicates that blood glucose values before and within 24 h of initiation of TPN are better predictors of hospital mortality and complications than the mean blood glucose during the entire duration of TPN.
How does TPN affect glucose?
In conclusion, our study showed that the amount of dextrose delivered via TPN might be associated with the development of hyperglycemia and poor clinical outcomes in critically ill patients without a history of diabetes mellitus and should be adapted carefully to maintain blood glucose within the target range.
What monitoring is required for a patient receiving TPN?
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.
Can TPN cause low blood sugar?
Conclusions: The occurrence of hypoglycemia in noncritically ill patients receiving PN is low. A lower BMI and a greater blood glucose variability and TPN duration are factors associated with the risk for hypoglycemia. IV insulin and glucose variability were predictors of symptomatic hypoglycemia.
How does TPN prevent hyperglycemia?
Adding insulin at the ratio of 1 unit of insulin per 11 g of dextrose in patients with diabetes receiving TPN containing 150–300 g of carbohydrates per day is an effective initial step to prevent and reduce hyperglycemia [79].
How does parenteral nutrition cause hyperglycemia?
In patients receiving parenteral nutrition (PN), glucose enters the peripheral circulation, reaching high serum levels and producing sustained hyperglycemia and hyperinsulinemia. Additionally, the patient may suffer side effects such as hyperosmolarity, glycosuria, excess CO2 production, and hepatic dysfunction [3,4].
What is the most common complication of TPN?
Fatty liver is the most common complication, whereas intrahepatic cholestasis or hepatitis are less frequent.
What is TPN monitoring?
Laboratory testing is an objective means of assessing organ function, electrolyte levels and to ensure the patient is receiving the appropriate calorie, carbohydrate and lipid combinations to meet nutritional needs without causing liver or other organ damage.
What is the nurse's responsibilities in administering TPN?
Assessment: The nurse assesses the client, they assess and validate the client's need for hyperalimentation including laboratory diagnostic test results, and they also establish baselines prior to the total parenteral nutrition feedings which include baseline bodily weight, baseline vital signs, baseline levels of ...
When a client is receiving total parenteral nutrition What is important for the nurse to assess?
When TPN is infusing, blood glucose levels should be monitored via accucheck every 4 hours to monitor for hyperglycemia.
Is basal insulin safe?
On the other hand, basal insulins have been proven safe and effective in the management of inpatient hyperglycemia in medicine and surgery patients. In a study in patients with type 1 diabetes, the use of insulin analogs resulted in less hypoglycemia compared with the use of NPH and regular insulin [56].
Does lower carbohydrate content reduce hyperglycemia?
Short-term and long-term studies in non-acutely ill patients with diabetes, the use of lower carbohydrate content in enteral formulas has been shown to reduce hyperglycemia, improve hemoglobin A1c, and lower insulin requirements compared with the standard high carbohydrate formulas [43–50].
Is hyperglycemia a complication of enteral nutrition?
Hyperglycemia is a frequent complication of enteral and parenteral nutrition in hospitalized patients. Extensive evidence from observational studies indicates that the development of hyperglycemia during parenteral and enteral nutrition is associated with an increased risk of death and infectious complications.
Is it safe to add insulin to a TPN bag?
Some studies have reported that the use of separate insulin infusion is more cost effective than adding insulin in the TPN bag. However, other studies have shown that adding insulin to TPN mixture is clinically safe and effective in controlling hyperglycemia during TPN.
Is hyperglycemia associated with adverse clinical outcomes?
The development of hyperglycemia during parenteral and enteral nutrition is independently associated with adverse clinical outcome and mortality. There are only few small prospective trials that addressed glycemic targets and outcomes in this patient population.
What is blood glucose monitoring?
Blood glucose monitoring observes for patterns in the fluctuation of blood glucose (sugar) levels that occur in response to diet, exercise, medications, and or pathological processes associated with blood glucose fluctuations such as diabetes.
How long does a glucose sensor stay on a patient?
The sensor can remain on the patient for 3 to 14 days, depending on the product. The sensor can be scanned with a reader, which displays the patient's current and trends in the last 8 hours of interstitial fluid glucose levels. CGM machines can store 90 days of glucose data.
How many mmol of glucose is homeostasis?
The human body attempts to maintain homeostasis in blood glucose levels (4 to 6 mmol or about 72 to 108 mg/dL). This is influenced by the functional capacity of the beta-cells of the pancreas, cellular (skeletal muscles, liver, and adipose tissue) sensitivity to insulin. [4]
How to collect second drop of blood?
Collect the second drop of blood as it forms by touching the tip of the glucose testing strip. Place glucometer down and cover the site of skin puncture with a clean tissue.
What is it called when the body does not respond to insulin?
In conditions like diabetes, there is either a lack of insulin or the body does not appropriately respond (otherwise called insulin resistance) to the actions of insulin (to facilitate cellular uptake of glucose or storage of excess glucose).
What happens if you have hyperglycemia?
If left untreated hyperglycemia may cause the client to go into a state of ketoacidosis where the body begins to process fats (gluconeogenesis) to produce the energy required for cellular function. This could be as a result of a lack of insulin produced by the pancreas (as seen in type 1 diabetes).
Does insulin help with gluconeogenesis?
Further, insulin enables the liver to inhibit gluconeogenesis , and facilitates the storage of glucose in the form of glycogen (glycogenesis) and fats (de novolipogenesis (DNL)) which serve as short- and long-term stores of energy respectively.[4] .
RESEARCH DESIGN AND METHODS
This work involved retrospective study of medical and surgical patients receiving TPN during the period of 1 January 2006 to 31 December 2006 at Grady Memorial Hospital in Atlanta, Georgia. Patients were managed after the hospital TPN nutrition protocol aimed to provide 25–35 kcal · kg −1 · day −1 and 1–2 g protein · kg −1 · day −1.
RESULTS
The study population included 276 consecutive medical (33%) and surgical (65%) patients (mean age 51 ± 18 years, BMI 26 ± 7 kg/m 2, known diabetes 19.2%, intensive care unit admission 78.2%). TPN was started 12 ± 12 days after admission and was given for a mean duration of 15 ± 24 days.
CONCLUSIONS
Malnutrition is reported in up to 40% of critically ill patients ( 1, 7) and is associated with increased risk of hospital complications, longer hospital stay, and mortality ( 8 ).
Acknowledgments
We appreciate the support of the Medical Records Department staff at Grady Memorial Hospital. G.E.U. is supported by research grants from the American Diabetes Association (7-03-CR-35) and the National Institutes of Health (M01 RR-00039).
What do nurses do with TPN?
Nurses caring for clients who are receiving TPN must apply their knowledge of the client's physiology into their care of the client. For example, they must apply sterile technique to avoid infection, they must closely monitor the client's blood glucose levels on a continuous basis because the contents of these total parenteral nutrition feedings are high in terms of dextrose content which can lead to hyperglycemia, they must also monitor these levels to determine if the client is being affected by hypoglycemia as a result of the insulin that is administered with these total parenteral nutrition feedings in order to prevent hyperglycemia, and, for example the nurse must monitor the client's intake and output knowing that, physiologically, the high osmolarity of the TPN can lead to osmotic diuresis and fluid imbalances.
How often should you change your parenteral nutrition tubing?
The total parenteral nutrition tubing should be changed every 24 hours and the dressing should be changed at least every 24 hours for the first several days of treatment. These changes can vary from facility to facility, so nurses must refer to their facility specific policies and procedures.
What is the result of high dextrose content of total parenteral nutrition?
Hyperglycemia: Hyperglycemia can occur as the result of the high dextrose content of the total parenteral nutrition solution as well as the lack of a sufficient amount of administered insulin. The signs and symptoms of hyperglycemia secondary to total parenteral nutrition are the same as those associated with poorly managed diabetes ...
What are the symptoms of hypoglycemia?
Hypoglycemia: Hypoglycemia secondary to total parenteral nutrition are the same as those associated with poorly managed diabetes and they include a headache, a low blood glucose level, shakiness, clammy and cool skin, blurry vision, diaphoresis and unconsciousness and seizures.
What is total parenteral nutrition?
Total parenteral nutrition is most often used for clients who are in need of complete bowel rest, those who are in a negative nitrogen balance as the result of a severe burn or another cause, among clients who have a severe medical illness or disease such as cancer or AIDS/HIV, when the client chooses to have this treatment.
What is the planning phase of nursing?
The planning phase of the nursing process in respect to total parenteral nutrition includes the establishment of client goals or expected outcomes and planning interventions. Some appropriate expected outcomes can include: The client will be free of any complications associated total parenteral nutrition. The client will have adequate nutrition.
What is the nursing process?
The nursing process as applied to the nursing procedures and the psychomotor includes assessment, nursing diagnoses, planning, establishing expected outcomes and evaluating the client's responses to this care and treatment.
What is TPN in medical terms?
Patients in hyperbolic states, such as burns, sepsis, or trauma. TPN is made up of two components: amino acid/dextrose solution and a lipid emulsion solution (see Figure 8.9). It is ordered by a physician, in consultation with a dietitian, depending on the patient’s metabolic needs, clinical history, and blood work.
What is TPN in nutrition?
Total parenteral nutrition (TPN), also known as parenteral nutrition (PN) is a form of nutritional support given completely via the bloodstream, intravenously with an IV pump. TPN administers proteins, carbohydrates, fats, vitamins, and minerals. It aims to prevent and restore nutritional deficits, allowing bowel rest while supplying adequate ...
What is TPN in a vein?
TPN may be administered as peripheral parenteral nutrition (PPN) or via a central line, depending on the components and osmolality. Central veins are usually the veins of choice because there is less risk of thrombophlebitis and vessel damage ...
How is TPN prepared?
TPN is prepared by a pharmacy, where the calories are calculated using a formula, and is usually mixed for a 24-hour continuous infusion to prevent vascular trauma and metabolic instability (North York Hospital, 2013).
Why do you need to have a TFI?
A physician may order a total fluid intake (TFI) for the amount of fluid to be infused per hour to prevent fluid overload in patients receiving TPN. It is important to keep track of all the fluids infusing (IV fluids, IV medications, and TPN) in order to avoid fluid overload (Perry et al., 2014).
Is TPN short term or long term?
TPN may be short-term or long-term nutritional therapy, and may be administered on acute medical floors as well as in critical care areas. The caloric requirements of each patient are individualized according to the degree of stress, organ failure, and percentage of ideal body weight.
Can TPN be used with any other medication?
TPN is not compatible with any other type of IV solution or medication and must be administered by itself. TPN must be administered using an EID (IV pump), and requires special IV filter tubing (see Figure 8.10) for the amino acids and lipid emulsion to reduce the risk of particles entering the patient.
Educating The Client on The Need For and Use of TPN
Applying A Knowledge of Client Physiology and Mathematics to TPN Interventions
- Nurses caring for clients who are receiving TPN must apply their knowledge of the client's physiology into their care of the client. For example, they must apply sterile technique to avoid infection, they must closely monitor the client's blood glucose levels on a continuous basis because the contents of these total parenteral nutrition feedings ar...
Administering Parenteral Nutrition and Evaluating The Client Responses
- Total parenteral nutrition is administered in a similar manner to that which is done with intravenous infusions with a few points of emphasis and differences as listed below. 1. Total parenteral nutrition feedings are refrigerated until they are ready to hang 2. Strict sterile asepsis is used. 3. Regular insulin can be added to the TPN solution to prevent hyperglycemia 4. Any time t…