This is just a sample exercise not a real person so here's the scenario:
Tim is a 30yo businessman who was diagnosed with Crohn's dz over ten years ago; otherwise, he's a healthy guy. He's been free of flare-ups for the past couple of years, but a recent business trip to Thailand (stress, new foods) may have been the trigger for his most recent flare-up, a particularly bad one which put him in your hospital and ultimately resulted in resectioning of his jejunum. Tim was NPO for 3d prior to surgery and 9d post-op; clearly an oversight (oops!) as a result of his being transferred from unit to unit in an effort to clear beds and match changes in staffing patterns as a result of the widespread flu-related shortages. He's had some D10W here and there, but that's it.
During your first examination he's developed a fistula in his lower abdomen. It's determined that the fistula originates in his medial jejunum. He is put on total parental nutrition.
Answer the following please
He's been NPO for 13 days
1. Should we put him on D25A8 @ 125mL/h. Any suggestions?
2. What do you think about placing the TPN catheter so the formula exits into his median cubital vein?[FONT=arial, helvetica, clean, sans-serif][COLOR=#333333]Just a little confused is D25A8 too much solution and do you think 125ml/h is too quick of a rate in which this solution is being put into the patient.
[FONT=arial, helvetica, clean, sans-serif][COLOR=#333333]For the TPN catheter I feel like there's a better alternative solution than using the median cubital vein because its so small compared to say the cephalic vein.
[FONT=arial, helvetica, clean, sans-serif][COLOR=#333333]Any suggestions is helpful and appreciated thank you
May 20, '13
I agree-- the MD should decide whether or not the patient needs TPN, how much, etc. This is NOT a nursing decision. However I might question the strength of the dextrose with a possible risk for re-feeding syndrome??? Maybe he should be started on something less strong? (I work peds, have never seen anything stronger than 17% Dextrose).
Also agree, TPN through central line only. I have had a few *rare* exceptions where TPN with D10 base was run through PIV. The MD was called and it was heavily documented and IV was assessed very very often and also documented. I remember one case the patient had lost their PICC and they cannot have TPN d/c suddenly-- blood sugar will drop. So they got D10NS20KCL until the next batch of TPN could be made up. That was a very temporary situation and I recall they were trying to place another PICC or broviac in the patient very soon.
Last edit by anon456 on May 20, '13
: Reason: more thoughts