TPN Policy and Procedure in LTC

Nurses General Nursing

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I am in the process of writing a policy and procedure for TPN in the subacute-LTC setting.

I'm having difficulty finding what the State Regs are so I know at least what is mandated by the state and want to find applicable clinical data so I can meet somewhere in the middle.

I have to present it to our medical director in order to convince him that indeed we will follow proper procedure, maintaining the safety and health of our resident, while honoring the state mandates and working within the confines of the LTC setting.

I'm expecting that we will need I&Os and daily weights.

RNs will change bags, tubings, filters, settings.

The pharmacy will be able to premix any additives.

I'm assuming there will be labs. How frequently do they need to be done and what tests? What about Accuchecks? Frequency?

I'm certain there are things that can go wrong during the course of infusion. What life threatening complications occur? Is there anything that would cause death or permanent injury in such a timeframe that we couldn't ship them out if necessary?

Every. Single. Person. That I talk to about TPN in a subacute/LTC setting fa-reaks out. "it's too expensive" "it's too complicated" "it's dangerous". We are nurses!! We know how to do this! Why does everyone trip out about it? Is there something I'm missing?

Thanks for your insight!

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You may want to call the facility's pharmacy to guide you on this. Our pharmacy supplies us with protocols to use. I believe accuchecks are done 4x/day with sliding scale insulin. Sometimes insulin is added to the TPN bag. Also know what to hang and at what rate in case the TPN needs to be stopped for any reason. Usually it's 10% dextrose at the same rate as the TPN was running at. Monitor the residents temp at least every shift. 2 nurses need to check the order against what's in the bag. Some meds/vitamins need to be added by nurses prior to hanging. The bag needs to be taken out of the fridge one hour before hanging. Your dietitian may also become involved to ensure that the residents nutritional needs are being met, example percentage of amino acids and fats in the TPN. These are things I can think of off the top of my head. Good luck.

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Specializes in LTC,Hospice/palliative care,acute care.

I think it's inappropriate for LTC but ok for sub acute rehab...I can just imagine trying to juggle the needs of a resident on TPN on my unit of 42 LOL's. It's a "nursing home" Our DON would not have it.We have several units without full time RN's-what then? Good luck in your setting.I'm sure the day will come when we have to do it too but I hope it's way in the future.

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You may want to call the facility's pharmacy to guide you on this. Our pharmacy supplies us with protocols to use. I believe accuchecks are done 4x/day with sliding scale insulin. Sometimes insulin is added to the TPN bag. Also know what to hang and at what rate in case the TPN needs to be stopped for any reason. Usually it's 10% dextrose at the same rate as the TPN was running at. Monitor the residents temp at least every shift. 2 nurses need to check the order against what's in the bag. Some meds/vitamins need to be added by nurses prior to hanging. The bag needs to be taken out of the fridge one hour before hanging. Your dietitian may also become involved to ensure that the residents nutritional needs are being met, example percentage of amino acids and fats in the TPN. These are things I can think of off the top of my head. Good luck.

sounds about the same as us.

Yep...call your pharmacy, they should have a P and P for this already. I'm not sure if ours is in the pharmacy manual and/ or the IV P and P book.

We do TPN in our LTC facility (not that often tho) I don't see what is so difficult about it. We have central lines, PICCS, Midlines, res getting IV push meds around the clock, res with multiple IV antibiotics and others. We are not "sub acute" but LTC and always have at least one RN in the building.

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It's plain just not done up here. TPN therapy is only used in active treatment.

It runs around $500/bag for the travisol.

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