TPN order I'm confused on if this is too much or too little for this patient

[ren09]

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?[h=1][/h][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.

[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.

[COLOR=#333333]Any suggestions is helpful and appreciated thank you :)

[turnforthenurse, MSN, NP]

What the heck is D25A8?

As for the catheter....TPN should always be given through a central line, whether it's a PICC, subclavian, internal jugular, port...it needs to a central line. TPN is hyperosmolar (>900mOsm/L) and therefore infusing a solution like that through a peripheral vein greatly increases the risk of phlebitis. PPN may given through a peripheral line, however.

[Roseyposey]

Is this your homework?

[Tait, MSN, RN]

I would call the MD and pharmacy. o.0

[eatmysoxRN, ASN, RN]

We typically consult dietician and pharmacy on all TPN. They are the best to make adjustments. I know I didn't learn enough about that in nursing school to make adjustments.

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~

[SuzieVN]

As an LPN for 4000 years or so, I must say, myself, that when I saw that in WA state, IV certified LPNs can give TPN (not to forget IV push meds?), I fell off my chair. Out of control. In those 4000 years of my experience, despite my top notch IV (physical) ability- TPN and my background do NOT gel. It scares me. Here we have an RN, for example, asking technical questions about TPN. It's not safe, it's not in the realm of an LPN. I'm just amazed at the psychotic variations in the various states' scopes of practice. It's insane.

[anon456, BSN, RN]

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.

[jadelpn, LPN, EMT-B]

It would astound me that a patient has been both NPO for weeks, and developed a fistula and no one noticed these two things? And given the fact that one could assume that multiple nurses assessed this patient, after surgery there were no I&O's done and no one noticed that there was no I's? Also given the fact the patient had IV dextrose "here and there" (SERIOUSLY???) How was that determined? And if in fact a nurse is ordered to give xyz TPN at blah blah an hour....that is an incomplete order....continuous, Q 12 hours....also there's loading doses involved and a nurse should always know what she is giving, what to look for as there can be serious reactions, some of the dosing can be based on lab values. TPN is no joke, and pharmacy needs to mix it and give you administration directions. Which should (as I have learned) always be given via a central line.

I may think FAR too much, however, I am curious as to if the vein questions are the "thing you get hung up on" as opposed to the multiple "what's wrong with this overall picture" of this scenario.

Look at your critical thinking skills. Should this have been a "real" patient, it would have/could have been a hot mess. Good reason to have malpractice insurance.

Not sure what class this is for, but the ethical and professional lines have been crossed on this one, and that should be part of your answer.

[IVRUS, BSN, RN]

As an LPN for 4000 years or so, I must say, myself, that when I saw that in WA state, IV certified LPNs can give TPN (not to forget IV push meds?), I fell off my chair. Out of control. In those 4000 years of my experience, despite my top notch IV (physical) ability- TPN and my background do NOT gel. It scares me. Here we have an RN, for example, asking technical questions about TPN. It's not safe, it's not in the realm of an LPN. I'm just amazed at the psychotic variations in the various states' scopes of practice. It's insane.

While it may seem daunting to you that an LPN can administer TPN to a patient, I think that with the appropriate education an LPN can indeed hang TPN as long as the state, and facility P&P are in agreement. There are some LPN's who have attended my IV classes which I'd trust more than many RN's who've never received such education. In my state of MO, those LPN's can indeed hang TPN, program PCA's, and place peripheral IV catheters, just to mention a few things in their scope of practice, as long as they have received the state mandated curriculum and successfully passed the class. No, they can't do IV push medications unless the pt is in a life threatening situation, and they can't hang Chemo or blood or blood products.

Now across the river, in Illinois, a LPN can't give ANY medication into any IV catheter over three inches in length, but if the nurse is educated and competency has been assessed, they can give IV antibiotics or fluids into that short term peripheral catheter.

[blondy2061h, MSN, RN]

2 weeks with no caloric intake? Was no one looking at lab values or assessing this guy? Or did labs get forgotten too?