Editing Nutrition (section)

=== Nursing Management of TPN ===

# '''Confirm central line tip placement by X-ray''' before the first infusion of a newly placed central catheter.
# '''Use a dedicated lumen.''' Do not infuse other medications, blood products, or draw blood from the TPN lumen unless policy explicitly permits it.
# '''Use an infusion pump and an in-line filter''' (typically 0.22 micron for lipid-free solutions and 1.2 micron for lipid-containing admixtures).
# '''Change the bag and tubing every 24 hours''' using strict aseptic technique. Refrigerate solution until use and remove it about 30 to 60 minutes before hanging.
# '''Inspect the bag''' before hanging. Discard if cloudy, discolored, or containing precipitate, and never add anything to the bag on the unit.
# '''Monitor capillary glucose every 4 to 6 hours''', at least initially. Hyperglycemia is the most common metabolic complication, and sliding-scale insulin is frequently required.
# '''Start slowly and taper off slowly.''' Initiate at a reduced rate and titrate up over 24 to 48 hours. '''Never abruptly discontinue TPN''', because the sustained endogenous insulin response causes rebound hypoglycemia. Taper the rate down, and if the bag runs out or the line fails, hang 10 percent dextrose in water at the same rate and notify the provider.
# '''Never "catch up"''' a TPN infusion that has fallen behind by increasing the rate, and never slow it abruptly. Both destabilize glucose.
# '''Monitor''' daily weight, strict intake and output, electrolytes, BUN and creatinine, liver function tests, triglycerides, and complete blood count.
# '''Assess the insertion site''' every shift for redness, drainage, tenderness, and swelling. TPN is an excellent bacterial growth medium and catheter-related bloodstream infection is the most common serious complication. A new fever in a patient on TPN is a catheter-related bloodstream infection until proven otherwise.