Therapeutics Iv Exam 3- Tpn

Front 1

key to when to use PTN

Back 1

GUT MUST NOT BE WORKING

Front 2

PN definition

Back 2

 Parenteral Nutrition (PN)- any type of item that provides nutrition (can be just like a bag of potassium)

Front 3

Total Nutrient Admixture (TNA) vs. TPN

Back 3

 Total Parenteral Nutrition (TPN)- we are trying to provide all nutrients

TNA- same, but term used when we've added fats to nutrition as well

Front 4

Peripheral Parenteral Nutrition (PPN)-

Back 4

can be any nutrition administered peripherally (not central)

Front 5

5 disease indications for TPN

Back 5

GI obstruction
Severe mucositis
Ileus (dysmotility)
Intractable nausea/vomiting
Severe diarrhea

Front 6

7 non-disease related indications for TPN

Back 6

Inability to obtain enteral access
GI rest (pancreatitis, GI fistula, wounds)
Poor GI perfusion
Short gut
High metabolic rates
Multiple OR trips- too many surgeries requiring fasting

Front 7

TPN CI (when not to use) (4)

Back 7

 GI tract that is functioning
 Inability to obtain IV access
 Estimated need for treatment less than 5 days
 Prognosis not warranting aggressive therapy- end of life care, DNR

Front 8

peripheral parenteral nutrition- need what type of veins?

site changes? if so how often?

short or long term? (give max duration)

Back 8

Need high quality veins!
 Site change every 48 hours
 Short term therapy (No more than 2 weeks)

Front 9

peripheral parenteral nutrition- kcal and mOsm req

Back 9

 < 1800 kcals
 < 900 mOsm

Front 10

% conc of dextrose and AA max that can be used for peripheral

Back 10

 5 – 10% dextrose
concentration max
 3% amino acid (AA)
concentration max

Front 11

size of volume with peripheral infusions- why?

usually higher in ____

Back 11

 More dilute, so larger volume
 Usually higher fat formulas

Front 12

PN is considered hypo or hypertonic to body fluids?

Back 12

HYPERTONIC DUUHHH BLOOD OSM IS LIKE 290

Front 13

3 issues if PN is given inappropriately

Back 13

Phlebitis, thrombosis
and extravasation if
give inappropriately

Front 14

mOsm per gram of dextrose
per g AA
per mEq

Back 14

5 mOsm/g dextrose
10 mOsm/g amino acid
1 mOsm/mEq

Front 15

central PN dilutional factor in superior vena cava

Back 15

Dilutional factor of 3600:1- super diluted so can't cause dmg to vessels!!YAYY

Front 16

benefit of central PN over peripheral

Back 16

Can provide PN that meets ALL
nutritional requirements

Front 17

placement of WHAT is important when determining proper central venous placement

what vein?

Back 17

TIP PLACEMENT
is Key!!!

Superior vena cava

Front 18

Percutaneous Nontunneled Catheter- when used?
access through which veins (4)

Back 18

Used more in acute care setting for short duration therapies

Access through subclavian, jugular,
femoral or antecubital but ULTIMATELY routed through vessel and tip goes into superior VC

Front 19

why is percutaneous nontunneled catheter called "nontunneled"

Back 19

nontunneled means it doesn't tunnel through skin , but may be
sutured at exit site
from skin- just goes right into vein

Front 20

Peripherally Inserted Central Venous Catheter (PICC) - tunneled or non tunneled

venous access where? (3 examples)

common where? (2)

Back 20

Type of nontunneled catheter

Access and placement
through a peripheral
vein, such as basilic,
cephalic and brachial

Common both in
acute care and in
home care

Front 21

Tunneled Central Venous Catheter- venipuncture site, exit site

Back 21

Percutaneous exit site under breast area (pt can see where shit is hooked up)

Actual venipuncture site into subclavian or
jugular veins

Front 22

tunneled central venous catheter- reason for using this one

Back 22

Concept is to separate venipuncture and exit sites to decrease risk it'll get into blood for infections so can use for long term care

Front 23

Implanted Port for Central Venous
Access- what is it

# of times you can access port

Back 23

Catheter attached to disk with self-sealing
silicone elastomer septum

Can access port up to 1000 to 2000 times

Front 24

Implanted Port for Central Venous
Access- placed where?

benefits (2)

Back 24

Placed into subcutaneous pocket
in anterior chest

Lower rates infection and thrombosis

Front 25

catheter complications (3) on insertion

Back 25

 Pneumothorax
 Nerve damage
 Malposition- at placement or it migrates- have to xray after placement to make sure it's in the right place

Front 26

catheter complications- occlusions (3)

Back 26

Kink
Fibrin sheath
Thrombus (clot)

Front 27

catheter complications- infection issues (2 locations)

Back 27

 At site
 Sepsis

Front 28

3 CHO for TPN

Back 28

 Dextrose most commoon
 Fructose
 Glycerin

Front 29

3 micronutrients for TPN

Back 29

 Electrolytes
 Vitamins
 Trace Minerals

Front 30

other shit you can add to TPN (6)

Back 30

 Insulin
 H2R2s
 Iron
 Heparin
 Albumin
 Additional vitamins

Front 31

for fixed TPN formulations (premade)- how would you adjust cals

Back 31

 Adjust calories by adjusting the infusion
rate

Front 32

std formulations can be used for which pt (2)

Back 32

if pt only needs to use for a few weeks- prob won't need adjustments

Can be used for patient with normal
daily nutrition needs

Front 33

stock solutions- never do what?

only use for what?

Back 33

 NEVER administered directly to a patient
 Only used to manufacture more
dilute infusions- ex) 30% fat emulsion

Front 34

fat emulsions- tonicity-->exception

implications

Back 34

All fat emulsions are isotonic EXCEPT 30% so don't ever infuse this peripherally

so can be infused peripherally

Front 35

due to _____ we can't use 9kcal/g for fat emulsion

Back 35

Due to glycerin, cannot use 9 kcals/gram we use for fat

Front 36

order of nutrient calculations - (9)

Back 36

1.Calories- how many do they need
2.Fluids - how much do they need
3.Amino Acids- how much of kcal will be AA
4.Lipids- % of kcal
5.Carbohydrates – use to QS to total calories needed
6.Electrolytes- normal or are labs off?
7.Vitamins- deficiency or no?
8.Trace Elements
9.Other ingredients

QS to total fluids

Front 37

pt with what 2 disease states may be sodium restricted

Back 37

 Pts with CHF or fluid overload may be restricted

Front 38

pt with what conditions may have larger sodium needs (3)

Back 38

 Pts with fistulas, NG tubes, small bowel losses may have large needs

Front 39

potassium needs will be affected by...

Back 39

acid base status

Front 40

Ca++ bound to what?

when would you calculate adjusted Ca

Back 40

Bound to albumin

Calculate adjusted Ca if
albumin levels low

Front 41

purpose of Cl and acetate in TPN

Back 41

Chloride and Acetate used to
balance formula

Front 42

Factors Affecting Calcium Phosphate **** KNOW THIS precipitation (4)

Back 42

pH of the solution- the lower the pH, the more is solubilized
Concentration of calcium and phosphate- As concentrations increase, risk for precipitation rises
Salt form of calcium-
 Type of phosphate- Potassium phosphate has high pH, so adding large quantities can increase pH of final solution

Front 43

CaCl vs. Ca gluconate- which is better? why?

Back 43

Calcium chloride has much higher % dissociation and more
risk for precipitation than calcium gluconate

Front 44

AA effect on ca phos precipitation (2)

dextrose effect

others (2)

Back 44

concentration of AA- AA have acidic pH (4.5-6.5) and buffer TPN so phosphate does not increase pH
composition of AA- AA may already contain phosphate or other lytes
concentration of dextrose- dextrose buffers- higher conc. better
temp of solution- higher temp = higher risk for precipitation
order of mixing- phosphate first, calcium last

Front 45

For fairly acidic amino acids (pH
around 4.5 like Aminosyn etc.)
and... AA Conc > 2% (FINAL CONC. in g/100mL)- rule of thumb for CaPhos precipitation- how to determine if it will precipitate

Back 45

Phosphate mMol+ Calcium (mEq) ≤ 30
should be fine

Amounts > 30 should raise a Big
Red Flag

Front 46

how to decrease risk of precipitates killing pt in TPN- (7)

general advice, TNA volume size, mixing order, minimum AA conc.

Back 46

 Follow compounder’s protocol!
 Use software or references to
check Ca-Phos compatibility
 Add phosphate before calcium
 Minimum AA concentration 3%
 Use minimum volumes for TNA
 Use EVA containers- DEHP may leach lipids
 Filtration of all parenteral
nutrition

Front 47

size filter to use for 2-in-1 TPN and 3-in-1 TPN

Back 47

 0.22 micron filter for all 2-in-1 (piggyback lipids)
 1.2 micron filter for 3-in-1

Front 48

lipid stability major issue and how it happens


what to do if this happens

what increases risk of this happening

Back 48

Negative charges in lipid emulsions keep fat particles in emulsion

If ionic forces broken down, fat particles
begin to clump and cause “cracking”

Cracked or marbled products must be
discarded!

Divalent and trivalent cations (calcium and shit in TPN) increase risk

Front 49

when compounding- order you should add lipids and dextrose and AA

why?

Back 49

When compounding, never add lipids directly to dextrose as too acidic pH

Add dextrose to amino acids and then add lipids

Front 50

when choosing something for GERD in TPN- what is compatible and what is not?

Back 50

all H2R2s

NOT PPIs

Front 51

2 compatible additives often added to TPN

Back 51

insulin
additional vitamins/trace minerals

Front 52

Iron and albumin addition to TPN- issues

Back 52

 Iron- Strongly ionized and can
crack lipid emulsions
Albumin- Strongly ionized and can
crack lipid emulsions

Front 53

things to be careful of when adding more shit to TPN (2)

Back 53

Additives may change pH and affect chance for calcium-phosphate
precipitation

Additives may cause creaming or cracking of lipid emulsions

Front 54

major contaminant of TPN

where is it found (2)

Back 54

Aluminum is a contaminant of many
ingredients utilized in manufacture of PN

 Phosphate products typically contain
 Amount on product labels and in package inserts

Front 55

Why is aluminum such a horrible contaminant- what does it do? concern for whom in particular (3)

keep total amount below what level

Back 55

Can be deposited in bone and in brain
 Concern for neonates, people in renal failure and people on long-term TPN
 Keep total amount in PN below 25mcg per liter

Front 56

continuous admin of TPN- what does this mean

typical in what setting

rate/conc when initiating

Back 56

 All ingredients administered over 24 hours
 Typical of acute care settings

 When initiate, start with lower concentration OR lower rate for initial 24 to 72 hours

Front 57

cyclic admin of TPN- admin over what duration/how to taper on and off (2)

setting

Back 57

 Nutrition administered over 12 to 14 hours

Taper patient on and off by using lower infusion rates

Typical of home care settings- don't have to always be attached to tubes

Total administered must
meet patient’s daily nutrition needs

Front 58

routine monitoring for TPN- what to monitor? also mention frequency (5)

Back 58

 Temperature daily
 Weight daily
 Glucose q 4- 6 hrs until
stable- to make sure pancreas can handle
 Electrolytes daily until
stable, then 2-3 x week
 I/O- inputs outputs

Front 59

4 nutritional labby protein things to monitor

Back 59

 Prealbumin/ albumin- assessment of nutrition status
 Transferrin
 Retinol binding protein
 Nitrogen balance- 24 hour urine collection

Front 60

TPN use by date - risk (when prepared in ISO class 5 LAFH) - why?

Back 60

Parenteral nutrition solutions involve multiple additives and complex
manipulations

Medium risk when prepared
in ISO Class 5 LAFH

Front 61

Medium Risk Use-By date RT and refrigeration (TPN without lipids: 2-in-1)

Back 61

 30 hours room temp
 9 days refrigerated

Front 62

TPN with LIPIDS use by dates at RT

hang time of lipids if admin separately

Back 62

 24 hours room temp when added to PN
 12 hours hang time when administered separately

Front 63

how often do you have to change sets?? and lines for 3-in-1 vs. 2-in-1

Back 63

 Every 24 hours for TNA (3-in-1)
 Every 72 hours for 2-in-1

Front 64

7 things that have to be on label

Back 64

pharmacy info/pt info
date/time to be administrated
base formula (amt of dextrose and shit) + electrolytes
route of admin (Central line?) and rate
volume/overfill
beyond use date
storage conditions

Front 65

4 things to inspect in the final check

Back 65

Visual inspection- against lighted white and/or black bg, look for visual defects within solution or container

compounding accuracy- weighing, checks

sterility testing- media fill test??

comparison of doc order to compounding worksheet to product to label