Clinical Reasoning Case Study Total Parenteral NutritionName ____.docx

1. Clinical Reasoning Case Study: Total Parenteral NutritionName
_____________________________
Chief Complaint CC/History of Present Illness:
Mrs. Morris is a 66-year-old woman who has been complaining
of nausea, vomiting, weakness, abdominal pain and abdominal
fullness for the past 3 days. She has had a fever for the last 24
hours and reports that her mid-abdominal pain is colicky and
“crampy”. She states her “Crohn’s” has been acting up for the
past 4 weeks with diarrhea, anorexia, extreme fatigue and
weight loss. She is 65 inches tall and weighs 65 kg with a usual
weight of 75 kg. Mrs. Morris was admitted to the Med/Surg unit
with a complete small bowel obstruction, multiple adhesions,
and exacerbation of Crohn's disease. She is NPO and an
exploratory lap is scheduled with lysis of adhesions and small
bowel resection to remove diseased bowel. Mrs. Morris will be
NPO postoperatively and it is expected that her GI tract will not
be accessible for at least 10-14 days.
Social and Past Medical History:
Mrs. Morris currently lives alone in a senior living apartment.
Her husband died of pancreatic cancer 2 months ago and they
had no children. She has had Crohn’s disease since she was 37
years old and was diagnosed with diabetes type 2, five years
ago.
Your Initial Nursing Assessment:
GENERAL APPEARANCE: anxious, appears weak and pale
SKIN/INTEG: skin dry, tenting noted, eyes sunken
RESP: breath sounds clear with equal aeration bilaterally, non-
labored
CARDIAC: skin pale, warm & dry, S1S2, no edema, pulses 2+
in all extremities

2. NEURO: alert & oriented x4,
GI/GU: abdomen firm and distended. Absent bowel sounds, has
not voided yet
MISC: complains of crampy, colicky abdominal pain in RLQ,
8/10, nausea and vomiting
Initial Vital Signs:
T: 100.8 F
P: 110
R: 22
BP: 100/60
O2 sats: 98%
Lab/diagnostic Results:
CBC
Current
High/Low/WNL?
WBC
15000
HGB
9 g/dL
Basic Metabolic panel
Current
High/Low/
WNL?
Sodium

3. 146
Potassium
3.3
Glucose
165
Albumin
2.9 g/dL
Prealbumin
5 mg
Transferrin
104 mg/dL
BUN
7
Creatinine
1.2
1.
What data is
RELEVANT and must be recognized by the nurse
as clinically significant to the need for nutritional support in
Mrs. Morris?
RELEVANT data:
CC:
Rationale:

4. Social & PMH:
Nursing Assessment:
Vital Signs:
Labs:
Physician Orders for Mrs. Morris:
Begin Total Parenteral Nutrition (TPN) through peripherally
inserted central catheter (PICC).
2.
Describe the difference between Peripheral Parenteral
Nutrition and Total Parenteral Nutrition.
Peripheral Nutrition
Peripheral Parenteral Nutrition
Total Parenteral Nutrition
% of dextrose allowed
Vascular route required
Advantages
Disadvantages

5. 3.
Describe the types of parenteral nutrition solutions.
2:1 solution
3:1 solution
Draw a picture of the IV set up for a 2:1 solution
4.
Describe the purpose of the components of Parenteral
Nutrition.
Dextrose
Protein
Lipids
Electrolytes
Vitamins
Minerals
Medications that can be added to PN
Rationale:
The TPN ordered is a 2:1 TPN solution of Dextrose 20% and
Amino Acids 2.75% @100ml/hr., and Lipids or IV Fatty
Emulsion (IVFE) 20% to be infused @10ml/hr. (See math
calculations at end of this case study)
5.
Calculate the
total 24 hour caloric content of the Dextrose,

6. Amino Acids and IVFE (Lipids) for Mrs. Morris.
6.
Define central venous catheter therapy
_____________________________________________
7.
Is a PICC line a central venous catheter? And if so,
why? _______________________________
8.
List the 5 key components of the Institute for
Healthcare Improvement (IHI) central line bundle that must be
implemented regarding the central venous catheter (CVC).
9.
Related to Mrs. Morris’s TPN and CVC therapy, what
nursing priority (s) will guide your plan of care? (these nursing
priorities may or may not be written as NANDA diagnostic
statements)
10.
What interventions will you initiate based on the
nursing priority (s) identified in # 9?
Nursing Interventions per Nursing Priority
Rationale:
11.
What body systems will you focus on based on Mrs.
Morris’s
TPN therapy and your nursing priority (s)?

7. 12.
Mrs. Morris is at risk for complications due to the
administration of TPN.
a.
What are the worst possible complications to anticipate
with TPN administration and CVC management?
b.
What signs/symptoms should the nurse anticipate to
identify the development of this complication? What relevant
nursing action will need to be implemented for this
complication?
A.
Potential Complications (list 5)
B.
Signs/Symptoms & relevant nursing action to
implement
13.
What is Mrs. Morris likely experiencing or feeling right
now in her situation?
14.
What can you do to engage yourself with Mrs. Morris’s
experience and show her that she matters to you as a person?
TPN CALORIC CONTENT MATH CALCULATIONS
A. Factors to memorize
1.

8. The percentage of substance in solution tells you how
many grams of that substance are present in 100 mL. For
example,
a. 5% Dextrose means there are 5 grams of dextrose in 100 ml.
(5g/100mL)
b. 4% Amino Acids means there are 4 grams of amino acids in
100 mls. (4g/100mL)
2. There are:
a. 3.4 kcal/gram of dextrose
b. 4 kcal/gram of protein
c. 9 kcal/gram of fat
3. Next, calculate the total amount the patient is receiving in a
24-hour period. For example, 10% Dextrose at 100 mL/hr. =
2400 mL in 24 hours. Calculate for each substance in the
solution or administration of the TPN.
4. Calculating caloric content:
a. A person receiving 1500 ml in a 24-hour period, of 50%
dextrose would receive how many calories in a 24-hour period?
1.)
50 grams dextrose
=
X grams dextrose
100ml
1500ml

9. 100X = 50 x 1500
X =
75000
100
X = 750 grams of dextrose
2.)
3.4 kcal =
X kcal
1 gram 750 gram
1X = 3.4 x 750
X =
2550
1
X =
2550 calories from dextrose/24 hours
5. For
each substance in TPN, (Dextrose, Amino Acids, IVFE),
the above calculations must be done to calculate the
total caloric intake for a 24-hour period.
PAGE

10. 1
Johns Hopkins Nursing Evidence-Based Practice
Appendix E
Research Evidence Appraisal Tool
Evidence level and quality rating:
Article title:
Number:
Author(s):
Publication date:
Journal:
Setting:
Sample (composition and size):
Does this evidence address my EBP question?
Yes
No-
Do not proceed with appraisal of this
evidence
Is this study:
QuaNtitative (collection, analysis, and reporting of numerical
data)
Measurable data (how many; how much; or how often) used to
formulate facts, uncover patterns in research, and generalize
results from a larger sample population; provides observed
effects of a program, problem, or condition, measured precisely,
rather than through researcher interpretation of data. Common
methods are surveys, face-to-face structured interviews,
observations, and reviews of records or documents. Statistical
tests are used in data analysis.
Go to

11. Section I: QuaNtitative
QuaLitative (collection, analysis, and reporting of narrative
data)
Rich narrative documents are used for uncovering themes;
describes a problem or condition from the point of view of those
experiencing it. Common methods are focus groups, individual
interviews (unstructured or semi structured), and
participation/observations. Sample sizes are small and are
determined when data saturation is achieved. Data saturation is
reached when the researcher identifies that no new themes
emerge and redundancy is occurring. Synthesis is used in data
analysis. Often a starting point for studies when little research
exists; may use results to design empirical studies. The
researcher describes, analyzes, and interprets reports,
descriptions, and observations from participants.
Go to
Section II: QuaLitative
Mixed methods (results reported both numerically and
narratively)
Both quaNtitative and quaLitative methods are used in the study
design. Using both approaches, in combination, provides a
better understanding of research problems than using either
approach alone. Sample sizes vary based on methods used. Data
collection involves collecting and analyzing both quaNtitative
and quaLitative data in a single study or series of studies.
Interpretation is continual and can influence stages in the
research process.
Go to
Section III: Mixed Methods
Johns Hopkins Nursing Evidence-Based Practice
Appendix E
Research Evidence Appraisal Tool

12. Page 6 of 10
Johns Hopkins Nursing Evidence-Based Practice
Appendix E
Research Evidence Appraisal Tool
The Johns Hopkins Hospital/ The Johns Hopkins University
1
Section I: QuaNtitative
Level of Evidence (Study Design)
Is this a report of a single research study?
A
· Yes
· No
Go to B
1. Was there manipulation of an independent variable?
· Yes
· No
2. Was there a control group?
· Yes
· No
3. Were study participants randomly assigned to the
intervention and control groups?
· Yes
· No
If
Yes to questions 1, 2, and 3, this is a
randomized controlled trial (RCT) or
experimental study.

13. LEVEL I
If
Yes to questions 1 and 2 and No to question
3orYes to question 1 and No to questions 2 and 3, this is
quasi-experimental.
(Some degree of investigator control, some manipulation of an
independent variable, lacks random assignment to groups, and
may have a control group).
LEVEL II
If
No to questions 1, 2, and 3, this is
nonexperimental.
(No manipulation of independent variable; can be descriptive,
comparative, or correlational; often uses secondary data).
LEVEL III
Study Findings That Help Answer the EBP Question
Skip to the
Appraisal of QuaNtitative Research Studies
section
Section I: QuaNtitative (continued)
Is this a summary of multiple sources of research evidence?
· Yes
Continue
· No
Use Appendix F
1. Does it employ a comprehensive search strategy and rigorous
appraisal method?
If this study includes research, nonresearch, and experiential
evidence, it is an integrative review (see Appendix F).
· Yes

14. Continue
· No
Use Appendix F
2. For systematic reviews and systematic reviews with meta-
analysis
(see descriptions below):
B
a. Are all studies included RCTs?
LEVEL I
b. Are the studies a combination of RCTs and quasi-
experimental, or quasi-experimental only?
LEVEL II
c. Are the studies a combination of RCTs, quasi-experimental,
and nonexperimental, or non- experimental only?
LEVEL III
A
systematic review employs a search strategy
and a rigorous appraisal method, but does not generate an effect
size.
A
meta-analysis, or systematic review with
meta-analysis, combines and analyzes results from studies to
generate a new statistic: the effect size.
Study Findings That Help Answer the EBP Question
Skip to the
Appraisal of Systematic Review (With or
Without a Meta-Analysis) section
Appraisal of QuaNtitative Research Studies

15. Does the researcher identify what is known and not known
about the problem and how the study will address any gaps in
knowledge?
· Yes
· No
Was the purpose of the study clearly presented?
· Yes
· No
Was the literature review current (most sources within the past
five years or a seminal study)?
· Yes
· No
Was sample size sufficient based on study design and rationale?
· Yes
· No
If there is a control group:
· Were the characteristics and/or demographics similar in both
the control and intervention groups?
· Yes
· No
N/A
· If multiple settings were used, were the settings similar?
· Yes
· No
N/A
· Were all groups equally treated except for the intervention
group(s)?
· Yes
· No
N/A
Are data collection methods described clearly?

16. · Yes
· No
> 0.70)?
· Yes
· No
N/A
Was instrument validity discussed?
· Yes
· No
N/A
If surveys or questionnaires were used, was the response
rate
> 25%?
· Yes
· No
N/A
Were the results presented clearly?
· Yes
· No
If tables were presented, was the narrative consistent with the
table content?
· Yes
· No
N/A
Were study limitations identified and addressed?
· Yes
· No
Were conclusions based on results?
· Yes
· No

17. Complete the
Quality Rating for QuaNtitative
Studiessection
Appraisal of Systematic Review (With or Without Meta-
Analysis)
Were the variables of interest clearly identified?
· Yes
· No
Was the search comprehensive and reproducible?
· Key search terms stated
· Yes
· No
· Multiple databases searched and identified
· Yes
· No
· Inclusion and exclusion criteria stated
· Yes
· No
Was there a flow diagram that included the number of studies
eliminated at each level of review?
· Yes
· No
Were details of included studies presented (design, sample,
methods, results, outcomes, strengths, and limitations)?
· Yes
· No
Were methods for appraising the strength of evidence (level and
quality) described?
· Yes
· No
Were conclusions based on results?
· Yes
· No

18. · Results were interpreted
· Yes
· No
· Conclusions flowed logically from the interpretation and
systematic review question
· Yes
· No
Did the systematic review include a section addressing
limitations
andhow they were addressed?
· Yes
· No
Complete the
Quality Rating for QuaNtitative Studies
section (below)
Quality Rating for QuaNtitative Studies
Circle the appropriate quality rating below:
A High quality: Consistent, generalizable results; sufficient
sample size for the study design; adequate control; definitive
conclusions; consistent recommendations based on
comprehensive literature review that includes thorough
reference to scientific evidence.
B Good quality: Reasonably consistent results; sufficient
sample size for the study design; some control, and fairly
definitive conclusions; reasonably consistent recommendations
based on fairly comprehensive literature review that includes
some reference to scientific evidence.
C Low quality or major flaws: Little evidence with inconsistent
results; insufficient sample size for the study design;
conclusions cannot be drawn.

19. Johns Hopkins Nursing Evidence-Based Practice
Appendix E
Research Evidence Appraisal Tool
Section II: QuaLitative
Level of Evidence (Study Design)
A
Is this a report of a single research study?
· Yes
this is
Level III
· No
go to II B
Study Findings That Help Answer the EBP Question
Complete the
Appraisal of Single QuaLitative Research
Studysection
(below)
Appraisal of a Single QuaLitative Research Study
Was there a clearly identifiable and articulated:
· Purpose?
· Yes
· No
· Research question?
· Yes
· No

20. · Justification for method(s) used?
· Yes
· No
· Phenomenon that is the focus of the research?
· Yes
· No
Were study sample participants representative?
· Yes
· No
Did they have knowledge of or experience with the research
area?
· Yes
· No
Were participant characteristics described?
· Yes
· No
Was sampling adequate, as evidenced by achieving saturation of
data?
· Yes
· No
Data analysis:
· Was a verification process used in every step by checking and
confirming with participants the trustworthiness of analysis and
interpretation?
· Yes
· No
· Was there a description of how data were analyzed (i.e.,
method), by computer or manually?
· Yes
· No
Do findings support the narrative data (quotes)?
· Yes
· No
Do findings flow from research question to data coll ected to

21. analysis undertaken?
· Yes
· No
Are conclusions clearly explained?
· Yes
· No
Skip to the
Quality Rating for QuaLitative
Studiessection
For summaries of multiple quaLitative research studies (meta-
synthesis), was a comprehensive search strategy and rigorous
appraisal method used?
B
· Yes
Level III
· No
go to
Appendix F
Study Findings That Help Answer the EBP Question
Complete the
Appraisal of Meta-Synthesis Studies section
(below)
Appraisal of Meta-Synthesis Studies
Were the search strategy and criteria for selecting primary
studies clearly defined?
· Yes
· No

22. Were findings appropriate and convincing?
· Yes
· No
Was a description of methods used to:
· Compare findings from each study?
· Yes
· No
· Interpret data?
· Yes
· No
Did synthesis reflect:
· Yes
· No
· New insights?
· Yes
· No
· Discovery of essential features of phenomena?
· Yes
· No
· A fuller understanding of the phenomena?
· Yes
· No
Was sufficient data presented to support the interpretations?
· Yes
· No
Complete the
Quality Rating for QuaLititative Studies
section (below)
Quality Rating for QuaLitative Studies
Circle the appropriate quality rating below:
No commonly agreed-on principles exist for judging the quality
of quaLitative studies. It is a subjective process based on the

23. extent to which study data contributes to synthesis and how
much information is known about the researchers’ efforts to
meet the appraisal criteria.
For meta-synthesis, there is preliminary agreement that quality
assessments should be made before synthesis to screen out poor-
quality studies1.
A/B
High/Good quality is used for single
studies and meta-syntheses2.
The report discusses efforts to enhance or evaluate the quality
of the data and the overall inquiry in sufficient detail; and it
describes the specific techniques used to enhance the quality of
the inquiry.
Evidence of some or all of the following is found in the report:
·
Transparency: Describes how information
was documented to justify decisions, how data were reviewed
by others, and how themes and categories were formulated.
·
Diligence: Reads and rereads data to check
interpretations; seeks opportunity to find multiple sources to
corroborate evidence.
·
Verification: The process of checking,
confirming, and ensuring methodologic coherence.
·
Self-reflection and self-scrutiny: Being
continuously aware of how a researcher’s experiences,
background, or prejudices might shape and bias analysis and
interpretations.
·

24. Participant-driven inquiry: Participants shape
the scope and breadth of questions; analysis and interpretation
give voice to those who participated.
·
Insightful interpretation: Data and
knowledge are linked in meaningful ways to relevant literatur e.
CLower-quality studies contribute little to the overall review of
findings and have few, if any, of the features listed for
High/Good quality.
1
https://www.york.ac.uk/crd/SysRev/!SSL!/WebHelp/6_4_ASSE
SSMENT_OF_QUALITATIVE_RESEARCH.htm
2 Adapted from Polit & Beck (2017).
Section III: Mixed Methods
Level of Evidence (Study Design)
You will need to appraise both the quaNtitative and quaLitative
parts of the study independently, before appraising the study in
its entirety.
1. Evaluate the quaNitative part of the study using

25. Section I.
Level
Quality
Insert here the level of evidence and overall quality for this
part:
2. Evaluate the quaLitative part of the study using
Section II.
Level
Quality
Insert here the level of evidence and overall quality for this
part:
3. To determine the level of evidence, circle the appropriate
study design:
·
Explanatory sequential designs collect
quaNtitative data first, followed by the quaLitative data; and
their purpose is to explain quaNtitative results using quaLitative
findings. The level is determined based on the level of the
quaNtitative part.
·
Exploratory sequential designs collect
quaLitative data first, followed by the quaNtitative data; and
their purpose is to explain quaLitative findings using the
quaNtitative results. The level is determined based on the level
of the quaLitative part, and it is always Level III.
·
Convergent parallel designs collect the
quaLitative and quaNtitative data concurrently for the purpose

26. of providing a more complete understanding of a phenomenon
by merging both datasets. These designs are Level III.
·
Multiphasic designs collect quaLitative and
quaNtitative data over more than one phase, with each phase
informing the next phase. These designs are Level III.
Study Findings That Help Answer the EBP Question
Complete the
Appraisal of Mixed Methods Studies section
(below)
Appraisal of Mixed Methods Studies3
Was the mixed-methods research design relevant to address the
quaNtitative and quaLitative research questions (or objectives)?
· Yes
· No
· N/A
Was the research design relevant to address the quaNtitative and
quaLitative aspects of the mixed-methods question (or
objective)?
· Yes
· No
· N/A
For convergent parallel designs, was the integration of
quaNtitative and quaLitative data (or results) relevant to
address the research question or objective?
· Yes
· No
· N/A
For convergent parallel designs, were the limitations associated

27. with the integration (for example, the divergence of quaLitative
and quaNtitative data or results) sufficiently addressed?
· Yes
· No
· N/A
Complete the
Quality Rating for Mixed-Method Studies
section (below)
3 National Collaborating Centre for Methods and Tools. (2015).
Appraising Qualitative, Quantitative, and Mixed Methods
Studies included in Mixed Studies Reviews: The MMAT.
Hamilton, ON: McMaster University. (Updated 20 July, 2015)
Retrieved from http://www.nccmt.ca/ resources/search/232
Quality Rating for Mixed-Methods Studies
Circle the appropriate quality rating below
A
High quality:
Contains high-quality quaNtitative and
quaLitative study components; highly relevant study design;
relevant integration of data or results; and careful consideration
of the limitations of the chosen approach.
B
Good quality:
Contains good-quality quaNtitative and
quaLitative study components; relevant study design;
moderately relevant integration of data or results; and some
discussion of limitations of integration.
C
Low quality or major flaws:
Contains low quality quaNtitative and
quaLitative study components; study design not relevant to

28. research questions or objectives; poorly integrated data or
results; and no consideration of limits of integration.
Week 3: Collaboration Cafe
With new information continually emerging, professional nurses
must be equipped to critique scholarly literature and discern its
value for practice. Select one current, quantitative scholarly
nursing article related to your PICOT question and determine its
strengths, limitations, and potential application.
Complete the
Johns Hopkins Nursing Evidence Based Practice
Appendix E Evidence Appraisal Tool. Once you’ve completed
the tool, use your own words to summarize your appraisal of the
article. Include the following:
· Description of the purpose
· Explanation of research design
· Discussion of sample
· Description of data collection methods
· Summary of findings
· Strengths of the study (minimum of 1)
· Limitations of the study (minimum of 1)
· Recommendations regarding potential application for future
practice that are insightful and appropriate.
Attach the article to your post, in addition to including the full
reference for the article in your post.
During the week, read a minimum of two articles posted by
peers and add your thoughts about whether you feel their article
would support an EBP change.
The John Hopkins tool
does not need to be turned in, it is a worksheet for you
to decide what type of article you have.

29. For full credit, submit your initial post by Wednesday at 11:59
PM MT. Complete your two responses to peers by Sunday at
11:59 PM MT.
**To view the grading criteria/rubric, please click on the 3 dots
in the box at the end of the solid gray bar above the discussion
board title and then Show Rubric.