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2. Assessing the need for tpn

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2. Assessing the need for tpn

  1. 1. A comprehensive nutritional assessment should be performed to determine the appropriateness of PN prior to central line placement. Goals of Nutritional Assessment  Establish baseline subjective and objective nutrition measurements  Identify Nutrition deficits  Determine Nutrition risk factors  Identify any medical or psychosocial factors that may influence nutritional support
  2. 2.  The main goal of Parenteral Nutrition is to achieve adequate nutritional status and positive nitrogen balance.  Evaluating nutritional status and determining the presence of, or risk of developing malnutrition is the main goal of any nutritional assessment.  It does not stop with the first evaluation, but must be as ongoing process to monitor the adequacy and effectiveness of nutritional support measures.
  3. 3. The four basic components of nutritional assessment include:  1. Anthropometrics  2. Clinical Information  3. Nutrition Intake History  4. Biochemical Data
  4. 4.  The most common anthropometrics used in the hospital setting are height and weight.  Current body weight is compared with usual and ideal body weight.  Weight loss is a good indicator of nutritional status.  Unintentional weight loss of more than 5% in 1 month or 10% in 6 months is clinically significant.  BMI (Body Mass Index) = weight in kgs divided by height in meters squared, used as index for both obesity and malnutrition.  Inspection of Body fat distribution via limb circumference and skinfold thickness.
  5. 5. Clinical information can be obtained from many different sources which include:  Medical record  Physician and other health care professionals  Patient/Family interviews  Physical appearance  Psychosocial evaluation
  6. 6. Site Some Possible deficiency Skin Dry and scaling. Pettechiae, Ecchymosis Follicular hyperkeratosis Pellagrous dermatosis “Flaky Paint” dermatosis Vit A VIt C or K Vit A,C or Essential Fatty acid Niacin, Tryptophan Protein Hair Dull, dry thin and brittle Protein and Essential Fatty Acid Eyes Eyelid lining and whites pale Bitot’s spots(buildup of keratin debris) Corners of eyes cracked, eyelids red inflamed Cornea dull, milky hazy or opaque Anemia Vit A Riboflavin and Niacin Vit A Mouth Magenta tongue, atrophied taste buds Glossitis Bleeding Gums Cheilosos(inflammation mouth/lips) Angular stomatitis Riboflavin Niacin, Folate, Vit B12 Vitamin C Riboflavin, Pyridoxine Riboflavin, Niacin, Iron, Pyroxine, Vit B12 General Appearance Edema Muscle wasting Decreased subcutaneous fat Protein Protein-Calorie Malnutrition Neurologic Disorientation Neuropathy Thiamin, Niacin Thiamin, Copper, Vit B 12 Adult and Enteral Parenteral Nutrition Handbook, UVA Health System Nutrition Services
  7. 7.  Fecal Fat Test: Measures the amount of fat in the stool, which helps estimate the percentage of dietary fat that the body does not absorb. The amount of fat absorption indicates how well the liver, gallbladder, pancreas, and intestines are working.  Esophagogastroduodenoscopy, EGD: An EGD may be performed to diagnose structural or functional abnormalities of the esophagus, stomach, and/or duodenum.  Gastric emptying scan: Method for measuring gastric motility. It determines how fast the stomach empties food into the small intestine after eating foods containing a radioisotope.
  8. 8.  Upper GI (gastrointestinal) series (also called barium swallow). Upper GI series is a diagnostic test that examines the organs of the upper part of the digestive system: the esophagus, stomach, and duodenum (the first section of the small intestine). Barium is swallowed and X-rays are then taken to evaluate the digestive organs.  Endoscopic retrograde cholangiopancreatography (ERCP). ERCP is a procedure that allows the doctor to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas.  CT-Scan: Computed tomography with contrast and small bowel radiography with either barium or oral water soluble contrast can differentiate obstruction from ileus. Contrast radiography is also fairly accurate in determining partial
  9. 9.  Religious and cultural preferences  Patient and/or caregiver ability to learn and safely manage PN in the home  Home environment/safety (eg, running water, cleanliness, storage, refrigeration, electricity)  Compliance
  10. 10.  Obtain 24 hour food recall and 3 day food record  Food Habits, including quality and quantity of ingested nutrients or supplements  Current appetite and changes in appetite  Gastrointestinal problems. Frequency/onset and s/s.  Factors that increase needs (eg, decubiti, surgical or surgical wounds, pregnancy, lactation)  Obtain history of food intolerances or allergies  Assess for chewing or swallowing issues  Assess for motor skills interfering with eating  Ascertain information re: any parenteral or enteral use in the past
  11. 11.  Serum Albumin: Major protein synthesized by the liver that maintains plasma oncotic pressure and important carrier of substances such as metabolites, enzymes, drugs, metals and hormones in the circulation. o Since albumin levels decrease during stress and illness it is not always a good indicator.  Prealbumin: Transports thyroxine and carrier for retinol- binding protein  Serum Transferrin: Transports iron in the plasma.
  12. 12.  Nitrogen Balance: The difference between dietary intake of nitrogen (mainly protein) and its excretion (as urea and waste products). o Healthy adults ingest the same as they excrete. o A negative nitrogen balance occurs with wasting, fasting and fevers, resulting in loss of body protein. o Accuracy depends on detailed 24 hour intake and 24 hour urine collection.  Total Lymphocyte count (TLC): Reflects a decline in the immune system and therefore proposed as a useful indicator of nutritional status.  A comprehensive metabolic panel: A group of blood tests. They provide an overall picture of the body's chemical balance and metabolism and a provides a baseline.
  13. 13.  Stool analysis: A stool analysis is a series of tests done on a stool (feces) sample to help diagnose certain conditions affecting the digestive tract. o These conditions can include infection (such as from parasites, viruses, or bacteria), poor nutrient absorption, or cancer.  Subjective Global Assessment (SGA) of Nutritional Status: Tool used to evaluate changes associated with weight, dietary intake, functional capacity, GI symptoms, and disease. o It categorizes nutritional status as well nourished, moderately nourished or severely malnourished based on findings.
  14. 14.  Parenteral nutrition concentration exceeding 10% Dextrose and/or 5% protein must be administered through a central line  Prior to initiation of PN solutions requiring access into a central vein, documentation confirming distal tip of catheter location in the superior vena cava must be obtained.  Acceptable access includes ports, tunneled catheters, PICC’s o Although usable for TPN, Femoral veins and non-tunneled catheters are generally inappropriate for home infusion.
  15. 15.  It is generally recommended that access device be used solely for TPN whenever possible to decrease potential contamination. When multiple lumens are present, designate 1 lumen for PN use only.  PPN (peripheral parenteral nutrition with dextrose concentration <10% and protein concentration <5%) is sometimes used for patients requiring short term nutrition support (7-10 days). It is rarely done in the home and only on a case by case basis.

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