Parenteral Nutrition Level 100 Course 2016 Option Care

Parenteral Nutrition Level 100 Course © 2016 Option Care Enterprises Inc. All rights reserved. 1

Outline • Introduction to parenteral nutrition (PN) • Components of PN • Types of nutrition administration • Compounding techniques • Referral and intake process • Nutrition assessment • Administration • Management of nutrition support patients • Physiologic and mechanical complications • Special patient populations © 2016 Option Care Enterprises Inc. All rights reserved. 2

Introduction to Parenteral Nutrition © 2016 Option Care Enterprises Inc. All rights reserved. 3

Parenteral Nutrition (PN) • PN is used for patients who have a functional impairment of the gastrointestinal tract that prevents nutrients from being absorbed well to maintain nutritional status • The first patient received home infusion Parenteral Nutrition (PN) in 1968 • The American Society for Parenteral and Enteral Nutrition (ASPEN) estimated that over 10, 000 outpatients and 25, 000 -30, 000 inpatients receive PN at a given time in the US • PN was previously called Total Parenteral Nutrition (TPN) © 2016 Option Care Enterprises Inc. All rights reserved. 4

What are alternative care settings for home infusion? • Alternative care settings are outpatient options for infusion including: • Patient homes • Ambulatory infusion centers • Physician-based • Hospital-based • Ambulatory infusion clinics infusion suite of the home infusion therapy provider © 2016 Option Care Enterprises Inc. All rights reserved. 5

Why a patient may need PN PN is only considered when adequate nutrition is not being maintained through the gastrointestinal tract • Some reasons a patient may need PN include: • Intestinal failure due to conditions such as Crohn’s Disease, Short Bowel Syndrome, etc. • Acute pancreatitis • Congenital conditions such as developmental failure • Tumors • Obstructions • Secondary gastrointestinal effects from chronic diseases • And so on • © 2016 Option Care Enterprises Inc. All rights reserved. 6

What is needed for a patient to receive PN • Before starting PN, certain patient criteria should be looked at • Documented medical necessity • Diagnosis and prognosis • Possible complications from oral or enteral methods • Previous unsuccessful attempts to treat by enteral route • Precertification from third parties and Medicaid programs • Does a patient with Medicare meet requirements set by Medicare © 2016 Option Care Enterprises Inc. All rights reserved. 7

What is needed for a patient to receive PN • A written order from a licensed prescriber with components, quantities, volumes, infusion rates, type of infusion device, frequency, restrictions, nursing orders, etc. • Baseline weight, height, vital signs, labs • A complete medication list with prescriptions, OTCs, home remedies, supplements to be reviewed by a pharmacist • Preferably before starting PN © 2016 Option Care Enterprises Inc. All rights reserved. 8

Components of Parenteral Nutrition © 2016 Option Care Enterprises Inc. All rights reserved. 9

Components of PN • Each PN is individualized to the patient and may contain: • Protein in the form of amino acids • Calories in the form of dextrose or combination of dextrose and fat • Fluids • Fat (lipid) emulsions • Electrolytes – sodium, potassium, chloride, magnesium, phosphorous, acetate, calcium • Vitamins – A, B, C, D, E, K, biotin, folic acid • Trace metals – zinc, copper, manganese, chromium, selenium, iodine • Other additives – iron, insulin, H 2 blockers (e. g. ranitidine), heparin, albumin, metoclopramide, L-carnitine, choline © 2016 Option Care Enterprises Inc. All rights reserved. 10

Types of Nutrition Administration © 2016 Option Care Enterprises Inc. All rights reserved. 11

Peripheral Parenteral Nutrition (PPN) • Usually reserved for patients that need short term therapy (< 5 -7 days) that do not suffer severe malnutrition, are not fluid restricted, and have good peripheral venous access • Solutions contain diluted amino acids and electrolytes and dextrose or glycerol for calories • May see formulations with fat emulsions as an additional calorie source © 2016 Option Care Enterprises Inc. All rights reserved. 12

Peripheral Parenteral Nutrition (PPN) • • Advantages • Peripheral or midline placement instead of central line • Commercially made solutions available Disadvantages • Daily requirements cannot be met without a large volume • Provides minimum calorie and protein • Meant for short-term use only • Can irritate peripheral veins and make it more difficult to maintain • Frequent change of venous access is needed © 2016 Option Care Enterprises Inc. All rights reserved. 13

Parenteral Nutrition (PN) • PN provides complete nutrition through a central line • Previously known as “Total Parenteral Nutrition (TPN)” but shorted to PN • Contains amino acids and glucose concentrations higher than can be used in peripheral parenteral nutrition • May be referred to as “ 2 in 1” also • Can contain electrolytes, vitamins, trace metals, and other additives as needed • Fat emulsion is given separately from PN © 2016 Option Care Enterprises Inc. All rights reserved. 14

Parenteral Nutrition (PN) • • Advantages • Adequate amounts of nutrients, calories, and volume to be used long term • Can use a micron filter to filter out bacteria • Can visually see if there are issues with the solution Disadvantages • Has to be given through a central line • Potential complications due to concentrations of components and rapid administration • More line manipulations needed and greater risk of infection or human error • More pumps, sets, and time needed • Potential for non-compliance © 2016 Option Care Enterprises Inc. All rights reserved. 15

Total Nutrient Admixtures (TNA) • Administration of complete nutrition through a central line • Difference between PN and TNA is that the fat emulsion is added into the glucose and amino acid solution for TNA • High concentration of glucose and amino acid requires use of a central line • Also known as “all in one”, “ 3 in 1”, or “triple mix” © 2016 Option Care Enterprises Inc. All rights reserved. 16

Total Nutrient Admixture (TNA) • • Advantages • Contains adequate components to be used long term • Fewer line manipulations needed than PN and less risk for infection and human error • Simplified process (fewer pumps, sets, supplies needed) • May lead to better utilization of lipids and may decrease insulin resistance Disadvantages • Has to be given through a central line • Not able to use bacteria micron filter • Cannot visually see issues with solution • Incompatible with many additives and some amino acids • Large fat particles can block filter © 2016 Option Care Enterprises Inc. All rights reserved. 17

Cyclic PN Therapy • Type of PN that is given over a limited number of hours • Limited hours of infusion help free patient for activities of daily living • Reserved for patients that are metabolically stable and can handle periods of infusion • Cardiovascular and renal systems have to be able to handle increased volumes during infusion periods • A patient may switch from continuous therapy to cyclic therapy by decreasing infusion time and increasing the rate • Cyclic therapy can vary from 10 to 20 hours depending on the patient’s response and tolerance to infusion © 2016 Option Care Enterprises Inc. All rights reserved. 18

Cyclic PN Therapy • • Advantages • Improved quality of life and compliance by allowing patient to resume normal daytime activities • Can reduce liver problems because of rest period between infusions • May help transition to oral diet by allowing hunger response to resume during noninfusion hours Disadvantages • More nursing time may be needed at first to teach • May not be appropriate for some patients if their cardiovascular system is not able to handle an increase in fluid volume during infusion hours • May not be advantageous for patients that require strict “NPO” (nothing by mouth) © 2016 Option Care Enterprises Inc. All rights reserved. 19

Compounding Techniques © 2016 Option Care Enterprises Inc. All rights reserved. 20

Compounding • It is necessary to use a laminar flood hood for PN • PN • has to be prepared under sterile conditions • High Efficiency Particulate Air (HEPA) filters remove 99. 97% of particles • Flow of air sweeps the work area and prevents contamination Automated admixture devices • Automated and safety • Requires intensive • compounding devices are preferred because of increased accuracy less manipulation of final bag, streamlines inventory, and is less labor Non-automated admixture • Done by hand follows a sequence of steps © 2016 Option Care Enterprises Inc. All rights reserved. 21

Referral and Intake Process © 2016 Option Care Enterprises Inc. All rights reserved. 22

Initial Responsibilities • Initial responsibilities • Assessment in the hospital before discharge is helpful • Introduction • Review to patient, caregiver, family member is important patient chart and get necessary documents • Coordinate with social work/case manager • Determine if the patient is appropriate for home care • Caregiver, significant other, or family member must be available and understand requirements • Home environment and facilities must be adequate • Reimbursement • Obtain needs to be considered before starting the most recent PN order 24 -hours before discharge • Let patient, caregiver, and family member know when visiting nurse and delivery driver is scheduled to arrive © 2016 Option Care Enterprises Inc. All rights reserved. 23

Patient Visits • • First visit • Resources that are used include PN Patient Education guide and PN Clinical Nursing Pathway • Assess patient, help ease anxiety levels, organize and prepare supplies • Educate patient and caregiver about setup and how to use PN Second visit • • Continue to use teaching materials and checklists to assess and train patient Third visit • Continue to assess patient • Frequency of visits may depend on • Acuteness • Learning • Anxiety of illness and patient ability to perform activities of daily living style level © 2016 Option Care Enterprises Inc. All rights reserved. 24

Nursing Interventions During Home Care Visits • Nurses can help in a variety of ways during home care visits including: • Determining if the patient is having problems with administration/pump • Obtaining blood samples • Checking vital signs and completing physical assessments • Providing emotional support and resources • Reinforcing education or home PN procedures • Reporting any physician visits, ER visits, hospitalizations, and any changes in medication to the health care team • Assisting with arrangement for shipping • Encouraging the patient to receive appropriate immunizations recommended by the doctor © 2016 Option Care Enterprises Inc. All rights reserved. 25

Nutrition Assessment © 2016 Option Care Enterprises Inc. All rights reserved. 26

Nutrition Assessments are the cornerstone of PN • Optimally, a baseline assessment should be done before starting PN and periodically throughout the course of therapy • A number of factors are analyzed during assessments including: • Patient history • Physical assessments • Lab data • Risk factors • Effects of disease states or metabolism on nutritional status and requirements • Anatomic and physiological functions and characteristics • Estimates for nutrient requirements • Goals of therapy © 2016 Option Care Enterprises Inc. All rights reserved. 27

Administration © 2016 Option Care Enterprises Inc. All rights reserved. 28

Infusion devices • Patient needs and items to consider • Pumps capable of large volume infusion rates • Does the pump need to be ambulatory? • Is the patient infusing at night only? • Are their mobility problems? • Can the patient carry two liters of formula if ambulatory? • How is the pump powered? If battery, are they expensive, replaceable, rechargeable, readily available? • Patient training materials • Teaching sheets for specific pumps • Manufacturer’s instruction material or training materials • Filters • All PN (without lipids) need a 0. 22 micron filter • All TNA solutions need a 1. 2 micron filter • Filters, tubing, PN formula must be changed every 24 hours and kept as a closed system whenever possible © 2016 Option Care Enterprises Inc. All rights reserved. 29

Management of Nutrition Support Patients © 2016 Option Care Enterprises Inc. All rights reserved. 30

Management of Nutrition Support Patients • Routine monitoring • • Nutrition assessments • • Should be done at the start of care and periodically after Lab value assessments • • Physical assessments, lab values, potential complications, teaching/learning, supplies Coordinate lab draws and obtain copies of results for patient record Pharmacy assessments • Review of physical assessments, nutritional assessments, lab data, nursing reports • Determine if therapy is achieving results and if equipment is working properly © 2016 Option Care Enterprises Inc. All rights reserved. 31

Management of Nutrition Support Patients • • • Patient/caregiver self-monitoring assessments • Patient/caregiver documentation must be put into the patient’s medical record • Assess if patient/caregiver is reporting problems correctly Patient teaching • Includes use of learning and teaching process steps, educational tools, teaching techniques • A major goal of patient education is patient compliance Monitoring lab test results • • Each lab test has its own reference range for normal values Lab test and nutrition considerations • Adjust components of PN as needed to be within the reference range for normal values © 2016 Option Care Enterprises Inc. All rights reserved. 32

Physiologic and Mechanical Complications © 2016 Option Care Enterprises Inc. All rights reserved. 33

Physiologic Complications • Complications that may occur with PN • High blood sugar • Low blood sugar • Electrolyte imbalances • Fluid overload • Dehydration • Acid base imbalance • Allergic reaction • Infection • Liver function test abnormalities • Overfeeding • Gallbladder complications • Refeeding syndrome © 2016 Option Care Enterprises Inc. All rights reserved. 34

Mechanical Complications • • PN-catheter related • Occlusions • Dislodging of catheter • Thrombus formation • Subjective complaints such as discomfort in arm, neck, shoulder, or chest In-line filtration • Lipid emulsion causing clogs of 0. 22 micron filters • TNA infusions require 1. 2 micron filters © 2016 Option Care Enterprises Inc. All rights reserved. 35

Special Patient Populations © 2016 Option Care Enterprises Inc. All rights reserved. 36

Special Patient Populations • Nutritional requirements may need to be adjusted for different patient populations • Pediatric patients • Infants, • Dosing all components of PN can be critical in pediatrics • Growth • children, and adolescents; typically birth to 18 years of age charts are used in addition to clinical pathways to monitor patients Elderly patients • Over • Loss age 65 of lean body mass, increase in total body fat, decrease in total body water • Decrease • in energy and calorie needs Pregnant patients with hyperemesis gravidarum • Severe and persistent type of nausea and vomiting © 2016 Option Care Enterprises Inc. All rights reserved. 37

Thank you © 2016 Option Care Enterprises Inc. All rights reserved. 38