Clinical Reasoning Case Study: Total Parenteral Nutrition Name _____________________________

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

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	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:
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

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, 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)?

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. 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

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.