Parenteral nutrition monitoring

Monitor patients for adequate oral intake. If the patient has weight loss, assess whether enteral or parenteral nutrition is needed. 

D/C all antiretrovirals symptomatic support with fluids some patients require IV bicarbonate, hemodialysis, parenteral nutrition, or mechanical ventilation once syndrome resolves, consider using NRTIs with 4- mitochondrial toxicity (ABC, TDF, 3TC, or FTC) monitor lactate after restarting NRTIs some clinicians use NRTI-sparing regimens. 

TABLE 97-8. Suggested Frequency of Monitoring Parameters in Hospitalized Patients Receiving Parenteral Nutrition... 

FIGURE 60-3. Monitoring strategy for parenteral nutrition. (TPN, total parenteral... 

Monitoring Perform periodic complete blood counts and clinical chemistry tests. Monitor serum amylase levels in those individuals who have a history of elevated amylase, pancreatitis, ethanol abuse, who are on parenteral nutrition, or who are otherwise at high risk of pancreatitis. 

A major complication of intravenous infusion is thrombophlebitis, which is a principle limitation of peripheral parenteral nutrition. Its precise pathogenesis is unclear, but venospasm has been proposed as the most likely cause. However, in a study with ultrasound techniques to monitor vein caliber, there was no evidence to support this hypothesis, although thrombophlebitis was observed (10). The author suggested that the initiating event may be venous endothelial trauma, caused by the venepuncture itself, abrasion at the catheter tip, or the delivery of the feeding solution. 

The best way to monitor excessive exposure to manganese includes serum manganese concentration measurement in combination with brain MRI scanning and perhaps a battery of neurofunctional tests (7). Studies have concentrated on manganese in patients on parenteral nutrition (8) and occupational exposure (9). 

These various reports stress the need to supplement parenteral nutrition with thiamine-containing vitamins unless there is adequate dietary intake, and to monitor serum thiamine and erythrocyte transketolase activity so that supplementary thiamine can be given in good time, if necessary intravenously (45). Giving thiamine will not rectify the various disorders if hepatic function is severely disturbed, because then thiamine is not phosphorylated and hence remains physiologically inactive. 

Since chronic renal insufficiency is frequently complicated by rises in serum potassium, phosphate, and magnesium, parenteral nutrition solutions used to treat malnourished patients with chronic renal insufficiency are usually prepared with little supplementation of these cations. Four patients with chronic renal insufficiency developed significant hypophosphatemia 3-5 days after starting parenteral nutrition. Other electrolyte abnormalities included hypomagnesaemia (n = 1) and hypokalemia (n — 3) (50). Hypophosphatemia may be the most significant of the electroljde risks in this clinical setting, and the electrolytes of such patients should be monitored closely when nutritional support is begun. 

Because copper is excreted primarily in the bile, some experts advocate reducing or curtailing copper supplementation in patients with chronic hyperbUrrubinemia. The earliest signs of copper deficiency are peripheral blood cytopenias (typically anemia and neutropenia) and occasionally thrombocytopenia, caused by reduced bone marrow production. The authors recommended that serum copper should be monitored quarterly and that copper should be included in the parenteral nutrition mixture three times a week, adjusting the frequency in response to serum copper concentrations. 

Caution Do not suddenly interrupt parenteral nutrition support therapy. The patient can experience hypoglycemia. Discontinue gradually by decreasing the infusion rate. Monitor for hypoglycemia. 

Why is it important to monitor for hyperglycemia when initiating parenteral nutrition support therapy The pancreas may not have time to adjust to the hypertonic dextrose solution, which is high in glucose. Hyperglycemia is usually temporary and dissipates once the pancreas adjusts. 

Supportive care may include hydration, enteral tube or parenteral nutrition, nasogastric suctioning for ileus, bowel and bladder care, prevention and treatment of decubitus ulcers, prevention and treatment of deep venous thromboses, intensive care, mechanical ventilation, treatment of secondary infections, and monitoring for impending respiratory failure (36,38). 

The candidates for home nutrition support should be clinically stable patients that require enteral or parenteral nutrition for a long term. Before initiation of home nutrition support, a nutrition assessment and a care plan should be performed and after initiation nutrition status should be monitored on a regular basis. 

The gastrointestinal (Gl) tract is the optimal route for providing nutrients unless obstruction, severe pancreatitis, or other Gl complications are present (see Fig. 136-1). Other considerations that may have an impact on determination of an appropriate route for nutrition support include expected duration of nutrition therapy and risk of aspiration. Patients who have nonfunctional Gl tracts or are otherwise not candidates for enteral nutrition (EN) may benefit from PN. Use of the intravenous route for nutrition support is also commonly referred to as total parenteral nutrition (TPN) or hyperalimentation. Routine monitoring is necessary to ensure that the nutrition regimen is suitable for a given patient as his or her clinical condition changes and to minimize or treat complications early. 

FIGURE 137-4. Monitoring strategy for patients receiving parenteral nutrition. 

Clinical and biochemical monitoring should always go hand in hand in the assessment of any form of nutritional support. In some circumstances the contribution of the laboratory may be the simple measurement of blood glucose, while in other simations the measurements and advice provided by the lab may dictate the regimen in a patient receiving parenteral nutrition. 

The client diagnosed with cancer of the ovary had an extensive resection of the bowel and is receiving total parenteral nutrition (TPN). Which laboratory data would the nurse monitor daily ... 

The food and milk interactions are established, clinically important, and result in an increase in the bioavailability of ciclosporin. The situation should therefore be monitored if any changes are made to the diet of patients taking ciclosporin. Patients should be warned because increased ciclosporin levels are associated with increased nephrotoxicity. Lipid admixtures in parenteral nutrition do not appear to affect ciclosporin pharmacokinetics and it is speculated that they may protect against ciclosporin-induced nephrotoxicity. Close supervision and monitoring is required. There is insufficient evidence to allow extrapolation of the results to bone-marrow transplant recipients with risk factors such as dysli-pidaemia, liver, or renal impairment. ... 

Interactions between theophylline and food have been thoroughly studied but there seems to be no consistent pattern in the way the absorption of different theophylline preparations is affected. Be alert for any evidence of an inadequate response that can be related to food intake. Avoid switching between different preparations, and monitor the effects if this is necessary. Consult the product literature for any specific information on food and encourage patients to take their theophylline consistently in relation to meals where this is considered necessary. Advise patients not make major changes in their diet without consultation. Monitor the effects of both enteral and parenteral nutrition, since theophylline dosage adjustments may he required. 

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