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File: Short Bowel Syndrome Diet Pdf 142826 | Tpn Item Download 2023-01-07 19-48-02
east jefferson general hospital parenteral nutrition solution order form standards and guidelines 1 all parenteral nutrition pn orders or changes must be written on the parenteral nutrition solution order form ...

icon picture PDF Filetype PDF | Posted on 07 Jan 2023 | 2 years ago
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                    East Jefferson General Hospital                                              
                               Parenteral Nutrition Solution                                     
                                  Order Form 
             
                                                   Standards and Guidelines: 
                1.  All Parenteral Nutrition (PN) orders or changes must be written on the Parenteral Nutrition Solution 
                    Order Form, & must be completed & submitted to Pharmacy by 14:00 daily. 
                2.  The standard administration time for all PN’s is 21:00 daily. 
                3.  Consider other I.V. fluids & I.V. medications when calculating total fluid volume per day.  4.
                    Consider other dextrose infusions when calculating daily dextrose dosage. 
                5.  Due to infection control issues and per approved policy, lipids & albumin are not mixed in PN 
                    solutions. 
                6.  Page 1 of this orderset should be completed only with the initial orders for Parenteral Nutrition. 
             
                  CHECK INDICATION FOR PARENTERAL NUTRITION 
                     Bowel Ischemia                        Severe/Acute Pancreatitis 
                     IBD / Short Bowel Syndrome            Pre-operatively: Severely malnourished & NPO at least 
                     Intractable Vomiting/Diarrhea           1 week prior to surgery 
                     GI Bleed/Bowel Obstruction            Inadequate (or expected inadequate) nourishment by 
                     Bowel Resection / Ileus                 Oral diet or enteral nutrition for 7 days 
                     High Output/Enteric Fistula           Other 
                    
             
                  ROUTINE PN ORDERS: (D/C ROUTINE PN ORDERS WHEN PN IS DISCONTINUED) 
             
            5  1. Initiate PN rate @ 30 ml/hr x 6 hours, then 60 ml/hr x 6 hours, then increase to target                                      
                (prescribed) rate.  For target rate of less than 75 ml/hr, initiate at 30 ml/hr x 6 hours, then  
                  increase to target rate. 
            5  2. Labs prior to starting PN:  CMP, Magnesium, Phosphate, Triglycerides, LFT’s, Prealbumin; 
            5  3. CMP, Magnesium, Phosphate on day 2 & 3, then twice weekly on Monday & Thursday; 
            5  4. Prealbumin, Triglyceride, LFT’s, Transferrin weekly after day 1; 
            5  5. Daily weights & strict intake/output daily (or per unit standard, if more frequent); 
            5  6. Accucheck every 6 hours.  If blood gluose is greater than 180 mg/dL, contact physician for orders. 
            5  7. If PN is started after 14:00 OR if any electrolytes in an existing PN must be reduced, hang  
                  the  standard protein/carbohydrate solution for route employed (Cental Route = 5% Amino Acids  
                  &  20% Dextrose, Peripheral Route = 4.25% Amino Acids & 5% Dextrose) without electrolytes 
                  until next routine hang cycle.  If any electrolyes in an existing PN must be increased, provide the  
                  amount to be increased via a rider. 
            5  8. Consult Dietary for nutritional assessment. 
            5  9. Consult Pharmacy for PN monitoring/control. 
             
               10. Other:_____________________________________________________________________ 
             
             
            _________________________________________ 
            Physician Signature                              Date/Time 
             
             
                                                                                                          Page 1 of 2
            *50015*                           FCO-730-1849 
            Rev: 7/2010 
             
                                                                                                      
                                                        
                           East Jefferson General Hospital                                                                       
                                      Parenteral Nutrition Solution                                                              
                                             Order Form 
                 
                Use “Standard Formulas” section for Protein/Carbohydrate concentrations of 5%/20% (Central) or 4.25%/5% (Peripheral) 
                and rates indicated.  Use “Custom Formulas” section for any other Protein/Carbohydrate concentrations and/or any other 
                rates.  The electrolytes noted in the “Custom Formulas” section are standard daily quantities.  For any changes in these, 
                simply strike thru the printed standard and enter the patient requirements in amount(s) per 24 hours. 
                 Standard Formulas              CENTRAL CENTRAL CENTRAL IDPN PERIPHERAL 
                                              Clinimix E 5/20       Clinimix E 5/20      Clinimix E 5/20       Clinimix 5/20       Clinimix E 4.25/5 
                  Check desired rate/formula                                                                                           
                Infusion Rate (ml/hr)                42 63 83  83 
                Total Volume (ml/day)              1000 1500 2000 1000 2000 
                Amino Acids                    5% final conc        5% final conc         5% final conc        5% final conc      4.25% final conc 
                Dextrose                      20% final conc        20% final conc       20% final conc       20% final conc        5% final conc 
                Dextrose (gm/day)                   200 300 400 200 100 
                Protein (gm/day)                     50 75 100 50 85 
                Calories (Kcal/day)                 880 1320 1760 880 680 
                Sodium (mEq/day)                     35 53 70  70 
                Potassium (mEq/day)                  30 45 60  60 
                Calcium (mEq/day)                   4.5 6.75 9  9 
                Phosphorus (mMol/day)                15 22.5 30  30 
                Magnesium (mEq/day)                  5 7.5 10  10 
                Chloride (mEq/day)                   39 59 78  78 
                Acetate (mEq/day)                    80 120 160  160 
                Chloride:Acetate Ratio              1:2 1:2 1:2  1:2 
                MVI (ml/day)                         10 10 10  10 
                Trace Elements (ml/day)              1 1 1  1 
                Reg Insulin (units/day)                    
                Ranitidine (mg/day)                        
                Vitamin C (mg/day)                         
                  Custom Formulas               CENTRAL PERIPHERAL  LIPIDS-INTERMITENT ONLY 
                                             Dextrose > 10%        Dextrose ≤10% 
                Amino Acid %                            FAT (GMS)    Kcal 
                Dextrose %                                                                20%, 250ml           50               500 
                                                        
                Infusion Rate (ml/hr)                                                     20%, 500ml          100             1000 
                                                        
                Total Volume (ml/day)                   Infuse over 12 hours (20:00 –08:00): 
                Sodium (mEq/day)                                                           3 x weekly (Monday, Wednesday, Friday) 
                                                     70 70 
                Potassium (mEq/day)                                                        2 x weekly (Monday, Friday) 
                                                     60 60 
                Calcium (mEq/day)                                                          Weekly 
                                                     9 9 
                Phosphorus (mMol/day)                                                      Daily 
                                                     30 30 
                Magnesium (mEq/day)                  10 10 
                Chloride (mEq/day)             Choose Ratio         Choose Ratio            **WHEN CONSIDERING THE TOTAL DOSAGE OF 
                                                                                          LIPIDS, REMEMBER TO ACCOUNT FOR OTHER FAT 
                Acetate (mEq/day)              Choose Ratio         Choose Ratio         EMULSION MEDICATIONS BEING ADMINISTERED TO 
                MVI (ml/day)                                                             THE PATIENT (I.E., PROPOFOL CONTAINS 10% LIPIDS 
                                                     10 10  WHICH GIVES 1.1 Kcal/ml)** 
                Trace Elements (ml/day)              1 1 
                Reg Insulin (units/day)                 CHLORIDE:ACETATE RATIO 
                Ranitidine (mg/day)                     
                                                                                          1:1                     1:2                    1:3 
                Vitamin C (mg/day)                      
                                                                                         2:1                     3:1                    MAX ACETATE 
                                                        
                                                                                        Unless otherwise checked, 1:1 ratio will be standard.          
                 
                _______________________________________________ 
                Physician Signature                                                 Date/Time      
                                                                                                                                             Page 2 of 2
                *50015*                           FCO-730-1849 
                Rev: 7/2010 
                 
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...East jefferson general hospital parenteral nutrition solution order form standards and guidelines all pn orders or changes must be written on the completed submitted to pharmacy by daily standard administration time for s is consider other i v fluids medications when calculating total fluid volume per day dextrose infusions dosage due infection control issues approved policy lipids albumin are not mixed in solutions page of this orderset should only with initial check indication bowel ischemia severe acute pancreatitis ibd short syndrome pre operatively severely malnourished npo at least intractable vomiting diarrhea week prior surgery gi bleed obstruction inadequate expected nourishment resection ileus oral diet enteral days high output enteric fistula routine d c discontinued initiate rate ml hr x hours then increase target prescribed less than labs starting cmp magnesium phosphate triglycerides lft prealbumin twice weekly monday thursday triglyceride transferrin after weights strict...

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