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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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