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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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