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HEALTH SERVICES CODE T.4
TITLE: TOTAL PARENTERAL NUTRITION
(TPN), ALSO KNOWN AS
NURSING PROCEDURE PARENTERAL NUTRITION (PN)
A. Set-Up & Administration
B. Care, Maintenance & Monitoring
C. Discontinuation
CATEGORY: RN, RPN – General
LPN – Additional Competency
PURPOSE
Set-up, administration, care, maintenance, monitoring and discontinuation of TPN in an
aseptic manner.
NURSING ALERT:
Follow TPN orders, (Adult TPN PPO360, Adult Base TPN PPO 359, Pediatric TPN PPO
654) for blood work and monitoring.
For Pediatrics a daily TPN Physician’s order is required. If there is no change to
order, “Same TPN” physician’s order is required.
A new TPN order form is needed for all changes with exception of rate. Rate
changes may be written on physician’s order sheet.
TPN must be ordered before 1100h. Pharmacy must receive TPN orders before 1200 hours
in order for it to be compounded for same day.
Strict aseptic technique must be maintained when preparing equipment and solutions.
Remove amino acid/dextrose solution from the refrigerator at least one hour before infusion
to avoid venous spasm and pain.
Must verify physician's orders against solution labels for additives with exception of chloride
and acetate and check expiry date before hanging TPN.
TPN is a high alert medication requiring independent double check at SMART pump
set up, hanging new bags and change of shift.
If TPN infusion is interrupted for > 4 hours, solutions and tubing must be discarded.
New tubing and solutions must be hung q 24 hours.
Observe solution for cloudiness, haziness, particles, and the bag for any leaks; if present
return solution to pharmacy.
If TPN is interrupted for more than 2 hours notify MRP and infuse D5W at 50 mL/hour as
noted on physician order form, unless otherwise specified by MRP.
For Pediatrics - run solution as ordered by MRP.
Solutions containing >10% dextrose and/or 5% protein must be administered through a
central venous access device.
Refer to nursing procedures C.2, I.7, P.11, T.3 for care and maintenance of CVAD’s
TPN should ideally be administered via a dedicated lumen, and this lumen should be
documented in patient care plan and nursing notes. If a separate lumen is not possible, stop
TPN during medication infusion and flush before and after.
Approved: December 17, 2021 Page 1 of 9
HEALTH SERVICES
CODE T.4
NOTE: There are two processes for ordering TPN:
1. Attending physician orders and monitors TPN.
2. A designated dietitian can initiate and manage TPN as follows:
Most Responsible Physician (MRP) writes an order for “TPN per
dietitian”, which gives authority for dietitian to initiate and manage
TPN including any subsequent changes.
A. SET-UP & ADMINISTRATION
EQUIPMENT
1. Personal Protective Equipment (PPE)
2. Infusion SMART pump
3. Sterile TPN pump tubing with Luer Lock® and a 0.2 micron filter for amino acids.
4. Use a 1.2-micron filter for all PN solutions with lipids [“total nutrient admixtures” (TNA)],
dextrose-amino acid mixtures, and lipid injectable emulsions. See appendix 3.
5. Medfusion Pump, if needed for lipids for pediatric patients
6. Sterile secondary IV pump tubing for lipids
7. Alcohol swabs
8. TPN solution
9. IV tubing label – stock # 200052
NURSING ALERT:
Base TPN for patients on adult nursing units at PH and RGH must be ordered by MRP or
dietician using Adult Base TPN PPO (PP-359) from pharmacy during regular hours.
Critical Care areas have base TPN available as ward stock for critical care patients only.
If adult base TPN is not available, running D5W is an appropriate alternative and should be
discussed with MRP.
TPN Registered Dietician (RD) on call or Unit RD (during regular work hours) should be
contacted to reassess TPN requirements at 0800h the next day.
PROCEDURE
1. Check amino acids solution and lipid solution against physician’s order for the following:
Correct patient
Expiration date
Formula compounds
Correct rates and volumes
Central Line or Peripheral Line TPN (Appendix 1)
NOTE: 2 RNs/LPNs are required to sign on MAR per Medication Administration
policy.
2. Observe amino acids solution for cloudiness, turbidity, particles and bag leaks.
NOTE: If any of these are present, return solution to pharmacy.
3. Perform hand hygiene.
Approved: December 17, 2021 Page 2 of 9
HEALTH SERVICES
CODE T.4
4. Don appropriate PPE.
5. Remove protective tab from bag of amino acid/dextrose solution, keeping end sterile.
NURSING ALERT:
Maintain sterility of connecting ends throughout procedure. Do not prime tubing around
highly contaminated areas such as sinks, garbage cans, dirty counters, etc.
6. Insert spike from filtered TPN tubing set into solution bag maintaining sterility of tubing
ends, and hang on IV pole.
7. Prime tubing as recommended by manufacturer’s instructions.
8. Remove tab on lipid bag, or cap of syringe
8.1 For solution in bags:
Secure port and hold straight.
Insert spike from secondary tubing set with upward twisting motion into the lipid
bag while maintaining sterility of tubing ends. Hang on IV pole.
NOTE: Do not force spike into hub.
8.2 For solution in a syringe:
Attach Luer lock end of tubing to Luer lock end of syringe.
Prime by pushing down on syringe plunger until a drop of fluid is seen coming
out of end of microbore tubing.
9. Prime secondary tubing (or microbore tubing, if lipids in syringe for pediatrics) as
recommended by manufacturer's instructions.
10. Connect secondary tubing to secondary port on cassette of TPN tubing.
11. Connect microbore tubing to Medfusion pump if lipids in syringe and connect microbore
tubing to the distal end of TPN tubing, using a y-site or double-ended connector.
12. Set TPN flow rates on SMART pump (and Medfusion pump) according to MRP order.
NOTE: Amino acids are infused on line A and lipids on line B with infusion
SMART pump set on concurrent mode.
Amino Acids are under parenteral nutrition on SMART pump. Choose
2:1, then in clinical use choose 24 hours if running TPN over 24 hours,
choose cyclic if running TPN over a time period (e.g. night time only).
Lipids are under lipids on the SMART pump. Choose the type of lipid
solution ordered (e.g. SMOF) when setting the lipids).
An independent double check is required at SMART pump set up.
Approved: December 17, 2021 Page 3 of 9
HEALTH SERVICES
CODE T.4
13. Check patient identification using two client identifiers
14. Cleanse connection site vigorously with alcohol swab for 15 seconds and let dry.
15. Use a dedicated lumen for TPN if possible and document the lumen in care plan and
nursing notes. If dedicated lumen not available, stop TPN infusion and flush lumen prior
and after medication administration.
16. Connect to client’s central venous access device (CVAD) or IV site as indicated.
NOTE: TPN solutions with less than 10% dextrose and an osmolarity less than
900 mOsm/L may be administered peripherally if CVAD is not available.
Find this information on the label of amino acid bag.
NOTE: Peripheral TPN should be limited to 10-14 days as a primary nutrition
source.
17. Start infusion.
NOTE: It is important to monitor peripheral venous access sites for phlebitis and
infiltration. If client develops pain, thrombophlebitis or infiltration, stop
infusion and notify physician.
18. Document and sign on M.A.R.
B. CARE, MAINTENANCE & MONITORING
PROCEDURE
1. Weigh patient pre-TPN and then per orders.
NOTE: Pediatrics require weight daily and height weekly.
2. Monitor blood glucose QID x 48 hours and then as ordered.
NOTE: Ensure a new TPN order form for all changes except rate, which can be
written on Physician’s Order sheet.
3. Obtain and record vital signs – including temperature, blood pressure, pulse and
respiration QID for duration of treatment unless otherwise ordered.
4. Clear SMART pump totals at end of shift and record accurate Intake and Output every
shift (q 12 hours) with 24 hour totals.
5. Change tubing and solutions every 24 hours if lipids running concurrently on Smart
Pump. (See Appendix 2).
NOTE: If TPN infusion is interrupted for more than 2 hours, solution and tubing
must be discarded. Notify MRP and infuse D5W at 50 mL/hour as
specified on the TPN orders unless otherwise specified by MRP.
Resume TPN as ordered when available.
Approved: December 17, 2021 Page 4 of 9
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