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Forms/Nutrition/FRM-NUT-001-TPN-Order-Form.md

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+# Total Parenteral Nutrition (TPN) Order Form
+
+| Form ID | FRM-NUT-001 | Revision | 1.0 |
+|---------|-------------|----------|-----|
+
+---
+
+## Patient Information
+
+| Field | Entry |
+|-------|-------|
+| Patient Name | |
+| MRN | |
+| Date of Birth | |
+| Weight | ______ kg (Date: ______) |
+| Gestational Age (if neonate) | ______ weeks |
+| Order Date | |
+| Start Date/Time | |
+
+## TPN Type
+
+- [ ] Central TPN (peripherally unsafe)
+- [ ] Peripheral TPN
+- [ ] Transitional (enteral feeds advancing)
+
+## Base Solution
+
+### Dextrose
+- Concentration: ______ % (peripherally safe ≤ 12.5%)
+- Goal calories from dextrose: ______ kcal/kg/day
+
+### Amino Acids
+- [ ] TrophAmine (pediatric)
+- [ ] Aminosyn
+- Concentration: ______ g/dL
+- Goal protein: ______ g/kg/day
+
+### Lipids
+- [ ] Intralipid 20%
+- [ ] SMOFlipid 20%
+- Dose: ______ g/kg/day
+- [ ] Infuse over 24 hours
+- [ ] Infuse over ______ hours
+
+## Electrolytes (per liter or per day)
+
+| Electrolyte | Amount | Unit |
+|-------------|--------|------|
+| Sodium Chloride | | mEq/L or mEq/day |
+| Sodium Acetate | | mEq/L or mEq/day |
+| Potassium Chloride | | mEq/L or mEq/day |
+| Potassium Acetate | | mEq/L or mEq/day |
+| Potassium Phosphate | | mmol/L or mmol/day |
+| Calcium Gluconate | | mEq/L or mEq/day |
+| Magnesium Sulfate | | mEq/L or mEq/day |
+
+## Vitamins and Trace Elements
+
+- [ ] MVI Pediatric: ______ mL/day
+- [ ] MVI-12 (>11 years): ______ mL/day
+- [ ] Trace Elements Pediatric: ______ mL/day
+- [ ] Zinc (additional): ______ mcg/kg/day
+- [ ] Selenium (additional): ______ mcg/kg/day
+
+## Volume and Rate
+
+**Total Volume:** ______ mL/day
+
+**Infusion Rate:** ______ mL/hour
+
+**Goal Fluid Intake:** ______ mL/kg/day
+
+## Additional Additives
+
+| Medication | Dose | Indication |
+|------------|------|------------|
+| Heparin | | mL |
+| Carnitine | | mg |
+| Cysteine | | mg |
+| Vitamin K | | mg |
+| Other: | | |
+
+## Enteral Nutrition
+
+**Current Enteral Intake:** ______ mL/kg/day
+
+**Enteral Formula/Breast Milk:**
+- Type: ______
+- Rate: ______ mL/hour or ______ mL q____hours
+
+**Plan:**
+- [ ] NPO
+- [ ] Advancing enteral feeds
+- [ ] Stable enteral feeds
+
+## Laboratory Monitoring
+
+### Required Labs
+- [ ] Daily: BMP, ionized calcium, magnesium, phosphorus
+- [ ] Twice weekly: CBC, LFTs, triglycerides, albumin
+- [ ] Weekly: Zinc, selenium (if on long-term TPN)
+
+### Latest Laboratory Values
+
+| Lab | Value | Date |
+|-----|-------|------|
+| Glucose | | |
+| Sodium | | |
+| Potassium | | |
+| Chloride | | |
+| CO2 | | |
+| BUN | | |
+| Creatinine | | |
+| Calcium (ionized) | | |
+| Phosphorus | | |
+| Magnesium | | |
+| Triglycerides | | |
+| AST/ALT | | |
+| Bilirubin (total/direct) | | |
+
+## Special Instructions
+
+
+
+## Pharmacist Review
+
+**Reviewed by:** ______________________ **Date/Time:** ______________
+
+**Comments/Recommendations:**
+
+
+
+## Physician Order
+
+**Ordered by:** ______________________ **Date/Time:** ______________
+
+**Attending Physician Verification:** ______________________ **Date/Time:** ______________
+
+---
+
+*Form FRM-NUT-001 Rev 1.0*
+
+**CRITICAL:** Verify calculations before compounding. Check for incompatibilities. Ensure peripheral safety if no central access.