# Total Parenteral Nutrition (TPN) Order Form

| Form ID | FRM-NUT-001 | Revision | 1.0 |
|---------|-------------|----------|-----|

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## 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:** ______________

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*Form FRM-NUT-001 Rev 1.0*

**CRITICAL:** Verify calculations before compounding. Check for incompatibilities. Ensure peripheral safety if no central access.