3.1 KiB
3.1 KiB
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.