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