Like I mentioned on Tuesday, I was in GI med two weeks ago and last week I was in GI surgery. I really liked GI surgery because there was a LOT of nutrition support – both tube feedings and TPN/vein nutrition. I love math, so I definitely love nutrition support.
This week was a huge turning point for me because I finally started writing my own TPNs. I know I’ve mentioned these a lot – so I wanted to take some time to explain them to y’all. This is my understanding, thus far, of TPN.
TPN stands for Total Parenteral Nutrition – which is nutrition that is completely broken down to individual molecules of dextrose (carbohydrate), amino acid (protein) and fatty acid (lipids). This is given through the vein – either in a peripheral vein (like an IV would be) or through a central line that dumps the nutrients straight into the veins that surround the heart. The blood delivers these nutrients straight to the organs for use. TPN is given when patients GI tract is not functional and nutrients cannot be broken down/and or absorbed into the GI tract and then moved into the blood stream that way.
TPN is the final step of nutrition support and our last resort in most cases. When patients can’t eat by mouth, we always want to feed enterally, or through a tube into the GI tract to ensure the GI tract stays viable. If you don’t use your GI tract for some time, essentially you will lose it. The cells will die and they will never be functional again. So TPN is used when we know we won’t be able to feed the gut for at least 5-7 days and can be used long term for life in some patients if they have severe GI problems.
TPN is very hard to write because it’s very volatile. In most patients, they aren’t taking in ANYTHING through the GI, so we have to provide everything they need in the TPN bag. In addition to the macronutrients – we are also giving micronutrients and electrolytes. We also can administer medications through the TPN bag, and we commonly give insulin because blood sugars are much higher on TPN. Essentially everything you put in that bag is being dumped, at a controlled rate via a pump, straight into the blood stream. The GI tract is not able to filter these nutrients slowly into the blood, so you have a constant stream of everything in the blood and it can be hard on the organs to constantly filter and use these nutrients.
We also are doing a lot of work with their fluid needs and working with the doctor to determine/supply the patients fluid needs for that day. The TPN runs exactly like an IV, so a lot of times the IV fluids will be reduced due to how much free water is in the TPN solution and/or how much extra sterile water we are adding to our bag.
We see these TPN patients every single day, including the weekend and we order them a brand new TPN bag every day based on their lab values from the day before. We correct all their electrolytes each day, as well as the medication levels, to keep these patients lab values as stable and in normal range as we can. At my hospital, these bags have to be ordered by 4pm and they are hung every night at 10pm. Every single one is custom made based on what we order for them to have. In addition to their lab values, we watch things like their triglyceride levels and liver function tests every few days to make sure we aren’t straining their bodies too much with our custom made formulas.
So this is obviously a daunting process. I’ve seen most of my preceptors write these, but I never understood how they were adjusting the electrolytes or how they knew what to do each day. GI surgery has one of the largest patient populations with TPNs because obviously we’re operating on the GI tract and it’s not always viable after surgery. My preceptor this week sat me down and taught me everything I needed to know for writing TPNs and gave me an amazing handout that walks you step by step through the process and the adjustments.
Because of her and because I caught on pretty quickly, I was writing my own TPNs without her by Wednesday. I wrote 3 TPNs Wednesday, Thursday and Friday and it was AMAZING. TPN writing has been the holy grail for me for weeks and I’m so happy this week I finally caught on and feel like I can do it mostly on my own now.
In addition to the TPNs, it was a lot of tube feedings and again with liquid diets – like last week. We can’t control when the patient is going to have their diet advanced in this situation, so we again become the advocate for them and watch to make sure they are advancing to a diet or receiving nutrition support within 5 days of becoming a Nothing by Mouth (NPO) order.
This week was all surgery patients. Here are some of the things I saw on the surgery floors, as well as in the surgery ICU:
- Head/neck cancer patients after surgery
- Mouth surgeries
- Gastrectomy (partial or full stomach removal)
- A TON of small bowel resections (cutting out portions of the small intestine and rejoining)
- Colon resections (partial and total)
- A ton of new ostomy patients
I did some diet educations on low fiber diets and also was supposed to do a new ostomy diet education and a gastrectomy diet education, but we had none ordered.
Overall other than nutrition support, I didn’t do a ton with the patient’s nutrition. I had a few patients that I spent a lot of time helping them with oral supplements and adding protein powder to their liquid diets. But again, I was working within the medical management of their GI disease.
I also spent time with an ET, or Enterostomal Therapy, nurse. These nurses teach patients how to care for their new ostomies and do some diet education with them. Unfortunately I had to leave half way through the session I saw for a new colostomy patient. It was way too much and I was not expecting the ostomy to look the way it did 3 days post surgery. Hopefully in a few months I’ll be able to try again with the ET nurse and see another ET nurse session.
Like I said, I loved this rotation. I really do love nutrition support and I definitely enjoyed all the work I did with it this week. I could definitely see myself doing my Staff Relief in this rotation to get more practice with TPNs. I actually felt like I made such an impact on the patients nutrition this week, much more than I felt I did in GI med.
I also had a patient that I followed from my GI med rotation into the GI surgery rotation and that was so special. I was the only person who cared for her from nutrition while she was in the hospital, so that was such a special experience for me and I really enjoyed it. I can’t wait to get into staff relief so I can see the same patients week after week and help them get better and out of the hospital.
Sadly, just as I get my feet wet with TPNs, I’m going to foodservice now. This week I’m in Purchasing/Production and rocking my white scrubs – so I’ll have more details about this first foodservice rotation for y’all next week.