TPN

TPN aka
Hyperalimentation

Indications for TPN

used to meet nutritional needs for pts who can't ingest, absorb, or digest essential nutrients via the GI
tract

TPN Nutrient Components

amino acids, glucose, fat emulsion, vitamins, electrolytes, minerals, trace elements, water, glucose
concentration (10% for adults, 15-25% depending on condition of pt)

Infusion Considerations
if glucose concentration > 10%, administered via central or PICC line; TPN infusions administered via a
"dedicated port" of a central line; TPN is "custom" mix and reconstituted in pharmacy under strict,
aseptic technique

Infusion Guidelines
Administered via an infusion pump usually over 24 hours; TPN, lipids, and tubing changed every 24
hours; TPN is administered with in line micron filter (special IV tubing), no meds are added to TPN
solution bags; infused as a closed system and no piggy backing; kept refrigerated until 30 min prior to
being infused

If TPN infusion unavailable

IV solution of Dextrose 10% and water (D10W) until TPN available, to prevent rebound hypoglycemia

Lipids
can be given as separate infusion and don't require refrigeration, may be administered via peripheral IV
catheter, do not require filtered IV tubing, no filter

Clinical Do's
check bag against order for correct pt name, formula, components, and expiration date; keep
refrigerated until ready to infuse, use strict aseptic technique, change solution and IV tubing every 24
hours, BG is monitored (at least 4x a day) and insulin administered per protocol; monitor for signs of
hyperglycemia; monitor central access site for signs of infection; monitor pt for signs & symptoms of
infection/sepsis

Clinical Don'ts
Don't store TPN solution at room temp - high glucose concentration and warmth promote bacterial
growth; Don't add any medications or anything to TPN bag on unit; Don't administer meds as a
secondary infusion to the TPN; Don't administer meds through the same central catheter lumen as TPN
solution

Examine solution for

turbidity, precipitation, cloudiness; examine container for any holes or cracks

Prior to hanging solution:

RN checks pharmacy label and prescriber order form for: pt name and MRN or birth date, solution
contents (every line), expiration date and time, signs off parenteral nutrition order

Procedure
prime IV tubing and hang solution on infusion pump using sterile technique, connect primed needleless
tubing to pt's IV catheter, date & time solutions hung and tubing

Infusion Maintenance
check pt and infusion rate every hour to maintain prescribed infusion rate; maintain secure connections
of entire system; assess central and peripheral VI sites for infection, phlebitis, pain, purulent drainage

Monitor pt for complications, such as

fluid volume excess, hyperglycemia, hypoglycemia, osmotic diuresis and fluid volume deficit, electrolyte
imbalances, s/sx of infection

Potential for Infection

monitor and assess for s/sx of systemic and line relation infection

systemic infection
fever, shakes, chills, lethargy, glucose consistently greater than 200 mg/dl; check WBC and differential

Causes of Hyperglycemia (glucose greater than 200 mg/dl)

too rapid infusion of TPN, infection/sepsis, medication induced, co-existing diabetes mellitus

Causes of Hypoglycemia (glucose less than 60 mg/dl)

abrupt decrease in rate, abrupt discontinuation of TPN

Risk for fluid volume overload

monitor s/sx: tachycardia, hypotension, distended neck veins, weight gain, crackles on lung auscultation;
maintain strict I&O, daily weights

Risk for fluid volume deficit

monitor for s/sx: decreased urine output, pt verbalized feelings of thirst, decreased skin turgor,
tachycardia, orthostatic hypotension; maintain strict I&O, daily weights

Risk for electrolyte imbalance

monitor and report s/sx: muscle weakness, lethargy, cramps, muscle twitching, cardiac rhythm changes;
monitor & report any abnormal serum electrolyte levels

Hypertriglyceridemia
infuse lipids as ordered, obtain baseline and weekly serum triglyceride levels, use caution when
administering meds that are lipid based

Hyperal & Intralipids

must be hung separately

IV tubing for TPN

0.22 micron filter

IV tubing for lipids

no filter
CHEMOTHERAPEUTIC AGENTS
Chemotherapeutic Agents
1. Antibiotics
2. Synthetic Drug

Antibiotics
- A chemical substance naturally produced by microorganism that has the capacity to inhibit or kill other
microbes

Synthetic Drug
synthesized; can me a modified natural antibiotic (semi-synthetic)

Spectrum of Activity
1. Narrow spectrum
2. Broad spectrum
3. Selective toxicity
4. Adverse effects
5. Mechanisms of drug resistance

Narrow spectrum
- Drugs that work against only a few kinds of pathogens. Example - penicillin is limited for treatment of
Gram positive infection

Broad spectrum
- Effective against many different types of microorganisms. Example - erythromycin can be be used to
treat Gram positive, Gram negative, chlamidial and rickettsial infections.
Selective toxicity
- want to select a drug that will have maximum activity against the pathogen with minimal damage to
host

Adverse effects
a. Allergic reaction
b. Toxic effects
c. Suppression of normal flora

Mechanisms of drug resistance

a. Plasmids
b. Contributing factors

Mechanisms of action
1. Inhibition of cell wall synthesis
2. Disruption of nucleic acid synthesis
3. Inhibition of protein synthesis
4. Disrupt cell membrane function
5. Antimetabolites

Inhibition of cell wall synthesis

disrupt peptidoglycan synthesis; can prevent assembly or peptide bridge formation
Disruption of nucleic acid synthesis
various mechanisms; base analogs are erroneously incorporated into nucleic acids; may interfere with
replication process

Inhibition of protein synthesis

accomplish this by binding to the ribosome complex and preventing translation; one issue with toxicity is
that mitochondrial ribosomes have same structure as prokaryotic ribosomes

Disrupt cell membrane function

may interact with phospholipids in membrane or complex sterols

Antimetabolites
- the drug mimics a growth factor; pathogen erroneously binds to the analog

Antibacterial Drugs that disrupt cell wall synthesis

1. Penicillin family
2. Cephalosporins
3. Bacitracin
4. Vancomycin

Penicillin family
- drugs that inhibit peptidoglycan synthesis by preventing the crosslinking of the NAM subunits. The
penicillin binds to and deactivates the enzyme that catalyzes the NAM crosslinking. Without the ability
to form peptidoglycan, the cell wall weakens and ultimately the cell lyses. The active portion of these
drugs are referred to as the beta lactam rings
a.Natural penicillins- Penicillin G (Discovered by Fleming in 1929) and Penicillin V
b.Semisynthetic penicillins- Methicillin, Ampicillin and Amoxicillin
c.β Lactam ring Structure - structure in the penicillin that is required for function
d.Resistance due to presence of Beta-lactamase, modification of the bacterial enzyme so that the drug
no longer binds, or a change in the bacterial outer membrane to prevent entrance of the drug.

Cephalosporins
- have a similar action to the penicillin family. They possess the beta lactam ring structure and disrupt
the formation of the peptidoglycan by blocking the crosslinking of NAM.
a.Spectrum - Gram positive, later generations are active against Gram negatives
b.Natural - Cephalothin
c.Semisynthetic - Ceflacor and Cephalexin
d.Resistance would be similar to penicillin family

Bacitracin
Appears to have three modes of action - interferes with cell wall synthesis, inhibits RNA transcription
and damages cell membrane.
a.Narrow spectrum - Gram +.
b.Topical use only - toxic to kidneys.
c.Resistance due to changes in the cell membrane that block entrance of the drug

Vancomycin
- Disrupts peptidoglycan (NAM)
a.Gram positive bacteria
b.Used to treat serious systemic infections
c.Resistance - VRE and VRSA

Antibacterial Drugs that disrupt protein synthesis

1. Aminoglycosides
2. Tetracycline
3. Chloramphenicol
4. Macrolides

Aminoglycosides
Aminoglycosides - This group of drugs target the 30S ribosomal subunit by changing its shape. This
makes it impossible for the ribosomes to read the mRNA correctly, disrupting protein synthesis.
d.Broad spectrum of activity.
e.Kanamycin, streptomycin, gentamycin, neomycin and tobramycin.
f.Toxicity - adverse effects include toxicity to kidneys and auditory nerves.
g.Resistance - Aerobic bacteria alter pores to prevent uptake of drug or synthesize enzymes that break
down the drug. Anaerobic bacteria are naturally resistant.

Tetracycline
Tetracycline- This group of drugs prevents the tRNA molecules from binding to the 30S ribosomal
subunit during protein synthesis, disrupting protein synthesis.
a. Broad spectrum of activity, most effective against Gram + and - bacteria.
b.Tetracycline, Doxycycline, and Trimocycline.
c. Adverse effects include diarrhea, nausea, sensitivity to light, complexes with calcium and discolors
teeth as well as affects bone strength.
d. Resistance due to alteration of pores to prevent drug entrance, alter binding site on ribosome to
allow tRNA binding with drug present, or actively pump drug out (Efflux)

Chloramphenicol
binds to the 50S ribosomal subunit and prevents protein synthesis by blocking movement along the
mRNA.
a.Broad spectrum
b.Toxicity- rarely used due to adverse effect; patient may suffer from aplastic anemia or neurological
damage
c.Resistance due to R - plasmid gene that codes for an enzyme that deactivates the drug.
Macrolides
binds to the 50S ribosomal subunit, blocking protein synthesis by preventing elongation.
a. Spectrum -effective against Gram + and a few gram
b. Erythromycin, Clarithromycin, and Azithromycin
c. Adverse effects include nausea, mild gastrointestinal pain and vomiting
d. Resistance due to changes in the bacterial ribosomal RNA that prevents the drug from binding or R
plasmid genes that code for macrolide digesting enzymes.

Antibacterial Drugs that disrupt nucleic acid synthesis

Quinolones

Antibacterial Drugs that disrupt folate biosynthesis

Sulfonamides

Quinolones
Inhibit topoisomerases, enzymes required for nucleic acid synthesis
a.Spectrum - Gram negatives and Gram positives
b. Ciproflaxacin and ofloxacin

Sulfonamides
A synthetic drug that is a growth analog of PABA. It binds irreversibly to the enzyme that produces folic
acid; inhibit folic acid synthesis
b. Broad spectrum.
c. Adverse effects are rare but include allergic reactions, anemia, jaundice and mental retardation of
fetus in the last trimester of pregnancy.
d. Competitive inhibition - competes with PABA for enzyme active site

Antibacterial Drugs that Disrupt Cell Membranes

Polymyxin B

Polymyxin B
Destroys cell membranes.
e. Spectrum -effective against Gram - bacteria, particularly Pseudomonas
f. Topical use only due to kidney toxicity
g. Resistance due to changes in the cell membranes that prohibit entrance of the drug.

Anti-viral drug Targets

1. Viral Uncoating
2. Base analogs
3. Reverse transcriptase inhibitors
4. Protease inhibitors
5. Neuraminidase inhibitors

Antifungal Drug Targets

Plasma membrane
1. Macrolide polyenes
2. Azoles

Macrolide polyenes
inhibit protein synthesis
a. Amphotericin B - used to treat systemic fungal infections; injury to plasma membrane
b. Nystatin - toxic for systemic use

Azoles
- interfere with sterol synthesis; plasma membrane synthesis
a. Ketoconazole - topical use for skin; oral use for systemic infections
b. Itraconazole and Fluconazole - interferes with ergosterol synthesis
c. Clotrimazole and Miconazole - topical use for skin and mucous membrane

Nucleic acid synthesis

Flucocytosine - inhibits RNA and DNA synthesis; systemic fungal infections

Cell Division
Griseofulvin - inhibition of mitotic microtubules; infections of skin
PATIENT CONTROLLED ANALGESIA

Patient Controlled Analgesia

PCA is a method of providing analgesia using a computerized pump that allows patients to self-
administer predetermined dose of opiods. Manage their own pain by delivering analgesic dose within
present parameters. Commonly used for postop procedures and those with extreme cancer pain.

PCA Indications
Moderate to severe pain requiring opiod medication. Pain anticipated to last more than 10-12 hours.
Patient willing to take control of their analgesia. Patient able to understand PCA. The oral route is not
appropriate.

PCA Contraindications
Lack of staff training in PCA. Patient's inability to understand PCA. Patient obtunded or sedated. Physical
impediments to pushing the PCA button. Opioids are contraindicated.

PCA Advantages
Patient has sense of control. Painless. Reduce demands of nursing. Adjustable to meet individual patient
needs.

PCA Disadvantages
Comprehension and cooperation of the patient. Not appropriate for ages under 7. Hazards due to
programming or delivery system.

Morphine
Schedule II drug. Metabolized in the liver and excreted in the kidneys. Contraindications: Allergic to
morphine, renal dysfunction, hepatic dysfunction, asthma. Slow onset. Advantages are inexpensive.
Disadvantage is slow onset, histamine release, increased accumulation of morphine with liver
dysfunction. Opioid side effects: nausea, sedation, respiratory depression.
Intravenous
Most commonly used. More rapid delivery method because it is injected. Can control timing of dosing of
their breakthrough analgesic based on their own assessment of their plan.

Epidural Catheters
Often used to provide pain relief during labor/delivery. Inserted and left in place for a few days. Provides
better postop analgesia and pain relief than IV. Enhanced exercise capacity.

Regional (Peripheral Nerve Catheter)

Nerve block technique: (brachial plexus, sciatic nerve, femoral nerve). Increased postop analgesia and
patient satisfaction. Infections and neuro complications are possible.

Transdermal
Relatively new method. Preprogrammed. Eliminates the need for venous access. Low intensity. 6
demand doses per hour.

Non-Pharm Methods
Cold therapy, elevation, compression, e-stim.

Loading Dose
The amount of drug required to achieve an initial level of analgesia. The size of the initial dose is
determined by: weight, age, physical status, and opioid tolerance.

Maintenance Dose
PCA dose of opioid is the amount of drug the PCA pump will deliver when the demand button is pressed.
It is the amount of the drug required to help maintain its effects.

Lockout Interval
Period that PCA unit is in refractory. Necessary safeguard to prevent patients from taking additional
doses before appreciating the effect of the preceding dose. Morphine- 8 min.

Four-hour Limit
Safety feature that prevents a patient from receiving more than a pre-determined amount of opioid
within a 4 hour period. Moving window that accounts for drug intake during the four hours preceding
any given moment. IF the four hour limit has been reached and the patient is in pain, four hour limit
should be increased and appropriate dose/ doses should be given.