Ordering Adult Total Parenteral

Nutrition (TPN)

All adult parenteral nutrition should be ordered within the Parenteral Nutrition (TPN) Adult Power Plan, with the exception of IDPN (please see IDPN QRG). Parenteral Nutrition (PN) is a complex and expensive process with potential risks and complications. Please refer to The Townsville Hospital Parenteral Nutrition (PN) in Adults procedure https://qheps.health.qld.gov.au/__data/assets/pdf_file/0037/474859/thhscli080406.pdf before ordering PN to ensure safe prescribing and administering of PN.

Placing the TPN order – initial prescribing

1. Navigate to Orders and click

2. Search for the Power Plan

3. Click on the order and click Done

4. Blood glucose monitoring, Line Care and Fluid balance orders have been pre-selected

5. Also tick Weight

6. Right click and Modify the Blood Glucose Monitoring POC order. Choose the appropriate order sentence for your patient as per local procedure.

7. Right click and Modify the Weight order. Choose the appropriate order sentence for your patient as per local procedure.

8. Untick TPN Additives (non-ICU) and select Cernevit and Addaven

a) If the Infuse Over time needs to be adjusted for either of these orders, right click on the order and select Modify. Change the infuse over hours and hit Enter on your keyboard. This will recalculate the Rate.

Dietitians will be required to enter a physician name and select Co-sign Required at this point. Until the Doctor co-signs this order, it will appear greyed-out in the MAR and there will be no task available for nursing staff to administer.

9. Select the appropriate PN solution for your patient as per local procedure.

10. A rate of 40mL/hr has been pre-filled for PN solutions within the Power Plan. Right click on the chosen solution and select Modify.

11. On the Continuous Details tab, adjust the infusion details if required:

a) Remove the Bag Volume

b) Enter the Rate and Infuse Over time

c) Press Enter on your keyboard. The bag volume will auto-calculate - this will reflect the total volume to be delivered across the infuse over period, NOT the bag volume.

12. Navigate to the Details tab:

a) Adjust the Requested start date/time. Ensure this time is in the future.

b) Review special instructions and ensure it includes Hang a new bag every 24hours. Remove Infuse one bag over 24hours if this is not appropriate.

c) The PN run time should also be documented in the special instructions ie run at 40ml/hr for 24/24

13. Click Initiate. You will be warned that interactions with parenteral solution and vitamins and trace elements will not be checked. Click OK.

14. Click Orders for Signature, review orders and Sign.

ALWAYS review the MAR/MAR Summary once the order is signed for by the MO to ensure it appears as expected.

Orders placed by the Dietitian will appear with the

status On Hold, Med Student. Until the MO co-signs this order, it will appear greyed-out on the MAR and there will be no task available for nursing staff to administer. For the Doctor to co-sign this they will need to right click on the order and select Cosign OR click on the Orders For Cosignature button below the orders screen.

Ordering a PN Solution that is not in the Power

Plan

The Baxter Olimel N9-840 electrolyte free solution is not included within the TPN Power Plan. It should be ordered within the Power Plan by following the below steps:

15. Follow steps 1-8 above

16. Order the PN solution from within the Power Plan by

clicking on Add to Phase and selecting Add Order…

17. Search for and select the correct solution

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18. Click Done

19. On the Continuous Details tab, adjust the infusion details:

a) Remove the Bag Volume

b) Enter the Rate and Infuse Over time

c) Press Enter on your keyboard. The bag volume will auto-calculate - this will reflect the total feed volume to be delivered across the infuse over period, NOT the bag volume.

20. Navigate to the Details tab

a) Remove the Duration of 1 and Duration unit of bag(s) to make this a continuous order

b) Adjust the Requested start date/time if required, otherwise it will set to the current date/time.

c) Review special instructions and ensure it includes Hang a new bag every 24hours.

d) The PN run time should also be documented in the special instructions ie run at 40ml/hr for 24/24

21. Click Initiate. You will be warned that interactions with parenteral solution and vitamins and trace elements will not be checked. Click OK.

22. Click Orders for Signature, review orders and Sign.

ALWAYS review the MAR/MAR Summary once the order is signed for by the MO to ensure it appears as expected.

Modifying the rate of the initial PN solution

23. Right click the original PN solution order and select Cancel/discontinue

Dietitians will not be able to complete this step. A Doctor will need to Cancel/Discontinue the original order.

24. Order the PN solution again from within the Power Plan

by clicking on Add to Phase and selecting Add Order

25. Search for and select the correct solution

26. Click Done

27. Repeat steps 19 – 22

When placed by the Dietitian this order will appear with the status of Proposal and will appear greyed-out on the MAR. For the Doctor to co-sign this they will need to right click on the order and select Accept.

Changing from one PN solution to another PN

solution

28. Right click the PN solution that you no longer require and select Cancel/discontinue

Dietitians will not be able to complete this step. A Doctor will need to Cancel/Discontinue the original order.

29. From within the Power Plan, select the lightbulb . This will show all the components within the Power Plan that have not yet been used.

30. Select the new PN solution by putting a tick in the check-box

31. Right click the new order and select Modify

32. Follow the instructions in Steps 10-14.

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