CHAPTER 6 daily schedule.7 Energy needs should be determined with the patient and


based on a goal weight for weight maintenance, weight gain, or weight loss. An administration schedule should be created, and blood glucose and serum electrolyte levels need to be stable before discharge. Patient intake and output data should be evaluated before hospital discharge to ensure that the HPN formula provides sufficient fluid for adequate urine production and that it accounts for all GI losses (eg, diarrhea, stoma or fistula effluent, emesis, gastrostomy tube output, or drains). The HPN formula should not provide excess fluid because this could lead to fluid overload, especially for patients with underlying comorbidities (eg, car- diac failure). Ensuring that the patient is receiving a stable PN formula before discharge should allow for weekly monitoring of laboratory values; more frequent monitoring is often not realistic in the home setting.7 The HPN formula should be similar to the hospital PN formula and con-


sist of macronutrients, vitamins, minerals, and electrolytes. HPN formulas may be made as a 2-in-1 (dextrose and protein) or 3-in-1 (dextrose, protein, and lipid) formula. Patients receiving 2-in-1 formulas where PN is the sole source of nutrition require lipids, which are infused separately, to be given at least once per week to meet essential fatty acid requirements. Patients who receive and absorb fat from oral or enteral nutrition may not need to receive IV lipids. Refer to Chapter 3 for more information on PN formulas. Some medications normally added to PN formulas prepared daily by


a hospital pharmacy cannot be premixed in HPN formulas because they are not stable for extended periods of time. Patients must be taught to inject these medications, which may include multivitamins, histamine 2-receptor antagonists, insulin, and octreotide, into their HPN formulas daily.18


Infusion Schedule


Patients receiving HPN typically have their HPN formula cycled during part of the day, which provides the following benefits:


ƒ Cycling allows the patient freedom from the pump and other PN equipment for a portion of the day, promoting a more normal life- style.


ƒ It allows time to administer other IV medications, such as anti- biotics or chemotherapy.


ƒ A cycled infusion may prevent parenteral nutrition–associated liver disease (PNALD) because the liver is not continuously


metabolizing the nutrients from the PN. This allows mobilization of stored glycogen and decreases the incidence of fatty liver.19,20


94


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