clinical guideline & competency total parenteral …

Author: Lizzie Hutchison & Wendy Saegenschnitter of 9

SETTING Bristol Royal Hospital for Children (BRHC), Neonatal Intensive Care Unit (NICU), St Michael’s Hospital

FOR STAFF All registered nurses who are competent as intravenous (IV) givers and in the administration of TPN.

PATIENTS Paediatric and neonatal inpatients

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GUIDANCE

This document is intended to provide guidance to nurses on the setting up, checking and administration of TPN (two nurses technique). One nurse setup technique has been deemed suitable in specialist areas where staffs are trained; in all other circumstances a two nurses setup technique should be followed.

Procedure does not include titration of fluids, adding on of Patient Controlled Analgesia (PCA) or insulin.

Nurse 1 – Set up Nurse Nurse 2 – Lead Nurse

SMOFF Lipid solutions sent in an infusion bag should be filtered using a 1.2 micron filter infusion set. SMOFF Lipid sent in a syringe does not require a filter.

Only NICU Aqueous solutions should be filtered using 0.2 micron filter.

Nurse 1

Wash and dry hands. Clean dressing trolley. Gather all equipment required:

Sterile field; Aqueous PN infusion set; Lipid (syringe) extension set or Lipid (bag) infusion set (for SMOFF lipid infusions

supplied in a bag this should be a 1.2micron filter blue infusion set, see note above); Vamin & Lipid label; Sterile gauze; 2% chlorhexidine in 70% alcohol wipes; Blue needles; 10ml syringe/s; 0.9% sodium chloride; Sterile gloves; MicroCLAVE needle free bung – Double extension set or Triple extension set (if due

weekly change);

Clinical Guideline & Competency TOTAL PARENTERAL NUTRITION (TPN) SETUP (TWO NURSES TECHNIQUE), CHECKING & ADMINISTRATION

Version v2.1 From: Dec 18 – To: Dec 20 Extended until January 2022

http://nww.avon.nhs.uk/dms/download.aspx?did=16168

Version v2.1 From: Dec 18 – To: Dec 20 Author: Lizzie Hutchison & Wendy Saegenschnitter of 9

Hat, sterile gown & mask (NICU only: Matching Michigan guideline).

Check Aqueous TPN & Lipid bags/syringe labels, prescription & pharmacy sheet for: Correct patient name; Date of birth; Hospital number; Correct day of PN (i.e. day 6, Tuesday); Expiry date; Glucose concentration correct for type of IV access (see note); Route of administration (central or peripheral).

Also assess Aqueous TPN & Lipid for particles, leakage and discolouration. If anydiscrepancy, contact pharmacist or medical staff.

Nurse 2 to handle bags/syringe & paperwork.

Nurse 1 Nurse 2

(NICU only) Put on hat & mask. Wash and dry hands thoroughly.

NICU: Wash hands with soap and water and dry thorough using sterile hand dressing towels.

BRHC: Wash and dry hands thoroughly and put on a clean, disposable apron.

Put on sterile gloves. (NICU only) Put on sterile gown. (NICU only) Take gloves from pack

and put them on following correctprocedure.

(NICU only) Hand nurse 1 sterile gown and sterile gloves, without contaminating them.

Take sterile field and open out on surface to be used.

Open sterile field/dressing pack and give to Nurse 1 without contaminating it.

Take items from nurse 2 and place on sterile field, protecting key parts.

Open giving sets, needles etc. and hand to Nurse 1 without contaminating them.

Connect any add on device to giving sets, close flow clamps, ensure all connections are securely attached to one another.

Check and draw up Sodium Chloride0.9% into syringes.

Prime MicroCLAVE Trifuse/Bifuseextension set (if due bung change)

Check and hold Sodium Chloride 0.9%, invert for Nurse 1 to draw up.

Spike infusion set into Aqueous TPN. Clean access ports on Aqueous PN with 2%chlorhexidine in 70% alcohol wipes

Remove protective cover/cap. Hold Aqueous PN so Nurse 1 can spike giving

Extended until January 2022


set. Place yellow Vamin label onto giving set

Spike infusion set into Lipid bag. For Lipid syringe screw on infusion

tubing to luer of lipid syringe

Clean access port on Lipid bag/syringe with 2% chlorhexidine in 70% alcohol wipes

Remove protective cover/cap. Hold Lipid so Nurse 1 can spike infusion set/for

Lipid syringe hold while Nurse 1 connects tubing

Place white Lipid label onto giving set

Prime infusion sets by opening flow clamps.

Ensure prime flow rate is slow enough and giving set is inverted to prevent air bubbles and ensuring the sterile field does not become wet.

If Lipid syringe push plunger to prime infusion tubing

(NICU only) Connect both giving sets together using appropriate MicroCLAVE Bifuse/Trifuse extension set & prime.

Any remaining ports to be primed using 0.9% saline.

Take unopened 70% alcohol with 2% chlorhexidine wipe to the patient along with the Aqueous TPN, Lipid.

Leave the prescription and pharmacy insert sheet outside the patient’s room. All checks should now be done between: PRODUCT, PUMP & PATIENT.

Go to patient & confirm identity against Aqueous TPN/Lipid bag/syringe (PRODUCT)

If there is ongoing infusion of TPN - Stop infusion pumps, clamp giving sets and clamp the patient’s IV line.

Disconnect the existing TPN infusion from patient.

Remove old infusion sets from pumps

Open 2% chlorhexidine in 70% alcohol wipes

for nurse 1.



Hold patient’s IV line for nurse 1.

Hold IV line with 2% chlorhexidine in 70% alcohol wipe or gauze.

If weekly MicroClave Bifuse or Trifuse extension bung due change do so now.

Clean with 2% chlorhexidine in 70% alcohol wipe and remove bung/extension set.

Clean lumen end with new 2% chlorhexidine in 70% alcohol wipe for 15 seconds, making sure you do not contaminate.

Allow to dry. Connect new bung/extension set

to line.

Clean bung hub for 15 seconds using scrubbing action, then leave to dry for 30 seconds.

Flush TPN lumen with 0.9% sodium chloride using a push-pause action.

Connect new TPN infusions lines to patient. Confirm infusion set is firmly connected to patient's bung.

Feed Aqueous TPN and then Lipid infusion lines into pump/syringe driver.

Independently checking from the Aqueous TPN PRODUCT, to the PUMP, and to the PATIENT IV connection, confirming the hourly rate is the same.

Independently check the Aqueous TPN PRODUCT volume to be infused is the same as the infusion PUMP volume limit.

Independently checking from the Lipid bag/syringe PRODUCT, to the PUMP, and to the PATIENT IV connection, confirming the hourly rate is the same.

Independently check the Lipid bag/syringe label PRODUCT volume is the same as the volume limit set on the infusion PUMP/syringe driver.

Start Aqueous TPN & Lipid infusions. Re-check correct infusion rates tracking from infusion bag/syringe to pump to patient. Agree this is correct.

Safely dispose of all used equipment and sharps.



Sign & document start time on prescription chart and pharmacy insert sheet.

Note:

At any change of nurse allocation (e.g. shift change over) the Aqueous TPN and Lipid infusion rates must be checked and confirmed as correct for the PATIENT against the TPN bag/syringe labels (PRODUCT) and the infusion PUMP setting. Each infusion line should be checked from the infusion bag or syringe along all the tubing with confirmation the PATIENT connection is secure. These checks should be documented.

Aqueous & Lipid rates must never be titrated higher than original pharmacy prescription due to the risk of electrolyte disturbance. Titration of TPN can only be at a rate lower than the pharmacy prescription. Where additional IV replacement is required TPN should not be used for this and an appropriate alternative IV fluid should be prescribed.

Due to the high concentration of glucose there is a risk of extravasation injury if Aqueous TPN infiltrates the patient’s tissue.

Any Aqueous TPN solution with a glucose concentration of 12.5% or greater should only be administered via a central line.

If peripheral administration is necessary the glucose concentration must be less than 12.5% and hourly IV cannula assessment (PIPA) undertaken and documented.

Wherever possible, ensure one lumen has been designated for TPN use. MicroCLAVE Bifuser/Trifusers used to connect lipid and aqueous solution to a single

patient lumen and provide additional access for blood sampling or antibiotic administration should be connected directly to the patients lumen end. These may then be changed as per weekly MicroCLAVE bung change protocol.

If the TPN administration set is disconnected from the patient at any time, the TPN and giving set must be discarded. A TPN infusion should never be restarted if disconnected.

Document hourly the infusion pump pressure setting, the rate & volume infused on fluid balance chart. Monitor patient’s overall fluid balance.

TPN should be run through its own infusion line and should not be mixed with other medication. Where this is not possible due to limited IV access then refer to the pharmacy infusion folder for compatibility information, or speak to your designated pharmacist.

Fill in a Trust incident form if there is any accidental disconnection, equipment fault or clinical incident.

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RELATED DOCUMENTS

Paediatric Parenteral Nutrition Guidance Parenteral Nutrition Worksheet for Nurses Central Venous Catheter Guidelines for Paediatrics Central Venous Catheter Competency Workbook

AUTHORISING BODY

Nurse Practice Group

QUERIES BRHC: TPN Clinical Nurse Specialist: Bleep 1051 Mobile 07900690035 NICU: Contact any senior nurse on NICU: Extension 21736/21737



http://workspaces/sites/Teams/IVAndCentralLineNurseGroupBCH/Working%20Group%20Papers/TPN%20worksheet%20%20March%202014.doc




Appendix A – Total Parenteral Nutrition (TPN) Nursing Competency Assessment for Setup, Checking, Administration & Care of a Patient. Aim: To ensure that all nursing staff involved in the setup, checking, administration and care for children and young people having PN are competent to undertake this skill as outlined in the PN guidelines. Entry Criteria:

A registered nurse who is competent in intravenous medication administration. Prior to undertaking this role the registered nurse will have:

o Read the Paediatric Total Parenteral Nutrition (TPN) Guide; o Completed the Total Parenteral Nutrition Worksheet.

Standard: To achieve competence the registered nurse should demonstrate knowledge, understanding and performance for all components at level 4 during formative assessment. Assessment: The registered nurse will have completed the Parenteral Nutrition Worksheet and then observe the practice of an experienced member of the ward nursing team; this will be followed by a period of supervised practice. Competency will be assessed through demonstration of the knowledge, understanding and performance of skills required. References: Paediatric Chief Pharmacist Group (2011) Improving Practice and Reducing Risk in the Provision of Parenteral Nutrition for Neonates & Children.

Knowledge and Understanding Criteria Level of achievement

Assessor Sign/date

Has completed the TPN worksheet

Can discuss the rational for TPN treatment for patient

Is aware of the monitoring & assessment required for a patient receiving TPN

Can identify the potential risks associated with TPN infusion

Understands why TPN with a glucose concentration >12.5% must be infused by a central line

Can discuss the assessment criteria for both peripheral and central lines during TPN infusion

Is aware when the MicroCLAVE Bifuse or Trifuse extension set (Bungs) are scheduled to be changed

Can discuss the underlying rational for using a sterile non touch technique when setting up TPN

Can identify the steps required to prevent the incorrect infusion of either Aqueous PN or Lipids



Can discuss what independent checking means

Understands that Aqueous & Lipid solution rates must never be titrated higher than the original pharmacy prescription. Titration of TPN must only be at a lower rate than the pharmacy prescription.

Knows who to contact if there is a problem or concern about TPN (normal working hours & out of hours)

Performance Criteria Independently checks from the Aqueous TPN & Lipid bag/syringe with prescription and pharmacy sheet before setup for;

Correct patient, date of birth, T number Correct day (e.g. day 6, Tuesday) Expiry date Route of administration appropriate for IV access Assess Aqueous PN/Lipid for particles, leaks,

discolouration

Gathers all necessary equipment

Demonstrates a safe & sterile non touch technique to setup & prime

Checks the patient identity from the patient wrist band with the Aqueous PN/Lipid bag/syringe labels & prescription on the fluid chart.

Scrubs the hub of the bung for 15 seconds & allows it to dry. Connects infusion lines to patient using Sterile technique.

Independently checks the hourly rate of Aqueous PN from the bag label is same as the rate set on the infusion pump

Independently checks the hourly rate of Lipid from the bag/syringe label is the same as the rate set on the infusion pump

Check that the infusion lines are securely connected to the patient’s IV device

Documents start of infusions on prescription sheet & pharmacy sheet

Ongoing care during PN infusion At start of shift, tracing the line from the Aqueous bag to the patient ensuring the correct line is in the correct pump by confirming correct hourly infusion rates.

At start of shift, tracing from the Lipid bag/syringe to the patient ensuring the correct line is in the correct pump by confirming correct hourly infusion rates.

At the start of shift checks that the infusion lines are securely connected to the patient

Documents hourly infusion pump pressure setting, check of rate and volume infused on fluid balance chart



Completes regular calculation and review of patient’s fluid status throughout shift.

For peripheral cannula: hourly assessment and documentation on the fluid balance chart using PIPA

For Central lines: each shift assessment and documentation of patency, exit site, dressing, statlock (securing device) & if bungs changed on Central Venous Catheter Assessment Record

Checks blood glucose levels as per clinical guidelines and patient’s condition dictates.

Takes bloods daily for electrolyte and liver function monitoring unless patient stable on long term PN

Understands the significance of a daily weight for all patient’s on PN (Not required for long term PN patient)



Direct Observation of Practice Record

Key Skills Observed: Setup, checking, administration & ongoing care of Parenteral Nutrition. Date Practitioner Name Assessor Name

Standard description

Comments – in depth knowledge and understanding displayed and ability to perform role

Further learning objectives identified

Level Description 1 Knows nothing about skill 2 Doubts knowledge and ability to perform the skill safely, without supervision 3 Could perform the skill safely with supervision 4 Confident of knowledge and ability to perform the skill safely 5 Could teach knowledge and skills to others and can demonstrate initiative and

adaptability to special problem situations (Hodge, R. 2003, Clinical competencies for Cardiac Nursing, South Devon Hospital Trust) Rating (please circle as appropriate)

1 2 3 4 5 Signatures: Practitioner

Assessor

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