Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Visit:
Initiation of parenteral nutrition (PN)
Follow-up for established PN (monitoring tolerance, adjusting formula)
Evaluation of new symptoms or complications potentially related
to PN (e.g., nausea, vomiting, electrolyte imbalance, catheter
site infection)
History of Present Illness:
Underlying medical condition necessitating PN (e.g., short bowel
syndrome, malabsorption, critical illness).
Date PN was initiated.
Route of PN access (central line, peripheral line).
Current PN formula and infusion rate.
Physical Examination:
General examination: Assess vital signs for signs of infection
(fever, tachycardia).
Focused examination of the PN access site: Evaluate for redness,
swelling, tenderness, or purulent drainage (signs of infection).
Laboratory Tests (as indicated):
Electrolytes (sodium, potassium, phosphorus, magnesium, calcium):
Monitor for electrolyte imbalances that may require adjustments in the PN formula.
Blood glucose: Monitor for hyperglycemia, a potential complication
of PN.
Liver function tests: Monitor for potential liver toxicity
associated with PN.
Complete blood count (CBC): May be used to monitor for signs of
infection.
Assessment:
PN tolerance: Evaluate if the patient tolerates PN with minimal
side effects (e.g., nausea, vomiting).
Nutritional status: Assess for any improvement in anthropometric
measurements (weight, body mass index) or laboratory markers of
nutritional deficiency (e.g., serum albumin).
Catheter site status: Evaluate for signs and symptoms of
catheter-related infections.
Plan:
PN formula adjustments: Based on laboratory results, nutritional
needs, and tolerance, the PN formula or infusion rate may be adjusted.
Monitoring: Schedule regular follow-up visits to monitor
laboratory values, weight, and for any potential complications.
Catheter care education: Reinforce proper catheter care techniques to minimize the risk of infection.
Transition to enteral feeding (if possible): If the underlying
condition allows, weaning from PN and transitioning to enteral feeding
should be considered, as it is the preferred route of nutrition.
Additional Notes:
Document the patient’s understanding of PN and any educational
needs.
Include a plan for addressing any identified complications
related to PN.
Consider consulting with a registered dietitian for optimizing
the PN formula and monitoring nutritional status.