Neonate/Pediatric TPN Monitoring Form - PGA - Riley Children’s Hospital at IU Health

Name: _______________________ MRN: ______________ DOB: ___________ Age: ____y____m_____d Admit Date: __________
Allergies: __________________________________ Dx: ________________________________________________________________

Measurement Date: _____________ OFC: ________________ Goals

Wt: ___________:_______%ile Wt. Age: ______________ Calories (kcal/day): _____________ kcal/kg: _______________
Ht: ___________:_______%ile Ht. Age: ______________ Protein (g/day): ________________ g/kg: _________________
Wt/Ht: _________:______%ile BMI: _________________ Fluid (mL/day): ________________ mL/kg: ________________
Wt. for Calc: ______________ IBW: _________________ Rate of Gain (g/day):____________

LABS
Date
Daily Weight (kg)
Na (135-145 mEq/L)
K (3.5-5.5 mEq/L)
Cl (95-105 mEq/L)
CO2 (22-27 mEq/L)
BUN/Cr
Gluc (65-110 mg/dL)
Ca (8.4-10.6 mg/dL)
PO4 ( mg/dL)
Mg (1.6-2.9 mEq/L)
Total / Conj. Bilirubin / / / / / / /
Cholesterol / TG / / / / / / /
AST / ALT / / / / / / /
AlkPhos / GGT / / / / / / /
Hgb / Hct / / / / / / /
WBC / Platelets / / / / / / /
INR
Albumin (3.5-5 g/dL)
Pre-Alb (10-40 mg/dL)
UrineNa (30-50mmol/L)

TPN ORDER
AA/Dex/Lipid (g/kg/day) / / / / / / / / / / / / / /
SMOF (g/kg/day)
Na (mEq/kg/day)
K (mEq/kg/day)
Cl (mEq/kgday)
Anions Acet Cl Acet Cl Acet Cl Acet Cl Acet Cl Acet Cl Acet Cl
Ca (mEq/kg/day)
Phos (mmol/kg/day)
Mg (mEq/kg/day)
Heparin (units/mL)
MVI / TMS Y N / Y N Y N / Y N Y N / Y N Y N / Y N Y N / Y N Y N / Y N Y N / Y N
Selenium (mcg/kg/day)
Zinc (mcg/kg/day)
Copper (mcg/kg/day)
Carnitine (mg/kg/day)
Additive #1
Additive #2
Rate or Cycle (mL/time)
TOTAL Volume (daily)
TOTAL Calories (daily)
kcal/kg │kcal/mL │ │ │ │ │ │ │
GIR (mg/kg/min)
NPC:Nitrogen (150-250:1)
Wt. Used for Order

DAILY I/O
INPUT
IVF (mL)
TPN (mL)
IV/EN Liquid Meds (mL)
EN Formula / Liquids
EN Route(s)
Total EN Fluid Volume
TOTAL INPUT (mL)
OUTPUT
Urine (mL │mL/kg/hr │#) │ │ │ │ │ │ │ │ │ │ │ │ │ │
Mixed Urine/Stool │mL Y N │ Y N │ Y N │ Y N │ Y N │ Y N │ Y N │
Stool (mL │#) │ │ │ │ │ │ │
Emesis (mL │#) │ │ │ │ │ │ │
Drains/G Tube/Misc. (mL)

Ostomy (mL/day)
TOTAL OUTPUT (mL)
I/O Difference (+ mL)

Home Diet:

Home Medications / Supplements:

Procedures:

Scope Results
Endoscopy:

Colonoscopy:

Progress Notes:
 Periodic Lab Monitoring of Trace Elements
Date:
Copper
Manganese
Chromium
Selenium
Carnitine
Aluminum
Zinc