Home Parenteral Nutrition (HPN) And Home Intravenous Fluid (IVF) – Passport

  • Reference Number: HEY-852/2016
  • Departments: Nutrition Support

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If I am admitted to hospital please contact the Nutrition Team on:

Mobile number – 07827 937025.

Switchboard telephone number – (01482) 328541. Ask for Bleep 771 for Castle Hill Hospital (CHH), or ask for Bleep 640 for Hull Royal Infirmary (HRI). (Between the hours of 7:00am to 4:00pm, from Monday to Friday.)

I am under the care of Hull and East Yorkshire Hospitals NHS Trust Nutrition Team.

I require Intravenous Nutrition (PN) and/or Intravenous Fluids (IVF).

If I am admitted to the Emergency department out of hours can you administer IV Fluids to keep me hydrated.

I am not able to drink large volumes of fluid as this increases my output.

Please contact a member of the Nutrition Team to discuss my care in further detail.

Name
Hospital Number
Date Of Birth
Contact Number
Home
Mobile
Next Of Kin
Home
Mobile
Surgical Consultant
Nutrition Consultant
Home Care Company
Contact Number

I am having Parenteral Nutrition/Intravenous Fluids

Past Medical History

 

 

Treatment Aim Maintain/improve nutritional status.
Maintain hydration.
Duration Of Treatment

 

 

Goals To provide safe delivery of Parenteral Nutrition (PN)/Intravenous Fluids (IVF).
Safety Considerations PN/IV Fluids are administered by a dedicated Central Venous Catheter (CVC) lumen and labelled “PN/IV Fluid use only”.

Full nursing support – your homecare nurse will care for your line as instructed by Hull and East Yorkshire Hospitals Trust.
Self-caring administer your PN/IV Fluid as directed by your nurse.

CVC exit site and dressings – inspect exit site twice daily.
For further information, refer to the nutrition support team troubleshooting guide and your additional individualised care plan provided from your home care company.

Monitoring PN/IV Fluids are to be administered as per the Nutrition Team instructions.

Your team will advise you of the frequency required for your follow up and outpatient appointments.

Please care for my line with strict asepsis

Line not to be used for administering anything except Parenteral Nutrition/Intravenous Fluids.

Line Care/Line Type

 

Date Line Inserted ___ / ___ / ______.
Tunnelled Line – Single/Dual Line length: ____ cm.
Single/Dual (circle).
PICC Line Line length: ____ cm.
Placed at: ____ cm.
Line Replacement Date ___ / ___ / ______.
Tunnelled Line – Single/Dual External line length: ____ cm.
PICC Line Line length: ____ cm.
Placed at: ____ cm.
Line Lock – Amount/Mls Antimicrobial agent.
Amount: _______ mls.
Line Use For PN/IV Fluids/Both PN/IVF/both (circle).
Weekly 7 Day Flush 10ml 0.9% Saline and when not in use.
Weekly Dressing And Needle Free Device Change Mon/Tue/Wed/Thu/Fri/Sat/Sun (due circle).

Eating and drinking

Please ensure if unable to use my central access that I have peripheral fluids prescribed until a member of the Nutrition Team is able to review me.

Able To Eat And Drink? Yes/no (circle).
Special Dietary Needs

 

 

Any Restrictions? Please List

 

 

Oral Fluid Restriction? Yes/no (circle). _______ mls.
Dioralyte Or St Marks Electrolyte Mix Dioralyte – number of sachets/1 litre of water.

St Marks Electrolyte Mix – 1 pot to 1 litre of water.

IV Fluids Regimen Volume _______ mls.
Days Infused Mon/Tue/Wed/Thu/Fri/Sat/Sun (circle).
PN Regimen Volume And Days Infused Refer to regime chart.

Weight/body mass index (BMI)

My Usual Weight Is
My Height Is
Date Weight BMI Initials
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       

Weekly Parenteral Nutrition (PN) and Intravenous (IV) Fluids regime

Type:

Lipid
Lipid Free
IV Fluids

Route:

TL
PICC

Duration:

Hours
And Rate Per Hour

Date And Initials
Monday

 

Tuesday

 

Wednesday

 

Thursday

 

Friday

 

Saturday

 

Sunday

 

Changes to weekly Parenteral Nutrition (PN) or Intravenous (IV) Fluids regime

Type:

Lipid
Lipid Free
IV Fluids

Route:

TL
PICC

Duration:

Hours
And Rate Per Hour

Date And Initials
Monday

 

Tuesday

 

Wednesday

 

Thursday

 

Friday

 

Saturday

 

Sunday

 

My current medications

Please do not amend my medication without speaking with a member of the Nutrition Team.

Medication Tick Initials
Codeine phosphate 30-60mg QDS.
Loperamide Cap/Melt.
2-16mg QDS. (Melt if >8mg.)
Omeprozole (MUPS) 20-40 mg 1-2 OD.
Lansoprozole Fast Tab 30 mg 1-2 OD.
Ranitidine 150mg BD.
Dioralyte Sachet – 10 Sachets in 1 litre of water.
St Marks Electrolyte Mix – 1 pot in 1 litre of water.
Vitamin/Mineral Supplements
Forceval.
Other
     
     
     

If I am started on Water Tablets or Antibiotics please discuss with a member of the Nutrition Team.

Additional medication/supplements

Medication/Supplements Dose Date And Initials
     
     
     
     
     
     
Any Other Information
     
     
     
     
     
     

Discharge planning

It may take up to 24 Hours to plan my discharge from hospital.

Please inform my:

Nutrition Nurse Pip Macelhinney
Nutrition Nurse Anita Middleton

Who will ensure my:

Home Care Company are informed.
Nursing Calls are arranged for me to go home.
Check I have enough supplies at home.
Ensure I have my Parenteral nutrition/ Intravenous fluids available.

(Delete if not applicable.)

Nutrition Team contacts

Any queries regarding my care please contact:

Hull and East Yorkshire Hospitals NHS Trust on (01482) 328541 or (01482) 875875.

Nutrition Specialist Nurses

Pip Macelhinney Mobile: 07827 937025.
Bleep 771/640.
Anita Middleton Mobile: 07827 937025.
Bleep 771/640.

Parenteral Nutrition Pharmacists

Sophie Khan Ext 4105 CHH,
bleep 904.
Sarah Westerhold HRI,
bleep 938.

Parenteral Nutrition Dietitians

Carly Killen Ext 3168/4490,
bleep 812.
Claire Hargraves Ext 3168/4490,
bleep 827.

Blank spaces for additional notes

   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   

If found, please return to:

Nutrition Team,
Hull and East Yorkshire Hospitals NHS Trust,
C/O 8th Floor,
Alderson House,
Hull Royal Infirmary,
HU3 2JZ.