Adult Health Nursing IIBlock 7.0

Parenteral Nutrition

Adult Health II Block 7.0

Block 7.0 Module 1.4

Learning Objectives

Differentiate between Total Parenteral Nutrition and Partial Parenteral NutritionDiscuss Nursing Considerations for Clients with Complications in Parenteral NutritionDiscuss Age-Related ConsiderationsPrioritize Nursing Care of Clients receiving Parenteral Nutrition

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Partial/Peripheral Parenteral Nutrition (PPN)

Used when client unable to take nutrition through GI tractNeed complete nutrition source, but are not totally depletedUsually used when client needs support less than 14 daysUsed when a central line is not indicatedDelivered through a peripheral veinConcentrations of 5%-10% dextrose and 2%-5% amino acidsLipids may be added as well

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PPN

PPN is mildly hypertonic (10%-20% dextrose)

Usually administered through a large peripheral vein or can use central line

Mid-line catheters are frequently used

PPN is most commonly used for short term therapy

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Total Parenteral NutritionTPN or Hyperalimentation

Goal: Prevent or Correct Nutritional Deficiencies to Minimize the Adverse Effects of Malnourishment

Used when client requires complete supportBeneficial for long term useAllows bowel rest and healingUsed for clients with large caloric and nutrient needsDelivered through a central line/PICC lineContains hypertonic glucose solutions-(20%-70% dextrose)

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TPN

Different from standard IV solutions in that it contains all nutrients including: Carbohydrates- CaloriesProtein-Amino Acids- Tissue growth and repairEssential Fatty Acids/20% Lipid Emulsions- Heat and

Energy, provides twice as many calories as proteins and carbs.

Vitamins- growth and maintenanceMineralsElectrolytes- K+, NA+ CA, Mg, phosphorusTrace ElementsCalories- High glucose concentration

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TPN

Basic Guideline for Initiating TPN

5-Day Rule:

Has not eaten for 5 days and not expected to eat within the next 5 days or inadequate nutrition for 7-10 days

Weight loss of 7% body weight and NPO for 5-7 days

Hypermetabolic state

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Common Conditions Requiring TPN

Chronic PancreatitisDiffuse PeritonitisBowel SyndromesGastric ParesisAlcoholismSevere BurnsAnorexiaCancerTrauma

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Complications

Metabolic

Mechanical

Infection

Fluid Imbalance

Most common complication of parenteral nutrition is hyperglycemia

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Metabolic Complications

Hyperglycemia

Hypoglycemia

Vitamin Deficiencies

Electrolyte Imbalance particular NA+, K+, CA+

Nursing Considerations

Monitor Daily Labs

Monitor Glucose-Accuchecks

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Mechanical Complications

Phlebitis

Air Embolism

Infiltration

Pneumothorax-Upon Subclavian Catheter placement

Assess Site for redness, swelling warmth or cold

Discourage client from talking/laughing when changing tubing

Chest X-Ray

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Complications-Infection

High Glucose concentration makes good medium for bacteria

Contamination of the catheter on insertion

Long Term Catheter Use

Nursing Considerations

Assess sites for redness, swelling, tenderness, drainage, warmth

Assess for fever, WBCs

STERILE dressing change every 72 hours or per agency protocol

DO NOT use TPN line for other IV fluids and medications.

May have to remove catheter, save the tip and send to lab

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Complications-Fluid Overload

Hyperosmotic Solution-3 to 6 times the osmolarity of blood so at risk for fluid shifts

Nursing Considerations

Daily Weights

Monitor Intake and Output

Assess breath sounds

MUST use a controlled infusion pump

Usual rate is 100cc/hr or less

NEVER speed up infusion to “catch up”Block 7.0 Module 1.4

A Word on Medications

Many references support a “NO medication added” to TPN however medications, usually only insulin (reduce the potential for hyperglycemia) and heparin (prevent fibrin buildup on the catheter tip) may be added BY THE PHARMACIST during preparing of the TPN solution

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Care of the Elderly

More vulnerable to fluid and electrolyte imbalancesMore vulnerable to CHF- Check historyIncrease incidence of glucose intoleranceAge-related physiological changes influence the reliability of measures used for nutritional assessment

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Nursing Care-Pre Infusion

Assess weight, BMI, nutritional status, diagnosis

Assess labs-CBC, Chemistry Profiles, PT/PTT,iron, lipid profile, liver function tests, Electrolytes, BUN/Creatinine and Blood Sugar

Line insertion is STRICT aseptic technique

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Nursing Care-Pre Infusion

Check PCP ordersMUST complete 2 nurse check prior to administration-Verify elements contained in the mixture is accurate to the prescriptionMUST use infusion pumpCheck bag for any leaks“Cracking”- Calcium or Phosphorous content of mixture is too high and presents with an oily appearance or a layer of fat on top of the mixture. DO NOT USE!!!!

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Nursing Care Pre Infusion

Must be refrigerated until ready to use then at room temperature prior to hanging

Careful in administering lipids either within the bag or piggyback to clients with hyperlipidemia or severe hepatic disease- usually contraindicated

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Nursing Care-During Infusion

Check rate not to exceed 100mls/hr

Never “catch up”

Continue to assess lab values, glucose/accuchecks, daily weights, intake and output

Continue to assess access site

Continue to assess “YOUR CLIENT”

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Nursing Care- During Infusion

If you run out of solution and new bag is not available you can hang a bag of D10% or D20% dextrose solutionIV tubing is changed every 24hours or with every new bag (check protocol)TPN bag discarded after 24 hoursDressing changes are STRICT ASEPTIC technique every 72 hours (check agency protocol)

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Nursing Care Post Infusion & When to Discontinue

NEVER discontinue TPN abruptly…WHY?

Should be decreasing infusion rates

Discontinue TPN:

When client is able to eat (60% of caloric requirements)

Weight gain is achieved (1 kg/day)

Albumin levels reach 3.5-5.0 g/dl

Serious complicationBlock 7.0 Module 1.4