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 lineMid-line catheters are frequently usedPPN 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 TPN5-Day Rule:

Has not eaten for 5 days and not expected to eat within the next 5 days or inadequate nutrition for 7-10 daysWeight loss of 7% body weight and NPO for 5-7 daysHypermetabolic state

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Common Conditions Requiring TPN

Chronic PancreatitisDiffuse PeritonitisBowel SyndromesGastric ParesisAlcoholismSevere BurnsAnorexiaCancerTrauma

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Complications

MetabolicMechanicalInfectionFluid Imbalance

Most common complication of parenteral nutrition is hyperglycemia

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Metabolic Complications

HyperglycemiaHypoglycemiaVitamin DeficienciesElectrolyte Imbalance particular NA+, K+, CA+

Nursing ConsiderationsMonitor Daily LabsMonitor Glucose-Accuchecks

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Mechanical Complications

PhlebitisAir EmbolismInfiltrationPneumothorax-Upon Subclavian Catheter placement

Assess Site for redness, swelling warmth or coldDiscourage client from talking/laughing when changing tubingChest X-Ray

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Complications-Infection

High Glucose concentration makes good medium for bacteriaContamination of the catheter on insertionLong Term Catheter Use

Nursing ConsiderationsAssess sites for redness, swelling, tenderness, drainage, warmthAssess for fever, WBCsSTERILE dressing change every 72 hours or per agency protocolDO 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 ConsiderationsDaily WeightsMonitor Intake and OutputAssess breath soundsMUST use a controlled infusion pumpUsual rate is 100cc/hr or lessNEVER 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, diagnosisAssess labs-CBC, Chemistry Profiles, PT/PTT,iron, lipid profile, liver function tests, Electrolytes, BUN/Creatinine and Blood SugarLine 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 hangingCareful 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/hrNever “catch up”Continue to assess lab values, glucose/accuchecks, daily weights, intake and outputContinue to assess access siteContinue 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 ratesDiscontinue 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/dlSerious complicationBlock 7.0 Module 1.4