7. parenteral nutrition basic ivt nov 2008

ASSOCIATION OF NURSING ASSOCIATION OF NURSING SERVICE ADMINISTRATORS OF SERVICE ADMINISTRATORS OF THE PHILIPPINES, INC. (ANSAP)THE PHILIPPINES, INC. (ANSAP)

means of providing protein, carbohydrates, fats, vitamins, and minerals to those who are unable to assimilate nutrients provided via the gastrointestinal tract.

safe and effective when delivered according to strict protocols by nutritional support team or other trained person.

Parenteral Nutrition Solution

- Hyperalimentation- IV

Hyperalimentation

-may contain two or more of the following elements:

• Carbohydrates• Proteins• Lipids• Electrolytes• Vitamins and Minerals• Trace Elements• Water

Total Parenteral NutritionTotal Parenteral Nutrition

-It is given when a patient requires an extended period of intensive nutritional support.

Peripheral Parenteral Peripheral Parenteral Nutrition Nutrition

(Partial Parenteral Nutrition)(Partial Parenteral Nutrition)

Normally prescribed for patients who can tolerate some oral feedings but cannot ingest adequate amounts of food to meet their nutritional needs.

Indications for Total Parenteral Nutrition

Long term therapy (2 weeks or more)

Supply large quantities of nutrients and calories (2,000 to 3,000 calories/day or more)

Indications for Total Parenteral Nutrition

Debiliating illness lasting longer than 2 weeks.

Inability to sustain adequate weight with oral or enteral feedings.

Indications for Total Parenteral Nutrition

Deficient or absent oral intake for longer than 7 days , as in cases of multiple trauma, severe burns, or anorexia nervosa.

Loss of at least 10% of pre – illness weight.

Indications for Total Parenteral Nutrition

Serum albumin level below 3.5g/dl.

Chronic vomiting or diarrhea.

GI disorders that prevent or severely reduce absorption.

Indications for Total Parenteral Nutrition

Poor tolerance of long-term enteral feedings.

Inflammatory GI Disorders.

Indications for Peripheral Parenteral Nutrition

Short term Therapy (3 weeks or less) is used to:

Maintain nutritional state in patients who can tolerate relatively high fluid volume.

Indications for Peripheral Parenteral Nutrition

Who usually resume bowel function and oral feedings in a few days, and who aren’t candidates for CV catheter.

Provide approximately 1,300 to 1,800 calories/day.

Methods of Administration

Central Venous Infusion

-long term parenteral nutrition

Peripheral InfusionPeripheral Infusion

-short term parenteral nutrition (1-3 weeks)

Administering Parenteral Nutrition

ContinuouslyContinuously- 24 hour period

CyclicallyCyclically-receives the entire 24-hour

volume over a shorter period, perhaps 8,10,14 or 16 hours.

Verify doctor’s orders.

Explain the procedure.

Obtain consent.

Select best available vein as the insertion site.

PPN should be at room temperature.

Proper use of infusion pump.

Check the written order against the written label on the bag.

Proper labeling.

Watch out for swelling at the peripheral insertion site.

Maintain the infusion rate and care for the tubing, dressing, infusion rate and I.V. devices.

Monitor patient for signs and symptoms of sepsis:

-glucose in urine-altered level of

consciousness-chills-malaise-hyperglycemia-leukocytosis-elevated temperature

Don’t allow TPN solutions to hang for more than 24 hours.

Change the tubing and filter every 24 hours, using strict aseptic technique. Make sure that all tubing junctions are secure.

Perform IV site care and dressing changes.

Check the infusion pump’s volume meter and time tape to monitor for irregular flow rate. Gravity should never be used to administer TPN.

Record the patient’s vital signs when you initiate therapy. Be alert for increased body temperature- one of the earliest signs of catheter-related sepsis.

Monitor your patient’s glucose levels.

Accurately record the patient’s daily fluid intake and output.

Assess the patient’s physical status daily. Weigh him at the same time each morning. Suspect fluid imbalance if the patient gains more than 1lb. per day.

Monitor the results of routine laboratory tests .

Provide emotional support.

Provide frequent mouth care for the patient.

Document all assessment findings and nursing interventions

Discontinuing therapy

When to wean and

when not to wean…

TOTAL TOTAL

PARENTERAL PARENTERAL

NUTRITIONNUTRITION

- wean for 24 hours to prevent rebound hypoglycemia.

PARTIAL PARENTERAL

NUTRITION

- can be discontinued without weaning.

Handling PN Hazards

Catheter Related

Metabolic

Mechanical

Catheter Related Complications

Clotted catheter•Reposition the catheter.

Dislodge catheter•Place a sterile gauze pad treated

with antimicrobial agent on the insertion site and apply pressure.

Cracked or broken tubing•Change the tubing immediately.

Pneumothorax•Assist with chest tube insertion.•Maintain chest tube suction as

ordered.

Sepsis

•Remove the catheter and culture the tip.

•Give appropriate antibiotics as ordered.

Metabolic Complications

Hyperglycemia•Start insulin therapy as ordered.•Adjust the TPN flow rate as

ordered.

Hypoglycemia•Infuse dextrose as ordered.

Metabolic acidosis

•Adjust the formula and assess for contributing factors.

Mechanical Complications

Air Embolism•Clamp the catheter.•Place the patient in

trendelenburg’s position on the left side.

•Give oxygen as ordered.•If cardiac arrest occurs, initiate

cardiopulmonary resuscitation.

Venous Thrombosis•Notify the doctor.•Administer heparin as ordered.•Venous flow studies may be done.

Too rapid an infusion•Check the infusion rate.•Check the infusion pump.

Extravasation•Stop the I.V. infusion.•Assess the patient for

cardiopulmonary abnormalities.

Phlebitis•Apply gentle heat to the insertion

site.•Elevate the insertion site, if possible.

Patient and Family Education

Assess patient and family’s level of understanding.

Inform the patient and family everything about all that they need to know regarding parenteral nutrition in a manner that they comprehend.

Secure inform consent about the procedure if the patient needs to have a central line for total parenteral nutrition.

Inform patient regarding the proper regulation of the parenteral nutrition.

Inform the patient to report any unusual feelings such as chest pain, tachycardia, pain at the insertion site and the likes that may indicate air embolism.

Inform the patient regarding the importance of blood sugar monitoring while on parenteral nutrition.

Inform the patient the signs and symptoms of hyper and hypoglycemia and report it if ever experienced.

Documentation

TPR blotting Sheet/Vital Signs Monitoring Sheet

Infusion Sheet

Diabetic Record Sheet

Nursing Care Plan

Progress Notes

Intake and Output Sheet

Problem Goal of

Care

Planned Intervention Response

-Nutrition less than body requirement.-To start parenteral nutrition

At the end of the 8 hours interventions, -the client may be able to understand the importance of the therapy-prescribed volume of infusion should be administered to the client.-prevent complications that the therapy might cause.

-assess client’s level of understanding.-explain the importance of the therapy to the client and family.-start the TPN as ordered using infusion pump for proper regulation.-watch out for signs and symptoms of adverse effects.-assess the infusion site for signs and symptoms of infection or phlebitis.-teach client/family regarding the proper way of doing hand washing.

-client verbalized understanding of the importance of the therapy.-correct volume of infusion administered.-demonstrate correct way of doing handwashing.

Date Focus Problem

Progress Notes

Sept. 17, 2008

-To start Total Parenteral Nutrition.

D- BMI of 18-unable to eat orally due to body weakness, nausea and vomiting.-To start TPN 2300kcal/day via central line.A- Assessed client’s level of understanding.-Explained the importance of the therapy to the client and relatives.-Explained the procedure to the client.-catheter site inspected for signs and symptoms of infection.-TPN started aseptically as ordered.-Infused proper volume of infusion as ordered via infusion pump.-Watched out for signs and symptoms of adverse reactions.-Client and relatives instructed on how to do proper handwashing.R- client verbalized understanding of the therapy-no signs and symptoms of infection or adverse effect from the therapy-400cc of TPN infused to client.-client understand importance of handwashing to prevent infection.