total parenteral nutrition final output

8/3/2019 Total Parenteral Nutrition Final Output

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TABLE OF CONTENTS:

PAGE

1) Objectives of Total Parenteral Nutrition-------------------------------------------- 1

2) Definition of Terms ----------------------------------------------------------------------- 2

3) Indications of Total Parenteral Nutrition -------------------------------------------- 2

4) Contraindication of Total Parenteral Nutrition -------------------------------------- 2

5) Purposes of Total Parenteral Nutrition ---------------------------------------------- 2

6) Methods of Administration ------------------------------------------------------------ 3- 4

7) Types of Catheters Used -------------------------------------------------------------- 4- 6

8) Composition of Total Parenteral Nutrition Mixtures ----------------------------- 6-7

9) Guidelines, Complications and Nursing Responsibilitiesof Total Parenteral Nutrition ---------------------------------------------------------- 7- 9

10) Procedure Guide with Rationale ------------------------------------------------------ 11



Total Parenteral Nutrition

Objectives:

After 5 hours of classroom discussion, the students will be able to:

1) define Total Parenteral Nutrition

2) enumerate the following:

a. purpose

b. indications

c. contraindications

3) cite the different methods of Total Parenteral Nutrition

4) identify the types of catheter used

5) state the following:

a. guidelines

b. complications

c. nursing responsibilities

6) demonstrate beginning skills on TPN

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I. DEFINITION

Total Parenteral Nutrition (TPN)

It is also known as hyperalimentation

It is the intravenous administration of carbohydrates, protein, electrolytes,vitamins, minerals, and fat emulsions through a venous access device directlyinto the intravascular fluid to provide nutrients required for metabolicfunctioning of the body

It supplies all daily nutritional requirements. TPN can be used in the hospitalor at home. Because TPN solutions are concentrated and can causethrombosis of peripheral veins, a central venous catheter is usually required.

Generally, this treatment is prescribed for patient who can’t absorb nutrientsthrough the GI tract for more than 10 days.

II. PURPOSE, INDICATIONS, AND CONTRAINDICATIONS OF TOTALPARENTERAL NUTRITION

Purpose:

improve nutritional status establish a positive nitrogen balance allow growth of new body tissue maintain muscle mass promote weight gain serves as alternatives for patients who are unable or unwilling to receive

adequate nourishment from a normal diet

Indications:

Debilitating illness lasting longer than 2 weeks- there is deficient or absentoral intake for longer than 7 days

Loss of 10 % or more of pre-illness weight Serum albumin level below 3.5 g/dl Excessive nitrogen loss from wound infection, fistulas, or abscesses renal or hepatic failure- limited volume of liquid intake A nonfunctioning GI tract for 5 to 7 days in a severely catabolic patient-

because there is an interruption in its continuity and its absorptive capacityis impaired

Paralytic Ileus- food cannot move down to the stomach due to absence ofperistalsis in the esophagus

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Severe malnutrition- usual food intake is not sufficient to meet the needsof the body

Intestinal Obstruction- because there is an interruption in intestinal motility Coma- it is indicated because nothing may be taken by mouth Anorexia Nervosa- unless psychological counseling has worked, TPN is

the only way to meet the nutritional needs of someone with this illness

Contraindications:

Patients who are unable to swallow Patients who are well nourished Patients who doesn’t have problem in digesting Nutritional requirements are high Inability to attain venous access Severe liver disease Abnormal lipid metabolism such as lipidemia

III. METHODS OF ADMINISTRATION

Peripheral Method- solutions are infused into peripheral veins when nutritional support is needed

for only short time- peripheral parenteral nutrition- less hypertonic, simple IV solutions- usual length of therapy using this method last for 5-10 days- can irritate the intima or small veins, causing phlebitis

Central Method

-Infuses hypertonic nutritional solutions through an indwelling central venouscatheter (CVC) with the tip placed in the superior vena cava. It provides moreconcentrated nutrition in an equal volume of fluid.

- Is used to provide complete, long term nutritional support for patients whocannot or will not consume an adequate oral or enteral intake.

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- Possible indications include:a. severe malnutrition; weight loss of 10% or moreb. gastrointestinal abnormalities: obstruction, peritonitis, impaired

digestion and absorption, chronic vomiting, chronic diarrhea, severeacute pancreatitis

c. after surgery or trauma, especially that involving extensive burnsmultiple fractures or sepsis

d. Acute liver and renal failure when amino acid requirements are alterede. Acquired immunodeficiency syndrome ( AIDS )f. Bone marrow transplantation

IV. TYPES OF CATHETERS USED

Midline Catheter- inserted through the veins in the antecubital fossa and extended 5-7 inches to

the vessel, where vein diameter is 5-6 millimeters

-cause less irritation because the catheter is so soft and the end is well insidethe vein

Percutaneous Central Catheter

- used for short term ( less than 30 days) IV therapy- inserted by the physician- most common site is subclavian vein, because this area provides a stable

insertion site to which the catheter can be anchored- allows the patient freedom of movement, and easy access to the dressing site- types: single, double, triple- lumen

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- threaded under the skin to the subclavian vein, and the distal end of thecatheter is advanced into the superior vena cava 2-3 cm above the junctionwith right atrium

Implanted Ports- used for long term IV therapy- instead of exiting from a skin, the end of the catheter is attached to a small

chamber that is placed in a subcutaneous pocket- subcutaneous port requires minimal care and allows the patient complete

freedom of activity- implanted ports are more expensive and access requires passing a special

needle (hubber-tipped) through the skin into the chamber

Composition of Total Parenteral Nutrition Mixtures

Parenteral nutrition solutions include dextrose , amino acid, lipid emulsion,electrolytes, vitamins, and trace elements in sterile water. The actualcomposition of the parenteral solutions depends on the site of infusion and the

patients fluid and nutrient requirements. Because there are standardconcentration of proteins, carbohydrate, and fat in standard volumes,individualization of parenteral solutions is somewhat limited

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Carbohydrate- The carbohydrates in parenteral solution is dextrose ( a form of glucose that

contains water), which provides 3.4 cal/g, not 4.0 cal/g like glucose

Protein

-Protein is provided as a mixture of essential and non essential amino acidsranging in initial concentration from 5% to 15% of the solution. The quantity ofamino acids provided depends on the patient’s estimated requirements andhepatic or renal failure.

Electrolytes, vitamins, trace elements- A quantity of electrolytes provided is based on the patient’s blood chemistry

values and physical assessment findings.- A standard multivitamin preparation may be added to the TPN solution.

Although it is now recognized that minerals and trace elements are a

necessary component of TPN to prevent deficiency symptoms, exactparenteral requirements for many of them are not known.

Medications- Are sometimes added to intravenous solutions by the pharmacist or infused

into them through a separate port. Heparin may be added to reduce fibrinbuildup on the catheter tip. In general, medications should not be added toTPN solutions because of the potential incompatibilities of the medication andnutrients in the solution.

V. GUIDELINES, COMPLICATIONS AND NURSING RESPONSIBILITIES

OF TOTAL PARENTERAL NUTRITION

Guidelines:

Nutritional IV solution is prepared by a pharmacist Nothing should be added to hyperalimentation Insertion should be done under a strict aseptic technique TPN solutions are initiated slowly and gradually advanced each day to the

desired rate

Patients should be weighed daily at the same time of the day Main-line IV tubing and filters are changed every 72 hours, and all

connections are taped securely to avoid breaks in the integrity of thesystem

Patients should be encouraged for ambulation

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COMPLICATIONS POSSIBLE CAUSE SIGNS AND

SYMPTOMS

NURSING

INTERVENTION

Air embolism Opened cathetersytem

Disconnected IVtubings

Air on IV tubings

-Apprehension-Chest pain-Dyspnea-Hypotension-Rapid and weakpulse-Respiratorydistress-Loud churningsound overpericardium

Clamp thecatheter whennot in use

Place the clientin a left sidelying positionwith head lowerthan the feet

Administeroxygen

Instruct theclient in thevalsalva

maneuver fortubing and capchanges

Hyperglycemia Clients receivingsolution tooquickly

Not enoughinsulin

Infection

-Coma- Confusion-Diaphoresis-Elevated bloodglucose(≥200mg/dL) - Excessive thirst

-Fatigue-Kussmaul’sRespiration-Restlessness

Slowed infusionrate

Administration ofRegular Insulinas prescribed

Monitor bloodglucose levels

Use Aseptictechnique

Hypervolemia Excessive fluidadministration

Administration offluid rapidly

Renal dysfunction Heart failure Hepatic failure

-Bounding pulse-Crackles on lungs-Headache-Increase bloodpressure- Jugular veindistention

- Weight gain

Slow or stop IVinfusion

Restrict IV fluids

Administerdiuretics

Use dialysis in

extreme cases Monitor intake

and output

Weigh patientdaily

Administer fluidvia infusionpump

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Assess client’shistory for risk ofhypervolemia

Hypoglycemia Parenteral Nutritionabruptlydiscontinued

Too much insulinadministration

-Anxiety- Diaphoresis- Low bloodpressure- Weakness- Shakiness

Monitor bloodglucose

Administration ofintravenousdextrose

Gradualdecrease of PNprior todiscontinue

Infuse 10%dextrose at thesame rate of PN

Sepsis Poor aseptic

technique Cathetercontamination

Contamination ofsolution

-Chills

-Fever-Elevated WBC-Erythema ordischarges atinsertion site

Removal of

catheter Obtain blood

cultures

Administerantibiotic asprescribed

Use strict aseptictechnique

Monitor vitalsigns

Change site

dressing,solution andtubing asspecified byagency policy

Assess IV sitefor signs ofinfection

Pneumothorax Incorrectplacement ofcatheter

-Absence ofbreath sounds onaffected site

- Chest orshoulder pain- Suddenshortness ofbreath-Tachycardia-Cyanosis

Monitor for signsof pneumothorax

Obtain chest X

ray afterinsertion ofcatheterplacement isverified

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Nursing Responsibilities:

Before:

1. Make sure that the solution, the patient, and the equipment are ready

2. Remove the solution from the refrigerator at least 1 hour before use to avoidpain, hypothermia, venous spasm, and venous constriction, which can resultfrom delivery of a chilled solution

3. Check the solution against the physician’s order for the correct patient name, expiration date, and formula components

4. Observe the container for cracks and the solution for cloudiness, turbidity, andparticles. If present, return the solution to the pharmacy

5. When you’re ready to administer the solution, explain procedure to the patient. 6. Check the name of the solution container against the name on the patient’s

wristband. Confirm the patient’s identity using two patient identifiers according tofacility policy.

7. Do medical handwashing. Then put on gloves and if specified by facility policy, amask. Throughout the procedure, use strict sterile technique.

During:

1. Instruct patient to do valsalva maneuver2. If indicated, attach a time tape to the parenteral nutrition container for accurate

measurement of fluid intake\ 3. Record the date and time you hung the fluid, and initial the parenteral nutrition

solution container4. Remove and discard your gloves

5. With the patient in the supine position, flush the catheter with normal salinesolution, according to facility policy

6. Then put on gloves, and clean the catheter injection cap with an alcohol pad7. Swab the catheter insertion site an iodine solution8. Gradually increase the infusion rate once the catheter position is confirmed

After:

1. Monitor vital signs 2. Check the infusion rate every 30 minutes to 1 hour 3. The area is checked for leakage, a kinked catheter and skin reactions such as

inflammation, redness, swelling, tenderness 4. Dressing and tubing are labeled with the date, time and insertion 5. When changing for dressing the nurse and patient wear masks 6. Dressing change is documented, and the condition of the area and the patient’s

reactions are reported

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Cebu Doctor’s University

College of Nursing

Mandaue City

TOTAL PARENTERAL NUTRITION

DEFINITION:

Total Parenteral Nutrition- administration of nutrients through a venous access devicedirectly into the intravascular fluid

PURPOSES:

to provide nutrients required for metabolic functioning of the body

MATERIALS: A lined tray containing:

Sterile kidney basin

TPN bag

Alcohol swabs

Hypoallergenic tape

IV tubing

Small hypotray

0.9% NaCl (Normal Saline

Solution)

Bandage scissors

Waste receptacle

PROCEDURE RATIONALE1. Read the patient’s chart.

2. Explain procedure to the patient.

3. Perform medical handwashing.

4. Prepare the materials. Place IV tubing in thekidney basin.

5. Prime the IV set using NSS, with the NSSflowing to the kidney basin.

6. Remove the NSS and connect the tube to the

To confirm physician’s order

To decrease patient’s anxiety

To prevent spread of microorganisms

To save time and energy; IV tubing must bekept clean

To check for the tubing’s patency; to avoidspillage

To prepare for administration



TPN bag

7. Place the primed IV tubing with the TPN bag,hypoallergenic tape, waste receptacle andalcohol swab on the hypotray

8. Bring the hypotray to the patient’s bedside

9. Prepare a strip of hypoallergenic tape. Hangthe TPN bag on the IV stand.

10. Disinfect the Y-port of the mainline tubing usingthe alcohol swab.

11. Insert the IV tube of the TPN bag into the Y-port. Secure the connection with hypoallergenic

plaster.

12. Close off the mainline, then open the regulatorof the TPN set.

13. Make the patient comfortable. Do after care.

14. Do documentation.

To save time and energy



To prevent spread of microorganisms

So that TPN is administered intravenously;

To avoid leakage

TPN can flow to the vein freely

To promote comfort; To promoteenvironmental sanitation

Basis for any legal purposes in the future andfor endorsement to other members of thehealth care team

total parenteral nutrition final output

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