Pharmacological and Parenteral Therapies

Pharmacological and Parenteral Therapies This section focuses on medications and alternative therapies available in healthcare. You will need to know about medication dosages, contraindications, administration routes, side effects, and pain management. Other topics may include questions regarding blood products and parenteral nutrition. Below are the listed major concepts covered in this category. Medication Effects Administering medication is much more than “giving” clients medicine. It requires a substantial amount of knowledge about each medication, including the potential effects (both intended and otherwise), interactions with other medications, and a thorough understanding of the patient’s health status, including the ability to tolerate each medication. Adverse Effects Adverse effects are undesired, harmful reactions of medications that may occur after a medication is given. These effects may be mild, moderate, or severe and can significantly impact the client. Nurses are responsible for assessing and monitoring clients, their medication regimen, and any adverse effects related to their medications or other therapies. Common signs of adverse effects include allergic reaction (anaphylaxis), skin, respiratory, gastrointestinal and/or circulatory changes. Other, more severe adverse effects include birth defects, hospitalization, coma, and even death. Nurses must know how to recognize these symptoms and initiate any needed, appropriate treatment steps. Contraindications Every medication has a list of conditions in which its use is not acceptable or safe. Common conditions that have medication contraindications include pregnancy, organ dysfunction, and allergy/sensitivity. Some medication contraindications are indicated by the category of medication, such as with the pregnancy categories: A, B, C, D, and X. Some medications are contraindicated with foods, such as grapefruit, Vitamin K, alcohol, and specific herbs (St. John’s Wort, Ginseng, Black Cohosh, Ginkgo Biloba). Other medications are contraindicated when the client is already on a specific medication regimen. The nurse must investigate the full medication list of the client, communicate current and future medication plans with the provider, and provide ample education to avoid medication contraindications. Side Effects Side effects are very similar to adverse effects. Side effects can occur in addition to the main intended effect of a medication or therapy. Some of the most common side effects for medications include headache, abdominal pain, nausea, vomiting, diarrhea, constipation, dizziness, drowsiness, lethargy, insomnia, and dermatitis. Many medications have very specific side effects and should be studied in preparation for the NCLEX exam. Clients should be educated on the most common side effects to increase their awareness and communication of these effects, should they occur. Some side effects may be treated with counter therapies, such as prescribing an anti-nausea medication with medications known to cause nausea or adding a probiotic supplement to take with antibiotics to help prevent or lessen diarrhea. When clients experience side effects, the nurse is responsible for discussing these changes with the ordering provider to determine if supportive or alternative therapies need to be considered. Interactions A thorough medication history is necessary to fully assess for any unwanted medication interactions. The nurse should discuss the usage of all prescription medications, over-the-counter (OTC) therapies, and other natural or herbal supplements with the client. Many clients unknowingly add incompatible complementary therapy, dietary changes, over-the-counter medications, and/or herbal supplements to their normal medication regimen, increasing their risk for adverse effects. In the hospital, some intravenous fluids will interact with prescribed medications and any incompatibilities should be identified and discussed with the ordering provider. Nurse Responsibilities The nursing responsibilities related to medication and fluid administration extend well beyond those listed above. Nurses are key in discussing medication names, dosages, rationales, intended effects, unintended effects, and contraindications with their clients. Nurses also help educate patients on how to take their medications; which ones need to be taken with or without food; how often to take their medications; and any additional specific instructions. Patients should be instructed when to call to report adverse reactions or concerns about side effects. Sometimes, because of the adverse effects, clients struggle with medication compliance and may abruptly stop or change their medications without medical orders to do so. The nurse should be aware of any medication changes and have an open communication plan with the ordering provider to help maximize the therapies of the client with minimal adverse reactions. Lastly, nurses are responsible for documenting all the discussions with both the client and ordering providers. Documentation is critical for any medical observations, client interactions, adverse reactions, nursing interventions, and/or emergency interventions performed. Blood and Blood Products The administration of blood and blood products is common in the hospital setting. Patients may need blood and blood products for a variety of reasons including hypovolemia, anemia, clotting disorders, platelet deficiencies, and trauma. Broad knowledge of blood type, blood administration protocols, and blood products is crucial. Prior to Administration The single, most important step of administering blood and blood products is proper patient identification. Each facility will have specific guidelines to follow to reduce errors in blood product administration. In general, the following steps should be taken: Identify the proper patient and reconcile the patient’s name and medical record with the information on the ordered blood product. Confirm that the ordered blood product matches the actual blood product. Check the blood type of the patient with the blood type of the product to be infused to ensure compatibility. This is called cross-matching. Verify that the blood product(s) is/are not expired. Lastly, confirm that patient consent has been obtained and is properly documented. This entire process is usually completed by a two-nurse team to help prevent any errors or missed steps. Administration After following the above steps for proper identification of the patient, product, and consent, the nurse should prepare for the administration of the designated blood product. Patient Evaluation Appropriate venous access to receive the blood product(s) needs to be identified and/or obtained. The ideal catheter gauge to deliver blood is an 18 gauge to 20 gauge. Central venous access devices may also be used for blood product administration. Larger bore or central intravenous catheters allow the blood product to be administered without clumping, crushing, or shredding of any of the blood components. Always ensure that any existing line is patent and functional prior to initiating an infusion. Documentation All aspects of the administration of blood and blood products will need to be documented. This will include (at a minimum): All steps of the verification process The exact times of the infusion (starting and stopping) Vital signs of the patient at initiation of infusion and at set intervals throughout the infusion All information on the blood product that was administered All information about the intravenous line that was used for the infusion All instructions given to the patient before, during, and after the procedure Administration and Patient Response There are a number of potential adverse patient reactions to the administration of blood and blood products. Mild to moderate adverse reactions include localized reactions around the intravenous line, urticaria, rash, pruritus, flushing, fever, restlessness, tachycardia, palpitations, mild dyspnea, and headache. Severe, and potentially life threatening, adverse reactions include rigors, severe hypotension, hematuria, unexplained bleeding (disseminated intravascular coagulation - DIC), anxiety, chest pain, respiratory distress, and anaphylaxis. The first step in any concern for a transfusion reaction is to stop the blood product infusion. This step is then quickly followed by interventions as designated by the protocols in place at individual facilities. Central Venous Access Devices Several types of central venous access devices are available for patients. Central lines are used for direct administration of intravenous medications, intravenous fluids, and/or blood products to the central venous system. Common locations for central venous access devices include access to the superior vena cava, inferior vena cava, subclavian vein, femoral vein, and internal jugular vein. Central venous access devices have specific instructions for use, care, and maintenance of the devices. Patient Education Many patients will be familiar with peripheral venous access, where short-term intravenous catheters are used to administer intravenous medications and fluids. Some patients, though, will require longerterm access or have medications ordered that are caustic to the peripheral venous paths. These patients qualify for the placement of central venous access devices. Central venous access devices allow intravenous medications, fluids, and blood products to release into the robust central venous system, instead of the more delicate peripheral venous system. Common reasons for needing a central venous access device include long-term intravenous antibiotic therapy, chemotherapy, parenteral nutrition (TPN), and simultaneous intravenous medication administration. Access Devices A tunneled catheter is placed in a central vein (usually the subclavian), then “tunneled” through the skin where it exits somewhere on the chest. The “tunnel” provides stability and helps to provide an infection barrier for long-term use of this type of device. Examples include a Hickman®, Groshong®, or Broviac® catheter. An implanted port is also tunneled beneath the skin, and a catheter is threaded into the superior vena cava. The port can be placed subcutaneously and accessed as needed. Examples of this type of device are the PowerPort®, Port-A-Cath®, and SlimPort® Dual-Lumen Rosenblatt™. A peripherally inserted central catheter (PICC) is usually placed above or below the antecubital area on the non-dominant arm and then advanced through the peripheral vein until the tip rests in the superior vena cava or cavoatrial junction. These lines may be left in place for long periods. Access Maintenance Nurses caring for patients with these devices will need to know how to care for them. Since these central venous access devices are in place long-term, cleaning and maintenance of the line will be required. Strict sterile technique is always required when accessing the line or changing the dressing of a central venous device. Chlorhexidine solution is often used for cleaning the individual lumens and insertion site of the device. Nurses and patients alike should wear a face mask when accessing the line or changing the dressing. The device line(s) may need to be routinely “locked” or flushed with normal saline or low-concentration Heparin when not in use to prevent clotting of the catheter. Dressing changes should also be performed every 2–7 days, depending on the type of dressing used and protocol of the facility. Dosage Calculation Medication dosage calculation requires familiarity with basic arithmetic, ratio and proportion, and algebra. Different measurements systems exist in the world, including the metric system, household measurements (teaspoons, tablespoons, cups, etc.), and apothecary measurements (ounce, minim, dram, etc.). In medicine, most adult doses differ from pediatric doses for the same medication. While adult medication follows a standard dosing guideline, most pediatric medications follow weight-based dosing. It is critical for nurses to know and understand how medications are dosed, which measurements to use, and provide the education needed for patients to understand the same. Calculations Many medication dosages, especially in the pediatric population, are based on body weight in kilograms (kgs). To convert weight from pounds to kilograms, simply divide the weight in pounds by 2.2. To find the dose of a medication, take the prescribed unit (mg, ml, cc, etc.) of the medication and multiply it by the patient’s weight in kilograms. Depending on whether the prescribed order is for a total daily dose or multiple timed doses, the nurse will be responsible for making sure the right dose is given at the right time, to the right patient. If trying to figure out how much of a medication to give at each dose, the total daily dose should be divided by the number of times the dose is given during the day. Doses may be given once daily (QD), twice daily (BID), three times a day (TID), or four times a day (QID). If scheduled at specific times, doses may be given at specific hourly intervals or before or after significant events, such as meals or before bed (HS). The use of the abbreviations given in the previous two sentences are generally not recommended. They are provided for informational purposes only. All medication orders with confusing or unclear abbreviations should be questioned and clarified with the ordering provider. intravenous fluids are given over a period of time. The rate of delivery must be calculated in order to give the appropriate medication dosage in the ordered amount of time. To calculate the amount of time in which an infusion should be given, take the total volume of the solution divided by the total time in minutes in which it should be given and multiplied by the drop/drip rate factor of the IV tubing being used. There are two types of IV tubing: microdrip (60 gtts/mL) and macrodrip (10–20 gtts/mL). Decision Making When performing calculations for medication and solution dosage, critical thinking skills are required to guide decision making. While calculation errors will inevitably occur, calculation results should be critically analyzed to make sure they make sense for the order and the client. Nurses need to carefully observe in which units their medications are prescribed and maintain continuity of those units throughout the medication calculation. Many medications and therapy calculations require an independent two-nurse double-check prior to medication administration. This helps to eliminate many calculation errors and ensure appropriate wasting of specific products. Independent double checks are required for high alert medications and infusions such as narcotics, insulin infusions, heparin infusions, chemotherapy, blood products, parenteral nutrition, and titrated infusions. Expected Actions and Outcomes Nurses are expected to know the expected action of, and intended outcomes of, any medications given to patients. Not only should the nurse anticipate these outcomes for their patients, they should also be able to educate and provide guidance to their patients regarding these medications. Information and Evaluation Numerous resources are available to help nurses navigate medication education. Most healthcare facilities have a drug formulary that nurses can reference. Pharmacists and pharmacy staff are knowledgeable resources to discuss questions or concerns about medications. Nursing handbooks, the Physician’s Desk Reference (PDR), or reliable Internet resources may also be helpful. Not only should nurses know where to gather unknown information about medications, they should be aware of all the medications their patients may be taking, acutely or chronically. Recognize that home remedies, herbal supplements, and apothecary are common practices and should be appropriately documented if used by the patient. It is important to understand each patient’s compliance with their prescribed regimen and if they feel the medication is achieving the expected outcome. Patients should be evaluated for adverse events, side effects, interactions or toxicity from any medication (or combination of medications). It is also good practice to regularly reconcile the patient’s actual use of medications with what is listed in the medical record. Clinical Decision Making Clinical decision making is required in all aspects of nursing. Nurses must anticipate the needs of their clients in regard to taking, tolerating, and sustaining medication therapy. Medications are administered in a number of ways. Depending on their administration, nurses should monitor for specific events. The bullets below help identify common expectations with each medication administration type. Oral (PO) Formulations—liquid, tablet, capsule, chewable Identify which medications can be crushed or must be taken whole. Some medications may be prescribed for sublingual (under the tongue) or buccal (between cheek and gum). Monitor for choking. Intradermal (ID) Formulation—injection After cleansing the injection side, use a small gauge needle, position the needle flush to near flush (5–15 degree angle) with the surface of the skin, bevel side up. Insert the needle into the skin in the dermal layer, and inject the solution. Volume <0.5ml Intradermal administration is most commonly used for sensitivity testing, such as allergy and tuberculosis (TB) testing. Monitor for injection site reaction. Subcutaneous (SubQ, SQ) Formulation—injection After washing hands, donning gloves, and cleansing the injection site, position the needle at a 45–90 degree angle to the site, squeeze the skin together (to ensure entering the subcutaneous, fatty layer, and not intramuscular layer), insert the needle into the skin bevel up, and inject the medication. Volume 0.5–1 ml Common injection sites: upper and outer area of the arm, front and outer sides of the thighs, abdomen (outside of 2 in around the navel), upper and outer area of the buttocks, and outer hip Subcutaneous medication administration is used for insulin and heparin administration. Educate clients to rotate their sites if chronically using subcutaneous injection sites to avoid tissue damage. Monitor for intended effects of the medication (e.g., decreased glucose with insulin administration, therapeutic lab levels, etc.). Intramuscular (IM) Formulation—injection After washing hands, donning gloves, and cleansing the injection site, position the needle at a 90-degree angle to the skin, bevel up, and insert into the intramuscular tissue. Aspirate the syringe to check for blood. If blood appears, withdraw the needle and restart administration. If no blood is present in the needle, inject the medication. Max volume to be injected into one muscle for adults is 3 mL; children under the age of 2 have a maximum volume of 1 mL. Common injection sites: deltoid, vastus lateralis, ventrogluteal, gluteus medius, dorsogluteal muscles For children under 3 years old, the anterolateral thigh muscle (vastus lateralis) is preferred. Needles of at least 1 inch in length are required to deliver medication intramuscularly. Medications requiring IM administration: antibiotics and most immunizations Monitor for effects of medication, anaphylaxis, and injection site changes. Topical Formulation—cream, ointment, patch It can be applied to the skin. Creams and ointments may be applied to specific areas of concern or on the whole body. Follow the prescription and directions given with the medication. Monitor for dermatitis, non-improved or worsening of the condition being treated. Transdermal Formulation—patch The option allows slow, continuous administration of medication. Patches are changed every 24–72 hours. Wash hands and don gloves. Apply the patch to a clean, dry, hairless, unbroken area of skin. Rotate sites with every patch change to avoid skin irritation. Common application sites: upper arm, chest, back, flank Examples of medications that are available as transdermal patches: Fentanyl, Scopolamine, Nitroglycerine, Clonidine, Nicotine, Methylphenidate, Lidocaine Monitor for dermatitis surrounding the sites. Ensure proper disposal of patches, especially narcotic patches, to eliminate unintended transmission of medication. Intravenous (IV) Formulation—infusion Medications are required to be administered through a venous access point. Intravenous lines may be peripheral or central. Medications that require venous access: injectable antibiotics, continuous sedation drips, IV fluids, injectable steroids, etc. See more information in the previous section regarding central venous access devices. Monitor for IV site reactions, phlebitis, infiltration, and device malfunction. While these are the most common routes for administration of medication, be aware there are still other routes available. Intrathecal (around the spinal cord), rectal, vaginal, ocular (in the eye), otic (in the ear), and inhaled medication routes are available for specific medications. These routes will be further explained in any medical surgical nursing text. Medication Administration Proper and appropriate medication administration is one of the most important jobs a nurse will encounter. There are numerous steps to be taken before, during, and after administration of medications. Checking clients’ rights and the rights of medication administration are crucial to ensuring safe delivery of healthcare. Most facilities have protocols nurses are required to follow to assist in minimizing errors of medication administration. Patient Education Patients and their caregivers will need to be educated on every aspect of their prescribed medications. This includes education on the name, dosage, intended purpose, potential side effects, potential interactions, and administration. Some medications require specific storage instructions. Certain medications, such as reconstituted antibiotics, some IM injections, and vaccinations must be refrigerated. Other medications must not be exposed to light. Many medications need to be discarded after specific periods. All medications should be stored out of the reach of children and be protected against unintended use by others. Instruct clients to take their full dose of medication for the duration instructed by the healthcare provider. This is especially important for antibiotics. Clients should also know the indications for which to call their healthcare provider with questions or concerns. If the patient is being educated on a self-administered medication (inhaler, injections, etc.), the proper technique should be taught along with how to properly dispose of any unused drug and/or biohazardous materials (e.g., syringes/needles). Information Review Prior to administering any medication, you will need to review several bits of essential information: Review the “rights” of administration Right client Right medication Right dose Right route Right time Right documentation (also known as the sixth right) Review pertinent patient data Vital signs Labs Current medications Medication interactions Diagnosis/diagnoses Review the patient’s medical history (for contraindications) and listed medication allergies. Administering Medication Many aspects are involved in the administration of a medication. First, one must have a working knowledge of pharmacological principles (pharmacokinetics, administration route, distribution, metabolism, and excretion) and understand how these principles apply to patients and their medications. Understand the proper preparation and administration of each medication, and keep in mind that pediatric and adult routes of administration may differ. Mixing Medications from Two Vials At times, it may be necessary to mix two, compatible medicines from different vials prior to injection. Combining insulin NPH and regular insulin is an example of this practice. When drawing up these different insulins, first draw up the clear, regular insulin followed by the cloudy, insulin NPH. Also, remember that prior to drawing up each medication, both vials will need to be cleansed with alcohol and the vials injected with the same amount of air as the dose without touching either medication with the needle. Documentation Documentation is known as the ‘sixth right’ of medication administration. Nurses are responsible for documenting the patient’s choices regarding medication administration. This includes route, whether the medication was omitted, held, or refused, interactions, effects, and any other observations. Medication Reconciliation A large number of medical errors occur due to poor or incomplete communication regarding a patient’s medications. A medication reconciliation is a process that can be used to prevent medical errors. It is particularly useful for newly admitted patients and those being transferred elsewhere or discharged. Here is the process: Make a list of the patient’s current medications and a list of newly prescribed medications. Critically compare the two and note discrepancies or inconsistencies. Report the findings to the appropriate healthcare provider and document the nursing actions. Remember that all over-the-counter medications, herbal or dietary supplements, blood or blood products, vaccinations, contrast or other diagnostic agents, and radioactive medications should be included on both of the lists. Titration A titration is an adjustment in the dosage of a given medication based upon certain parameters or criteria. These will usually be defined in the healthcare provider’s order for the medication. The two most common types of medications used in this way are insulin and certain blood pressure medications. Handling and Disposal Each facility or agency will have its own specific guidelines as to the handling and disposal of unused medication. They will also have specific guidelines on the handling of specific medications such as narcotics and chemotherapy. Patients will need education on the process of taking and managing medications at home. Nurses should indicate which patients need specific supplies such as needles, syringes, sharps containers, and information regarding community disposal sites/narcotic collection days. Evaluation Always verify the medication order for accuracy. Ensure that all aspects are correct and that the order is valid and signed by the prescriber. The nurse will be held responsible if medications are administered in an incorrect order, an incorrect dose, or on the incorrect patient. Parenteral and Intravenous Therapies Intravenous therapy is used for a variety of reasons. Understand the indications for its use, the differences between the fluids that are used, and the equipment involved. There are four basic types of intravenous therapy: peripheral, central, continuous, and intermittent. Preparation Patient education and preparation are needed prior to initiating an intravenous line or therapy. This includes a discussion on potential problems or complications from this type of therapy as well as what certain alarms and signals can mean on any pump equipment that is being used. Patients may receive intermittent infusions at home or facilities with home health nursing, at infusion centers, or in the hospital. Remember to critically evaluate the indication for and location IV access when selecting a vein. As a general rule, it is preferable to use the largest vein above or below the antecubital area on the patient’s non-dominant hand. Veins in the legs and hands are not ideal for IV use. Do not place an IV on the same side as a patient’s mastectomy, paralysis, or dialysis access. Also avoid veins distal to a previous access site with an infusion and/or phlebitis. Larger veins will be necessary for large bore catheters for trauma patients, to deliver blood products, chemotherapy, or for parenteral nutrition. Smaller veins may be used if the patient only needs IV fluids with or without medications. Always critically evaluate the best vein and location to use based on the patient’s needs and medical condition(s). Care and Monitoring Obtaining IV access is only one part of this type of medication administration. Nurses must then know how to calculate the rate of infusions for both medications and fluids. Drip Rates Critical thinking skills are required to determine the drip rate for the administration of fluids/medications. In general, the rate of infusion, in gtts/min, can be determined by the total amount of fluid to be delivered divided by time in minutes, multiplied by the drip/drop factor for the IV tubing that is being used. Standard IV tubing comes in different drip/drop rates. There is micro tubing that flows at a rate of 60 gtt/min. There is also macro tubing that flows at rates of either 10, 15, or 20 gtt/min. Drip rates of IV tubing are usually provided in problems related to calculating medication rate. Infusion Pumps While infusion pumps allow for convenience and are widely used, manual calculation of medication administration allows for error reduction in incorrect drip rates and pump malfunctions. Check drip rates by actually counting the drops that are given over 1 minute or by calculating the amount of intravenous solution administered in a set period. Both of these numbers should be checked against the manual rate calculations. Monitoring and Site Care Care and monitoring of all intravenous lines is done by licensed medical staff. It cannot be delegated to other non-licensed support staff. Since all intravenous lines (peripheral, central, PICC, and venous access devices) are potential sites for infection, fastidious care and monitoring is necessary. Facilities will have protocols in place regarding the care of their IV catheters. Most facilities practice peripheral line dressing changes every 24 hours. Central line changes must be performed with sterile technique, patient masks, and occlusive, preferably transparent, dressings. These dressings may stay in place between 3 and 7 days. All dressings that become non-occlusive, have significant drainage, or have questioned integrity should be changed. Pharmacological Pain Management In healthcare, clients are often prescribed PRN or as needed medications for pain management. Some clients may request the medications. Others may need to be encouraged to use them. Nurses must assess their patients’ needs for PRN medication administration. They should also understand any regulations that are associated with the administration of narcotic pain therapy. Assessment Each patient will require an assessment of their level of pain. This may be accomplished with various numeric/graphic scales, the PQRST method, and/or standardized pain assessment scales. For those unable to use a pain scale due to disability or age, pain assessment can be completed by monitoring the patient’s nonverbal language and vital signs. Nurses should be aware that pregnant women and children require additional assessments in regard to their pain. Medication administration for these populations can vary significantly from the standard adult population. Patient assessment for pain management should also include the routes for administering PRN prescriptions. Oral, topical, subcutaneous, IM, and IV medication routes are commonly used in pain management. Determining appropriate medication routes requires critical thinking and understanding of the clients’ abilities and conditions. For example, a client with vomiting and retching due to post-surgical anesthesia should not have pain medications administered orally. If the orders prescribed do not match the client’s abilities or is compatible with specific conditions, the nurse should notify the ordering healthcare provider to prescribe a more appropriate therapy. Administration Pharmacologic medicines that have analgesic effect can be broadly grouped into one of two categories: opioid and non-opioid analgesics. In general, opioid medications are indicated for moderate to severe pain and non-opioid are used in mild to moderate pain. Weight-based dosing is generally used for neonates, infants, and young children. Adults generally have a standard dosing schedule. In geriatric patients, medication doses may need to be adjusted due to chronic disease and organ dysfunction (renal, hepatic, etc.), as this may affect metabolism and excretion of the drug. Documentation Documentation of the pain assessment findings, medication, dose, and route must be supplied in the patient’s medical record. Regulatory Guidelines Due to the illegal diversion of controlled substance medications by healthcare personnel, stringent regulatory guidelines have been developed for all healthcare facilities. Most of the time, an automated system in place counts the medications and keeps careful track of who is accessing them and which patient(s) they are for. In the event that a facility does not have an electronic narcotic monitoring system, there will be a multitiered system in place to prevent diversion. Examples of controlled substance management systems include: Obtaining a nurse’s signature prior to release of controlled substances from the pharmacy Delivering controlled substance administration, waste, and count sheets with all controlled medications Using locked storage containers Assigning an accountable nurse with single key access to perform controlled substance medication counts at the beginning of every shift Requiring a secondary nurse to witness and sign documentation of any controlled-substance removal, waste, and administration. Evaluation Any time that a pain medication is given, it is imperative to observe and evaluate for its intended therapeutic effect on the patient. Assessment for effectiveness can be completed using the same scales discussed above for assessment of pain. The results of both tests should be documented within the patient’s medical record as well as the patient’s ability to meet the expected outcomes as a result of reduced pain (sleep, ambulation, etc.). Total Parenteral Nutrition (TPN) TPN is also known as hyperalimentation. It is nutrition that is provided intravenously to a patient and bypasses the gastrointestinal system. While it is more costly than enteral nutrition, TPN is indicated in certain patient populations. It does, however, also carry its own set of risk factors. Side Effects TPN should be administered via a central line (PICC line, port, subclavian venous line, etc.). There is a high risk of peripheral vein thrombosis caused by the solution being high concentration due to the requirement to pack in all the daily nutrients and electrolytes. In the case of any central line, there may be complications with line placement, and conditions such as pneumothorax, hemothorax, or hydrothorax could occur. In relation to the TPN administered, infection, fluid overload, hyperglycemia, hypoglycemia, and air emboli are all potential adverse side effects/complications. Review the signs and symptoms of these complications. Patient Education All patients should receive education on why they need TPN and how it will be delivered. They should be informed of all of the potential risks and complications associated with TPN therapy. Patients will also need to understand and be informed on all aspects of the placement, care, and maintenance of the intravenous line (peripheral or central) that will be used to deliver their TPN. Nursing Skills The following nursing skills will be applicable and should be used when caring for a patient on or considering TPN: Assessment—validation of the need for TPN and recording of baseline findings (weight, vitals, glucose, protein, electrolytes, intake, and output) Nursing diagnoses—actual and potential Planning—establishment of expected outcomes and client goals for TPN therapy Evaluating the response to treatment—reassessment of the same criteria evaluated prior to TPN and determination of the effectiveness of treatment Other applicable skills will include the use of aseptic technique, proper maintenance and changing of tubings, bags, and bottles, maintenance of the catheter insertion site, and mathematical skills to calculate and control the rate of infusion. Lastly, you must also apply your knowledge of your patient’s pathophysiology to prevent infection, balance the interplay between the dextrose content of the solution and any insulin that is given, and closely monitor intake and output to avoid fluid imbalance. Administration and Evaluation Strict sterile procedure must be followed when administering TPN. Direct your patient to bear down, performing a valsalva maneuver, whenever tubing, bags, or bottles are changed to avoid an air embolism. Move quickly, but carefully, during these tasks. Evaluate for the client’s response to the TPN and any changes in the client’s status. Monitor glucose levels, level of consciousness (LOC), and electrolyte levels throughout the duration of TPN therapy.