Total Parenteral Nutrition

CHAPTER 10 CLINICAL NUTRITION UNIT 2 CHAPTER 10 Total Parenteral Nutrition Parenteral nutrition (PN) is used when a client’s gastrointestinal tract is not functioning, or when a client cannot physically or psychologically consume sufficient nutrients orally or enterally. Based upon the client’s nutritional needs and anticipated duration of therapy, PN can be given as either total parenteral nutrition (TPN) or peripheral parenteral nutrition (PPN). TPN provides a nutritionally complete solution. It can be used when caloric needs are very high, when long-term therapy is indicated, or when the solution to be administered is hypertonic (composed of greater than 10% dextrose). It can only be administered in a central vein. PPN is administered for up to 14 days into a peripheral vein. It is nutritionally incomplete because it has a low dextrose content. It is indicated for clients who require short-term nutritional support with fewer calories per day. The solution must be isotonic and contain no more than 10% dextrose and 5% amino acids. COMPONENTS OF PARENTERAL NUTRITION SOLUTIONS Lipids (fats) are available in concentrations of 10%, 20%, and 30%. Lipids are formulated from a combination of soybean oil and or sa o er oil, and egg phospholipids, which gives lipids a milky or opaque appearance. ● IV lipids are contraindicated for clients who have severe hyperlipidemia, severe hepatic disease, or an allergy to soybean oil, eggs, or sa o er oil ● Lipid emulsion provides the needed calories when de trose concentration must be reduced due to uid restrictions or persistent hyperglycemia. They also correct or pre ent essential fatty acid de ciency ● Lipid emulsion provides the calories without increasing the osmolality of the PN solution. ● Total nutrient admixtures are available that combine lipids into the PN solution containing dextrose and amino acids, rather than administering the solutions separately. Not all facilities use this three-in-one solution. ◯ Three-in-one infusions reduce body carbon dioxide production and buildup of fat in the liver. Protein is provided as a mixture of essential and nonessential amino acids and is available in concentrations of 3% to 20%. The client’s estimated requirements and liver and kidney function determine the amount of protein provided. Other substances can be added to the PN solution by pharmacy services. ● Insulin can be added to reduce the potential for hyperglycemia. ● eparin can be added to pre ent brin buildup on the catheter tip. ● Glutamine, antioxidants, prebiotics, or probiotics might be prescribed based on individual client needs. ! Administering any IV medication through a PN IV line or port is contraindicated. INDICATIONS DIAGNOSES ● PN includes amino acids, dextrose, electrolytes, vitamins, and trace elements in sterile water. Fats (lipids) are added to the parenteral solution or given as an intermittent infusion. Carbohydrate or dextrose solutions are available in concentrations of 2.5% to 10% for PPN and up to 70% for TPN. ● A higher concentration of dextrose is often prescribed for a client on uid restrictions ● A lower-dextrose concentration can be used to help control hyperglycemia. Electrolytes, vitamins, and trace elements are essential for normal body functions. The amounts added are dependent upon the client’s blood chemistry values and physical ndings, hich are used to determine the quantity of electrolytes. Additional vitamin K can be added to the PN solution. ● ● TPN is commonly used in clients who need intense nutritional support for an extended period of time, including clients undergoing treatment for cancer, bowel disorders, those who are critically ill, and those su ering from trauma or e tensi e burns, as these conditions are associated with high caloric requirements. PPN can be used when the client is unable to consume enough calories to meet metabolic needs or when nutritional support is needed for a short time. Clients can receive PN at home as nutrition replacement or to supplement nutrition. Typically, the client will have a tunneled catheter, and feedings can occur while the client sleeps. DESIRED THERAPEUTIC OUTCOMES ● ● ● Improved nutritional status Weight maintenance or gain Positive nitrogen balance EVIDENCE SUPPORTING EFFECTIVENESS ● ● ● Daily weight: Maintenance of baseline or gain of up to 1 kg/day Increases in prealbumin level (expected reference range of 15 to 36 mg/dL) Blood urea nitrogen level within the expected reference range (10 to 20 mg/dL) CONSIDERATIONS ● ● ● ● PREPARATION OF THE CLIENT ● ● ● ● ● Prior to initiating PN, review the client’s weight, BMI, nutritional status, diagnosis, and current laboratory data This can include C C, blood chemistry pro le, T a TT, iron, total iron binding capacity, lipid pro le, liver function tests, electrolyte panel, BUN, prealbumin and albumin level, creatinine, blood glucose, and platelet count. Assess the client’s educational needs. Use an electronic infusion device to prevent the accidental overload of a solution. A micron lter on the I tubing is re uired hen administering solution This lter is not added to the IV tubing when administering a lipid emulsion. aluate for allergies to soybeans, sa o er, or eggs if lipids are prescribed. ● ● NURSING ACTIONS ● ● Ask the provider about giving some enteral substance during long-term PN administration, such as diluted juice, to prevent atrophy of the gastrointestinal tract. PN should be discontinued as soon as possible to avoid potential complications, but not until the client’s enteral or oral intake can provide 60% or more of estimated caloric requirements. ! Discontinuation should be done gradually ONGOING CARE Nursing care is focused on preventing complications through consistent monitoring peci c monitoring guidelines vary among health care facilities. ● Parameters can include I&O, daily weights, vital signs, pertinent laboratory values (e.g., electrolytes), and evaluation of the client’s underlying condition. This data is used to determine the client’s response to therapy, whether the formulation of the solution is correct, and to pre ent nutrient de ciencies or to icities ● Monitor blood and urine glucose as prescribed and per facility guidelines. Sliding scale insulin can treat or prevent hyperglycemia, or regular insulin can be added to the PN solution. ● onitor o rate carefully ◯ Administering the solution too slowly will fail to meet the client’s nutritional needs. ◯ Administering the infusion too rapidly can cause hyperosmolar diuresis, which can lead to dehydration, hypovolemic shock, seizures, coma, and death. ◯ To avoid hypoglycemia, an IV of dextrose 10% to 20% in water is administered if the PN solution is unavailable. ◯ Do not attempt to increase the rate of the PN solution to “catch up.” Hyperglycemia, hyperosmolar diuresis, and uid o erload can occur if the solution is increased when available. Monitor for “cracking” of TPN solution. This occurs if the calcium or phosphorous content is high or if poor-salt albumin is added. A “cracked” TPN solution has an oily appearance or a layer of fat on top of the solution and should not be used. Verify the prescription of the PN solution with a second nurse prior to administration. If the PN solution is prepared and stored in the refrigerator, allow it to come to room temperature for 1 hr prior to administering it. Maintain strict aseptic techniques to reduce the risk of infection. The high dextrose content of PN contributes to bacterial growth. Use sterile technique when changing central line dressing and tubing. Change the bag and IV tubing for the dextrose solution e ery hr unless facility policy di ers ith intermittent IV lipid infusions, ensure the solution does not hang more than 12 hr to prevent microbial growth. Ensure lipid infusion is stopped 12 hr prior to obtaining a blood specimen for triglycerides to ensure accurate results. to avoid rebound hypoglycemia. ● ● During transition, the client will need enteral or oral nutrition. Oral nutrition usually begins with clear liquids that are low in fat or substances that might irritate the client’s gastrointestinal tract. The client might not have an appetite for 1 to 2 weeks, so PN infusion will need to continue until the client can take in adequate calories through other means. Educate the client and family regarding home PN, including aseptic preparation and administration techniques, blood glucose monitoring, and criteria to evaluate for complications. COMPLICATIONS Infection and sepsis are evidenced by a fever or elevated WBC count. Infection can result from contamination of the catheter during insertion, contaminated solution, or a long-term indwelling catheter. Metabolic complications include hyperglycemia, hypoglycemia, hyperkalemia, hypophosphatemia, hypocalcemia, dehydration (related to hyperosmolar diuresis resulting from hyperglycemia , and uid o erload (as evidenced by weight gain greater than 1 kg/day and edema). Mechanical complications include catheter misplacement resulting in pneumothorax or hemothorax (evidenced by shortness of breath, diminished or absent breath sounds), arterial puncture, catheter embolus, air embolus, thrombosis, obstruction, and bolus infusion due to incorrectly set or malfunctioning electronic pumps. Refeeding syndrome occurs when the body rapidly changes from catabolic (seen in starvation states) to anabolic metabolism when nutrition is started. It is characterized by uid and electrolyte imbalances potassium, magnesium, phosphate). Manifestations include shallow respirations, confusion, sei ures, ea ness, cardiac rhythm changes, uid retention, and acidosis. NURSING ACTIONS ● ● ● ● ● ● ● ● Monitor for manifestations of fever, chills, increased WBCs, and redness around the catheter insertion site. Use strict aseptic technique when setting up the IV tubing, changing the site dressing, and accessing or deaccessing the IV access. Change the PN bag and tubing set every 24 hr or per facility protocol. Monitor blood glucose per prescription or facility policy. Administer sliding scale insulin or plan for insulin to be added to the TPN solution to treat hyperglycemia. Plan to administer additional dextrose to treat hypoglycemia. Monitor daily weights, I&O, and oral intake of nutrients. Notify the provider of weight gain greater than 1 kg/day. Anticipate a decrease in the concentration of the solution, rate of administration, or volume of lipid emulsion to treat weight gain. Application Exercises 1. A. Examine trends in weight loss. B. Review prealbumin finding. C. Administer an IV solution of 20% dextrose. D. Add a micron filter to IV tubing. E. Use an IV infusion pump. 2. A charge nurse is providing information about fat emulsion added to total parenteral nutrition (TPN) to a group of nurses. Which of the following statements by the charge nurse are appropriate? (Select all that apply.) A. “Concentration of lipid emulsion can be up to 30%.” B. “Adding lipid emulsion gives the solution a milky appearance.” C. “Check for allergies to soybean oil.” D. “Lipid emulsion prevents essential fatty acid deficiency.” E. “Lipids provide calories by increasing the osmolality of the PN solution.” 3. A charge nurse is teaching a group of nurses about medication compatibility with TPN. Which of the following statements should the charge nurse make? A. “Use the Y-port on the TPN IV tubing to administer antibiotics.” B. “Regular insulin can be added to the TPN solution.” Active Learning Scenario A nurse is teaching a client about complications that can occur when receiving total parenteral nutrition (TPN). What should the nurse include in the teaching? Use the ATI Active Learning Template: Basic Concept to complete this item to include the following. A nurse is planning care for a client who has a new prescription for peripheral parenteral nutrition (PPN). Which of the following actions should the nurse include in the plan of care? (Select all that apply.) C. “Administer heparin through a port on the TPN tubing.” D. “Administer vitamin K IV bolus via a Y-port on the TPN tubing.” 4. RELATED CONTENT: Identify three complications of TPN. Describe two nursing actions related to each complication. A nurse is preparing to administer lipid emulsion and notes a layer of fat floating in the IV solution bag. Which of the following actions should the nurse take? A. Shake the bag to mix the fat. B. Turn the bag upside down one time. C. Return the bag to the pharmacy. D. Administer the bag of solution as it is. 5. A nurse is caring for a client who is receiving TPN through a central venous access device, but the next bag of solution is not available for administration at this time. Which of the following is an appropriate action by the nurse? A. Administer 20% dextrose in water IV until the next bag is available. B. Slow the infusion rate of the current bag until the solution is available. C. Monitor for hyperglycemia. D. Monitor for hyperosmolar diuresis. Application Exercises Key 1. A. CORRECT: Examining trends in weight loss will help to evaluate the outcome of PPN. B. CORRECT: Reviewing the prealbumin finding will determine nutritional deficiency over a short period of time. C. An IV solution of 20% dextrose is administered only as TPN using a central vein. D. CORRECT: A micron filter is always used when infusing PN solution. E. CORRECT: An IV infusion pump is always used to regulate the flow and provide accurate delivery of the PN solution. Active Learning Scenario Key Using the ATI Active Learning Template: Basic Concept RELATED CONTENT Infection and sepsis Monitor for manifestations of fever, chills, increased WBCs, and redness around catheter insertion site. Use aseptic technique when setting up the IV tubing and accessing or deaccessing the port. Use sterile technique when changing central line dressing and tubing. Change the PN bag and tubing set every 24 hr or per facility protocol. ● ● ● ● Hyperglycemia Administer sliding scale insulin or plan for insulin to be added to the TPN solution. Monitor blood glucose. ● 2. A. CORRECT: Lipid emulsion is available in 10%, 20%, and 30% concentrations depending upon the client’s carbohydrate and caloric needs. B. CORRECT: The lipid emulsion is formulated from safflower and/or soybean oils and egg phospholipid, making the solution appear milky. C. CORRECT: Lipid emulsion is formulated from safflower and/or soybean oil and egg phospholipid. The nurse should check for allergies to these ingredients. D. CORRECT: Lipid emulsion is used for additional calories as concentrated energy and to prevent essential fatty acid deficiency. E. Lipids provide the calories needed without increasing osmolality of the PN solution. 3. A. Administering any IV medication through a Y-port on the TPN line is contraindicated. B. CORRECT: Regular insulin may be added to the TPN solution to decrease hyperglycemia. C. Heparin may be added to the TPN solution to decrease clot formation in the cannula, but it is not injected directly into a port on the TPN tubing. D. Vitamin K can be added to the TPN solution, but it should not be administered IV bolus through the TPN IV line. 4. A. Shaking the bag is not an appropriate action because “cracking” of the solution has occurred and it should not be administered. B. Turning the solution upside down does not resolve the problem because cracking of the TPN has occurred and it should not be administered. C. CORRECT: Returning the solution to the pharmacy is an appropriate action by the nurse because cracking of the solution has occurred and it should not be administered. The pharmacist and provider will need to adjust the formulation of the solution to prevent cracking. D. Administering the solution as it is would not be an appropriate nursing action because cracking of the solution has occurred. Infusion of a cracked solution can lead to fat or particulate embolisms. 5. A. CORRECT: Administering 20% dextrose in water IV until the TPN solution is available will prevent hypoglycemia. B. Decreasing the rate of the TPN solution is not an appropriate action because the decreased rate can cause hypoglycemia. C. The client should be monitored for hypoglycemia when the TPN solution is not infusing and adequate glucose is not provided. D. Monitor the client for hyperosmolar diuresis when the TPN solution has infused too fast. ● Hypoglycemia Inform the provider and plan to give additional dextrose. Monitor frequent blood glucose. ● ● Weight gain greater than 1 kg/day Inform the provider and anticipate a decrease in the concentration, rate of administration or volume of lipid emulsion. Monitor the client’s intake of oral nutrients. ● ●