Adult Health Nursing II

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Adult Health Nursing II Block 7.0
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Parenteral Nutrition

• Adult Health II Block 7.0

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Learning Objectives

• Differentiate between Total Parenteral Nutrition
  and Partial Parenteral Nutrition
• Discuss Nursing Considerations for Clients with
  Complications in Parenteral Nutrition
• Discuss Age-Related Considerations
• Prioritize 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 tract
• Need complete nutrition source, but are not
  totally depleted
• Usually used when client needs support less than
  14 days
• Used when a central line is not indicated
• Delivered through a peripheral vein
• Concentrations of 5-10 dextrose and 2-5 amino
  acids
• Lipids 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 line
• Mid-line catheters are frequently used
• PPN 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 support
• Beneficial for long term use
• Allows bowel rest and healing
• Used for clients with large caloric and nutrient
  needs
• Delivered through a central line/PICC line
• Contains hypertonic glucose solutions-(20-70
  dextrose)

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TPN

• Different from standard IV solutions in that it
  contains all nutrients including
• Carbohydrates- Calories
• Protein-Amino Acids- Tissue growth and repair
• Essential Fatty Acids/20 Lipid Emulsions- Heat
  and
• Energy, provides twice as many
  calories as
• proteins and carbs.
• Vitamins- growth and maintenance
• Minerals
• Electrolytes- K, NA CA, Mg, phosphorus
• Trace Elements
• Calories- High glucose concentration

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TPN

• Basic Guideline for Initiating TPN
• 5-Day Rule
• Has not eaten for 5 days and not expected to
  eat within the next 5 days or inadequate
  nutrition for 7-10 days
• Weight loss of 7 body weight and NPO for 5-7
  days
• Hypermetabolic state

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Common Conditions Requiring TPN

• Chronic Pancreatitis
• Diffuse Peritonitis
• Bowel Syndromes
• Gastric Paresis
• Alcoholism
• Severe Burns
• Anorexia
• Cancer
• Trauma

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Complications

• Metabolic
• Mechanical
• Infection
• Fluid Imbalance
• Most common complication of parenteral nutrition
  is hyperglycemia

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Metabolic Complications

• Nursing Considerations
• Monitor Daily Labs
• Monitor Glucose-Accuchecks

• Hyperglycemia
• Hypoglycemia
• Vitamin Deficiencies
• Electrolyte Imbalance particular NA, K, CA

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Mechanical Complications

• Phlebitis
• Air Embolism
• Infiltration
• Pneumothorax-Upon Subclavian Catheter placement

• Assess Site for redness, swelling warmth or cold
• Discourage client from talking/laughing when
  changing tubing
• Chest X-Ray

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Complications-Infection

• Nursing Considerations
• Assess sites for redness, swelling, tenderness,
  drainage, warmth
• Assess for fever, WBCs
• STERILE dressing change every 72 hours or per
  agency protocol
• DO NOT use TPN line for other IV fluids and
  medications.
• May have to remove catheter, save the tip and
  send to lab

• High Glucose concentration makes good medium for
  bacteria
• Contamination of the catheter on insertion
• Long Term Catheter Use

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Complications-Fluid Overload

• Nursing Considerations
• Daily Weights
• Monitor Intake and Output
• Assess breath sounds
• MUST use a controlled infusion pump
• Usual rate is 100cc/hr or less
• NEVER speed up infusion to catch up

• Hyperosmotic Solution-3 to 6 times the osmolarity
  of blood so at risk for fluid shifts

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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
  imbalances
• More vulnerable to CHF- Check history
• Increase incidence of glucose intolerance
• Age-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, diagnosis
• Assess labs-CBC, Chemistry Profiles, PT/PTT,iron,
  lipid profile, liver function tests,
  Electrolytes, BUN/Creatinine and Blood Sugar
• Line insertion is STRICT aseptic technique

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Nursing Care-Pre Infusion

• Check PCP orders
• MUST complete 2 nurse check prior to
  administration-Verify elements contained in the
  mixture is accurate to the prescription
• MUST use infusion pump
• Check 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 hanging
• Careful 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/hr
• Never catch up
• Continue to assess lab values, glucose/accuchecks,
  daily weights, intake and output
• Continue to assess access site
• Continue 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 solution
• IV tubing is changed every 24hours or with every
  new bag (check protocol)
• TPN bag discarded after 24 hours
• Dressing 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 abruptlyWHY?
• Should be decreasing infusion rates
• Discontinue 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/dl
• Serious complication