Learning Objectives
Differentiate between Total Parenteral Nutrition and Partial Parenteral NutritionDiscuss Nursing Considerations for Clients with Complications in Parenteral NutritionDiscuss Age-Related ConsiderationsPrioritize 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 tractNeed complete nutrition source, but are not totally depletedUsually used when client needs support less than 14 daysUsed when a central line is not indicatedDelivered through a peripheral veinConcentrations of 5%-10% dextrose and 2%-5% amino acidsLipids 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 supportBeneficial for long term useAllows bowel rest and healingUsed for clients with large caloric and nutrient needsDelivered through a central line/PICC lineContains hypertonic glucose solutions-(20%-70% dextrose)
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TPN
Different from standard IV solutions in that it contains all nutrients including: Carbohydrates- CaloriesProtein-Amino Acids- Tissue growth and repairEssential Fatty Acids/20% Lipid Emulsions- Heat and
Energy, provides twice as many calories as proteins and carbs.
Vitamins- growth and maintenanceMineralsElectrolytes- K+, NA+ CA, Mg, phosphorusTrace ElementsCalories- 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 PancreatitisDiffuse PeritonitisBowel SyndromesGastric ParesisAlcoholismSevere BurnsAnorexiaCancerTrauma
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Complications
Metabolic
Mechanical
Infection
Fluid Imbalance
Most common complication of parenteral nutrition is hyperglycemia
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Metabolic Complications
Hyperglycemia
Hypoglycemia
Vitamin Deficiencies
Electrolyte Imbalance particular NA+, K+, CA+
Nursing Considerations
Monitor Daily Labs
Monitor Glucose-Accuchecks
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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
High Glucose concentration makes good medium for bacteria
Contamination of the catheter on insertion
Long Term Catheter Use
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
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Complications-Fluid Overload
Hyperosmotic Solution-3 to 6 times the osmolarity of blood so at risk for fluid shifts
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”Block 7.0 Module 1.4
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 imbalancesMore vulnerable to CHF- Check historyIncrease incidence of glucose intoleranceAge-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 ordersMUST complete 2 nurse check prior to administration-Verify elements contained in the mixture is accurate to the prescriptionMUST use infusion pumpCheck 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 solutionIV tubing is changed every 24hours or with every new bag (check protocol)TPN bag discarded after 24 hoursDressing 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 abruptly…WHY?
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 complicationBlock 7.0 Module 1.4