Adult Health Nursing II
Block 7.0
Parenteral Nutrition
Adult Health II Block 7.0
Block 7.0 Module 1.4
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
Block 7.0 Module 1.4
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
Block 7.0 Module 1.4
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
Block 7.0 Module 1.4
Total Parenteral Nutrition
TPN 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)
Block 7.0 Module 1.4
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
Block 7.0 Module 1.4
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
Block 7.0 Module 1.4
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
Hyperglycemia
Hypoglycemia
Vitamin
Deficiencies
Electrolyte
Imbalance
particular NA+,
K+, CA+
Nursing Considerations
Monitor Daily Labs
Monitor GlucoseAccuchecks
Block 7.0 Module 1.4
Mechanical Complications
Phlebitis
Air Embolism
Infiltration
PneumothoraxUpon Subclavian
Catheter
placement
Assess Site for
redness, swelling
warmth or cold
Discourage client
from
talking/laughing
when changing
tubing
Chest X-Ray
Block 7.0 Module 1.4
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”
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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
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 complication
Block 7.0 Module 1.4