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SAN JOSE STATE UNIVERSITY
School of Nursing
Nursing 155
Care of the Client Receiving Parenteral Nutrition
KEY
Independent Learning Activities
Learning Outcomes
1. Describe the five typical components of a total parenteral nutrition (TPN) solution.
2. Identify five common clinical situations in which TPN might be used.
3. Identify common complications of TPN.
4. List nursing assessments or interventions that would help prevent, or treat, the following
complications of TPN: infection, hypoglycemia, hyperglycemia, electrolyte imbalance, and
air embolus
5. Describe types of patients who are likely to receive fat emulsion (lipids) in TPN.
6. Contrast peripheral parenteral nutrition (PPN) with TPN.
7. Describe nursing care for the client receiving TPN.
8. Discuss why TPN infusions are gradually increased to the target rate, and weaned slowly.
TPN
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Learning Activities
1. Briefly describe each of the 5 typical components of (TPN) solution listed below:
Component
What is it?
Purpose
Carbohydrates
Dextrose 20% - 50%
Provides majority of calories and
energy needed to maintain
physiologic function, metabolism of
amino acids, and wound healing
Protein
Amino acids or
protein hydrosylates
Provides protein necessary for
tissue building and wound healing
Electrolytes
Na+, K+, Cl-,
magnesium, Ca++,
Necessary to maintain physiologic
function. Dosed according to
Phosphate
patient need.
Trace elements
Zinc, copper,
manganese, cobalt,
selenium, iodine
Necessary to maintain physiologic
function. Dosed according to
patient need.
Vitamins
Added to 1 liter of
TPN solution per
day. Vitamin K and
folic acid are given
Necessary to maintain physiologic
function. Dosed according to
patient need.
separately; they are
not given IV
2. List 5 specific clinical situations in which TPN might be used.
GI tract anomalies and
Burns
Chronic diarrhea and
fistula
vomiting
Diverticulitis
Failure to thrive
GI obstruction
Granulomatous enterocolitis
Hypermetabolic states such
as sepsis, or fractures
Inflammatory bowel disease
such as Crohn’s disease or
ulcerative colitis
Acute or chronic renal
Malnutrition
failure and reversible hepatic
failure (extreme caution
should be used in these
cases)
Pancreatitis
Severe anorexia nervosa
Short bowel syndrome
Malabsorption
TPN
Complicated surgery or
trauma
Severe peptic ulcer disease
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3. In each of the categories listed below, write 3 possible complications of TPN.
a. Infection
o fungus
o gram-positive bacteria
o gram-negative bacteria
b. Metabolic problems
o glucose metabolism:
 hyperglycemia, hypoglycemia, HHNK, glycosuria, osmotic diuresis,
ketoacidosis
o amino acid metabolism:
 serum amino acid imbalances, elevated serum ammonia, prerenal
azotemia
o essential fatty acid deficiency,
o electrolyte and vitamin imbalances
o trace mineral deficiencies
c. Mechanical problems
o insertion:
 air embolus, pneumo-, hemo-, or hydrothorax, hemorrhage
o dislodgement
o thrombosis of great vein
o phlebitis
4. What nursing assessments or interventions would help prevent the following complications
of TPN?
a. Infection
o assess for impaired immune status
o refrigerate solution until 30 minutes before infusing
o follow protocols for tubing and dressing changes
o inspect the catheter insertion site for signs of inflammation and infection
b. Hyper-, hypoglycemia, electrolyte imbalances
o monitor for signs/symptoms hyperglycemia: thirst, polyuria, confusion, elevated
fasting blood glucose, blurred vision, dizziness, nausea and vomiting, dehydration,
Kussmaul respirations
o monitor for signs/symptoms hypoglycemia: sweating, hunger, weakness, tremors
TPN
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o monitor serum electrolytes daily until stable
o hyperkalemia: muscle weakness, flaccid paralysis, cardiac arrhythmias, abdominal
cramps, diarrhea
o monitor for hypokalemia: general weakness, decreased muscle tone, weak or
irregular pulse, low blood pressure, shallow respirations, abdominal distention, ileus
o check blood glucose Q4 hours
o maintain accurate infusion rate: do not speed up or slow down infusion
o check infusion frequently and use a pump
o never increase or decrease flow rate by more than 10%
o never stop TPN abruptly unless it is replaced by another glucose source
c. Air embolus
o place patient in Trendelenburg’s position when placing central venous catheter
o instruct patient in Valsalva maneuver when catheter is inserted
o use Trendelenburg’s position and Valsalva maneuver when changing tubing
o monitor for signs of air embolus such as abnormal blood gases, cough, cyanosis,
pain, anxiety, fatigue, respiratory rate and depth changes, altered chest excursion,
shortness of breath
o if embolism is suspected, place patient in Trendelenburg’s position on the left side
o continue to observe for shock, cough, shortness of breath
o notify physician immediately
5. Which patients would be likely to receive fat emulsion (lipids)?
Fat emulsion would be used in:
o patients receiving peripheral parenteral nutrition (PPN) who need additional
calories,
o patients receiving long-term parenteral nutrition who require a source of essential
fatty acids,
o patients receiving TPN who have high caloric needs.
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6. Contrast the differences between TPN and PPN by filling in the table.
TPN
PPN
Concentration of dextrose:
Concentration of dextrose:
20%-50%
20% maximum
Method of administration:
Method of administration:
Central venous catheter, PICC line
Large peripheral veins
Indications for use:
Indications for use:
long-term nutritional support, the patient has
high protein and caloric requirements,
suitable peripheral veins are not available
nutritional support is needed for only a short
time (up to 2 weeks), protein and caloric
requirements are not excessively high, risk of
a central catheter is too great, nutritional
support is used to supplement inadequate
oral intake
7. List 5 nursing assessments or interventions for the client receiving TPN.
o vital signs Q 4-8 in early therapy
o monitor catheter insertion site for inflammation that may signal infection
o change dressing and tubing according to agency policy
o weigh daily initially, then weekly when the patient is stable
o blood analysis that includes blood glucose, electrolytes, protein, complete blood
count, and enzyme studies 3X/week until stable, then weekly
8. Why is TPN infused at a rate that gradually increases over 24 to 48 hours, and weaned
slowly, as well?
Infusing the solution slowly allows the pancreas time to adjust to the increased amount of
glucose in circulating blood. Likewise, TPN should be weaned off slowly to give pancreatic
islet cells time to adjust to the decreasing levels of glucose.
TPN