ASSOCIATION OF NURSING SERVICE ADMINISTRATORS OF THE PHILIPPINES, INC.

(ANSAP)
in cooperation with

Our Lady of the Pillar Medical Center

TOTAL PARENTERAL NUTRITION

A N N E C H R I S T I N E R . I N D U C T I V O , R N

Just the facts

y This lecture will help you understand and deal

with total parenteral nutrition (TPN). y We will focus on:

to identify patients who would benefit from TPN  what each TPN component is and how TPN is delivered  how to recognize & prevent complications associated with TPN  how to care for a patient receiving TPN, and  the promotion of nutritional health
 how

A look at TPN
y Total Parenteral Nutrition (TPN), also known as

hyperalimentation, is a highly concentrated, hypertonic nutrient solution administered by way of an infusion pump through a large central vein. y For patients with high caloric and nutritional needs due to illness or injury, TPN provides crucial calories, restores nitrogen balance, and replaces essential fluids, vitamins, electrolytes, minerals, and trace elements. y It also promotes tissue and wound healing and normal metabolic function. y TPN gives the bowel a chance to heal; reduces activity in the gallbladder, pancreas, and small intestine; and is used to improve a patients response to surgery.

Common components of TPN solutions

y dextrose 50% in
y vitamins
 Folic

water (D50W) y amino acids y electrolytes

 Calcium  Chloride  Magnesium  Phosphorus  Potassium  Sodium

acid  Vitamin B  Vitamin C  Vitamin D  Vitamin K

y other additives
 Acetate  Micronutrients  Amino

acids

Who needs TPN?

y Patients who cant meet their nutritional needs by oral and

enteral feedings may require I.V. nutritional supplement or TPN. Generally, this treatment is prescribed for any patient who cant absorb nutrients from the GI tract for more than 10 days. y More specific indications include:
o o o o

o o

debilitating illness lasting longer than 2 weeks loss of 10% or more of pre-illness weight serum albumin below 3.5 g/dl excessive nitrogen loss from wound infection, fistulas, or abscesses renal or hepatic failure nonfunction of the GI tract lasting for 5 to 7 days

TPN triggers
y Common illnesses or treatments that can trigger the need for TPN

include inflammatory bowel disease, ulcerative colitis, bowel obstruction or resection, radiation enteritis, severe diarrhea or vomiting, AIDS, chemotherapy, and severe pancreatitis, all of which hinder a patients ability to absorb nutrients. y In addition, patients may benefit from TPN after major surgery or if they have a high metabolic rate due to sepsis, trauma, or burns of more than 40% of total body surface area. y Infants with congenital or acquired disorders may need TPN to promote proper growth and development. y TPN has limited value for well-nourished patients whose GI tracts are healthy or will most likely resume normal function within 10 days. The treatment also may be inappropriate for a patient with a poor prognosis or when the risks of TPN outweigh its benefits.

Todays TPN trends

y The trend of todays nutritional supplementation is

to individualize TPN formulas depending on the patients specific needs. y As a result, standard TPN mixtures are becoming less popular. y Nutritional support teams consisting of nurses, doctors, pharmacists, and dietitians assess, prescribe for, and monitor patients receiving TPN.

Lipid Emulsions
 

are thick emulsions of several essential fatty acids assist in wound healing, in the production of red blood cells, and in prostaglandin synthesis. are given in conjunction with TPN or may be given alone through a peripheral or central venous line. should be given cautiously in patients with liver disease, pulmonary disease, anemia, coagulation disorders, or any patient at risk for developing a fat embolism. should be avoided in patients who have conditions that disrupt normal fat metabolism, such as pathologic hyperlipidemia, lipid nephrosis, and acute pancreatitis. Make sure to report adverse reactions to the doctor so the TPN regimen may be changed as needed.

Adverse reactions to lipid emulsions

y Immediate or early adverse reactions to lipid emulsions

include:
          

dyspnea cyanosis nausea or vomiting headache flushing or diaphoresis lethargy or syncope chest and back pain slight pressure over the eyes irritation at the site hypercoagulability thrombocytopenia.

Adverse reactions to lipid emulsions

y Delayed complications associated with

prolonged administration include:
 hepatomegaly  splenomegaly  jaundice  blood

dyscrasias  fatty liver syndrome

Parenteral Nutrition
y Administration of Parenteral Nutrition requires an

easily placed, well tolerated central venous access device (CVAD) that can be used for extended periods of time. y I.V. Nurse Therapists are responsible for the daily care and are held accountable for preventing and minimizing the many device-related complications.

How to infuse TPN

y TPN, a hypertonic solution, may be up to six

times the concentration of blood, which makes the solution too irritating for a peripheral vein. y TPN must be infused through a central vein. y TPN may be infused around the clock or for a part of the day y A sterile catheter made of polyurethane, polyvinyl chloride, or silicone rubber (silastic) is inserted in the subclavian or jugular vein.

Why go peripheral?
y A peripherally inserted central catheter, a variation

of central venous therapy, can be used for therapy lasting 3 months or more. The catheter is inserted through the basilic or cephalic vein and threaded so that the tip lies in the superior vena cava. y The patient generally experiences less discomfort with a peripheral catheter, especially if he can move around easily. Movement stimulates blood flow and decreases the risk of phlebitis. y Peripherally inserted central catheters are fast becoming the preferred choice for intermediateterm therapy, both at home and in the hospital.

Complications
y Signs and symptoms of electrolyte imbalances caused by TPN

administration include abdominal cramps, lethargy, confusion, malaise, muscle weakness, tetany, convulsions, and cardiac arrhythmias. Acid-base imbalances can also occur due to the patients condition or the TPN content. Look for these other complications: y congestive heart failure (CHF) or pulmonary edema, both of which may occur from fluid and electrolyte administration and can lead to tachycardia, lethargy, confusion, weakness, and labored breathing y hyperglycemia as a result of dextrose infusing too quickly, a condition that may require an adjustment in the patients insulin dosage y adverse reactions to medications added to TPN for example, added insulin can cause hypoglycemia, which can result in confusion, restlessness, lethargy, pallor, and tachycardia.

Nurses Duties and Responsibilities in Parenteral Nutrition

Constant assessment and rapid intervention are critical for patients receiving TPN. When caring for a patient on TPN, youll want to take these actions:

Assess and monitor

y Carefully monitor patients receiving TPN to detect early

signs of complications, such as metabolic problems, CHF, pulmonary edema, or allergic reactions. Adjust the TPN regimen as needed. y Assess the patients nutritional status, and weigh the patient at the same time each morning after he voids, in similar clothing, and on the same scale. Weight gain may indicate fluid overload. A patient shouldnt gain more than 3 lb (1.4 kg) a week. y Assess for peripheral and pulmonary edema. y Monitor serum glucose levels every 6 hours initially, then once a day. Stay alert for signs of thirst and polyuria, symptoms of hyperglycemia. Periodically confirm serum glucose meter readings with laboratory tests.

Assess and monitor

y Monitor for signs and symptoms of glucose metabolism

y y y

disturbance, fluid and electrolyte imbalances, and nutritional problems. Some patients may require insulin added directly to the TPN for the duration of treatment. Monitor electrolyte and protein levels daily at first, and then twice a week for serum albumin. Albumin levels may drop initially as treatment restores hydration. Check renal function by monitoring BUN and creatinine levels; increases may indicate excess amino acid intake. Assess nitrogen balance with 24-hour urine collection. Assess liver function with liver function tests, bilirubin, triglyceride, and cholesterol levels. Abnormal values may indicate intolerance.

Assess and monitor

y In most institutions, central lines and

peripherally inserted central catheters require an order and a patient-consent form. Only an RN specializing in inserting those lines should obtain the form. (See Teaching about TPN.)


Teaching about TPN

Be sure to cover these topics with your patient to evaluate his learning: explanation of TPN and its specific use for the patient adverse reactions or catheter complications and when to report them basic care of a TPN line maintenance of equipment.

y Obtain a chest X-ray to check the catheter

placement after insertion.

Infuse properly
y Review the patients serum chemistry and nutritional

studies, and alert the doctor of abnormal results, which may indicate that the TPN fluid concentration or ingredients may need to be adjusted to meet the patients specific needs. y Avoid an adverse reaction by starting TPN slowly about 1,000 calories over 24 hours and increasing gradually. Continually monitor the patients cardiac and respiratory status. When a patient is severely malnourished, starting TPN may spark refeeding syndrome, which includes a rapid drop in potassium, magnesium, and phosphorus levels. To avoid compromising cardiac function, initiate feeding slowly and monitor the patients electrolyte levels closely until they stabilize.

Infuse properly
y Because the TPN solution is high in glucose, start the

infusion slowly. Doing so will allow the patients pancreatic beta cells to adapt to the glucose by increasing insulin output. Within the first 3 to 5 days of TPN, the typical adult can tolerate about 3 L of solution a day without suffering an adverse reaction. y Occasionally a patient may react adversely to specific ingredients in the TPN solution. Protein may need to be reduced if BUN and creatinine levels are elevated. y Alert the doctor if TPN needs to be stopped and glucose given orally or I.V. The patients diagnosis and pre-existing physical condition need to be considered when determining the composition and amount of electrolytes used for the TPN solution.

Set up
y Use an infusion pump for rate control. y Flush central lines according to protocol. y If using a single-lumen central venous line, dont

use the line for blood and blood products, or give a bolus injection, administer simultaneous I.V. solutions, measure the central venous pressure, or draw blood for lab tests y Never add medications to a TPN solution container. Dont use a three-way stopcock unless absolutely necessary; add-on devices increase the risk of infection. y Explain the insertion procedure to the patient.

Monitor during the infusion

y Record vital signs at least every 4 hours.

Temperature elevation is one of the earliest signs of catheter-related sepsis. y Assess the patient daily. Measure arm circumference and skinfold thickness over the triceps, if ordered. y Perform site care and dressing changes at least three times a week (once a week for transparent semipermeable dressings), or whenever the dressing becomes wet, soiled, or nonocclusive. Use strict aseptic technique.

Monitor during the infusion

y Monitor for and document signs of

inflammation and infection.

 Documenting
When

TPN

documenting about TPN, youll want to include these points: adverse reactions or catheter complications signs of inflammation or infection at I.V. site nursing interventions and the patients response time and date of administration set changes specific dietary intake.

Monitor during the infusion

y Change the I.V. administration set according to

your facilitys policy, and always use aseptic technique. Changes of I.V. administration sets are usually done every 24 hours for TPN. y Do not allow TPN solutions to hang for more than 24 hours. y The TPN solution should be clear. If you see particulate matter, cloudiness, or an oily layer in the bag when preparing to hang a TPN solution, return the bag to the pharmacy.

Follow up
y Provide emotional support, especially if eating is

restricted due to the patients condition. provide frequent mouth care. y While weaning the patient from TPN, document his dietary intake and total calorie and protein intake. Use percentages when recording food intake.

Follow up
y When discontinuing TPN, decrease the infusion

slowly, depending on current glucose intake. Slowly decreasing the infusion minimizes the risk of hyperinsulinemia and resulting hypoglycemia. Weaning usually takes place over 24 to 48 hours but can be completed in 4 to 6 hours if the patient receives sufficient oral or I.V. carbohydrates. y Report any adverse reactions to the doctor promptly. y Prepare your patient for home care. y Accurately document all aspects of care, according to your facilitys policy.

Quick Quiz
1.

The patient most likely to benefit from TPN is:

A.

B. C.

a well-nourished patient whose GI tract will resume normal function within 10 days a patient with a chronic, intractable condition a patient with a nonfunctioning GI tract lasting 5 to 7 days

Quick Quiz
2.

When a severely malnourished patient starts receiving TPN, his lab tests show a rapid drop in potassium, magnesium, and phosphorus levels. The findings indicate:
A. B. C.

fluid shock refeeding syndrome hypovolemia

Quick Quiz
3. The type of I.V. catheter recommended for TPN expected to last months or years is the:
A. B. C.

silastic catheter polyvinyl chloride catheter metal-winged catheter

Quick Quiz

4. When preparing to hang a TPN solution, you see an oily layer in the bag. You should:
A. gently agitate the solution to disperse the contents. B. hang the solution; the oily layer will disperse in time. C. return the solution to the pharmacy

Quick Quiz

5. Site care and dressing changes for a patient with TPN should be performed at least:
A. once a week B. three times a week C. every day

Quick Quiz

6. Infusions of lipid emulsions are useful for promoting:

A. wound cleaning B. coagulation in bleeding disorders. C. a reduction in inflammation from pancreatitis.

Quick Quiz

7. The tip of a peripherally inserted

central catheter is usually placed in the:
A. right atrium B. internal jugular vein C. superior vena cava