Module 6: Parenteral Nutrition

Question 1

Parenteral Nutrition Info

Answer 1

-used when the GI tract is not sufficiently functional
and is delivered through a catheter placed in a central
venous line in a vein in the arm, neck, or chest. The tip
lies within the proximal third of the superior vena cava,
the inferior vena cava, or the right atrium, allowing
delivery of fluids directly into the bloodstream

-Total parenteral nutrition (TPN) means that all daily
nutritional requirements are received intravenously.
-Peripheral parenteral nutrition (PPN) is delivered through a vein other than the superior vena cava

-Patients who require PN infusions usually have medical
or surgical conditions that are often associated with GI
fluid losses and organ dysfunction.

Question 2

PN Components

Answer 2

-components of the PN solution are amino acids,
glucose, and lipids as energy sources, with the addition
of electrolytes, minerals, trace elements, vitamins, and
water. The addition of lipid emulsion to the PN solution
results in a preparation called a 3:1, 3-in-1, or total
nutrition admixture (TNA)

-Because hyperglycemia has been linked to increased
infection rates, monitoring blood glucose levels during a
PN infusion is an important procedure.

Question 3

Principles for Practice

Answer 3

-When the goal is to prepare a patient for a cyclic home
infusion of PN, monitor glucose levels approximately 2
hours after an infusion begins (peak level) and 2 hours
after it ends (trough level) to evaluate the need for
adding regular human insulin to the infusion bag

PN may pose concerns for members of ethnic
groups or people with philosophical beliefs that
include diet restrictions.
 The components of PN are largely synthetic and do
not contain pork.
 The lipid emulsion contains egg phospholipid, a
product that may be objectionable to vegan patients.

Question 4

Managing critically ill patients in ICU

Answer 4

Enteral nutrition is preferred over PN.
 If the patient was healthy before a critical illness, with no evidence of protein calorie malnutrition, use of PN should be reserved and initiated only after the first 7 to 10 days of hospitalization, when enteral nutrition is not available.
 PN should only be used if duration is greater than 7 days.
 In stabilized PN patients, reintroduce oral or enteral nutrition.
 Do not terminate PN until 60% of nutritional needs are met.
 Initiating supplemental PN prior to this 7- to 10-day period in critically ill patients on some enteral nutrition does not improve outcomes and may be detrimental to patients

Question 5

Safety Guidelines

Answer 5

CPN using concentrated dextrose solutions should not
be infused into a peripheral intravenous (IV) or midline
catheter.
 PPN is used only for very short-term situations or when there is the need for very low caloric requirements.
 Many hospitals use peripherally inserted central
catheters.

Following central venous catheter insertion, do not
initiate PN until placement of venous catheter tip is
confirmed by a radiograph or through the use of ECG tip verification technology.
 PN without lipids can be infused using tubing with a 0.20-μm filter, and lipid-containing emulsions (3-in-1) can be infused using a larger 1.2-μm filter.
 Adequate electrolyte repletion should occur prior to the initiation of PN.
 As there is a risk of bloodstream infection in patients with catheters, regular monitoring of vital signs is important.

Question 6

Administering CPN (Central Peripheral Nutrition)

Answer 6

Central parenteral nutrition (CPN)
 Use strict aseptic technique
 Apply critical thinking
* Make accurate clinical judgments regarding a patient’s
response to the infusion
* Anticipate possible complications

Question 7

Unexpected Outcome: There is redness, swelling, and tenderness around central venous access site, indicating possible exit site infection

Answer 7

Notify health care provider.
* Apply warm compress and initiate daily site care as ordered.
* Systemic antibiotic therapy may be ordered

Question 8

Unexpected Outcome: Patient develops fever, malaise, and chills, indicating systemic infection.

Answer 8

Check exit site for signs of infection.
* Notify health care provider and consult about need to obtain cultures of exit site or blood.
* Systemic antibiotic therapy may be ordered

Question 9

Unexpected Outcome: Serum glucose level is greater than 150 mg/dL or target set by health care provider. Indicates intolerance to glucose load in solution or may indicate new-onset infection

Answer 9

Notify health care provider.
* Verify that blood was not drawn with PN infusing or that proper procedures to interrupt PN and discard first blood draw was followed.
* Possible need for addition of insulin to CPN, modification of CPN solution, or sliding-scale insulin coverage

Question 10

Administering PPN with Lipid (Fat) Emulsion

Answer 10

Indications for PPN
 Adequate peripheral access
 Ability to tolerate larger volumes of fluid
 Ability to tolerate lipid emulsions
-This therapy is for short-term use, usually 2
weeks or less