Parenteral Nutrition - 6

Question 1

What is it?

Answer 1

• Parenteral Nutrition (TPN, PN) - Administration of nutrients via a route other than GI system
• Enteral – nutrition via GI(eg. G, NG tubes, oral)
• Other fluids not sufficient to meet nutritional needs
• Average adult needs a minimum of 1200-1500 calories per day

Question 2

What’s in it?

Answer 2

• Base solution of dextrose and amino acids – hyperal or hyperalimentation fluid
• Pharmacy adds electrolytes, vitamins, and trace elements per patient needs
• Very hypertonic (draw fluid into intravascular space)
• Typically a yellowish tinge, 2,000-3,000mls
• Lipids – given with TPN, over 12 hours, white color, smaller volume, pt. at risk for fat embolism

–distal lumen

Question 3

What’s in it? Cont.

Answer 3

•Lipids may have egg yolk present, check for allergies
•Hyperal may contain:
-insulin – control blood sugar levels
-and/or heparin – usually only in neonates, helps keep central line patent for longer and prevents infection in central line – prevents bacteria from adhering to surfaces

Question 4

Your pt is receiving TPN for treatment of malnutrition. Which value would be the most helpful in evaluating the effectiveness of this treatment?
 A – Blood glucose level
 B – Serum albumin level
 C – Serum phosphate level
 D –Hemoglobin and Hematocrit

Answer 4

B

protein turns into albumin - levels stay pretty consistant

phosphate levels indicate refeeding syndrome

Question 5

Nursing Care

Answer 5

•Special IV tubing (run through different channels)
•Needs a filter – prevent air, particulate matter from infusing
-60 micron - hyperal - always use - line will have y-site
-10 micron - lipids - depends on lipid manufacturer for use - no y-site on line
•Almost always given via a central line, PICC, etc
•Can be given peripherally, monitor for phlebitis
•Lipids – Good for 12 hours
•Hyperalimentation (Hyperal) - Good for 24 hours

Question 6

Nursing Care

Answer 6

•Keep refrigerated until use
•Don’t add anything to TPN
– also nothing through y-site
– can flush with NS
•Change IV dressing per orders (PICC, CL, PIV) and monitor site
•Educate pt and family on PN
•TPN/Lipids/Hyperal expire – assess bag and content for separation, expiry dates, sediment, etc
•Give TPN and Lipids AS THEY ARE ORDERED
-ex. – new bag ordered to be hung while old bag is still running

Question 7

Cycling

Answer 7

• Typically given over a 24 hour period but may be less, e.g. 12 hour cycle
• Cycle usually starts at night because patients at home on TPN start at night for quality of life

Question 8

Scaling up/down

Answer 8

• TPN often started at a lower rate and increased gradually to desired rate/amount
• Same for stopping
• Helps prevent hypo/hyperglycemia and refeeding syndrome when at risk
• Not always necessary but generally better outcomes

Question 9

Most common complications

Answer 9

•Hypo/hyperglycemia
•Phlebitis, other IV catheter complications
•Electrolyte imbalances/fluid imbalances (overload & deficit both)
- TPN is not fluid replacement, TPN is “food”
- also needs to be on a fluid

Question 10

Refeeding syndrome

Answer 10

•Complication which occurs in the severely malnourished or starved once nutritional support is provided
•Alcoholism, vomiting, diarrhea, chemotherapy can all predispose a pt
•Characterized by fluid retention and electrolyte imbalances
 HALLMARK SIGN IS HYPOPHOSPHATEMIA
 Muscle weakness, mental status change, <2.4 mg/dl

cells deplete nutrients in attempt to digest nutrients

phosphate, calcium, macronutrients

Question 11

Assessment

Answer 11

•Weight, Is&Os, general nutrition
•Serum electrolyte levels (phosphate)
•Blood glucose levels for all PN pts. Q6
 Why do you think that is? (insulin fluctuates throughout day, intake levels do not)
•Albumin levels (prealbumin)
 Why do you think that is? (tissue growth and repair; protein synthesis)
•Why is the patient getting this?
 Nutrition obviously, tissue healing, supplementary nutrition, total nutrition?