Parentral Nutrition

Question 1

how many calories a day is normal?

Answer 1

2000

critical ill PTs may rqr 3000-5000 per day

Question 2

PTN indicated if…

Answer 2

1. GI tract is incapacitated or needs complete rest
2. intest obstruction
3. uncontrolled vomit
4. high risk aspiration
5. supplement to inadequate oral intake
6. severe burns with negative nitrogen balance (intake > loss)
7. debilitating disease
8. metastatic ca
9. AIDS
10. 10% weight loss from pre-illness weight
11. inability to take oral foods or fluids within 7 days after surgery
12. hypercatabolic situation- excess metabolic breakdown
13. major infection with fever
14. burns
15. short gut syndrome, enterocutaneous fistula, renal failure, hepatic failure
16. albumin < 35 (normal 35-50)

Question 3

what is TPN?

Answer 3

> infusion of hyperosmolar glucose, amino acids, vitamins, electrolytes, minerals and trace elements

> may contain 20-60% glucose and 3.5-10% protein (A.A’s)
can enhance would healing and prevent cellular catabolism of SCf fat and muscle tissue

> can meet total nutrition needs but :

• 3x more expensive
• high infection rate
• does not promote GI motility/integrity, liver function or body weight gain

contains:
carbs, fats, proteins, lytes, vitamins, trace elements

Question 4

TPN advantages

Answer 4

> dextrose solution administered as calorie source
beneficial for long term use (greater then 3 weeks)
good for PT with large caloric needs
provides calories, restores nitrogen balance, and replaces essential vitamins, electrolytes and minerals
promotes tissue syntheses, would healing, normal metabolic finction
allows bowel rest and healing
improves tolerance to surgery
is nutritionally complete

Question 5

TPN disadvantages

Answer 5

> minor surgical procedure for insertion of tunneled cath or implanted port (central line)

> may cause metabolic complications (glucose intolerance, electrolyte imbalance, EFAD (essential fatty acid deficiency)

> fat emulsions may not be utilized effectivly in some severly stressed PTs (esp. burns)

> risk for pneumothorax or hemothorax with central line incertion

Question 6

additives to TPN

Answer 6

> insulin- regular only. hyperglycemia is a common complication

> heparin.- 1000-3000 U/L sometimes added to decrease potential formation of fibrin sleeve which could = venous thrombosis

> histamine 2 inhibitors (cimetidine, pepcid, zantac) to prevent stress ulcers

> minerals

Question 7

risks of TPN

Answer 7

Catheter related same as insertion CVC

metabolic related:
> rebound hypogycemia/hyperglycemia
> EFAD essential fatty acid deficiency 
> hyperammonemia 
> electrolyte imbalance

infectious and septic:
> catheter related sepsis

nutrition alterations:
>refeeding syndrome- metabolic disturbances from reintroduction of nutrient to starved PT
>altered mineral imbalance
> altered vitamin imbalace

Question 8

PN

vs

PPN

Answer 8

peripheral parentral nutrition:
> prevents damage to veins

> isotonic PN solutions usually contain 5-10% dextrose and 3-5% amino acids plus electrolytes, vitamins and mineral and fat as needed

> osmolarity greater than 600 needs to use CVAD to prevent complications like phlebitis

> PPN used for short-term nutrition support in non-hypermetabolic conditions

Question 9

PPN advantages and disadvan

Answer 9

advantages:
> no need for central line
> less hypertonic solution
> reduced chance of metabolic complications
> increases caloric sorce along with fat emulsion

Disadvantages:
> cant be used in nutritionally depleted PTs
> cant be used in vol reduced PTs
does not usually increase PTs weight
> may cause phlebitis

Question 10

nursing assessments of PN

Answer 10

1. verify correct placement of central line
2. monitor VS
3. monitor blood glucose
4. weigh daily
5. accurate I&O
6. monitor for infection
7. physician order
8. assess solution
9. tubing and solution changes

Question 11

nursing interventions

Answer 11

> dressing changes
> tubing, filters and IV pumps
> lab tests
> storing
> documenting
> maintain vascular access 
> prevent infection
> rate monitoring

Question 12

total nutrient admixture

Answer 12

> dextrose, amino acids, fat emulsions in one container

> usually milky white and opaque, may have yellow hue if vitamins added

> cost effective, nursing time saved (only one solution to hang)

> must be admin via 1.2 micron filter bc of mean particle size of fat dropplets

Complications:
>cholestasis (stop bile flow) may develop, long-chain triglycerides may depress the immune system, catheter occlusion from fat deposits, bacterial growth

Question 13

highlight of PN:

Answer 13

> admin central or periph

> yellow unless mixed with fats

> use filter tubing

> change tubing q 24 hrs** or with every bag change

> monitor blood sugar reg

> never stop abrupt! use emerg D10 if desperate!!!

> wean on and off

Question 14

to start PN…

Answer 14

dont forget to flush a tiny bit, asperate blood and then flush the rest.

Question 15

when it is needed long term. longer then 4 weeks, what method do you use?

Answer 15

PICC peripheral

tunneled

IVAD (implanted vascular access device)

less hypertonic if delivered through peripheral central vein.

Question 16

carbs

Answer 16

provide 60-70% energy we need

strength will depend

Question 17

amino acids

Answer 17

provide 15-20% energy we need

3.5-20% concentration

Question 18

fat emulsion

Answer 18

provides 30% energy we need

need filter

> start infusion rate slow in case of an adverse reaction

Question 19

vitamins

Answer 19

PN contain a standard multivitamin

> mineral and trace elements- promote normal metabolism

> electrolytes-

> water

> regular insulin- to contol blood glucose
- hyperglycemia if too rapid infusion

> heparin- to reduce blood clot

Question 20

types of admin

Answer 20

continuous- over 24 hrs

intermit- 12 hr infusions given at night. allows for PT to go about their day

Question 21

refeeding syndrome

Answer 21

for malnourished PTs

rapid drop in potassium, magnesium and phosphate serum levels