PARENTERAL NUTRITION
Nursing Science V
I. Parenteral Nutrition (PN)
 Description
o Parenteral nutrition (also termed total parenteral nutrition
or TPN) supplies nutrients via the veins.
o PN supplies carbohydrates in the form of dextrose, fats in
an emulsified form, proteins in the form of amino acids,
vitamins, minerals, electrolytes, and water.
o PN prevents subcutaneous fat and muscle protein from
being catabolized by the body for energy.
 Indications
o Clients with severely dysfunctional or nonfunctional
gastrointestinal tracts who are unable to process nutrients
may benefit from PN.
o Clients who can take some oral nutrition, but not enough
to meet their nutrient requirements, may benefit from PN.
o Clients with multiple gastrointestinal surgeries,
gastrointestinal trauma, severe intolerance to enteral
feedings, or intestinal obstructions, or who need to rest
the bowel for healing, may benefit from PN.
o Clients with severe nutritionally deficient conditions such
as acquired immunodeficiency syndrome, cancer, burn
injuries, or malnutrition, or clients receiving
chemotherapy, may benefit from PN.
 Administration of PN
o Central vein
 PN is administered through a central vein when the
client requires a larger concentration of carbohydrates
(greater than 10% glucose concentration).
 The subclavian or internal jugular vein is the insertion
site for central access normally used when PN is a
short-term intervention (less than 4 weeks).
 When PN is anticipated for an extended period (longer
than 4 weeks), a more permanent catheter, such as a
peripherally inserted central catheter (PICC) line, a
tunneled catheter, or an implanted vascular access
device, is used.
o Peripheral vein
 PN can be administered through a peripheral vein,
typically in the arm through a traditional intravenous
catheter, or through a midline catheter, which is
placed in an upper arm vein such as the brachial or
cephalic vein with the tip ending below the level of the
axillary line.
 PN administered through a peripheral vein delivers
isotonic or mildly hypertonic solutions as compared to
the solutions administered through a central vein.
II. Components of Parenteral Nutrition
 Carbohydrates
o The strength of the dextrose solution depends on the
client’s nutritional needs, the route of administration
(central or peripheral), and agency protocols.
o Carbohydrates typically provide 60% to 70% of calorie
(energy) needs.
 Amino acids (protein)
o Concentrations range from 3.5% to 20%; lower
concentrations are most commonly used for peripheral
vein administration and higher concentrations are most
often administered through a central vein.
o About 15% to 20% of total energy needs should come from
protein.
 Fat emulsion (lipids)
o Lipids provide up to 30% of calorie (energy) needs.
o Lipids provide nonprotein calories and prevent or correct
fatty acid deficiency.
o Lipid solutions are isotonic and therefore can be
administered through a peripheral or central vein; the
solution may be administered through a separate
intravenous (IV) line below the filter of the main IV
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Nursing Science V
administration set by a Y-connector or as an admixture to
the PN solution (3-in-1 admixture consisting of dextrose,
amino acids, and lipids).
o Most fat emulsions are prepared from soybean or
safflower oil, with egg yolk to provide emulsification; the
primary components are linoleic, oleic, palmitic, linolenic,
and stearic acids.
o Glucose-intolerant clients or clients with diabetes mellitus
may benefit from receiving a larger percentage of their PN
from lipids, which helps control blood glucose levels and
lower insulin requirements caused by infused dextrose.
o Examine the bottle for separation of emulsion into layers
or fat globules or for the accumulation of froth; if
observed, do not use and return the solution to the
pharmacy.
o Additives should not be put into the “fat emulsion
solution.
o Follow agency policy regarding the filter size that should
be used; usually a 1.2-μm filter or larger should be used
because the lipid particles are too large to pass through a
0.22-μm filter.
o Infuse solution at the flow rate prescribed—usually slowly
at 1 mL/minute initially—monitor vital signs every 10
minutes, and observe for adverse reactions for the first 30
minutes of the infusion. If signs of an adverse reaction
occur, stop the infusion and notify the health care provider
(HCP)
o If no adverse reaction occurs, adjust the flow rate to the
prescribed rate.
o Monitor serum lipids 4 hours after discontinuing the
infusion.
 Vitamins
o PN solutions usually contain a standard multivitamin
preparation to meet most vitamin needs and prevent
deficiencies.
o Individual vitamin preparations can be added, as needed
and as prescribed.
 Minerals and trace elements: Commercial mineral and trace
element preparations are available in various concentrations
to promote normal metabolism.
 Electrolytes: Electrolyte requirements for individuals receiving
PN therapy vary, depending on body weight, presence of
malnutrition or catabolism, degree of electrolyte depletion,
changes in organ function, ongoing electrolyte losses, and the
disease process.
 Water: The amount of water needed in a PN solution is
determined by electrolyte balance and fluid requirements.
 Regular insulin: May be added to control the blood glucose
level because of the high concentration of glucose in the PN
solution.
 Heparin: May be added to reduce the buildup of a fibrinous
clot at the catheter tip.
III. Administration and Discontinuation
 Types of administration
o Continuous PN
 Infused continuously over 24 hours
 Most commonly used in a hospital setting
o Intermittent PN
 In general, 12-hour infusions are usually given at night
 Allows client requiring PN on a long-term basis to
participate in activities of daily living during the day
without the inconvenience of an IV bag and pump set
 Monitor glucose levels closely because of the risk of
hypoglycemia
 Discontinuing PN therapy
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Nursing Science V
o Evaluation of nutritional status by a nutritionist is done
before PN is discontinued.
o If discontinuation is prescribed, gradually decrease the
flow rate for 1 to 2 hours while increasing oral intake (this
assists in preventing hypoglycemia).
o After removing the IV catheter, change the dressing daily
until the insertion site heals.
o Encourage oral nutrition.
o Record oral intake, body weight, and laboratory results of
serum electrolyte and glucose levels.
IV. Complications
 Description
o Pneumothorax and air embolism are associated with
central line placement; air embolism is also associated
with tubing changes.
o Other complications include infection (catheter-related),
hypervolemia, and metabolic alterations such as
hyperglycemia and hypoglycemia; these complications are
usually caused by the PN solution itself.
 Air embolism
o Air embolism occurs because of the entry of air into the
catheter system.
o Instruct the client in the Valsalva maneuver for IV tubing
and cap changes.
o For tubing and cap changes, place the client in the
Trendelenburg position (if not contraindicated) with the
head turned in the opposite direction of the insertion site
(increases intrathoracic venous pressure); also, ask the
client to take a deep breath, hold it, and bear down.
o Check all catheter connections and secure (use tape per
agency protocol) tubing connections.
o If an air embolism is suspected, do the following:
 Clamp the IV catheter.
 Place the client in a left side–lying position with the
head lower than the feet (to trap air in right side of the
heart).
 Notify the HCP.
 Administer oxygen as prescribed.
 Hyperglycemia
o Hyperglycemia occurs because of the high concentration
of dextrose (glucose) in the solution. If the client receives
the solution too rapidly, does not receive enough insulin,
or contracts an infection, hyperglycemia can occur.
o Assess the client for a history of glucose intolerance.
o Assess the client’s medication history (cortico-steroids
may increase the blood glucose level).
o Begin infusion at a slow rate (usually 40 to 60 mL/hour) as
prescribed.
o Monitor blood glucose levels every 4 to 6 hours until
stable, then check every 24 hours (agency protocol for
monitoring blood glucose levels is followed).
o Administer regular insulin as prescribed.
 Hypervolemia
o Hypervolemia occurs if the client receives the IV solution
too rapidly; the client with cardiac, renal, or hepatic
dysfunction is at high risk.
o PN is always delivered via an electronic infusion device.
o Never increase the infusion rate to “catch up” if the IV
infusion gets behind.
o Monitor intake and output.
o Weigh the client daily (ideal weight gain is 1 to 2 lb/week).
 Hypoglycemia
o Hypoglycemia occurs when the PN is abruptly
discontinued or when too much insulin is administered.
o Monitor the blood glucose level.
o Gradually decrease the infusion rate when discontinuing
PN.
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Nursing Science V
o When an infusion of hypertonic glucose is stopped, an
infusion of 10% dextrose should be instituted and
maintained for 1 to 2 hours to prevent hypoglycemia.
o Assess the blood glucose level 1 hour after discontinuing
PN.
o Prepare for the administration of glucose or IV dextrose if
hypoglycemia occurs.
 Infection
o Infection can occur as a result of poor aseptic technique or
via catheter or solution contamination.
o Use strict aseptic technique. Because the PN solution has a
high concentration of glucose, it is a medium for bacterial
growth.
o Monitor temperature. If the client has a fever, suspect
sepsis.
o Assess the IV site for redness, swelling, tenderness, or
drainage.
o Change the PN solution every 12 to 24 hours as prescribed
or according to agency protocol.
o Change the IV tubing every 24 hours or according to
agency protocol.
o Change the dressing at the IV site every 48 hours or
according to agency protocol
 Pneumothorax
o Pneumothorax can occur as a result of inexact catheter
placement that results in puncture of the pleural space.
o After insertion of the catheter, obtain a portable chest x-
ray film to confirm correct catheter placement and to
detect the presence of a pneumothorax. PN is not initiated
until correct catheter placement is verified and the
absence of pneumothorax is confirmed.
V. Additional Nursing Considerations
 Check the PN solution with the HCP’s prescription to ensure
that the prescribed components are contained in the solution;
some health care agencies require validation of the
prescription by two registered nurses).
 To prevent infection and solution incompatibility, IV
medications and blood are not given through the PN line.
 Monitor partial thromboplastin time and prothrombin time
for clients receiving anticoagulants.
 Monitor electrolyte and albumin levels and liver and renal
function studies, as well as any other prescribed laboratory
studies.
 In severely dehydrated clients, the albumin level may drop
initially after initiating PN, because the treatment restores
hydration.
 With severely malnourished clients, monitor for “refeeding
syndrome” (a rapid drop in potassium, magnesium, and
phosphate serum levels).
 Abnormal liver function values may indicate intolerance to or
an excess of fat emulsion or problems with metabolism with
glucose and protein.
 Abnormal renal function tests may indicate an excess of amino
acids.
 PN solutions should be stored under refrigeration and
administered within 24 hours from the time they are prepared
(remove from refrigerator 0.5 to 1 hour before use).
 PN solutions that are cloudy or darkened should not be used
and should be returned to the pharmacy.
 Additions of substances such as nutrients to PN solutions
should be made in the pharmacy and not on the nursing unit.
 Consultation with the nutritionist should be done on a regular
basis (as prescribed or per agency protocol).
VI. Home Care Instructions