Total parenteral nutrition

Definition
Intravenous administration of
varying combinations of hypertonic or
isotonic glucose, lipids, amino acid,
electrolytes, vitamins and trace
elements through a venous access
device (VAD) directly into the
intravascular fluid to provide nutrients
for patients who are unable to receive
adequate nutrition through
gastrointestinal tract.
Purposes
 To provide nutrients required for the
normal metabolism, tissue
maintenance, repair and energy
demands.
 To bypass the GI tract for patients who
are unable to take food orally.
Indications
 Patient who cannot tolerate enteral
nutrition because of
◦ Paralytic ileus
◦ Intestinal obstruction
◦ Acute pancreatitis
◦ Inflammatory bowel disease
◦ Gastro intestinal fistula
◦ Severe diarrhea
◦ Persistent vomiting
◦ Malabsorption
Indications
 Hyper metabolic states for which enteral
therapy either not possible or inadequate
◦ Severe burns
◦ NPO for more than 5 days
◦ Acute renal failure
◦ Multiple fractures
◦ Tumor in GI tract
 Patient at risk for malnutrition of
◦ Gross under weight
◦ Metastatic cancer
Methods of parenteral
nutrition
Methods of parenteral
nutrition
 Total nutrient admixture into a central
vein (TNA)
◦ It is indicated for patients requiring parenteral
feeding for seven or more days. Given
through a central vein often into the superior
venacava.
◦ Parenteral formula combines
 CHO in the form of a concentrated 20-70%
dextrose solution
 Proteins as amino acids
 Lipids in the form of an emulsion (10-20%)
including triglycerides, phospholipids and glycerol.
 Water
 Vitamins and minserals
Methods of parenteral
nutrition
 Peripheral parenteral nutrition
◦ This parenteral formula combines
carbohydrates a lesser concentrated
glucose solution with amino acids,
vitamins, minerals
◦ Given through peripheral vein
◦ Indicated for patients requiring nutrition
for fewer less than 7 days
Total parenteral nutrition
 This parenteral formula combines
glucose, amino acids, vitamins &
minerals
 Given through a central I V line
 If lipids are given intermittently mixed
with TPN
 Fat emulsion (lipids): it is composed of
triglycerides (10-20%)
◦ Eg : Phospolipids ,Glycerol and water
◦ May be given centrally or peripherally
Articles
 Central venous access devices: long
term VAD such as thick man, Broviac
or Groshung catheters or peripherally
inserted cenrtral catheter (PICC line)
or periheral IV access
 Volume control infuser
 Filters 0.22 micron for TPN (without fat
emulsion)3.2 micron filter for TNA or
fat emulsion
Central venous access devices
 Volume control infuser
Filters 0.22 micron for TPN / 3.2
micron filter for TNA
Articles
 Bag of parenteral nutrition
 Administration tubing with luer-lock
connections
 Hypoallergic tape
 Face mask
 Sterile gloves
 Bag of parenteral nutrition
luer-lock connections Sterile gloves

Facemask Hypoallergic tape

Procedure
Nursing action Rationale
Performing Nutritional assessment Provides baseline data

Check physician’s order Parenteral therapy must be ordered

by physician
Explain the procedure
Obtain informed consent
Collect needed equipment for the
procedure
Remove the bag of parenteral Decrease the incidence of
nutrition from refrigerator at least hypothermia, pain &vaso spasm
1hr before procedure (if
refrigerator)
Inspect fluid for presence of Indicates fluid separation TPN
creaming or any change in solution should be clear with out
constitution clouding
Nursing action Rationale
Wash hands and done cap, mask, Follow strict aseptic precautions
gown and sterile gloves

Using strict aseptic technique , Prevents chances of developing air

attach tubing (with filter)to TNA bag embolus
purge out air
Close all clamps on new tubing
and insert tubing into volume
control infuses
Place the patient in supine Supine position with head turned
position and turn head away from one side opens the angle b/w
VAD insertion site clavicle and first rib
Clean the insertion site with alcohol
and providone-odine solution
Assist physician while inserting
VAD
After insertion of VAD connect
tubing to hub of VAD using sterile
technique and make sure that the
connection is secured using luer-
lock connection
Nursing action Rationale
Open all clamps and regulate flow
through volume control infuser
Monitor administration hourly,
assessing for integrity of fluid and
administration system and patient
tolerance
Record the procedure
Clinical Data Monitored Daily
• General sense of well-being

• Strength as evidenced in getting out of bed, walking, resistance

exercise as
appropriate

•Vital signs including temperature, blood pressure, pulse, and

respiratory rate
•Fluid balance: weight at least several times weekly, fluid intake
(parenteral and enteral) vs. fluid output (urine, stool, gastric drainage,
wound, ostomy)
•Parenteral nutrition delivery equipment: tubing, pump, filter, catheter,
Dressing

•Nutrient solution composition

Laboratory Daily

Finger-stick glucose Three times daily until

stable
Blood glucose, Na, K, Daily until stable and
Cl, HCO3, BUN fully
advanced, then twice
weekly
Serum creatinine, Baseline, then twice
albumin, PO4, Ca, weekly
Mg, Hb/Hct, WBC
INR Baseline, then weekly

Micronutrient tests As indicated

Discontinuation of TPN should take place
when the patient can satisfy 75% of his or
her caloric and protein needs with oral
intake or enteral feeding.
To discontinue TPN, the infusion rate
should be halved for 1 hour, halved
again the next hour, and then
discontinued.
Tapering in this manner prevents
rebound hypoglycemia from
hyperinsulinemia.
It is not necessary to taper the rate if the
patient demonstrates glycemic stability.
Complications
 Sepsis
◦ Causes :
 High glucose content of fluid
 Venous access device contamination
◦ Interventions
 Monitor temperature , WBC count, and insertion
site for signs and symptoms of infection
 Maintain strict surgical asepsis when changing
dressing and tubing
 Consider deceasing glucose content of fluid
 Consider removal of venous access device with
replacement in alternate site
 If blood culture is positive consider antibiotic
therapy
Complications
 Electrolyte imbalance
◦ Causes :
 Iatrogenic
 Effects of underlying diseases, ie. Fistula,
diarrhea, vomiting
◦ Interventions
 Monitor for signs and symptoms of electrlyte
imbalances
 Treat underlying cause
 Change concentration of electrolytes in TNA as
necessary
Complications
 Hyperglycemia
◦ Causes :
 High glucose content of fluid
 Insufficient insulin secretion
◦ Interventions
 Monitor blood glucose frequently
 Decrease glucose content of fluid if possible
 Administer insulin
Complications
 Hypoglycemia
◦ Causes :
 Abrupt discontinuation of TNA
 Administration through a central vein
◦ Interventions
 After discontinuation of centrally administered
TNA, start 10% dextrose at the same rate
Complications
 Hypervolemia
◦ Causes :
 Iatrogenic
 Underlying heart diseases such as congestive
heart failure and renal failure
◦ Interventions
 Monitor intake & out put, daily weight,CVP,
breath sounds and peripheral edema
 Consider administering more concentrated TNA
solution
Complications
 Hepatic dysfunction
◦ Causes :
 High concentration of CHO, fats relative to
protein

◦ Interventions
 Monitor liver function test, triglyceride levels,
and presence of jaundice
 Consider alternation in formula
Complications
 Hypercarbia
◦ Causes :
 High carbohydrate content of fluid

◦ Interventions
 Consider changing formula to increase the
proportion of fat relative to carbohydrate
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