TOTAL PARENTRAL NUTRITION

DEFINITION
Intravenous administration of varying combinations of hypertonic or isotonic glucose, lipids,
amino acids, electrolytes, vitamins and trace elements through a venous access device
directly into the intravascular fluid to provide nutrients for patients who are unable to receive
adequate nutrition through gastrointestinal tract.

PURPOSE
1. To provide nutrients required for the normal metabolism, tissue maintenance, repair and
energy demands.
2. To bypass the GI tract for patients who are unable to take food orally.

INDICATION
1. Patient who cannot tolerate enteral nutrition because of:
 Paralytic ileus
 Intestinal obstruction
 Acute pancreatitis
 Short bowel syndrome
 Inflammatory bowel disease
 Gastrointestinal fistula
 Severe diarrhoea e.g ulcerative colitis
 Persistent vomiting
 Malabsorption
2. Hyper metabolic states for which enteral therapy is either not possible or inadequate
 Severe burns
 Trauma /surgery when nothing can be taken be taken by mouth for more than 5 days.
 Acute renal failure
 Multiple fractures
 Tumour in GI tract
3. Patient at risk for malnutrition because of
 Gross underweight more than 80%below the standard
 Metastatic cancer
 NPO for more than 5 days.

CONTRAINDICATION
Treating a patient with TPN when it is not indicated is not only frustrating for the
doctor as well as the patient but is also an unnecessary drain on scarce resources.
Definite contraindications to TPN include the following :

1. Where gastrointestinal feeding is possible. Almost always this is the best route to provide
nutrition to the patient .
2. Patients with good nutritional status in whom only short term TPN support is anticipated.
3. Irreversibly decerebrate patients.
4. Lack of specific therapeutic goal: TPN should NOT be used to prolong life if death is
inevitable .
5. Severe cardiovascular instability or metabolic derangements. These should be corrected
before attempting intravenous hyperalimentation.
6. Infants with less than 8 cm of small bowel as it has been conclusively proved that they
cannot adapt to enteral feeding despite prolonged periods of TPN.

METHODS OF PARENTERAL NUTRITION

1. Total nutrient admixture into a central vein. This parenteral formula combines
carbohydrate in the form of a concentrated dextrose solution, proteins in the form of
amino acids; lipids in the form of an emulsion including triglycerides, phospholipids,
glycerol and water; vitamins and minerals. It is indicate for patients requiring parenteral
feeding for seven or more days. Given through a central vein often into the superior vena
cava.
2. Peripheral parental nutrition-This parenteral formula combines carbohydrates a lesser
concentrated glucose solution with amino acids,vitamins,minerals and lipids. Given
through a peripheral vein and it is indicated for patients requiring parenteral nutrition for
fewer than 7 days.
3. Total parenteral nutrition-This parenteral formula combines glucose, amino acids,
vitamins and minerals. Given through a central IV line. If lipids are needed, they are
given intermittently mixed with the TPN.
4. Fat emulsion (lipids)-It is composed of triglycerides e.g phospholipids, glycerol and
water. May be given centrally or peripherally.

ARTICLES
1. Central venous access devices: long term VADs such as Hickman, Broviac or Groshung
catheters or peripherally inserted central catheter or peripheral IV access.
2. Volume control infuser.
3. Filters :0.22 micron for TPN (without fat emulsion).3.2 micron filters for TNA or fat
emulsion.
4. Bag of parenteral nutrition.
5. Administration tubing withLuer –lock connections.
6. Hypo allergic tape.
7. Face mask optional
8. Sterile gloves

PROCEDURE
1. Assess the need for parenteral nutrition by performing nutritional assessment.
2. Check physician’s order for method of parenteral nutrition (TNA, TPN, PPN or
lipids) and flow rate.
3. Explain the procedure in detail to the patient and relatives.
4. Obtain informed consent.
5. Collect needed equipment for the procedure.
 6. Remove the bag of parenteral nutrition from refrigerator at least 1 hour before
procedure if refrigerated.
7. Inspect fluid for presence of creaming or any change in constitution.
8. Wash hands, don cap, mask,gown and sterile gloves.
9. Using strict aseptic technique, attach tunings to TNA bag and purge out air.
10. Close all clamps or new tunings and insert tunings into volume control infuser.
11. Place the patient in supine position and turn head away from VADinsertion site.
12. Clean the insertion site with alcohol and povidone iodine solution.
13. Assist physician while inserting VAD.
14. 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.
15. Open all clamps and regulate flow through volume control infuser.
16. Monitor administration hourly assessing for integrity of fluid and administration
system and patient tolerance.
17. Record the procedure.

COMPLICATIONS

COMPLICATIONS CAUSE INTERVENTIONS

1. Sepsis  High glucose content  Monitor temperature,
of fluid. WBCcount and insertion site for
 Venous access signs and symptoms of
device infection.
contamination.  Maintain strict surgical asepsis
when changing dressing and
tubing.
 Consider decreasing glucose
content of fluid.
 Consider removal of venous
access device with replacement
in alternate site.
 If blood culture is positive,
consider institution of antibiotic
therapy.

2. Electrolyte  Iatrogenic  Monitor the signs and symptoms

imbalance  Effect of underlying of electrolyte imbalance.
disease, i,e fistula ,  Treat underlying cause.
diarrhoea, vomiting.  Change concentration of
electrolytes inTNA as necessary.
3. Hyperglycaemia  High glucose content  Monitor blood glucose
of fluid. frequency
 Insufficient insulin  Decrease glucose content of
secretion fluid if possible.
 Administer exogenous insulin.
4. Hypoglycaemia  Abrupt  After discontinuation of
discontinuation of centrally administeredTNA,start
TNA administration 10%dextrose at the same rate.
through a central
vein
COMPLICATIONS CAUSE INTERVENTIONS

1. Hypervolemia  Iatrogenic  Monitor intake and output,

 Underlying disease daily weight, CVF breath
such as congestive sounds and peripheral edema.
heart failure and renal  Consider administering more
failure concentrated TNA solution.
2. Hyperosmolar  High osmolarity of  Consider decreasing the
diuresis parenteral nutrition concentration or amount of
fluid. fluid administered.

3. Hepatic  high concentration of  Monitor liver function tests,

dysfunction carbohydrates /fats for triglyceride levels and
relative to protein. presence of jaundice.
 Consider alteration in formula.
4. Hypercarbia  High carbohydrate  Consider changing formula to
content of fluid increase the proportion of fat
relative to carbohydrates.

5. Lipids intolerance  Low birth weight or  Monitor for bleeding.

premature infant.  Monitor oxygen levels for
 History of liver impaired oxygenation.
disease.  Monitor fat overload
 History of elevated syndrome.
triglycerides.  Monitor triglyceride levels and
liver function test,
hepatosplenomegaly,
decreased coagulation,
cyanosis, dyspnea.
 Monitor allergic reaction such
as nausea, vomiting, headache,
chest pain, back pain and
fever.
 Administer lipid containing
solution slowly.
6. Lipid particulate  Unstable mixture of  Observe for cracking or
aggregation dextrose solution with creaming of fluid and avoid
lipid emulsion. use of fluid with these
characteristics.

SPECIAL CONSIDERATION
1. Strict surgical asepsis is mandatory throughout the insertion of the catheter, when
handling the solution and tubes and when caring for the site of insertion. The parenteral
 line can serve as an excellent culture medium since it directly leads to blood, bacterial
invasion leads to septicaemia.
2. Psychological support is necessary, as the patient is not taking anything orally, for a long
time.
3. As nothing enters the GI tract, bowel elimination will decrease and it should be explained
to the patient.
4. Because TPN solutions are high in glucose, infusion is started slowly to prevent
hyperglycaemia.
5. Rate of infusion for an adult is 1 litre the first day, 2 liters for 24 to48 hrs, and 3 liters
without 3 to 5 days.
6. To prevent hypoglycaemia, while discontinuing parenteral nutrition,the solution should
be reduced gradually over 48 hrs.
7. TPN is given for fewer than 7 days.

BIBLIOGRAPHY
1. Clinical nursing procedures the art of nursing practice, Annamma Jacob, Rekha R,
JadhavSonaliTarachand, second edition, page no.186-189.
2. Fundamentals of nursing, A procedure manual, The trained nurses’ association of India,
pp 391-395.
3. https://www.redcrossblood.org/donate-blood/blood-donation-process/what-happens-to-
donated-blood/blood-transfusions.html.
4. https://en.wikipedia.org/wiki/Blood_transfusion.
5. https://www.google.com/search?
q=blood+transfusion+procedure&source=lnms&tbm=isch&sa=X&ved=0ahUKEwi0mPS
Prs3iAhX87HMBHYFZAj8Q_AUIECgB&biw=1366&bih=625