Chapter 10: Total Parenteral Nutrition

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Questions and Answers

What is a potential consequence of administering the PN solution too rapidly?

Improvement in nitrogen balance

Management of hyperglycemia

Fluid overload (correct)

Increased caloric intake

Which of the following should NOT be added to a PN solution due to contraindications?

IV medications via the PN IV line (correct)

Insulin for hyperglycemia management

Glutamine for enhanced recovery

Heparin to prevent catheter complications

What monitoring parameter is essential to evaluate the client's response to therapy during PN administration?

Blood and urine glucose levels (correct)

Daily physical exercise levels

Fluid intake from oral sources

Nutritional supplements intake

What is an indicator that a TPN solution is 'cracked' and should not be used?

Oily appearance with a layer of fat on top Signup and view all the answers

Which statement about the discontinuation of PN in a client is correct?

PN should be gradually reduced until 50 to 75% of caloric needs are met by enteral or oral intake. Signup and view all the answers

What is the primary distinction between total parenteral nutrition (TPN) and peripheral parenteral nutrition (PPN)?

TPN requires central vein administration while PPN is given via peripheral veins. Signup and view all the answers

Which of the following statements about lipids in parenteral nutrition is NOT correct?

Lipids are always administered in a concentrated form. Signup and view all the answers

In order to control hyperglycemia, which dextrose concentration would be most appropriate for parenteral nutrition?

2.5% Signup and view all the answers

What criteria must be met for a solution to be classified as peripheral parenteral nutrition (PPN)?

It must be isotonic with a dextrose concentration of no more than 10%. Signup and view all the answers

Which component of parenteral nutrition is critical for correcting essential fatty acid deficiency?

Lipids Signup and view all the answers

What complication is specifically associated with a prolonged indwelling catheter?

Infection Signup and view all the answers

Which of the following is NOT a manifestation of refeeding syndrome?

Elevated blood glucose Signup and view all the answers

Which nursing action is appropriate when monitoring for metabolic complications in a patient receiving total parenteral nutrition?

Monitor daily weights and I&O Signup and view all the answers

During arterial blood gas sampling, why is it important to perform an Allen’s test?

To verify the patency of the ulnar artery Signup and view all the answers

Which of the following correctly describes the indication for pulmonary function tests?

Evaluate lung function and identify breathing difficulties Signup and view all the answers

Which of the following correctly describes the difference between hypovolemic shock and dehydration?

Hypovolemic shock is characterized by significant loss of body fluid, affecting oxygen delivery to tissues. Signup and view all the answers

Which laboratory finding would most likely indicate a state of dehydration?

BUN greater than 25 mg/dL. Signup and view all the answers

What is the primary nursing intervention for a patient showing signs of hypovolemic shock?

Administering oxygen and monitoring vital signs frequently. Signup and view all the answers

Which condition is most likely to lead to relative dehydration?

Fluid redistribution from plasma to interstitial spaces. Signup and view all the answers

Which of the following conditions is NOT typically indicated for performing a thoracentesis?

Chronic Obstructive Pulmonary Disease (COPD) Signup and view all the answers

What effect does aging have on fluid balance in older adults?

Reduced renal function heightens the risk of fluid imbalance. Signup and view all the answers

What is the maximum amount of fluid that can be safely removed during a thoracentesis procedure at one time?

1 L Signup and view all the answers

Which of the following actions is essential to prevent complications during and after thoracentesis?

Monitor the client's vital signs and respiratory status hourly after the procedure Signup and view all the answers

Which assessment finding after thoracentesis would most likely indicate a pneumothorax?

Asymmetrical chest wall movement Signup and view all the answers

Which of the following laboratory analyses is NOT typically performed on aspirated fluid during thoracentesis?

Blood cholesterol levels Signup and view all the answers

What is a key nursing action when caring for a client with fluid volume excess who has pulmonary edema?

Position the client in high-Fowler’s to maximize ventilation Signup and view all the answers

Which of the following is NOT a common cause of fluid overload in patients?

Prolonged fasting without water Signup and view all the answers

During assessment of a client with suspected hypervolemia, which vital sign finding would most likely be observed?

Tachycardia Signup and view all the answers

What laboratory finding would be expected in a client experiencing fluid volume excess?

Decreased urine sodium Signup and view all the answers

What dietary recommendation should be made to a patient at risk for fluid volume excess?

Low-sodium diet to prevent fluid retention Signup and view all the answers

What is the primary consequence of hyponatremia on cellular function?

Cellular edema due to water influx Signup and view all the answers

Which condition may cause relative sodium deficits due to dilution?

Psychogenic polydipsia leading to hypotonic fluid excess Signup and view all the answers

Which laboratory finding is indicative of SIADH in cases of hyponatremia?

Urine sodium levels greater than 20 mEq/L Signup and view all the answers

Which of the following treatments should be avoided in managing hyponatremia?

Rapid sodium replacement exceeding 12 mEq/L in 24 hours Signup and view all the answers

What is a common symptom observed in patients with hypovolemic hyponatremia?

Diminished peripheral pulses Signup and view all the answers

Which clinical assessment finding would suggest a patient may be hypervolemic due to hyponatremia?

Bounding pulse quality Signup and view all the answers

Which of the following medications promotes the excretion of excess fluid in cases of hyponatremia?

Conivaptan Signup and view all the answers

What is the critical sodium level indicating severe hyponatremia?

120 mEq/L Signup and view all the answers

Which nursing action is crucial when administering hypertonic saline for treating hyponatremia?

Monitor sodium levels frequently Signup and view all the answers

In the context of sodium regulation, which hormone directly influences sodium retention in the kidneys?

Aldosterone Signup and view all the answers

Study Notes

Total Parenteral Nutrition (TPN) and Peripheral Parenteral Nutrition (PPN)

Parenteral Nutrition (PN) is used when the gastrointestinal tract is non-functional or when oral intake is inadequate.
TPN provides complete nutritional support and is given via central veins, suitable for high caloric needs and hypertonic solutions.
PPN is administered through peripheral veins for short-term support, containing lower concentrations of dextrose (≤10%).

Components of Parenteral Nutrition Solutions

PN includes amino acids, dextrose, electrolytes, vitamins, and trace elements, typically dissolved in sterile water.
Lipids are added to the solution or infused separately, aiding in calorie provision without raising osmolality.
Dextrose concentrations vary: PPN (2.5%-10%), TPN (up to 70%).
Monitoring of electrolytes, vitamins, and trace elements is essential based on blood chemistry and client needs.

Indications for PN

TPN is indicated for clients needing long-term nutritional support, such as those with cancer, bowel disorders, critical illness, and significant trauma.
PPN is suited for those unable to meet caloric needs temporarily.

Desired Therapeutic Outcomes of PN

Enhanced nutritional status and weight stabilization or increase.
Positive nitrogen balance; improvement in prealbumin (normal range 15-36 mg/dL) and blood urea nitrogen (normal range 10-20 mg/dL).

Patient Preparation and Ongoing Care

Review client’s nutritional status, lab data, and educational needs before starting PN.
Use electronic infusion devices and micron filters during administration to avoid overload.
Monitor vital signs, laboratory results, fluid intake/output, and weight daily to prevent complications.

Complications and Monitoring

Potential complications include infection, metabolic abnormalities (hyperglycemia, hypoglycemia, electrolyte imbalance), and mechanical issues (catheter misplacement, air embolism).
Monitor for fever, increased white blood cells, glucose levels, and weight gain exceeding 1 kg/day.
For hyperglycemia, administer insulin; for hypoglycemia, additional dextrose is necessary.

Respiratory Diagnostic and Therapeutic Procedures

Evaluate respiratory status through tests like pulmonary function tests (PFTs), arterial blood gases (ABGs), bronchoscopy, and thoracentesis.
Ensure informed consent for procedures and educate clients on preparation.

Pulmonary Function Tests (PFTs)

Assess lung function by measuring volumes, capacities, diffusion, and exchange rates.
Advisable to refrain from smoking and inhaler use pre-testing.

Arterial Blood Gases (ABGs)

ABG measures pH, PaO2, PaCO2, HCO3¯, and SaO2 to evaluate oxygenation and acid-base status.
Prior to arterial puncture, perform Allen’s test to check ulnar circulation.

Thoracentesis

A procedure to remove fluid or air from the pleural space for diagnosis or relief.
Position the client upright; apply ultrasound for safer needle insertion.
Monitor vital signs and respiratory status post-procedure; assess for complications like pneumothorax and mediastinal shift.

Fluid Imbalances

Maintain homeostasis with fluid volume, osmolality, electrolyte concentration, and pH balance.
Healthy adults have 55%-60% body weight as fluid; less in older adults (50%-55%).
Hypernatremia (water deficit) and hyponatremia (water excess) are key osmotic imbalances to monitor.### Body Fluids Overview
Body fluids are categorized into two compartments: Intracellular Fluid (ICF) and Extracellular Fluid (ECF).
ICF comprises two-thirds of body water, while ECF contains one-third.
ECF is further subdivided into:
- Intravascular fluid: Blood plasma.
- Interstitial fluid: Located between cells, outside blood vessels.
- Transcellular fluids: Secreted by epithelial cells (e.g., cerebrospinal, synovial fluids).

Dehydration

Dehydration refers to fluid deficiency in the body due to insufficient intake or excess loss.
Actual dehydration: Direct loss of body fluid.
Relative dehydration: Fluid shift from plasma to interstitial space.
Hypovolemia: Fluid volume deficit, involving loss of both water and electrolytes.

Causes of Dehydration and Isotonic Fluid Volume Deficit

Excessive gastrointestinal loss: Vomiting, diarrhea, fluid removal via nasogastric suction.
Excessive skin loss: Diaphoresis without replacing sodium and water.
Renal losses: Diuretic use, kidney disease, adrenal insufficiency.
Third spacing associated with burns or plasma loss.
Altered intake: Anorexia, nausea, impaired swallowing.

Expected Findings in Hypovolemia

Vital signs: Hypothermia, tachycardia, hypotension, orthostatic hypotension, tachypnea.
Neuromuscular: Dizziness, syncope, confusion, weakness, fatigue.
Gastrointestinal: Thirst, dry mouth, nausea, acute weight loss.
Renal: Oliguria (reduced urine output) and poor skin turgor.

Impact of Age on Fluid Balance

Older adults experience greater fluid imbalance risks due to:
- Decreased skin elasticity.
- Reduced kidney filtration ability.
- Loss of muscle mass, which retains water.

Laboratory Tests for Fluid Imbalance

Hematocrit: Increased in hypovolemia.
BUN: Elevated (> 25 mg/dL) due to hemoconcentration.
Urine specific gravity: > 1.030 indicates dehydration.
Blood sodium: Elevated (> 145 mEq/L).
Blood osmolality: Increased (> 295 mOsm/kg).

Patient-Centered Care for Dehydration

Monitor intake and output (I&O) and vital signs, including orthostatic blood pressure.
Implement oral or IV rehydration therapy.
Weight monitoring every 8 hours during fluid replacement.
Assess for changes in mental status as indicators of fluid imbalance.

Complications Associated with Dehydration

Hypovolemic shock: Characterized by decreased mean arterial pressure, reducing tissue perfusion.
Nursing actions include oxygen administration, fluid replacement, and hemodynamic monitoring.

Overhydration

Defined as excess fluid in the body due to high intake or ineffective removal.
Hypervolemia: Fluid volume excess affecting sodium and water balance.
Greater risks in older adults due to age-related physiological changes.

Causes of Hypervolemia

Heart failure, kidney disease, cirrhosis, corticosteroid use.
Overhydration due to excessive water intake or inadequate electrolyte replacement.

Signs and Symptoms of Fluid Volume Overload

Vital Signs: Tachycardia, bounding pulse, hypertension, tachypnea.
Neuromuscular: Weakness, changes in consciousness, seizures.
Gastrointestinal: Ascites, increased bowel motility.
Respiratory: Crackles, cough, dyspnea.

Laboratory Tests for Fluid Overload

Hematocrit: Decreased.
Blood osmolarity: Decreased.
Urine sodium: Decreased.
BUN: Decreased due to plasma dilution.

Nursing Care in Fluid Volume Excess

Monitor I&O and daily weights.
Assess breath sounds and peripheral edema; maintain sodium-restricted diet as prescribed.
Educate on the importance of fluid restrictions and daily weight monitoring.

Electrolyte Imbalances

Electrolytes (charged ions) are categorized as cations (positively charged) and anions (negatively charged).
Sodium (Na+) is the primary cation in ECF, crucial for nerve impulse transmission and muscle contraction.

Hyponatremia

Defined as serum sodium < 136 mEq/L, leading to cellular edema.
Caused by excessive loss via diuretics, sweating, or dilutional scenarios (hypotonic fluid excess).
Clinical findings include headaches, confusion, seizures, and gastrointestinal symptoms.

Hypernatremia

Defined as serum sodium > 145 mEq/L, causing cellular dehydration.
Results from water deprivation, excessive sodium intake, or certain medications.
Symptoms include thirst, hyperthermia, muscle twitching, and potential seizures.

Nursing Actions for Sodium Imbalances

For Hyponatremia: Administer sodium-elevating IV fluids, encourage sodium-rich foods.
For Hypernatremia: Promote fluid intake, restrict sodium, and monitor diuretics effectively.

Complication Management

Severe electrolyte imbalances can lead to seizures or cardiac issues; impose seizure precautions and monitor vital signs closely.### Potassium Imbalances
Potassium (K+) is the major intracellular cation, with 98% located within cells and essential for cell metabolism and nerve impulse transmission.
Hypokalemia is defined as blood potassium levels below 3.5 mEq/L, caused by potassium loss or movement into cells.

Hypokalemia

Risk Factors:
- Overuse of diuretics, digitalis, corticosteroids.
- Increased aldosterone secretion, Cushing’s syndrome.
- Gastrointestinal losses from vomiting, diarrhea, and excessive laxative use.
- Prolonged NPO status and impaired kidney disease.
- Conditions like alkalosis or hyperinsulinism.
Expected Findings:
- Vital signs may show decreased blood pressure and weak pulse.
- Neurological symptoms include altered mental status and lethargy, progressing to confusion or coma.
- ECG changes may show flattened T waves, prominent U waves, and prolonged PR intervals.
- Gastrointestinal symptoms include nausea, vomiting, and constipation.
- Respiratory issues may present as shallow breathing.
Diagnostic Procedures:
- ECG shows T wave changes and dysrhythmias linked to hypokalemia.
Nursing Care:
- Administer potassium replacement; avoid IM/subcutaneous routes.
- Monitor cardiac rhythms, urine output, and respiratory function.
- Educate clients on potassium-rich foods like bananas, dairy, and avocados.

Hyperkalemia

Hyperkalemia is identified when blood potassium levels exceed 5.0 mEq/L, which can cause cardiac complications.
Risk Factors:
- Common in older adults with decreased hormone regulation.
- Kidney failure, excessive potassium intake, and certain medications (ACE inhibitors, potassium-sparing diuretics).
Expected Findings:
- Vital signs may show slow, irregular pulse and hypotension.
- ECG may display peaked T waves and other rhythm disturbances.
- Gastrointestinal symptoms can include diarrhea and increased bowel motility.
Diagnostic Procedures:
- Blood tests will show elevated potassium levels; arterial blood gas tests may reveal metabolic acidosis.
Patient-Centered Care:
- Monitor I&O and muscle function; implement fall precautions.
- Identify and restrict potassium-rich foods; administer IV insulin and glucose to shift potassium intracellularly.

Acid-Base Imbalances

Acid-base balance is crucial for normal cellular function, involving hydrogen ion concentration regulation.
Compensation Mechanisms:
- Chemical Buffers: Immediate response to pH changes, involving bicarbonate and protein buffers.
- Respiratory System: Alters CO2 levels through changes in breathing rate—higher breathing removes CO2 (reducing acidity), while lower slows it (increasing acidity).
- Kidney Function: Slowest yet most efficient buffer, managing bicarbonate levels based on blood hydrogen levels—reabsorbing or excreting bicarbonate as needed.
Types of Imbalances:
- Examples include metabolic acidosis/alkalosis and respiratory acidosis/alkalosis, each affecting pH, which is maintained between 7.35 and 7.45 for optimal functioning.

Other Electrolyte Imbalances

Calcium Imbalances:
- Hypocalcemia: Blood calcium levels drop below 9.0 mg/dL, leading to tetany and neuromuscular excitability.
Magnesium Imbalances:
- Hypomagnesemia occurs with levels below 1.3 mg/dL, presenting risks like dysrhythmias and neuromuscular dysfunction.
Interprofessional consultations may include nephrology for electrolyte management, respiratory services for oxygen needs, and nutritional services for dietary modifications.

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Explore the key concepts of Total Parenteral Nutrition (TPN) in Chapter 10. This quiz covers the indications for TPN, its nutritional components, and when it is preferred over Peripheral Parenteral Nutrition (PPN). Test your knowledge and understanding of this essential aspect of clinical nutrition.