ATI/NCLEX REVIEW. Parenteral Nutrition.

• Parenteral nutrition (PN) is the IV administration of nutrients for clients with insufficient oral or enteral intake.
• PN can be used short-term.
• RNs can delegate PN administration to LPNs when the client is stable, but not to assistive personnel (AP) due to the skill's complexity.

Safety Considerations

• Determine if the client has allergies, especially to eggs, to prevent allergic reactions.
• Verify client identification to ensure the correct procedure is performed on the correct client.
• Standard and infection control precautions prevent the transmission of infectious organisms.
• Follow the rights of medication administration to reduce medication errors: right client, medication, dose, route, time, documentation, assessment, evaluation, refusal, education.

Equipment

• Nonsterile gloves and PPE are needed if contact with blood or body fluids is possible.
• The client’s medication administration record (MAR) provides orders and instructions that must be followed.
• Parenteral nutrition (PN) solution should be administered per the provider’s order.
• Antiseptic solution and gauze are used to scrub catheter hubs or ports to reduce infection risk.
• A protective cover for PN solution prevents vitamin degradation in solutions without lipids.
• Syringes with appropriate flush solution are needed if the infusion is not continuous, to maintain IV tubing patency.
• IV administration and secondary sets are required if lipids aren't included in the PN solution; label sets with date, time, and nurse's initials.
• Filters are needed to prevent infusion of foreign matter or microorganisms.
• Filters include: 0.22-micron filter for PN without lipids and 1.2-micron filter for solutions with albumin or lipids
• Infusion pumps are needed to infuse the PN solution at a specified rate to prevent complications.
• Glucose meters are needed because parenteral nutrition can cause blood glucose level alterations.

General Steps Prior to Medication Administration

• Review the client’s medical record for allergies, medical history, medications, vital signs, lab values, and the provider’s prescription to identify contraindications. Review facility policy and procedure manual for the skill.
• Obtain and ensure supplies are clean and working properly prior to beginning the procedure.
• Providing privacy is a part of maintaining client confidentiality.
• Introduce yourself to the client to promote a therapeutic nurse-client relationship.
• Perform hand hygiene and put on appropriate PPE if indicated for infection control.
• Identify the client using two unique identifiers to ensure correct procedure is performed on right patient.
• Confirm the client’s allergy status to prevent allergic reaction.
• Educate the client on medication name, purpose, adverse effects, administration procedure, and verify understanding and right to refuse.
• Medication should only be prepared for one client at a time, in an environment free of distractions, and ensure it aligns with the provider's prescription.
• Identify the client’s need for the medication, interactions, contraindications, adverse effects, safe dosing, and any age/condition considerations.
• Remove the prescribed PN solution from the medication supply refrigerator and allow the PN to warm to room temperature for 30 to 60 minutes before initiating the infusion. Ensure that the solution has a protective dark cover over the bag if the solution does not contain lipids.
• Check the client’s MAR against the provider’s prescription.
• Compare the medication label against the MAR and check the expiration date of the medication.
• Perform the dosage calculation, if needed.
• Allowing the PN to warm to room temperature decreases the incidence of hypothermia, vasospasm, venous constriction, and pain at the IV site.

Step-by-Step at the Bedside

• Remove PN bag from refrigerator and allow the solution to warm to room temperature for 30 to 60 minutes.
• Check the PN bag for sediment, discoloration, or cloudiness to ensure that the medication has not expired. Squeeze the solution bag to ensure that there is no leakage.
• Check client’s health status, including focused assessments related to PN administration (insertion site abnormalities, pain level, catheter integrity, etc.) to provide baseline data.

Parenteral Nutrition Administration via Peripheral Line

• Prepare the medication administration set using aseptic technique by clamping the tubing and attaching the inline filter:
  • 0.22-micron filter for PN without lipids or fat emulsion
  • 1.2-micron filter for solutions with albumin or lipids
• Prime the set and spike the infusion port of the solution bag.
• Apply additional PPE per facility protocol.
• Vigorously scrub the hub of the catheter or infusion port.
• Confirm patency of central line catheter by aspiration of blood and flushing of the line using a facility-approved solution.
• Connect the medication administration set and filter to the catheter hub port.
• Clamping the tubing prior to attaching the inline filter reduces the incidence of an air embolism.
• Using inline filters for PN administration reduces the risk of harm to the client due to microorganisms, particles, or microprecipitates.

Parenteral Nutrition Administration via Central Line

• Prepare the medication administration set using aseptic technique by clamping the tubing and attaching the inline filter:
  • 0.22-micron filter for PN without lipids or fat emulsion
  • 1.2-micron filter for solutions with albumin or lipids
• Prepare a sterile field and open all sterile items.
• Apply additional PPE per facility protocol.
• Vigorously scrub the hub of the central venous catheter.
• Confirm catheter patency by blood aspiration and flush the catheter using a facility-approved solution.
• Connect the medication administration set and filter to the central venous catheter hub port.
• Most central line infections are due to contamination from skin bacteria, thus preparing a sterile field minimizes the chance of cross-contamination
• Administer parenteral nutrition via central line with an electronic infusion pump.
• Adjust the rate of administration on the pump and start the infusion. Electronic infusion pumps are used for PN therapy to maintain an accurate rate of PN solution administration.
• Place a label on the tubing with the date and time and the nurse’s initials. PN administration sets should be changed every 24 hours, and every 12 hours for lipid emulsions.
• Remove PPE and dispose of used materials to reduce risk of contamination.
• Discuss findings with the client as indicated to decrease anxiety and promote the nurse-client relationship, as well as client involvement in their care.
• Ensure client safety before leaving the room by placing the call light and needed items within reach, and lower the bed to the lowest position with the brakes locked.
• Evaluate the outcome of the medication at the appropriate time frame to ensure effectiveness and identify any adverse effects.

Client Considerations

• Consider the age and medical history of the client when administering PN, as PN solution composition is unique.

Interventions for Unexpected Outcomes

• Sudden increase in weight and shortness of breath:
  • Auscultate lung fields for crackles
  • Check oxygenation level with pulse oximeter
  • Elevate head of bed
  • Apply supplemental oxygen as needed
  • Notify provider
• Chills/fever or elevated heart rate: check catheter insertion site for redness, pain, or drainage, and notify provider, as these could indicate infection.

Documentation

• Document on the client’s MAR and in medical record per facility policy, including:
  • Date and time of administration
  • Nurse’s initials and signature
  • Medication, dose, and route
  • Pertinent findings prior to administration
  • Client education provided
  • Client’s response to medication
  • Unexpected outcomes and notification of provider

Learn the basics of Parenteral Nutrition (PN), including safety considerations and necessary equipment. Understand the roles of RNs, LPNs, and assistive personnel in PN administration. Review key safety steps, including allergy checks and following medication administration rights.