Total Parenteral Nutrition (TPN) - PDF

CHAPTER 10 UNIT 2 CLINICAL NUTRITION Lipids (fats) are available in concentrations of 10%, 20%, Total Parenteral and 30%. Lipids are formulated from a combination of CHAPTER 10...

CHAPTER 10 UNIT 2 CLINICAL NUTRITION Lipids (fats) are available in concentrations of 10%, 20%, Total Parenteral and 30%. Lipids are formulated from a combination of CHAPTER 10 soybean oil and or sa o er oil, and egg phospholipids, Nutrition which gives lipids a milky or opaque appearance. IV lipids are contraindicated for clients who have severe hyperlipidemia, severe hepatic disease, or an allergy to soybean oil, eggs, or sa o er oil Parenteral nutrition (PN) is used when a client’s Lipid emulsion provides the needed calories when de trose concentration must be reduced due to uid gastrointestinal tract is not functioning, or when restrictions or persistent hyperglycemia. They also a client cannot physically or psychologically correct or pre ent essential fatty acid de ciency Lipid emulsion provides the calories without increasing consume sufficient nutrients orally or enterally. the osmolality of the PN solution. Based upon the client’s nutritional needs and Total nutrient admixtures are available that combine lipids into the PN solution containing dextrose anticipated duration of therapy, PN can be and amino acids, rather than administering the given as either total parenteral nutrition (TPN) or solutions separately. Not all facilities use this three-in-one solution. peripheral parenteral nutrition (PPN). ◯ Three-in-one infusions reduce body carbon dioxide production and buildup of fat in the liver. TPN provides a nutritionally complete solution. Protein is provided as a mixture of essential It can be used when caloric needs are very high, and nonessential amino acids and is available in when long-term therapy is indicated, or when concentrations of 3% to 20%. The client’s estimated requirements and liver and kidney function determine the the solution to be administered is hypertonic amount of protein provided. (composed of greater than 10% dextrose). It can Other substances can be added to the PN solution by only be administered in a central vein. pharmacy services. Insulin can be added to reduce the potential PPN is administered for up to 14 days into a for hyperglycemia. eparin can be added to pre ent brin buildup on the peripheral vein. It is nutritionally incomplete catheter tip. because it has a low dextrose content. It is Glutamine, antioxidants, prebiotics, or probiotics might be prescribed based on individual client needs. indicated for clients who require short-term nutritional support with fewer calories per day. ! Administering any IV medication through a PN IV line or port is contraindicated. The solution must be isotonic and contain no more than 10% dextrose and 5% amino acids. INDICATIONS COMPONENTS OF PARENTERAL DIAGNOSES NUTRITION SOLUTIONS TPN is commonly used in clients who need intense PN includes amino acids, dextrose, electrolytes, vitamins, nutritional support for an extended period of time, and trace elements in sterile water. Fats (lipids) including clients undergoing treatment for cancer, are added to the parenteral solution or given as an bowel disorders, those who are critically ill, and those intermittent infusion. su ering from trauma or e tensi e burns, as these conditions are associated with high caloric requirements. Carbohydrate or dextrose solutions are available PPN can be used when the client is unable to consume in concentrations of 2.5% to 10% for PPN and up to enough calories to meet metabolic needs or when 70% for TPN. nutritional support is needed for a short time. A higher concentration of dextrose is often prescribed Clients can receive PN at home as nutrition replacement for a client on uid restrictions or to supplement nutrition. Typically, the client will A lower-dextrose concentration can be used to help have a tunneled catheter, and feedings can occur while control hyperglycemia. the client sleeps. Electrolytes, vitamins, and trace elements are essential for normal body functions. The amounts added are dependent upon the client’s blood chemistry values DESIRED THERAPEUTIC OUTCOMES and physical ndings, hich are used to determine the Improved nutritional status quantity of electrolytes. Additional vitamin K can be added Weight maintenance or gain to the PN solution. Positive nitrogen balance NUTRITION FOR NURSING CHAPTER 10 TOTAL PARENTERAL NUTRITION 61  EVIDENCE SUPPORTING EFFECTIVENESS Monitor for “cracking” of TPN solution. This occurs if the calcium or phosphorous content is high or if Daily weight: Maintenance of baseline or gain of up poor-salt albumin is added. A “cracked” TPN solution to 1 kg/day has an oily appearance or a layer of fat on top of the Increases in prealbumin level (expected reference range solution and should not be used. of 15 to 36 mg/dL) Verify the prescription of the PN solution with a second Blood urea nitrogen level within the expected reference nurse prior to administration. range (10 to 20 mg/dL) If the PN solution is prepared and stored in the refrigerator, allow it to come to room temperature for 1 hr prior to administering it. CONSIDERATIONS Maintain strict aseptic techniques to reduce the risk of infection. The high dextrose content of PN contributes PREPARATION OF THE CLIENT to bacterial growth. Use sterile technique when changing central line dressing Prior to initiating PN, review the client’s weight, BMI, and tubing. Change the bag and IV tubing for the dextrose nutritional status, diagnosis, and current laboratory solution e ery hr unless facility policy di ers ith data This can include C C, blood chemistry pro le, intermittent IV lipid infusions, ensure the solution does T a TT, iron, total iron binding capacity, lipid pro le, not hang more than 12 hr to prevent microbial growth. liver function tests, electrolyte panel, BUN, prealbumin Ensure lipid infusion is stopped 12 hr prior to obtaining a and albumin level, creatinine, blood glucose, and blood specimen for triglycerides to ensure accurate results. platelet count. Assess the client’s educational needs. Use an electronic infusion device to prevent the NURSING ACTIONS accidental overload of a solution. Ask the provider about giving some enteral substance A micron lter on the I tubing is re uired hen during long-term PN administration, such as diluted juice, administering solution This lter is not added to to prevent atrophy of the gastrointestinal tract. the IV tubing when administering a lipid emulsion. PN should be discontinued as soon as possible to avoid aluate for allergies to soybeans, sa o er, or eggs if potential complications, but not until the client’s enteral lipids are prescribed. or oral intake can provide 60% or more of estimated caloric requirements. ONGOING CARE ! Discontinuation should be done gradually Nursing care is focused on preventing complications to avoid rebound hypoglycemia. through consistent monitoring peci c monitoring During transition, the client will need enteral or oral guidelines vary among health care facilities. nutrition. Oral nutrition usually begins with clear Parameters can include I&O, daily weights, vital signs, liquids that are low in fat or substances that might pertinent laboratory values (e.g., electrolytes), and irritate the client’s gastrointestinal tract. The client evaluation of the client’s underlying condition. This might not have an appetite for 1 to 2 weeks, so PN data is used to determine the client’s response to infusion will need to continue until the client can take therapy, whether the formulation of the solution is in adequate calories through other means. correct, and to pre ent nutrient de ciencies or to icities Educate the client and family regarding home PN, Monitor blood and urine glucose as prescribed and per including aseptic preparation and administration facility guidelines. Sliding scale insulin can treat or techniques, blood glucose monitoring, and criteria to prevent hyperglycemia, or regular insulin can be added evaluate for complications. to the PN solution. onitor o rate carefully ◯ Administering the solution too slowly will fail to meet COMPLICATIONS the client’s nutritional needs. Infection and sepsis are evidenced by a fever or elevated ◯ Administering the infusion too rapidly can cause WBC count. Infection can result from contamination of hyperosmolar diuresis, which can lead to dehydration, the catheter during insertion, contaminated solution, or a hypovolemic shock, seizures, coma, and death. long-term indwelling catheter. ◯ To avoid hypoglycemia, an IV of dextrose 10% to 20% in water is administered if the PN solution Metabolic complications include hyperglycemia, is unavailable. hypoglycemia, hyperkalemia, hypophosphatemia, ◯ Do not attempt to increase the rate of the PN solution hypocalcemia, dehydration (related to hyperosmolar to “catch up.” Hyperglycemia, hyperosmolar diuresis, diuresis resulting from hyperglycemia , and uid o erload and uid o erload can occur if the solution is (as evidenced by weight gain greater than 1 kg/day and increased when available. edema). 62 CHAPTER 10 TOTAL PARENTERAL NUTRITION CONTENT MASTERY SERIES  Mechanical complications include catheter misplacement Application Exercises resulting in pneumothorax or hemothorax (evidenced by shortness of breath, diminished or absent breath sounds), arterial puncture, catheter embolus, air embolus, 1. A nurse is planning care for a client who has a new prescription for peripheral parenteral nutrition (PPN). thrombosis, obstruction, and bolus infusion due to Which of the following actions should the nurse incorrectly set or malfunctioning electronic pumps. include in the plan of care? (Select all that apply.) Refeeding syndrome occurs when the body rapidly changes A. Examine trends in weight loss. from catabolic (seen in starvation states) to anabolic B. Review prealbumin finding. metabolism when nutrition is started. It is characterized by C. Administer an IV solution of 20% dextrose. uid and electrolyte imbalances potassium, magnesium, D. Add a micron filter to IV tubing. phosphate). Manifestations include shallow respirations, confusion, sei ures, ea ness, cardiac rhythm changes, uid E. Use an IV infusion pump. retention, and acidosis. 2. A charge nurse is providing information about fat NURSING ACTIONS emulsion added to total parenteral nutrition (TPN) to a group of nurses. Which of the following statements by Monitor for manifestations of fever, chills, increased the charge nurse are appropriate? (Select all that apply.) WBCs, and redness around the catheter insertion site. A. “Concentration of lipid emulsion Use strict aseptic technique when setting up the IV can be up to 30%.” tubing, changing the site dressing, and accessing or B. “Adding lipid emulsion gives the deaccessing the IV access. Change the PN bag and tubing solution a milky appearance.” set every 24 hr or per facility protocol. C. “Check for allergies to soybean oil.” Monitor blood glucose per prescription or facility policy. D. “Lipid emulsion prevents essential Administer sliding scale insulin or plan for insulin to be fatty acid deficiency.” added to the TPN solution to treat hyperglycemia. E. “Lipids provide calories by increasing Plan to administer additional dextrose to the osmolality of the PN solution.” treat hypoglycemia. Monitor daily weights, I&O, and oral intake of nutrients. Notify the provider of weight gain greater than 1 kg/day. 3. A charge nurse is teaching a group of nurses about Anticipate a decrease in the concentration of the medication compatibility with TPN. Which of the solution, rate of administration, or volume of lipid following statements should the charge nurse make? emulsion to treat weight gain. A. “Use the Y-port on the TPN IV tubing to administer antibiotics.” B. “Regular insulin can be added to the TPN solution.” Active Learning Scenario C. “Administer heparin through a port on the TPN tubing.” A nurse is teaching a client about complications that can D. “Administer vitamin K IV bolus via occur when receiving total parenteral nutrition (TPN). a Y-port on the TPN tubing.” What should the nurse include in the teaching? Use the ATI Active Learning Template: Basic Concept to complete this item to include the following. 4. A nurse is preparing to administer lipid emulsion and notes a layer of fat floating in the IV solution bag. RELATED CONTENT: Identify three complications of TPN. Which of the following actions should the nurse take? Describe two nursing actions related to each complication. A. Shake the bag to mix the fat. B. Turn the bag upside down one time. C. Return the bag to the pharmacy. D. Administer the bag of solution as it is. 5. A nurse is caring for a client who is receiving TPN through a central venous access device, but the next bag of solution is not available for administration at this time. Which of the following is an appropriate action by the nurse? A. Administer 20% dextrose in water IV until the next bag is available. B. Slow the infusion rate of the current bag until the solution is available. C. Monitor for hyperglycemia. D. Monitor for hyperosmolar diuresis. NUTRITION FOR NURSING CHAPTER 10 TOTAL PARENTERAL NUTRITION 63  Application Exercises Key Active Learning Scenario Key 1. A. CORRECT: Examining trends in weight loss will Using the ATI Active Learning Template: Basic Concept help to evaluate the outcome of PPN. RELATED CONTENT B. CORRECT: Reviewing the prealbumin finding will determine nutritional deficiency over a short period of time. Infection and sepsis C. An IV solution of 20% dextrose is administered Monitor for manifestations of fever, chills, increased only as TPN using a central vein. WBCs, and redness around catheter insertion site. D. CORRECT: A micron filter is always used Use aseptic technique when setting up the IV tubing when infusing PN solution. and accessing or deaccessing the port. E. CORRECT: An IV infusion pump is always used to regulate Use sterile technique when changing central line dressing and tubing. the flow and provide accurate delivery of the PN solution. Change the PN bag and tubing set every NCLEX Connection: Pharmacological and Parenteral Therapies, ® 24 hr or per facility protocol. Total Parenteral Nutrition (TPN) Hyperglycemia Administer sliding scale insulin or plan for insulin 2. A. CORRECT: Lipid emulsion is available in 10%, to be added to the TPN solution. 20%, and 30% concentrations depending upon the Monitor blood glucose. client’s carbohydrate and caloric needs. Hypoglycemia B. CORRECT: The lipid emulsion is formulated from safflower and/or soybean oils and egg phospholipid, Inform the provider and plan to give additional dextrose. making the solution appear milky. Monitor frequent blood glucose. C. CORRECT: Lipid emulsion is formulated from safflower Weight gain greater than 1 kg/day and/or soybean oil and egg phospholipid. The nurse Inform the provider and anticipate a decrease in the concentration, should check for allergies to these ingredients. rate of administration or volume of lipid emulsion. D. CORRECT: Lipid emulsion is used for additional Monitor the client’s intake of oral nutrients. calories as concentrated energy and to prevent essential fatty acid deficiency. NCLEX® Connection: Pharmacological and Parenteral Therapies, E. Lipids provide the calories needed without Nutrition and Oral Hydration increasing osmolality of the PN solution. NCLEX® Connection: Pharmacological and Parenteral Therapies, Total Parenteral Nutrition (TPN) 3. A. Administering any IV medication through a Y-port on the TPN line is contraindicated. B. CORRECT: Regular insulin may be added to the TPN solution to decrease hyperglycemia. C. Heparin may be added to the TPN solution to decrease clot formation in the cannula, but it is not injected directly into a port on the TPN tubing. D. Vitamin K can be added to the TPN solution, but it should not be administered IV bolus through the TPN IV line. NCLEX® Connection: Pharmacological and Parenteral Therapies, Total Parenteral Nutrition (TPN) 4. A. Shaking the bag is not an appropriate action because “cracking” of the solution has occurred and it should not be administered. B. Turning the solution upside down does not resolve the problem because cracking of the TPN has occurred and it should not be administered. C. CORRECT: Returning the solution to the pharmacy is an appropriate action by the nurse because cracking of the solution has occurred and it should not be administered. The pharmacist and provider will need to adjust the formulation of the solution to prevent cracking. D. Administering the solution as it is would not be an appropriate nursing action because cracking of the solution has occurred. Infusion of a cracked solution can lead to fat or particulate embolisms. NCLEX® Connection: Pharmacological and Parenteral Therapies, Nutrition and Oral Hydration 5. A. CORRECT: Administering 20% dextrose in water IV until the TPN solution is available will prevent hypoglycemia. B. Decreasing the rate of the TPN solution is not an appropriate action because the decreased rate can cause hypoglycemia. C. The client should be monitored for hypoglycemia when the TPN solution is not infusing and adequate glucose is not provided. D. Monitor the client for hyperosmolar diuresis when the TPN solution has infused too fast. NCLEX® Connection: Pharmacological and Parenteral Therapies, Total Parenteral Nutrition (TPN) 64 CHAPTER 10 TOTAL PARENTERAL NUTRITION CONTENT MASTERY SERIES  NCLEX® Connections When reviewing the following chapters, keep in mind the relevant topics and tasks of the NCLEX outline, in particular: Health Promotion and Maintenance HEALTH PROMOTION/DISEASE PREVENTION Identify risk factors for disease/illness. Educate the client on actions to promote/ maintain health and prevent disease. HEALTH SCREENING: Perform targeted screening assessments. HIGH-RISK BEHAVIORS: Assist the client to identify behaviors/risks that may impact health. Basic Care and Comfort ELIMINATION: Assess and manage client with an alteration in elimination. NUTRITION AND ORAL HYDRATION Provide nutritional supplements as needed. Evaluate the impact of disease/illness on the nutritional status of a client. Physiological Adaptation ALTERATIONS IN BODY SYSTEMS: Implement interventions to address side ad erse e ects of radiation therapy ILLNESS MANAGEMENT: Educate the client about managing illness. FLUID AND ELECTROLYTE IMBALANCES: Manage the care of the client ith a uid and electrolyte imbalance Reduction of Risk Potential POTENTIAL FOR ALTERATIONS IN BODY SYSTEMS: Identify client potential for aspiration. SYSTEM SPECIFIC ASSESSMENTS: Assess the client for signs of hypoglycemia or hyperglycemia NUTRITION FOR NURSING NCLEX® CONNECTIONS 65 66 NCLEX® CONNECTIONS CONTENT MASTERY SERIES