Lesson 38: Parenteral Nutrition
the use of an in-line filter to trap crystals in the solution.
Parenteral nutrition (PN) refers to the administration of
nutrients by a route other than the GI tract (e.g., the
bloodstream); PN provides carbohydrates, fats, and proteins
in the form of amino acids, vitamins, minerals, trace
elements, water, and electrolytes.
Insulin may be added to control the blood glucose level
because of the high concentration of glucose in the PN
solution.
Heparin may be added to reduce buildup of a fibrinous clot at
the catheters tip.
Indications
PN is used when the gastrointestinal (GI) tract is severely
dysfunctional or non-functional.
Multiple GI surgeries, GI trauma, intestinal obstruction,
severe intolerance of enteral feedings, and any other time
that the bowel needs to rest for healing are indications for
the use of PN.
Acquired immunodeficiency syndrome (AIDS), cancer,
and malnutrition are other conditions that sometimes require
the use of PN.
Guidelines for Administering Parenteral Nutrition
Check the components of the solution against the health care
providers prescription.
The solution should be stored under refrigeration and
administered within 24 hours of the time when it was
prepared. (Remove the solution from the refrigerator 30
minutes to 1 hour before use.)
A solution that is cloudy or darkened should not be used;
instead, it should be returned to the pharmacy.
As a means of preventing infection and solution
incompatibility, intravenous (IV) medications and blood are
not given through the PN line.
Monitor electrolytes, albumin, and liver and renal function
parameters.
A therapeutic response to PN is signaled by weight gain,
ideally 1 to 3 lb (0.5 to 1.4 kg) per week.
Intravenous Access
PN is administered by way of central venous access
(subclavian or internal jugular vein, shown in the figure) when
the client requires a high concentration of carbohydrates
(more than 10% glucose).
When it is anticipated that PN will be required for an
extended period (more than 4 weeks), a more permanent
catheter (e.g., a peripherally inserted central catheter (a.k.a. a
PICC line), a tunneled catheter, or an implanted vascular
access device may be used.
Peripheral parenteral nutrition (PPN), administered through a
peripheral vein, is used for short periods (5 to 7 days) to
deliver isotonic or mildly hypertonic solutions; the delivery of
highly hypertonic solutions into peripheral veins can cause
sclerosis, phlebitis, or swelling.
Both PN and PPN must be administered through tubing with
A 0.22-m filter is sufficient for the administration of
solutions without lipid additives.
Lipids (Fat Emulsion)
Lipids, or fat emulsion, are administered to prevent or correct
fatty acid deficiency.
Fat emulsion may be administered into a peripheral vein.
Assess the client for allergy to eggs or any of the components
of the lipid emulsion solution; commercial lipid emulsions are
formulations of safflower oil, soybean oil, or a combination,
with glycerol added for tonicity and egg phospholipid as an
emulsifying agent.
Examine the bottle for separation of emulsion into layers or
fat globules and for the accumulation of froth. If any of these
findings is noted, do not use the solution; instead, return it to
the pharmacy.
Do not put additives into the fat emulsion solution.
Do not use an IV filter to administer a lipid emulsion-only
solution; particles in the fat emulsion are too large to pass
through filters.
If the fat emulsion has been added to the PN solution, use a
filter gauge of 1.2 m or larger to allow it to pass through.
The solution is supplied in a glass container for
administration; use vented IV tubing.
Initially the infusion is usually administered at 1.0 mL/min;
check vital signs every 10 minutes and observe the client for
adverse reactions, especially in the first 30 minutes of the
infusion; if signs of an adverse reaction occur, stop the
infusion and notify the health care provider.
If no adverse reaction occurs, adjust the flow to the
prescribed rate.
Monitor serum lipids for 4 hours after the infusion is
discontinued.
Monitor laboratory values for evidence of impaired liver
function, indicating the livers inability to metabolize the
lipids.
Complications of Parenteral Nutrition
Pneumothorax
Pneumothorax, an accumulation of air between the lung and
chest cavity, is a rare complication of central line placement.
Once the catheter has been inserted, a portable chest x-ray is
obtained to confirm correct catheter placement and to detect
the presence of a pneumothorax.
PN is not initiated until correct catheter placement is verified
and the absence of pneumothorax is verified.
Air Embolism
Air embolism an air bubble in the bloodstream is a
complication associated with central line placement and
tubing changes.
Instruct the client in the Valsalva maneuver for tubing and
cap changes.
 For tubing and cap changes, place the client in a head-down
position with the head turned in the opposite direction from
the insertion site to increase intrathoracic venous pressure.
Check all catheter connections and tape tubing connections.
If an air embolism is suspected, place the client in a left side
lying position with the head lower than the feet (to trap air in
right side of the heart), administer oxygen as prescribed, and
notify the health care provider.
Infection
Infection in a client receiving PN is usually catheter-related;
the PN solution contains a high concentration of glucose,
making it an ideal medium for bacterial growth.
Use strict aseptic technique.
Monitor the clients temperature and assess the site of IV
access for redness, swelling, tenderness, or drainage.
If signs of infection appear at the site, the IV line must be
removed and restarted at a different site, the tip of the IV
catheter is sent to the laboratory for culture, and blood
specimens for culture are obtained.
Change the PN solution every 12 to 24 hours or in accordance
with agency protocol.
Change the IV tubing in accordance with CDC guidelines and
agency protocol.
Change the dressing at the IV site per CDC guidelines and
agency protocol.
Fluid Overload
Fluid overload, an excess of fluid in the body, occurs when an
IV solution is administered too rapidly.
As a means of preventing fluid overload, PN is always
delivered with the use of an electronic infusion device.
Never increase the infusion rate to catch up if an IV infusion
falls behind.
Monitor the client's intake and output.
In addition to watching for other signs of fluid overload,
weigh the client daily. The ideal weight gain with PN is 1 to 3
lb/wk (0.5 to 1.4 kg), so any greater gain is cause for concern.
Hyperglycemia
Hyperglycemia is usually caused by the components of the PN
solution itself.
Assess the client for history of glucose intolerance and review
the clients medication history (e.g., corticosteroids may
increase blood glucose).
Begin the infusion at a slow rate (usually 40 mL/hr), as
prescribed.
Check the blood glucose concentration every 4 to 6 hours or
in accordance with agency protocol.
Watch for other signs of hyperglycemia, especially the three
Ps: polydipsia, polyuria, and polyphagia.
Start sliding-scale insulin therapy (regular insulin
administration on the basis of blood glucose level) as
prescribed.
Hypoglycemia
Hypoglycemia is usually a result of an abrupt discontinuation
of PN solution.
When discontinuing PN, gradually decrease the rate of
infusion; when an infusion of hypertonic glucose is stopped,
an infusion of 10% dextrose should be instituted and
maintained for 1 to 2 hours to prevent hypoglycemia.
Assess the blood glucose level 1 hour after discontinuing PN.
Watch for other signs of hypoglycemia.
Prepare to administer glucose if hypoglycemia occurs.
Home Care Instructions for Parenteral Nutrition
Teach the client how to obtain, store, and administer PN
fluids.
Teach the client how to change a sterile dressing.
Instruct the client to check his or her weight each day, at the
same time of day and wearing similar clothing.
Stress that weight gain of more than 3 lb/wk (1.4 kg/week)
may indicate excessive fluid intake and should be reported to
the health care provider.
Teach the client to check the blood glucose level and report
abnormalities immediately.
Instruct the client and family to watch for signs and
symptoms of complications; provide the client with a list of
these signs and symptoms and discuss the need to contact
the health care provider.
Instruct the client to report edema of the arm or at the
catheter insertion site, neck pain, or jugular distention as
possible signs of thrombosis.
Leakage of fluid from the insertion site or pain or discomfort
as the fluid is infused may indicate displacement of the
catheter and must be reported immediately.
Stress to the client the importance of follow-up care.
Priority Points to Remember!
After a central venous catheter is inserted, a portable chest
radiograph should be performed to confirm correct catheter
placement and to detect pneumothorax. PN should not be
initiated until it is determined that no pneumothorax is
present.
Check the components of the PN solution against the health
care providers prescription.
PN solution should be stored under refrigeration and
administered within 24 hours of the time at which the
solution was prepared. (Remove the solution from the
refrigerator 30 minutes to 1 hour before use.)
PN solution that is cloudy or darkened should not be used;
instead, it should be returned to the pharmacy.
PN is always delivered with the use of an electronic infusion
device.
As a means of preventing infection and solution
incompatibility, IV medications and blood are never given
through the PN line.
Before administering lipids, assess the client for an allergy to
eggs or any of the components of the lipid emulsion solution.
 Examine the lipid preparation for separation of emulsion into
layers or fat globules and for the accumulation of froth; if
such separation is noted, do not use the solution and return it
to the pharmacy.
Use strict aseptic technique when caring for the central
venous catheter. (Not only is the central line a possible
avenue for the entry of microorganisms into the body, but
the PN solution also contains a high concentration of glucose,
making it an ideal medium for bacterial growth).
Check the blood glucose level every 4 to 6 hours or in
accordance with agency protocol.
If an air embolism is suspected, place the client in a left side
lying position with the head lower than the feet (which traps
air in right side of the heart), administer oxygen as
prescribed, and notify the health care provider.
To help prevent hypoglycemia, gradually decrease the
infusion rate when discontinuing PN.
Provide instructions to the client who will be receiving PN at
home.