TABLE OF CONTENTS: PAGE 1) Objectives of Total Parenteral Nutrition-------------------------------------------- 1 2) Definition of Terms ----------------------------------------------------------------------- 2 3) Indications of Total Parenteral Nutrition --------------------------------------------

2 4) Contraindication of Total Parenteral Nutrition -------------------------------------- 2 5) Purposes of Total Parenteral Nutrition ---------------------------------------------- 2 6) Methods of Administration ------------------------------------------------------------ 3- 4 7) Types of Catheters Used -------------------------------------------------------------- 4- 6 8) Composition of Total Parenteral Nutrition Mixtures ----------------------------- 6-7 9) Guidelines, Complications and Nursing Responsibilities of Total Parenteral Nutrition ---------------------------------------------------------- 7- 9 10) Procedure Guide with Rationale ------------------------------------------------------ 11

Total Parenteral Nutrition

Objectives: After 5 hours of classroom discussion, the students will be able to: 1) define Total Parenteral Nutrition 2) enumerate the following: a. purpose b. indications c. contraindications

3) cite the different methods of Total Parenteral Nutrition 4) identify the types of catheter used 5) state the following: a. guidelines b. complications c. nursing responsibilities

6) demonstrate beginning skills on TPN

I.

DEFINITION

Total Parenteral Nutrition (TPN) It is also known as hyperalimentation It is the intravenous administration of carbohydrates, protein, electrolytes, vitamins, minerals, and fat emulsions through a venous access device directly into the intravascular fluid to provide nutrients required for metabolic functioning of the body It supplies all daily nutritional requirements. TPN can be used in the hospital or at home. Because TPN solutions are concentrated and can cause thrombosis of peripheral veins, a central venous catheter is usually required. Generally, this treatment is prescribed for patient who cant absorb nutrients through the GI tract for more than 10 days.

II.

PURPOSE, INDICATIONS, AND CONTRAINDICATIONS OF TOTAL PARENTERAL NUTRITION

Purpose: improve nutritional status establish a positive nitrogen balance allow growth of new body tissue maintain muscle mass promote weight gain serves as alternatives for patients who are unable or unwilling to receive adequate nourishment from a normal diet

Indications: Debilitating illness lasting longer than 2 weeks- there is deficient or absent oral intake for longer than 7 days Loss of 10 % or more of pre-illness weight Serum albumin level below 3.5 g/dl Excessive nitrogen loss from wound infection, fistulas, or abscesses renal or hepatic failure- limited volume of liquid intake A nonfunctioning GI tract for 5 to 7 days in a severely catabolic patientbecause there is an interruption in its continuity and its absorptive capacity is impaired Paralytic Ileus- food cannot move down to the stomach due to absence of peristalsis in the esophagus

 Severe malnutrition- usual food intake is not sufficient to meet the needs of the body Intestinal Obstruction- because there is an interruption in intestinal motility Coma- it is indicated because nothing may be taken by mouth Anorexia Nervosa- unless psychological counseling has worked, TPN is the only way to meet the nutritional needs of someone with this illness Contraindications: Patients who are unable to swallow Patients who are well nourished Patients who doesnt have problem in digesting Nutritional requirements are high Inability to attain venous access Severe liver disease Abnormal lipid metabolism such as lipidemia

III.

METHODS OF ADMINISTRATION Peripheral Method solutions are infused into peripheral veins when nutritional support is needed for only short time peripheral parenteral nutrition less hypertonic, simple IV solutions usual length of therapy using this method last for 5-10 days can irritate the intima or small veins, causing phlebitis

Central Method Infuses hypertonic nutritional solutions through an indwelling central venous catheter (CVC) with the tip placed in the superior vena cava. It provides more concentrated nutrition in an equal volume of fluid. Is used to provide complete, long term nutritional support for patients who cannot or will not consume an adequate oral or enteral intake.

Possible indications include: a. severe malnutrition; weight loss of 10% or more b. gastrointestinal abnormalities: obstruction, peritonitis, impaired digestion and absorption, chronic vomiting, chronic diarrhea, severe acute pancreatitis c. after surgery or trauma, especially that involving extensive burns multiple fractures or sepsis d. Acute liver and renal failure when amino acid requirements are altered e. Acquired immunodeficiency syndrome ( AIDS ) f. Bone marrow transplantation

IV.

TYPES OF CATHETERS USED

Midline Catheter - inserted through the veins in the antecubital fossa and extended 5-7 inches to the vessel, where vein diameter is 5-6 millimeters - cause less irritation because the catheter is so soft and the end is well inside the vein

Percutaneous Central Catheter used for short term ( less than 30 days) IV therapy inserted by the physician most common site is subclavian vein, because this area provides a stable insertion site to which the catheter can be anchored allows the patient freedom of movement, and easy access to the dressing site types: single, double, triple- lumen

to ensure accessibility, a triple lumen subclavian catheter should be used because it offers 3 parts for various uses. 16 gauge distal lumen- used to infuse blood or other viscous fluids 18 gauge middle lumen- reserved for TPN solution 18 gauge proximal port- used for administering blood a port not being used can be for fluid administration can be used for drawing blood single lumen percutaneous catheter is used for administering TPN, but various restrictions apply blood cannot be withdrawn from the catheter and medications be administered if medications are given, they must be infused through a separate IV line transfusion of blood products also cannot be given through the main line

Peripherally Inserted Central Catheter - used for immediate length (3-12 months) IV therapy - basilica or cephalic vein is accessed through the antecubital space and tip ends up in the superior vena cava

Tunneled Central Catheter - this catheter may remain in place for many years - this cuffed and can have single or double lumens: Hickman/ Broviac and Groshong catheter

threaded under the skin to the subclavian vein, and the distal end of the catheter is advanced into the superior vena cava 2-3 cm above the junction with right atrium

Implanted Ports - used for long term IV therapy - instead of exiting from a skin, the end of the catheter is attached to a small chamber that is placed in a subcutaneous pocket - subcutaneous port requires minimal care and allows the patient complete freedom of activity - implanted ports are more expensive and access requires passing a special needle (hubber-tipped) through the skin into the chamber

Composition of Total Parenteral Nutrition Mixtures Parenteral nutrition solutions include dextrose , amino acid, lipid emulsion, electrolytes, vitamins, and trace elements in sterile water. The actual composition of the parenteral solutions depends on the site of infusion and the patients fluid and nutrient requirements. Because there are standard concentration of proteins, carbohydrate, and fat in standard volumes, individualization of parenteral solutions is somewhat limited

 Carbohydrate - The carbohydrates in parenteral solution is dextrose ( a form of glucose that contains water), which provides 3.4 cal/g, not 4.0 cal/g like glucose Protein - Protein is provided as a mixture of essential and non essential amino acids ranging in initial concentration from 5% to 15% of the solution. The quantity of amino acids provided depends on the patients estimated requirements and hepatic or renal failure. Electrolytes, vitamins, trace elements - A quantity of electrolytes provided is based on the patients blood chemistry values and physical assessment findings. - A standard multivitamin preparation may be added to the TPN solution. Although it is now recognized that minerals and trace elements are a necessary component of TPN to prevent deficiency symptoms, exact parenteral requirements for many of them are not known. Medications - Are sometimes added to intravenous solutions by the pharmacist or infused into them through a separate port. Heparin may be added to reduce fibrin buildup on the catheter tip. In general, medications should not be added to TPN solutions because of the potential incompatibilities of the medication and nutrients in the solution.

V.

GUIDELINES, COMPLICATIONS AND NURSING RESPONSIBILITIES OF TOTAL PARENTERAL NUTRITION

Guidelines: Nutritional IV solution is prepared by a pharmacist Nothing should be added to hyperalimentation Insertion should be done under a strict aseptic technique TPN solutions are initiated slowly and gradually advanced each day to the desired rate Patients should be weighed daily at the same time of the day Main-line IV tubing and filters are changed every 72 hours, and all connections are taped securely to avoid breaks in the integrity of the system Patients should be encouraged for ambulation

COMPLICATIONS

POSSIBLE CAUSE

SIGNS AND SYMPTOMS -Apprehension -Chest pain -Dyspnea -Hypotension -Rapid and weak pulse -Respiratory distress -Loud churning sound over pericardium

NURSING INTERVENTION Clamp the catheter when not in use Place the client in a left side lying position with head lower than the feet Administer oxygen Instruct the client in the valsalva maneuver for tubing and cap changes Slowed infusion rate Administration of Regular Insulin as prescribed Monitor blood glucose levels Use Aseptic technique Slow or stop IV infusion Restrict IV fluids Administer diuretics Use dialysis in extreme cases Monitor intake and output Weigh patient daily Administer fluid via infusion pump

Air embolism

Opened catheter sytem Disconnected IV tubings Air on IV tubings

Hyperglycemia

Clients receiving solution too quickly Not enough insulin Infection

Hypervolemia

Excessive fluid administration Administration of fluid rapidly Renal dysfunction Heart failure Hepatic failure

-Coma - Confusion -Diaphoresis -Elevated blood glucose (200mg/dL) - Excessive thirst -Fatigue -Kussmauls Respiration -Restlessness -Bounding pulse -Crackles on lungs -Headache -Increase blood pressure - Jugular vein distention - Weight gain

Hypoglycemia

Parenteral Nutrition abruptly discontinued Too much insulin administration

-Anxiety - Diaphoresis - Low blood pressure - Weakness - Shakiness

Sepsis

Poor aseptic technique Catheter contamination Contamination of solution

-Chills -Fever -Elevated WBC -Erythema or discharges at insertion site

Pneumothorax

Incorrect placement of catheter

-Absence of breath sounds on affected site - Chest or shoulder pain - Sudden shortness of breath -Tachycardia -Cyanosis

Assess clients history for risk of hypervolemia Monitor blood glucose Administration of intravenous dextrose Gradual decrease of PN prior to discontinue Infuse 10% dextrose at the same rate of PN Removal of catheter Obtain blood cultures Administer antibiotic as prescribed Use strict aseptic technique Monitor vital signs Change site dressing, solution and tubing as specified by agency policy Assess IV site for signs of infection Monitor for signs of pneumothorax Obtain chest X ray after insertion of catheter placement is verified

Nursing Responsibilities: Before: 1. Make sure that the solution, the patient, and the equipment are ready 2. Remove the solution from the refrigerator at least 1 hour before use to avoid pain, hypothermia, venous spasm, and venous constriction, which can result from delivery of a chilled solution 3. Check the solution against the physicians order for the correct patient name, expiration date, and formula components 4. Observe the container for cracks and the solution for cloudiness, turbidity, and particles. If present, return the solution to the pharmacy 5. When youre ready to administer the solution, explain procedure to the patient. 6. Check the name of the solution container against the name on the patients wristband. Confirm the patients identity using two patient identifiers according to facility policy. 7. Do medical handwashing. Then put on gloves and if specified by facility policy, a mask. Throughout the procedure, use strict sterile technique. During: 1. Instruct patient to do valsalva maneuver 2. If indicated, attach a time tape to the parenteral nutrition container for accurate measurement of fluid intake\ 3. Record the date and time you hung the fluid, and initial the parenteral nutrition solution container 4. Remove and discard your gloves 5. With the patient in the supine position, flush the catheter with normal saline solution, according to facility policy 6. Then put on gloves, and clean the catheter injection cap with an alcohol pad 7. Swab the catheter insertion site an iodine solution 8. Gradually increase the infusion rate once the catheter position is confirmed After: 1. Monitor vital signs 2. Check the infusion rate every 30 minutes to 1 hour 3. The area is checked for leakage, a kinked catheter and skin reactions such as inflammation, redness, swelling, tenderness 4. Dressing and tubing are labeled with the date, time and insertion 5. When changing for dressing the nurse and patient wear masks 6. Dressing change is documented, and the condition of the area and the patients reactions are reported

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Cebu Doctors University College of Nursing Mandaue City

TOTAL PARENTERAL NUTRITION DEFINITION: Total Parenteral Nutrition- administration of nutrients through a venous access device directly into the intravascular fluid

PURPOSES: to provide nutrients required for metabolic functioning of the body

MATERIALS: A lined tray containing: Sterile kidney basin TPN bag Alcohol swabs Hypoallergenic tape IV tubing Small hypotray 0.9% NaCl (Normal Saline Solution) Bandage scissors Waste receptacle

PROCEDURE 1. Read the patients chart. 2. Explain procedure to the patient. 3. Perform medical handwashing. 4. Prepare the materials. Place IV tubing in the kidney basin. 5. Prime the IV set using NSS, with the NSS flowing to the kidney basin. 6. Remove the NSS and connect the tube to the

RATIONALE To confirm physicians order To decrease patients anxiety To prevent spread of microorganisms To save time and energy; IV tubing must be kept clean To check for the tubings patency; to avoid spillage To prepare for administration

TPN bag 7. Place the primed IV tubing with the TPN bag, hypoallergenic tape, waste receptacle and alcohol swab on the hypotray 8. Bring the hypotray to the patients bedside 9. Prepare a strip of hypoallergenic tape. Hang the TPN bag on the IV stand. 10. Disinfect the Y-port of the mainline tubing using the alcohol swab. 11. Insert the IV tube of the TPN bag into the Yport. Secure the connection with hypoallergenic plaster. 12. Close off the mainline, then open the regulator of the TPN set. 13. Make the patient comfortable. Do after care. 14. Do documentation. To save time and energy

To save time and energy

To save time and energy

To prevent spread of microorganisms

So that TPN is administered intravenously; To avoid leakage

TPN can flow to the vein freely To promote comfort; To promote environmental sanitation Basis for any legal purposes in the future and for endorsement to other members of the health care team