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Parenteral
Nutrition
Ahmad Thanin
INTRODUCTION
It is essential that all patients receive adequate food and drink
appropriate to their needs and while many will be able to manage
independently, some patients will need assistance.
All patients admitted to care settings should have nutritional
screening performed within the first 24 hours using a validated
tool such as the Malnutrition Universal Screening Tool (MUST).
This is essential as it helps to ascertain whether a patient needs
help and informs their nutritional plan of car
Assisting patients with eating and drinking to
prevent malnutrition
• Vitamins
• Protein,
• Minerals and Energy and this will have an adverse effect on the body.
Patients with malnutrition will have a deficit of
• Poor Wound Healing,
• Skin Breakdown,
• increased risk of sepsis and hospital-acquired infections, such as Chest and
Urinary Tract Infections
Complications associated with malnutrition include
‘Malnutrition Universal Screening Tool’
‘MUST’ is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition
(undernutrition), or obese. It also includes management guidelines which can be used to develop a care
plan.
It is for use in hospitals, community and other care settings and can be used by all care workers.
This guide contains:
•A flow chart showing the 5 steps to use for screening and management
•BMI chart
•Weight loss tables
•Alternative measurements when BMI cannot be obtained by measuring weight and height.
The 5 ‘MUST’ Steps
Step 1
Measure height
and weight to get
a BMI score using
chart provided. If
unable to obtain
height and
weight, use the
alternative
procedures
shown in this
guide.
Step 2
Note percentage
unplanned
weight loss and
score using
tables provided.
Step 3
Establish acute
disease effect
and score.
Step 4
Add scores from
steps 1, 2 and 3
together to
obtain overall
risk of
malnutrition.
Step 5
Use management
guidelines and/or
local policy to
develop care
plan.
Medical conditions that may need assistance
with eating and drinking
Swallowing complications:
• may be associated with conditions such as stroke, Parkinson’s disease, motor neurone disease and multiple sclerosis
Cancer:
• some patients with cancer have increased energy requirements but they may feel unable to eat due to nausea,
vomiting, pain or gastrointestinal obstruction.
• Patients prescribed chemotherapy often experience a change in taste which can affect their appetite
Surgery:
• people who have had surgery require extra energy to help heal wounds, but they can sometimes find eating difficult
due to pain and nausea
Other:
• people with severe learning disabilities, visual impairment or dementia, and older people who have an acute delirium,
need specialist support to ensure they are adequately nourished
Clinical
Nutrition can
be taken in
three ways:
DEPENDENT PATIENT FEEDING
The dependent patient who does not require
enteral or parenteral feeding may still need help
with eating.
Many conditions, including cancer, cerebrovascular
accident (CVA) and multiple sclerosis, can cause
feeding difficulties.
PHASES OF SWALLOWING
The oral phase
• the food is chewed and mixed with saliva to make a bolus.
The pharyngeal phase
• the swallowing reflex is triggered when the bolus touches the back of the patient’s oral cavity.
• The epiglottis is lowered, and the larynx moves under the base of the tongue closing the
airway.
• The presence of the bolus in the pharynx stimulates a wave of peristalsis.
The esophageal phase
• the bolus is moved through the esophagus to the stomach by peristalsis.
DEPENDENT PATIENT FEEDING
BEFORE FEEDING
The dependent patient’s ability to eat must be fully assessed.
Aspiration of food or drink is a particular risk.
•Aspiration can cause a blockage in the bronchus and lead to aspiration pneumonia.
If the patient has dysphagia, a swallowing assessment should be carried out by a competent practitioner
using an appropriate assessment tool.
Information can also be obtained through a barium swallow test.
The patient should be placed in an upright position with his or her head tilted slightly forward to aid
swallowing.
DEPENDENT PATIENT FEEDING
DURING FEEDING
Keep the patient upright.
• The nurse who is helping the patient to eat should sit in the patient’s line of vision and provide prompting, encouragement and direction, both verbally and non-verbally, when
appropriate.
Avoid hovering with the next spoonful of food as this may cause a patient to hurry and worsen any swallowing difficulties.
• Patience, attention and time are essential.
Allow at least 5-10 seconds for each bite or sip.
Allow the patient to take a drink between each mouthful of food to ease the process of eating.
The patient should be observed for pouching (the unconscious collecting of food on one side of the mouth), particularly after a stroke.
• When the patient has a hemiplegia, the head should be tilted slightly towards the stronger side to avoid pouching.
The patient should remain upright for 15 minutes after eating.
Ensure that suction apparatus at the bedside has been checked.
Report and document any instances of choking.
DEPENDENT PATIENT FEEDING
Parenteral Nutrition
Parenteral nutrition or parenteral feeding is simply defined as the intravenous
administration of nutrients, maybe as a supplement or as the sole source of
nutrition.
Total parenteral nutrition or TPN is a wonderful advance in medical nutrition
therapy because it’s now possible to feed people who were once un feedable.
Unlike the normal enteral nutrition in which nutrients are orally consumed and
fed into the digestive system, in parenteral nutrition, nutrients are absorbed
directly into the bloodstream.
What are the side effects of parenteral
nutrition?
The most common side effects of parenteral nutrition are mouth sores, poor night vision,
and skin changes.
Other less common side effects include:
• Changes in heartbeat,
• convulsions or seizures
• difficulty breathing
• fatigue
• fever or chills
• stomach pain, vomiting
• swelling of your hands, feet, or legs
• tingling in your hands or feet
Nursing Care of
Patients on PN
The Ward Nursing
Staff will Perform
the Following Tasks
on PN patients:
Prior to PN administration:
• The patient's identity is verified.
• The PN label is reviewed for accuracy against the
physician’s order.
• The PN label is reviewed for expiration dates.
• The PN bag is visually inspected for precipitates or
other visual changes.
Do not hang if there is not an identity match.
Daily weights (before starting PN and daily
thereafter).
The Ward Nursing Staff will Perform the
Following Tasks on PN patients:
Minimum 8 hourly temperature reading and blood pressure.
observe for clinical evidence of infection, and general well being.
Notify the physician for any of the following:
• Critical laboratory values
• Signs and symptoms of venous access infection or infiltration
• Signs and symptoms of acute lipid intolerance: fever, chills, vomiting, urticaria, chest/back pain
with onset during infusion
• Signs and symptoms of rapid infusion reaction to lipids: palpitations, tachypnea, wheezing,
cyanosis, nausea, pain at injection site, headache, oily taste in mouth
• Signs and symptoms of fluid volume overload or dehydration.
The Ward Nursing Staff will Perform the
Following Tasks on PN patients:
Maintain accurate fluid balance flow chart and summary.
Glucose monitoring 6 hourly for the first 24 hours, then daily when stable (or
more frequently in the neonatal population) and as clinically indicated.
Daily assessment for venous access site infection or leakage, unless a neonate
or up to age 6, or suffering from some impairment and unable to reliably
express themselves -then Q shift - or more frequently.
The Ward Nursing Staff will Perform the
Following Tasks on PN patients:
Bag change will be at 18:00 hours each day.
PN solution will be sent from pharmacy in amber light-resistant covering that should be zipped to the tubing
connection to minimize any light.
The UV light protective covering should be always maintained.
Bags and tubing should not be in direct sun light.
An electronic infusion pump is required to infuse PN and lipid emulsion.
The PN infusion and lipid must be completed within 24 hours of initiating the infusion. Any remaining contents after
24 hours are discarded.
The Ward Nursing Staff will Perform the Following
Tasks on PN patients:
Administration sets, extension tubing and in-line filter (for PN and lipid infusions) are changed every 24 hours.
Use only low sorbing (non-DEHP [diethyl hexyl phthalate]) tubing for PN and lipid emulsion administration.
An occluded filter should never be removed to allow a PN formulation (including Clinimix) to infuse freely.
When administering lipids as piggyback, use an in-line Y-set (pediatrics or adults) or another secure needleless connector.
Attach a sterile lure locking connector cap when the line is not in use.
When PN administration is temporarily held, a sterile luer locking connector cap should be attached to the PN solution
tubing; the same PN solution can be reconnected to complete the infusion within 24 hours from initiation of the bag
The Ward Nursing Staff will Perform the
Following Tasks on PN patients:
Avoid administration of medications via PN line. In patient populations
with limited venous access, compatible drugs may be infused with the
PN only under the following conditions:
• There is documented compatibility of the medication when infused with the PN and / or
lipid
• EXCEPTION: In pediatrics and in patients with limited venous access, incompatible drugs
may be given via the PN line when:
• PN infusion is held
• The line is flushed before and after the drug
• The patient is monitored for fluctuations in blood glucose when PN is interrupted for
greater than one ho
The Ward Nursing Staff will Perform the
Following Tasks on PN patients:
The flow rate can only be changed when an order is written by a physician.
Avoid interruption of the infusion unless necessary.
Documentation:
• Bag and prescription checked to assure accuracy prior to PN initiation.
• Record inputs and outputs on flow sheet. Sign for on Medical Administration Record (MAR).
• Dressing change.
Care and Management of the PN catheter Insertion Site
Do not use topical antibiotic ointment or creams on insertion site.
The dedicated PN port should not be used for collecting specimens (except in
patients with no other possible access).
The site may be dressed with either a transparent or gauze dressing, which
must completely and securely cover the site.
All dressings must be checked for integrity every shift by nursing and changed
if no longer providing a secure, protective covering for the site.
Care and Management of the PN catheter Insertion Site
• Gauze dressings must be changed every 72 hours or if the integrity of the dressing becomes compromised
(dressing loose, soiled or wet), for central and peripheral catheters
• Transparent dressings may remain in place up to 7 days.
• Dressings should be changed more frequently if an appropriate protective covering is not maintained.
• Dressings should be changed weekly for PICCs.
Frequency of dressing change:
• oropharyngeal for internal jugular access.
• urine and feces for femoral access.
Care must be taken to prevent contamination of the site with infected secretions:
Site Inspection and Documentation
Daily (or more frequent in pediatrics) inspection
and palpation of the site must be performed and
documented by Nursing. Aseptic technique is used.
The site should be assessed for the presence of
erythema, induration and purulent drainage and
so noted in the progress notes by Nursing.
Suspected Infection
Lines should be removed, and the site changed if the patient
appears to be septic and no other source is evident.
If sepsis is suspected or the central line is removed due to
evidence of local infection (induration, purulent drainage), the
distal 2 inches of the catheter should be aseptically cut and sent
to microbiology for semi-quantitative analysis.

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Parenteral Nutrition

  • 2. INTRODUCTION It is essential that all patients receive adequate food and drink appropriate to their needs and while many will be able to manage independently, some patients will need assistance. All patients admitted to care settings should have nutritional screening performed within the first 24 hours using a validated tool such as the Malnutrition Universal Screening Tool (MUST). This is essential as it helps to ascertain whether a patient needs help and informs their nutritional plan of car
  • 3. Assisting patients with eating and drinking to prevent malnutrition • Vitamins • Protein, • Minerals and Energy and this will have an adverse effect on the body. Patients with malnutrition will have a deficit of • Poor Wound Healing, • Skin Breakdown, • increased risk of sepsis and hospital-acquired infections, such as Chest and Urinary Tract Infections Complications associated with malnutrition include
  • 4. ‘Malnutrition Universal Screening Tool’ ‘MUST’ is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition (undernutrition), or obese. It also includes management guidelines which can be used to develop a care plan. It is for use in hospitals, community and other care settings and can be used by all care workers. This guide contains: •A flow chart showing the 5 steps to use for screening and management •BMI chart •Weight loss tables •Alternative measurements when BMI cannot be obtained by measuring weight and height.
  • 5. The 5 ‘MUST’ Steps Step 1 Measure height and weight to get a BMI score using chart provided. If unable to obtain height and weight, use the alternative procedures shown in this guide. Step 2 Note percentage unplanned weight loss and score using tables provided. Step 3 Establish acute disease effect and score. Step 4 Add scores from steps 1, 2 and 3 together to obtain overall risk of malnutrition. Step 5 Use management guidelines and/or local policy to develop care plan.
  • 6. Medical conditions that may need assistance with eating and drinking Swallowing complications: • may be associated with conditions such as stroke, Parkinson’s disease, motor neurone disease and multiple sclerosis Cancer: • some patients with cancer have increased energy requirements but they may feel unable to eat due to nausea, vomiting, pain or gastrointestinal obstruction. • Patients prescribed chemotherapy often experience a change in taste which can affect their appetite Surgery: • people who have had surgery require extra energy to help heal wounds, but they can sometimes find eating difficult due to pain and nausea Other: • people with severe learning disabilities, visual impairment or dementia, and older people who have an acute delirium, need specialist support to ensure they are adequately nourished
  • 8. DEPENDENT PATIENT FEEDING The dependent patient who does not require enteral or parenteral feeding may still need help with eating. Many conditions, including cancer, cerebrovascular accident (CVA) and multiple sclerosis, can cause feeding difficulties.
  • 9. PHASES OF SWALLOWING The oral phase • the food is chewed and mixed with saliva to make a bolus. The pharyngeal phase • the swallowing reflex is triggered when the bolus touches the back of the patient’s oral cavity. • The epiglottis is lowered, and the larynx moves under the base of the tongue closing the airway. • The presence of the bolus in the pharynx stimulates a wave of peristalsis. The esophageal phase • the bolus is moved through the esophagus to the stomach by peristalsis. DEPENDENT PATIENT FEEDING
  • 10. BEFORE FEEDING The dependent patient’s ability to eat must be fully assessed. Aspiration of food or drink is a particular risk. •Aspiration can cause a blockage in the bronchus and lead to aspiration pneumonia. If the patient has dysphagia, a swallowing assessment should be carried out by a competent practitioner using an appropriate assessment tool. Information can also be obtained through a barium swallow test. The patient should be placed in an upright position with his or her head tilted slightly forward to aid swallowing. DEPENDENT PATIENT FEEDING
  • 11. DURING FEEDING Keep the patient upright. • The nurse who is helping the patient to eat should sit in the patient’s line of vision and provide prompting, encouragement and direction, both verbally and non-verbally, when appropriate. Avoid hovering with the next spoonful of food as this may cause a patient to hurry and worsen any swallowing difficulties. • Patience, attention and time are essential. Allow at least 5-10 seconds for each bite or sip. Allow the patient to take a drink between each mouthful of food to ease the process of eating. The patient should be observed for pouching (the unconscious collecting of food on one side of the mouth), particularly after a stroke. • When the patient has a hemiplegia, the head should be tilted slightly towards the stronger side to avoid pouching. The patient should remain upright for 15 minutes after eating. Ensure that suction apparatus at the bedside has been checked. Report and document any instances of choking. DEPENDENT PATIENT FEEDING
  • 12. Parenteral Nutrition Parenteral nutrition or parenteral feeding is simply defined as the intravenous administration of nutrients, maybe as a supplement or as the sole source of nutrition. Total parenteral nutrition or TPN is a wonderful advance in medical nutrition therapy because it’s now possible to feed people who were once un feedable. Unlike the normal enteral nutrition in which nutrients are orally consumed and fed into the digestive system, in parenteral nutrition, nutrients are absorbed directly into the bloodstream.
  • 13.
  • 14. What are the side effects of parenteral nutrition? The most common side effects of parenteral nutrition are mouth sores, poor night vision, and skin changes. Other less common side effects include: • Changes in heartbeat, • convulsions or seizures • difficulty breathing • fatigue • fever or chills • stomach pain, vomiting • swelling of your hands, feet, or legs • tingling in your hands or feet
  • 15. Nursing Care of Patients on PN The Ward Nursing Staff will Perform the Following Tasks on PN patients: Prior to PN administration: • The patient's identity is verified. • The PN label is reviewed for accuracy against the physician’s order. • The PN label is reviewed for expiration dates. • The PN bag is visually inspected for precipitates or other visual changes. Do not hang if there is not an identity match. Daily weights (before starting PN and daily thereafter).
  • 16. The Ward Nursing Staff will Perform the Following Tasks on PN patients: Minimum 8 hourly temperature reading and blood pressure. observe for clinical evidence of infection, and general well being. Notify the physician for any of the following: • Critical laboratory values • Signs and symptoms of venous access infection or infiltration • Signs and symptoms of acute lipid intolerance: fever, chills, vomiting, urticaria, chest/back pain with onset during infusion • Signs and symptoms of rapid infusion reaction to lipids: palpitations, tachypnea, wheezing, cyanosis, nausea, pain at injection site, headache, oily taste in mouth • Signs and symptoms of fluid volume overload or dehydration.
  • 17. The Ward Nursing Staff will Perform the Following Tasks on PN patients: Maintain accurate fluid balance flow chart and summary. Glucose monitoring 6 hourly for the first 24 hours, then daily when stable (or more frequently in the neonatal population) and as clinically indicated. Daily assessment for venous access site infection or leakage, unless a neonate or up to age 6, or suffering from some impairment and unable to reliably express themselves -then Q shift - or more frequently.
  • 18. The Ward Nursing Staff will Perform the Following Tasks on PN patients: Bag change will be at 18:00 hours each day. PN solution will be sent from pharmacy in amber light-resistant covering that should be zipped to the tubing connection to minimize any light. The UV light protective covering should be always maintained. Bags and tubing should not be in direct sun light. An electronic infusion pump is required to infuse PN and lipid emulsion. The PN infusion and lipid must be completed within 24 hours of initiating the infusion. Any remaining contents after 24 hours are discarded.
  • 19. The Ward Nursing Staff will Perform the Following Tasks on PN patients: Administration sets, extension tubing and in-line filter (for PN and lipid infusions) are changed every 24 hours. Use only low sorbing (non-DEHP [diethyl hexyl phthalate]) tubing for PN and lipid emulsion administration. An occluded filter should never be removed to allow a PN formulation (including Clinimix) to infuse freely. When administering lipids as piggyback, use an in-line Y-set (pediatrics or adults) or another secure needleless connector. Attach a sterile lure locking connector cap when the line is not in use. When PN administration is temporarily held, a sterile luer locking connector cap should be attached to the PN solution tubing; the same PN solution can be reconnected to complete the infusion within 24 hours from initiation of the bag
  • 20. The Ward Nursing Staff will Perform the Following Tasks on PN patients: Avoid administration of medications via PN line. In patient populations with limited venous access, compatible drugs may be infused with the PN only under the following conditions: • There is documented compatibility of the medication when infused with the PN and / or lipid • EXCEPTION: In pediatrics and in patients with limited venous access, incompatible drugs may be given via the PN line when: • PN infusion is held • The line is flushed before and after the drug • The patient is monitored for fluctuations in blood glucose when PN is interrupted for greater than one ho
  • 21. The Ward Nursing Staff will Perform the Following Tasks on PN patients: The flow rate can only be changed when an order is written by a physician. Avoid interruption of the infusion unless necessary. Documentation: • Bag and prescription checked to assure accuracy prior to PN initiation. • Record inputs and outputs on flow sheet. Sign for on Medical Administration Record (MAR). • Dressing change.
  • 22. Care and Management of the PN catheter Insertion Site Do not use topical antibiotic ointment or creams on insertion site. The dedicated PN port should not be used for collecting specimens (except in patients with no other possible access). The site may be dressed with either a transparent or gauze dressing, which must completely and securely cover the site. All dressings must be checked for integrity every shift by nursing and changed if no longer providing a secure, protective covering for the site.
  • 23. Care and Management of the PN catheter Insertion Site • Gauze dressings must be changed every 72 hours or if the integrity of the dressing becomes compromised (dressing loose, soiled or wet), for central and peripheral catheters • Transparent dressings may remain in place up to 7 days. • Dressings should be changed more frequently if an appropriate protective covering is not maintained. • Dressings should be changed weekly for PICCs. Frequency of dressing change: • oropharyngeal for internal jugular access. • urine and feces for femoral access. Care must be taken to prevent contamination of the site with infected secretions:
  • 24. Site Inspection and Documentation Daily (or more frequent in pediatrics) inspection and palpation of the site must be performed and documented by Nursing. Aseptic technique is used. The site should be assessed for the presence of erythema, induration and purulent drainage and so noted in the progress notes by Nursing.
  • 25. Suspected Infection Lines should be removed, and the site changed if the patient appears to be septic and no other source is evident. If sepsis is suspected or the central line is removed due to evidence of local infection (induration, purulent drainage), the distal 2 inches of the catheter should be aseptically cut and sent to microbiology for semi-quantitative analysis.