meeting nutritional needs

2. Total parenteral nutrition

3. Definition
Intravenous administration of
varying combinations of hypertonic or
isotonic glucose, lipids, amino acid,
electrolytes, vitamins and trace
elements through a venous access
device (VAD) directly into the
intravascular fluid to provide nutrients
for patients who are unable to receive
adequate nutrition through
gastrointestinal tract.

4. Purposes
 To provide nutrients required for the
normal metabolism, tissue
maintenance, repair and energy
demands.
 To bypass the GI tract for patients who
are unable to take food orally.

5. Indications
 Patient who cannot tolerate enteral
nutrition because of
◦ Paralytic ileus
◦ Intestinal obstruction
◦ Acute pancreatitis
◦ Inflammatory bowel disease
◦ Gastro intestinal fistula
◦ Severe diarrhea
◦ Persistent vomiting
◦ Malabsorption

6. Indications
 Hyper metabolic states for which enteral
therapy either not possible or inadequate
◦ Severe burns
◦ NPO for more than 5 days
◦ Acute renal failure
◦ Multiple fractures
◦ Tumor in GI tract
 Patient at risk for malnutrition of
◦ Gross under weight
◦ Metastatic cancer

7. Methods of parenteral
nutrition

8. Methods of parenteral
nutrition
 Total nutrient admixture into a central
vein (TNA)
◦ It is indicated for patients requiring parenteral
feeding for seven or more days. Given
through a central vein often into the superior
venacava.
◦ Parenteral formula combines
 CHO in the form of a concentrated 20-70%
dextrose solution
 Proteins as amino acids
 Lipids in the form of an emulsion (10-20%)
including triglycerides, phospholipids and glycerol.
 Water
 Vitamins and minserals

9. Methods of parenteral
nutrition
 Peripheral parenteral nutrition
◦ This parenteral formula combines
carbohydrates a lesser concentrated
glucose solution with amino acids,
vitamins, minerals
◦ Given through peripheral vein
◦ Indicated for patients requiring nutrition
for fewer less than 7 days

10. Total parenteral nutrition
 This parenteral formula combines
glucose, amino acids, vitamins &
minerals
 Given through a central I V line
 If lipids are given intermittently mixed
with TPN
 Fat emulsion (lipids): it is composed of
triglycerides (10-20%)
◦ Eg : Phospolipids ,Glycerol and water
◦ May be given centrally or peripherally

11. Articles
 Central venous access devices: long
term VAD such as thick man, Broviac
or Groshung catheters or peripherally
inserted cenrtral catheter (PICC line)
or periheral IV access
 Volume control infuser
 Filters 0.22 micron for TPN (without fat
emulsion)3.2 micron filter for TNA or
fat emulsion

12. Central venous access devices

13.  Volume control infuser

14. Filters 0.22 micron for TPN / 3.2
micron filter for TNA

15. Articles
 Bag of parenteral nutrition
 Administration tubing with luer-lock
connections
 Hypoallergic tape
 Face mask
 Sterile gloves

16.  Bag of parenteral nutrition

17. luer-lock connections Sterile gloves
Facemask Hypoallergic tape

18. Procedure
Nursing action Rationale
Performing Nutritional assessment Provides baseline data
Check physician’s order Parenteral therapy must be ordered
by physician
Explain the procedure
Obtain informed consent
Collect needed equipment for the
procedure
Remove the bag of parenteral
nutrition from refrigerator at least
1hr before procedure (if
refrigerator)
Decrease the incidence of
hypothermia, pain &vaso spasm
Inspect fluid for presence of
creaming or any change in
constitution
Indicates fluid separation TPN
solution should be clear with out
clouding

19. Nursing action Rationale
Wash hands and done cap, mask,
gown and sterile gloves
Follow strict aseptic precautions
Using strict aseptic technique ,
attach tubing (with filter)to TNA bag
purge out air
Prevents chances of developing air
embolus
Close all clamps on new tubing
and insert tubing into volume
control infuses
Place the patient in supine
position and turn head away from
VAD insertion site
Supine position with head turned
one side opens the angle b/w
clavicle and first rib
Clean the insertion site with alcohol
and providone-odine solution
Assist physician while inserting
VAD
After insertion of VAD connect
tubing to hub of VAD using sterile
technique and make sure that the
connection is secured using luer-
lock connection

20. Nursing action Rationale
Open all clamps and regulate flow
through volume control infuser
Monitor administration hourly,
assessing for integrity of fluid and
administration system and patient
tolerance
Record the procedure

21. Clinical Data Monitored Daily
• General sense of well-being
• Strength as evidenced in getting out of bed, walking, resistance
exercise as
appropriate
•Vital signs including temperature, blood pressure, pulse, and
respiratory rate
•Fluid balance: weight at least several times weekly, fluid intake
(parenteral and enteral) vs. fluid output (urine, stool, gastric drainage,
wound, ostomy)
•Parenteral nutrition delivery equipment: tubing, pump, filter, catheter,
Dressing
•Nutrient solution composition

22. Laboratory Daily
Finger-stick glucose Three times daily until
stable
Blood glucose, Na, K,
Cl, HCO3, BUN
Daily until stable and
fully
advanced, then twice
weekly
Serum creatinine,
albumin, PO4, Ca,
Mg, Hb/Hct, WBC
Baseline, then twice
weekly
INR Baseline, then weekly
Micronutrient tests As indicated

23. Discontinuation of TPN should take place
when the patient can satisfy 75% of his or
her caloric and protein needs with oral
intake or enteral feeding.
To discontinue TPN, the infusion rate
should be halved for 1 hour, halved
again the next hour, and then
discontinued.
Tapering in this manner prevents
rebound hypoglycemia from
hyperinsulinemia.
It is not necessary to taper the rate if the
patient demonstrates glycemic stability.

24. Complications
 Sepsis
◦ Causes :
 High glucose content of fluid
 Venous access device contamination
◦ Interventions
 Monitor temperature , WBC count, and insertion
site for signs and symptoms of infection
 Maintain strict surgical asepsis when changing
dressing and tubing
 Consider deceasing glucose content of fluid
 Consider removal of venous access device with
replacement in alternate site
 If blood culture is positive consider antibiotic
therapy

25. Complications
 Electrolyte imbalance
◦ Causes :
 Iatrogenic
 Effects of underlying diseases, ie. Fistula,
diarrhea, vomiting
◦ Interventions
 Monitor for signs and symptoms of electrlyte
imbalances
 Treat underlying cause
 Change concentration of electrolytes in TNA as
necessary

26. Complications
 Hyperglycemia
◦ Causes :
 High glucose content of fluid
 Insufficient insulin secretion
◦ Interventions
 Monitor blood glucose frequently
 Decrease glucose content of fluid if possible
 Administer insulin

27. Complications
 Hypoglycemia
◦ Causes :
 Abrupt discontinuation of TNA
 Administration through a central vein
◦ Interventions
 After discontinuation of centrally administered
TNA, start 10% dextrose at the same rate

28. Complications
 Hypervolemia
◦ Causes :
 Iatrogenic
 Underlying heart diseases such as congestive
heart failure and renal failure
◦ Interventions
 Monitor intake & out put, daily weight,CVP,
breath sounds and peripheral edema
 Consider administering more concentrated TNA
solution

29. Complications
 Hepatic dysfunction
◦ Causes :
 High concentration of CHO, fats relative to
protein
◦ Interventions
 Monitor liver function test, triglyceride levels,
and presence of jaundice
 Consider alternation in formula

30. Complications
 Hypercarbia
◦ Causes :
 High carbohydrate content of fluid
◦ Interventions
 Consider changing formula to increase the
proportion of fat relative to carbohydrate

31. THANK YOU