TPN is a form of intravenous nutrition given through a central line into a large vein. It provides nutrients like carbohydrates, proteins, fats, electrolytes, vitamins and minerals. TPN must be given centrally because the solutions are hyperosmolar and could damage peripheral veins. Central lines include PICCs, ports and central venous catheters. Selection depends on factors like the patient's condition and the characteristics and duration of therapy. TPN administration requires strict aseptic technique and monitoring of glucose, weight and other lab values.

2. AdministeringTPNThrough A Central Line

3. TPN is a specialized form of nutritional support in which nutrients are given intravenously

4. TPN is infused into a large-diameter vein, such as the superior vena cavaTPN solutions are usually hyperosmolar, and thus you have to administer them into a large-diameter vein to prevent sclerosis of vein tissue

5. Examples of central venous access devices include central venous catheters, peripherally inserted central catheters (PICCs), and implanted infusion ports

6. Central Venous Access DevicesPICCImplanted Infusion PortCentral Venous Catheter

7. Selection of the ideal vascular access device depends on client factors, device characteristics, therapeutic issues, and duration of therapy

8. Client FactorsCondition of veins

9. Hypercoagulability state

10. Skin disorders

11. Known allergies to catheter materials

12. Altered dexterity

13. Developmental disabilities

14. Needle phobia

15. Body image impairment

16. Previous experience with vascular access deviceDevice CharacteristicsDesign of device

17. Low risk for infection (e.g., antibacterial coatings)Therapeutic IssuesNumber of lumens

18. Durability

19. Characteristics of solutions or emulsions

20. Dextrose concentration >10% requires central vein access

21. Solution with osmolarity >600 mOsm/L requires central vein accessIndications for TPN Nonfunctional GI TractExtended Bowel RestPreoperative

22. Nonfunctional GI Tract• Massive small bowel resection/GI surgery/massive GI bleed• Paralytic ileus• Intestinal obstruction• Short bowel syndrome• Trauma to abdomen, head, or neck• Severe malabsorption• Intolerance to enteral feeding• Chemotherapy, radiation therapy, bone marrow transplantation

23. Extended Bowel Rest• Enterocutaneous fistula• Inflammatory bowel disease exacerbation• Severe diarrhea• Moderate to severe pancreatitis

24. Preoperative TPN• Preoperative bowel rest• Treatment for comorbid severe malnutrition in patients with nonfunctional GI tracts• Severely catabolic patients when GI tract nonusable for more than 4 to 5 days

25. Parenteral nutrition includes mixtures of carbohydrates (10% to 70% dextrose solution), amino acids (protein/nitrogen), fats (fatty acids), electrolytes, vitamins, and trace elements (e.g., zinc, copper, and chromium)

26. The TPN and mixture that is used depends on the clients needs This determination is made by the physician and nutritional support teamA doctors order is required to administer TPN

27. AssessmentAssess indications of and risks for protein-calorie malnutrition

28. Inspect condition of central vein access site

29. Assess vital signs, auscultate patient's lung sounds, and measure weight

30. Consult with physician and dietitian on calculation of calorie, protein, and fluid requirements for patient

31. Verify physician's order for nutrients, minerals, vitamins, trace elements, electrolytes, and added medications as well as flow rate. Check for compatibility of added medicationsPlanningExpected outcomes following completion of procedure: A. Patient's ideal weight gain is usually between 1 and 3 lb. per weekB. Serum glucose levels are less than 150 mg/dL or maintained between 80 and 110 mg/dL. Check physician's order for desired glucose range C. Central venous access device is patent, and site is free of pain, swelling, redness, or inflammation D. Patient is afebrile2. Explain purposes of TPN3. If TPN solution is refrigerated, remove from refrigeration 1 hour before infusion

32. ImplementationStrict aseptic technique is requiredPerform hand hygiene and apply clean gloves

33. Compare label of TPN bag with medication administration record (MAR) or computer printout; check for correct additives and solution expiration date. Also check patient's nameInspect TPN solution for particulate matter or, if it is a 3:1 solution, inspect emulsion for a cream layer or separation of fat into a layer. If there is a thin layer of aggregated fat droplets about 1 to 2 cm in thickness, invert bag back and forth gently to mix

34. Identify patient. Use at least two patient identifiers

35. Attach appropriate filter to IV tubing.Prime tubing with TPN solution, making sure no air bubbles remain, and turn off flow with roller clamp. Connect end of tubing to appropriate port of central catheter, and label port. Open roller clamp to rate that maintains patency of line

36. Place IV tubing into IV infusion pump, open roller clamp completely, and regulate flow rate on pump as ordered

37. The port being used for TPN should be dedicated to TPN administration ONLY.Infuse all IV medications or blood through an alternative IV line. Do not obtain blood samples or central venous pressure readings through same lumen or port used for TPN

38. Do not interrupt TPN infusion (e.g., during showers, transport to procedure, blood transfusion), and be sure that rate does not exceed ordered rate

39. Change infusing tubing and filter using strict aseptic technique. Change IV administration sets for TPN every 72 hours, for 3:1 and fat emulsions every 24 hours, and immediately upon suspected contamination

40. Discard used supplies, and perform hand hygiene

41. EvaluationMonitor flow rate routinely, at least hourlyMonitor fluid intake every 8 hoursObtain daily weights or weights as orderedAssess for fluid retention; palpate skin of extremities, auscultate lung sounds

42. Monitor patient's glucose level every 6 hours or as ordered, and monitor other laboratory parameters daily or as orderedInspect central venous access siteMonitor for fever, elevated white blood cell count and malaise

43. DocumentationRecord condition of central venous access device, rate and type of infusion, catheter lumen used for infusion, intake and output (I&O) every 8 hours, blood glucose levels, vital signs, and weights

44. The Endhttp://findarticles.com/p/articles/mi_qa3689/is_200111/ai_n8997797/“Administering Total Parental Nutrition”Edwina A McConnellNovember 2001