total parenteral nutrition final output
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8/3/2019 Total Parenteral Nutrition Final Output
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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 Responsibilitiesof Total Parenteral Nutrition ---------------------------------------------------------- 7- 9
10) Procedure Guide with Rationale ------------------------------------------------------ 11
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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
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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 directlyinto the intravascular fluid to provide nutrients required for metabolicfunctioning of the body
It supplies all daily nutritional requirements. TPN can be used in the hospitalor at home. Because TPN solutions are concentrated and can causethrombosis of peripheral veins, a central venous catheter is usually required.
Generally, this treatment is prescribed for patient who can’t absorb nutrientsthrough the GI tract for more than 10 days.
II. PURPOSE, INDICATIONS, AND CONTRAINDICATIONS OF TOTALPARENTERAL 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 absentoral 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 patient-
because there is an interruption in its continuity and its absorptive capacityis impaired
Paralytic Ileus- food cannot move down to the stomach due to absence ofperistalsis in the esophagus
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Severe malnutrition- usual food intake is not sufficient to meet the needsof 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 doesn’t 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 venouscatheter (CVC) with the tip placed in the superior vena cava. It provides moreconcentrated nutrition in an equal volume of fluid.
- Is used to provide complete, long term nutritional support for patients whocannot or will not consume an adequate oral or enteral intake.
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- Possible indications include:a. severe malnutrition; weight loss of 10% or moreb. gastrointestinal abnormalities: obstruction, peritonitis, impaired
digestion and absorption, chronic vomiting, chronic diarrhea, severeacute pancreatitis
c. after surgery or trauma, especially that involving extensive burnsmultiple fractures or sepsis
d. Acute liver and renal failure when amino acid requirements are alterede. 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 insidethe 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
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- threaded under the skin to the subclavian vein, and the distal end of thecatheter is advanced into the superior vena cava 2-3 cm above the junctionwith 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 actualcomposition of the parenteral solutions depends on the site of infusion and the
patients fluid and nutrient requirements. Because there are standardconcentration of proteins, carbohydrate, and fat in standard volumes,individualization of parenteral solutions is somewhat limited
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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 acidsranging in initial concentration from 5% to 15% of the solution. The quantity ofamino acids provided depends on the patient’s estimated requirements andhepatic or renal failure.
Electrolytes, vitamins, trace elements- A quantity of electrolytes provided is based on the patient’s 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, exactparenteral 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 fibrinbuildup on the catheter tip. In general, medications should not be added toTPN solutions because of the potential incompatibilities of the medication andnutrients 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 thesystem
Patients should be encouraged for ambulation
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COMPLICATIONS POSSIBLE CAUSE SIGNS AND
SYMPTOMS
NURSING
INTERVENTION
Air embolism Opened cathetersytem
Disconnected IVtubings
Air on IV tubings
-Apprehension-Chest pain-Dyspnea-Hypotension-Rapid and weakpulse-Respiratorydistress-Loud churningsound overpericardium
Clamp thecatheter whennot in use
Place the clientin a left sidelying positionwith head lowerthan the feet
Administeroxygen
Instruct theclient in thevalsalva
maneuver fortubing and capchanges
Hyperglycemia Clients receivingsolution tooquickly
Not enoughinsulin
Infection
-Coma- Confusion-Diaphoresis-Elevated bloodglucose(≥200mg/dL) - Excessive thirst
-Fatigue-Kussmaul’sRespiration-Restlessness
Slowed infusionrate
Administration ofRegular Insulinas prescribed
Monitor bloodglucose levels
Use Aseptictechnique
Hypervolemia Excessive fluidadministration
Administration offluid rapidly
Renal dysfunction Heart failure Hepatic failure
-Bounding pulse-Crackles on lungs-Headache-Increase bloodpressure- Jugular veindistention
- Weight gain
Slow or stop IVinfusion
Restrict IV fluids
Administerdiuretics
Use dialysis in
extreme cases Monitor intake
and output
Weigh patientdaily
Administer fluidvia infusionpump
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Assess client’shistory for risk ofhypervolemia
Hypoglycemia Parenteral Nutritionabruptlydiscontinued
Too much insulinadministration
-Anxiety- Diaphoresis- Low bloodpressure- Weakness- Shakiness
Monitor bloodglucose
Administration ofintravenousdextrose
Gradualdecrease of PNprior todiscontinue
Infuse 10%dextrose at thesame rate of PN
Sepsis Poor aseptic
technique Cathetercontamination
Contamination ofsolution
-Chills
-Fever-Elevated WBC-Erythema ordischarges atinsertion site
Removal of
catheter Obtain blood
cultures
Administerantibiotic asprescribed
Use strict aseptictechnique
Monitor vitalsigns
Change site
dressing,solution andtubing asspecified byagency policy
Assess IV sitefor signs ofinfection
Pneumothorax Incorrectplacement ofcatheter
-Absence ofbreath sounds onaffected site
- Chest orshoulder pain- Suddenshortness ofbreath-Tachycardia-Cyanosis
Monitor for signsof pneumothorax
Obtain chest X
ray afterinsertion ofcatheterplacement isverified
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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 avoidpain, hypothermia, venous spasm, and venous constriction, which can resultfrom delivery of a chilled solution
3. Check the solution against the physician’s order for the correct patient name, expiration date, and formula components
4. Observe the container for cracks and the solution for cloudiness, turbidity, andparticles. If present, return the solution to the pharmacy
5. When you’re ready to administer the solution, explain procedure to the patient. 6. Check the name of the solution container against the name on the patient’s
wristband. Confirm the patient’s identity using two patient identifiers according tofacility policy.
7. Do medical handwashing. Then put on gloves and if specified by facility policy, amask. Throughout the procedure, use strict sterile technique.
During:
1. Instruct patient to do valsalva maneuver2. 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 container4. Remove and discard your gloves
5. With the patient in the supine position, flush the catheter with normal salinesolution, according to facility policy
6. Then put on gloves, and clean the catheter injection cap with an alcohol pad7. Swab the catheter insertion site an iodine solution8. 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 patient’s
reactions are reported
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Cebu Doctor’s University
College of Nursing
Mandaue City
TOTAL PARENTERAL NUTRITION
DEFINITION:
Total Parenteral Nutrition- administration of nutrients through a venous access devicedirectly 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 RATIONALE1. Read the patient’s chart.
2. Explain procedure to the patient.
3. Perform medical handwashing.
4. Prepare the materials. Place IV tubing in thekidney basin.
5. Prime the IV set using NSS, with the NSSflowing to the kidney basin.
6. Remove the NSS and connect the tube to the
To confirm physician’s order
To decrease patient’s anxiety
To prevent spread of microorganisms
To save time and energy; IV tubing must bekept clean
To check for the tubing’s patency; to avoidspillage
To prepare for administration
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TPN bag
7. Place the primed IV tubing with the TPN bag,hypoallergenic tape, waste receptacle andalcohol swab on the hypotray
8. Bring the hypotray to the patient’s bedside
9. Prepare a strip of hypoallergenic tape. Hangthe TPN bag on the IV stand.
10. Disinfect the Y-port of the mainline tubing usingthe alcohol swab.
11. Insert the IV tube of the TPN bag into the Y-port. Secure the connection with hypoallergenic
plaster.
12. Close off the mainline, then open the regulatorof 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 promoteenvironmental sanitation
Basis for any legal purposes in the future andfor endorsement to other members of thehealth care team
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