Parenteral Feeding

NDT Class Reporting ; Parenteral Feeding ; Nursing Students

1. Parenteral FEEDING

2. What is parenteral feeding? “Parenteral” means “alongside” or “outside” the GIT. It is the administration of drugs or nutrients by vein (intravenously)

3. --developed in the 1960’s to sustain the lives of individuals with severe GI impairment, may also be called, “Total Parenteral Nutrition” (TPN) “Central Venous Nutrition” (CVN) or, “Intravenous Hyperalimentation ” (IVH) –the term “ Hyperalimentation ”, the practice of hyperalimenting or overfeeding patients. --“Parenteral Nutrition” is the preferred term.

4. Parenteral Nutrition Indications : Pt. unable to meet nutritional needs either by an oral diet or through the use of enteral nutrition . Inability to digest and absorb nutrients, such as in massive bowel resection or short bowel syndrome; intractable vomiting, as in hyperemesis gravidarum ; GI tract obstruction; Impaired GI motility and Abdominal trauma, injury or infection.

5. Decision related to PN prescription : Pt . nutritional assessment The length of time the pt. will require nutrition support Pt. dx and current medical condition **Certification of medical necessity for PN must be established in order to ensure the patient’s care is financially feasible.

6. TYPES OF ACCESS

7. Peripheral Parenteral Nutrition (PPN) refers to the administration of large-volume, dilute solutions of nutrients into a vein in the arm or back of the hand and is used infrequently. PPN requires large volumes to meet nutritional needs and this makes this route unacceptable for any fluid-restricted patient. The high osmolality of PPN may cause small veins to collapse, and peripheral access is difficult to maintain for more than few days.

8. Venous access Feeding directly into the venous system and large-diameter veins allows for use of high-osmolality solutions of >900 mOsm /L. Short-Term Venous Access Central Venous Catheter (CVC ) -- or central line inserted percutaneously (through the skin) at the bedside while the pt. is under local anesthesia. These catheters are inserted into large veins such as subclavian , jugular or femoral veins in the center of the body . -- reside in the superior vena cava or inferior vena cava, in the case of femoral placement . -- available in single, double or triple lumen models . -- The lumen of the catheter refers to the interior tube through which the PN sol. passes.

9. --if a catheter with sufficient lumen is available, a pt. may receive meds, fluids, and nutrients at the same time. --catheters are usually changed every few days to help decrease the risk of infection inherent with an opening from the skin into a large, central vein.

10. Peripherally Inserted Central Catheter (PICC ) -- unlike the CVC which requires a bedside surgical procedure by an MD for insertion, the PICC can be inserted by specially trained nurses, this increases the availability of the procedure and decreases costs . -- PICC lines are inserted into the arm and threaded into the subclavian vein to the vena cava.

11. Long-Term Venous Access –tunneled under the skin Tunneled Catheters --( Hickmans , Broviac , Groshong ) most often enter the vein on the upper chest wall and exit the body near the xyphoid process, axilla, or abdominal wall . -- considered permanent . -- If TC contains more than one lumen, it can accommodate infusion of medication, fluids or blood products in addition to PN . -- useful for pt. who receive frequent doses of IV meds in addition to PN.

12. Implantable Ports –are similar to tunneled catheters in that they must be placed in the operating room by a surgeon . -- they are available with single and double ports, and are suitable for long term access . -- unlike TC, they lie completely under the skin, which decreases the risk of infection and makes them more acceptable to pt. with body image concerns, usually place below the clavicle on the chest wall. NURSING INTERVENTION: may be required to change needles used to gain access these ports.

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14. SOLUTIONS --PN formulas are mixed, or “compounded”; and automated compounder is used to combine all nutrients needed for a 24hr infusion into a single container. --PN is compounded from amino acid, dextrose, and lipid solutions. --solubility is an important consideration affecting both the maximum amount of nutrients and the minimum amount of the fluid that can be incorporated.

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16. PARENTERAL NUTRITION SUBSTRATES : Protein –included in PN in the form of individual amino acids in amt. consistent. Carbohydrate –serve as an energy source. Lipid –provides essential fatty acids and vit . K, as well as concentrated source of energy, and avenue to meet energy needs if the pt. is unable to tolerate higher carbohydrate load. Electrolytes Vitamins and Minerals

17. MONITORING and EVALUATION: Complications --Pt. receiving PN can suffer serious life-threatening consequences including death if PN is not appropriately monitored and managed. --monitoring is intense during the first few days, but it decreases as the pt. reaches goal feeding and become stable. --I and O monitoring is usually initiated. --Lab monitoring: testing for hyperglycemia (3-4x a day) and daily measurement of serum electrolytes, BUN and creatinine, magnesium, and phosphorus. At baseline, serum triglyceride are drawn to assess lipid tolerance (and if abnormal, the may be drawn weekly thereafter.) --Pt. receiving PN may experience electrolyte imbalance, underfeeding/overfeeding, hyperglycemia, and refeeding syndrome.

18. --CHOLESTASIS –condition in which bile accumulates in the gallbladder because it contracts infrequently without enteral stimulation. =for this reason, many pt. who require PN may receive trophic or “trickle” amounts of enteral feedings . S/ sx : Clay- colored or white stools. Dark urine. Inability to digest certain foods. Itching. Nausea or vomiting. Pain in the right upper part of the abdomen. Yellow skin or eyes. Pediatric Cholestasis Jaundice

19. --if PN is administered continuously for several weeks, transient elevation in liver enzyme may be noted. These usually disappear after PN is discontinued, but may respond to intermittent or cyclic feedings, adjustment in the lipid-dextrose ratio, and kcal reduction if overfeeding is operative. --Pt. receiving PN can develop serious unfections , (than those pt. receiving oral or enteral nutrition) : maybe caused by, improperly prepared PN sol. GI tract may become one route of uinfection , because nonfunctioning GI may become permeable to bacteria, and infection may result. Reference: Nutrition Therapy and Pathophysiology By Marcia Nelms (Author), Kathryn P. Sucher (Author), Karen Lacey (Author), Sara Long Roth (Author )

20. GROUP 8 Carpio , Rosemarie Fontanilla, Sharlene Navarro, Christine Ortega, Leira Tupil , Christian Submitted to: Mrs. Thelma de los Reyes