TOTAL PARENTERAL NUTRITION

1st Year MSc Nursing
Mdical- Surgical Nursing
MIMS CON

1. Prepared by Ms.Theertha P Krishna 1 st Year MSc Nursing MIMS CON

2. 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 .

3. 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.

4. 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

5. 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

6. Methods of parenteral nutrition

7. 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 minerals

8. 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

9. Methods of parenteral nutrition 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.

10. Methods of parenteral nutrition Fat emulsion (lipids): it is composed of triglycerides (10-20%) Eg : Phospholipids ,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 central catheter (PICC line ) or peripheral 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 Hypo allergic tape Face mask Sterile gloves

16. Bag of parenteral nutrition

17. 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

18. Inspect fluid for presence of creaming or any change in constitution Indicates fluid separation TPN solution should be clear with out clouding 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 -iodine 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

19. 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

20. Discontinuation of TPN 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.

21. Complications Sepsis Electrolyte imbalance Hyperglycemia Hypoglycemia Hypervolemia Hepatic dysfunction Hypercarbia