Total parentral nutrition

meeting nutritional needs

1. Total parenteral nutrition

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. 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

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 minserals

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. 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

10. 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

11. Central venous access devices

12. Volume control infuser

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

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

15. Bag of parenteral nutrition

16. luer -lock connections Sterile gloves Facemask Hypoallergic tape

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

18. 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

19. 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

20. 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, D ressing Nutrient solution composition

21. Laboratory Daily Finger-stick glucose Three times daily until stable Blood glucose, Na, K, Cl, HCO 3 , BUN Daily until stable and fully advanced, then twice weekly Serum creatinine, albumin, PO 4 , Ca, Mg, Hb/Hct, WBC Baseline, then twice weekly INR Baseline, then weekly Micronutrient tests As indicated

22.  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.

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

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

30. Thank you