focus on parenteral nutrition (relates to chapter 40, “nursing management: nutritional...

Focus on Focus on Parenteral NutritionParenteral Nutrition

(Relates to Chapter 40, (Relates to Chapter 40, “Nursing Management: Nutritional “Nursing Management: Nutritional

Problems,” Problems,” in the textbook)in the textbook)

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

2

Parenteral NutritionParenteral Nutrition

•Parenteral nutrition (PN)Parenteral nutrition (PN) Administration of nutrients Administration of nutrients

by route other than GI tract by route other than GI tract (i.e., bloodstream)(i.e., bloodstream)

Used whenUsed when•GI tract cannot be used for GI tract cannot be used for ingestion, digestion, and ingestion, digestion, and absorption of essential absorption of essential nutrientsnutrients


3

Parenteral Nutrition (PN)Parenteral Nutrition (PN)

• Goal: Meet nutritional needs Goal: Meet nutritional needs and allow growth of new body and allow growth of new body tissuetissue

• Regular IV solutions Regular IV solutions Dextrose in water or dextrose in Dextrose in water or dextrose in

lactated Ringer’slactated Ringer’s• No proteinNo protein• 170 calories per liter170 calories per liter


4


• Normal adult requires Normal adult requires minimum 1200 to 1500 minimum 1200 to 1500 calories/day.calories/day.

• Regular dextrose solutions Regular dextrose solutions could exceed capacity of could exceed capacity of cardiovascular system.cardiovascular system.

• Injury, surgery, burns, Injury, surgery, burns, malnourished—increase malnourished—increase nutritionalnutritional needs needs


5

Common Indications for Common Indications for PNPN•Chronic or intractable Chronic or intractable

diarrhea and vomitingdiarrhea and vomiting•Complicated surgery or Complicated surgery or

traumatrauma•Gastrointestinal obstructionGastrointestinal obstruction•Gastrointestinal tract Gastrointestinal tract

anomalies and fistulaeanomalies and fistulae•MalnutritionMalnutrition


6


•CompositionComposition Base solutions contain Base solutions contain

dextrose and amino acids.dextrose and amino acids. Pharmacy adds prescribed Pharmacy adds prescribed

electrolytes, vitamins, and electrolytes, vitamins, and trace elements.trace elements.

Three-in-one contains fat Three-in-one contains fat emulsion, dextrose, and amino emulsion, dextrose, and amino acids.acids.


7


•Calories supplied primarily Calories supplied primarily from carbohydrates from carbohydrates (dextrose) and fat emulsion (dextrose) and fat emulsion 1 g dextrose provide 3.4 1 g dextrose provide 3.4

calories.calories. Fat emulsion has 1 Fat emulsion has 1

calorie/mL for 10% or 2 calorie/mL for 10% or 2 calories/mL for 20% solution.calories/mL for 20% solution.


8


• 25 to 30 calories/kg/day25 to 30 calories/kg/day Fats not to exceed 2.5 Fats not to exceed 2.5

g/kg/dayg/kg/day


9


•Nausea, vomiting, and Nausea, vomiting, and elevated temperature may elevated temperature may occur if lipids are infused occur if lipids are infused too rapidly.too rapidly.

•Protein provided 1 to 1.5 Protein provided 1 to 1.5 g/kg/day, depending on g/kg/day, depending on needsneeds


10


• Exact quantities of Exact quantities of electrolytes needed are electrolytes needed are determined by blood determined by blood testing.testing.

•Vitamin K may be ordered Vitamin K may be ordered separately, as it is not separately, as it is not included in the preparation. included in the preparation.


11

Parenteral NutritionParenteral Nutrition•Methods of administrationMethods of administration

Central or peripheral useCentral or peripheral use Central parenteral nutrition Central parenteral nutrition

through catheter whose tip through catheter whose tip lies in superior vena cavalies in superior vena cava•Subclavian or jugular veinSubclavian or jugular vein•Peripherally inserted central Peripherally inserted central catheters (PICCs)catheters (PICCs)

•Long-term parenteral supportLong-term parenteral support


12


Peripheral parenteral nutritionPeripheral parenteral nutrition•Through peripherally inserted Through peripherally inserted catheter or vascular access devicecatheter or vascular access device

•Short-term supportShort-term support•Protein and caloric requirements not Protein and caloric requirements not highhigh

•Risk of central catheter too greatRisk of central catheter too great•Supplement inadequate oral intakeSupplement inadequate oral intake


13


•Central and peripheral Central and peripheral nutrition differ in tonicitynutrition differ in tonicity Central solutions are hypertonic.Central solutions are hypertonic.

•Large central vein can handle high Large central vein can handle high glucose content ranging from 20% glucose content ranging from 20% to 50%.to 50%.

Peripheral solutions are Peripheral solutions are hypertonic.hypertonic.•Peripheral vein can handle glucose Peripheral vein can handle glucose up to 20%.up to 20%.


14

Parenteral NutritionParenteral Nutrition•PN solutions are prepared PN solutions are prepared

by pharmacist or trained by pharmacist or trained technician under strict technician under strict aseptic techniques.aseptic techniques. Nothing is added to solution Nothing is added to solution

after it is prepared.after it is prepared. Solutions are good for 24 Solutions are good for 24

hours. hours.


15

Parenteral NutritionParenteral Nutrition•PN solutions are prepared by PN solutions are prepared by

pharmacist or trained technician pharmacist or trained technician under strict aseptic techniques.under strict aseptic techniques. Must be refrigerated until 30 Must be refrigerated until 30

minutes before useminutes before use Must be labeled with nutrient Must be labeled with nutrient

content, all additives, time mixed, content, all additives, time mixed, and date and time of expirationand date and time of expiration


16

Parenteral NutritionParenteral Nutrition•Catheter placement under Catheter placement under

sterile conditions by physician sterile conditions by physician or advanced practice nurse or advanced practice nurse Isotonic IV solution infused until Isotonic IV solution infused until

x-ray confirms correct placementx-ray confirms correct placement Site covered with sterile Site covered with sterile

dressingdressing Date marked on dressingDate marked on dressing


17

Parenteral Nutrition Parenteral Nutrition •Complications of PNComplications of PN

InfectionInfection•Must have filter Must have filter •With lipids: Tubing, filter With lipids: Tubing, filter change every 24 hourschange every 24 hours

•With amino acids, dextrose: With amino acids, dextrose: Filter, tubing change every 72 Filter, tubing change every 72 hourshours

•Fungus, Gram +/- bacteriaFungus, Gram +/- bacteria


18


•Complications of PN Complications of PN (cont’d)(cont’d) Metabolic problemsMetabolic problems

•Hyperglycemia, hypoglycemia, Hyperglycemia, hypoglycemia, prerenal azotemia, fatty acid prerenal azotemia, fatty acid deficiency, electrolyte deficiency, electrolyte disturbances, hyperlipidemia, disturbances, hyperlipidemia, mineral deficienciesmineral deficiencies


19


•Complications of PN Complications of PN (cont’d)(cont’d) Mechanical problemsMechanical problems

• Insertion problemsInsertion problems•Dislodgement, thrombosis of Dislodgement, thrombosis of great vein, phlebitisgreat vein, phlebitis


20

Parenteral NutritionParenteral NutritionNursing ManagementNursing Management

•Vital signs every 4 to 8 hoursVital signs every 4 to 8 hours•Daily weightsDaily weights•Blood glucoseBlood glucose

Check initially every 4 to 6 Check initially every 4 to 6 hours.hours.

• ElectrolytesElectrolytes•BUNBUN•CBCCBC


21


•Hepatic enzymesHepatic enzymes•Dressing changesDressing changes

Site observation keySite observation key•Refeeding syndromeRefeeding syndrome• Infusion pump must be Infusion pump must be

used.used. Need to periodically check Need to periodically check

volume infusedvolume infused


22


•Before administering, Before administering, check label and ingredients check label and ingredients against order.against order.

• Examine bag for signs of Examine bag for signs of contamination.contamination.


23


•Watch for infection and Watch for infection and septicemia.septicemia. Local manifestationsLocal manifestations

•ErythemaErythema•TendernessTenderness•Exudate at catheter insertion siteExudate at catheter insertion site

SystemicSystemic•Fever, chillsFever, chills•Nausea/vomitingNausea/vomiting•MalaiseMalaise


24


•Blood and catheter cultures Blood and catheter cultures if infection suspectedif infection suspected

•X-ray: To check changes in X-ray: To check changes in pulmonary statuspulmonary status

•After PN therapy, daily After PN therapy, daily dressing changes until dressing changes until healsheals


25


•Home nutrition supportHome nutrition support EducationEducation

•Catheter careCatheter care•Side effectsSide effects


26


•Assistance with Assistance with reimbursement procedures reimbursement procedures

•Resources and peer Resources and peer support support


27

The health care provider orders a 10% fat The health care provider orders a 10% fat emulsion solution to be administered to a emulsion solution to be administered to a critically ill patient who is currently critically ill patient who is currently receiving peripheral parenteral nutrition. receiving peripheral parenteral nutrition. Which of the following assessment findings Which of the following assessment findings would alert the nurse to a systemic would alert the nurse to a systemic problem related to lipid administration?problem related to lipid administration?

1. The onset of vomiting and fever1. The onset of vomiting and fever2. Retention of fluid with peripheral edema2. Retention of fluid with peripheral edema3. A random capillary blood glucose level of 3. A random capillary blood glucose level of 148 mg/dL148 mg/dL4. Erythema, tenderness, and exudate at 4. Erythema, tenderness, and exudate at the catheter insertion site the catheter insertion site

Audience Response Question


29


• 75-year-old woman is 75-year-old woman is scheduled to have scheduled to have exploratory surgery exploratory surgery tomorrow for a bowel tomorrow for a bowel obstruction.obstruction.

•History of type 2 diabetesHistory of type 2 diabetes


30


•Orders call for a PICC Orders call for a PICC insertion because the insertion because the physician anticipates a physician anticipates a need for resting her GI need for resting her GI tract.tract.


31


•Her son is here for the surgery, Her son is here for the surgery, and he is concerned about and he is concerned about when she can eat “regular when she can eat “regular food” after the surgery.food” after the surgery.

•She lives in an assisted living She lives in an assisted living facility, and her son visits a facility, and her son visits a few times a week.few times a week.


32

Discussion QuestionsDiscussion Questions

1.1.What can you tell the son What can you tell the son about feeding after her about feeding after her surgery?surgery?

2.2.What are you concerned What are you concerned about because she is a about because she is a diabetic?diabetic?


33

Discussion QuestionsDiscussion Questions

3.3. What will you teach her What will you teach her and her son to monitor?and her son to monitor?

4.4. What resources are What resources are available to help her at available to help her at home?home?


focus on parenteral nutrition (relates to chapter 40, “nursing management: nutritional...

Documents