Week 3: Administering Parenteral Nutriton

micronutrients in PN

ELECTROLYTES Sodium, potassium, chloride, calcium, magnesium, phosphate VITAMINS AND TRACE ELEMENTS Zinc, copper, chromium, manganese

indication of PPN

(1) nutritional support is needed for only a short time, (2) protein and caloric requirements are not high, (3) the risk of a central catheter is too great, or (4) PN is used to supplement inadequate oral intake.

PN associated liver disease (PNALD)

(long-term PN) Monitor liver function tests, serum bilirubin, thought to be due to overfeeding, reduce dextrose and lipids in PN solution, cycle PN, infuse for 12 hours and hold for 12 hours, discontinue PN and initiate EN if possible

Fat emulsions [Contraindications/Cautions]

*Contra*: pt w/ a disturbance in fat metabolism (hyperlipidemia) *Cautions*: pt at risk for fat embolism (fractured femur), allergy to eggs or soybeans severe hepatic disease

Components of parenteral nutrition

-Protein in the form of amino acids -Carbohydrates in the form of dextrose -Fat as lipid emulsion -In addition to protein, carbohydrates and fat, PN also provides other dietary components, including: -Electrolytes -Vitamins -Trace minerals -Water

patient monitoring PN

Fluid status I&O Daily weights Signs and symptoms of fluid overload or dehydration Electrolytes Blood glucose q4-6 hours or as prescribed Vital signs q4-8 hours or as prescribed Liver and Renal function Serum lipid levels

below

For 2-in-1 PN place the filter [] the Y-site where the dextrose-amino acid admixture and the lipids connect.

central line-associated bloodstream infection (CLABSI)

Full barrier precautions during catheter insertion, dressing changes, do not disconnect tubing unnecessarily, perform hand hygiene before touching CVAD, dressing over insertion site, scrub hub on IV tubing before accessing, monitor signs of infection (fever, WBC, erythema, tenderness at catheter insertion site)

8 to 10, 0.11

Give IV fat emulsions separately over [] to [] hours. The infusion rate should not exceed [] g/kg/hr.

serum electrolyte alterations

I&O, electrolytes, Monitor chemistry lab values and work with nutrition/pharmacy team to modify formula. TPN formula can be modified daily.

hyperglycemia and hypoglycemia

IV pump, taper rate up slowly during 1st hr, monitor BG q4-6 hrs, cover with insulin as needed, never suddenly decrease TPN rate, taper rate down gradually over 1 hour

need for extended bowel rest

•Inflammatory bowel disease exacerbation •Ischemic bowel •Severe pancreatitis •Complicated GI surgery

infusion pump

•To avoid Fat Overload Syndrome, lipid emulsion must be administered via an [] []. Infusion rate should not exceed 0.17g/kg/hour (ASPEN, 2014 Parenteral Nutrition Safety consensus recommendations

dextrose, amino acids

2 in 1 solution [] and [] [] solution are administered together in one bag.

particulate, infectious

•Why must a filter be place on parenteral nutrition administration tubing? •In-line intravenous filters reduce exposure to [] matter during parenteral nutrition therapy. •They also have a limited role in reducing [] complications of PN. They block certain microbes from reaching the circulation.

PPN osmolality

<800 mOsm <15% Dextrose

Central parenteral nutrition osmolality

>800 mOsm > 15% Dextrose

q24h

A new parenteral nutrition bag should be hung every 24 hours.

What is parenteral nutrition?

A specialized form of nutrition which is administered intravenously directly into the bloodstream

Hypertriglyceridemia

Administer fat emulsion with IV pump, monitor triglyceride levels, hold fat emulsion if lipids are administered in combination with other meds (Propofol)

centeral parenteral nutrition

Administered via a central line Indicated when long-term PN support is needed or patient has high calorie needs Dextrose content ranges from 20-50%, making the solution hypertonic

thrombosis/phlebitis

Assure appropriate osmolarity of the solution. (less than 800 mOsm for peripheral IV site) Assure adequate fixation of the catheter (by sutureless fixation devices). Use polyurethane and silicone catheters rather than Teflon. Administer peripheral parenteral nutrition via a midline catheter.

examining the solution

Check for leaks, color changes, particulate matter, and fat emulsion cracking (separating into layers) If any of these are present, do not administer the solution. Return it to the pharmacy and obtain a new solution

2000-4000 calories

CPN daily caloric intake

infection risk reduced

Catheter site care Central line management Aseptic technique and hand hygiene Tubing and filter changes Lipids q 24h tubing changes Without lipid q72h tubing changes Compliance with hang time Lipids or PN with lipids = 12 hours Without lipids = 24 hours

dilution, thrombophlebitis

Central PN must be infused in a large central vein so that rapid [] can occur. The use of a peripheral vein for hypertonic, central PN solutions would cause irritation and [].

2 in 1 solution PN

Dextrose and amino acids solution are administered together in one bag. Lipids (if ordered) are infused separately

3 in 1 solution PN

Dextrose, amino acid, and fat emulsion are all administered in one

preventing hypoglycemia in PN

Do not abruptly discontinue PN Rate of infusion should be tapered down prior to stopping If a PN solution bag should empty before the next solution is available, IV dextrose solution should be given to prevent hypoglycemia Central: 10% or 20% dextrose solution Peripheral: 5% or 10% dextrose solution (D5W, D10W) Monitor blood glucose levels closely

peripheral parenteral nutrition (PPN)

Intravenous nutrition administered through veins on the periphery of the body rather than through a central vein or artery

20

Lipid are stable for [] hours in a 3 in 1 admixture.

refeeding syndrome

Metabolic disturbances that occurs when initiating nutrition to patients who are starved or severely malnourished. Can lead to abnormally low serum phosphorus, potassium, and magnesium levels after the initiation of PN. Electrolyte abnormalities can result in cardiac dysrhythmias, delirium and seizures. Identify patients at risk for refeed syndrome before initiating nutrition support. Correct hypophosphatemia, hypokalemia, and hypomagnesemia before nutrition support is initiated. Nutrient support should be initiated slowly and then cautiously increased to goal over the course of 3-5 days.

manifestations of fat overload syndrome

Nausea, vomiting Fever Sudden elevation of serum triglycerides Coagulopathy Metabolic acidosis Respiratory failure Liver failure

14, fewer, 10

PPN Administered for up to [] days May also be used to supplement oral intake Contains [] nutrients Dextrose content cannot exceed []%

700-2000 calories

PPN caloric intake

filtered

Parenteral nutrition infusions must be [] to protect the patient from: Particulates, microparticulates, microorganisms, air embolism

safety for parenteral nutrtion

Parenteral nutrition must be administered via a dedicated line Administering any IV medication through a PN IV line or port is contraindicated Parenteral nutrition must be administered using an infusion pump Parenteral nutrition must be administered using an IV filter Parenteral nutrition without lipids must be changed after 24 hours of hang time Parenteral nutrition with lipids must be changed after 12 hours of hang time Parenteral nutrition must be inspected for cracks, leaks, color changes, particulates, and fat emulsion cracking prior to administration Parenteral nutrition flow rate must be monitored carefully Parenteral nutrition cannot be stopped abruptly

infection

Parenteral nutrition solutions are good mediums for microorganism growth Fat emulsion (lipids) are especially good mediums and have an increased risk of []

intravenously

Parenteral solutions are administered: Intravenously Topically by Mouth by Inhalation

Intravenous lipid emulsion

Provides energy and prevents essential fatty acid deficiencies Fat emulsions primarily contain soybean or safflower triglycerides with egg phospholipids added as an emulsifier. Available in 10%, 20%, or 30% solutions

parenteral nutrition basics

Provides nutrition when the GI tract cannot be used for ingestion, digestion, and absorption of essential nutrients Customized to meet nutritional needs of each individual patient May be used as short-term or long-term nutritional therapy May be administered via a central line or peripheral IV access Requires proper nursing management and close monitoring for complications

intestinal failure

The reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes

12

When administering the lipid emulsion separately, lipids are only stable for [] hours (INS, 2016).

total parenteral nutrition (TPN)

[] [] [] if fat emulsion (lipids) are added

enteral nutrition

alternate form of feeding that involves passing a tube into the gastrointestinal tract to allow instillation of the appropriate formula

Bleeding, pneumothorax, dysrhythmias, air embolism and extravasation

associated with intravenous line insertion and use.

dextrose

carbohydrates in PN

long-term support, high calorie needs

central parenteral nutrition indications

hypertonic solutions

central parenteral nutrition solutions >800 mOsm > 15% Dextrose

fluid overload

complication of peripheral parenteral nutrition

tube feeding or gavage feeding

enteral nutrition two other names

fat emulsion (lipids)

fat in PN

12 hours

hang time for lipids

24 hours

hang time without lipids

functional GI tract

in order to receive at Enteral feeding, a pt must have a:

fluid overload

intravenous fluid emulsion They provide a large number of calories in a relatively small amount of fluid. This is beneficial when the patient is at risk for [] [].

1.2-micron size filter

is used with the administration of all PN formulas' The dextrose-amino acids (2-in-1) admixtures with lipids administered separately -and- Total Nutrient Admixtures (3-in-1).

Fat overload syndrome

lipid emulsion must be administered slowly via an Infusion pump to prevent what?

q4-6 hrs

monitor BG how often

q4-8 hrs

monitor vital signs how often

indications of PN

nonfunctional GI tract or need for extended bowel rest

GI tract

parenteral nutrition Provides nourishment to an individual when the [] [] cannot be used.

infusion pump

parenteral nutrition must be infused using an [] [] Avoid administration that is too fast or too slow Periodically check volume infused

amino acid solution

protein in PN

nonfunctional GI tract

​​Obstruction Malabsorption ((Short bowel syndrome, necrotizing enterocolitis, massive abdominal trauma, complications of bariatric surgery, chemotherapy, radiation related enteritis) mobility issue (•Hirschsprung's, prolonged ileus) Chronic severe diarrhea and vomiting Complicated Surgery or Trauma GI bleed Chemotherapy, radiation therapy Short bowel syndrome