Parenteral Nutrition

72 hours

Change the parenteral nutrition administration system every ____ when infusion a 2-in-1 mixture and every 24 hours for a 3-in-1 mixture

24 hours

Do not hang a single container of PN for more than ___ or lipids more than 12 hours.

essential fatty-acid deficiencies and help control hyperglycemia during periods of stress.

Sometimes adding intravenous fat emulsions to PN supports the patient's need for supplemental kilocalories to prevent ______ and ____

poorer quality of life

· Patients receiving parenteral nutrition at home frequently administer the entire daily solution over 12 hours at night. The allows the patient to disconnect from the infusion each morning, flush the central line, and have independent mobility during the day. - Home parenteral nutrition often interferes with patient's normal activities, causing a ___ -Clients receiving PN at home will have a tunneled catheter, and feedings can occur when the client sleeps

small frequent meals

· Patients who make the transition from PN to oral feedings typically have early satiety and decreased appetite. Gradually decrease PN in response to increased oral intake. -If oral intake is inadequate, ___ are helpful. Recommend calorie/protein counts when patients begin taking soft foods.

superior vena cava

· Patients with short-term nutritional needs often receive IV solutions of less than 10% dextrose via a peripheral vein in combination with amino acids and lipids. · Peripheral parenteral nutrition solutions are used temporarily · Parenteral nutrition with greater than 10% dextrose (like TPN) requires a CVC that a health care provider places into a high-flow central vein such as the ____ under sterile conditions.

10% dextrose and 5% amino acids

· Peripheral Parenteral nutrition can be used when the client is unable to consume enough calories to meet metabolic needs or when nutritional support is needed for a short time. · Peripheral Parenteral Nutrition solutions must be isotonic and contain no more than ____ · Can be used for clients who have some oral intake · Often used for lipids when they are not included in the primary nutrient solution because they are considered isotonic

3-20%

· Protein is provided as a mixture of essential and nonessential amino acids and is available in concentrations of ___. The client's estimated requirements and liver/kidney function determine the amount of protein provided.

catheter sepsis

· Suspect ____ if a patient develops chills, fever, or glucose intolerance and has a positive blood culture. To prevent infection, change the TPN infusion tubing every 24 hours.

move toward the use of GI tract constantly

· The goal of parenteral nutrition is to _____. -Disuse of the GI tract is associated with villus shrinkage/atrophy and generalized cell shrinkage. Bacteria may move from the unused gut into the bloodstream resulting in gram-negative septicemia.

osmotic diuresis and dehydration

· Too rapid-administration of hypertonic dextrose can result in an ___.

central line

· Total parenteral nutrition is always administered through a ______, is a 2-in-1 formula in which administration of fat emulsions occurs separately from the protein and dextrose solution.

A. Concentration of lipid emulsion can be up to 30% B. Adding lipid emulsion gives the solution a milky appearance C. Check for allergies to soybean oil D. Lipid emulsion prevents essential fatty acid deficiency

A charge nurse is providing information about a fat emulsion added to total parenteral nutrition (TPN) to a group of nurses. Which of the following statements by the charge nurse are appropriate? (SATA) A. Concentration of lipid emulsion can be up to 30% B. Adding lipid emulsion gives the solution a milky appearance C. Check for allergies to soybean oil D. Lipid emulsion prevents essential fatty acid deficiency E. Lipids provide calories by increases osmolality of the PN solution

B. Regular insulin can be added to the TPN solution

A charge nurse is teaching a group of nurses about medication compatibility with TPN. Which of the following statements should the charge nurse make? A. Use the Y-port of the TPN tubing to administer antibiotics B. Regular insulin can be added to the TPN solution C. Administer heparin through a port on the TPN tubing D. Administer vitamin K IV bolus via a y-port on the TPN tubing.

A. Administer 20% dextrose in water IV until the next bag is available

A nurse is caring for a client who is receiving TPN through a central venous access device, but the next bag of solution is not available for administration at this time. Which of the following is an appropriate actions by the nurse? A. Administer 20% dextrose in water IV until the next bag is available B. Slow the infusion rate of the current bag until the solution is available C. Monitor for hyperglycemia D. Monitor for hyperosmolar diuresis

A. Examine trends in weight loss B. Review prealbumin finding D. Add a micron filter to IV tubing E. Use an IV infusion pump

A nurse is planning care for a client who has a new prescription for peripheral parenteral nutrition. Which of the following actions should the nurse include in the plan of care? (SATA) A. Examine trends in weight loss B. Review prealbumin finding C. Administer an IV solution of 20% dextrose D. Add a micron filter to IV tubing E. Use an IV infusion pump

C. Return the bag to the pharmacy

A nurse is preparing to administer lipid emulsion and notes a layer of fat floating in the IV solution bad. Which of the following actions should the nurse take? A. Shake the bag to mix the fat B. Turn the bag upside down one more time C. Return the bag to the pharmacy D. Administer the bag of solution as is.

separate peripheral line, through the central line using Y-connector tubing, or as an admixture to the PN solution

Administer fat emulsions through a _____, _____, or ____.

soybeans, safflower, or eggs

Baseline Assessment Parameters: · Weight, height, BMI, nutritional status, diagnosis, laboratory data (CBC, chemistry) · Serum chemistry (chem 24), coagulation profile, iron, total iron binding capacity (TIBC) and Mg · Assess for allergies to ____ if lipids are prescribed · Liver function tests · Individualized energy, nutrient, and fluid needs

· Catheter-related complications · Coagulopathies · Local and systemic complications related to central line placement and use · Clients whose GI tracts should resume normal functioning in 7 to 10 days · Clients with functional GI tracts · Poor prognosis or terminal illness with no other therapy

Contraindications for Parenteral Nutrition Support:

· Improved nutritional status · Weight maintenance or gain --Daily weight is maintained or gain up to 1kg/day · Positive nitrogen balance --Increases in prealbumin level (normal: 15-36mg/dL) o Increases in BUN (normal: 10-20mg/dL)

Desired outcomes of Parenteral Nutrition:

oil droplets or an oily, creamy layer on the surface

Do not use a total nutrient admixture if you observe ______ of the admixture. This observation indicates that the emulsion has broken into large lipid droplets that cause fat emboli if administered.

sterile mask and gloves

During CVC dressing changes always use a ____ and assess insertion sites for S/S of infection. Change the CVC dressing per policy and anytime it becomes wet or contaminated -Use alcohol/chlorhexidine gluconate to clean the injection port or hub 15 seconds before and after each time it is used.

hypoglycemia

If an infusion falls behind schedule, do not increase the rate in an attempt to catch up. Sudden discontinuation of a solution can cause ____. Usually it is recommended to infuse 10% dextrose when discontinuing parenteral nutrition suddenly. (patients with diabetes are more at risk)

monitor blood glucose every 6 hours, initiate TPN slowly and taper up to a maximal infusion rate, add additional insulin if problem persists or patient has diabetes.

If hyperglycemia occurs during parenteral nutrition, a patient will show signs of thirst, headache, lethargy, and increased urination. -If hyperglycemia occurs during parenteral nutrition, a nurse should ____

50% dextrose or glucagon

If hypoglycemia occurs during parenteral nutrition, a patient will show signs of diaphoresis, shakiness, confusion, and loss of consciousness. -If hypoglycemia occurs during parenteral nutrition, a nurse should not abruptly discontinue TPN (instead taper the rate down to within 10% of infusion rate 1-2 hours before stopping), test blood glucose and administer IV bolus of ____ per protocol

10%, 20%, and 30%

Intravenous lipids are available in concentrations of ___, ___, and ____ and are formulated from a combination of soybean oil and phospholipids giving the solution a milky/opaque appearance.

dedicated line

Nursing Responsibilities for parenteral nutrition: · When giving PN solutions, monitor for fever, chills, increased WBC, and redness · To treat hypoglycemia, administer additional dextrose · Notify the provider of weight gain greater than 1kg/day · When giving PN solutions, anticipate decrease in the concentration of the solutions, rate of administration, or volume of lipid emulsion to treat weight gain. · Run TPN through a _____ · Change solutions and tubing per protocol · Assess clients for complications · Follow protocol for discontinuing · Provide client and family with accurate information · Document client response

Hypertonic

Nutrient solutions for total parenteral nutrition therapy are ALWAYS ______, customized to the patient containing various dietary elements, and contain 50% to 70% dextrose solutions

75%

Once meeting ___% of nutritional needs by enteral feedings or reliable dietary intake, it is usually safe to discontinue parenteral nutrition therapy. - Discontinuation may occur if complications occur or if the therapy is not working

· May be part of the TPN solution · May be administered centrally via Y-connection · May be administered separately via a peripheral line · MUST be inspected for separation or oil droplets · High risk for infection

Special Considerations for Lipids:

dextrose 10-20%

To avoid hypoglycemia, an IV _____ is administered if the PN solution is unavailable

· Patients who cannot digest or absorb enteral nutrition benefit from parenteral nutrition · Patients in highly stressed physiological states like sepsis, head injury, or burns are candidates for parenteral nutrition. · Small bowel obstruction · Peritonitis · Intractable vomiting · Severe acute pancreatitis · Short bowel syndrome · Prolonged ileus

Typical Parenteral Nutrition Clients:

1.2-micron filter

Use a ____ filter for 3-in-1 formulas and an inline 0.22-micron filter for PN solutions that don't include fat emulsions.

Insulin

___ can be added to PN solutions to reduce potential for hyperglycemia

Pneumothorax

___ results from a puncture injury to the pulmonary system and involves accumulation of air in the pleural cavity with subsequent collapse of the lung and impaired breathing. -Clinical symptoms: sudden sharp chest pain, dyspnea, coughing. -____ often occurs with parenteral nutrition during CVC placement. Monitor the patient with a CVC for the first 24 hours for S/S of __ and pulmonary distress.

Metabolic

____ complications include hyperglycemia, hypoglycemia, hyperkalemia, hypophosphatemia, hypocalcemia, dehydration, and fluid overload (weight gain greater than 1kg/day and edema)

Catheter occlusion

____ is present when there is sluggish or no flow through the catheter. Temporarily stop the infusion and flush with saline per protocol. If this is unsuccessful, attempt to aspirate a clot. If still unsuccessful, follow policy for use of a thrombolytic agent.

Total parenteral nutrition

____ is used when a client will need this type of nutrition for an extended time period -____ is used in clients who need intense nutritional support for an extended period of time, cancer treatment, bowel disorders, critically ill, suffering trauma, burns (high caloric requirement situations)

Mechanical

_____ complications include catheter misplacement resulting in pneumothorax or hemothorax (evidenced by SOB, diminished/absent breath sounds), arterial puncture, catheter embolus, air embolus, thrombosis, obstruction, and bolus infusion due to incorrectly set/malfunctioning electronic pumps.

Parenteral nutrition

_____ is a form of specialized nutrition support provided intravenously. A basic PN formula consists of crystalline amino acids, hypertonic dextrose, electrolytes, vitamins, and trace elements. -_____ can occur in many settings including the patient's home. Regardless of setting, adhere to principles of asepsis and infusion management to ensure safe nutrition support. -____ therapy requires clinical and laboratory monitoring by a multidisciplinary team. Consistent reevaluation for the continuation of PN is required

Refeeding syndrome

_____ occurs when the body rapidly changes from catabolic (starvation) to anabolic metabolism when nutrition is started. -Characterized by fluid/electrolyte imbalances (potassium, magnesium, and phosphate), shallow respirations, confusion, seizures, weakness, cardiac rhythm changes, fluid retentions, and acidosis.

Total parenteral nutrition

______ provides a nutritionally complete solutions that can be used when caloric needs are very high, when long-term therapy is indicated, or when the solution to be administered is hypertension (composed of greater than 10% dextrose)

without increasing osmolality of the PN solution

o Fat emulsions provide needed calories when dextrose concentration must be reduced due to fluid restriction, persistent hyperglycemia, and correcting/preventing essential fatty acid deficiency Provides calories without ____

3-in-1 admixture or total nutrient admixture

o The addition of a fat emulsion to a PN solution is called a _____ or _____ -Total nutrient admixtures are available that combine lipids into the PN solution containing dextrose and amino acids, rather than administering the solutions separately. (3-in-1 solution) -3-in-1 infusions reduce body carbon dioxide production and buildup of fat in the liver.

air embolus

· An ___ can occur during insertion of the catheter or when changing the tubing or cap. To prevent __, turn the patient into a left lateral decubitus position and have them perform a Valsalva maneuver (holding breath and bearing down) during catheter insertion. (also maintain integrity of the closed IV system) -The increased venous pressure created by the maneuver prevents air from entering the bloodstream

infusion pump

· Before beginning any PN infusion, verify the health care provider's order and inspect the solution for particulate matter or a break in fat emulsion. · ALWAYS use an ____ for PN to deliver a constant rate. The initial rate delivers 50% of estimated needs in the first 24-48 hours and gradually increases the rate until patient's complete nutrition needs are supplied.

2.5%-10%

· Carbohydrate or dextrose parenteral nutrition solutions are available in concentrations of ____ for PPN and up to 70% for TPN. -A higher concentration of dextrose is often used for a client on fluid restrictions -A lower concentration of dextrose can be used to help control hyperglycemia.

move intracellularly

· Electrolyte and mineral imbalances often occur with PN. -Administration of concentrated glucose accompanies an increase in endogenous insulin production, which causes cations (potassium, magnesium, and phosphorus) to ___. -Monitor blood glucose levels every 6 hours to assess for hyperglycemia and administer supplemental insulin as needed -If electrolyte imbalance occurs during parenteral nutrition, a nurse should check TPN for supplemental electrolyte levels, notify the MD of imbalances, maintain a steady rate of infusion, and monitor intake and output.

room temperature before administering.

· If a PN solution has been prepared and refrigerated, allow it to warm to _____

recognize that ventilator-dependent patients are at risk, provide 30-60% of energy requirements for order

· If hypercapnia occurs during parenteral nutrition, a patient will show signs of increase O2 consumption, CO2, respiratory quotient greater than 1, and minute ventilation. -If hypercapnia occurs during parenteral nutrition, a nurse should ____

monitor blood glucose, BUN, osmolarity, glucose in urine, and fluid loss. Administer insulin as needed, replace fluids as needed. Maintain constant infusion rate and provide 30% of daily energy needs as fat

· If hyperglycemic hyperosmolar nonketotic syndrome (or coma) HHNS occurs, a patient will show signs of hyperglycemia (>500mg/dL), glycosuria, serum osmolarity greater than 350, confusion, azotemia, headache, dehydration, hypernatremia, metabolic acidosis, convulsions, and coma. -If hyperglycemic hyperosmolar nonketotic syndrome (or coma) HHNS occurs, A nurse should ______. -Patients at risk are those receiving steroids, older adults with diabetes, impaired renal or pancreatic function, increased metabolism, septic.

exclusively dedicated to Total Parenteral Nutrition

· If you are using a CVC that has multiple lumens, use a port that is _____. Label the port for total parenteral nutrition and do not infuse other solutions or medications through it

fever or elevated WBC count.

· Infections and sepsis are evidenced by a ____ or _____ -Infection can result from contamination of the catheter during insertion, contaminated solutions, or a long-term indwelling catheter

12 hours

· Maintain strict aseptic techniques to reduce the risk of infection. (high dextrose increases bacterial growth) -Use sterile technique when changing central line dressings and tubing. Change the bad and IV tubing for the dextrose solution every 24 hours. -With intermittent IV lipid infusion, ensure the IV bag does not hang more than ___ to prevent bacterial growth

chest x-ray

· Nurses with special training insert peripherally inserted central catheters (PICCs) that start in a vein of the arm and then thread into the subclavian or superior vena cava vein · After the IV catheter is placed, wait to flush and use the catheter until position confirmation by radiology. The provider secures the CVC with a securement device and covers it with a sterile dressing. -Before applying the sterile dressing, stabilize the PICC with sterile strips of tape. A ____ verifies catheter tip placement for a CVC or PICC before starting Parenteral Nutrition infusion.

one third to one half

· Once patients are meeting ___ of their kilocalorie needs per day, health care providers usually decrease PN by half the original volume and increase EN feeds to meet the patient's nutritional needs.

clear liquids

· PN should be discontinued as soon as possible to avoid complications, but not until the client's enteral/oral intake can provide 60% or more of estimated caloric requirements - Discontinuation should be done gradually to prevent hypoglycemia -During transition, the client will need enteral/oral nutrition. Oral nutrition usually begins with ___ that are low in fat or substances that might irritate the client's gastrointestinal tract.

24 hours

· Use STERILE TECHNIQUE when administering parenteral nutrition because of danger of infection which is high with concentrated dextrose solutions especially · Hang solutions within ___ of mixing

cracking

· When giving PN solutions, monitor for "_____" of a TPN solution. This happens if the calcium or phosphorus content is high or if poor-salt albumin is added. "cracked" TPN solution has an oily appearance or layer of fat on top of the solution and shouldn't be used.

Peripheral parenteral nutrition

· ____ is administered up to 14 days into a peripheral vein, and the solution is nutritionally incomplete (low dextrose content) · Used for clients who do not need to gain weight, need a short-term nutritional support with fewer calories per day.