TOTAL PARENTERAL NUTRITION
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TOTAL PARENTERAL NUTRITION
- TPN supplies necessary nutrients via veins.
- It supplies carbohydrate in the form of dextrose or Glucose, fat in special emulsified form, Proteins in the form of amino acids, vitamins minerals, and water.
- Severe dysfunction or non functioning of GI tracts.
- When GI tract is unable be process nutrient normally.
- Client who can’t take enough nutrient orally.
- Client with multiple abdominal surgery and GI trauma.
- Severe intolerance to enteric feeding.
- Intestinal obstruction or bowel needs to rest for healing.
- Client with AIDS, Cancer, malnutrition or client receiving chemotherapy.
Components of TPN
- For CPN (Central PN) 50% to 70% of glucose hypertonic solution.
- For PPN (Peripheral PN) 5% to 10% of glucose hypotonic solution.
- Carbohydrate provides 60% to 70% of total caloric.
Protein ( Amino acids)
- It provides 3% to 15% of the total calories.
- Lipids or Fat emulsion,
- Provides 30% of total calories.
Other components include Vitamins,Minerals, Water,Electrolyte.
- May be added to control the blood glucose level because of the high concentration of glucose solution in TPN.
- May be added to reduce the buildup of clot.
Central Parenteral nutrition (CPN)
- It is used when patient needs large concentration of glucose more than 10%.
- Subclavian or internal jugular veins are used for short term use.
- Peripherally inserted central catheter is used for long term use more than 4 weeks.
Peripheral Parenteral nutrition (PPN)
- Administered through a peripheral vein.
- Used for short periods (5 to 7 days
- Used when the client needs only small concentration of glucose, fat and proteins.
- Used to deliver isotonic or mildly hypertonic solutions.
- The delivery of highly hypertonic solution into the peripheral veins can cause sclerosis, phlebitis, or swelling.
- Sudden onset of chest or shoulder pain,
- Sudden onset of shortness of birth.
- Absence of breath sound of affected side.
- Monitor for signs of Pneumothorax.
- After insertion of the catheter obtain a portable X-ray to confirm correct catheter placement.
- After confirmation of catheter placement initiated TPN.
- Air embolism
- Respiratory distress,
- Chest pain,
- Rapid and weak pulse.
- Instruct the client to do valsava maneuver for tubing / cap changes.
- During tubing/cap changing, place client in a head down position, with the head turned in the opposite direction of insertion site (to increase intrathoracic venous pressure )
- Check all the connection and tape tubing connection.
- If air embolism is suspected. Place the client in a left side lying position with the head lower than the feet (to trap air in right side of the heart)
- Notify the physician.
- Administer the oxygen.
- fever, Chills,
- Erythema or drainage at the insertion site,
- elevated WBC,
- Septic shock,
- Use strict aseptic technique.
- Monitor temperature.
- Assess IV site for redness, swelling, tenderness, or drainage.
- Change TPN solution every 12 to 24 hours,
- Change tubing every 24 hours.
- Change dressing at IV site every 48 hours,
- If infection occur IV line must be removed and restart at a different site.
- Remove the tip of the catheter and sent for culture and sensitivity.
- Do blood C/S also.
- Start antibiotics according to the result.
- Fluid overload
- Bounding pulse.
- Jugular vein distension,
- Increased blood pressure,
- Crackles on lung auscultation.
- Weight gain.
- It occur if the client receives the IV solution too rapidly.
- TPN is must give via infusion pump
- monitor 1/0.
- Weigh daily ( ideal weight gain is 1 to 3 pounds per week )
- Increased blood glucose level.
- Confusion, weakness.
- Coma, kussmaual’s respiration.(diabetic keto acidosis)
- Assess the client for a history of glucose intolerance.
- Assess the client medication history.
- Begin infusion at slow rate usually 40ml/hour.
- Never increase the infusion rate to ‘catch up’ if the IV infusion gets behind.
- Monitor blood glucose level every 4 to 6 hours.
- Start insulin if necessary.
- Blood glucose level less than 70 mg/dl.
- Weakness, Anxious, Diaphoresis, Hunger.
- Continue blood glucose monitoring,
- Gradually decrease infusion before stopping TPA.
- When an infusion of hypertonic glucose is stopped, an infusion of 10% dextrose should be instituted and maintained for 1 to 2 hours to prevent hypoglycemia.
- Monitor blood glucose level 1 hour after stopping TPN.
- If hypoglycemia occur administer glucose.
Additional Nursing Care
- Always check the TPN solution with doctor order to ensure that the prescribed components are present or not.
- To prevent infection and solution incompatibility IV medications and blood are not given through the TPN line.
- Monitor Blood coagulation study.
- Monitor electrolytes, albumin, and liver, and renal function tests.
- Abnormal LFT indicate intolerance to fat emulsion or problems with metabolism with glucose and protein.
- Use TPN within 24 hr from the time of preparation.
- Remove the TPN from the refrigeration one hour before administration.
- TPN Solution that is cloudy or darkened should not be used and should be returned to the pharmacy.
- Obtain weight daily at same time, in same cloth. If weight gain is more than 3 pound/week indicate excessive fluid intake and should be reported.
- Check the S/S of infection, thrombosis, air embolism, and catheter displacement.
- TPN and PPN must be administered through tubing with in-line filter to remove crystals.
- A 0.22 micron filter is used for administer solution without lipid additives if lipid has added to it 1.2 micron filter or larger filter should be use.
- Use Vented IV tubing.