TOTAL PARENTERAL NUTRITION : SHORT NOTE FOR NURSES

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.
Indication


  • 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

Carbohydrates  

  • 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.

Fat

  • Lipids or Fat emulsion,
  • Provides 30% of total calories.

Other components include Vitamins,Minerals, Water,Electrolyte.

Insulin 

  • May be added to control the blood glucose level because of the high concentration of glucose solution in TPN.

Heparin 

  • May be added to reduce the buildup of clot.
Intravenous Sites 

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.
Complications 
  1. Pneumothorax

S/S  

  • Sudden onset of chest or shoulder pain,
  • Sudden onset of shortness of birth.
  • Absence of breath sound of affected side.

Management

  • 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.

 

  1. Air embolism

S/S

  • Respiratory distress,
  • Apprehension,
  • Chest pain,
  • Dyspnea,
  • Hypotension,
  • Rapid and weak pulse.

Management 

  • 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.
  1. Infection

S/S

  • fever, Chills,
  • Erythema or drainage at the insertion site,
  • elevated WBC,
  • Septic shock,

Management


  • 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.
  1. Fluid overload

S/S

  • Bounding pulse.
  • Jugular vein distension,
  • Headache,
  • Increased blood pressure,
  • Crackles on lung auscultation.
  • Weight gain.

Management

  • 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 )
  1. Hyperglycemia

 S/S  

  • Increased blood glucose level.
  • Confusion, weakness.
  • Coma, kussmaual’s respiration.(diabetic keto acidosis)

Management 

  • 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.  
  1. Hypoglycemia

S/S

  • Blood glucose level less than 70 mg/dl.
  • Shakiness,
  • Weakness, Anxious, Diaphoresis, Hunger.

Management

  • 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.
Administration  
  • 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.

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