Focus on Parenteral Nutrition (Relates to Chapter 40, “Nursing Management: Nutritional Problems,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition Parenteral nutrition (PN) Administration of nutrients by route other than GI tract (i.e., bloodstream) Used when GI tract cannot be used for ingestion, digestion, and absorption of essential nutrients Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Parenteral Nutrition (PN) Goal: Meet nutritional needs and allow growth of new body tissue Regular IV solutions Dextrose in water or dextrose in lactated Ringer’s No protein 170 calories per liter Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition Normal adult requires minimum 1200 to 1500 calories/day. Regular dextrose solutions could exceed capacity of cardiovascular system. Injury, surgery, burns, malnourished—increase nutritional needs Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Common Indications for PN Chronic or intractable diarrhea and vomiting Complicated surgery or trauma Gastrointestinal obstruction Gastrointestinal tract anomalies and fistulae Malnutrition Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition Composition Base solutions contain dextrose and amino acids. Pharmacy adds prescribed electrolytes, vitamins, and trace elements. Three-in-one contains fat emulsion, dextrose, and amino acids. Examples include electrolytes (e.g., sodium, potassium, chloride, calcium, magnesium, phosphate) and trace elements (e.g., zinc, copper, chromium, manganese). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition Calories supplied primarily from carbohydrates (dextrose) and fat emulsion 1 g dextrose provide 3.4 calories. Fat emulsion has 1 calorie/mL for 10% or 2 calories/mL for 20% solution. The daily administration of between 100 and 150 g of dextrose (1 g provides approximately 3.4 calories, as opposed to oral carbohydrates, which provide 4 calories) has a protein-sparing effect. Adequate nonprotein calories in the form of glucose and fat must be provided to allow metabolism of amino acids for wound healing and not as energy. The contents of fat emulsion are primarily soybean or safflower triglycerides, with egg phospholipids added as an emulsifier. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition 25 to 30 calories/kg/day Fats not to exceed 2.5 g/kg/day The maximum fat-emulsion amount should not exceed a dose of 2.5 g/kg/day, and it should be administered slowly over 12 to 24 hours. Critically ill patients may not tolerate this dose, and close monitoring of triglyceride levels may be indicated. It is becoming more common to administer lipid-free PN for the first 3 to 5 days of critical illness. The administration of fat emulsion is contraindicated in the patient with a disturbance in fat metabolism. It should also be used with caution in the patient who is in danger of fat embolism (e.g., fractured femur) and in the patient with an allergy to eggs. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition Nausea, vomiting, and elevated temperature may occur if lipids are infused too rapidly. Protein provided 1 to 1.5 g/kg/day, depending on needs In a nutritionally depleted patient under the stress of illness or surgery, requirements can exceed 150 g/day to ensure a positive nitrogen balance. Under the most recent guidelines, protein intake levels of 1.5 to 2 g/kg/day are suggested for most patients with moderate to severe stress. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition Exact quantities of electrolytes needed are determined by blood testing. Vitamin K may be ordered separately, as it is not included in the preparation. The following are ranges for average daily electrolyte requirements for adult patients without renal or hepatic impairment: ● Sodium: 1 to 2 mEq/kg ● Potassium: 1 to 2 mEq/kg ● Chloride: As needed to maintain acid-base balance ● Magnesium: 8 to 20 mEq ● Calcium: 10 to 15 mEq ● Phosphate: 20 to 40 mmol Zinc, copper, chromium, manganese, selenium, molybdenum, and iodine supplements may be added according to the patient’s condition and needs. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition Methods of administration Central or peripheral use Central parenteral nutrition through catheter whose tip lies in superior vena cava Subclavian or jugular vein Peripherally inserted central catheters (PICCs) Long-term parenteral support Central PN is indicated when long-term support is necessary, or when the patient has high protein and caloric requirements. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition Peripheral parenteral nutrition Through peripherally inserted catheter or vascular access device Short-term support Protein and caloric requirements not high Risk of central catheter too great Supplement inadequate oral intake Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition Central and peripheral nutrition differ in tonicity Central solutions are hypertonic. Large central vein can handle high glucose content ranging from 20% to 50%. Peripheral solutions are hypertonic. Peripheral vein can handle glucose up to 20%. Blood is isotonic and measures approximately 280 mOsm/L. The standard IV solutions of D5W and normal saline are essentially isotonic. Central PN solutions are hypertonic, measuring at least 1600 mOsm/L. Another potential complication of PPN is fluid overload. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition PN solutions are prepared by pharmacist or trained technician under strict aseptic techniques. Nothing is added to solution after it is prepared. Solutions are good for 24 hours. The FDA recommends that a 0.22-micron Millipore filter be placed on parenteral solutions not containing fat emulsion, and a 1.2-micron filter be placed on solutions containing fat emulsion. Filters and IV tubing are changed every 24 hours if PN with lipids is being administered, and every 72 hours for PN with amino acids and dextrose. The tubing and the filter should be clearly labeled with the date and time they are put into use. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition PN solutions are prepared by pharmacist or trained technician under strict aseptic techniques. Must be refrigerated until 30 minutes before use Must be labeled with nutrient content, all additives, time mixed, and date and time of expiration Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition Catheter placement under sterile conditions by physician or advanced practice nurse Isotonic IV solution infused until x-ray confirms correct placement Site covered with sterile dressing Date marked on dressing To control the rate of infusion, peripheral PN solutions should be administered with a volumetric controller; a pump is used for central PN solutions. If a PN formula bag should empty before the next solution is available, a 10% or 20% dextrose solution (based on the amount of dextrose in the central PN solution) or a 5% dextrose solution (based on the amount of dextrose in the peripheral PN solution) may be administered to prevent hypoglycemia. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition Complications of PN Infection Must have filter With lipids: Tubing, filter change every 24 hours With amino acids, dextrose: Filter, tubing change every 72 hours Fungus, Gram +/- bacteria The major complications are presented in Table 40-15. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition Complications of PN (cont’d) Metabolic problems Hyperglycemia, hypoglycemia, prerenal azotemia, fatty acid deficiency, electrolyte disturbances, hyperlipidemia, mineral deficiencies Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Parenteral Nutrition Complications of PN (cont’d) Mechanical problems Insertion problems Dislodgement, thrombosis of great vein, phlebitis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Parenteral Nutrition Nursing Management Vital signs every 4 to 8 hours Daily weights Blood glucose Check initially every 4 to 6 hours. Electrolytes BUN CBC Body weight is considered the sum of the changes in protein, fat, and water. On a daily basis, body water fluctuates more than protein or fat. Analysis must be made of whether gains or losses in weight are caused by fluid gained from edema, fluid lost through diuresis, or actual increases or decreases in tissue weight. Some increase in the blood glucose level is expected during the first few days after PN is started. Efforts are made to maintain a glucose range of 110 to 150 mg/dL. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Parenteral Nutrition Nursing Management Hepatic enzymes Dressing changes Site observation key Refeeding syndrome Infusion pump must be used. Need to periodically check volume infused Carefully observe the catheter site for signs of inflammation and infection. Phlebitis can readily occur in the vein as a result of the hypertonic infusion, and the area can become infected. The patient receiving PN may be immunosuppressed and thus more susceptible to opportunistic infections. Refeeding syndrome is characterized by fluid retention, electrolyte imbalances (hypophosphatemia, hypokalemia, hypomagnesemia), and hyperglycemia. Conditions that predispose patients to refeeding syndrome include long-standing malnutrition states such as chronic alcoholism, vomiting and diarrhea, chemotherapy, and major surgery. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Parenteral Nutrition Nursing Management Before administering, check label and ingredients against order. Examine bag for signs of contamination. Also examine solutions for leaks, color changes, particulate matter, clarity, and fat emulsion cracking. It is the nurse’s responsibility to ensure that the PN solution is discontinued and replaced with a new solution if the bag is not empty at the end of 24 hours. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Parenteral Nutrition Nursing Management Watch for infection and septicemia. Local manifestations Erythema Tenderness Exudate at catheter insertion site Systemic Fever, chills Nausea/vomiting Malaise If no other causes of infection can be identified, a catheter-related infection is suspected. Because of the risk of infection, catheters with antibiotic or antiseptic surfaces may be used. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Parenteral Nutrition Nursing Management Blood and catheter cultures if infection suspected X-ray: To check changes in pulmonary status After PN therapy, daily dressing changes until heals When the catheter tip of a short-term catheter is the source of infection, antibiotic therapy may not be necessary because removal of the catheter can eliminate the problem. A general rule is that 60% of caloric needs should be met orally before discontinuation of PN or EN. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Parenteral Nutrition Nursing Management Home nutrition support Education Catheter care Side effects It is important for the nurse to educate the patient or the family about catheter or tube care, proper technique in mixing and handling of the solutions and tubing, and associated side effects and complications. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Parenteral Nutrition Nursing Management Assistance with reimbursement procedures Resources and peer support Home nutrition therapies are expensive. For patients to be reimbursed for expenses, specific criteria must be met. (See chapter for details.) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Audience Response Question The health care provider orders a 10% fat emulsion solution to be administered to a critically ill patient who is currently receiving peripheral parenteral nutrition. Which of the following assessment findings would alert the nurse to a systemic problem related to lipid administration? 1. The onset of vomiting and fever 2. Retention of fluid with peripheral edema 3. A random capillary blood glucose level of 148 mg/dL 4. Erythema, tenderness, and exudate at the catheter insertion site Answer: 1 Rationale: Patients receiving lipids are at extreme risk for infection because fat emulsions at room temperature are a medium for microorganism growth. Catheter-related infections can occur in patients receiving parenteral nutrition; local or systemic manifestations of infection may occur. Adverse reactions from lipid administration may include allergic reactions, dyspnea, cyanosis, fever, flushing, phlebitis, chest and back pain, and pain at the IV site. Hyperglycemia and fluid overload are other potential complications; however, infection would pose the highest risk for patients receiving lipids. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 28

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study 75-year-old woman is scheduled to have exploratory surgery tomorrow for a bowel obstruction. History of type 2 diabetes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study Orders call for a PICC insertion because the physician anticipates a need for resting her GI tract. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study Her son is here for the surgery, and he is concerned about when she can eat “regular food” after the surgery. She lives in an assisted living facility, and her son visits a few times a week. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Discussion Questions What can you tell the son about feeding after her surgery? What are you concerned about because she is a diabetic? She will be fed through the PICC only until she is able to eat 60% of her calories orally. Then she will be back to eating “normally.” Her blood glucose should be monitored closely. A slight increase in blood glucose is to be expected at the outset of PN. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Discussion Questions What will you teach her and her son to monitor? What resources are available to help her at home? 3. If she continues PN at home, she should be taught proper tube care and should learn the signs of infection. 4. OLEY foundation (see resources at end of chapter for a complete list) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.