BMI values of 19-25 are appropriate for 19-34 yr olds, whereas BMI values of 21-27 are appropriate for individuals older than 35 yr of age. Obesity is defined as BMI greater than 27.5, with severe or morbid obesity greater than 40. A BMI of 16-18.5 is considered mild to moderate malnutrition, whereas a value lower than 16 indicates severe malnutrition.

Biochemical Data

If an individual is ill, these biochemical data are more accurate as predictors of outcome or recovery than as indicators of nutritional state.

Protein status

Evaluated via the following tests, with normal values in parentheses: serum albumin (3.5-5.0 g/dL), transferrin (200-400 mg/dL), and prealbumin (20-30 mg/dL). Normal values may vary somewhat with different laboratory procedures and standards. Albumin and transferrin have relatively long half-lives of 14-20 days and 8-10 days, respectively, whereas prealbumin (a short-phase protein) has a very short half-life of 48-72 hr. If hydration status is normal and anemia is absent, albumin and transferrin levels can be used as baseline indicators of adequacy of protein intake and synthesis. For evidence of response to nutritional therapy, prealbumin values are the most useful when patient has normal renal function.

Iron status

Measurement of RBC size (i.e., mean corpuscular volume [MCV] [normal: 80-95 µm³]) aids in determining the type of nutrient anemia. In iron-deficiency anemia, RBCs are smaller than normal, whereas in folate or vitamin B₁₂ deficiencies, RBCs are larger than normal.

Estimating Nutritional Requirements

The primary goal of nutritional support is to meet the needs for body temperature, metabolic processes, and tissue repair. Having collected all the data, energy needs may be estimated using the following options.

Calorie estimation

Prevents overfeeding, and calculates the total calorie intake as follows:

Average nourished patient	25 total calories per kg of body weight
Mildly stressed patient	30 total calories per kg of body weight
Severely stressed patient	35 total calories per kg of body weight
Morbidly obese patient	18 total calories per kg of body weight

Distribution of calories

A relatively normal distribution of calories is adequate. Percentages of total calories from carbohydrates (CHOs), protein, and fat should equal approximately 60%, 15%-20%, and 15%-25%, respectively.

Protein requirements

Usually 0.8-1.5 g/kg/24 hr. (Protein will be restricted if patient has hepatic or renal failure that is not being treated with dialysis.)

CHO requirements

Daily glucose administration of 9-15 g/kg/24 hr is an adequate range. Excess amounts of CHO are not utilized or tolerated. Overfeeding of CHO may lead to hyperglycemia, increased CO₂ production, hypophosphatemia, and fluid overload in short-term use or fatty liver syndrome in long-term use.

Fat requirements

Fat can be administered in minimal quantities to satisfy needs for essential fatty acids but should not exceed 1 g fat/kg/24 hr because of the potential for suppression of the immune system.

Special diets for organ-specific pathologic conditions

Commercially available oral supplements and enteral formulas are available for patients with respiratory disease, DM, renal failure, hepatic failure, inflammatory bowel disease, and immune compromise. Well-designed clinical trials may not be available to support the suggested indication.

Vitamin and essential trace mineral requirements

In general, follow the recommended dietary allowances (RDAs) to provide minimum quantities of vitamins, minerals, and essential fatty acids. For specific patients, supplement specific vitamins or minerals needed in increased amounts for existing disease states (e.g., burns: zinc, vitamins A and C; chronic alcohol ingestion: thiamine, folate, vitamin B₁₂).

Fluid requirements

Many factors affect fluid balance. Under usual circumstances, an estimate of fluid needs can be made by providing 1 mL of free water for each calorie provided, or 30-50 mL/kg body weight. Daily loss of water includes approximately 1400 mL in urine (60 mL/hr), 350 mL via respiration, 600 mL as evaporation through skin, and about 200 mL in feces. Fluid losses are 100-150 mL/day for each degree of temperature increase above 37° C. If loss by any of these routes is increased, fluid needs will increase; if loss by any of these routes is impaired, fluid restriction may be necessary. Areas to include in the nursing assessment for fluid requirements are:

♦ I&O: Evaluate that neither one is in excess of the other and for decreases in urine output.

♦ Daily weights: Rapid changes may represent problems with technique or equipment rather than actual changes in body weight. If sudden increases in weight occur, look for imbalances in I&O, occurrence of edema, and dilution of serum electrolytes.

♦ Presence or absence of edema.

♦ Skin turgor: May be helpful in younger patients, but less useful in older adults because of normal changes in skin elasticity that occur with aging.

Nutritional Support Modalities

Overview/Pathophysiology

Specialized nutritional support refers to provision of an artificial formulation of nutrients via the oral, enteral, or parenteral route for the treatment or prevention of malnutrition. Oral supplements are preferred because they are less invasive, more natural, and less costly, and enteral nutrition is preferred over parenteral.

Terms associated with formulas for oral supplements or enteral delivery

See TABLE 13-1.

TABLE 13-1 DESCRIPTIVE TERMS ASSOCIATED WITH TYPES OF ENTERAL FORMULAS

TERM	DEFINITION
Isotonic	Formula having an osmolarity of 300 mOsm/L, which is the same as blood
	Osmotic gradient between the formula and the blood flow within the intestines is equal
Hypertonic	Formula having an osmolarity greater than 300 mOsm/L, usually in the range of 450-600 mOsm/L; osmotic gradient between the formula and the blood flow within the intestines is unequal, and the formula will pull fluid into the intestines during the digestive process
Osmolarity	Referred to as mOsm/L and describes the osmotic gradient between blood and the intestines; normal level found in the blood is300 mOsm/L
Caloric density	Number of calories delivered to patient in each mL of liquid feeding
	Ranges from 0.5-2 kcal/mL
Modular	Consists of a single nutrient that may be combined with other modules (nutrients) to treat specific deficits (e.g., protein, carbohydrate, or fat) in an individual

Nutritional composition

See TABLE 13-2.

TABLE 13-2 NUTRITIONAL COMPOSITION OF ENTERAL FORMULAS AND ORAL SUPPLEMENTS

COMPONENT	TYPE	DESCRIPTION
Protein	Polymeric	Standard, complete protein nitrogen source
	Hydrolyzed	Reduced into smaller forms to assist with absorption
	Elemental/free amino acids	Simple amino acids that require no further digestion and are ready for absorption
		Usually increases formula osmolarity; bitter taste
Carbohydrate		The most easily digested and absorbed component in enteral formulas; 80% of all carbohydrate is broken down and absorbed as simple glucose in the normal intestine; most commercially available formulas are lactose free
Fat	Long-chain triglycerides	Provide an isotonic, concentrated energy source
	Medium-chain triglycerides	Used for patients with impaired fat digestion and absorption; no stimulation of pancreatic lipase secretion
	Omega-3 fatty acids	Addition of fish oils to improve immune function of the body by producing eicosapentaenoic acid
Fiber		Soy polysaccharide is most commonly added to enteral formulas as a treatment for diarrhea, although its usefulness has not been proven with research; because fiber is absorbed in the large intestine, a patient with an ileostomy would not benefit; formula viscosity increases with fiber, and it should be delivered via an enteral tube 10F or larger with an enteral feeding pump

Types of feeding tubes

Small-bore nasal tubes

Defined as 12F or smaller tube; require abdominal x-ray examination for confirmation of placement. Composition may be polyurethane, silicone, or polyvinyl chloride. Location cannot be verified in the gastrointestinal (GI) tract by auscultation after injecting an air bolus, asking patient to speak, or submerging the tube’s proximal tip into a glass of water. Usual length of tube is 36-45 inches, and it may or may not require a stylet for insertion. The physician should determine whether the distal tip ends in the stomach or small intestine. Insertion by a nurse is determined by hospital policy. The tube also may be inserted using fluoroscopy in the radiation or endoscopy department. Because of their diameter and composition, these tubes are easily dislocated proximally in the GI tract without any external signs.

Large-bore nasal tubes

Defined as larger than 12F tube; best practice is x-ray examination for confirmation of placement. Composition is either polyurethane or polyvinyl chloride. Usual length of tube is 36 inches. Stylet is not required for insertion. Insertion may be performed by a nurse.

Gastrostomy tubes

Exit stomach directly through abdominal wall and are usually anchored with either a balloon or a disk on the inside of the stomach. Generally they are 12F or larger. Composition may be polyurethane, silicone, or rubber, and these tubes may contain multiple ports for insertion of air into the balloon, delivery of medications, and the main lumen. Initially a physician in the radiology, endoscopy, or surgery department performs the insertion. When the tube is placed by a physician in the radiology or endoscopy department, the common term used to describe the tube is percutaneous endoscopic gastrostomy (PEG). Reinsertion by a nurse is determined by hospital policy.

Gastrostomy button

Placed into a mature gastrostomy stoma. It fits into the stoma tract flush with the outer abdominal wall. The button contains an antireflux valve to prevent leakage, but gastric samples or residuals usually cannot be obtained via the button.

Jejunostomy tubes

Placed by a physician either surgically or percutaneously (percutaneous endoscopic jejunostomy [PEJ]). Diameter is usually about 12F-18F. Anchoring the tube inside the jejunum presents a problem because a balloon larger than 5 mL may cause bowel obstruction. Confirmation of position requires x-ray examination with contrast. No residuals should be obtained from this tube. If the tube becomes displaced, the entry site into the jejunum will close down rapidly (approximately 20-30 min). Reinsertion by a nurse is determined by hospital policy, but it is not recommended without special training.

Gastrostomy-jejunostomy tubes

Exit stomach directly through the abdominal wall with a small-bore jejunostomy tube placed through the main lumen of the gastrostomy and the distal tip positioned in the jejunum.

BOX 13-1 presents nursing care guidelines for enteral tubes.

BOX 13-1 GENERAL NURSING CARE GUIDELINES FOR ENTERAL TUBES

Best patency is maintained with regular flushing of the tube before and after each medication, before and after each intermittent feeding, and routinely during continuous feedings.

Flush tube with water using 25-50 mL, depending on physician prescription and patient’s underlying medical condition. Dark cola also has been suggested as a potential agent for flushing tubes.

Because of impurities and bacteria in tap water, sterile water has been suggested for high-risk patients, including infants and older adults, and for any tube feeding that enters the body in the small intestine. (Check agency policy for type of water used to flush enteral feeding tubes in your patient population.)

If the enteral tube becomes clogged, it is best to identify whether the change in flow was related to formula buildup within the tube or a chemical reaction from medications being administered through the tube. If the tube is clogged with formula, products that have been suggested for declogging it are dark cola, hot water, and pancrease or other commercially available enzymatic medication pushed down the tube, using a push-pull method and correct syringe size recommended by the manufacturer. If the tube has become clogged with medications, hot water may be used via the aforementioned push-pull method. Mechanical devices are also available for declogging a tube, but use may be restricted to trained individuals within the institution. (Check with agency policy for type of declogging recommended in enteral feeding tubes.)

Always insert smallest-bore tube possible to minimize complications. A large-bore nasogastric tube may be used temporarily in the stomach until a small-bore tube can be placed; a small-bore tube must be inserted if intestinal placement is required for delivery of the formula.

When anchoring the tube in place, ensure adequate skin protection and observe for pressure on the skin.

Nasal tubes may result in pressure on the nares if the tube is taped too tightly to the nose. (Check with agency policy for frequency of nasal assessment recommended for nasal enteral feeding tubes.)

Gastric tubes may result in an increase in reflux or damage to the stoma if the tube is angled and pulled flat against the abdominal wall. Some newer tubes are being designed with an angle to facilitate taping to the abdominal wall.

If bumpers are used with a gastric tube, check with manufacturer or agency policy to identify whether it is necessary to routinely rotate the bumper around the tube while inspecting the skin daily.

If bumpers are used with a gastric tube, a dressing may not be necessary and may be avoided under the bumpers to prevent too much pulling on the tube. A dressing under a bumper may cause internal and external anchoring devices to become too tight and may thereby produce some vascular insufficiency to the abdominal wall.

If inserting a small-bore feeding tube, always verify initial placement in the stomach or small intestine with x-ray film before initiating the feeding.

Use manufacturer recommendations regarding syringe size when irrigating the tube.

Verify with pharmacy that medications are appropriate for administration via an enteral feeding tube. Change in route or delivery form may be necessary to maintain medication effects. For example:

Time-released medications may have to be changed to a short-acting form because time-released medications should not be crushed.

A medication that is absorbed in the stomach may have to be reevaluated when the distal tip of the tube is in the small intestine.

Elixirs or suspensions may be suggested because they are easier than a crushed pill to administer through an enteral tube.

Feeding sites

Stomach

Simulates normal GI functions; may be used for bolus, intermittent, or continuous feedings; indicated for patients who have intact gag or cough reflex.

Duodenum, jejunum

Must be used for continuous feedings only, to prevent dumping syndrome and diarrhea. A small-bore diameter tube is recommended.

BOX 13-2 and TABLE 13-3 present guidelines for administration of enteral products.

BOX 13-2 GENERAL NURSING CARE GUIDELINES FOR ADMINISTRATION OF AN ENTERAL FORMULA

Perform frequent oral care, especially if the individual is not taking any food by mouth.

Monitor patient to ensure delivery of prescribed volume and formula type.

Monitor daily weights.

Initially, monitor electrolyte values daily until they are stable with appropriate replacements.

If the individual has a history of glucose intolerance or is taking medications that may cause hyperglycemia, or if an increase in blood glucose is noted on serum electrolyte values, routine monitoring of the glucose should include bedside assessments q4h and treatment appropriate for maintaining glucose within normal limits.

Monitor I&O q8h. Separate intake of formula from intake of other nutrients or fluids. Keep enteral tube flushing amounts separate from enteral formula intake.

Administer formula at full strength.

Use an enteral pump for all continuous administrations of formula.

If using an open delivery system, do not use formula that has been opened for more than 24 hr. If using a closed delivery system, refer to manufacturer or agency policy for duration of hang time.

Refer to agency policy regarding checking of residuals.

Several key points in the delivery of enteral formulas established by Hazard Analysis Critical Control Point (HACCP) developed by the U.S. Department of Agriculture (USDA) and the Food and Drug Administration (FDA) include the following:

Train staff to ensure that preparation and sanitation procedures are followed.

Perform meticulous handwashing when handling all aspects of the products, including bag, formula, pump and additives.

Only hang a volume of formula that will infuse within a designated timeframe. Mark bag indicating how long it should hang.

If giving intermittent feedings, flush bag and set with water between feedings. Refer to agency policy for type of water to be used (sterile vs. tap).

Clean top of the can, if using one, with alcohol before opening and pouring into enteral bag.

Refrigerate and date all opened containers of formula.

Dispose of enteral bag, administration set, and syringes q24h.

Wear gloves while handling the equipment and products.

TABLE 13-3 ADMINISTRATION OF ENTERAL PRODUCTS

TYPE	DEFINITION	COMPLICATIONS
Bolus	Given by gravity; pushed via syringe	May cause cramping, bloating, nausea, diarrhea, aspiration; not recommended
Intermittent	Administered over 30-60 min via infusion bag; total volume should not exceed 450 mL/feeding	May cause cramping, nausea, bloating, diarrhea, aspiration; may need to ↓ infusion rate to ↓ complications
Continuous	Given at the same infusion rate over 24 hr; may be cycled over 12-24 hr if patient tolerates the volume	May cause cramping, nausea, bloating, diarrhea, aspiration; may need to ↓ infusion rate to ↓ complications

Total Parenteral Nutrition

Overview/Pathophysiology

Total parenteral nutrition (TPN) provides some or all nutrients by the IV route. TPN is used to provide complete nutrition for patients who cannot receive enteral nutrition or to supplement nutritional needs of patients who are unable to absorb sufficient calories via the GI tract. TPN is more expensive than enteral nutrition and has the potential for causing severe complications more rapidly.

Parenteral solutions

IV solutions are customized combinations of dextrose (CHO), amino acids (protein), IV fat emulsions (fat), electrolytes, vitamins, and trace metals.

CHO

Dextrose provides the bulk of calories and energy needs, with concentrations ranging from 5%-70%. The percentage of dextrose selected is based on the available administration site and patient’s volume status. All final mixed solutions that are more than 12.5% dextrose must be administered via central venous catheter (CVC). (If unsure or if information is unavailable on the infusion container related to infusion route, consult with pharmacist or refer to hospital policy.) The average amount of CHO calories delivered is approximately 60% of the total. The more CHO is delivered, the greater is the potential for complications, which include fatty liver syndrome, increased CO₂ production, and hyperglycemia.

Protein

Synthetic crystalline essential and nonessential amino acid formulations are available in concentrations of 3.5%-15%. Special amino acid formulations are available that vary the ratio of essential to nonessential amino acids for specific disorders (e.g., liver, renal disease). The amount of protein delivered depends on patient’s renal and hepatic function.

Fat

Intravenous fat emulsion (IVFE) of 10%, 20%, or 30% is an isotonic solution providing essential fatty acids and a source of concentrated calories.

When fats are mixed in the same infusion bag with the CHO and amino acids, the solution is referred to as a total nutrient admixture (TNA) or a 3 : 1 solution (all three nutrient components in one bag). The IVFE may be given piggyback into the amino acid/dextrose infusion to infuse over 8-12 hr. The amount of IVFE administered may be reduced or removed for patients who have hypertriglyceridemia (e.g., patients receiving antirejection medication following organ transplant, coronary artery disease, pancreatitis, acquired immunodeficiency syndrome [AIDS]). Determine whether patient has an egg allergy because long-chain triglycerides in IVFEs may originate from phospholipids in egg yolks. If a patient develops a rash during IVFE infusion, consider an allergy immediately. If the ratio of the protein, CHO, and IVFE in the admixture is not stable, separation of the intravenous fats from the emulsion may occur and is called “cracking” of the solution. The intravenous fats may float on top of the mixture much like an egg yolk floating in the solution or appear as an uneven yellow consistency. In addition, “oiling out” may occur and looks like an oil slick or oil droplets on top of the solution. Return to the pharmacy any solution that appears “different,” and do not use it.

BOX 13-3 presents guidelines for administration of TPN.

BOX 13-3 GENERAL NURSING CARE GUIDELINES FOR THE ADMINISTRATION OF TOTAL PARENTERAL NUTRITION

Use a 0.22-µm filter on all solutions containing amino acids and dextrose; use a 1.2-µm filter with all solutions containing amino acids, dextrose, and IVFEs. The purpose of the filter is to reduce infusion of crystals that may form from the interaction between calcium and phosphorus in the admixture. In addition, the 0.22-µm filter removes bacteria that may be in the infusion or IV system.

Administer all solutions via an IV infusion pump.

Monitor CVC insertion site for signs and symptoms of infection.

Maintain sterile, occlusive dressing on central catheter insertion site.

Refrigerate solution, if it is agency policy, until 30-60 min before administration.

The total number of calories initiated is determined by a person trained in nutritional therapy (RN, RD, or RPh) and is based on patient’s metabolic and nutritional status.

The infusion may be initiated at full rate.

Tapering is not necessary for initiation or discontinuation.

Solution may be administered over 12-24 hr, depending on patient’s medical condition.

IV push administration of D₅₀ or infusion of D₁₀W is not required with an interruption in the infusion.

Monitor for hyperglycemia.

Nondiabetic: q6h for 24-48 hr, then discontinue if no signs of glucose intolerance have occurred. If the individual is glucose-intolerant, advance bedside assessment to q4h, and begin administration of sliding scale insulin as prescribed.

Diabetic: q4h, with sliding scale regular insulin prescribed; consult with health care provider who specializes in care of the diabetic patient.

CVC, Central venous catheter; D₅₀, 50% dextrose; D₅₀W, 50% dextrose in water; IV, intravenous; IVFE, intravenous fat emulsion; RD, registered dietitian; RN, registered nurse; RPh, registered pharmacist.

Selection of administration site

Central venous catheter (CVC)

Used for all IV solutions whose final concentration is greater than 12.5% dextrose or a solution with an osmolarity 800 mOsm/L or greater. (If unsure or if information is unavailable on the infusion container related to infusion route, consult with a pharmacist or refer to hospital policy.) CVC use requires a large central vein with the distal tip of the catheter in the superior vena cava. The flow of blood through the large vessels rapidly dilutes hypertonic solutions and decreases the potential for thrombophlebitis.

Peripheral venous catheter

Reserved for individuals with a need for nutritional support for short-term periods, with small nutritional requirements, and for whom CVC access is unavailable. Only a low-osmolarity solution (less than 800 mOsm/L) can be used. To reduce osmolarity of the base solution, dilution of the components is usually required. The required large volume limits the type of patients in whom this admixture can be administered. (If unsure or if information is unavailable on the infusion container related to infusion route, consult with a pharmacist or refer to hospital policy.)

See TABLE 13-4 for types of CVCs used for administration of parenteral nutrition. TABLE 13-5 presents guidelines for management of catheter complications.

TABLE 13-4 TYPES OF CENTRAL VENOUS CATHETERS USED FOR ADMINISTERING PARENTERAL NUTRITION

CATHETER	DESCRIPTION
Temporary
Multilumen	May have up to 4 lumens; dedicate 1 lumen (preferably distal) for administration of TPN; may be inserted by physician at the bedside
PICC	May be single or dual lumen; may be used for home TPN administration because catheter may remain in place for several months; may be placed by either RN trained in IV catheter insertions or physician (usually radiologist)
Permanent
Right atrial	Placed by physician, usually surgically, into subclavian or jugular vein with catheter tunneled and exiting from the skin; the catheter usually contains a Dacron cuff from which the catheter exits the vessel; this catheter is associated with the lowest infection rate of all central venous catheters
IVAD	May be placed in either radiology department or OR; designed for repeated access over a long period, thus making repeated venipunctures unnecessary

IV, Intravenous; IVAD, implantable venous access device; OR, operating room; PICC, peripherally inserted central venous catheter; RN, registered nurse; TPN, total parenteral nutrition.

TABLE 13-5 MANAGEMENT OF CATHETER COMPLICATIONS IN PATIENTS RECEIVING PARENTERAL NUTRITION

POTENTIAL COMPLICATION	MANAGEMENT STRATEGY
Infection: insertion site	Maintain occlusive, dry dressing
	Change dressing per institutional policy using sterile technique
	When drainage appears at insertion site, change the dressing immediately
	Culture the drainage prn
	Remember: Patients who are neutropenic will develop redness at catheter insertion site because of their decrease in neutrophils
Infection: bacteremia	Observe temperature curve for signs/symptoms of increase
	Monitor for chills, rigor, tachycardia
	Maintain occlusive, dry dressing; change per institutional policy using sterile technique
	If prescribed, obtain blood cultures: one from catheter and one from a peripheral site to differentiate whether the organism is from the catheter or another site within patient
	Restrict blood drawing from lumen used for TPN administration
	Maintain blood glucose within normal limits
	Change IV caps on each lumen per hospital policy
	Use only Luer-Lok connections
	Have extra skin prep, sterile supplies available for physician during insertion of a temporary catheter
Catheter occlusion	Flush routinely using positive pressure and saline solution before and after each piggyback infusion and blood drawing; if the catheter manufacturer recommends heparin, use a heparinized solution following saline administration; if an individual develops HIT, eliminate all heparin products from IV lines, even in catheters whose manufacturer recommends using heparin
	Maintain IV filter to reduce infusion of any crystals that may have formed during admixture process
	Do not try to push occlusion through the catheter
	Notify physician
Leakage or catheter puncture	Do not insert needles into lumen cap
	Notify physician immediately if this occurs and prepare for changing of catheter (if temporary catheter) or repair of catheter (if right atrial catheter)
Pneumothorax	Position rolled towel under patient’s back, parallel to the spine, before physician inserts temporary catheter
	Obtain chest x-ray film after inserting catheter and before using catheter (except in an emergency)
	Listen for breath sounds bilaterally
	Evaluate for onset of acute chest pain that occurred with catheter insertion
	Evaluate for ear pain on the side of attempted insertion
	Assess for dyspnea or shortness of breath
	Remember: The greater the number of attempts for insertion, the greater the chance of a pneumothorax
Air embolism	Examine catheter to determine whether an open port has enabled entry of air into circulatory system
	Clamp catheter if open to air
	Turn patient onto left side with head down and feet up
	Immediately notify physician of this medical emergency after positioning patient correctly
	Administer oxygen as prescribed
CVC thrombosis with upper extremity DVT	Assess any swelling of upper extremities, noting skin color, size of extremity, presence or absence of pulses
	Notify physician of upper extremity size change
	Elevate extremity
	Evaluate need for removal of CVC
	Administer anticoagulation therapy as prescribed
	Monitor laboratory parameters per agency policy to assess results of anticoagulation therapy, if indicated
Pulmonary thromboembolism	Evaluate for presence of pleuritic pain
	Assess for predisposing factors such as surgery, high estrogen states (pregnancy or use of birth control pills), history or presence of malignancy, trauma, immobilization, presence of CVC, heart failure, spinal cord injury, history of previous thromboembolic disease, history of hypercoagulable states, history of hematologic conditions (e.g., polycythemia vera), nephritic syndrome, inflammatory bowel disease
	Assess for dyspnea or shortness of breath, hemoptysis, cough, fever, syncope, and orthopnea
	Encourage use of sequential compression devices when in bed, if medically indicated
	Use antiembolism stockings, if medically indicated
	Encourage ambulation, if medically indicated
	Administer oxygen for hypoxemia
	Administer anticoagulation therapy as prescribed
	Monitor laboratory parameters per agency policy to assess anticoagulation therapy, if indicated
Pulmonary edema	Monitor I&O, daily weights
	Assess for frothy sputum; dyspnea, shortness of breath, cyanosis
	Administer oxygen as prescribed
	Assess need for fluid restriction

CVC, Central venous catheter; DVT, deep vein thrombosis; HIT, heparin-induced thrombocytopenia; I&O, intake and output; IV, intravenous; prn, as needed; TPN, total parenteral nutrition.