Parenteral Nutrition Administration
When a patient can’t meet his nutritional needs by oral or enteral feedings, he may require IV nutritional support, or parenteral nutrition. The patient’s diagnosis, history, and prognosis determine the need for parenteral nutrition. Generally, this treatment is prescribed for any patient who can’t absorb nutrients though the GI tract for more than 7 to 10 days.1
More specific indications include debilitating illness lasting longer than 2 weeks; loss of 10% or more of pre-illness weight; serum albumin level below 3.5 g/dL; excessive nitrogen loss from wound infection, fistulas, or abscesses; renal or hepatic failure; or a nonfunctioning GI tract for 5 to 7 days in a severely catabolic patient.
Common illnesses that can trigger the need for parenteral nutrition include inflammatory bowel disease, radiation enteritis, severe diarrhea, intractable vomiting, and moderate to severe pancreatitis. A massive small-bowel resection, bone marrow transplantation, high-dose chemotherapy or radiation therapy, and major surgery can also hinder a patient’s ability to absorb nutrients, requiring parenteral nutrition.
Parenteral nutrition shouldn’t be given to patients with a normally functioning GI tract, and it has limited value for well-nourished patients whose GI tract will resume normal function within 10 days. It also may be inappropriate for patients with a poor prognosis or if the risks of parenteral nutrition outweigh the benefits.
Parenteral nutrition may be given through a peripheral or central venous (CV) access device. Depending on the solution, it may be used to boost the patient’s caloric intake, supply full caloric needs, or surpass the patient’s caloric requirements.
The type of parenteral solution prescribed depends on the patient’s condition and metabolic needs and on the administration route. The solution usually contains protein, carbohydrates, electrolytes, vitamins, and trace minerals. A lipid emulsion provides the necessary fat. (See Types of parenteral nutrition.)
Total parenteral nutrition (TPN) refers to any nutrient solution, including lipids, given through a CV access device. Peripheral parenteral nutrition (PPN), which is given through a peripheral catheter, supplies full caloric needs while avoiding the risks that accompany CV access. To keep from sclerosing the vein through which it’s administered, the dextrose in PPN solution must be limited to 10% or less.2 Therefore, the success of PPN depends on the patient’s tolerance for the large volume of fluid necessary to supply his nutritional needs.
It’s not uncommon for a patient to need an increase in the glucose content beyond the level a peripheral vein can handle. For example, most TPN solutions are six times more concentrated than blood; because of this, they must be delivered into a vein that has a high blood flow rate to dilute the solution.
The most common delivery route for TPN is through a CV access device into the superior vena cava.
Equipment
Bag or bottle of prescribed parenteral nutrition solution ▪ IV administration set ▪ sterile IV tubing ▪ 0.2-micron filter (or 1.2-micron filter if solution contains lipids or albumin)2 ▪ time tape ▪ alcohol pads ▪ electronic infusion pump ▪ preservative-free normal saline solution ▪ intake-and-output record ▪ gloves ▪ Optional: mask.
Preparation of Equipment
Remove the solution from the refrigerator 30 minutes to 1 hour before use.2
Implementation
Verify the doctor’s order3 and make sure that the prescribed therapy is appropriate for the patient’s age, condition, and access device and that the dose, rate, and route are appropriate for the patient.2
Make sure that the solution container is labeled with the patient’s identifiers and that the formula components have been added according to the doctor’s order. Perform an independent double-check with another nurse if required by your facility.
Inspect the integrity of the container and solution, and check the expiration date; return the solution to the pharmacy if the integrity of the container is compromised, the solution is cloudy or contains particles, or the solution is expired.
Confirm the patient’s identity using at least two patient identifiers according to your facility’s policy.2,7
Explain the procedure to the patient and answer all questions to allay his anxiety.
Compare the patient’s name and second patient identifier on the solution container against the name on the patient’s identification band.7
If your facility uses a bar code scanning system, scan your identification badge, the patient’s identification band, and the solution’s bar code according to your facility’s policy.
Connect the IV infusion pump administration set and the micron filter (if the tubing doesn’t contain an in-line filter); insert the filter as close to the catheter insertion site as possible.8
Squeeze the IV drip chamber and, holding the drip chamber upright, insert the tubing spike into the IV bag or bottle. Then release the drip chamber.
Prime the administration set tubing by inverting the filter at the distal end of the tubing and then opening the roller clamp. Let the solution fill the filter and the tubing; gently tap the tubing, filter, and Y-ports to dislodge trapped air.
Types of Parenteral Nutrition
| Type | Solution Components/Liter | Uses | Special Considerations |
|---|---|---|---|
| Total parenteral nutrition (TPN) by way of central venous (CV) access |
|
| Basic solution
|
| Total nutrient admixture |
|
|
|
| Peripheral parenteral nutrition |
|
| Basic solution
|
Attach the IV administration set tubing to the electronic infusion pump following the manufacturer’s instructions, and set the infusion rate, concentration, and volume to be infused. Make sure that the infusion pump alarms are turned on and functioning. Label the container and IV tubing with the date, time, and your initials.
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