Parenteral Nutrition Monitoring
Parenteral nutrition requires careful monitoring. Because the typical patient is in a protein-wasting state, parenteral nutrition therapy causes marked changes in fluid and electrolyte status and in glucose, amino acid, mineral, and vitamin levels. If the patient displays an adverse reaction or signs of complications, the parenteral nutrition regimen can be changed, as needed. (See “Parenteral nutrition administration,” page 546.) Assessing a patient’s nutritional status includes a physical examination as well as reviewing body weight, body composition, somatic and visceral protein stores, and laboratory values. Assessing the patient’s condition to detect complications requires recognizing the signs and symptoms of such complications, understanding of laboratory test results, and keeping careful records.
Because the parenteral nutrition solution is high in glucose content, the infusion must start slowly to allow the patient’s pancreatic beta cells to adapt to it by increasing insulin output. Within the first 3 to 5 days of parenteral nutrition, the typical adult patient can tolerate 3 L of solution daily without adverse reactions. Lipid emulsions also require monitoring.
Gloves ▪ parenteral nutrition solution and administration equipment ▪ blood glucose meter ▪ stethoscope ▪ sphygmomanometer ▪ watch with second hand ▪ scale ▪ input and output chart ▪ additional equipment for nutritional assessment, as ordered ▪ Optional: face mask.
Preparation of Equipment
For information on preparing the infusion pump and parenteral nutrition solution, see the appropriate procedures. Make sure each bag or bottle has a label listing the expiration date, glucose concentration, and total volume of solution. (If the bag or bottle is damaged and you don’t have an immediate replacement, hang a bag of dextrose 10% in water until the new container is ready.)
Confirm the patient’s identity using at least two patient identifiers according to your facility’s policy.4,5
Explain the procedure to the patient to diminish his anxiety and encourage cooperation. Instruct him to inform you if he experiences any unusual sensations during the infusion.
Record vital signs at least every 8 hours, or as ordered, because temperature elevation may be a sign of intravascular catheter-related bloodstream infection.
Change the continuously used administration tubing and filters no more frequently than every 96 hours if lipids aren’t being infused; replace tubing every 24 hours if lipids are being infused continuously, or according to your facility’s policy. If lipids are administered intermittently, change the administration tubing with each new container. Change the administration tubing immediately if contamination is suspected or if the integrity of the product or system has been compromised.6,7
If the patient has a short peripheral catheter, don’t perform routine site care; instead, change the dressing if it becomes damp or soiled or is no longer intact.6,8 (See “IV catheter maintenance,” page 431.)
If the patient has a short-term central venous (CV) access device, routine dressing changes depend on the type of dressing. Change transparent semipermeable dressings at least every 7 days; change gauze dressings every 2 days. Change either dressing if it becomes damp or soiled or is no longer intact.6,8 Dressing changes should also include cleaning the catheter-skin junction with an antiseptic solution and replacing the stabilizing device, if used.6 (See “Central venous access catheter,” page 133.)
Physically assess the patient daily; monitor for signs of peripheral and pulmonary edema. Inspect the vascular catheter insertion site daily and palpate for tenderness through the intact dressing. Remove the dressing and thoroughly examine the site if fever, tenderness, or other findings that suggest a local or bloodstream infection exist.6,8 If ordered, measure the patient’s arm circumference and skin-fold thickness over the triceps.
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