Component/

Potential Problem

Nursing Management

Preparation of
parenteral
nutrition (PN)
solutions

All PN solutions are prepared by a pharmacist or a trained technician using strict aseptic techniques under a laminar flow
hood.
Add nothing to PN solutions after they are prepared in the pharmacy. Danger of drug incompatibilities and contamination is
high.
Limit number of personnel involved in the preparation and administration of PN to reduce risk of infection.
PN solutions are ordered daily to adjust to the patients current needs.
PN solution label indicates the nutrient content, all additives, the time mixed, and the date and time of expiration. In
general, solutions are good for 24hr and must be refrigerated until 30min before use.

IV filters, tubing,
and infusion
pumps

Proper aseptic techniques are followed to reduce infection risk.

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.
Change filters and IV tubing q24hr if PN with lipids is being administered and q72hr for PN with amino acids and dextrose.
Label tubing and the filter with the date and the time they are put into use.
Control rate of infusion. Peripheral PN solutions should be administered with a volumetric controller, whereas a pump is
used for central PN solutions. An infusion pump is used during administration of PN to maintain rate.
Set alarm to alert for tubing obstruction.
Periodically check the volume infused because pump malfunctions can alter the rate.

Catheter site care

Change dressings covering the catheter site according to institutional protocol, ranging from every other day to once a
week. The procedure for changing the dressing is similar to that followed after catheter insertion.
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.
High-risk patients include those who are immunosuppressed. Note subtle signs of infection in patients receiving
chemotherapy, corticosteroids, or antibiotics, which can mask signs of infection.
If an infection is suspected during a dressing change, a culture specimen of the site and drainage should be sent for
analysis, and the health care provider notified immediately.

Ensuring patient
safety

Check the label and ingredients in the solution to see that they match what the health care provider ordered before starting
PN.
Examine the solution for leaks, color changes, particulate matter, clarity, and fat emulsion cracking. If present, promptly
return it to the pharmacy for replacement.
Ensure that the PN solution is discontinued and replaced with a new solution if the bag is not empty at the end of 24hr. At
room temperature, the solution, especially when containing fat emulsion, is a good medium for microorganism growth.
Sometimes fat emulsions are infused separately from the PN solution. The preferred delivery method is a continuous low
volume, such as 20% lipids delivered over 12hr.
Monitor for adverse reactions, including allergic manifestations, dyspnea, cyanosis, fever, flushing, phlebitis, chest and back
pain, and pain at the IV site.
IV fat administration provides a large number of calories in a relatively small amount of fluid. This is beneficial when the
patient is at risk for fluid overload.

Hypoglycemia

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 5% dextrose solution (based on the amount of dextrose in the peripheral
PN solution) may be administered to prevent hypoglycemia.

Hyperglycemia

Initially check glucose blood levels at bedside q4-6hr with glucose-testing meter (see Chapter 49) for hyperglycemia
(metabolic complication of PN).
Maintain a glucose range of 110-150mg/dL. A sliding scale dose of insulin may be ordered to keep the glucose level in
normal range.
Insulin can be added to the PN admixture, but the dosage will not be able to be changed for 24hr.

Catheter-related
infections

Catheter-related infection and septicemia can occur in patients receiving PN. Local manifestations of infection include
erythema, tenderness, and exudate at the catheter insertion site. Systemically, the patient may have fever, chills, nausea,
vomiting, and malaise.
If no other causes can be identified, a catheter-related infection is suspected. Because of the risk of infection, catheters
with antibiotic or antiseptic surfaces may be used.
To determine the causative organism, cultures are performed of the catheter tip, if the catheter has been removed, or of
the blood in the catheter, if it is still in place. Blood cultures are drawn simultaneously from the catheter and a peripheral
vein.
A chest x-ray is taken to detect changes in pulmonary status. Antibiotics may be prescribed. A new central line may or may
not be immediately placed depending on the patients condition.

Transitioning to
oral nutrition

Encourage oral nourishment and maintain a careful record of intake. A general rule is that 60% of caloric needs should be
met orally before discontinuation of PN or EN.
Once the catheter is removed, change dressing daily and assess wound healing.

General nursing
considerations

Monitor initial vital signs q4-8hr in the patient receiving PN.

Weigh patient daily as a measure the patients hydration status. 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.
Assess whether gains or losses in weight are caused by fluid gained from edema, fluid lost through diuresis, or actual
increase or decrease in tissue weight.
Assess blood levels of glucose, electrolytes, and urea nitrogen. A complete blood count and hepatic enzyme studies are
followed a minimum of three times per week until stable and then weekly as the patients condition warrants. Assessment
of these important values assists you in evaluating the patients tolerance of PN.

Copyright 2014, 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, an imprint of Elsevier Inc.

Gastrointestinal System

eTABLE 40-8 NURSING MANAGEMENT OF PARENTERAL NUTRITION INFUSIONS