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ASSIGNMENT
ON
TOTAL PARENTERAL
NUTRITION

Submitted by, Submitted to,

Mrs. Gayathri R Mrs.Sumitha
1st Year MSc Nursing SeniorLecturer
Upasana college of Upasana college of
Nursing Kollam Nursing Kollam

Submitted on:03.12.2018
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INTRODUCTION
Parenteral nutrition (PN) is the feeding of specialist nutritional products to a
person intravenously, bypassing the usual process of eating and digestion. The
products are made by specialist pharmaceutical compounding companies and is
considered to be the highest risk pharmaceutical preparation available as the
products cannot undergo any form of terminal sterilization. The person receives
highly complex nutritional formulae that contain nutrients such
as glucose, salts, amino acids, lipids and added vitamins and dietary minerals. It
is called total parenteral nutrition (TPN) or total nutrient admixture (TNA)
when no significant nutrition is obtained by other routes, and partial parenteral
nutrition (PPN) when nutrition is also partially enteric. It may be
called peripheral parenteral nutrition (PPN) when administered through vein
access in a limb rather than through a central vein as central venous
nutrition (CVN).

CONTENT
TOTAL PARENTERAL NUTRITION
Total parenteral nutrition (TPN) is a method of feeding that bypasses the
gastrointestinal tract. Fluids are given into a vein to provide most of the nutrients
the body needs.

Medical uses
Total parenteral nutrition (TPN) is provided when the gastrointestinal tract is non
functional because of an interruption in its continuity (it is blocked, or has a leak
- a fistula) or because its absorptive capacity is impaired.[1] It has been used
for comatose patients, although enteral feeding is usually preferable, and less
prone to complications. Parenteral nutrition is used to prevent malnutrition in
patients who are unable to obtain adequate nutrients by oral or enteral routes. The
Society of Critical Care Medicine (SCCM) and American Society for Parenteral
and Enteral Nutrition recommends waiting until hospital day number seven.[3]
Absolute indications for TPN

 Short bowel syndrome

 Small bowel obstruction
 Active gastrointestinal bleeding
 Pseudo-obstruction with complete intolerance to food
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 High-output (defined as > 500ml/day) enteric-cutaneous fistulas (unless a

feeding tube can be passed distal to the fistula)
Gastrointestinal disorders
TPN may be the only feasible option for providing nutrition to patients who do
not have a functioning gastrointestinal tract or who have disorders requiring
complete bowel rest, including bowel obstruction short bowel
syndrome gastroschisis, prolonged diarrhoea regardless of its cause very
severe Crohn's disease or ulcerative colitis and certain pediatric GI disorders
including congenital GI anomalies and necrotizing enterocolitis
In cancer
The benefit of TPN to cancer patients is largely debated, and studies to date have
generally showed minimal long term benefit.

Duration
Short-term PN may be used if a person's digestive system has shut down (for
instance by peritonitis), and they are at a low enough weight to cause concerns
about nutrition during an extended hospital stay. Long-term PN is occasionally
used to treat people suffering the extended consequences of an accident, surgery,
or digestive disorder. PN has extended the life of children born with non existent
or severely deformed organs.
Living with TPN
Approximately 40,000 people use TPN at home in the United States, and because
TPN requires anywhere from 10–16 hours to be administered, daily life can be
affected. Although daily lifestyle can be changed, most patients agree that these
changes are better than staying at the hospital Many different types of pumps exist
to limit the time the patient is “hooked-up”. Usually a backpack pump is used,
allowing for mobility. The time required to be connected to the IV is dependent
on the situation of each patient; some require once a day, or five days a week
It is important for patients to avoid as much TPN related change as possible in
their lifestyles. This allows for the best possible mental health situation;
constantly being held down can lead to resentment and depression. Physical
activity is also highly encouraged, but patients must avoid contact sports
(equipment damage) and swimming (infection). Many teens find it difficult to
live with TPN due to issues regarding body image and not being able to
participate in activities and events
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Complications
TPN fully bypasses the GI tract and normal methods of nutrient absorption.
Possible complications, which may be significant, are listed below. Other than
those listed below, other common complications of TPN include
hypophosphatemia, hypokalemia, hyperglycemia, hypercapnia, decreased copper
and zinc levels, elevated prothrombin time (if associated with liver injury),
hyperchloremic metabolic acidosis and decreased gastrointestinal motility
Infection
TPN requires a chronic IV access for the solution to run through, and the most
common complication is infection of this catheter. Infection is a common cause
of death in these patients, with a mortality rate of approximately 15% per
infection, and death usually results from septic shock When using central venous
access, the subclavian (or axillary) vein is preferred due to its ease of access and
lowest infectious complications compared to the jugular and femoral vein
insertions
Blood clots
Chronic IV access leaves a foreign body in the vascular system, and blood clots
on this IV line are common Death can result from pulmonary embolism wherein
a clot that starts on the IV line breaks off and travels to the lungs, blocking blood
flow.
Patients on TPN who have such clots occluding their catheter may receive
a thrombolytic flush to dissolve the clots and prevent further complications.
Fatty liver and liver failure
Fatty liver is usually a more long term complication of TPN, though over a long
enough course it is fairly common. The pathogenesis is due to using linoleic acid
(an omega-6 fatty acid component of soybean oil) as a major source of
calories TPN-associated liver disease strikes up to 50% of patients within 5–7
years, correlated with a mortality rate of 2–50%. Onset of this liver disease is the
major complication that leads TPN patients to requiring an intestinal transplant
Intralipid (Fresenius-Kabi), the US standard lipid emulsion for TPN nutrition,
contains a 7:1 ratio of n-6/n-3 ratio of polyunsaturated fatty acids(PUFA). By
contrast, Omegaven has a 1:8 ratio and showed promise in multiple clinical
studies. Therefore n-3-rich fat may alter the course of parenteral nutrition
associated liver disease.
Hunger
Because patients are being fed intravenously, the subject does not physically eat,
resulting in intense hunger pangs (pains). The brain uses signals from
the mouth (taste and smell), the stomach/gastrointestinal tract (fullness)
and blood (nutrient levels) to determine conscious feelings of hunger. In cases of
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TPN, the taste, smell and physical fullness requirements are not met, and so the
patient experiences hunger, despite the fact that the body is being fully nourished.
Patients who eat food despite the inability can experience a wide range of
complications.
Cholecystitis
Total parenteral nutrition increases the risk of acute cholecystitis due to complete
disuse of gastrointestinal tract, which may result in bile stasis in the gallbladder.
Otherpotential
:hepatobiliarydysfunctions include steatosis, steatohepatitis, cholestasis,
and cholelithiasis Six percent of patients on TPN longer than 3 weeks and 100%
of patients on TPN longer than 13 weeks develop biliary sludge. The formation
of sludge is the result of stasis due to lack of enteric stimulation and is not due to
changes in bile composition. Gallbladder sludge disappears after 4 weeks of
normal oral diet. Administration of exogenous cholecystokinin (CCK) or
stimulation of endogenous CCK by periodic pulse of large amounts of amino
acids have been shown to help prevent sludge formation. These therapies are not
routinely recommended Such complications are suggested to be the main reason
for mortality in people requiring long-term total parenteral nutrition, such as
in short bowel syndrome In newborn infants with short bowel syndrome with less
than 10% of expected intestinal length, thereby being dependent upon total
parenteral nutrition, 5 year survival is approximately 20%.
Gut atrophy
Infants who are sustained on TPN without food by mouth for prolonged periods
are at risk for developing gut atrophy
Other complication
Other complications are either related to catheter insertion, or metabolic,
including re-feeding syndrome. Catheter complications include pneumothorax,
accidental arterial puncture, and catheter-related sepsis. The complication rate at
the time of insertion should be less than 5% Catheter-related infections may be
minimised by appropriate choice of catheter and insertion technique.Metabolic
complications include the re-feeding syndrome characterised
by hypokalemia, hypophosphatemia and hypomagnesemia. Hyperglycemia is
common at the start of therapy, but can be treated with insulin added to the TPN
solution. Hypoglycaemia is likely to occur with abrupt cessation of TPN. Liver
dysfunction can be limited to a reversible cholestatic jaundice and to fatty
infiltration (demonstrated by elevated transaminases). Severe hepatic dysfunction
is a rare complication Overall, patients receiving TPN have a higher rate of
infectious complications. This can be related to hyperglycemia.
Pregnancy
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Pregnancy can cause major complications when trying to properly dose the
nutrient mixture. Because all of the baby’s nourishment comes from the mother’s
blood stream, the doctor must properly calculate the dosage of nutrients to meet
both recipients’ needs and have them in usable forms. Incorrect dosage can lead
to many adverse, hard-to-guess effects, such as death, and varying degrees
of deformation or other developmental problems
It is recommended that parenteral nutrition administration begin after a period of
natural nutrition so doctors can properly calculate the nutritional needs of
the fetus. Otherwise, it should only be administered by a team of highly skilled
doctors who can accurately assess the fetus needs

Total parenteral nutrition

. The use of standardized parenteral nutrition solutions is cost effective and may
provide better control of serum electrolytes. Ideally each patient is assessed
individually before commencing on parenteral nutrition, and a team consisting of
specialised doctors, nurses, clinical pharmacists and registered dietitians evaluate
the patient's individual data and decide what PN formula to use and at what
infusion rate.
For energy only, intravenous sugar solutions with dextrose or glucose are
generally used. This is not considered to be parenteral nutrition as it does not
prevent malnutrition when used on its own. Standardized solutions may also
differ between developers. Following are some examples of what compositions
they may have. The solution for normal patients may be given both centrally and
peripherally.

Examples of total parenteral nutrition solutions

Substance Normal patient High stress Fluid-restricted

Amino acids 85 g 128 g 75 g

Dextrose 250 g 350 g 250 g

Lipids 100 g 100 g 50 g

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Na+ 150 mEq 155 mEq 80 mEq

K+ 80 mEq 80 mEq 40 mEq

Ca2+ 360 mg 360 mg 180 mg

Mg2+ 240 mg 240 mg 120 mg

Acetate 72 mEq 226 mEq 134 mEq

Cl− 143 mEq 145 mEq 70 mEq

P 310 mg 465 mg 233 mg

MVI-12 10 mL 10 mL 10 mL

Trace elements 5 mL 5 mL 5 mL

Components
Prepared solutions
Prepared solutions generally consist of water and electrolytes; glucose, amino
acids, and lipids; essential vitamins, minerals and trace elements are added or
given separately. Previously lipid emulsions were given separately but it is
becoming more common for a "three-in-one" solution of glucose, proteins, and
lipids to be administered.
Added components
Individual nutrient components may be added to more precisely adjust the body
contents of it. That individual nutrient may, if possible, be infused individually,
or it may be injected into a bag of nutrient solution or intravenous fluids (volume
expander solution) that is given to the patient.
Administration of individual components may be more hazardous than
administration of pre-mixed solutions such as those used in total parenteral
nutrition, because the latter are generally already balanced in regard to e.g.
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osmolarity and ability to infuse peripherally. Incorrect IV administration of

concentrated potassium can be lethal, but this is not a danger if the potassium is
mixed in TPN solution and diluted.
Vitamins may be added to a bulk premixed nutrient immediately before
administration, since the additional vitamins can promote spoilage of stored
product] Vitamins can be added in two doses, one fat-soluble, the other water-
soluble. There are also single-dose preparations with both fat- and water-soluble
vitamins such as Cernevit.
Minerals and trace elements for parenteral nutrition are available in prepared
mixtures, such as Addaven.
Emulsifier
Only a limited number of emulsifiers are commonly regarded as safe to use for
parenteral administration, of which the most important is lecithin Lecithin can be
biodegraded and metabolized, since it is an integral part of biological membranes,
making it virtually non-toxic. Other emulsifiers can only be excreted via the
kidneys,creating a toxic load. The emulsifier of choice for most fat emulsions
used for parenteral nutrition is a highly purified egg lecithin, due to its low
toxicity and complete integration with cell membranes.
Use of egg-derived emulsifiers is not recommended for people with an egg
allergy due to the risk of reaction. In situations where there is no suitable
emulsifying agent for a person at risk of developing essential fatty acid
deficiency, cooking oils may be spread upon large portions of available skin for
supplementation by transdermal absorption.
Another type of fat emulsion Omegaven is being used experimentally within the
US primarily in the pediatric population. It is made of fish oil instead of the egg
based formulas more widely in use. Research has shown use of Omegaven may
reverse and prevent liver disease and cholestasis.
Minimizing manipulation of and contact with the intravenous catheter, the
administration set, and the PN bag itself, including routine line changes, can
lower the risk for catheter-related infections. Human studies of 24- versus 72-
hour PN line changes revealed a significant decrease in the incidence of
nosocomial septicemia when changes were prolonged to 72 hours. The authors of
the study speculated that decreased septicemia was due to the fact that most of
the contamination was introduced through the open catheter hub during
intravenous line changes. In the case of patients receiving PN through a central
catheter, multi-lumen central catheters do not have an increased risk for infection
versus single-lumen catheters as long as the lumen dedicated to PN is kept sterile
as outlined in BOX 3 and is dedicated solely to PN.
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DISCONTINUING PARENTERAL NUTRITION

The parenteral nutrition solution is discontinued gradually to allow the patient to

adjust to decreased levels of glucose. If the PN solution is abruptly terminated,
isotonic dextrose is administered for 1 to 2 hrs to protect against rebound
hypoglycaemia. Providing oral carbohydrates shortens the tapering time. Once all
IV therapy is completed, the nurse(with physicians order) removes the non
tunnelled central venous catheter or PICC & applies an occlusive dressing to the
exit site. Tunnelled catheters & implanted ports are removed only by the
physician.

NURSING DIAGNOSIS

 Imbalanced nutrition less than body requirement related to inadequate oral

intake of nutrients.
 Risk for infection related to contamination of the central catheter site or
infusion line.
 Risk for immobility related to fear that the catheter will become dislodged
or occluded.
 Risk for ineffective therapeutic regimen management related to knowledge
deficit about home & PN therapy.

NURSING INTERVENTIONS

 Maintaining optimal nutrition.

 Maintaining fluid balance.
 Encouraging activity.
 Promoting home & community based care.
 Teaching patient self care.
 Community based care.
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CONCLUSION

Parenteral nutrition is a viable nutritional choice for small animal patients that
cannot receive nutrition enterally. It is possible to both obtain and administer PN
in a private practice setting. PN formulations should be obtained from a pharmacy
where appropriate protocols are followed to safely compound the solution.
However, once the PN has been formulated, special equipment-other than an
aseptically placed and maintained catheter dedicated specifically to PN-is not
required for administration.

BIBLIOGRAPHY
 Brunner & Suddarth,Text book of medical surgical nursing,11th
edition,,Published by Wolters Kluers pvt ltd,Page no:1193-1199
 www.pubmed.com