TOTAL PARENTRAL NUTRITION

DEFINITION:

Intravenous administration of varying combinations of hypertonic or

isotonic glucose, lipids, amino acid, electrolytes, vitamins and trace
elements through a venous access device(VAD) directly into the
intravascular fluid to provide nutrients for patients who are unable to
receive adequate nutrition through gastrointestinal tract.

PURPOSES:

➢ To provide nutrients required for the normal metabolism, tissue

maintenance, repair and energy demands.
➢ To bypass the GI tract for patients who are unable to take food
orally.

INDICATIONS:
Patient who cannot tolerate enteral nutrition because of-
o Paralytic ileus
o Intestinal obstruction
o Acute pancreatitis
o Inflammatory bowel disease
o Gastro intestinal fistula
o Severe diarrhea
o Persistent vomiting
o Malabsorption
Hyper metabolic states for which enteral therapy either not possible or
inadequate-
 o Severe burns
o NPO for more than 5days
o Acute renal failure
o Multiple fractures
o Tumor in GI tract
Patient at risk for malnutrition of-
o Gross under weight
o Metastatic cancer

CONTRAINDICATIONS:
o Functional and accessible GI tract
o Patient is taking oral diet
o Prognosis does not warrant aggressive nutrition
support(terminally ill)
o Risk exceeds benefit
o Patient expected to meet needs within 14days.

SCIENTIFIC PRINCIPLES:
o Provision of adequate calories
o Provision of adequate water
o Provision of adequate nitrogen
o Provision of adequate electrolytes
o Provision of adequate vitamins

PREPARATION OF PATIENT/UNIT:
1. Check name, bed no, and other identification mark of the patient
2. Check the diagnosis and the need of total parenteral nutrition
3. Assess the patient for any clinical conditions
 4. Assess the patients vital signs and any complications before
starting the procedure
5. Explain the need of total parenteral nutrition and the sequence of
procedure.
6. Gain the patient’s confidence
7. Keep the patient in proper position

PREPROCEDURE ASSESSMENT OF PATIENT:

Assessment Additional Information

Intravenous line should remain patent, free from infection.

Dextrose in TPN increases risk of infection. Assess for signs and

CVC/peripheral IV line
symptoms of infections at site (redness, tenderness, discharge) and
systemically (fever, increased WBC, malaise). Dressing should be dry
and intact.

Monitor for evidence of edema or fluid overload. Over time,

Daily or biweekly weights measurements will reflect weight loss/gain from caloric intake or
fluid retention.

QID (4 times a day) capillary blood glucose initially to monitor

glycemic control, then reduce monitoring when blood sugars are
Capillary or serum blood
stable or as per agency policy. May be done more frequently if
glucose levels
glycemic control is difficult. Indicates metabolic tolerance to dextrose
in TPN solution and patient’s glycemic status.

Monitor and record every eight hours or as per agency policy.

Monitor for signs and symptoms of fluid overload (excessive weight
gain) by completing a cardiovascular and respiratory assessment.
Assess intakes such as IV (intravenous fluids), PO (oral intake), NG
Monitor intake and output
(nasogastric tube feeds). Assess outputs: NG (removed gastric content
through the nasogastric tube), fistula drainage, BM (liquid bowel
movements), colostomy/ileostomy drainage, closed suction drainage
devices (Penrose or Jackson-Pratt drainage) and chest tube drainage.

Review lab values for increases and decreases out of normal range.
Lab values include CBC, electrolytes, calcium, magnesium,
Daily to weekly blood work
phosphorus, potassium, glucose, albumin, BUN (blood urea
nitrogen), creatinine, triglycerides, and transferrin.
 Most patients will be NPO. Proper oral care is required as per agency
Mouth care
policy. Some patients may have a diet order.

Vital signs are more frequently monitored initially in patients with

Vital signs
TPN.

ARTICLES:

1. Bag of parenteral nutrition

2. Administration nutrition with luer-lock connections
3. Hypoallergic tape
4. Face mask
5. Sterile gloves
6. Central venous access devices: long term VAD such as thick man,
broviac or Gros hung catheters or peripherally inserted central
catheter(PICC line)
7. Volume control infuser
8. Filters 0.22 micron for TPN(without fat emulsion) 3.2 micron
filter for TNA or fat emulsion

STEPS OF THE PROCEDURE:

Nursing Action Rationale

Performing Nutritional assessment Provides baseline data
Check physician’s order Parenteral therapy must be ordered by
physician
Explain the procedure
Obtain informed consent
Collect needed equipment for the procedure
Remove the bag of parenteral nutrition from Decrease the incidence of hypothermia,
refrigerator at least 1hr before procedure pain and vasospasm
Inspect fluid for presence of creaming or any Indicates fluid separation TPN solution
change in constitution should be clear without clouding

Wash hands and don cap, mask, gown, sterile Follow strict aseptic precautions
gloves

Using sterile aseptic technique, attach tubing Prevents chances of developing air
(with filter) to TNA bag purge out air. Use sterile embolus
aseptic technique, attach tubing (with filter) to
TNA bag purge out air

Close all clamps on new tubing and insert

tubing into volume control infuses

Place the patient in supine position and head Supine position with head turned one side
away from VAD insertion site opens the angle between clavicle and first
rib

Clean the insertion site with alcohol and Assist physician while inserting VAD
povidone-iodine solution

After insertion VAD connect tubing to hub of

VAD using sterile technique and make sure that
the connection is secured using luer-lock
connection

Open all clamps and regulate flow through

volume control infuser

Monitor administration hourly, assessing for

integrity of fluid and administration system and
patient tolerance
Record the procedure

AFTER CARE OF ARTICLES:

• Collect all the articles used and take them to the utility room.
• Clean them first in cold watter and then with warm soapy water
• Rinse them thoroughly, dry them and send for sterilization
• Wash hands

POST PROCEDURE CARE:

• To avoid severe metabolic distress, nutritional therapy may be

prescribed, using the enteral route whenever possible.
• Motility disorders of the stomach must be recorded.
• Total energy requirement is between 30 and 35 kcal/kg/day.
• About 50-70% should be provided in the form of carbohydrates,
and 20-30% in the form of lipids.
• The ideal nitrogen administration is 250-300 mg/kg/day.
• An adequate follow up must include clinical and biochemical
parameters.

DOCUMENTATION:

• Maintenance of weight and strength with the overall health status

must be documented.
• Prokinetic medications used, dosage, and dates of use.
• Medical records must document necessity for protein orders
outside the range of 0.8-1.5 g/kg/day, dextrose
concentration<10% or lipid use>1500 gm/months
 CHECKLIST:

TOPIC: TOTAL PARENTRAL NUTRITION

S.NO STEPS OF THE PROCEDURE YES NO

1. Confirm patient identity
according to the policy
2. Identify appropriate
administration route for type
of PN, confirm catheter tip
placement and patency
3. Identify pertinent allergies
such as egg allergies for
patient receiving ILE and
acknowledge review by
prescriber
4. Check PN label against the
original order via
standardized form/EHR PN
template
5. Inspect PN admixture to
detect defects visual changes
initially and then during the
infusion of recognition of
compromised admixture
6. Accurately program PN
infusion pump including
correct rate and infusion
time
7. Express knowledge of policy
on verifying pump settings
during the infusion and at
handoffs
8. Demonstrate accurate use of
 IV filters on PN
administration tubing,
express knowledge of
occluded filter policy
9. Trace PN tubing to the
catheter/body prior to
attaching PN, label PN tubing
to pump(s) to verify infusion
source
10. Express knowledge of
maintaining PN infusion at
prescribed rate (avoid
interruptions)
11. Demonstrate knowledge of
medications administration
guidelines (co-infusion and
not adding medications to
the PN bag)
12. Demonstrate vascular access
device (VAD) dressing care
procedures and aseptic

SUBMITTED BY:
1. KUMARI ABHILASHA
AIN/2107/465
2. HAINASHRI BORO
AIN/2017/466