Parenteral Nutrition Because the caloric and nutritional value of PPN is limited, it is best suitedfor patients
who need short-term nutrition support (7–10 days) and do not requiremore than 2500
Also referred to as total parenteral nutrition (TPN) or intravenoushyperalimentation, is
the IV infusion of dextrose, water, fat, proteins, electrolytes, vitamins, and trace
elements. Because TPN solutionsarehypertonic (highly concentrated in
comparison to the soluteconcentration of blood), they are injected only into high-
flowcentral veins, where they are diluted by the client’s blood.
*Hypertonic solution causes water movement from the cell going to theareaof higher
solute concentration.
*Hypertonic solutions cause cells to shrink.
TPN is a means of achieving an anabolic state in clients who are unabletomaintain a
normal nitrogen balance. Such clients may include thosewithsevere malnutrition,
severe burns, bowel disease disorders (e.g., ulcerativecolitis or enteric fistula), acute
renal failure, hepatic failure, metastatic cancer, or major surgeries where nothing may
be taken by mouth for more than5days.
*anabolic state- state when the body builds and grows, a metabolic processthat
involves repair for growth and building.
Catheter Placement
PN may be infused via peripheral or central veins.
Peripheral parenteral nutrition (PPN) - is not widely used because solutionsinfused
into peripheral veins must beisotonic(i.e., they must havelowconcentrations of
dextrose and amino acids) to prevent phlebitis andincreased risk of thrombus
formation.
cal/day. PPN is contraindicated in patients who needafluidrestriction, such as in
patients with renal failure, liver failure, or congestiveheart failure.
Central PN infuses a hypertonic, nutritionally complete solution throughalarge
diameter central vein so that it is quickly diluted. A physician threadsa
central venous catheter through the jugular or subclavian vein until thetipislocated just
above the heart.
Specially trained nurses can place a peripherally inserted central catheter (PICC) at
bedside.
The line is usually inserted on the inside of the elbow and threaded sothetipof the
catheter rests at the superior vena cava.
Composition of PN
PN solutions provide protein, carbohydrate, fat, electrolytes, vitamins, andtrace
elements in sterile water. Th
ey are
“compounded” or mixedinthehospital pharmacy, either manually by the pharmacist or
through automatedcompounding equipment, which allows individualization of the
solutionbasedon the patient’s fluid and nutrient requirements.
Automated compounders can mix a 24-hour batch of PN solution into a
singlecontainer, that is, either a two-in-one formula (dextrose and amino acids) or
athree-in-one formula (dextrose, amino acids, and lipids). Most hospitals use a two-
in-one systemand deliver lipids separately.
 reduce the risk of impaired liver function relatedtoexcessive glycogen and fat
deposition.
When it is given during the night, cyclic PN frees the patient to participateinnormal
activities during the day.
When the patient is able to begin consuming food enterally (orally or by tubefeeding),
the amount of PN is gradually reduced to compensate for calories consumedenterally.
It is recommended that PN be discontinued when enteral feedingprovides more than
60% of calorie goals (McClave et al., 2009).

Medications
Medications are sometimes added to intravenous solutions by the pharmacist or
infused
into them through a separate port. Patients receiving PN may have insulinordered if
glucose levels are greater than 150 to 200 mg/dL (levels higher thannormal are
considered acceptable because there is no fasting statewithcontinuous infusions).
Heparin may be added to reduce fibrin buildup on the catheter tip. In general,
medications should not be added to PN solutions because of the potential
incompatibilities of the medication and nutrients in the solution.

Initiation and Administration

PN is initiated and administered according to facility protocol, typically asa24-hour
infusion in critically ill patients.
PN is infused slowly (i.e., 1 L in the first 24 hours) to give the body timetoadapt to the
high concentration of glucose and the hyperosmolality of thesolution. After the first 24
hours, the rate of delivery is gradually increasedby1 L/day until the optimal volume is
achieved.
Continuous drip by pump infusion is needed to maintain a slow, constant flowrate. If
the rate of delivery falls behind or speeds up, the drip rate is adjustedto the correct
hourly rate only; no attempts are made to “catch up” totheordered volume.
For stable patients who require long-term or home PN cyclic PNinsteadof continuous
PN.
Cyclic PN: infusing PN at a constant rate for 8 to 12 hours/day. This offersthepatient
periodic freedom from the equipment (Stout and Cober, 2011) andallow serum
glucose and insulin levels to drop during the periods whenPNisnot infused, which may