Download Parenteral Nutrition: A Basic Overview

Parenteral
Nutrition:
A Basic Overview
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor,
professor of academic medicine, and
medical author. He graduated from Ross
University School of Medicine and has completed his clinical clerkship training in
various teaching hospitals throughout New York, including King’s County Hospital
Center and Brookdale Medical Center, among others. Dr. Jouria has passed all
USMLE medical board exams, and has served as a test prep tutor and instructor for
Kaplan. He has developed several medical courses and curricula for a variety of
educational institutions. Dr. Jouria has also served on multiple levels in the academic
field including faculty member and Department Chair. Dr. Jouria continues to serves
as a Subject Matter Expert for several continuing education organizations covering
multiple basic medical sciences. He has also developed several continuing medical
education courses covering various topics in clinical medicine. Recently, Dr. Jouria
has been contracted by the University of Miami/Jackson Memorial Hospital’s
Department of Surgery to develop an e-module training series for trauma patient
management. Dr. Jouria is currently authoring an academic textbook on Human
Anatomy & Physiology.
Abstract
All individuals need food to sustain life, but sometimes nutrients
cannot be absorbed through the stomach or bowel, or food digested
due to illness or injury. When this occurs with patients, the standard
method of eating is replaced by parenteral nutrition, which is a
lifesaving measure that involves placing an intravenous catheter in a
large vein and supplying proteins, carbohydrates, fats, vitamins, and
minerals through the intravenous solution directly to the blood supply.
Mechanical pumps are typically used to dispense the solution at
specified intervals. If needed, parenteral nutrition can be a lifelong
treatment.
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Continuing Nursing Education Course Planners
William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner
Policy Statement
This activity has been planned and implemented in accordance with
the policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's
Commission on Accreditation for registered nurses. It is the policy of
NurseCe4Less.com to ensure objectivity, transparency, and best
practice in clinical education for all continuing nursing education (CNE)
activities.
Continuing Education Credit Designation
This educational activity is credited for 2 hours. Nurses may only claim
credit commensurate with the credit awarded for completion of this
course activity.
Statement of Learning Need
Parenteral nutrition delivers essential basic nutrients and trace
elements and is provided generally through a central intravenous
route. It is a lifesaving method to provide nutrition for patients unable
to obtain nutrients by ingesting food.
Course Purpose
To provide nursing professionals with basic knowledge of parenteral
nutrition when it is indicated, and of its benefits and risks.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses
and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, MSN, FPMHNP-BC
Release Date: 1/1/2016
Termination Date: 3/24/2018
Please take time to complete a self-assessment of knowledge,
on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge
learned will be provided at the end of the course.
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1. A patient is administered nutrition through a feeding tube.
Which type of nutrition does this indicate?
A. parenteral
B. enteral
C. total parenteral nutrition
D. total enteral nutrition
2. Parenteral nutrition solution contains all of the following
EXCEPT?
A. proteins
B. carbohydrates
C. vitamins
D. fiber
3. For short term parenteral nutrition therapy of less than
two weeks, which one of the following methods are
typically used:
A. tunneled VADs
B. subclavian vein access
C. PICCs
D. None of the above
4. A patient in need of parenteral nutrition therapy has a
high gastric output. This patient will need additional
quantities of which electrolyte:
A. Magnesium
B. potassium
C. phosphorus
D. chloride
5. All of the following are preventive measures concerning
the potential for infection related to parenteral nutrition
therapy, EXCEPT:
A. thorough hand hygiene measures
B. use of PICC lines
C. proper catheter care
D. use of implanted ports
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Introduction
When a patient cannot digest food due to illness, nutrients may need
to be provided by other means. One method, known as parenteral
nutrition, involves feeding the patient intravenously, bypassing the
usual process of eating and digestion.1 The concept of parenteral
nutrition was initially practiced in the 17th century when practitioners
infused, wine, ale, and opiates into the veins of dogs.2 It was not until
the 1960s that parenteral nutrition was developed as a bedside
technique for hypertonic fluids to be administered through large veins
as a source of full nutritional needs for patients.3
Normal digestion occurs when food is broken down in the bowel and
stomach. This absorbed food in the bowel is then carried to other parts
of the body by the blood. Parenteral nutrition bypasses digestion in the
bowel and stomach through insertion of a food mixture into the blood
by an intravenous (IV) catheter.1 This mixture contains carbohydrates,
proteins, as well as other vitamins and minerals.4 The IV catheter can
stay in place as long as needed to supply nutrition to the patient.
Initiation and monitoring of parenteral nutrition is usually undertaken
by a multidisciplinary team of physicians, dietitians, nurses, and
pharmacists.5
Routes of administration for parenteral nutrition can be done centrally
or peripherally, depending on factors, such as duration of treatment
and indication. Regardless of the chosen route of administration,
clinicians should rely on strict aseptic technique along with a lumen
dedicated exclusively for parenteral nutrition administration.2
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Parenteral Versus Enteral Nutrition
The term parenteral nutrition has long been synonymous with “total
parenteral nutrition.” However, total parenteral nutrition can be a
misleading term, because many patients who receive nutrition by vein
also concomitantly receive nutrition through the mouth by enteral
(tube) feedings. This concept of intravenous and enteral nutrition
includes almost 90% of surgical patients and 100% of anaesthetized
patients, who receive intravenous fluids perioperatively.3
Enteral nutrition also relies on a special food mixture of carbohydrates,
proteins, fats, as well as vitamins and minerals, which are fed to the
patient through a tube inserted into the stomach or bowel.1 There are
various types of tubes that are employed in enteral nutrition. One type
of tube placed through the nose is known as a nasoenteral or
nasogastric feeding tube. Another type of procedure, known as a
gastrostomy or jejunostomy utilizes a tube inserted directly into the
stomach or bowel through the skin.1
There is a strong belief among nutritionists that enteral nutrition is
preferable to parenteral nutrition; however, several factors, such as
specific indication or duration play a role on which method to use.6
The literature has been mixed concerning the comparison of these two
types of nutritional delivery. Proponents of parenteral nutrition state
that it delivers more reliable calories than enteral nutrition.
Conversely, proponents of enteral nutrition cite that enteral nutrition
has showed consistently better outcomes in patients compared to
those who receive parenteral nutrition.6,7,8 Regardless of whether the
clinician chooses parenteral or enteral nutrition, careful attention must
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be rendered on issues, such as safety, indications, delivery methods,
and calorie calculations.9
Candidates for Parenteral Nutrition
Parenteral nutrition is used in a variety of situations. When a patient’s
gastrointestinal tract is nonfunctional, a variety of factors may play a
role.3 These include:10,11

Severe pancreatitis

Short-bowel syndrome

Inflammatory bowel disease

Gastrointestinal fistulae

Bowel obstruction

Acute cardiovascular collapse

Selected oncology patients
To help determine whether a patient has a functioning gastrointestinal
tract, clinicians must gather specific information through a health
history, which focuses on nutrition. Questions should be catered
toward dietary intake, along with any difficulties with swallowing,
chewing, digestion, and elimination.10,11 Physical examination should
include measurements for body weight and height, as well as a careful
inspection of the oral cavity, abdomen, rectal area, neck, and head.
Endoscopic and radiological testing of the gastrointestinal tract may
also be warranted along with laboratory values for glucose, lipid levels,
serum electrolytes, proteins, along with renal and liver function.10,11
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IV Access
After all signs have indicated that parenteral nutrition is a viable option
for the patient, the caregiver must determine, where parenteral
nutrition therapy should be administered, and for how long.
Determining how long the therapy should be (short term versus long
term), assists the caregiver in deciding which type of vascular access
device to use. To avoid needless catheterizations, medical staff should
take into account certain considerations prior to intravenous access.
These considerations include the following:4

Activity level

Patient and/or caregiver ability to care for the vascular access
device

Body image concerns

Additional therapies needed

Previous history of vascular access devices
The type of application and correct placement is an important
component to parenteral nutrition. Common intravenous access sites
for parenteral nutrition include:
Parenteral Nutrition IV Access Sites

Trans-lumbar/trans-hepatic venous access

Peripherally inserted central catheter

Tunneled central venous catheter

Internal jugular vein

Subclavian vein

Subcutaneous port

Cephalic vein

Cephalic venous access

Basilic vein
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Choices for vascular access include tunneled VADs with an anchoring
cuff, implantable ports, and peripherally inserted central catheters
(PICC).4,12 For short term parenteral nutrition therapy of less than a
couple of weeks, PICC lines are typically used.12 Advantages of PICC
lines are decreased risk of catheter compilations, cost-effectiveness,
and ease of removal. Potential disadvantages are that the patient may
be less dependent due to the fact that the dressing must remain dry. A
greater risk of thrombosis may also be present with PICCs.4,13
For long-term parenteral nutrition therapy, tunneled catheters remain
the first line option. Advantages include ease of self-care and a lower
risk of thrombosis.4,13 Implanted ports placed under the skin are
another viable option for long-term parenteral nutrition. The chief
advantage of this option is minimal alteration to the patient’s body
image, as well as no concern for accidental pulling of the device.
Parenteral Nutrition Solutions
There are standard solutions that are used for parenteral solution as
well as solutions that are formulated specific to the patient. Solutions
are prepared in the pharmacy using aseptic technique under a
laminar-flow filtered air hood.4,5 The solutions are usually made in liter
batches. The solutions can also be quite complex containing up to 40
different additives. The two main components in parenteral nutrition
solutions are amino acids and dextrose. Other additives include
electrolytes, fats, vitamins, minerals, and trace elements.14
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Amino Acids
Amino acids are used in parenteral nutrition formulas as a source of
protein. Standard solutions contain approximately 40% essential and
60% nonessential amino acids.14 More concentrated amino acid
preparations are useful on patients with renal failure. For patients with
end-stage liver disease, solutions with more branch-chained amino
acids may be warranted.15 Some solutions also contain phosphate,
which helps in compatibility when dosing with electrolytes.4
Studies have also shown that about 80% of patients who rely on
parenteral nutrition for their full source of nutrients have been found
to have low levels of choline in the blood.4 Choline is a nonessential
amino acid that is found in many foods; thus, explaining why
deficiencies are so common. However, it is not commonly added to
parenteral nutrition formulations because it can be synthesized
endogenously. Nevertheless, current studies have suggested that
choline supplementation may be warranted in patients receiving
parenteral nutrition, due too the fact that pathways allowing for
synthezation may be altered during parenteral nutrition therapy.4
Dextrose
During perenteral nutrition therapy, carbohydrates are the primary
source of calories and are supplied in the form of dextrose. Dextrose is
a readily available, inexpensive energy source that can be
administered with commercial solutions. Concentrations range from
5% to 70%.4 As the concentration of dextrose increases, the tonicity
of the parenteral nutrition solution also increases.
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Electrolytes
Requirements for electrolytes, such as magnesium, phosphorus, and
potassium are influenced by the amount of carbohydrates present in
the parenteral nutrition solution. In other words, as the amount of
carbohydrates increase, so does the need for electrolytes.16 Typical
solutions contain electrolytes, such as chloride, calcium, potassium,
phosphorus, and magnesium. The types and amounts of electrolytes
added to the solution also depend on the specific patient’s diagnosis
and metabolic requirements. For example, patients with high gastric
output may require additional chloride. Conversely, patients with renal
problems may require reduction in certain electrolytes, such as
magnesium, phosphorus, and potassium, due to the fact that they
may be difficult to secrete.4
Fats
Fat is available in parenteral nutrition solutions as an oil-in-water
emulsion. These IV fat emulsions contain a mixture of egg
phospholipids as an emulsifier, water, and safflower or soybean oil as
a source of polyunsaturated fatty acids.4 Glycerol is also added to the
solution. The goal of this lipid emulsion supplementation is to prevent
fatty acid deficiency. When used properly, relatively few complications
are seen with lipid emulsions. However, caution must be used for
patients who may have allergies to eggs.17
Vitamins
Parenteral nutrition solutions typically contain approximately 12 to 13
essential vitamins.15 The amount of vitamins added to the solution is
based on the current U.S. Food and Drug Administration (FDA)
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guidelines. During times of multivitamin shortages, the American
Society for Parenteral and Enteral Nutrition recommends IV vitamin
supplementation to be administered three times weekly.4 The specific
amount of required vitamins may also be dependant on the condition
of the patient. For example, parenteral nutrition solutions for pregnant
women may include additional amounts of folic acid.
Trace Elements
Trace elements are routinely added to parenteral nutrition solutions.
Examples include copper, zinc, chromium, and selenium.4,15 These
trace elements can be delivered individually or in various combinations
depending on the specific needs of the patient. Patients with iron
deficiencies may also require additional iron supplementation.
Monitoring Patients With Parenteral Therapy
There are no current professional society guidelines for monitoring
patients receiving parenteral nutrition therapy. This is, in part, due to
a lack of controlled trials along with a lack of evidence-based
guidelines for monitoring and treating potential complications
associated with parenteral nutrition.4 However, due to several known
potential complications, practitioners routinely conduct clinical
monitoring as well as several additional tests for patients receiving
therapy. In addition to clinical monitoring of the parenteral nutrition
solution, patients will also require routine blood tests.3 This is
particularly important at the beginning of therapy to assess for
conditions such as hyperglycemia or significant shifts in electrolytes.3
Trace elements should also be measured, and patients on long-term
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parenteral nutrition therapy should have three to six month checks on
vitamin levels.
Assessing the quantitave needs concerning micronutrients and
macronutrients can help reduce the likelihood of complications
associated with parenteral nutrition. At the initiation of therapy,
glucose should be monitored several times a day until stable.
Laboratory tests also include levels, such as electrolytes, phosphate,
magnesium, plasma urea, and blood gases.4 Liver function tests,
plasma and urine osmolality, and plasma proteins should also be
measured routinely.4
Complications
Complications associated with parenteral nutrition therapy are either
metabolic due to the nutritional formula or nonmetabolic due to faulty
delivery technique. Metabolic complications include alteration in serum
electrolytes and hyperglycemia. Patients who receive more than 10%
concentrations of dextrose are at a greater risk for developing
hyperglycemia.14 Overfeeding is also a common cause of
hyperglycemia in patients receiving parenteral nutrition. Incorrect
placement of the central line may result in an air embolism,
hematoma, or pneumothorax. For this reason, a chest x-ray must be
used to confirm proper placement of the central line catheter tip prior
to infusion.14
Thrombosis can occur at the catheter tip from the formation of a fibrin
sheath on the outside of the catheter. A thrombolytic agent can be
useful in clearing a catheter occlusion caused by a fibrin sheath. Some
patients with permanent central catheters may also be administered
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low-dose warfarin to help prevent thrombosis.15 Additionally, as in
most procedures, infection is always a cause for concern. Preventive
measures include thorough hand hygiene measures and proper
catheter care techniques.14 Tunneled catheters or implanted ports with
the fewest lumens necessary should be the primary choice due to the
fact that they have the lowest incidence of infection.4
Catheter-Related Infections
Catheter-related infections are one of the most common causes of
concern in parenteral nutrition therapy. Common organisms found in
catheter-related sepsis include:

Staphylococcus aureus

Candida sepsis

Klebsiella pneumoniae

Pseudomonas aeruginosa

S. albus

Enterobacter sepsis
Central venous catheter-related infections greatly increase morbidity,
mortality, and length of hospital stay. Research has also shown that
they also are a significant contributor to expenses related to
healthcare. According to recent literature, the healthcare expenses
range from $33,000 to $65,000 per occurrence.4
Typical signs of catheter-related infections include fever, elevated
temperature, and chills. Fever during parenteral nutrition therapy
should always be investigated. If temperature remains elevated for
more than 24 hours, the central catheter infusion should be
stopped.14,18 Laboratory findings that may indicate infection include
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increased white blood cell count, positive blood cultures, and elevated
liver enzymes.19
Blood Clots
Patients who are administered long-term parenteral nutrition therapy
are at increased risk for blood clots. This is due to the fact that longterm intravenous access may result in the accumulation of a foreign
body within the vascular system.20 Routine heparin flushes can help
prevent clots. Catheters should also be flushed before and after each
use and all parenteral nutrition solutions should be inspected for
formation of precipitant inside the bag. Experts also recommend using
IV filters, and always consulting with the pharmacist prior to adding
anything to the solution.20
Liver Disease
Another potential complication of long-term administration of
parenteral nutrition is liver disease. Recent research published in the
Journal of Parenteral and Enteral Nutrition reported that liver disease
has been found in 26% of patients who were administered parenteral
nutrition for two years and the incidence climbed to 50% in those who
received parenteral nutrition therapy for more than three years.4
When laboratory results indicate elevated liver enzymes, clinicians
should investigate the cause paying close attention to any
hepatobilliary complications.4 These abnormalities are typically
classified into two categories – hepatic steatosis and cholestasis.21
Hepatic steatosis is essentially the accumulation of excess fat in the
liver due to increased amounts of alanine aminotransferase and
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aspirate aminotransferase.15,21 Hepatic steatosis is reversible following
reduction in calories.21
Cholestasis occurs when bile becomes blocked and cannot flow from
the liver to the duodenum. Research has proven that many patients on
long-term parenteral nutrition therapy develop some cholestasis.15
This is due to the absence of enteral intake, which can cause failure of
the gallbladder to become stimulated. When this happens, it does not
empty and bile becomes thick and can eventually result in billiary
obstruction.15 The best preventive method to avoid cholestasis is to
occasionally substitute parenteral nutrition with enteral feedings if
possible.15
Metabolic Bone Disease
Metabolic bone disease is another potential complication of long-term
parenteral nutrition therapy.4,15 This condition encompasses
abnormalities related to bone density, metabolism, and strength,
which ultimately results in conditions, such as osteoporosis and
osteomalacia.4
Current studies suggest that metabolic bone disease results in
osteoporosis in approximately 67% of patients who receive long term
parenteral nutrition. This same research also reports that osteopenia
results in about 84% of long-term parenteral nutrition patients.4
Although the cause of metabolic bone disease is uncertain, several
preventive strategies do exist, such as careful attention to the
amounts of magnesium, calcium, Vitamin D, and phosphorus that are
provided in parenteral nutrition solutions.15
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Refeeding Syndrome
Refeeding syndrome occurs when significant shifts in fluids and
electrolytes occur. Significant shifts in fluids and electrolytes occur
when malnourished patients are introduced to normal nutrition
parenterally or enterally.22 When the body is malnourished over time,
and then suddenly flooded with nutrients, a hypermetabolic state
ensues. Glucose use pushes magnesium, potassium, and phosphorus
rapidly into the starved cells of the malnourished patient. This drastic
movement of electrolytes results in a drop in the patients’ magnesium,
serum potassium, and phosphorus levels.22
This potentially lethal metabolic complication can result in muscle
weakness, immune dysfunction, peripheral edema, hyperglycemia,
decreased gastric motility, ketoacidosis, ventricular dysrhythmias, and
cardiac failure.22 Patients who are most at risk include those who have
been without significant nutrition for a week or longer. These patients
should have a parenteral nutrition program slowly introduced and
should also be carefully monitored.
Weaning from Parenteral Nutrition
Prior to completely stopping parenteral nutrition, other alternative
methods should be established. Parenteral nutrition should never be
stopped abruptly due to the fact that hypoglycemia can occur.2 Once
the patient has reached the nutritional requirements, infusion
schedules may be slowly reduced. When the infusion schedules
change, laboratory studies are assessed to evaluate fluid and
electrolyte stability.4 After the solutions are reduced to a minimum of
three days weekly, the patient’s parenteral nutrition therapy is stopped
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for one week. The patient’s weight and enteral intake is carefully
monitored. Laboratory studies are also checked again. If they are
found to be normal, the parenteral nutrition can be formally
discontinued.4
Quality of Life
There are several support groups that provide educational resources
for patients. One such example is the Oley Foundation, which is a
nonprofit organization that assists patients who receive parenteral
nutrition. It provides patient-focused newsletters aimed at increasing
the quality of life. It also provides annual conferences along with
networking and peer support groups for patients.4
Summary
Parenteral nutrition is an important part of maintaining nutrition for
patients who are unable to properly digest food. In some cases, this
lifesaving therapy can be combined with intake through enteral
nutrition to help nourish patients. Parenteral nutrition is used in a
variety of situations, such as when a patient’s gastrointestinal tract is
nonfunctional. A variety of factors can affect gastrointestinal tract
functioning, including severe pancreatitis, short-bowel syndrome,
inflammatory bowel disease, gastrointestinal fistulae, bowel
obstruction, acute cardiovascular collapse, and selected oncology
patients.
During parenteral therapy, a multidisciplinary team approach is utilized
to ensure that correct solutions are administered concerning each
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patient’s unique set of needs. Additionally, initiation and monitoring of
parenteral nutrition requires a multidisciplinary team, which includes
physicians, dietitians, nurses, and pharmacists. Routes of
administration for parenteral nutrition can be done centrally or
peripherally, depending on factors, such as duration of treatment and
indication. Careful attention and thorough monitoring is crucial to
reduce the likelihood of complications associated with parenteral
nutrition therapy. Nurses are an integral part of the nutritional support
team and must have the necessary clinical and communication skills
required for working collaboratively with all team members to ensure
that patient’s receive safe and appropriate parenteral therapy for
nutritional support.
Please take time to help NurseCe4Less.com course planners
evaluate the nursing knowledge needs met by completing the
self-assessment of Knowledge Questions after reading the
article, and providing feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
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1. A patient is administered nutrition through a feeding tube.
Which type of nutrition does this indicate?
A. parenteral
B. enteral
C. total parenteral nutrition
D. total enteral nutrition
2. Parenteral nutrition solution contains all of the following
EXCEPT?
A. proteins
B. carbohydrates
C. vitamins
D. fiber
3. For short term parenteral nutrition therapy of less than
two weeks, which one of the following methods are
typically used:
A. tunneled VADs
B. subclavian vein access
C. PICCs
D. None of the above
4. A patient in need of parenteral nutrition therapy has a
high gastric output. This patient will need additional
quantities of which electrolyte:
A. magnesium
B. potassium
C. phosphorus
D. chloride
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5. All of the following are preventive measures concerning
the potential for infection related to parenteral nutrition
therapy, EXCEPT:
A. thorough hand hygiene measures
B. use of PICC lines
C. proper catheter care
D. use of implanted ports
6. To determine whether a patient has a functioning
gastrointestinal tract condition, clinicians must gather
specific information through:
A. a health history that focuses on nutrition.
B. a physical examination, including measurements for body
weight and height.
C. an endoscopic and radiological.
D. All of the above. *
7. Glucose use pushes _________________________
rapidly into the starved cells of the malnourished patient.
A. magnesium, potassium, and phosphorus *
B. sodium, chloride, and potassium
C. protein and albumin
D. None of the above.
8. True or False. Research has proven that many patients on
long-term parenteral nutrition therapy develop some
cholestasis.
A. True *
B. False
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9. The goal of lipid emulsion supplementation is to prevent
____________________ deficiency.
A. fatty acid *
B. protein
C. carbohydrate
D. Answers B and C above
10. Common organisms found in catheter-related sepsis include
all of the following EXCEPT:
A. Staphylococcus aureus
B. Treponema pallidum *
C. Candida sepsis
D. Klebsiella pneumoniae
Correct Answers:
1. B
2. D
3. C
4. D
5. B
6. D
7. A
8. A
9. A
10. B
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References Section
The reference section of in-text citations include published works
intended as helpful material for further reading. Unpublished works
and personal communications are not included in this section, although
may appear within the study text.
1.
American Society for Parenteral & Enteral Nutrition. What is
Parenteral Nutrition?
http://www.nutritioncare.org/About_ASPEN/About_A_S_P_E_N_/
Accessed on March 1, 2014
2.
Ghosh D, Neild P. Parenteral Nutrition. Clin Med. 2011; 10(6):
620-623
3.
Cano NJ, Aparicio G, Carrero B, et al. Guidelines for adult
parenteral nutrition. Clin Nutr. 2009; 28: 359-479
4.
Kirby D, Corrigan M, Speerhas R, Emery D. Home parenteral
nutrition tutorial. J Parenter Enteral Nutr. 2012; 36(6): 632-644
5.
Speerhas R, Rhoda K, In: Couglin KL, DeChicco R, Hamilton C,
eds. Cleveland Clinic Nutrition Support Team Manual. Cleveland,
OH: Cleveland Clinic; 2011: 81-98
6.
Seres D, Valcarcel M, Guillaume A. Advantages of enteral nutrition
over parenteral nutrition. Therap Adv Gastroenterol. 2013; 6(2):
157-167
7.
Akashi Y, Hiki N, Nunobe S, Jiang X, Yamaguchi T. Safe
management of anastomotic leakage after gastric cancer surgery
with enteral nutrition via a nasointestinal tube. Langenbecks Arch
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