Download Parenteral nutrition

PARENTERAL NUTRITION
Total parenteral nutrition (TPN) is the provision of
intravenous nutrients to patients whose
gastrointestinal (GI) tract is not functioning or cannot
be accessed and to patients whose nutritional needs
cannot be met with oral diets or enteral feeding. The
patient receives a combination of nutrients- crystalline
amino acids, dextrose, electrolytes, vitamins, minerals,
trace elements and lipid/fat emulsion administered
intravenously.
Once limited to critical care areas, TPN is now
present on post surgical floors and medical units,
when feeding by mouth is not possible, when a
person's digestive system cannot absorb nutrients
due to chronic disease, or, alternatively, if a
person's nutritional requirements cannot be met
by enteral feeding (tube feeding) and/or through
oral diet.
WHAT IS TPN?
Total parental nutrition (TPN) is the practice of
nourishing a patient intravenously, bypassing the
usual process of eating and digestion. It is a form of
specialized nutrition, including amino acids,
dextrose, fat emulsion, vitamins, minerals and trace
elements given intravenously.
• It is osmotically active and must be administered
carefully to prevent trauma to the vascular portal of
entry.
• It is administered intravenously and can be
administered through a peripherally inserted central
catheter (PICC), a central venous line (CVC) or a large
peripheral line.
• TPN is ALWAYS administered through an
infusion pump.
The sterile bags of nutrients are infused continuously
through the pump over a 12 hour or 24 hour period to
prevent vascular trauma and metabolic instability.
INDICATIONS FOR TPN ADMINISTRATION
• If there is intolerance to oral intake or enteral feeds and if the
patient is NPO for an extended period of time.
Short-term TPN (7 to 10 days) or long-term TPN (>10 days) is
used to treat patients whose GI tract is not functioning or not
accessible for various reasons.
Indications for TPN administration
PHYSIOLOGICAL CONDITION - Non functional GI tract
CLINICAL MANIFESTATION:
• Massive small bowel resection/ GI surgery
• Paralytic ileus
• Small bowel ileus (dilated bowel with air/fluid levels on CT scan)
• Intestinal obstruction
• Trauma to abdomen, head , neck
• Severe malabsorption
• Intolerance to enteral feeding (protracted nausea/vomiting)
• Bowel infarction/bowel ischemia
• Chemotherapy, radiation therapy, bone marrow transplant
• High output small bowel fistula >500ml/d
• Mechanical small bowel obstruction
Indications for TPN administration
PHYSIOLOGICAL CONDITION – Extended Bowel Rest
• Inflammatory bowel disease exacerbation
• Severe diarrhea
• Moderate to severe pancreatitis
Indications for TPN administration
PHYSIOLOGICAL CONDITION – Preoperative TPN
• Preop bowel rest
• Treatment for comorbid severe malnutrition in patients with nonfunctioning GI tracts
• Severe catabolic patients when GI tract is non-useable for more than
3 to 5 days
COMPOSITION OF TPN SOLUTIONS
TPN is specialized nutrition including amino acids, dextrose, fat
emulsions, vitamins, minerals and trace elements prepared in a
sterile bag for intravenous administration.
2 components: amino acids/dextrose solution and lipid emulsion.
TPN is ordered by the physician depending on the patient’s clinical
history and current metabolic needs.
ACCESS ROUTES FOR TPN ADMINISTRATION
TPN solutions must be carefully administered intravenously because
it is osmotically active and can cause trauma to the vascular portal of
entry.
TPN is best administered through a large vein through a PICC or CVC.
Peripheral IV is the last resort. The risk/benefit decision to use
peripheral parenteral nutrition should include as many phlebitismitigating techniques as possible.
TPN is NOT compatible with any other solutions and must be
administered by itself. An infusion pump must be used to
regulate the administration because it may lead to
hypoglycemia
Parenteral nutrition solutions containing final
concentrations exceeding 10% dextrose should
be administered through a central vascular
access device (CVAD) with the tip located in
the central vasculature, preferably the superior
vena cava right atrium junction for adults.
INS Standards of Practice 2011, pg. S91
FOOD FOR THOUGHT
• Consult religious leaders about continuous infusion of TPN
solution during fasting periods, i.e., Ramadan, Yom Kippur.
Devout followers may insist on fasting.
Follow agency policy and procedures when administering TPN.