This study guide is about total parenteral nutrition and 4 nursing care plan examples for total parenteral nutrition. Use it to create educational nursing care plans for total parenteral nutrition.
Total Parenteral Nutrition
What is total parenteral nutrition?
Total Parenteral Nutrition (TPN feeding) is a method of administration of essential nutrients to the body through a central vein.
Partial parenteral nutrition supplies only part of daily nutritional requirements, supplementing oral intake. Many hospitalized patients are given dextrose or amino acid solutions by this method.
Total parenteral nutrition (TPN) supplies all daily nutritional requirements. TPN can be used in the hospital or at home. Because TPN solutions are concentrated and can cause thrombosis of peripheral veins, a central venous catheter is usually required.
Parenteral nutrition should not be used routinely in patients with an intact gastrointestinal (GI) tract. Compared with enteral nutrition, it has the following disadvantages:
It causes more complications.
It does not preserve GI tract structure and function as well.
It is more expensive.
When is TPN therapy indicated to patients?
TPN may be the only feasible option for patients who do not have a functioning GI tract or who have disorders requiring complete bowel rest, such as the following:
Some stages of ulcerative colitis
Certain pediatric GI disorders (eg, congenital GI anomalies, prolonged diarrhea regardless of its cause)
Short bowel syndrome due to surgery
What nutritional content does TPN require?
TPN requires water (30 to 40 mL/kg/day), energy (30 to 35 kcal/kg/day, depending on energy expenditure; up to 45 kcal/kg/day for critically ill patients), amino acids (1.0 to 2.0 g/kg/day, depending on the degree of catabolism), essential fatty acids, vitamins, and minerals. Children who need TPN may have different fluid requirements and need more energy (up to 120 kcal/kg/day) and amino acids (up to 2.5 or 3.5 g/kg/day).
Basic TPN solutions are prepared using sterile techniques, usually in liter batches according to standard formulas. Normally, 2 L/day of the standard solution is needed. Solutions may be modified based on laboratory results, underlying disorders, hypermetabolism, or other factors.
Most calories are supplied as carbohydrates. Typically, about 4 to 5 mg/kg/minute of dextrose is given. Standard solutions contain up to about 25% dextrose, but the amount and concentration depend on other factors, such as metabolic needs and the proportion of caloric needs that are supplied by lipids.
Commercially available lipid emulsions are often added to supply essential fatty acids and triglycerides; 20 to 30% of total calories are usually supplied as lipids. However, withholding lipids and their calories may help obese patients mobilize endogenous fat stores, increasing insulin sensitivity.
What do TPN solutions require?
Many TPN solutions are commonly used. Electrolytes can be added to meet the patient’s needs.
TPN solutions vary depending on other disorders present and patient age, as for the following:
For renal insufficiency not being treated with dialysis or for liver failure: Reduced protein content and a high percentage of essential amino acids
For heart or kidney failure: Limited volume (liquid) intake
For respiratory failure: A lipid emulsion that provides most of the nonprotein calories to minimize carbon dioxide production by carbohydrate metabolism
For neonates: Lower dextrose concentrations (17 to 18%)
How is TPN administered?
Because the central venous catheter needs to remain in place for a long time, strict sterile techniques must be used during insertion and maintenance of the TPN line. The TPN line should not be used for any other purpose. External tubing should be changed every 24 hours with the first bag of the day. In-line filters have not been shown to decrease complications. Dressings should be kept sterile and are usually changed every 48 hours using strict sterile techniques.
If TPN is given outside the hospital, patients must be taught to recognize symptoms of infection, and qualified home nursing must be arranged.
The solution is started slowly at 50% of the calculated requirements, using 5% dextrose to make up the balance of fluid requirements. Energy and nitrogen should be given simultaneously. The amount of regular insulin given (added directly to the TPN solution) depends on the plasma glucose level; if the level is normal and the final solution contains 25% dextrose, the usual starting dose is 5 to 10 units of regular insulin/L of TPN fluid.
How can the progress of patients with a TPN be monitored?
Progress of patients with a TPN line should be followed on a flowchart. An interdisciplinary nutrition team, if available, should monitor patients. Weight, complete blood count, electrolytes, and blood urea nitrogen should be monitored often (eg, daily for inpatients). Plasma glucose should be monitored every 6 hours until patients and glucose levels become stable. Fluid intake and output should be monitored continuously. When patients become stable, blood tests can be done much less often.
Liver tests should be done. Plasma proteins (eg, serum albumin, possibly transthyretin or retinol-binding protein), prothrombin time, plasma and urine osmolality, and calcium, magnesium, and phosphate should be measured twice/week. Changes in transthyretin and retinol-binding protein reflect overall clinical status rather than nutritional status alone. If possible, blood tests should not be done during glucose infusion.
Full nutritional assessment (including BMI calculation and anthropometric measurements) should be repeated at 2-week intervals.
What are the most common complications of TPN?
About 5 to 10% of patients with a TPN line have complications related to central venous access.
Catheter-related sepsis rates have decreased since the introduction of guidelines that emphasize sterile techniques for catheter insertion and skincare around the insertion site. The increasing use of dedicated teams of physicians and nurses who specialize in various procedures including catheter insertion also has accounted for a decrease in catheter-related infection rates.
Glucose abnormalities (hyperglycemia or hypoglycemia) or liver dysfunction occur in > 90% of patients.
Glucose abnormalities are common. Hyperglycemia can be avoided by monitoring plasma glucose often, adjusting the insulin dose in the TPN solution, and giving subcutaneous insulin as needed. Hypoglycemia can be precipitated by suddenly stopping constant concentrated dextrose infusions. Treatment depends on the degree of hypoglycemia. Short-term hypoglycemia may be reversed with 50% dextrose IV; more prolonged hypoglycemia may require an infusion of 5 or 10% dextrose for 24 hours before resuming TPN via the central venous catheter.
Hepatic complications include liver dysfunction, painful hepatomegaly, and hyperammonemia. They can develop at any age but are most common among infants, particularly premature ones (whose liver is immature).
Liver dysfunction may be transient, evidenced by increased transaminases, bilirubin, and alkaline phosphatase; it commonly occurs when TPN is started. Delayed or persistent elevations may result from excess amino acids. Pathogenesis is unknown, but cholestasis and inflammation may contribute. Progressive fibrosis occasionally develops. Reducing protein delivery may help.
Painful hepatomegaly suggests fat accumulation; carbohydrate delivery should be reduced.
Hyperammonemia can develop in infants, causing lethargy, twitching, and generalized seizures. Arginine supplementation at 0.5 to 1.0 mmol/kg/day can correct it.
If infants develop any hepatic complications, limiting amino acids to 1.0 g/kg/day may be necessary.
Abnormalities of serum electrolytes and minerals should be corrected by modifying subsequent infusions or, if correction is urgently required, by beginning appropriate peripheral vein infusions. Vitamin and mineral deficiencies are rare when solutions are given correctly. Elevated blood urea nitrogen may reflect dehydration, which can be corrected by giving free water as 5% dextrose via a peripheral vein.
Volume overload (suggested by > 1 kg/day weight gain) may occur when patients have high daily energy requirements and thus require large fluid volumes.
Metabolic bone disease, or bone demineralization (osteoporosis or osteomalacia), develops in some patients given TPN for > 3 months. The mechanism is unknown. Advanced disease can cause severe periarticular, lower-extremity, and back pain.
Adverse reactions to lipid emulsions (eg, dyspnea, cutaneous allergic reactions, nausea, headache, back pain, sweating, dizziness) are uncommon but may occur early, particularly if lipids are given at > 1.0 kcal/kg/hour. Temporary hyperlipidemia may occur, particularly in patients with kidney or liver failure; treatment is usually not required. Delayed adverse reactions to lipid emulsions include hepatomegaly, mild elevation of liver enzymes, splenomegaly, thrombocytopenia, leukopenia, and, especially in premature infants with respiratory distress syndrome, pulmonary function abnormalities. Temporarily or permanently slowing or stopping lipid emulsion infusion may prevent or minimize these adverse reactions.
Gallbladder complications include cholelithiasis, gallbladder sludge, and cholecystitis. These complications can be caused or worsened by prolonged gallbladder stasis. Stimulating contraction by providing about 20 to 30% of calories as fat and stopping glucose infusion several hours a day is helpful. Oral or enteral intake also helps. Treatment with metronidazole, ursodeoxycholic acid, phenobarbital, or cholecystokinin helps some patients with cholestasis.
4 Nursing Care Plan Examples for Total Parenteral Nutrition
The major goals for the patient undergoing total parental nutrition may include improvement of nutritional status, maintaining fluid balance, and absence of complications.
Imbalanced Nutrition: Less Than Body Requirements
- Imbalanced Nutrition: Less Than Body Requirements
May be related to
- GI tract function alterations
- Lengthy NPO status
- Increased metabolic rate or other conditions necessitating increased intake such as burns, infections, chemotherapy
- Refusal to eat due to psychological reasons
Possibly evidenced by
- Reduced muscle mass
- Reduced total protein, transferrin, and serum albumin levels
- Electrolyte imbalances
- Poor skin turgor
- Poor wound healing
- Weight loss below 20% ideal
- Client will achieve an adequate nutritional status, as evidenced by stable weight or weight gain and by improved albumin levels.
|Assess skin integrity and wound healing.||Skin integrity changes and wound healing are used as parameters in monitoring the effectiveness of TPN feeding.|
|Measure intake and output accurately; Monitor weight daily; Monitor calorie counts, including calories provided by TPN.||TPN composition is based on the calculated nutritional needs of the client. Before the therapy is started, a thorough baseline assessment will be completed by health care members which includes physicians, nurses, dieticians, and pharmacists is done. Changes in fluid balance, weight, and caloric intake are used to assess TPN effectiveness. Daily weights are done to determine if nutritional goals are being met. Weight is also used to assess fluid volume status. Weight gain of more than 1/2 pound per day may indicate fluid retention.|
|Assist with the insertion and maintenance of central venous or peripherally inserted central catheters (PICC).||Since the osmolality of TPN solution is high, it is administered into the vascular system using a catheter inserted into a central vein with a high-volume blood flow. The tip of the catheter is usually placed in the superior vena cava. X-ray confirmation of accurate catheter placement is necessary before TPN administration is initiated. Normal saline or other isotonic solutions may be infused through the central catheter until placement is confirmed.|
|Encouraged additional oral fluid intake as indicated.||Additional oral fluids may be given to a client receiving TPN to maximize nutritional support. Clients may benefit psychologically from having oral intake, especially at shared mealtimes with family members.|
|Administer the prescribed rate of TPN solution via an infusion pump.||Electronic infusion pumps are used during the therapy to maintain an accurate rate of administration. A delayed administration time of TPN withholds the client of needed nutrition; Rapid administration can precipitate a hyperglycemic crisis because the hormonal response (i.e., insulin) may not be available to allow the use of the increased glucose load.|
|Collaborate with another nutritional support team, dietician, pharmacy, home health nurse.||The risk for most complications that occur in the hospital is decreased when the administration of parenteral nutrition is supervised by an experienced nutritional support team.|
Risk for Excess Fluid Volume
- Risk for Excess Fluid Volume
May be related to
- Inability to tolerate increased vascular load
- Rapid infusion of TPN
Possibly evidenced by
- [not applicable]
- Client will maintain normal fluid volume, as evidenced by balanced intake and output, absence of edema, and absence of excessive weight gain.
|Assess for the following signs and symptoms of excess fluid volume:|
||These respiratory changes are caused by the accumulation of fluid in the lungs.|
||Edema occurs when fluid accumulates in the extravascular spaces. Edema usually begins in the fingers, facial area, and presacral area. Generalized edema, called anasarca, occurs later and involves the entire body. A weight gain of more than half a pound per day is an indication of fluid volume excess.|
||Increased central venous pressure is noticed first as distention of the jugular veins.|
|Monitor laboratory studies such as serum sodium levels.||Hypernatremia may cause or aggravate edema by holding fluid in the extravascular spaces.|
|Place the client in a semi-Fowler’s or high-Fowler’s position.||Maintaining the head of the bed elevated will promote ease in breathing. This position also allows pooling of fluid in the bases and for gas exchange to be more available to the lung tissue.|
|Handle with caution on extremities with edema.||Edematous skin is more susceptible to injury and breakdown.|
|Administer diuretics such as furosemide (Lasix) as indicated.||Diuretics promote the excretion of fluids.|
Risk for Deficient Fluid Volume
- Risk for Deficient Fluid Volume
May be related to
- Decrease serum protein level
- Increase blood sugar
- Inability to respond to thirst mechanism due to NPO status
Possibly evidenced by
- [not applicable]
- Client will be normovolemic as evidenced by systolic BP 90 mm Hg or higher, absence of orthostasis, heart rate of 60 to 90 beats per minute, urine output of at least 30 ml per hour, and normal skin turgor.
|Assess for the signs and symptoms of deficient fluid volume:|
||Decreased fluid volume results in dry skin and poor skin turgor.|
||A compensatory increase in heart rate occurs with fluid volume deficit.|
||Fluid volume deficit decreases the circulatory volume and contributes to a decrease in blood pressure.|
||Urine becomes more concentrated with a decrease in fluid volume.|
|Assess urine output hourly.||Urine output consistently below fluid intake signifies fluid volume deficit and the need for additional fluid to prevent dehydration.|
|Monitor laboratory studies as indicated:|
||Usually, protein levels are monitored every 3 to 7 days; Low serum protein levels may lead to a loss of fluids from intravascular spaces, secondary to low colloidal pressures.|
||Hyperglycemia, caused by infusion of a high concentration of glucose in the TPN solution, can lead to hyperosmolar, nonketotic coma with subsequent dehydration secondary to osmotic diuresis.|
|Encourage an additional oral fluid intake unless contraindicated. Administer maintenance or bolus fluids as prescribed, in addition to TPN.||Clients who are NPO and only receiving TPN may not be receiving an adequate amount of fluids, especially because TPN is initiated in low administration rates; therefore additional fluids may be required.|
|Weigh client daily during the first week of the administration of TPN then weekly thereafter.||Daily weights are necessary to determine if nutritional goals are being met. Weight is also used to assess fluid volume status. A weight loss of more than half a pound per day may indicate a fluid volume deficit.|
|Administer TPN at the ordered rate; if the infusion is interrupted, infuse 10% dextrose in water until the TPN infusion is restarted.||This substitute infusion provides needed fluid in addition to protecting the client from sudden hypoglycemia; hypoglycemia can result when the high glucose concentration to which the client has metabolically adjusted is suddenly withdrawn.|
Risk for Altered Body Composition
- Risk for Altered Body Composition
May be related to
- Essential fatty acid deficiency (EFAD)
Possibly evidenced by
- [not applicable]
- Client will maintain normal blood glucose and serum electrolyte levels.
|Assess for signs and symptoms of essential fatty acid deficiency:|
||This change links to Vitamin D and E deficiencies.|
||These findings are caused by coagulopathy secondary to inadequate vitamin K levels.|
||This change relates to Vitamin A and E deficiencies.|
|Assess for signs and symptoms of electrolyte imbalances:|
||Changes in the level of consciousness such as confusion and lethargy; muscle weakness; ST-segment depression, U-wave, and ventricular dysrhythmias.|
||Changes in the level of consciousness such as confusion and lethargy; Nausea, vomiting, muscle weakness, tremors, and seizures.|
||Changes in the level of consciousness, muscle weakness.|
||Paresthesia, tetany, seizures, positive Chvostek’s sign, irregular heart rate.|
||Muscle weakness, cramping, twitching, tetany, seizures, irregular heart rate.|
|Assess blood glucose levels for signs and symptoms of:|
||Signs of hypoglycemia such as clammy skin, agitation, weakness, and tremors are most likely to be seen when TPN infusion rates are decreased or the infusion is stopped.|
||Signs of hyperglycemia such as thirst, polyuria, confusion, and glycosuria are most likely to be seen on initiation of TPN.|
|Assess for signs and symptoms of fat embolism.||Clients who are receiving fat emulsions are prone to fat embolism (headache, cyanosis, skin flushing, and dyspnea) which is a rare but serious complication of the infusion.|
|Monitor serum triglyceride levels.||Clients receiving an IV fat emulsion should have their triglyceride monitored any time changes are made in the amount of fat administered.|
|Administer electrolyte replacement therapy as indicated.||Electrolytes are supplied based on the client’s calculated need.|
|Taper off the rate of TPN when discontinuing the therapy.||This measure prevents a hypoglycemic episode caused by abrupt TPN withdrawal.|
|Do the following when TPN solution stops or must be stopped suddenly:|
||This measure facilitates the metabolic use of glucose.|
||This solution provides a higher concentration of glucose to prevent sudden hypoglycemia.|
||These measures prevent hypoglycemia during resuscitation.|