Total parenteral nutrition: provide nutrition through a central venous line to patients who are in a catabolic state; are malnourished and cannot tolerate food by mouth; are in negative nitrogen balance; or have conditions that interfere with protein ingestion, digestion, and absorption, Crohn’s disease, major burns, and side effects of radiation therapy of abdomen.
1. Types of solutions:
  1. Hydrolyzed proteins (Hyprotein, Amigen).
  2. Synthetic amino acids (Freamine).
  3. Usual components:
    1. 3-8% amino acid.
    2. 10-25% glucose.
    3. Multivitamins.
    4. Electrolytes.
    5. Fats (lipid or fat emulsions). Lipid emulsions are contraindicated if patient has allergy to eggs.
  4. Supplements that can be added:
    1. Fructose.
    2. Alcohol.
    3. Minerals: iron, copper, calcium.
    4. Trace elements: iodine, zinc, magnesium, e. Vitamins: A, B, C.
    5. Androgen hormone therapy.
    6. Insulin.
    7. Heparin.
2. Administration:
  1. Dosage varies with clinical condition; 1 L q5-8h; rate of flow must be constant.
  2. Solution prepared under laminar flow hood (usually in pharmacy); solution must be refrigerated; when refrigerated, expires in 24 hours; once removed from refrigerator, expires in 12 hours.
  3. Incompatible with many antibiotics; check with pharmacy.
  4. Route: catheter inserted in a large vein (subclavian) by physician; placement confirmed by x-ray before beginning infusion.
    
    Hyperalimentation. Patient with subclavian hyperalimentation line.
  5. Side effects:
    1. Hyperosmolar coma.
    2. Hyperglycemia >130 mg/dL.
    3. Septicemia.
    4. Thrombosis/sclerosis of vein.
    5. Air embolus.
    6. Pneumothorax.
  6. Prolonged use: >10 days, fat needed; intralipids piggybacked close to insertion site; do not give through filter; observe for hypersensitivity (tachypnea, tachycardia, nausea, urticaria).
3. Analysis/nursing diagnosis:
  1. Fluid volume excess, potential, related to inability to tolerate amount and consistency of solution.
  2. Fluid volume deficit related to state of malnutrition.
  3. Risk for injury related to possible complications.
  4. Altered nutrition, more or less than body requirements, related to ability to tolerate parenteral nutrition.
4. Nursing care plan/implementation:
  1. Goal: prevent infection.
    1. Dressing change:
      1. Strict aseptic technique.
      2. Nurse and patient wear mask during dressing change.
      3. Cleanse skin with solution as ordered:
        
        Acetone to defat the skin, destroy the bacterial wall.
        
        Iodine 1% solution as antiseptic agent.
      4. Dressing changed q48-72h; transparent polyurethane dressings may be changed weekly.
      5. Mark with nurse’s initials, date and time of change.
    2. Air occlusive dressing.
    3. Attach final filter on tubing setup, to prevent air embolism.
    4. Solution: change ql2h to prevent infection.
    5. Culture wound and catheter tip if signs of infection appear.
    6. Monitor temperature q4h.
    7. Use lumen line for feeding only (not for CVP or medications).
  2. Goal: prevent fluid and electrolyte imbalance.
    1. Daily weights.
    2. I&O.
    3. Blood glucose q4h using glucometer; may need insulin coverage.
    4. Specific gravity q8h to determine hydration status; normal serum osmolality 275-295 mOsm, TPN 600-1400 mOsm.
    5. Infusion pump to maintain constant infusion rate.
  3. Goal: prevent complications.
    1. Warm TPN solution to room temperature to prevent chills.
    2. Monitor for signs of complications.
      1. Infiltration.
      2. Thrombophlebitis.
      3. Fever.
      4. Hyperglycemia.
      5. Fluid imbalance.
    3. Have patient perform Valsalva maneuver or apply a plastic-coated clamp when changing tubing to prevent air embolism.
    4. Tape tubings together to prevent accidental separation.
5. Evaluation/outcome criteria:
  1. Specific gravity between 1.010 and 1.020.
  2. Wounds begin to heal.
  3. Weight: no further loss, begins to gain.

TABLE 7-26 Complications Associated with Total Parenteral Nutrition
Problem	Nursing Interventions
Infection
Local infection (pain, redness, edema) Generalized, systemic infection (elevated temperature, WBC)	Sterile dressings; administer antibiotics as ordered; general comfort measures
Arterial Puncture
Artery is punctured instead of vein Physician aspirates bright-red blood that is pulsating strongly	Needle is withdrawn and pressure is applied
Air Embolus
Air enters venous system during catheter insertion or tubing changes; or catheter/tubing pull apart Chest pain, dizziness, cyanosis, confusion	Stat ABGs, chest x-ray, ECG Connect catheter to sterile syringes, and aspirate air Clean catheter tip, connect to new tubing B Place patient on left side with head lowered (left Trendelenburg prevents air from going into pulmonary artery) Prevention: have patient perform Valsalva maneuver or use plasticcoated clamp on catheter at insertion or tubing changes
Catheter Embolus
Catheter must be checked for placement by x-ray and observed when removed to be sure it is intact	Careful observation of catheter Monitor for signs of distress
Pneumothorax
If needle punctures pleura, patient reports dyspnea, chest pain	May seal off or may need chest tubes