Question

A 45-year-old patient is receiving parenteral nutrition through a subclavian triple-lumen catheter. • What are indications for parenteral nutrition?

• Using the nursing process as a framework for care of the patient receiving parenteral nutrition support, what are complications that may arise in this patient? What nursing measures should be implemented?

Answer 1

Indications

• Inadequate absorption resulting from short bowel syndrome
• Gastrointestinal fistula
• Bowel obstruction
• Prolonged bowel rest
• Severe malnutrition, significant weight loss and/or hypoproteinaemia when enteral therapy is not possible
• Other disease states or conditions in which oral or enteral feeding are not an option

The major goals for the patient undergoing total parental nutrition may include improvement of nutritional status, maintaining fluid balance, and absence of complications.

Here are four (4) total parenteral nutrition nursing care plans (NCP) and nursing diagnosis:

• Nursing Care Plans
  • Imbalanced Nutrition: Less Than Body Requirements
  • Risk for Excess Fluid Volume
  • Risk for Deficient Fluid Volume
  • Risk for Altered Body Composition
• See Also

Imbalanced Nutrition: Less Than Body Requirements

Imbalanced Nutrition: Less Than Body Requirements:Intake of nutrients insufficient to meet metabolic needs.

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

Desired Outcomes

• Client will achieve an adequate nutritional status, as evidenced by stable weight or weight gain and by improved albumin levels.

Nursing Interventions	Rationale
Assess skin integrity and wound healing.	Skin integrity changes and wound healing are used as parameters in monitoring the effectiveness of TPN therapy.
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 include 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 salineor 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 other 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: At risk for an increased isotonic fluid retention.

May be related to

• Inability to tolerate increased vascular load
• Rapid infusion of TPN

Possibly evidenced by

• [not applicable]

Desired Outcomes

• Client will maintain normal fluid volume, as evidenced by balanced intake and output, absence of edema, and absence of excessive weight gain.

Nursing Interventions	Rationale
Assess for the following signs and symptoms of excess fluid volume:
Shortness of breath; Crackles upon auscultation.	These respiratory changes are caused by the accumulation of fluid in the lungs.
Edema	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.
Distention of jugular veins	Increased central venous pressure is noticed first as distention of the jugular veins.
Monitor laboratory studies such as serum sodium level.	Hypernatemia 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 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 diureticssuch as furosemide (Lasix) as indicated.	Diuretics promotes the excretion of fluids.

Risk for Deficient Fluid Volume

Risk for Deficient Fluid Volume: At risk for experiencing vascular, cellular, or intracellular dehydration.

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]

Desired Outcomes

• 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.

Nursing Interventions	Rationale
Assess for the signs and symptoms of deficient fluid volume:
Skin integrity	Decreased fluid volume results in dry skin and poor skin turgor.
Tachycardia	A compensatory increase in heart rate occurs with fluid volume deficit.
Hypotension	Fluid volume deficit decreases circulatory volume and contributes to a decrease blood pressure.
High urine specific gravity	Urine becomes more concentrated with a decrease in fluid volume.
Assess urine output hourly.	Urine output consistently below than fluid intake signifies fluid volume deficit and the need for additional fluid to prevent dehydration.
Monitor laboratory studies as indicated:
Serum protein levels.	Usually, protein levels are monitored every 3 to 7 days; Low serum protein level may lead to a loss of fluids from intravascular spaces, secondary to low colloidal pressures.
Blood sugar levels.	Hyperglycemia, caused by infusion of a high concentration of glucose in the TPN solution, can lead to hyperosmolar, nonketotic coma with subsequent dehydrationsecondary 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 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

May be related to

• Essential fatty acid deficiency (EFAD)
• Hyperglycemia
• Hypoglycemia
• Hyponatremia
• Hypokalemia
• Hypophosphatemia
• Hypocalcemia
• Hypomagnesemia

Possibly evidenced by

• [not applicable]

Desired Outcomes

• Client will maintain normal blood glucose and serum electrolyte levels.

Nursing Interventions	Rationale
Assess for signs and symptoms of essential fatty acid deficiency:
Dry, scaly skin	This changes links to Vitamin D and E deficiencies.
Easily bruised and thrombocytopenia	These findings are caused by coagulopathy secondary to inadequate vitamin K levels.
Poor wound healing	This changes relates to Vitamin A and E deficiencies.
Assess for signs and symptoms of electrolyte imbalances:
Hypokalemia	Changes in the level of consciousness such as confusion and lethargy; muscle weakness; ST-segment depression, U-wave, and ventricular dysrhythmias.
Hyponatremia	Changes in the level of consciousness such as confusion and lethargy; Nausea, vomiting, muscle weakness, tremors, and seizures.
Hypophosphatemia	Changes in the level of consciousness, muscle weakness.
Hypocalcemia	Paresthesia, tetany, seizures, positive Chvostek’s sign, irregular heart rate.
Hypomagnesemia	Muscle weakness, cramping, twitching, tetany, seizures, irregular heart rate.
Assess blood glucose levels for signs and symptoms of:
Hypoglycemia	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.
Hyperglycemia	Signs of hyperglycemia such as 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 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:
For hyperglycemia, administer insulin as ordered.	This measure facilitates the metabolic use of glucose.
For a clotted catheter or if subsequent TPN bags are not available, hang 10@ dextrose and water at the rate of the TPN infusion.	This solution provides a higher concentration of glucose to prevent sudden hypoglycemia.
For emergency or cardiac arrest situations, stop the infusion; administer bolus doses of 50 % dextrose.	These measures prevent hypoglycemia during resuscitation.

Complications
Mechanical, infectious and nutritional complications can arise, including:

Mechanical pneumothorax, malposition, embolism
Infectious sepsis, thrombophlebitis
Nutritional complications including
fluid overload/dehydration
electrolyte imbalance
hyperglycaemia/hypoglycaemia
over feeding
re-feeding syndrome
nutrient deficiency
hepatobiliary dysfunction.