AKAL COLLEGE OF NURSING, ETERNAL

UNIVERSITY BARU SAHIB

SUBJECT- MEDICAL SURGICAL NURSING

TOTAL
PARENTERAL
NUTRITION

SUBMITTED TO: SUBMITTED BY:

Miss. Lovepreet Kaur Miss. Kiran
Kumari
Nursing Tutor BS21MHNS001
ACN, Baru Sahib M.Sc. Nursing 1 st
Year

SUBMITTED ON: - 11th Feb ,2022

 TOTAL PARENTERAL NUTRITION
Definition
Intravenous administration of varying combinations of hypertonic or isotonic glucose,
lipids, amino acid, electrolytes, vitamins and trace elements through a venous access
device (VAD) directly into the intravascular fluid to provide nutrients for patients who
are unable to receive adequate nutrition through gastrointestinal tract.
Purposes
 To provide nutrients required for the normal metabolism, tissue maintenance, repair and
energy demands.
 To bypass the GI tract for patients who are unable to take food orally.
Indications
Patient who cannot tolerate enteral nutrition because of
 Paralytic ileus
 Intestinal obstruction
 Acute pancreatitis
 Inflammatory bowel disease
 Gastro intestinal fistula
 Severe diarrhoea
 Persistent vomiting
 Malabsorption
Hyper metabolic states for which enteral therapy either not possible or inadequate
Severe burns
NPO for more than 5 days
Acute renal failure
Multiple fractures
Tumour in GI tract
Patient at risk for malnutrition of
 Gross under weight
 Metastatic cancer
Methods of parenteral nutrition
7. Methods of parenteral nutrition  Total nutrient admixture into a central vein (TNA) ◦
It is indicated for patients requiring parenteral feeding for seven or more days. Given
through a central vein often into the superior venacava. ◦ Parenteral formula combines 
CHO in the form of a concentrated 20-70% dextrose solution  Proteins as amino acids 
Lipids in the form of an emulsion (10-20%) including triglycerides, phospholipids and
glycerol.  Water  Vitamins and minserals
8. Methods of parenteral nutrition  Peripheral parenteral nutrition ◦ This parenteral
formula combines carbohydrates a lesser concentrated glucose solution with amino acids,
vitamins, minerals ◦ Given through peripheral vein ◦ Indicated for patients requiring
nutrition for fewer less than 7 days
9. Total parenteral nutrition  This parenteral formula combines glucose, amino acids,
vitamins & minerals  Given through a central I V line  If lipids are given intermittently
mixed with TPN  Fat emulsion (lipids): it is composed of triglycerides (10-20%) ◦ Eg :
Phospolipids ,Glycerol and water ◦ May be given centrally or peripherally
10. Articles  Central venous access devices: long term VAD such as thick man, Broviac
or Groshung catheters or peripherally inserted cenrtral catheter (PICC line) or periheral
IV access  Volume control infuser  Filters 0.22 micron for TPN (without fat
emulsion)3.2 micron filter for TNA or fat emulsion
11. Central venous access devices
12.  Volume control infuser
13. Filters 0.22 micron for TPN / 3.2 micron filter for TNA
14. Articles  Bag of parenteral nutrition  Administration tubing with luer-lock
connections  Hypoallergic tape  Face mask  Sterile gloves
15.  Bag of parenteral nutrition
16. luer-lock connections Sterile gloves Facemask Hypoallergic tape
17. Procedure Nursing action Rationale Performing Nutritional assessment Provides
baseline data Check physician’s order Parenteral therapy must be ordered by physician
Explain the procedure Obtain informed consent Collect needed equipment for the
procedure Remove the bag of parenteral nutrition from refrigerator at least 1hr before
procedure (if refrigerator) Decrease the incidence of hypothermia, pain &vaso spasm
Inspect fluid for presence of creaming or any change in constitution Indicates fluid
separation TPN solution should be clear with out clouding
18. Nursing action Rationale Wash hands and done cap, mask, gown and sterile gloves
Follow strict aseptic precautions Using strict aseptic technique , attach tubing (with
filter)to TNA bag purge out air Prevents chances of developing air embolus Close all
clamps on new tubing and insert tubing into volume control infuses Place the patient in
supine position and turn head away from VAD insertion site Supine position with head
turned one side opens the angle b/w clavicle and first rib Clean the insertion site with
alcohol and providone-odine solution Assist physician while inserting VAD After
insertion of VAD connect tubing to hub of VAD using sterile technique and make sure
that the connection is secured using luer- lock connection
19. Nursing action Rationale Open all clamps and regulate flow through volume control
infuser Monitor administration hourly, assessing for integrity of fluid and administration
system and patient tolerance Record the procedure
20. Clinical Data Monitored Daily • General sense of well-being • Strength as evidenced
in getting out of bed, walking, resistance exercise as appropriate •Vital signs including
temperature, blood pressure, pulse, and respiratory rate •Fluid balance: weight at least
several times weekly, fluid intake (parenteral and enteral) vs. fluid output (urine, stool,
gastric drainage, wound, ostomy) •Parenteral nutrition delivery equipment: tubing, pump,
filter, catheter, Dressing •Nutrient solution composition
21. Laboratory Daily Finger-stick glucose Three times daily until stable Blood glucose,
Na, K, Cl, HCO3, BUN Daily until stable and fully advanced, then twice weekly Serum
creatinine, albumin, PO4, Ca, Mg, Hb/Hct, WBC Baseline, then twice weekly INR
Baseline, then weekly Micronutrient tests As indicated
22. Discontinuation of TPN should take place when the patient can satisfy 75% of his or
her caloric and protein needs with oral intake or enteral feeding. To discontinue TPN, the
infusion rate should be halved for 1 hour, halved again the next hour, and then
discontinued. Tapering in this manner prevents rebound hypoglycemia from
hyperinsulinemia. It is not necessary to taper the rate if the patient demonstrates glycemic
stability.
23. Complications  Sepsis ◦ Causes :  High glucose content of fluid  Venous access
device contamination ◦ Interventions  Monitor temperature , WBC count, and insertion
site for signs and symptoms of infection  Maintain strict surgical asepsis when changing
dressing and tubing  Consider deceasing glucose content of fluid  Consider removal of
venous access device with replacement in alternate site  If blood culture is positive
consider antibiotic therapy
24. Complications  Electrolyte imbalance ◦ Causes :  Iatrogenic  Effects of
underlying diseases, ie. Fistula, diarrhea, vomiting ◦ Interventions  Monitor for signs
and symptoms of electrlyte imbalances  Treat underlying cause  Change concentration
of electrolytes in TNA as necessary
25. Complications  Hyperglycemia ◦ Causes :  High glucose content of fluid 
Insufficient insulin secretion ◦ Interventions  Monitor blood glucose frequently 
Decrease glucose content of fluid if possible  Administer insulin
26. Complications  Hypoglycemia ◦ Causes :  Abrupt discontinuation of TNA 
Administration through a central vein ◦ Interventions  After discontinuation of centrally
administered TNA, start 10% dextrose at the same rate
27. Complications  Hypervolemia ◦ Causes :  Iatrogenic  Underlying heart diseases
such as congestive heart failure and renal failure ◦ Interventions  Monitor intake & out
put, daily weight,CVP, breath sounds and peripheral edema  Consider administering
more concentrated TNA solution
28. Complications  Hepatic dysfunction ◦ Causes :  High concentration of CHO, fats
relative to protein ◦ Interventions  Monitor liver function test, triglyceride levels, and
presence of jaundice  Consider alternation in formula
29. Complications  Hypercarbia ◦ Causes :  High carbohydrate content of fluid ◦
Interventions  Consider changing formula to increase the proportion of fat relative to
carbohydrate
30. THANK YOU