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LPN IV Series: Parenteral Nutrition

2 Contact Hours

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This peer reviewed course is applicable for the following professions:

Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN)

This course will be updated or discontinued on or before Thursday, June 1, 2023

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

This course is 1 of 8 courses available on CEUfast to meet the 24 hour written portion of the Florida LPN IV Certification requirement. The remaining 6 hours on the return demonstration of IV skills must be completed in person. To find a provider, or if you are interested in becoming a provider, refer to our Provider Information page.

100% of participants will be able to administer parenteral nutrition.

After completing this continuing education course, the participant will be able to meet the following objectives:

Discuss the indications for PN administration.
Identify the types of PN.
Discuss administration of PN.
Monitor for complications of PN.
Discuss multi-lumen central VADS.

CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated: 5/18/2022

To earn of certificate of completion you have one of two options:

Take test and pass with a score of at least 80%
Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
(NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)

Authors: Wesley Hunter (RN, PMT) , Desiree Reinken (MSN, APRN, NP-C) , Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)

Introduction

Parenteral nutrition (PN) is feeding nutritional products IV. The usual process of eating and digestion is bypassed.

PN is indicated for the following conditions(Nettina, 2019):

Patients who cannot tolerate enteral feeding
- Paralytic ileus
- Intestinal obstruction
- Acute pancreatitis
- Severe malabsorption
- Persistent vomiting and the jejunal route are not possible
- Enterocutaneous fistula
- Inflammatory bowel disease
- Short bowel syndrome
Hypermetabolic states where enteral therapy is not possible
- Burns
- Trauma
- Sepsis
Patients with specific nutritional needs that are not met by enteral feeding

There are three types of PN:
PN Type (Nettina, 2019)	Composition	Notes
Total nutrient admixture (TNA)	20%-70% dextrose 3%-15% proteins in the form of amino acids Lipids 10%-30% emulsion composed of triglycerides, egg phospholipids, glycerol, water Vitamins minerals	Must infuse through a central line Indicated when parenteral feeding is for 7 or more days
Peripheral parenteral nutrition (PPN)	Less concentrated dextrose Amino acids Vitamins Minerals Lipids Fewer calories Sometimes has higher lipid calories than carbohydrate calories	May infuse through a peripheral line Indicated when parenteral nutrition is less than 7 days
Total Parenteral Nutrition (TPN)	Dextrose Amino acids Vitamins Minerals	Must infuse through a central line TPN and lipids may be given intermittently or mixed together

TNA (Nettina, 2019):

Must be given through a central line
May be ordered before surgery to improve fluid, electrolyte balance and nutritional status
May be ordered if unable to take food or fluids orally
May be necessary to correct protein deficiency from chronic obstruction, paralytic ileus or infection
Severe diarrhea
Rest the intestinal tract and restore nitrogen balance
Combines dextrose, amino acids, vitamins, and minerals
Given through a central IV line

TPN and lipids may be given intermittently or mixed together

Fat Emulsion (Lipids)

10%-30% emulsion composed of triglycerides, egg phospholipids, glycerol, water and vitamin K
Lipids may be given centrally or peripherally

A filter should be used if possible. A 0.22-micron filter is used for PN without lipids.

A 1.2-micron filter is used for TNA with lipids.

PN cannot be administered with any other solutions, medications or blood.

When changing tubing in a central line, have the patient perform a Valsalva maneuver to prevent air from being sucked into the tubing.

Tubing used for parenteral nutrition should be changed every 24 hours. Tubing for fat emulsion infusion must be changed every 12 hours. Use strict sterile technique when changing tubing or dressings.

Check frequently for tolerance and complications.

Complications

Complication (Nettina, 2019)	Causes	Monitor for signs	Intervention
Sepsis	High glucose content of fluid Venous access device contamination	Temperature WBC Insertion site infection	Maintain sterile technique when changing dressing and tubing Consider removal of venous access device with replacement of alternative site If blood culture is positive, the provider may institution of antibiotics
Electrolyte imbalance	Iatrogenic (caused by the treatment, in this case, PN administration) Effects of underlying disease (fistula, diarrhea, vomiting Blood sample contaminated by PN	Electrolytes initially at least daily	Treat underlying cause Provider may change concentration of electrolytes in PN
Hyperglycemia	Insufficient insulin secretion High glucose content of PN Blood sample contaminated by PN	Frequent blood glucose	Administer insulin Provider may decrease glucose content of PN
Hypoglycemia	Abrupt discontinuation of PN		To stop PN, reduce rate by 50%, then DC after 2 hours If PN must be stopped abruptly, hang a separate dextrose solution if insulin has been administered
Hypervolemia	Iatrogenic Underlying disease (CHF, renal failure)	Intake and output (I&O) Daily weights Central venous pressure (CVP) Breath sounds Peripheral edema	Provider may order more concentrated PN
Hyperosmolar diuresis	High osmolarity of PN	I&O Daily weights CVP	Provider may decrease concentration of PN
Hepatic dysfunction	Iatrogenic	Liver function Triglycerides Jaundice	Provider may change macronutrients in PN
Hypercapnia	Excessive calories		Provider may reduce calories
Lipid intolerance	Low birth weight or premature neonate History of liver disease History of elevated triglycerides	Bleeding (occult blood in stool, coagulation studies, platelet levels) SAO2 Fat overload syndrome Triglyceride levels Liver function Hepatosplenomegaly Decreased coagulation Cyanosis Dyspnea Allergic reaction (nausea, vomiting, headache, chest pain, back pain, fever)	Administer lipid solutions slowly initially, while observing for allergy symptoms
Lipid particulate aggregation	Unstable mixture of dextrose solution with lipids		Observe for cracking or creaming of fluid and discontinue or do not use lipids with these characteristics

Long-term VADs

Hickman
Broviac
Groshong
Peripherally inserted central catheter (PICC)

A multi-lumen central VAD allows concomitant administration of PN and other solutions, including medications or blood. The different lumens do not mix because the lumens end at different lengths along the catheter. So, the two lumens are infusing at different locations.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.

Reflect on Practice ImpactDescribe how this course will impact your practice. (No Test)

Remember my preference

Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

References

Nettina, Sandra M., “The Lippincott Manual of Nursing Practice” 11th Ed. Wolter Kluwer, Philadelphia, 2019.

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