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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 Sunday, March 7, 2027

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 does not meet the Florida LPN IV Certification requirement.

≥ 92% of participants will know how to administer parenteral nutrition properly.

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

Identify indications for parenteral nutrition administration.
Compare the various types of parenteral nutrition.
Summarize the delivery and administration of parenteral nutrition.
Monitor for complications of parenteral nutrition.
Evaluate specific recommendations for nutritionally-at-risk patients.

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: 3/7/2023

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

Introduction

Good nutrition is essential for all ages. It is necessary for children and young adults for adequate growth. At any stage of life, nutrition is essential for healing and vitality. Our bodies require specific amounts of vitamins, electrolytes, minerals, fats, proteins, and carbohydrates. Typically, we receive these vital elements from intaking foods and liquids. However, some individuals do not have an adequately functioning gastrointestinal (GI) tract. Without a properly functioning GI system, the body does not readily digest necessary nutrients, such as carbohydrates and protein (Baiu & Spain, 2019). In these cases, parenteral nutrition (PN) is often warranted.

PN is a way of intravenously (IV) feeding and providing nutritional products. 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- this is where the muscles of the intestines or stomach are paralyzed, limiting the passing of food and sometimes blocking the intestine (Weledji, 2020)
- Intestinal obstruction- this is where something is blocking the stomach or intestine, not allowing food or drink to pass through (Catena et al., 2019)
- Acute pancreatitis- this is where the pancreas becomes inflamed, and patients are not allowed to eat anything by mouth (Chatila et al., 2019)
- Severe malabsorption
- Persistent vomiting
- The jejunal route is not possible- this is feeding that goes directly into the small bowel (Pang et al., 2017)
- Enterocutaneous fistula- this is where stomach contents leak into the skin because of a bad connection between the intestine or stomach and skin (Tuma et al., 2020)
- Inflammatory bowel disease- this is inflammation of the digestive tract (Seyedian et al., 2019)
- Short bowel syndrome- this is where the body is not able to absorb enough nutrients because the small intestine is smaller than usual (Shakhsheer & Warner, 2019)
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 specific recommendations on when and how PN is indicated, depending on the age and status of the patient.

A nutritionally-at-risk adult may have one of the following:

Involuntary loss of 10 lbs or more within six months
Body mass index (BMI) less than 18.5 kg/m2
Unintentional weight loss of 10% of usual body weight within six months or 5% within one month
Increased metabolic requirements
Inadequate intake (Worthington et al., 2017)

A nutritionally-at-risk child may have one of the following:

BMI for age/sex less than the 5th percentile
Inadequate intake
Increased metabolic requirements
Weight for length, height, or sex less than the 10th percentile
Insufficient intake and weight gain (Worthington et al., 2017)

A nutritionally-at-risk infant with nutritional inadequacy is categorized as either high risk or moderate risk.

A high-risk infant may have the following:

Preterm birth
Low birth weight, usually less than 1000 g
GI dysfunction (Worthington et al., 2017)

An infant at moderate risk may have the following:

Later preterm birth, usually around 30 weeks
Birthweight between 1000-1500 g
Illness or congenital abnormalities (Worthington et al., 2017)

Delivery of Parenteral Nutrition

Now that we have discussed why PN is required, we must discuss how it can be delivered. Central parenteral nutrition (CPN) provides nutrients via a central vein. Peripheral parenteral nutrition (PPN) offers nutrients via a peripheral vein (Kohlhardt et al., 1994). When administering PN, specific types of catheters are used and will be discussed next.

Types of Catheters

External (Tunneled) Catheters

A tunneled central line is often referred to as a tunneled central venous catheter. It is a catheter placed in a vein, often for long-term purposes. Tunneled catheters are most commonly placed in the internal jugular vein in the neck. Other areas for placement include the femoral vein near the groin, the transhepatic vein near the liver, and the subclavian vein in the chest, or the back.

With tunneled catheters, there is an insertion site, and then the catheter is tunneled under the skin and brought out at an exit site (Moran et al., 1987).

Peripherally Inserted Central Catheter (PICC)

A PICC line is a thin, long tube inserted through a vein in the arm and passed through to the more prominent veins near the heart. Specifically, it is threaded into a large vein above the right side of the heart called the superior vena cava. PICC lines can be left in for up to 18 months, which may be highly beneficial for someone who is chronically malnourished.

There are risk factors associated with insertion as well as complications. Anytime the skin is broken, there is a small risk of infection. Rarely, bleeding, blot clots, and allergic reactions are possible (Velissaris et al., 2019).

Long-term Venous Access Devices (VADs)

Long-term VADs are essential for patients requiring catheter access for extended periods of time.

There are different kinds of long-term VADs, and they include:

Hickman
Broviac
Groshong

Hickman, Broviac, and Groshong are examples of tunneled catheters. A tunnel ensures a distance between the catheter's entry and exit site, decreasing the chance of infections. A Dacron cuff is used to secure the catheter. Single, double, or triple lumens are available for use (Wu et al., 2016; Moir & Bodenham, 2018).

A Groshong, a tunneled catheter, uses a specialized valve that allows for decreased flushing. Flushing can be done with saline flushes instead of heparin, and the specialized valve prevents the reflux of blood into the catheter, so no clamping is required (Ishizuka et al., 2008).

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 varying lengths along the catheter. So, the two lumens are infusing at different locations.

Types of Parenteral Nutrition

There are three types of PN, and they include total nutrient admixture (TNA), peripheral parenteral nutrition (PPN), and total parenteral nutrition (TPN). Table 1 outlines the differences between common PN types.

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

Tubing should be changed every 12-24 hours, depending on the type of PN being administered. Use strict sterile technique when changing tubing or dressings.

Table 1: Types of Parenteral Nutrition
PN Type	Composition	Notes
TPN	Dextrose Amino acids Vitamins Minerals	Must infuse through a central line TPN and lipids may be given intermittently or mixed together.
TNA	20%-70% dextrose 3%-15% proteins in the form of amino acids Lipids 10%-30% emulsion composed of triglycerides, egg phospholipids, glycerol, and water Vitamins Minerals	Must infuse through a central line Indicated when parenteral feeding is for seven or more days.
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 seven days.
(Nettina, 2019)

TPN

TPN supplies all necessary nutrient requirements. It is administered via a central venous catheter because the solution is concentrated and can potentially cause clots. Typically, 2 L/day of the standard solution is needed, but it ultimately depends on the status and requirements of the patient.

Most calories supplied through TPNs are carbohydrates. Around 4 to 5 mg/kg/minute of dextrose is supplied. Typical solutions contain about 25% dextrose, but it depends on other factors, such as the metabolic needs of the patient and the proportion of caloric needs supplied by lipids (Thomas, 2022).

TPN and lipids may be given intermittently or mixed together. Lipids may be given centrally or peripherally and comprise a 10%-30% emulsion composed of triglycerides, egg phospholipids, glycerol, and water.

When administering, a filter should be used if possible. A 0.22-micron filter is used for PN without lipids, and a 1.2-micron filter is used for TNA with lipids (Nettina, 2019).

TNA

TNA is a type of complete PN that contains necessary macronutrients, including intravenous fat emulsions (IVFE), dextrose, and amino acids (Gervasio, 2015).

TNA may be ordered before surgery to improve fluid and electrolyte balance and nutritional status to stabilize a patient. It also may be necessary to correct protein deficiency from chronic obstruction, paralytic ileus, infection, or severe diarrhea. TNA is indicated if a patient cannot take food or fluids orally or if the intestinal tract requires rest while nitrogen balance is restored (Nettina, 2019).

TNA is often given through a central line as there is less chance of adverse effects. Caloric requirements are dependent upon the clinical condition and status of the patient.

PPN

PPN is a type of PN administered through a peripheral intravenous line, usually in a limb or the neck. It is usually only indicated for seven days or less. Because of the location of the IV, the solution is required to be much more diluted than other forms of PN. The solution must be diluted to prevent blood clots or extravasation, which is medication that leaks from the vein into the tissue (Flores Dueñas et al., 2021). Because of the dilution, PPN does not provide as much nutrition or calories as TPN solutions.

Regardless of the type of PN being administered, frequent monitoring is required to determine tolerance and the presence of complications.

Complications of Parenteral Nutrition

Several complications of PN could occur and must be watched for. Table 2 outlines some of the more frequently seen complications, their causes, signs and symptoms, and potential interventions. Some complications, both common and uncommon, will be detailed more in-depth.

Table 2: Parenteral Nutrition Complications
Complication	Causes	What to Monitor	Intervention
Sepsis	High glucose content of fluid Venous access device contamination	Temperature WBC count Insertion site infection	Maintain sterile technique when changing dressing and tubing. Consider removal of line with replacement of alternative site If the blood culture is positive, the provider may initiate 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 and at least daily	Treat underlying cause. Provider may change the 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	Frequent blood glucose	To stop PN, reduce the rate by 50%, then discontinue after 2 hours. If PN must be stopped abruptly, hang a separate dextrose solution if the insulin has been administered.
Hypervolemia	Iatrogenic Underlying disease (heart or 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 the concentration of PN.
Hepatic dysfunction	Iatrogenic	Liver function Triglycerides Jaundice	Provider may change macronutrients in PN.
Hypercapnia	Excessive calories	Arteria blood gasses	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) Oxygenation levels 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	Monitor the lipid composition	Observe for cracking or creaming of fluid and discontinue or do not use lipids with these characteristics.
(Nettina, 2019)

Though PN is often essential and beneficial, it is not without potential adverse effects and complications.

Patients receiving PN long-term are at an increased risk of bone demineralization and catheter infections (Hartl et al., 2009).

Refeeding syndrome is a potentially fatal complication caused by fluid and electrolyte shifts in already malnourished patients receiving PN. Significant signs and symptoms of refeeding syndrome include trouble breathing, seizures, weakness of the heart, coma, and even death (Reber et al., 2019).

Hepatic and metabolic complications are possible and include high blood sugar, high triglycerides, fatty liver, and osteoporosis. Elevated triglycerides are often seen in up to 50% of patients receiving PN. These high levels can induce acute pancreatitis, further complicating the healing process (Hartl et al., 2009).

Electrolyte imbalances can occur while administering PN to restore a patient's nutritional status. Electrolytes should be monitored initially with administration and at least daily (Nettina, 2019).

Hyperglycemia and hypoglycemia may also occur with the administration of PN. Hyperglycemia occurs due to a high glucose content of the PN or if the patient has insufficient insulin creation. The patient would need to be administered insulin. Hypoglycemia occurs if PN is discontinued too quickly. To reduce the risk of hypoglycemia developing, discontinue PN slowly (Nettina, 2019).

Monitoring and Weaning

All patients receiving any type of PN require frequent monitoring, not only for complications but for progress and improvement. Providers of care should consider planning to wean patients when PN is meeting caloric needs and requirements and oral intake is possible. To decrease PN, a provider can reduce the number of days the patient receives infusions each week or decrease the amount being infused each time (DiBaise et al., 2006).

Case Study

John, a 45-year-old male, was admitted to the hospital with acute pancreatitis. He has been unable to tolerate anything orally for the past six days. After nearly 24 hours in the hospital, John still cannot have anything by mouth. Providers decide that PN is warranted.

Susie, a nurse, is caring for John during his stay. John has a peripheral line, perfect for the administration of PPN. After the administration, John starts experiencing side effects. He has developed a fever, fatigue, and sweating. Susie chalks it up to the side effects of being renourished and does not report the signs and symptoms.

As it turns out, the peripheral line through which the PPN was being administered was infected, and the solution was not getting through the line.

What should Susie have done differently in this scenario? If she had monitored the line more frequently or followed up on the side effects John was experiencing, the infection/side effects could have been prevented.

What next steps should be taken? The PPN should be immediately discontinued so a new line can be started. Susie should be counseled on adequately caring for patients receiving any type of PN.

Conclusion

PN is commonly used in many care settings for patients requiring assistance with nutrition. PN is indicated for multiple reasons. Patients with a dysfunctional GI tract, those with hypermetabolic states, such as in the case of trauma/burns, or those who cannot tolerate enteral feedings would benefit from some form of PN. There are different types of PN, and each is made up of different contents. Depending on the caloric requirements of the patient, they may benefit from either TPN, PPN, or TNA. Patients may have a peripheral or central line for administration, including a PICC line or a VAD for long-term requirements. Though PN is beneficial, it is not without complications and adverse effects. Patients may experience hyperglycemia, hypoglycemia, electrolyte imbalances, hepatic dysfunction, and sepsis. Each complication requires specific monitoring and interventions.

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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

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