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LPN IV Series: Parenteral Nutrition

2.00 Contact Hours
This course is applicable for the following professions:
Licensed Nursing Assistant (LNA), Licensed Practical Nurse (LPN)
This course will be updated or discontinued on or before Monday, December 14, 2020
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.
Course Description
100% of participants will be able to administer parenteral nutrition. Contact hours for LPNs in any state are earned by completing this course. This is part of a series of 24 contact hours of courses to prepare for LPN IV Certification in Florida. Florida certification participants must schedule a 6-hour live presentation and return demonstration to complete IV Certification. The live presentation is not provided by CEUFast.com.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. 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) , Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)

Outcomes

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

Objectives

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

Introduction

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

PN is indicated for the following conditions1:

  • Patients who cannot tolerate enteral feeding
    • Paralytic ileus
    • Intestinal obstruction
    • Acute pancreatitis
    • Severe malabsorption
    • Persistent vomiting and jejunal route is 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 Type1

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:1

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 of 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 Valsalva maneuver to prevent air from being sucked into 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

Complications

Complication1

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

References

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