Administering Total Parenteral Nutrition (TPN)

• To provide a nutrition source for patients who are unable to process nutrients normally; nutrients for patients requiring bypass of the gastrointestinal tract; and increased calories for patients in a catabolic state.
• To prevent or correct a deficiency of essential fatty acids.

• Determine patient's ability to understand purpose of TPN therapy.
• Assess patient's nutrition status.
• Assess nutrition needs of patients who are unable to process nutrients normally (gastrointestinally).
• Check prescriber's orders for correct additives in each hyperalimentation bottle, bag, or other type of container.
• Check rate of infusion according to prescriber's orders, and monitor closely.
• Check facility policy and procedure. Many require tubing and filter change with every bottle/bag.
• Monitor patient's blood glucose level regularly.
• Keep family informed of therapy procedure, possible complications, and patient tolerance if patient has difficulty understanding information.
• Store TPN solution in the refrigerator until 30 minutes before use. (Some pharmacies deliver the solution before each infusion. Make sure TPN was mixed within 24 hours of infusion.)

Special Considerations

Elderly and Pediatric Patients

• Monitor elderly patients and children closely for signs of overload and hyperglycemia, and notify prescriber.

Relevant Nursing Diagnoses

• Altered nutrition: less than body requirements related to nausea, vomiting, anorexia, and/or surgery

• TPN is infused at prescribed flow rate and tolerated by patient
• Dressing at catheter insertion site remains dry and intact
• Catheter insertion site remains free of infection and inflammation
• Patient receives nutrients necessary for tissue repair
• Patient's blood glucose level is maintained within normal parameters

• Hyperalimentation solution (TPN) (refrigerated)
• Clean gloves (optional)
• Intravenous tubing, filter, and infusion pump
• Extension tubing
• Blood glucose testing monitor (e.g., Accucheck)
• Intake and output (I & O) record

• Identify patient; explain procedure and its purpose.
• Meets patient's right to be informed, and encourages cooperation.
• Gather equipment, and place at bedside.
• Enhances organization and provides optimal lighting environment.
• Wash hands, and don clean gloves
• Reduces transmission of infectious microorganisms.
• Position in bed in supine position.
• Provides patient comfort.
• Obtain TPN bag after allowing it to warm to room temperature.
• Solution is refrigerated to prevent growth of organisms, but should be left at room temperature for 30 minutes to 1 hour before use.
• Check the bag for leaks, cloudiness, or floating particles. Do not use if any of these are present.
• Reduces chances of adverse events and contamination.
• Check bag for patient's name, correct bag number, expiration date, and any additives. Compare with original order.
• Ensures that correct infusion is administered.
• Connect IV tubing and filter to TPN solution container.
• Ensure tubing and container are properly connected; changing filter and tubing every 24 hours or with each bottle/bag prevents growth of microorganisms that can cause infection.
• Prime IV tubing to clear air.
• Prevents air from entering patient's bloodstream, which will cause air embolism.
• Place IV tubing through infusion pump. Set pump to correct rate.
• Infusion pump controls rate and prevents complications associated with too-rapid infusion.
• Using sterile technique, connect IV tubing to lumen of central catheter. Make sure the lumen is dedicated to TPN administration.
• Reduces risk from contamination and line sepsis.
• After TPN and tubing are changed and infusion pump is started at prescribed rate, remove gloves and discard, then wash hands.
• Ensures solution has begun without complications; prevents transmission of infectious microorganisms.

Evaluation and Follow-Up Activities

• Evaluate patient compliance and tolerance
• Assess vital signs; notify prescriber if temperature is elevated
• Assess blood glucose every 6 hours. Administer regular insulin according to sliding scale, if indicated
• Monitor serum electrolytes for potential imbalances
• Monitor and maintain an accurate intake and output record
• Weigh patient daily or at least three times per week to assess for fluid overload
• Assess for TPN therapy complications—that is, air embolus, hyperglycemia, osmotic diuresis, infiltration, or sepsis
• Change filter daily
• Change TPN tubing and needleless access cap every 24 hours for TPN with lipids and every 48 hours for TPN without lipids. Check facility policy
• Monitor and change dressing using sterile technique at IV (central line) catheter insertion site every 72 hours

Key Points for Reporting and Recording

• Record date and time of TPN bottle/bag hung, flow rate, and tubing change. A special TPN form may be used for documentation for this procedure.
• Results of finger-stick blood glucose checks.
• If insulin is required, type, amount, and site administered.
• Condition of catheter (central line) insertion site; status of dressing and if changed.
• Patient's weight.
• I & O.
• Any problems the patient has with TPN therapy.