Parenteral Nutrition

Amino acid An organic compound that is the building block of protein
Anabolism The constructive phase of metabolism; the building of complex substances in the body tissues
Anthropometry Measurement of the size, weight, and proportions of the human body
Carbohydrate A group of organic compounds including sugars, starches, and glycogen
Catabolism The destructive phase of metabolism; the breakdown of complex substances in the body; opposite of anabolism
Cyclic parenteral nutrition Delivery of parenteral nutrition over a reduced time frame, i.e., 8 to 16 hours rather than a 24-hour continuous infusion
Essential fatty acid deficiency (EFAD) Complication resulting from an inadequate intake of fatty acids that cannot be synthesized by the body; thus, requiring diet modification or IV administration of specific lipids
Fat Biological substances that are insoluble in water but soluble in other solvents; break down into fatty acids and glycerol
Lipid injectable emulsion (ILE) Combination of liquid, lipid, and emulsifying system for IV use; the solution has limited ability to be mixed with other solutions; previously referred to as an IV fat emulsion (IVFE)
Parenteral nutrition (PN) Nutrients that are administered intravenously, including carbohydrates, proteins, fats, electrolytes, vitamins, and trace elements
Peripheral parenteral nutrition (PPN) Intravenous administration of parenteral nutrition via the peripheral veins
Refeeding syndrome A rare syndrome associated with the institution of nutritional support in a severely malnourished patient; resultant metabolic and hormonal changes, including hypophosphatemia, which can lead to cardiac failure
Total nutrient admixture (TNA) A parenteral nutrition solution formula that includes amino acids, fat, dextrose, and all other additives in a single container

Introduction ⬆ ⬇

The American Society for Parenteral and Enteral Nutrition (ASPEN) is a multidisciplinary professional organization of providers, nurses, dietitians, pharmacists, allied health professionals, and researchers dedicated to patients receiving optimal nutrition care. ASPEN provides numerous evidence-based clinical practice guidelines and standards of practice, which are referenced throughout this chapter. Nutritional support nursing is a professional nursing specialty that focuses on the care of individuals with potential or known nutritional alterations. The nutrition support nurse encompasses nursing activities that focus on:

Protection, promotion, and optimization of nutritional health and functional abilities
Prevention of nutrition-related illness and injury
Alleviation of suffering through the diagnosis and treatment of nutrition-related human response
Advocacy in the care of persons, families, communities, and populations with known or potential alterations in nutrition (DiMaria-Ghalili et al., 2016)

The scope of practice includes, but is not limited to, direct patient care; consultation with nurses and other health-care professionals in a variety of clinical settings; education of patients, students, colleagues, and the public; participation in research; and administrative functions. Nurses can attain certification as a nutrition support clinician (CNSC) through the National Board of Nutrition Support, an independent credentialing board established by ASPEN.

All nurses, whether or not specialized in nutrition support, must recognize the importance of adequate nutrition and the adverse effects of malnutrition. Specialized nutritional support, such as parenteral or enteral nutrition, is indicated in some patients and will be administered by specialized or certified nurses as well as the generalist nurse. The focus of this chapter is administration of parenteral nutrition (PN). Goals of PN include:

1.To provide all essential nutrients in adequate amounts to sustain nutritional balance during periods when oral or enteral routes of feedings are not possible or are insufficient to meet the patient's caloric needs

2.To preserve or restore the body's protein metabolism and prevent the development of protein or caloric malnutrition

3.To diminish the rate of weight loss and to maintain or increase body weight

4.To promote wound healing

5.To replace nutritional deficits

Websites

American Society for Parenteral and Enteral Nutrition (ASPEN): https://www.nutritioncare.org

National Board of Nutrition Support Certification, Inc.: https://www.nutritioncare.org/NBNSC

Nursing Process ⬆ ⬇

The nursing process is a six-step process for problem-solving to guide nursing action (see Chapter 1 for details on the steps of the nursing process). The following table focuses on nursing diagnoses, nursing outcomes classification (NOC), and nursing interventions classification (NIC) for patients receiving nutritional support. Nursing diagnoses should be patient-specific and outcomes and interventions individualized. The NOC and NIC presented here are suggested directions for development of specific outcomes and interventions.

Nursing Diagnoses Related to Nutritional Support	Nursing Outcomes Classification (NOC)	Nursing Interventions Classification (NIC)
Risk for imbalanced fluid volume related to: PN regimen and changes in output (e.g., diarrhea, fistula drainage) or excess fluid intake	Fluid balance, hydration	Fluid management, fluid monitoring
Risk for electrolyte imbalance related to: Dependence upon PN	Electrolyte and acid-base balance	Electrolyte monitoring; laboratory data interpretation
Risk for unstable blood glucose level related to: Dependence upon PN	Blood glucose level	Hyperglycemia and hypoglycemia management
Risk for impaired liver function related to: Long-term dependence upon PN	Liver function; knowledge: disease process
Risk for infection, related to: Impaired skin as evidenced by presence of VAD	Immune status, knowledge of infection management, risk control, risk detection	Infection control, infection protection
Imbalanced nutrition: Less than body requirements, related to: Inability to ingest/absorb nutrients	Nutritional status, nutrient intake; food and fluid intake; weight control	Feeding, nutrition management, nutrition therapy
Impaired skin integrity, related to: Presence of VAD	Tissue integrity: Skin and mucous membranes	Skin care, skin surveillance, incisional (VAD) site care
Readiness for enhanced self-care related to: Desire to enhance ability to perform self-care HPN activities	Adherence behavior; self-care status	Coping enhancement; energy management; learning facilitation
Risk for caregiver role strain related to: Complexity of care activities	Caregiver role endurance; caregiver stressors; caregiver emotional health; caregiver performance; caregiver-patient relationship	Caregiver support

Source: Ackley et al., 2020; Herdman et al., 2021.

Chapter Highlights ⬆ ⬇

Indications for PN include:
- Nonfunctioning GI tract
- Inability to receive adequate nutrition via the oral or enteral route
Effects of malnutrition include a decrease in protein stores, albumin depletion, and impaired immune status.
Nutritional assessment includes:
- History (medical, social, dietary, medications)
- Anthropometric measurements (height, weight, skinfold tests, mid-arm circumference)
- Results of laboratory tests (serum albumin, transferrin, prealbumin and retinol-binding protein, total lymphocyte counts, electrolytes)
- Determination of energy requirements
- Physical examination
PN is an IV solution that includes carbohydrates, amino acids, lipids, electrolytes, multivitamins, and minerals formulated to meet an individual patient's needs.
Modalities for delivery of nutritional support include:
- Enteral nutrition
- PN, which may be administered via a peripheral vein or a central vein
PPN, delivered into a peripheral vein, is indicated for short-term nutritional support for patients who are malnourished or at risk for malnutrition, and are not candidates for enteral nutrition.
PN delivered via a CVAD is the IV administration of hypertonic glucose (20% to 70%) and amino acids (3.5% to 15%), along with all additional components required for complete support.
All PN, PPN solutions, and ILE must be filtered with a 1.2-micron filter
Complications of PN include:
- VAD-related complications
- Metabolic complications
- Nutritional complications

Thinking Critically: Case Study

A 45-year-old man is admitted with severe exacerbation of his Crohn's disease. He is 6 feet 1 inch tall, weighs 132 lb (60 kg), and has experienced a 45-lb weight loss in the past 3 months (25%). He is weak and pale and has dry mucous membranes, a red beefy tongue, and cracks at the sides of his mouth. He has an ileostomy and has developed a draining enterocutaneous fistula. Because of severe malabsorption as a result of the Crohn's disease, PN is ordered. He is to receive a solution of 20% dextrose, 50 g of protein/L with standard electrolytes, and daily multivitamins and trace elements. The goal is 2 L of this solution per day. With lipids, this will provide an average of 2,260 calories per day and 100 g of protein. The solution is initiated at 1 L/day and is increased according to patient tolerance. The PN will be infused through a peripherally inserted central catheter.

Case Study Questions

1.What are the points of care in monitoring this patient?

2.Why is the presence of the enterocutaneous fistula significant in terms of this patient's nutritional needs (considering increased fluid requirements and wound healing)?

3.For which potential complications related to PN is this patient at risk?

Media Link: Chapter post tests and answers are provided on FADavis.com, along with case studies and critical thinking activities.

References ⬆

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section name header

Learning Objectives ⬇

Glossary ⬆ ⬇

Introduction ⬆ ⬇

Nursing Process ⬆ ⬇

Chapter Highlights ⬆ ⬇

References ⬆