Nursing Considerations

Initiating PN

• Obtain appropriate IV access (Seres, 2017):
  • PN may be administered through a peripherally inserted central catheter (PICC), subclavian, internal jugular, or femoral central venous catheter. Tunneled catheters (i.e. Hickman, Groshong, or implanted infusion port) may be preferred if recurrent infection.
  • When possible, infuse PN into a dedicated single lumen central venous catheter; multiple lumen central venous catheters should have one port dedicated to the infusion of PN.
  • Partial parenteral nutrition (PPN) solutions contain a lower concentration of dextrose than total parenteral nutrition (TPN). PPN can be administered through a larger peripheral vein while TPN solutions must be infused through a central venous access device.
• Some additives may not be stable in the solution for more than 24 hours (i.e. multivitamins, trace elements, medications such as insulin) and must be added to the bag just before administering. Add clearest additives first.
• Remove PN solution bag from refrigerator at least 1 to 2 hours before hanging to allow solution to warm up to room temperature. Do not place in hot water, warmer or microwave.
• Verify PN orders including composition and infusion rate with label on the bag; check expiration date and ensure the solution will not expire while it is infusing. Solutions may hang for a maximum of 24 hours.
• Observe bag for leaks, color, separation, and precipitate formation. If signs of separation (“oiling out”), immediately discard the bag.
• Always administer PN using an electronic infusion pump.
• If PN must be stopped unexpectedly, administer 10% dextrose in water (as ordered) at same rate as nutrition solution to prevent hypoglycemia.
• Provide line care using infection control techniques including hand hygiene, aseptic technique to change dressings and caps; never use a stopcock to administer PN solution.
• Avoid piggybacking other medications into the same line as PN solution.
• Change tubing every 24 hours. Change dressings per hospital protocol or if soiled, wet, or loose.

Monitoring

• Assess routinely for signs and symptoms of infection including new hyperglycemia, leukocytosis, fever, chills, or tenderness, warmth, drainage, pain, and swelling at the catheter site.
• Perform physical assessment per unit specific protocols. Obtain laboratory data: electrolyte levels, including calcium, phosphorus, and magnesium monitored daily until stable; aminotransferases, bilirubin, and triglyceride levels once a week during treatment.
• Measure and document fluid intake and output.
• Glycemic control: target blood glucose range of 140 or 150-180 mg/dL for ICU patients.
• Monitor vitamin and trace element levels in long-term PN therapy.

Complications

• Refeeding Syndrome: In patients with significant weight loss or long-term malnutrition, starting PN can induce “refeeding syndrome” manifested by electrolyte disturbances and fluid shifts or overload. Hypophosphatemia (may be lethal), hypokalemia, low magnesium and any electrolyte imbalance should be corrected before PN is started. In patients at risk, begin PN at 25% of estimated daily needs and slowly increase to goal. Provide supplemental thiamine for the first 3 days.

• Central Line Associated Bloodstream Infection (CLABSI): high risk due to malnourishment, immunocompromised state, and long-term IV therapy.

  • Adhere to your institution’s central line bundle protocol

  • Dedicated single-lumen subclavian catheter for PN administration may decrease CLABSI.

• PN-associated liver disease (PNALD): symptoms range from transient elevations in liver function tests (LFTs) to fibrosis, cirrhosis, and irreversible hepatic failure.

• Metabolic bone disease (MB): abnormal bone metabolism resulting in decreased bone density and increased fracture risk; monitor serum calcium, phosphorus, and magnesium.

• Destabilization of formula which may lead to emboli: monitor PN solution for faint cream layer, separation of oil and water.

• Hyperglycemia: compounded by metabolic stress, steroid therapy, diabetes, obesity, sepsis and excessive glucose formulations.

• Hypercapnea: results from oxidation of glucose to carbon dioxide.

Transitioning to enteral nutrition (EN) (Malone, 2014):
In patients stabilized on PN, periodically repeated efforts should be made to initiate EN.

• As tolerance improves and the volume of EN calories delivered increases, the amount of PN calories supplied should be reduced.

• PN should be discontinued when ≥ 60% of target energy requirements are being delivered by the enteral route.