Total Parenteral Nutrition (Nursing)

00:01 Hello! My name is Diana Shenefield. And the topic of this lecture is total parenteral nutrition, commonly called TPN. So, what are we going to be talking about in this lecture? I know you know about TPN. Just need to review that TPN can be given peripherally or through a central line. But again, what is the purpose of TPN and what is the reason that we need to know about that with NCLEX? So we’re going to talk a little bit about that.

00:29 So, our learning outcomes. One, what are the side effects of our patient getting TPN? And we know anytime we put something in somebody’s body, there’s always a potential for side effects.

00:40 So, what are the specific side effects for a patient receiving TPN? And then what do I need to know as a nurse to administer TPN to my patient? So first off, we need to talk about why would a patient need total parenteral nutrition or TPN. What patients am I going to be taking care of that might have this ordered, might need this in the near future? What’s going on with their body systems that they would need to have total parenteral nutrition? And one of the things is that they have something going on in their gut. For some reason, they can’t eat through their mouth. The food can’t go through their gut. So, they can’t have an NG feeding, a G tube feeding.

01:25 There’s something going on that I need to bypass their gut and put the nutrition right into their vascular system. So again, if you think about what patients does that entail, what patients should I be thinking ahead and thinking that they may need total parental nutrition. Those are the patients that we need to be watching for, patients that have any kind of disease process that’s going on in the GI. Maybe they’ve had a GI surgery, that’s going to be an extensive rehab that they’re going to have to have some kind of nutrition before their gut is ready for food. And then we have our trauma patients, our burn patients where they can’t eat enough to have the right nutrition for healing. So again, those patients are the ones I need to be thinking about total parenteral nutrition. And again, lot of times, these patients will go home with total parenteral nutrition. So, what kind of teaching needs to go along with that? What kind of home healthcare are they going to need? And what patients would be sent home with it? Where we do it in the hospital, we can monitor them, but what kind of monitoring needs to happen once they go home? So let’s talk a little bit about TPN. We know it’s the bag, the big bag that hangs. It gives our patients nutrition. And a lot of times we joke and say, “Here’s your steak even though you can’t taste it.” But what is it about the TPN that we need to know? One of the things we need to be assured of is our IV line. If it’s going to be a peripheral IV, what kind of things do I need to be watching for as for as infiltration, extravasation? What kind of damages being done to the vessels? If it’s going to be given through a central line, whether it’s a Hickman or whether it’s a port, what are the side effects of that? We always think about infection, control.

03:18 We think about dressing changes. So again, be familiar with the different ways that we can administer TPN. And then, what kind of ingredients are in the TPN? Some of the times, you know, you just have minerals, you just have trace elements, you have vitamins, you have dextrose, you have amino acids, you have water. But other times you have things like lipids. Maybe they’ve added insulin, maybe they’ve added heparin. Again, that changes the whole complex of the TPN. It also changes what I need to be watching for as a nurse.

03:52 We know that when you give TPN, it has to be checked by two RNs. It comes from the pharmacy.

03:57 It is a medication. So again, understanding what I’m looking for, understanding how the physician writes the prescription for the TPN. How many calories? How many carbohydrates? How many fats? How many proteins? Again, that’s a scientific process looking at what the patient needs. But as a nurse, I need to understand what they’re getting and what is going to be doing to the patient. Again, there's different ways. If a patient is going to be going home on TPN or they’re going to be on TPN for a long period of time, we know that a central catheter is going to be the technique of choice, because our peripheral lines just don’t work really well for long period of getting TPN, because of all the elements that is in it. So again, once the patient has a central line, we’ll probably be either assisting the physician on putting the central line in, so knowing that we need to watch for a pneumothorax. Again, as we’ve talked in other sessions, knowing what the possible complications are. So, we’re starting right off with, you know, if you’re doing a peripheral IV, what are the possible complications of putting in a peripheral IV? A central line. If a physician is putting in a central line for TPN, what are the possible complications just on the insertion? So, watching for pneumothorax, how would you know if your patient has a pneumothorax? Again, you would have decrease breath sounds.

05:23 So, run all that through your mind. Again, we always hope that our patients don’t have any complications. But in reality, we know that doesn’t happen. So, are you prepared for those complications? And then remembering, if you have a patient receiving TPN, we don’t put anything else in that IV line, whether it’s central or peripheral.

05:44 We don’t mix any medications in it. We don’t mix blood with it. We don’t put any other fluids with it. And we monitor our input and output very closely. So again, running that through your mind, making sure that you understand that, and then always looking for signs of infection. What do we know about TPN? TPN is high in glucose, and bacteria love glucose.

06:07 So, watching those IV sites for potential infection is a major risk factor that we need to be watching for as nurses. Monitoring blood glucose level. Because we are putting the sugars and amino acids and everything right into the blood line, we know that we have a fast effect on a patient’s blood glucose. So these patients need to be monitored at least every couple of hours on their blood glucose to make sure they’re not becoming hyperglycemia. What about daily weights? We’re putting fluids into the patient.

06:43 We’re putting them right into their vascular system. So we need to make sure, one we’re not over-hydrating, but two, if they’re not gaining weight and we’re wanting them to gain weight, then what’s wrong with the TPN? Does it not have the right amount of elements in it? So again, monitoring for the reason they’re getting the TPN, but also watching for side effects. And then lab values. In the TPN, we have glucose. So we need to be watching for glucose levels. But there’s also potassium and sodium. And so, watching those levels to make sure that we’re not over-compensating or under-compensating for what the body is doing. And as the body is repairing itself, it’s going to take over some of the process of managing potassium and sodium as well.

07:31 And the kidneys hopefully are going to kick in and start working better filtering. So, we need to watch those constantly to make sure that we’re not over-correcting or under-correcting.

07:44 And then the rate of administration. Because these fluids have lots of sugar in them and lots of proteins, the prescribed infusion rate needs to be adhered to. And why is that? It’s just like if I went down to the local 7/11 and had a big gulp of 7-Up or maybe Mountain Dew and had a big old candy bar. All of the sudden, I’m going to get this big rush of sugar. We don’t want that for our patients. We want constant. So, as you’re giving the TPN, making sure that it doesn’t run out, making sure that the patient doesn’t have long times with no TPN. Not increasing the rate real fast just to get it in because what does that do to the patient? What kind of potential risks could you be causing? And then what are the adverse effects? Again, we talked a little bit about that. Hyperglycemia or hypoglycemia, depending on what the concentration of sugar is. Are we giving too much potassium? Is there a chance that we could throw our patient into an arrhythmia because of potassium? What about blood clots? What about infection? All of those things are things that we need to be watching for. TPN is a wonderful, wonderful formula for patients that need it, but it also comes with side effects. And so, just hanging the TPN, nurses’ responsibility goes way beyond that. We need to be monitoring our patients for therapeutic effects and for side effects. And then understanding why is it if a patient doesn’t need their TPN anymore, do we not just turn it off? And again, we kind of go back to our big gulp of Mountain Dew and our big candy bar. Once you get that rush of sugar, the body gets used to a certain sugar level. And if you just turn off the TPN, the patient’s blood sugar level will drop, and they’ll go into a hypoglycemia. That’s why we taper it off. If there’s heparin in it or if there’s insulin in it, we’ve kept the body at a maintained level. And if I just turn it off, what’s going to happen with the patient? So, running that through your mind, being able to explain that to a patient as to why we have to wind it down. Again, it’s an understanding of what’s the purpose of the TPN and what is it providing for the patient and what are the side effects? And again, looking for weight gain. If I have a patient that’s severely emaciated and I’m giving them TPN because they can’t absorb food through the gut, I hope the goal is to increase calories, and with that is to increase weight. So I need to be watching weights. I need to be watching lab values. I need to be trending lab values. Just because I’m in the normal range doesn’t mean that that’s all the trending I need to do. I need to be watching because every 24 hours when the physician reorders that TPN, they need to know what’s going on with the patient. Does something in the TPN need to be adjusted? So again, doing great monitoring, watching weights, watching eyes and nose, and monitoring those lab values.

10:49 So again, we’re going to just talk a little bit more about possible complications.

10:55 Fluid overload. Again, this is extra fluid. Maybe this is all the fluid that your patient is getting, but if your patient happens to be getting blood or happens to be getting antibiotics or fluids, remember that all of that is added to the volume of the TPN. So, are you watching for fluid overload? Are you listening for crackles in the lungs? Are you watching for edema? Are you monitoring input and output and how the kidneys are perfusing? Air embolus. Anytime we have an IV, we’re always worried about air embolus. So, do you know the signs and symptoms of that? And are you watching for that? Infection. Again, TPN is high in glucose, and we know bacteria love glucose. And so, making sure that we’re watching for not only site infection but are you watching for a sepsis as well? Sepsis, which I just mentioned, again, can happen without us even catching it if you have an infection at the site that wasn’t caught in time. So again, do you know the signs and symptoms of sepsis and infection? And if you don’t, you need to go back and review that. We've got hyper and hypoglycemia. We are artificially giving this patient sugar that they’re not eating.

12:11 So we need to make sure we’re watching for both too much and too little.

12:16 So again, understanding TPN. Sometimes we think, “Why is this a whole topic in itself?” And it’s because TPN is so important to our patient’s wound healing and to our patient’s body healing and system healing, but it doesn’t come without complications. So you need to make sure you understand what the complications are and how I would be able to assess and what the signs and symptoms are so that you can keep your patients safe and give good nursing care. Good luck on your NCLEX.