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.
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.
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.
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.
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.
We know that when you give TPN, it has to be checked
by two RNs. It comes from the pharmacy.
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.
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.
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.
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.
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.
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.
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.
So again, we’re going to just talk a little
bit more about possible complications.
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.
So we need to make sure we’re watching for
both too much and too little.
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.