Transcript Parenteral Nutrition

Chapter 55
Nutritional Supplements
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Nutrition Supplements
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Dietary products used to provide nutritional
support
Can be given in a variety of ways
Vary in amounts and complexity of
carbohydrates, protein, and fat content
Electrolytes, vitamins, minerals, and osmolality
may also vary
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Nutrition Supplements (cont’d)
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Malnutrition
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Enteral nutrition
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The body’s nutritional needs are not met by nutrient
intake
Provision of food or nutrients through the GI tract
Parenteral nutrition
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Delivery of nutrients directly into the circulation by
means of an intravenous solution
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Enteral Nutrition
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Provision of food or nutrients through the GI tract
Oral consumption is the most common and least
invasive route
Feeding tubes through various routes can be
used for enteral nutrition
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Enteral Nutrition (cont’d)
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Feeding tubes are used for those with:
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Abnormal esophageal or stomach peristalsis
 Altered anatomy secondary to surgery
 Depressed consciousness
 Impaired digestive capacity
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Enteral Formulation Groups
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Provide basic building blocks for anabolism
Supply complete dietary needs through the GI tract
by oral route or by feeding tube
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Elemental
 Polymeric
 Modular
• Carbohydrate formulations
• Fat formulations
• Protein formulations
 Altered amino acid formulations
 Impaired glucose tolerance
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Enteral Formulation Group:
Elemental
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Peptamen, Vital HN, Vivonex Plus, Vivonex TEN
Minimal digestion needed; residual is minimal
Used for malabsorption, partial bowel
obstruction, irritable bowel disease, other
conditions
Hyperosmolarity of formulas may cause GI
problems
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Enteral Formulation Group:
Polymeric
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Complete, Ensure, Ensure Plus, Isocal,
Osmolite, Portagen, Jevity, Sustacal
Preferred over elemental formulations for
patients with fully functional GI tracts and few
specialized nutrient requirements; cause fewer
GI problems
Most closely resemble normal dietary intake
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Enteral Formulation Group:
Modular
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Three types
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Carbohydrate: Moducal, Polycose
Fat: MCT Oil, Microlipid
Protein: Casec, ProMod, Propac, Stresstein
Single nutrient formulas
Intended for use with monomeric or polymeric
formulations
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Enteral Formulation Group:
Altered Amino Acid
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Amin-Aid, Hepatic-Aid, Travasorb Renal, TraumAid HBC
Contain varying amounts of specific amino acids
Used for patients with diseases associated with
altered metabolism capabilities
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Question
A patient who has a history of type 1 diabetes
mellitus is in need of enteral nutrition. Which
enteral formulation does the nurse anticipate
administering to this patient?
A. Ensure
B. Glucerna
C. Polycose
D. Jevity
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Enteral Formulation Group:
Impaired Glucose Tolerance
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Glucerna
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Contains proteins, carbohydrates, fat, sodium,
potassium
Used in patients with impaired glucose tolerance
(e.g., diabetic patients)
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Enteral Nutrition:
Interactions
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Various nutrients can interact with drugs to
produce significant food-drug interactions
Enteral nutrition can delay absorption of some
medications
Enteral nutrition may inactivate some
medications (e.g., tetracycline and nutrient
formulations that contain calcium)
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Question
The nurse is administering tube feeding to a
patient taking multiple medications. The nurse is
most concerned about absorption of which
medication when administered with tube feedings?
A. digoxin
B. penicillin
C. phenytoin
D. furosemide
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Enteral Nutrition:
Adverse Effects
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Gastrointestinal intolerance
Dumping syndrome
Aspiration pneumonia
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Question
The nurse identifies which condition as the most
common adverse effect of nutritional
supplements?
A.
Infection
B.
Phlebitis
C.
Diarrhea
D.
Hyperglycemia
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Parenteral Nutrition
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Totally digested nutrients are given
intravenously, directly into the circulatory system
The entire GI system is bypassed, eliminating
the need for absorption, metabolism, or bowel
elimination
Total parenteral nutrition (TPN)
Peripheral parenteral nutrition (PPN)
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Parenteral Nutrition (cont’d)
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Formulations vary according to individual patient
nutritional needs
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Amino acids
 Carbohydrates
 Lipids
 Trace elements
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Amino Acids
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Protein synthesis, or anabolism
Types of amino acids
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Essential
 Nonessential
 Semiessential
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Amino acid crystalline solutions (Aminosyn 3%,
5%, and 10%, and FreAmine III 8.5% and 10%)
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Carbohydrates
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Carbohydrates are usually supplied to patients
through dextrose
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Peripheral parenteral nutrition (PPN) dextrose
concentrations are usually kept below 10% to
decrease the possibility of phlebitis
Central TPN dextrose concentrations can range from
10% to 50%, but they are commonly 25% to 35%
Supplemental insulin may be given
simultaneously in nutritional supplements
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Fats
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Intravenous fat emulsions serve two functions
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Supply essential fatty acids
Source of energy or calories
Essential fatty acid deficiency
Lipid emulsions, Intralipid and Liposyn, are
available as 10%, 20%, or 30% emulsions
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Varying Amounts of Energy from 1 g of
Dextrose, Fat, or Protein
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Parenteral Nutrition (cont’d)
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Peripheral total parenteral nutrition
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Temporary, short term (less than 2 weeks)
Dextrose concentration generally less than 10%
Total parenteral nutrition
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Long-term use (over 2 weeks)
Dextrose concentrations may be 10% to 50%, but are
commonly 25% to 35%
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Peripheral TPN
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Used to provide nutrients to patients who need
more nutrients than present oral intake can
provide
Indicated for:
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Procedures that restrict oral feedings
Anorexia caused by chemotherapy or radiation
treatments
GI illnesses that prevent oral food intake
Postsurgical patients
When nutrition deficits are minimal, but oral nutrition
will not be started for more than 5 days
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Question
When caring for a patient receiving PPN, it is most
important for the nurse to assess for the
development of which adverse effect?
A. Hypertension
B. Anemia
C. Renal failure
D. Phlebitis
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Peripheral TPN:
Adverse Effects
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Phlebitis is the most devastating adverse effect
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Can lead to loss of a limb
Fluid overload
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Central TPN
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Delivered through a large central vein
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Subclavian
Internal jugular
Long-term use (more than 7 to 10 days)
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Central TPN (cont’d)
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Disadvantages are the risks associated with
central line insertion, use, and maintenance
Higher risk for infection, catheter-induced
trauma, metabolic alterations
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Central TPN (cont’d)
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Delivers total dietary nutrients to patients who
require nutritional supplementation
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Patients with large nutritional requirements (metabolic
stress or hypermetabolism)
 Patients who need nutritional support for more than 7
to 10 days
 Patients who are unable to tolerate large fluid loads
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Central TPN:
Adverse Effects
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Most common are those surrounding the use of
the central line for the delivery of TPN
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Infection
Catheter-induced trauma
Greater chance for hyperglycemia because of
the larger and more concentrated volumes given
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Trace Elements
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Chromium
Copper
Iodine
Manganese
Molybdenum
Selenium
Zinc
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Nursing Implications
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Ensure that a complete nutritional assessment is
taken, including a dietary history, weekly and
daily food intakes, and weight and height
measurements
Consult with a registered dietitian
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Nursing Implications (cont’d)
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Assess baseline laboratory studies, such as total
protein, albumin, BUN, RBC, WBC, cholesterol
Collect anthropometric data
Assess for allergies to components of enteral
nutritional supplements (such as whey, egg
whites)
Assess for lactose intolerance
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Nursing Implications (cont’d)
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If administering enteral nutrition by tube
feedings, follow facility policy for ensuring proper
tube placement and for checking residual
volumes before administering a feeding
Follow procedures for flushing tubing to prevent
clogging the feeding tube with formula
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Nursing Implications (cont’d)
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Carefully monitor how the patient is tolerating
enteral feedings
Keep in mind that most enteral feedings are
started slowly, and the rate is increased
gradually
Monitor for signs of lactose intolerance
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Cramping
Diarrhea
Abdominal bloating
Flatulence
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Nursing Implications (cont’d)
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Follow facility policies and procedures for care
and maintenance of TPN IV lines, including
tubing and dressing changes
Monitor patient’s temperature; report any
increase immediately
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Nursing Implications (cont’d)
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Monitor blood glucose levels with a glucometer
Monitor for hyperglycemia
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Headache, dehydration, weakness
Monitor for hypoglycemia
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Cold, clammy skin, dizziness, tachycardia, tingling of
the extremities
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Classroom Response Question
A patient is receiving peripheral parenteral nutrition (PPN).
When the current bag is empty, the nurse discovers that the
next ordered bag is not yet ready from the pharmacy. What
will the nurse do?
A. Convert the IV to an IV lock until the next bag is ready.
B. Hang a bag of 10% dextrose.
C. Hang a bag of 20% dextrose.
D. Notify the physician that the bag is not ready.
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Nursing Implications (cont’d)
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While on TPN, the pancreas provides increased
amounts of insulin to cover the increased
glucose levels
If TPN is discontinued abruptly, rebound
hypoglycemia may occur until the pancreas has
time to adjust to changing glucose levels
If TPN must be discontinued abruptly, then
infuse 5% to 10% glucose to prevent
hypoglycemia according to facility policy
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Nursing Implications (cont’d)
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Monitor for fluid overload while on TPN
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Weak pulse
 Hypertension
 Tachycardia
 Confusion
 Decreased urine output
 Pitting edema
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Monitor daily weights and intake and output
volumes
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Nursing Implications (cont’d)
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Monitor for therapeutic responses to nutritional
supplementation
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Improved well-being, energy, strength, and
performance of activities of daily living
 Increased weight
 Laboratory studies that reflect a more positive
nutritional status
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Question
The nurse is assessing a patient admitted to the
unit following major bowel surgery. The nurse
anticipates administering which type of nutrition for
this patient?
A.
Enteral feedings through a percutaneous
endoscopic gastrostomy (PEG) tube
B.
Peripheral parenteral nutrition
C.
Total parenteral nutrition
D.
A high-residue diet
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