Lesson 38: Parenteral Nutrition
tubing with the use of an in-line filter to trap crystals in the
 Parenteral nutrition (PN) refers to the administration
of nutrients by a route other than the GI tract (e.g., the
bloodstream); PN provides carbohydrates, fats, and proteins
in the form of amino acids, vitamins, minerals, trace
elements, water, and electrolytes.
 Insulin may be added to control the blood glucose
level because of the high concentration of glucose in the PN
solution.
 Heparin may be added to reduce buildup of a
fibrinous clot at the catheter’s tip.
Indications
 PN is used when the gastrointestinal (GI) tract is
severely dysfunctional or non-functional.
 Multiple GI surgeries, GI trauma, intestinal
obstruction, severe intolerance of enteral feedings, and any
other time that the bowel needs to rest for healing are
indications for the use of PN.
 Acquired immunodeficiency syndrome
(AIDS), cancer, and malnutrition are other conditions that
sometimes require the use of PN.
 Guidelines for Administering Parenteral Nutrition
 Check the components of the solution against the
health care provider’s prescription.
 The solution should be stored under refrigeration
and administered within 24 hours of the time when it was
prepared. (Remove the solution from the refrigerator 30
minutes to 1 hour before use.)
 A solution that is cloudy or darkened should not be
used; instead, it should be returned to the pharmacy.
 As a means of preventing infection and solution
incompatibility, intravenous (IV) medications and blood are
not given through the PN line.
 Monitor electrolytes, albumin, and liver and renal
function parameters.
 A therapeutic response to PN is signaled by weight
gain, ideally 1 to 3 lb (0.5 to 1.4 kg) per week.
 Intravenous Access
 PN is administered by way of central venous access
(subclavian or internal jugular vein, shown in the figure) when
the client requires a high concentration of carbohydrates
(more than 10% glucose).
 When it is anticipated that PN will be required for an
extended period (more than 4 weeks), a more permanent
catheter (e.g., a peripherally inserted central catheter (a.k.a. a
PICC line), a tunneled catheter, or an implanted vascular
access device may be used.
 Peripheral parenteral nutrition (PPN), administered
through a peripheral vein, is used for short periods (5 to 7
days) to deliver isotonic or mildly hypertonic solutions; the
delivery of highly hypertonic solutions into peripheral veins
can cause sclerosis, phlebitis, or swelling.
 Both PN and PPN must be administered through
solution.
 A 0.22-µm filter is sufficient for the administration of
solutions without lipid additives.
 Lipids (Fat Emulsion)
 Lipids, or fat emulsion, are administered to prevent
or correct fatty acid deficiency.
 Fat emulsion may be administered into a peripheral
vein.
 Assess the client for allergy to eggs or any of the
components of the lipid emulsion solution; commercial lipid
emulsions are formulations of safflower oil, soybean oil, or a
combination, with glycerol added for tonicity and egg
phospholipid as an emulsifying agent.
 Examine the bottle for separation of emulsion into
layers or fat globules and for the accumulation of froth. If any
of these findings is noted, do not use the solution; instead,
return it to the pharmacy.
 Do not put additives into the fat emulsion solution.
 Do not use an IV filter to administer a lipid emulsion-
only solution; particles in the fat emulsion are too large to
pass through filters.
 If the fat emulsion has been added to the PN
solution, use a filter gauge of 1.2 µm or larger to allow it to
pass through.
 The solution is supplied in a glass container for
administration; use vented IV tubing.
 Initially the infusion is usually administered at 1.0
mL/min; check vital signs every 10 minutes and observe the
client for adverse reactions, especially in the first 30 minutes
of the infusion; if signs of an adverse reaction occur, stop the
infusion and notify the health care provider.
 If no adverse reaction occurs, adjust the flow to the
prescribed rate.
 Monitor serum lipids for 4 hours after the infusion is
discontinued.
 Monitor laboratory values for evidence of impaired
liver function, indicating the liver’s inability to metabolize the
lipids.
 Complications of Parenteral Nutrition
Pneumothorax
 Pneumothorax, an accumulation of air between the
lung and chest cavity, is a rare complication of central line
placement.
 Once the catheter has been inserted, a portable
chest x-ray is obtained to confirm correct catheter placement
and to detect the presence of a pneumothorax.
 PN is not initiated until correct catheter placement is
verified and the absence of pneumothorax is verified.
Air Embolism
 Air embolism — an air bubble in the bloodstream —
is a complication associated with central line placement and
tubing changes.
 Instruct the client in the Valsalva maneuver for
tubing and cap changes.
 For tubing and cap changes, place the client in a
head-down position with the head turned in the opposite
direction from the insertion site to increase intrathoracic
venous pressure.
 Check all catheter connections and tape tubing
connections.
 If an air embolism is suspected, place the client in a
left side–lying position with the head lower than the feet (to
trap air in right side of the heart), administer oxygen as
prescribed, and notify the health care provider.
Infection
 Infection in a client receiving PN is usually catheter-
related; the PN solution contains a high concentration of
glucose, making it an ideal medium for bacterial growth.
 Use strict aseptic technique.
 Monitor the client’s temperature and assess the site
of IV access for redness, swelling, tenderness, or drainage.
 If signs of infection appear at the site, the IV line
must be removed and restarted at a different site, the tip of
the IV catheter is sent to the laboratory for culture, and blood
specimens for culture are obtained.
 Change the PN solution every 12 to 24 hours or in
accordance with agency protocol.
 Change the IV tubing in accordance with CDC
guidelines and agency protocol.
 Change the dressing at the IV site per CDC guidelines
and agency protocol.
Fluid Overload
 Fluid overload, an excess of fluid in the body, occurs
when an IV solution is administered too rapidly.
 As a means of preventing fluid overload, PN is always
delivered with the use of an electronic infusion device.
 Never increase the infusion rate to catch up if an IV
infusion falls behind.
 Monitor the client's intake and output.
 In addition to watching for other signs of fluid
overload, weigh the client daily. The ideal weight gain with PN
is 1 to 3 lb/wk (0.5 to 1.4 kg), so any greater gain is cause for
concern.
Hyperglycemia
 Hyperglycemia is usually caused by the components
of the PN solution itself.
 Assess the client for history of glucose intolerance
and review the client’s medication history (e.g.,
corticosteroids may increase blood glucose).
 Begin the infusion at a slow rate (usually 40 mL/hr),
as prescribed.
 Check the blood glucose concentration every 4 to 6
hours or in accordance with agency protocol.
 Watch for other signs of hyperglycemia, especially
the “three P’s”: polydipsia, polyuria, and polyphagia.
 Start sliding-scale insulin therapy (regular insulin
administration on the basis of blood glucose level) as
prescribed.
Hypoglycemia
 Hypoglycemia is usually a result of an abrupt
discontinuation of PN solution.
 When discontinuing PN, gradually decrease the rate
of infusion; when an infusion of hypertonic glucose is
stopped, an infusion of 10% dextrose should be instituted and
maintained for 1 to 2 hours to prevent hypoglycemia.
 Assess the blood glucose level 1 hour after
discontinuing PN.
 Watch for other signs of hypoglycemia.
 Prepare to administer glucose if hypoglycemia
occurs.
 Home Care Instructions for Parenteral Nutrition
 Teach the client how to obtain, store, and administer
PN fluids.
 Teach the client how to change a sterile dressing.
 Instruct the client to check his or her weight each
day, at the same time of day and wearing similar clothing.
 Stress that weight gain of more than 3 lb/wk (1.4
kg/week) may indicate excessive fluid intake and should be
reported to the health care provider.
 Teach the client to check the blood glucose level and
report abnormalities immediately.
 Instruct the client and family to watch for signs and
symptoms of complications; provide the client with a list of
these signs and symptoms and discuss the need to contact
the health care provider.
 Instruct the client to report edema of the arm or at
the catheter insertion site, neck pain, or jugular distention as
possible signs of thrombosis.
 Leakage of fluid from the insertion site or pain or
discomfort as the fluid is infused may indicate displacement
of the catheter and must be reported immediately.
 Stress to the client the importance of follow-up care.
 Priority Points to Remember!
 After a central venous catheter is inserted, a portable
chest radiograph should be performed to confirm correct
catheter placement and to detect pneumothorax. PN should
not be initiated until it is determined that no pneumothorax is
present.
 Check the components of the PN solution against the
health care provider’s prescription.
 PN solution should be stored under refrigeration and
administered within 24 hours of the time at which the
 solution was prepared. (Remove the solution from the
refrigerator 30 minutes to 1 hour before use.)
 PN solution that is cloudy or darkened should not be
used; instead, it should be returned to the pharmacy.
 PN is always delivered with the use of an electronic
infusion device.
 As a means of preventing infection and solution
incompatibility, IV medications and blood are never given
through the PN line.
 Before administering lipids, assess the client for an
allergy to eggs or any of the components of the lipid emulsion
solution.
 Examine the lipid preparation for separation of
emulsion into layers or fat globules and for the accumulation
of froth; if such separation is noted, do not use the solution
and return it to the pharmacy.
 Use strict aseptic technique when caring for the
central venous catheter. (Not only is the central line a possible
avenue for the entry of microorganisms into the body, but the
PN solution also contains a high concentration of glucose,
making it an ideal medium for bacterial growth).
 Check the blood glucose level every 4 to 6 hours or in
accordance with agency protocol.
 If an air embolism is suspected, place the client in a
left side–lying position with the head lower than the feet
(which traps air in right side of the heart), administer oxygen
as prescribed, and notify the health care provider.
 To help prevent hypoglycemia, gradually decrease
the infusion rate when discontinuing PN.
 Provide instructions to the client who will be
receiving PN at home.