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Majuvy L. Sulse MSN, CCRN
• Use safe and accurate techniques when
caring for clients who are receiving
Hyperalimentation and who have central
venous catheters
Parenteral Nutritiondelivery/introduction of
nutrients, including
amino acids, lipids,
vitamins, minerals and
water, through a venous
access device (VAD)
directly into the
intravascular fluid
required for metabolic
functioning of the body.
Components of TPN
• Calories
– Carbohydrates-100-150 g/day
– Fat (emulsions)-10%, 20%, 30% (1 cal/ml)
• Soybean or safflower triglycerides with eggs as emulsifier.
• 2.5g/kg/day
• Administered slowly over 12-24 hours
• Protein
– Amino acids
– Daily requirement-45-65 g
– 1-1.5g/kg/day
• Trace elements
• Vitamins
Components of TPN
• Electrolytes
– Na:1-2 mEq/kg
– K: 1-2 mEq/Kg
– Mg: 8-20mEq
– Ca: 10-15mEq
– Phosphate: 20-40mmol
Paralytic Ileus
Intestinal obstruction
Acute pancreatitis
Persistent vomiting/ Severe diarrhea
Inflammatory bowel disease
Severe anorexia nervosa
Methods of Delivery
Peripheral Parenteral Nutrition (PPN)
Lesser concentrated glucose solution with amino
acids, vitamins, minerals & lipids given through a
Total Parenteral Nutrition (TPN)
Combines glucose (20-70%), amino acids, vitamins, &
minerals via a CENTRAL line
Lipids 10%-20% emulsion composed of triglycerides,
egg phospholipids, glycerol, & water
may be given intermittently or mixed with the TPN thru
a central line
Nursing Management
VS monitored every 4-8 hours or as per facility policy
Strict I & O
Ensure that the correct infusion rate is delivered.
Blood levels of glucose, electrolytes, BUN, CBC &
hepatic profile depending on patient status and protocol
Blood glucose testing at bedside as per
protocol/physician’s order
Daily weights
Monitor peripheral or central lines for signs & symptoms
of infection.
Aseptic dressings change as per facility protocol
Patient education or significant others
Administration of Parenteral nutrition
• Ensure correct order from healthcare provider
• Remove TPN from refrigerator at least 1 hr before
• Inspect fluid for presence of cracking or creaming
• Wash hands
• Use strict sterile technique, attach tubing with filter (0.22
micro Millipore for non fat emulsion solution & 1.2 micron
with fat emulsion solutions) to PN bag and purge air
• Close all clamps on new tubing. Insert tubing into volume
control infuser
• If VAD has a clamp at proximal end, clamp tubing. If no
clamp is available on central VAD, instruct the patient to
Valsalva manuever while new tubing is connected.
Connect tube to hub of VAD
Administration of Parenteral nutrition
• Monitor administration hourly, assessing for the integrity
of fluid, patient tolerance & complications.
• If new TPN solution is not available, hang D10W
• Document tubing change & fluid administration,
observations, complications & any treatment given
• If to be discharged with TPN, teach patient & family
regarding proper storage, handling and administration of
• NOTE: TPN solution, Tubing & Filter are changed
every 24 hours or as per hospital policy
Central Venous Access Devices
• Placement of flexible catheter into
a client’s central veins most
commonly SVC
• Purpose
Long term IV therapy
Long term antibiotic therapy
Blood/ blood product transfusions
Administration of total parenteral
– Measure direct pressure readings
– Chemotherapy
– Enhancing diagnostic agents
Central Venous Access Devices
• Peripherally inserted central catheters
• Single or double lumen polymer
about 45-60 cm gauge 24-16
• Done under sterile conditions by
physician or trained RN
• Local anesthetic is used
• Inserted above antecubital fossausually basilic (preferred) or
cephalic veins with tip at distal 3rd
of SVC
• Sterile dressings covers the site
• X-ray confirms placement of tip
before line is used
• Used for long-term IV/ TPN therapy
• May remain in place 6-12 months
Central Venous Access Devices
• Nontunneled percutaneous catheters
Inserted to SVC or Jugular vein
Short term use
15-20 cm long dual or triple lumens
Contraindications: ICP, respiratory conditions, spinal
curvatures, trauma/surgery/radiation on neck & chest
• Tunneled Central catheters
• Frequent & long term therapy
• Dacron Cuff placed inside the subcutaneous tissue,
granulation occurs anchoring the catheter and providing
barrier to microrganisms
Tunneled Central catheters
Catheters cont’d
• Central venous pressure catheter (CVP)
• Same as PICC but done by physician only
• Subclavian, External jugular, femoral
Triple Lumen CVP
Double Lumen CVP
Catheters cont’d
• Implanted infusion ports
• Consists of a catheter placed
into a desired vein and the other
end connected to a port placed
surgically in a subcutaneous
pocket on a chest wall
• Port consists of metal sheath
with self sealing silicone septum
• Accessed via the septum by
Huber-point needle that is
deflected to avoid coring of the
Implanted infusion ports
Nursing Responsibilities
• Maintenance of CV lines-observe for signs & symptoms
of infection
• To change Central venous catheter as directed by
• Obtain equipment
• Explain procedure to patient
• Place in patient comfortable supine with head
turned away from site
• Wash hands
• Don gloves & carefully remove old dressing
• Inspect insertion site for complications
Nursing Responsibilities
• Clean insertion site with each alcohol swab at
insertion site and moving outward in a circular
• Repeat using povidone-iodine swab/Chlorhexidine
• Allow to dry
• Apply new transparent dressing
• Loop and tape tubing to the skin but do not tape
over the dressing
• Document dressing change and observation of
insertion site
• Teach patient/family instruction regarding sterile
dressing change and report signs of infection, fluid
extravasation & phlebitis and inform nursing
Complications of TPN
Fluid overload
Hyperglycemia/hypoglycemia/ hyperosmolar states
Biliary complications
Electrolyte & vitamin excesses or deficiencies
• Catheter sepsis-staph aureus & epidermis, fungus, gram +
and/or gram-
• Mechanical
• Air embolus, hemothorax, pneumothorax, hydrothorax,
chylothorax, thrombosis, phlebitis, dislodgement of tube,
brachial plexus injury
Nursing Diagnosis
• Imbalanced nutrition: less than body
• Risk for Infection
• Risk for Impaired skin integrity
• Risk for fluid volume overload