Administering Parenteral Nutrition

Administering Parenteral Nutrition

Equipment
■ PN solution.
■ Procedure gloves.
■ Sterile gloves (per agency policy and type of tubing connection).
■ IV administration set, extension set if indicated.
■ 0.22-micron filter (1.2-micron filter if solution contains albumin or lipids).
■ Time tape.
■ 70% alcohol pads or CHG-based pads.
■ Infusion pump.
■ 10-mL syringe and saline.
■ Blood glucose testing monitor.
■ I&O record.
■ Transparent dressing or sterile gauze and tape (if dressing is to be changed).
■ If the dressing is to be changed, you also need a transparent dressing or sterile gauze, tape, and a mask.
■ Catheter stabilization device.
■ Be Smart! A catheter stabilization device (e.g., StatLock) is recommended for all catheters and must be changed with each dressing change.
■ Be Safe! Keep the PN solution refrigerated until 1 hour before use; do not give cold. Do not hasten warming by placing in a microwave oven or hot water bath.
■ Be Safe! IV tubing and equipment must be free of plasticizers (DEHP) when fat emulsion is to be infused.

Assessment
■ Check the patient record for prescriber’s orders for type and concentration of additives and rate of infusion.
■ Check agency policy. Some agencies require tubing and filter change with every bottle or bag. The CDC recommends changing the PN set every 72 hours and a fat emulsion set at least every 24 hours.
■ Assess:
■ Nutrition status and nutritional needs (e.g., daily weights, I&O, lab results).
■ Blood glucose level.
■ Patency of the IV site. If PN is being administered continuously by pump and the infusion is running and there is no leakage from the insertion, you can begin the first few steps of the procedure.
■ Be Safe! You must confirm that proper catheter tip placement has been established before the initial PN administration. Post-Procedure Reassessment These are immediate post-procedure evaluations. An extensive description of ongoing monitoring is beyond the scope of this handbook.
■ Assess VS, I&O, and weight.
■ Observe that the solution is infusing at the prescribed rate.
■ Assess patient’s tolerance to the infusion (e.g., observe for pulmonary edema; check lab results).
■ Observe for skin rashes, flushing, color changes, or other signs of allergic reactions; notify the primary provider.
■ Be Safe! Monitor blood glucose and do not increase the infusion rate until glycemic control is established.

Key Points
■ Perform preprocedure assessments.
■ Position the patient supine.
■ Examine the PN solution for leaks, cloudiness, and particles. If the solution contains lipids, also look for a brown layer, oil droplets, or oil on the surface. Have a coworker verify.
■ Identify the patient, using two identifiers; have identification verified by a second staff member.
■ Compare the bag to the patient’s ID band and with the original prescription.
■ Observe meticulous sterile technique in the appropriate steps of the procedure. During all steps, observe careful aseptic (clean) technique. Or follow agency policy.
■ Attach the new administration set to the new bag. Use a filter.
■ Prime the tubing (either now or after placing in the pump).
■ Be Safe! PN solutions must be administered by infusion pump.
■ Place the tubing in the infusion pump; set the rate.
■ Clamp the catheter and the old administration set.
■ Remove gloves, perform hand hygiene, and don clean or sterile gloves (per agency policy).
■ Carefully identify the correct IV catheter and lumen for the PN (usually the largest one).
■ Scrub all surfaces of the needleless connector and Luer-Lok threads with an antiseptic pad for at least 15 seconds.
■ Aspirate or flush to determine patency of the IV line.
■ Be Safe! If you meet resistance when flushing, do not flush forcibly. Try measures such as repositioning the patient and asking him to cough. If you still cannot flush, notify the primary provider.
■ Be Safe! Trace the tubing back to the patient, attach the new infusion tubing to the designated PN lumen, and secure the Luer-Lok connection. Have the patient perform the Valsalva maneuver when connecting the tubing for the new infusion.
■ Start the infusion.
■ Be Safe! Set pump alarms; be sure they are working.
■ Label the tubing.
■ Be Safe! If the infusion rate falls behind or the pump gives occlusion alarms:
■ Check that the pump is turned on.
■ Change the filter if it is clogged.
■ Try measures to relieve occlusion: aspirate the line and flush gently, reposition the patient and ask him to cough, roll the shoulder or raise the arm on the side the catheter is on.
■ If these measures do not work, change the pump and have it checked in engineering.
■ Do not attempt to catch up by increasing the rate.

Documentation
■ A special form may be used for documenting PN administration.
■ Record the bag number, date and time hung, volume, type of fluid, rate of delivery, and additives.
■ Document pre- and postadministration assessment data, including:
■ Complications and response to therapy.
■ Patient’s tolerance of procedure.
■ Results of fingerstick blood glucose checks.
■ Weight.
■ I&O.
■ Document the date and time of dressing or tubing change (if performed).
■ If insulin is required, record the type, amount, and route/site administered.