Parenteral Nutrition
Administering Parenteral Nutrition Through a Central Line (CPN)
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Take the Review Test:
Safety
- Compare the patient’s baseline vital signs; electrolyte, glucose, and triglyceride levels; weight; and fluid intake and output with treatment values, and investigate any rapid change in such values.
- To spot signs of infection early, be aware of the patient’s recent temperature range.
- Use strict aseptic technique when caring for central venous catheters and PICC lines.
- Do not use central peripheral nutrition (CPN) solution if it has coalesced, as evidenced by formation of a thick, dense layer of fat droplets on its surface. If the solution appears abnormal in any way, request a replacement from the pharmacy.
- To prevent electrolyte and other metabolic abnormalities, increase the infusion rate gradually.
- If PN must be discontinued suddenly, prevent hypoglycemia by hanging an infusion of 10% dextrose in water at the same infusion rate.
- Infuse PN solution, including lipids, within 24 hours. Never attempt to catch up on a delayed infusion.
Equipment
(Roll cursor over items to see labels)
IV infusion tubing with Luer-Lok tip
Parenteral (PN) solution
IV filter: 1.2-µm filter and 1, 0.22-µm filter
IV infusion pump
Tape
Alcohol swabs
Clean gloves
PrintableDelegation
The skill of administering central peripheral nutrition (CPN) may not be delegated to nursing assistive personnel (NAP). Delegation of related skills varies according to each state’s Nurse Practice Act. Before delegating related skills, be sure to inform NAP of the following:
- Instruct NAP to report the following to you:
- Pump alarm sounds
- Catheter dressing is wet
- Patient’s temperature becomes elevated or other vital signs fall out of range
- Patient has any complaints
- Instruct NAP to perform fingerstick blood glucose monitoring as directed and report any abnormal results to you.
Preparation
- Review the patient’s medical history, and assess for indications of and risks for protein/calorie malnutrition. Confer with the nutritional support team regarding the following:
- Weight loss from baseline or ideal body weight
- Muscle atrophy/weakness
- Edema
- Lethargy
- Failure to wean from ventilatory support
- Chronic illness
- Nothing by mouth for more than 6 days
- Levels of serum albumin, total protein, transferrin, prealbumin, and triglycerides
- Electrolyte values
- Renal, cardiac, and hepatic function
- Allergies
- Inspect the condition of the central venous access site for the presence of inflammation, edema, and tenderness. Confirm the patency of the tubing.
- Assess vital signs, auscultate lung sounds, measure weight, and check the patient’s blood glucose level by fingerstick.
Follow-up
- Monitor the flow rate routinely (at least hourly).
- Monitor the patient’s fluid intake and urine and gastrointestinal fluid output every 8 hours.
- Obtain the patient’s weight daily or as ordered.
- Assess the patient for fluid retention by palpating the skin of the extremities and auscultating lung sounds.
- Monitor the patient’s glucose level every 6 hours or as ordered, and monitor other laboratory parameters daily or as ordered.
- Inspect the central venous access site.
- Monitor the patient for increased temperature, elevated white blood cell count, and malaise.
Documentation
- Record the condition of the central venous access device, the rate and type of infusion, the catheter lumen used for the infusion, intake and output (I&O) every 8 hours, blood glucose levels, vital signs, and weight measurements.
- If signs of infection, occlusion, fluid retention, or infiltration occur, notify the health care provider.
Review Questions
1. A patient for whom an intravenous antibiotic is prescribed has a multilumen central line in place for central parenteral nutrition (CPN). What should the nurse do?
Infuse the antibiotic through another lumen of the multilumen central line.
Interrupt the CPN infusion only long enough to administer the antibiotic.- Rearrange the antibiotic administration schedule so it does not interfere with the CPN.
- Ask the prescriber if the route of administration for the antibiotic can be changed.
CORRECT. IV medications and blood should be infused through a different line or lumen than CPN.
INCORRECT. The parenteral nutrition must not be interrupted for medication administration.
INCORRECT. Intravenous medications are to be infused through an alternative line or lumen, not through the same lumen or port being used for parenteral nutrition.
INCORRECT. It would be inappropriate for the nurse to ask the prescriber to change the route of administration for the antibiotic. Another lumen can be used, or another line can be placed for intravenous medication administration.
2. A patient’s central parenteral nutrition (CPN) order has been changed to a different solution, and the present solution is to be discontinued immediately. What should the nurse do until the new solution is delivered by the pharmacy?
- Discontinue the present CPN solution, and clamp the catheter hub.
- Continue the present CPN solution, but readjust the flow to a keep-vein-open (KVO) rate.
- Hang an infusion of 0.9% normal saline at the same infusion rate as the CPN.
- Hang an infusion of 10% dextrose in water at the same infusion rate as the CPN.
INCORRECT. Discontinuing the present CPN solution could cause the patient to develop hypoglycemia.
INCORRECT. Continuing the present CPN solution at a keep-vein-open (KVO) rate could cause the patient to develop hypoglycemia.
INCORRECT. Normal saline will not prevent the patient from developing hypoglycemia.
CORRECT. If CPN must be discontinued suddenly, a solution of 10% dextrose in water can be given at the same infusion rate in order to prevent hypoglycemia.
3. Which action will best minimize a patient’s risk for infection while receiving central parenteral nutrition (CPN)?
- Infuse the CPN only with a filter in the line.
- Assess the patient frequently for signs and symptoms of infection.
- Change the CPN infusion tubing at least once every 24 hours.
- Frequently inspect the patient’s central venous access site.
INCORRECT. Using a filter prevents particulate matter or large droplets of lipid from reaching the patient, but it will not minimize the patient’s risk for infection.
INCORRECT. Assessing the patient frequently for signs and symptoms of infection will not reduce the patient’s risk for infection.
CORRECT. Changing the CPN infusion tubing at least once every 24 hours will minimize the patient’s risk for infection.
INCORRECT. Frequently inspecting the patient’s central venous access site will not minimize the patient’s risk for infection.
4. When preparing to infuse a bag of parenteral nutrition through a patient’s central line, the nurse notices that the solution has coalesced. What is his or her best response?
- Warm the infusion in the microwave.
- Vigorously shake the bag.
- Contact the pharmacy for a new infusion bag.
- Increase the infusion rate on the pump.
INCORRECT. Parenteral infusions are not to be heated in the microwave.
INCORRECT. Shaking a bag of parenteral solution that has coalesced is not appropriate practice.
CORRECT. A solution that has coalesced cannot be used. A replacement must be requested from the pharmacy.
INCORRECT. Increasing the rate on the infusion pump is not an appropriate response, since the solution cannot be infused.
5. Which nursing action will best ensure the safety of a patient who is about to receive an infusion of parenteral nutrition?
- Assess the patient’s blood glucose level by fingerstick.
- Verify the physician’s order for central parenteral nutrition (CPN) and the flow rate.
- Confirm that the CPN infusion pump’s alarm system is functioning properly.
- Instruct the patient concerning the purpose for administering the CPN solution.
INCORRECT. Assessing the patient’s blood glucose level is not the best action to ensure patient safety.
CORRECT. Verifying the physician’s order for CPN and the flow rate will help ensure that the right solution is administered to the right patient at the right rate.
INCORRECT. Confirming that the CPN infusion pump’s alarm system is functioning properly is not the best action to ensure patient safety.
INCORRECT. Providing patient education before starting the infusion is appropriate but will not ensure patient safety.
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