TOTAL PARENTERAL NUTRITION (TPN)

1. INTRODUCTION
Total Parenteral Nutrition (TPN), also known as hyperalimentation or intravenous feeding, is a method of providing complete nutritional
support directly into the bloodstream, bypassing the gastrointestinal (GI) tract. It is used for patients who are unable to absorb nutrients through
the GI tract or when the GI tract needs to be rested. TPN solutions are complex, highly concentrated formulations containing a customized blend
of carbohydrates (dextrose), amino acids (protein), fats (lipids), electrolytes, vitamins, trace elements, and sterile water. Due to its
hyperosmolarity and the risk of infection, TPN is typically administered via a central venous access device (CVAD).

2. DEFINITION
Total Parenteral Nutrition (TPN) is the intravenous administration of a complete nutritional solution directly into a large central vein to
provide all necessary calories, protein, fats, vitamins, minerals, and fluids for patients whose gastrointestinal system is unable to adequately
absorb or utilize nutrients.

3. PURPOSES
 Provide Complete Nutritional Support: To deliver all essential nutrients when oral or enteral feeding is impossible, insufficient, or
contraindicated.
 Prevent Malnutrition: To prevent or reverse the effects of protein-calorie malnutrition.
 Promote Tissue Healing and Growth: To support wound healing, tissue repair, and overall anabolism, especially in hypercatabolic
states.
 Improve Patient Outcomes: To enhance immune function, reduce complications, and improve recovery in critically ill or compromised
patients.
 Rest the Gastrointestinal Tract: To allow the bowel to heal in conditions like severe Crohn's disease, pancreatitis, or short bowel
syndrome.
 Support Organ Function: To maintain essential metabolic processes and organ function when the body cannot derive sufficient energy
from food.
4. INDICATIONS
 Non-functional GI Tract:
o Severe malabsorption syndromes (e.g., short bowel syndrome, severe Crohn's disease, ulcerative colitis exacerbation).
o Prolonged ileus or bowel obstruction.
o Intractable vomiting or diarrhoea.
o Severe pancreatitis.
o GI fistulas (high output).
o Paralytic ileus extending beyond 7-10 days.
 Inadequate Oral/Enteral Intake for Prolonged Periods:
o Severe anorexia nervosa.
o Hyperemesis gravidarum refractory to other treatments.
o Severe burns or trauma with hypermetabolic states where enteral feeding cannot meet caloric needs.
o Severe critical illness (e.g., sepsis, multi-organ failure) where enteral feeding is not tolerated or sufficient.
o Pre-operative nutritional repletion in severely malnourished patients undergoing major surgery.
o Post-operative complications (e.g., prolonged NPO status, anastomotic leaks).
 Certain types of cancer with severe cachexia or GI involvement.

5. CONTRAINDICATIONS
 Functional GI Tract: If the gastrointestinal tract is functional and accessible, enteral nutrition (tube feeding) is preferred due to lower
cost, reduced risk of infection, and maintenance of gut integrity.
  Short-Term Nutritional Support: If parenteral nutrition is only needed for less than 5-7 days in a well-nourished patient (unless severe
stress/malnutrition exists).
 Inability to Establish Safe Venous Access: Without a suitable central venous access device, TPN cannot be administered.
 Terminal Illness with No Clinical Benefit: When the patient's prognosis is very poor and TPN would only prolong suffering without
improving quality of life.
 Uncontrolled Sepsis/Shock (relative): TPN should generally be delayed until the patient is hemodynamically stable and infection is
under control, as it can worsen hyperglycaemia and immune suppression.
 Severe Electrolyte or Metabolic Imbalances: These should be corrected before initiating TPN.
 Lack of Informed Consent.

6. EQUIPMENT
 Prescribed TPN Solution Bag: Custom-prepared by pharmacy, containing dextrose, amino acids, lipids, electrolytes, vitamins, and trace
elements.
 IV Administration Set: Dedicated TPN tubing with an in-line filter (usually 0.22 micron for non-lipid solutions, 1.2 micron for solutions
containing lipids).
 Infusion Pump: Volumetric pump for precise, controlled administration.
 Alcohol Swabs/Antiseptic Cleansing Solution: For cleaning catheter hub (e.g., chlorhexidine-based).
 Sterile Gloves: For catheter site care and connections.
 Non-sterile Gloves: For general handling.
 PPE: Mask and gown, if required by policy.
 Needleless Connector Caps/Disinfecting Caps: (e.g., Curos caps) for catheter ports.
 Syringes and Saline Flush: For flushing catheter.
  Labels: For tubing and solution bag.
 IV Pole.
 Blood Glucose Monitoring Supplies: Glucometer, test strips, lancets.
 Vital Signs Equipment: BP cuff, thermometer, pulse oximeter.
 Scale: For daily weight measurement.
 IV Site Dressing Supplies: If dressing change is due (sterile gloves, chlorhexidine/povidone-iodine, transparent semi-permeable
dressing).
 Emergency Supplies: Dextrose 50% for hypoglycaemia, insulin for hyperglycaemia.

7. BEFORE CARE (Patient Preparation and Assessment)

Thorough preparation and assessment are critical before initiating TPN:
 Verify Physician's Order:
o Confirm the patient's name, date of birth, medical record number.
o Verify the TPN formula, infusion rate, start time, and duration.
o Check for any specific instructions (e.g., cycling schedule, insulin drip orders).
o Ensure accompanying orders for labs (e.g., daily electrolytes, glucose, liver function tests, albumin).
 Patient Assessment:
o Baseline Vital Signs: Obtain blood pressure, heart rate, respiratory rate, temperature.
o Current Weight: Obtain baseline weight and compare with previous weights.
o Fluid Status: Assess for signs of fluid overload (e.g., edema, crackles, shortness of breath) or dehydration (e.g., dry mucous
membranes, poor skin turgor).
 o Glucose Level: Obtain baseline blood glucose.
o Electrolyte Status: Review recent lab results for electrolytes (Na, K, Cl, Mg, Phos, Ca), BUN, creatinine, liver function tests, and
blood glucose. Report any significant abnormalities to the physician before initiation.
o Allergies: Verify patient allergies, especially to components of TPN (e.g., soy, egg for lipids).
o Pain Assessment: Ask about any pain or discomfort.
o Central Venous Access Device (CVAD) Assessment:
 Confirm presence of a central line (PICC, CVC, implanted port).
 Inspect the insertion site for signs of infection (redness, swelling, warmth, tenderness, drainage) or dislodgement.
 Verify patency by flushing with saline.
 Ensure a dedicated lumen for TPN (preferably distal lumen or a single-lumen catheter).
 Patient Education:
o Explain the purpose of TPN, the infusion process, and the importance of not tampering with the line.
o Instruct patient to report any discomfort, pain, or changes at the catheter site.
o Educate on the need for frequent blood glucose monitoring.
 Prepare the Environment:
o Ensure a clean, uncluttered environment.
o Minimize traffic and distractions during connection.
 Prepare TPN Solution:
o Retrieve TPN solution from the pharmacy.
o Inspect the Bag:
  Clarity: Check for clarity and absence of particulate matter or precipitates.
 Separation: If lipids are included (3-in-1 solution), check for "cracking" or "creaming" (separation of the lipid emulsion,
appearing as an oil layer on top or aggregation of fat globules) which indicates instability and should not be used. It should
appear milky white and homogeneous.
 Expiration Date: Verify the expiration date and time.
 Integrity: Check the bag for leaks or damage.
o Warmth: Allow the TPN solution to warm to room temperature (usually 1-2 hours) before infusion. Do NOT microwave or use
hot water.

8. STEPS OF CARE IN DETAILS

Phase 1: Preparation of Supplies and Hand Hygiene
1. Perform Hand Hygiene: Thoroughly wash hands with soap and water or use an alcohol-based hand rub.
2. Gather Equipment: Assemble all necessary equipment at the bedside.
3. Don Gloves and Mask: Don clean gloves. Consider wearing a mask and having the patient wear a mask as per facility policy for central
line access to prevent contamination.
4. Prime the TPN Tubing:
o Hang the TPN bag on an IV pole.
o Spike the TPN bag aseptically with the appropriate TPN administration set (with filter).
o Important: Ensure the correct filter size (0.22 micron for non-lipid solutions, 1.2 micron for solutions containing lipids).
o Slowly open the roller clamp or unclamp the tubing to allow the solution to fill the entire length of the tubing, removing all air.
This is called "priming."
o Close the clamp once primed.
 o Label the tubing with the date and time of connection. (Tubing is typically changed every 24 hours, or as per policy).
Phase 2: Connecting to Central Venous Access Device (CVAD)
1. Identify Dedicated Lumen: Identify the dedicated lumen for TPN administration. This should ideally be a distal lumen or a single-
lumen catheter, to minimize risk of medication incompatibilities and contamination.
2. Prepare Catheter Hub:
o Scrub the hub of the dedicated CVAD lumen thoroughly with an antiseptic swab (e.g., chlorhexidine or alcohol) for at least 15-30
seconds, following facility policy. Allow to air dry completely.
3. Flush CVAD Lumen:
o Using a pre-filled saline syringe (10 mL or larger), connect it to the scrubbed hub.
o Unclamp the CVAD lumen.
o Aspirate for blood return to confirm patency and intraluminal placement.
o Flush the lumen using a pulsatile (push-pause) technique to clear the line. Clamp the lumen while pushing the last 0.5-1 mL of
saline (positive pressure technique) to prevent blood reflux.
4. Connect TPN Tubing:
o Maintain sterility of the TPN tubing end.
o Connect the primed TPN administration set to the scrubbed and flushed CVAD lumen. Ensure a secure, luer-lock connection.
5. Secure and Program Pump:
o Place the tubing into the infusion pump.
o Program the infusion pump with the prescribed TPN rate (ml/hr) and volume to be infused.
o Initiate the infusion at the prescribed rate. TPN is typically started slowly and gradually increased to the target rate over a few
hours to allow the patient to adjust metabolically, especially with glucose load. Follow physician orders for initiation rate.
Phase 3: Ongoing Monitoring During Infusion
1. Monitor Patient Closely:
o Vital Signs: Monitor vital signs per protocol (e.g., every 4-8 hours). Report any fever, tachycardia, or changes in blood pressure.
o Blood Glucose: Monitor blood glucose levels frequently (e.g., every 4-6 hours initially, then daily or as prescribed). Administer
insulin sliding scale as ordered.
o Fluid Balance: Monitor intake and output (I&O) strictly. Weigh patient daily at the same time, using the same scale, wearing
similar clothing.
o Catheter Site: Inspect the CVAD insertion site every shift for signs of infection (redness, swelling, warmth, pain, drainage) or
dislodgement. Perform dressing changes per policy (e.g., every 7 days for transparent dressings, or if soiled/loose).
o Signs of Complications: Continuously assess for signs of fluid overload, dehydration, metabolic imbalances, and infection.
o Patient Comfort: Assess for any discomfort, nausea, or abdominal pain.
o TPN Solution and Tubing: Ensure the solution is infusing correctly, no kinks in tubing, and the solution remains clear and free
of precipitates. Check tubing date.
Phase 4: Discontinuation (if applicable)
1. Gradual Tapering: TPN should generally be tapered gradually over several hours (e.g., 2-4 hours) before discontinuation to prevent
rebound hypoglycemia, unless glucose-containing IV fluids are concurrently administered.
2. Prepare for Disconnection:
o Perform hand hygiene and don gloves.
o Clamp the TPN tubing and the CVAD lumen.
o Scrub the hub of the CVAD lumen with antiseptic.
3. Disconnect and Flush:
 o Disconnect the TPN tubing from the CVAD lumen.
o Flush the CVAD lumen with saline using positive pressure technique.
o Apply a new needleless connector cap/disinfecting cap to the CVAD lumen.
4. Dispose of Equipment: Dispose of the TPN bag, tubing, and all used supplies in appropriate waste receptacles.

9. AFTER CARE (Post-Procedure and Documentation)

 Documentation: Meticulously record:
o Date and time of TPN initiation/discontinuation or bag change.
o Type and volume of TPN solution.
o Infusion rate and total volume infused.
o CVAD lumen used and its condition.
o Patient's vital signs.
o Blood glucose readings and insulin administration.
o Daily weight and fluid balance (I&O).
o Assessment of CVAD site.
o Any complications observed and nursing interventions.
o Patient's tolerance and response to TPN.
o Nurse's signature.
 Ongoing Monitoring: Continue to monitor blood glucose, electrolytes, and fluid balance as per physician's orders.
 Transition to Other Feeding: If TPN is discontinued, ensure adequate alternative nutritional support (e.g., oral intake, enteral feeding) is
initiated.
  Patient Education Reinforcement: Reinforce teaching on catheter care, signs of complications, and importance of reporting any
concerns.

10. COMPLICATIONS
TPN, while life-sustaining, carries significant risks:
 Infection (Catheter-Related Bloodstream Infection - CRBSI):
o Cause: Contamination during insertion or care, migration of skin flora along the catheter. TPN is an excellent medium for
bacterial growth.
o Signs/Symptoms: Fever, chills, tachycardia, localized redness, pain, or purulent drainage at the catheter site.
o Nursing Action: Strict aseptic technique is paramount. Monitor vital signs, assess site, obtain blood cultures (from catheter and
peripheral), administer antibiotics, potentially catheter removal.
 Metabolic Complications:
o Hyperglycemia:
 Cause: Excessive dextrose, insufficient insulin, stress.
 Signs/Symptoms: High blood glucose, polyuria, polydipsia, fatigue.
 Nursing Action: Monitor blood glucose frequently, administer insulin as ordered, notify physician, adjust TPN rate if
necessary.
o Hypoglycemia (Rebound):
 Cause: Abrupt cessation or rapid tapering of TPN without concurrent glucose infusion.
 Signs/Symptoms: Shakiness, sweating, confusion, headache, pallor, tachycardia.
 Nursing Action: Administer D50W (dextrose 50%) or glucagon, notify physician, ensure gradual tapering.
o Electrolyte Imbalances:
  Cause: Inadequate or excessive electrolytes in TPN, fluid shifts. Common imbalances include hypokalemia,
hypophosphatemia, hypomagnesemia, hypercalcemia.
 Signs/Symptoms: Varies depending on electrolyte.
 Nursing Action: Monitor labs closely, administer replacement as ordered, notify physician for critical values.
o Refeeding Syndrome:
 Cause: Rapid reintroduction of nutrition in severely malnourished patients, leading to rapid shifts in fluids and
electrolytes (especially phosphorus, potassium, magnesium).
 Signs/Symptoms: Muscle weakness, respiratory depression, arrhythmias, fluid overload, confusion.
 Nursing Action: Prevent by initiating TPN slowly, monitor electrolytes extremely closely, replace deficiencies, especially
phosphate.
o Liver Dysfunction:
 Cause: Excess calories (especially dextrose), lipid overload, underlying liver disease.
 Signs/Symptoms: Elevated liver enzymes (ALT, AST, bilirubin), jaundice.
 Nursing Action: Monitor LFTs, notify physician, may require TPN modification or cycler schedule.
 Mechanical Complications (related to CVAD):
o Pneumothorax/Hemothorax:
 Cause: During central line insertion.
 Signs/Symptoms: Shortness of breath, chest pain, decreased breath sounds.
 Nursing Action: Monitor respiratory status, prepare for chest tube insertion, ensure chest X-ray post-insertion.
o Air Embolism:
 Cause: Air entering the catheter lumen during insertion, disconnection, or line breaks.
  Signs/Symptoms: Sudden shortness of breath, chest pain, pallor, tachycardia, hypotension.
 Nursing Action: Clamp catheter immediately, position patient in Trendelenburg on left side, administer oxygen, notify
physician, prepare for aspiration of air.
o Catheter Occlusion:
 Cause: Thrombus formation (blood clot) or precipitate in the lumen.
 Signs/Symptoms: Inability to flush or aspirate blood, resistance to infusion.
 Nursing Action: Assess for kinks, reposition patient, attempt gentle aspiration/flush, notify physician for thrombolytic
agent.
o Catheter Dislodgement/Migration:
 Cause: Improper securing, patient pulling.
 Signs/Symptoms: Pain, swelling, leakage at insertion site, inability to infuse, arrhythmias.
 Nursing Action: Secure catheter, notify physician, verify placement with X-ray.
 Fluid Overload:
o Cause: Too rapid infusion, excessive fluid volume in TPN, patient with compromised cardiac/renal function.
o Signs/Symptoms: Edema, dyspnea, crackles in lungs, rapid weight gain, elevated BP.
o Nursing Action: Slow infusion rate, monitor I&O, daily weights, assess respiratory status, administer diuretics as ordered, notify
physician.

11. NURSES' RESPONSIBILITIES

o Accurately verify physician's orders against the TPN solution from pharmacy.
o Inspect TPN solution for clarity, precipitates, and expiration.
o Ensure all necessary equipment is available and sterile.
o Strict adherence to aseptic technique during TPN bag and tubing changes, catheter care, and any access to the CVAD. This is the
single most important intervention to prevent CRBSIs.
o Perform meticulous hand hygiene, don appropriate PPE (gloves, mask).
o Thoroughly scrub the hub before each access.
o Maintain a dedicated lumen for TPN.
o Perform comprehensive baseline and ongoing assessments (vital signs, weight, fluid status, lab results).
o Monitor blood glucose levels frequently and administer insulin as prescribed.
o Assess the CVAD insertion site for signs of infection or complications every shift.
o Monitor for signs and symptoms of all potential TPN complications (infection, metabolic imbalances, mechanical issues).
o Properly prime TPN tubing with the correct filter.
o Program and manage the infusion pump accurately.
o Ensure TPN is infused at the prescribed rate, especially with gradual initiation/tapering.
o Change TPN bags and tubing according to facility policy (typically every 24 hours).
o Manage CVAD patency by flushing appropriately.
o Maintain accurate and thorough documentation of all TPN-related activities, including assessments, infusions, lab results, and
complications.
o Identify and troubleshoot common problems related to TPN administration (e.g., pump alarms, catheter occlusion, signs of fluid
imbalance).
o Communicate effectively with the physician, dietitian, pharmacist, and other healthcare team members regarding the patient's
nutritional status, lab results, and any concerns.
 o Report any significant changes or complications promptly.

BIBLIOGRAPHY:-
 Brunner and Suddarth’s.(2016), Text book of medical surgical nursing; 12th edition: publish by. Lippincott Williums and wilkins, page no-
800-801
 Dr. Auradha. S.(2018), a text book of fundamentals of nursing; 1st edition: publish by. Vijayam publication, prakasam road, tirupati-
517501; page no-502-504
 Javed Ansari and Davinden kaur.(2011), Text book of medical surgical nursing volume-ii; 1st edition: publish by pee vee, page no-2033-
2039
 Lewis.Bucher, Heitkempeer, Harding, Kwong.(2017), Roberts medical surgical nursing, assessment and management of clinical
problems; 3rd south asia edition: publish by RELX India pvt.ltd , new delhi; page no-110-111
 WWW.GOOGLE.COM
 WWW.WIKIPEDIA.COM
 https//slideshare.com