Administration of Parenteral Nutrition (Adult Inpatient)

ADMINISTRATION OF PARENTERAL
NUTRITION PROCEDURE (ADULT
INPATIENT)

1
Author (s): Clinical policy Advisor/Nutrition Nurse Specialist
Version: 2
Status: Approved Authorised by: Clinical Policy, Documentation and Information Group
th th
Date of Authorisation: 12 October 2015 Review Date: 12 October 2018
Date added to Intranet: October 2015
 Administration of Parenteral Nutrition (Adult Inpatient)

1. Indications for Parenteral Nutrition ........................................................................ 3

2. Route of administration .......................................................................................... 3

3. Procedure for the administration of Parenteral Nutrition ........................................ 4

4. Disconnecting Parenteral Nutrition ........................................................................ 7

5. Clinical Monitoring ................................................................................................. 8

6. Nursing Management ............................................................................................ 9

7. References .......................................................................................................... 10

2
Author (s): Clinical policy Advisor/Nutrition Nurse Specialist
Version: 2
Status: Approved Authorised by: Clinical Policy, Documentation and Information Group
th th
Date of Authorisation: 12 October 2015 Review Date: 12 October 2018
Date added to Intranet: October 2015
 Administration of Parenteral Nutrition (Adult Inpatient)
Parenteral nutrition (PN) is the direct infusion into a vein, of solutions containing the
essential nutrients in quantities to meet all the daily needs of the patient.

1. Indications for Parenteral Nutrition

1.1 Nutrition is best supplied via the alimentary tract and parenteral nutrition (PN) should
only be used where the intestine in unavailable or unable to absorb nutrients.

1.2 PN is not an emergency procedure and should be started electively with clear aims.
PN should be established early in already malnourished or those patients with extreme
metabolic stress i.e. 1-3 days into admission. In well nourished patients, with a non
functioning GI tract, PN should be considered if recovery is not expected within 5-7
days.
1.3 PN should not be started until the patient has had a full clinical and dietetic nutritional
assessment; a plan for feed has been formulated and adequate venous access in
place.

1.4 Specific indications include.

• Intestinal obstruction
• Short bowel syndrome
• Inflammatory diseases such as Crohn’s disease
• Intolerance of, or inability to provide adequate nutrition by enteral nutrition
• As an aid to resting the bowel.
1.5 Relative contra – indications include:
• Well nourished patients whose GI tract is likely to be useable within 5- 7 days
(including post-operative period)
• When dependence on PN is anticipated to be less than 5 days
• Proven untreatable disease

2. Route of administration

The traditional method of access is a central venous catheter. The major hazard
associated with the delivery of PN via a central venous catheter is infection.. Therefore
catheter insertion should only take place using strict aseptic technique. On general wards
this will mean insertion in a theatre environment by appropriately trained and supervised
staff. A skin-tunnelled catheter is the catheter of choice for long-term nutrition. The
number of lumens will depend on the patient's peripheral venous access and the number
of additional therapies required. If veins are considered inadequate then a double or triple
lumen catheter should be inserted. If there is no other option than to use a multi-lumen
catheter, then one lumen should be used exclusively for the PN. The lumen identified for
exclusive PN use should be clearly labelled as such.

Central venous catheter with tip placement in the superior vena cava is required because
PN solutions are hyperosmolar and there is a risk of thrombophlebitis associated with
feeding into peripheral veins. However, it has been shown that with care and attention,

3
Author (s): Clinical policy Advisor/Nutrition Nurse Specialist
Version: 2
Status: Approved Authorised by: Clinical Policy, Documentation and Information Group
th th
Date of Authorisation: 12 October 2015 Review Date: 12 October 2018
Date added to Intranet: October 2015
 Administration of Parenteral Nutrition (Adult Inpatient)
peripheral veins can be used to provide short-term peripheral PN. This would be a
peripherally inserted central catheter (PICC).

The catheter or catheter lumen used for administration of PN should only be used for that
exclusive purpose and administering other drugs or infusions down the line must be
avoided. If the administration of any additional medications, blood products or CVP
readings are required, then these should be carried out using a separate lumen or a
separate peripheral device. Pharmacy advice should be sought if administering drugs
down a separate lumen to ensure compatibility with the PN solution.

3. Procedure for the administration of Parenteral Nutrition

Equipment required for setting up PN

• patients prescription chart
• prescribed bag of Parenteral Nutrition
• intravenous infusion stand
• clean dressing trolley
• PN intravenous administration giving set unless bag pre spiked with specific
filtration and needle free system connector.
• PN solutions should be removed from refrigeration two hours prior to infusion
in order to reach approximate room temperature.
• clean dressing trolley
• Sterile dressing pack
• Sterile gloves
• Swabs containing 2% chlorhexidine in 70% isopropyl alcohol (known allergy
contact pharmacy)
• volumetric pump
• 10ml Sodium chloride 0.9% for injection
• sterile 10ml syringe (nothing smaller)
• sharps bin

Action Rationale
Ensure the intravenous access has been To ensure that the devise is safe and in the
approved for use and is documented correct position prior to infusing PN.
in the healthcare record before
administering PN

A single lumen catheter should be used for There is greater risk of infection the
the administration of PN. If a multi-lumen more times a line is manipulated
catheter is used, PN should to be
administered via a lumen kept exclusively
for this purpose and strict aseptic technique
implemented when handling this lumen.
There is greater risk of infection the more
times a line is manipulated
Blood should not be sampled from this line.
Explain and discuss the procedure with the To ensure that the patient understands the
4
Author (s): Clinical policy Advisor/Nutrition Nurse Specialist
Version: 2
Status: Approved Authorised by: Clinical Policy, Documentation and Information Group
th th
Date of Authorisation: 12 October 2015 Review Date: 12 October 2018
Date added to Intranet: October 2015
 Administration of Parenteral Nutrition (Adult Inpatient)
patient. procedure and gives their valid consent
Before administering any PN check that it is To protect the patient from harm
due and has not been given already.
Before administering any PN consult the To ensure that the patient is given the
patient’s correct drug in the prescribed dose using
prescription chart and ascertain the the appropriate diluent and by the correct
following: route To protect the patient from harm.
(a)Drug To comply with NMC (2008a) Standards for
(b)Dose/rate Medicines Management.
(c)Date and time of administration
(d)Route and method of administration
(e)Validity of prescription
(f)Signature of prescriber.
Wash hands with bactericidal soap and To prevent contamination of medication and
water or bactericidal alcohol handrub. equipment
Prime the intravenous administration set To ensure removal of air from set and check
with PN mixture and hang it on the that tubing is patent. To prepare for
Infusion stand. administration. However, if the solution
Administration sets used for PN should be contains only glucose and amino acids,
changed every 24 hours or immediately administration sets in continuous use do not
upon suspected contamination or when the need to be replaced more frequently than
integrity of the product or system has been every 72 hours.
compromised.
PN should never be disconnected and then
reconnected unless in an emergency (If it is
necessary to disconnect the PN in the
middle of an infusion then the whole bag
must be discarded and a new one
commenced).
Draw up 10ml solution for injection to be To prepare for administration.
used for maintaining patency, for example
0.9% sodium chloride using an aseptic
technique.
Place the syringes in a clinically clean To ensure top shelf is used for sterile
receiver or tray on the bottom shelf of the dressing pack in order to minimize the risk
dressing trolley of contamination.
Collect the other equipment and place it on To ensure all equipment is available to
the bottom shelf of the dressing trolley. commence procedure.
Place a sterile dressing pack on top of the To minimize risk of contamination.
trolley.
Check that all necessary equipment is To prevent delays and interruption of the
present. procedure.
Wash hands thoroughly using bactericidal To minimize the risk of cross-infection
soap and water or bactericidal alcohol
handrub before leaving the treatment room.
Proceed to the patient. Check patient’s To minimize the risk of error and ensure the
identity against prescription chart and correct drug is given to the correct patient
prepared drugs.
Open the sterile dressing pack. To minimize the risk of cross-infection
5
Author (s): Clinical policy Advisor/Nutrition Nurse Specialist
Version: 2
Status: Approved Authorised by: Clinical Policy, Documentation and Information Group
th th
Date of Authorisation: 12 October 2015 Review Date: 12 October 2018
Date added to Intranet: October 2015
 Administration of Parenteral Nutrition (Adult Inpatient)
Open the 2% chlorhexidine swab packet To ensure the correct cleaning
and empty it onto the pack. swab is available
Wash hands with bactericidal soap and To minimize the risk of cross-infection.
water or with a bactericidal alcohol handrub.
Inspect the insertion site of the device. To detect any signs of inflammation,
infiltration, and soon. If present, take
appropriate action
Wash and dry hands. To minimize the risk of
contamination
Put on sterile gloves. To protect against contamination
with hazardous substances, for
example cytotoxic drugs
Place a sterile towel under the patient’s To create a sterile area on which to work.
arm.
Clean the needle-free cap with 2% To minimize the risk of contamination and
chlorhexidine swab, and allow drying for 30 maintain a closed system
seconds.
Aspirate 5-10 mls from the line and there is To ensure the patency of the line.
a good backflow of blood on aspiration.
Inject gently 10 ml of 0.9% sodium chloride To confirm the patency of the device.
for injection.
Check that no resistance is met, no pain or To ensure the device is patent
discomfort is felt by the patient, no swelling
is evident, no leakage occurs around the
device
If concerned about the position of the line To reduce the risk of extravation
please check with medical staff.
Connect the infusion to the device. To commence treatment.
Insert the tubing into an infusion pump and To check the infusion is flowing freely.
start pump. PN must always be
administered via an infusion device.
Check the insertion site and ask the patient To confirm that the vein can accommodate
if they are comfortable. the extra fluid flow and that the patient
experiences no pain.
Adjust the flow rate as prescribed. To ensure that the correct speed of
administration is established
Tape the administration set if necessary in a To reduce the risk of mechanical phlebitis or
way that places no strain on the device, infiltration
which could in turn damage the vein.
Remove gloves. To ensure disposal.
The equipment must be cleared away and To ensure that the equipment used is sterile
new equipment only prepared when prior to use.
required at the end of the infusion.
Monitor flow rate and device site frequently. To ensure the flow rate is correct and the
patient is comfortable, and to check for
signs of infiltration

6
Author (s): Clinical policy Advisor/Nutrition Nurse Specialist
Version: 2
Status: Approved Authorised by: Clinical Policy, Documentation and Information Group
th th
Date of Authorisation: 12 October 2015 Review Date: 12 October 2018
Date added to Intranet: October 2015
 Administration of Parenteral Nutrition (Adult Inpatient)
4. Disconnecting Parenteral Nutrition

Action Rationale
Stop the infusion when all the fluid has been To ensure that all the prescribed mixture
delivered. has been delivered and prevent air infusing
into the patient
Wash hands and put on sterile gloves. To protect against contamination with
hazardous substances.
Disconnect the infusion set and clean the To minimize the risk of contamination
injection site of the cap with 2%
chlorhexidine swab and allow 30 seconds to
dry
Flush the device with 10 ml of 0.9% sodium To flush any remaining irritating solution
chloride. away from the cannula.
(The PN must not be stopped or
disconnected for any other reason than
completion of prescribed volume or an
emergency).
Attach a new sterile injection cap if To maintain a closed system
necessary (weekly). If changing the cap
wipe the end of the line with 2%
Chlorhexadine and allow the cap to dry.
Flushing must follow with 0.9% saline To maintain the patency of the device and if
chlorideAdminister flushing solution using needle was used, to enable reseal of the
the push-pause technique and ending with injection site
positive pressure.

Remove gloves and wash hands. To ensure disposal.

7
Author (s): Clinical policy Advisor/Nutrition Nurse Specialist
Version: 2
Status: Approved Authorised by: Clinical Policy, Documentation and Information Group
th th
Date of Authorisation: 12 October 2015 Review Date: 12 October 2018
Date added to Intranet: October 2015
 Administration of Parenteral Nutrition (Adult Inpatient)

5. Clinical Monitoring

During intravenous feeding monitoring is necessary to detect and minimize complications

(see table below). Once feeding is established and the patient is bio chemically stable
then the frequency of monitoring may be reduced if the clinical condition of the patient
permits. Additional patient monitoring such as 24-hour urine collection for urinary urea,
nitrogen and serum zinc may be carried out where indicated, e.g. in severe malnutrition.

Monitoring of PN – reference: NICE GUIDELINES: Nutrition Support in Adults 2006

Parameter Frequency of monitoring

SEWS 6hrly
Body weight Twice weekly
MUST Weekly
Fluid balance Daily
Sodium, Potassium, Urea and Baseline
Creatinine Daily until stable
1 or 2 x week thereafter
Blood glucose Baseline, Daily until stable
3X weekly thereafter

BM monitoring (Capillary Blood 6 hourly for 48 hours then twice daily for the
Glucose) duration of PN and at instruction of medical
staff*
Magnesium and Phosphate Baseline
Daily if refeeding risk
3 x weekly until stable, weekly thereafter
LFT including INR Baseline
Twice weekly until stable, weekly thereafter
Calcium and albumin Baseline, weekly thereafter
CRP Baseline, twice weekly thereafter
Trace elements, e.g. selenium, One month after commencing PN
copper, manganese, zinc 3 – 6 monthly for long term PN

Capillary Blood glucose (BM) should be monitored 6 hourly and venous (formal laboratory)
blood glucose once every 24 hours when starting on PN. Twice daily BM monitoring
should continue throughout duration of PN but formal laboratory glucose can be tested 3
times weekly once stable. More frequent monitoring may be required if BM’s or formal
blood glucose measurements are erratic or if insulin treatment is prescribed.
8
Author (s): Clinical policy Advisor/Nutrition Nurse Specialist
Version: 2
Status: Approved Authorised by: Clinical Policy, Documentation and Information Group
th th
Date of Authorisation: 12 October 2015 Review Date: 12 October 2018
Date added to Intranet: October 2015
 Administration of Parenteral Nutrition (Adult Inpatient)

*Where 2 or more blood glucose or BM readings are greater than 10, advice should be
sought from the oncall diabetic team (Specialist Registrar or Nurse Specialist) regarding
the requirement for treatment with insulin.

Glucose intolerance and mild hyperglycaemia is common when high concentrations of

glucose are being infused intravenously.

Treatment with insulin is often required but this should be discussed with the diabetic team
first.

BM monitoring frequency should be increased until blood levels stabilise, as directed by

medical staff.

Parenteral nutrition should not be terminated until oral or enteral tube feeding is well
established. The patient needs to be taking a minimum of 50% of their nutritional
requirements via the enteral route. It is important that all members of the multidisciplinary
team are involved in the decision to terminate PN.

6. Nursing Management

Action Rationale
Daily weight before PN and twice weekly 1) Weekly measurements are used to
(Daily if there is a concern about fluid assess change in tissue mass and therefore
balance) adequacy of energy provision. Takes into
2) BMI weekly account muscle and fat.
2) Support aims/goals related to achieving
and ideal body weight.
6 hourly temperature, pulse, respirations & Observe for evidence of infection/ general
Blood pressure. wellbeing
Accurate fluid balance chart To maintain accurate fluid balance-prevent
under/over hydration.
Capillary blood glucose monitoring 6 hourly To detect hyperglycaemia and/or
for 48 hours – then twice daily hypoglycaemia.
Patient may require sliding scale Insulin if
Blood sugar >10mmols
Daily assessment of vascular line To detect exit site infection/ leakage
Dressing changes 48 hours after insertion, To maintain line integrity and reduce risk of
thereafter weekly or more frequent if loose, CRBSI.
soiled or wet.
Twice weekly urinary sodium. For nitrogen balance and electrolytes

9
Author (s): Clinical policy Advisor/Nutrition Nurse Specialist
Version: 2
Status: Approved Authorised by: Clinical Policy, Documentation and Information Group
th th
Date of Authorisation: 12 October 2015 Review Date: 12 October 2018
Date added to Intranet: October 2015
 Administration of Parenteral Nutrition (Adult Inpatient)

7. References

Royal Cornwall Hospital Clinical Guideline for Adult Total Parenteral Nutrition in the
Hospital Setting Available from:
http://www.rcht.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/Gastroente
rology/ProcedureForCommencingPeripheralParenteralNutritionpdf.pdf Last Accessed 18th
February 2015

Nice Nutrition support in adults: Oral nutrition support, enteral tube feeding and
parenteral nutrition Available from:
http://www.nice.org.uk/guidance/cg32/chapter/guidance Last Accessed 18th February
2015

Nursing Times Management and effects of parenteral nutrition Available from:

http://www.nursingtimes.net/nursing-practice/specialisms/nutrition/management-and-
effects-of-parenteral-nutrition/203586.article# Last Accessed 18th February 2015

10
Author (s): Clinical policy Advisor/Nutrition Nurse Specialist
Version: 2
Status: Approved Authorised by: Clinical Policy, Documentation and Information Group
th th
Date of Authorisation: 12 October 2015 Review Date: 12 October 2018
Date added to Intranet: October 2015