Chapter 8: IV Therapy

8.12 Parenteral Nutrition (PN)

Critical Thinking Exercises: Questions, Answers, and Sources / References

  1. Describe refeeding syndrome and state one method to reduce the risk of refeeding syndrome.

Answer: Refeeding syndrome is caused by rapid refeeding after a period of malnutrition. It can result in metabolic and hormonal changes, and it is characterized by electrolyte shifts (decreased phosphate, magnesium, and potassium in serum levels) that may lead to widespread cellular dysfunction. Phosphorus, potassium, magnesium, glucose, vitamin, sodium, nitrogen, and fluid imbalances can be life-threatening.

High-risk patients include the chronically undernourished and those with little intake for more than 10 days. Patients with dysphagia are at higher risk.

The syndrome usually occurs 24 to 48 hours after refeeding has started. The shift of water, glucose, potassium, phosphate, and magnesium back into the cells may lead to muscle weakness, respiratory failure, paralysis, coma, cranial nerve palsies, and rebound hypoglycemia.

Interventions: PN infusion rate should be based on the severity of undernourishment for moderate- to high-risk patients. PN should be initiated slowly and titrated up for four to seven days. All patients require close monitoring of electrolytes (daily for one week, then usually three times/week). Always follow agency policy. Blood work may be more frequent depending on the severity of the malnourishment.

 

Copied from Anderson, R. (2018). Clinical Procedures for Safer Patient Care – Thompson Rivers University Edition. Adapted from Clinical Procedures for Safer Patient Care by G. R. Doyle and J. A. McCutcheon. Chapter 11  Parenteral Nutrition. https://pressbooks.bccampus.ca/clinicalproceduresforsaferpatientcaretrubscn/chapter/8-12-parenteral-nutrition-pn/

 

Sources:

Chowdary, K. V. R., & Reddy, P. N. (2010). Parenteral nutrition: Revisited. Indian Journal of Anaethestic, 54(2), 95-103. doi: 10.4103/0019-5049.63637.

Mehanna, H., Nankivell, P. C., Moledina, J., & Travis, J. (2009). Refeeding syndrome — awareness, prevention and management. Head and Neck Oncology, 1(4). https://doi.org/10.1186/1758-3284-1-4.

O’Connor, A., Hanly, A. M., Francis, E., Keane, N., & McNamara, D. (2013). Catheter associated blood stream infections in patient receiving parenteral nutrition: A prospective study of 850 patients. Journal of Clinical Medical Research, 5(1),18-21. https://dx.doi.org/10.4021%2Fjocmr1032w.

Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby.

  1. A patient receiving PN for the past 48 hours has developed malaise and hypotension. What potential complication are these signs and symptoms related to?

Answer:

Rule out potential hypoglycemia if PN solution contains insulin. Assess blood glucose.

Consider possible PN specific potential complications such as those in the following table:

Complication  Rationale and Interventions
Catheter-related bloodstream infection (CR-BSI), also known as sepsis
  •  There’s an increased risk of CR-BSI with TPN, due to the high dextrose concentration of TPN. Symptoms include tachycardia, hypotension, elevated or decreased temperature, increased breathing, decreased urine output, and disorientation.
  • Interventions: Strict adherence to aseptic technique with insertion, care, and maintenance; avoid hyperglycemia to prevent infection complications; closely monitor vital signs and temperature. IV antibiotic therapy is required. Monitor white blood cell count and patient for malaise. Replace IV tubing  as per agency policy (usually every 24 hours).

 
Hyperglycemia
  • Related to sudden increase in glucose after recent malnourished state. After starvation, glucose intake suppresses gluconeogenesis by leading to the release of insulin and the suppression of glycogen. Excessive glucose may lead to hyperglycemia, with osmotic diuresis, dehydration, metabolic acidosis, and ketoacidosis. Excess glucose also leads to lipogenesis (again caused by insulin stimulation). This may cause fatty liver, increased CO2 production, hypercapnea, and respiratory failure.
  • Interventions: Monitor blood sugar frequently QID (four times per day), then less frequently when blood sugars are stable. Follow agency policy for glucose monitoring with TPN. Be alert to changes in dextrose levels in amino acids and the addition/removal of insulin to TPN solution.

 
Refeeding syndrome
  • Refeeding syndrome is caused by rapid refeeding after a period of malnutrition. It can result in metabolic and hormonal changes, and it is characterized by electrolyte shifts (decreased phosphate, magnesium, and potassium in serum levels) that may lead to widespread cellular dysfunction. Phosphorus, potassium, magnesium, glucose, vitamin, sodium, nitrogen, and fluid imbalances can be life-threatening.
  • High-risk patients include the chronically undernourished and those with little intake for more than 10 days. Patients with dysphagia are at higher risk.
  • The syndrome usually occurs 24 to 48 hours after refeeding has started. The shift of water, glucose, potassium, phosphate, and magnesium back into the cells may lead to muscle weakness, respiratory failure, paralysis, coma, cranial nerve palsies, and rebound hypoglycemia.
  • Interventions: PN infusion rate should be based on the severity of undernourishment for moderate- to high-risk patients. PN should be initiated slowly and titrated up for four to seven days. All patients require close monitoring of electrolytes (daily for one week, then usually three times/week). Always follow agency policy. Blood work may be more frequent depending on the severity of the malnourishment.

Copied from Anderson, R. (2018). Clinical Procedures for Safer Patient Care – Thompson Rivers University Edition. Adapted from Clinical Procedures for Safer Patient Care by G. R. Doyle and J. A. McCutcheon.  Chapter 8.12 Parenteral Nutrition (PN). https://pressbooks.bccampus.ca/clinicalproceduresforsaferpatientcaretrubscn/chapter/8-12-parenteral-nutrition-pn/

 

Sources:

Chowdary, K. V. R., & Reddy, P. N. (2010). Parenteral nutrition: Revisited. Indian Journal of Anaethestic, 54(2), 95-103. doi: 10.4103/0019-5049.63637

Mehanna, H., Nankivell, P. C., Moledina, J., & Travis, J. (2009). Refeeding syndrome — awareness, prevention and management. Head and Neck Oncology, 1(4). doi: 10.1186/1758-3284-1-4

O’Connor, A., Hanly, A. M., Francis, E., Keane, N., & McNamara, D. (2013). Catheter associated blood stream infections in patient receiving parenteral nutrition: A prospective study of 850 patients. Journal of Clinical Medical Research, 5(1),18-21. doi: 10.4021/jomr1032w

Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical skills and nursing techniques (9th ed.). St Louis, MO: Elsevier-Mosby.

Chapter 8.12 Parenteral Nutrition Sample quiz questions

 

3. When considering a plan of care for a patient receiving PN therapy, the nurse must consider: (Select all that apply)

Risk of refeeding syndrome Correct Happens when malnourished people are re-nourished too quickly. Results in electrolyte imbalances)
Risk of air emboli Correct When changing lines there is risk of air emboli. Preventative strategies include clamping of open ended catheters when changing lines, use of needleless caps,  Trendelenburg positioning and valsalva maneuver if absolutely necessary during line changes
Risk of catheter related blood stream infection Correct Principles of asepsis when changing lines, changing dressings, changing bags is paramount
Risk of inadequate nutrition Correct If PN mixture is not adequate, malnutrition can persist. Regular bloodwork will determine therapeutic effects of PN.
Risk of liver dysfunction Correct PN carries a risk for liver dysfunction, thus the need for liver function monitoring through bloodwork
Risk of hyperglycemia Correct PN has high glucose levels and as such there is increased risk for hyperglycemia for the person with diabetes and those with borderline diabetes normally controlled with diet and exercise

Source:

Interior Health. (2012). Parenteral practices manual.  http://insidenet.interiorhealth.ca/Clinical/parenteralccr/Pages/Manual.aspx.

Mehanna, H., Nankivell, P. C., Moledina, J., & Travis, J. (2009). Refeeding syndrome — awareness, prevention and management. Head and Neck Oncology, 1(4). https://doi.org/10.1186/1758-3284-1-4.

Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby.

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