 Hi, welcome to Versing School Explained, and this video on parenteral nutrition. Now, when we think about parenteral nutrition, it is any nutrition that is administered directly through the bloodstream basically bypassing the GI system. Reasons that the patients might need to require parenteral nutrition usually have to do with a disorder or disturbance in the GI tract. Now, this can be anything ranging from severe anorexia, GI surgery or major trauma, as well as severe vomiting and diarrhea, malabsorption disorders, as well as GI obstructions. Any parenteral nutrition is basically consistent of the three basic nutrients that our bodies need to sustain themselves, which is dextrose, amino acids, and fats, basically meaning carbohydrates, proteins, and lipids, or fats. And then, depending on what the patient's needs and labs will show, the pharmacists who usually reconstitutes or mixes these solutions, they will add electrolytes, vitamins, as well as trace minerals. Now, one special thing about parenteral nutrition, if we really think about it, it always has to be given, or most of the cases, it's going to be given through a central line. And what that basically means is that it will be administered through epaix or peripherally inserted central line or a central line itself. And the reason being is that these solutions are very extremely hypertonic. So it can be up to 1,600 million osmos. And if you think about our blood strength, typically it contains about 285 to 295 on osmolarity. So this is very, very hypertonic solutions. And if we administer it into a large blood vessel, the blood that flows through the bloodstream there kind of dilutes the solution as it enters the bloodstream and absorbs it a little bit better. Now, for a central parenteral nutrition, the glucose content can be as high as 20 to 50%, which is really, really high. There is also the option of administering peripheral parenteral nutrition, which will basically be a regular peripheral IV, but the risk for phlebitis is really high. Actually, phlebitis is a risk of both central as well as peripheral nutrition, but definitely much higher. So with a small element of the IV catheter. Now, for peripheral parenteral nutrition, it's still a hypertonic solution, but it might be less concentrated, such as 800 milli-ozmos compared to 1600, which is double up here. And to compare the central and peripheral, so central is usually administered when long-term nutrition through the bloodstream is expected to occur, as well as when the patient has high caloric and high protein intake needs. This could also mean that this is maybe somebody who had a burn injury, in addition to a GI malabsorption of who is going to be required to be on a ventilator for a prolonged period of time, unable to tolerate p.o. intake. Now, for peripheral specifically, it requires a large amount of fluid to be administered in addition to the nutrition, which puts the patient at risk of fluid volume, overload of fluid volume excess. So we always have to be carefully monitoring the patient's fluid volume status. Now, management of parenteral nutrition requires specific nursing interventions and management. I've written down the most important ones here. So first of all, it is always prepared under aseptic technique by a pharmacist or a specially trained pharmacy technician. And the solution is usually refrigerated until 30 minutes prior to the start of the administration. And that says basically to keep it viable or you could really call it food safety, right? Because there's fats and Olympics and carbohydrates in there that can otherwise spoil very easily. Now, the infusion, because these solutions can be very concentrated, a filter tubing is always required. And I encourage you to always check with your facilities policy and procedure depending on the filter, the micron filters that you will need. Typically it is more of a filter requirement if fats are being administered because they're kind of thicker solutions. The tubing has to be changed for policy and procedure. In general, the tubing when fats are administered can be changed at 24 hours. But if there are no fats, it can be changed every 72 hours. But again, check with the procedure and policy at the facility that you're at. All tubing has to be labeled so that we know when we have to change the tubing. And then if it is administered through a central line, whether that's a pic or a triple lumen, there will always be more than one lumen or most of the time. So typically a pic line has two lumens or specifically designated lines and the central line typically has three. That's why it's also called a triple lumen central line. And what that means is that there's three pores that you can hook up different IV lines. And if it is a central line, always use a designated lumen for the nutrition. That way you can keep it separate. You're not going to inadvertently hook up antibiotics or any other solutions to this designated nutrition line. And you can certainly label that on the patient's side of the border of the central line as well. And then always, always have it on an IV pump for regulation because we are administering hypertonic solutions into the patient's bloodstream. So we want to make sure that the pump controls the flow rate rather than estimating the drops that we are administering. Now for sight care because we're dealing mostly with a central line here, we always have to perform dressing changes according to the policy and procedure to the facility and always check for signs and symptoms of phlebitis. And these are redness, swelling, pain, edema, those kind of things. And whenever there is a smaller vein involved, it can be, is definitely at higher risk for phlebitis. Now if you are suspecting phlebitis, definitely culture the site right away and definitely notify the healthcare provider, they may or may not want to discontinue that line and then start another one depending on the patient's special circumstances. Now patient safety is always our number one concern. And so when we administer parenteral nutrition, we want to always check the order in the bag ingredients. Just like a bag of an antibiotic would be labeled with the medication as well as the milligrams or grams of the dosage. The parenteral nutrition bags will be labeled exactly as to how much, how many grams and milligrams and micrograms of the electrolytes, minerals, dextrose and so forth that they contain. And so always double and triple check these orders just like you would with any other medication and make sure that you check it against the order. Now this is a little bit more of a tedious process because there might be many more ingredients than like in a normal saline solution. And then definitely check the bags for leeks, any kind of color change or particulates because we're now dealing with vitamins, electrolytes, trace minerals or proteins that can kind of get a little bit crystallized. So we want to make sure that there are no particulates in there because if the end of the blood stream that could be disastrous outcome for the patient and the fat could be separated. So basically if you think about when you're cooking and you have a fat like a butter that's solid at room temperature but then as you eat it it becomes a little bit more liquid. So the fat on the back can kind of look the same way. So if that occurs, if you see that the fat is separating definitely send it back to the pharmacy because it basically means that it could be spoiled just like food. So you would want them to mix the bag again. This DC or discontinue the bag after 24 hours even if the bag is not empty. And that's basically another safety issue because we have such a high concentrate of dextrose, amino acids and fats it's a breeding ground for bacteria. So after 24 hours even if there's still some remaining in the bag just discard it and get a new IV, parenteral nutrition back from the pharmacy. And then certainly you wanna watch the patient for signs and symptoms of an adverse reaction such as anything that could mean that they are allergic to any of the ingredients such as rash, shortness of breath, fever, chest pain, back pain or flamboylis like we already discussed. Now because we're administering such high concentrations of glucose the patient is at an increased risk for hypo and hyperglycemia. So now let's say that the bag of the parenteral nutrition runs out and it's going to take the pharmacy several minutes or maybe even up to an hour to mix another bag of this. So in the meantime, the patient is used to getting these high concentrations of dextrose. So if we now abruptly discontinue the administration they might severely get hypoglycemic. So we always need to check the glucose contents of the bag and then depending on whatever that content is administer dextrose D5, D10 or D20 or even D50 basically meaning dextrose 5%, 10%, 20% in the interim to keep the patient's blood sugar up and prevent them from crashing with hypoglycemia. Now because again, we have such high glucose content the patient is at high risk for hyperglycemia which is why we wanna check blood glucose levels every four to six hours or per policy and procedure as well as the patient will be on a sliding scale insulin to control their blood sugar levels. Keep in mind that these patients are typically either acutely or chronically ill and they are at high risk for infection. So that's why we also want to keep the hyperglycemia under control. Now because we have a central line for the most part catheter associated infections can certainly happen. So we wanna check locally for signs and symptoms of infection as well as be very aware that the patient might turn septic because it is a direct access into the patient's blood stream therefore we need to watch out for those signs and symptoms. And if we associate or we suspect any of these adverse reactions to be happening then we should anticipate the blood cultures and the chest x-ray to be ordered to check for any pulmonary changes from fluid volume overload as well as check for blood stream infections. Now for nursing assessment because we are giving the patient hypertonic IV solutions as well as basically giving them nutrition via the IV. We wanna check vital signs frequently or for policy and procedure. Daily weight and eyes and nose are going to be very important not only in the short term we'll check for fluid volume overload or deficit but also to check and see if the nutrition is actually working. Because now we're giving them carbohydrates, proteins and fat to basically sustain themselves. And so if they've been malnourished then we wanna see are they actually gaining weight or is this actually working? Are those the appropriate caloric requirements? We certainly wanna closely keep an eye on blood sugars as we discussed here and the electrolytes because we know that we're administering that and the pharmacist will keep an eye on that but it's also the nurse's responsibility to keep checking for any kind of signs and symptoms of potential electrolyte imbalances. We certainly wanna keep an eye out for renal function because we're given fluids and hypotonic solutions in the ID and then we wanna check lipid panels specifically triglycerides because we're given them fats directly into their ID. Now for complications, there is such a thing called refeeding syndrome and refeeding syndrome is basically something that occurs when patients have been malnourished or not receiving the appropriate amount of nutrition for quite some time. So an example would be somebody with chronic alcoholism or after they've had chemotherapy or major surgery and what that means, refeeding syndrome because now their body is basically going into shock with all this nutrition that they're all of a sudden receiving that they haven't received in so long that they might go into fluid volume overload and then electrolyte imbalances can occur and the most common ones here, are hypophosphatemia, hypokalemia, and hypomagnesemia. And we know that the potassium and magnesium would always have to check for dysrhythmias and then the patient can also have peristeges such as numbness and tingling and they might go into respiratory areas. So we have to very, very carefully monitor them. And then another complication is hypo and hyperbolicemia that we already discussed, altered renal function and lipid panel. But this is why we're assessing these things here to make sure the patient doesn't suffer any of these complications. And then any other catheter or central line associated complications are right here in purple. So these can be an air ambulance, a pneumothorax or a hemothorax and that is basically mostly when the central line is being inserted and the lung is punctured or blood vessel is punctured there. Either can be hemorrhage, the central line can be occluded or dislodged. It can develop a thrombus, it can develop phlebitis like we already talked about or it can lead to sepsis. So thank you for watching this video on parenteral nutrition that is very important in terms of nursing management. The most important things there are the complications that I have here highlighted in purple as well as the risk for hypo and hyperglycemia and then the checking and keeping the patient safe. Thanks for watching this video. Please subscribe and like this video, give me a thumbs up and I look forward to seeing you soon.