Page 429 - Nutrition Essentials for Nursing Practice

C H A P T E R 1 5 Feeding Patients: Oral Diets and Enteral and Parenteral Nutrition 417

Cyclic PN: infusing PN Because rapid changes in the infusion rate can cause severe hyperglycemia or hypo-
at a constant rate for 8 glycemia and the potential for coma, convulsions, or death, rate changes must be made
to 12 hours/day. incrementally. Continuous drip by pump infusion is needed to maintain a slow, constant
flow rate. If the rate of delivery falls behind or speeds up, the drip rate is adjusted to the
correct hourly rate only; no attempts are made to “catch up” to the ordered volume. Other
nursing management considerations appear in Box 15.6.

Overall, studies support the use of cyclic PN instead of continuous PN for stable
patients who require long-term or home PN (Stout and Cober, 2011). Infusions given over
a 10- to 14-hour period offer the patient periodic freedom from the equipment (Stout and
Cober, 2011) and allow serum glucose and insulin levels to drop during the periods when
PN is not infused, which may reduce the risk of impaired liver function related to excessive
glycogen and fat deposition. When it is given during the night, cyclic PN frees the patient
to participate in normal activities during the day.

During the switch from continuous to cyclic PN, the infusion time may be gradually
decreased by several hours each day, as ordered, and assessment is ongoing for signs of
glucose intolerance. To give the pancreas time to adjust to the decreasing glucose load,
the infusion rate may be tapered near the end of each cycle to reduce the risk of rebound

Box 15.6 NURSING MANAGEMENT CONSIDERATIONS FOR
PARENTERAL NUTRITION

■ Once parenteral nutrition solutions are prepared, they must be used immediately
or refrigerated. It is recommended that solutions be removed from the refrigera-
tor 1 hour before infusion because they must reach approximately room tempera-
ture before they are hung. Once hung, the solution is infused or discarded within
24 hours.

■ Inspect the solution for “cracking” (appearance of a layer of fat on top or oily
globules in the solution), which may occur in three-in-one mixtures if the calcium
or phosphorus content is relatively high or if salt-poor albumin has been added.
A “cracked” solution cannot be infused; notify the pharmacy and the physician,
who may need to adjust the original PN order to eliminate or reduce the offending
component.

■ Monitor the flow rate to avoid complications and ensure adequate intake.

■ Observe for side effects of PN: weight gain greater than 1 kg/day (indicative of fluid
overload), elevated temperature or sepsis, high blood glucose levels, shortness of
breath, tightness of chest, anemia, nausea and vomiting, jaundice, allergy to protein
content of the solutions, pneumothorax, or cardiac arrhythmias.

■ Monitor laboratory data and clinical signs to prevent the development of nutrient
deficiencies or toxicities.

■ Some patients may feel hungry while receiving PN and should be allowed to eat, if
possible. If oral intake is contraindicated, give mouth care.

■ Begin weaning the client from PN to EN or oral intake as soon as possible. Gradual
weaning is necessary to prevent rebound hypoglycemia. PN can be discontinued
when enteral intake (an oral diet, tube feeding, or combination of the two) provides
at least 60% of estimated calorie requirements.

■ Patients who have permanently nonfunctional gastrointestinal tracts require PN
indefinitely. For home PN to be successful, clients and their families must be
physically and emotionally prepared. Intensive counseling focuses on preparation
and administration of the solution, catheter and equipment care, and assessment
skills as well as the psychological impact of permanent PN.