Nursing Process

Assessment
 Obtain baseline vital signs for future comparison.
 Confirm baseline weight.
 Determine laboratory results. Electrolytes, glucose, and protein levels frequently change during TPN
therapy. Early laboratory results are useful for future comparison.
 Check urine output. Report abnormal findings.
 Read the label on the TPN solution. Compare the solution with the order.
Nursing Diagnoses
 Risk for fluid volume excess related to excess fluid infusion or renal dysfunction
 Risk for fluid volume deficit related to osmotic diuresis resulting from hyperosmolar TPN solution
 Risk for infection related to TPN solution that has a high glucose concentration
 Ineffective breathing pattern related to complication from the insertion of subclavian line
Planning
 Client’s nutrient needs will be met via TPN.
 The common complication from TPN therapy infection will be avoided.
Nursing Interventions
 Check vital signs. Report changes.
 Determine body weight and compare with baseline weight.
 Monitor laboratory results and report abnormal findings, especially electrolytes, protein, glucose.
Compare laboratory changes with the baseline findings.
 Measure intake and output. Fluid volume deficit or excess could occur. Because the TPN solution is
hyperosmolar, fluid shifts occurs, which can cause osmotic diuresis.
 Monitor temperature changes for possible infection or febrile state. Use aseptic technique when
changing dressings and solution bottles or bags.
 Check blood glucose level periodically. When TPN therapy is started, there may be a transient
elevated glucose level until the beta cells adjust to the secretion of insulin. If this occurs, the flow
rate of TPN should be started slowly and gradually increased as the blood glucose level decreases.
Regular insulin may be added to the TPN fluids to correct elevated glucose levels.
 Refrigerate TPN solution that is not in use. High glucose concentration is an excellent medium for
bacterial growth.
 Monitor the flow rate of TPN. Start with 60 to 80 ml/hour and increase the rate slowly to the ordered
level to avoid hyperglycemia.
 Have client perform the Vasalva maneuver to avoid air embolism by taking a breath, holding it, and
bearing down. if the line is opened to air when changing the solution bag or bottle and IV tubing, an
air embolism could occur.
 Observe cardiac status because the Valsalva’s maneuver can cause cardiac dysrhythmias.
 Check signs and symptoms of overhydration, including coughing, dyspnea, neck vein engorgement,
or chest rales. Report findings.
 Follow the institution’s procedure for changing dressing and tubing. Usually, the tubing is changed
daily and the dressing is changed every 24 hours for the first 10 days and then every 48 hours
thereafter.
 Do not draw blood, give medications, or check central venous pressure via TPN line. Results could
be invalid.
 Client Teaching
 Provide emotional support to client and family before and during TPN therapy.
 Be available to discuss client’s concerns or refer client to the appropriate health care provider.
 Instruct client to notify the health care provider immediately with any discomforts or reactions.
 Keep client informed of progress and effectiveness of TPN.
Evaluation
 Evaluate client’s positive and negative response to the TPN therapy.
 Determine periodically whether client’s serum electrolytes, protein, and glucose levels are within
desired ranges.
 Evaluate nutritional status by weight changes, energy levels, feeling of well-being, symptom control,
or healing.