home care of the patient receiving TPN
home care of the patient receiving TPN
Editor's Note: In Part 1 of this article on total parenteral nutrition in home care (Sept. 18), Jan Rayl described TPN, when it is indicated and what it includes.
In part 1 we met Carrie T, who had just returned home from the hospital after being diagnosed with pancreatic pseudocyst. An airport reservations agent, Carrie is the mother of two teenage children and her husband owns a small business, thus his work hours are long.
Carrie had a bout of pancreatitis 10 years ago, which cleared up after a week in the hospital receiving IV fluids. However, with this latest flare-up she was in the hospital for 2 weeks and the latest tests show that the cyst is 12 cm by 9 cm. Carrie has been prescribed hyperalimentation, or total parenteral nutrition (TPN), at home.
Complications of patients receiving TPN at home can fall into three basic categories: septic, mechanical and metabolic. Serious complications can often be avoided by careful patient monitoring.
Septic Complications—a disease-producing organism in the blood causes sepsis. Contamination can lead to sepsis and can occur with mixing, preparation, catheter connection, catheter site care or taking blood specimens. The most common cause of sepsis is catheter-related infection, which often occurs when strict aseptic technique is not followed or when the catheter is seeded with microorganisms. Good handwashing and aseptic techniques by nurses, caregivers and patients are imperative with handling TPN. Patients requiring TPN are often prone to infections because of their poor nutrition and disease process.
Signs and symptoms of sepsis include redness, tenderness and drainage at the IV access site; fever above 100.5 F; shaking chills; abscess and wound drainage changes; signs of UTI or URI. The most common organisms are Staphylococcus epidermis, Staphylococcus aureus, Candida albicans and gram-negative bacteria.
Antibiotics are used to initially treat infections, and catheter-site dressings are changed frequently. However, catheter removal may be necessary, especially if the infecting organism is a fungus. Early detection is imperative as is, and this can't be stressed often enough, teaching the patients and caregivers to use good handwashing and aseptic technique.
Several mechanical complications may occur during TPN, of which the most common are occlusion, thrombosis, and breaks or leaks in the system. Listed below are complications and some solutions.
* Occlusion—Inability to irrigate the catheter. Teach the patient to check the clamp first as this is the most common problem. If the catheter will still not irrigate, do not use force to try to irrigate. Since urokinase has been taken off the market, tissue plasminogen activator (tPA)—not cost-effective in the home—may be administered in the hospital setting to prevent occlusions. Patients may require hospital treatment for this complication and may need to have the catheter replaced.
* Thrombosis—Blockage of the vessel with a clot can be a medical emergency. Monitor the access site for signs of redness, local tenderness, warmth, edema, palpable chord in the vessel, neck vein distention and discoloration of the extremity. Two home patients called me with the complaint "my arm looks a little purple or bruised"—one had a PICC line and one had a Groshong catheter. In both cases, the arm was a little cool and dusky in color. They both were sent to the hospital where vein studies revealed huge clots in the vessel.
Another patient with a Hickman catheter developed a red streak in the jugular vein overnight. Again, after transport to the hospital, the vein study revealed a large clot. No matter how non-specific the patient's complaints are, the nurse must follow up, inspect the site and assess the patient.
* Breaks or leaks in the system—The most common cause of a leak in the system is not connecting the bag properly or tightly. A leak can occur by spiking the bag and puncturing it, or by improperly connected pieces for whatever IV system is in use.
When connecting a patient to TPN, the IV tubing must be connected with some type of luer lock. This is standard on all IV tubing systems. What often happens is the patient does not twist far enough or push tight enough and the tubing is not really connected. This can leave a pathway open for microorganisms to enter. Proper patient education can prevent this problem. Double check all connections. From time to time a nurse will find defective equipment. When this happens, return it to the pharmacy so that they can follow up with the manufacturer.
A break in the system in the home setting is often from a patient who uses scissors near their catheter or tubing and cut the line. This type of break will require a catheter repair and may necessitate the catheter being removed or changed.
Uncommon mechanical complications associated with TPN include air embolism, bleeding and cracked TPN.
Air embolism—Presents with cyanosis, tachycardia, tachypnea, dyspnea, chest pain and cardiac arrest, and intervention includes clamping the catheter as close to the body as possible, laying the patient on side with chin to chest, contact physician or 911 to transport.
Prevention includes using luer lock connections and always clamping the catheter prior to opening the system—the exception is a Groshong, which is only clamped when damaged—and if disconnection occurs, clamping immediately.
Bleeding—Free flow of blood from catheter. Interventions: clamp the catheter and flush as ordered. Prevention: secure all connections with luer lock connections, keep the height of pole mounted solution container at least 30 inches above the patient. Note: In the home, the pump is usually portable without a pole and pole height is not an issue.
Cracked TPN—As discussed in part 1, TPN, which is 3:1 (amino acids, dextrose and lipids) can separate into its component parts. When this happens it can have an "oil and vinegar" look with a yellowish cast. If the TPN is not the usual milky white solution prior to adding the multivitamins it should not be administered. Multivitamins make the solution a pale yellow but the color is even throughout. Cracked TPN is an uneven color and dark yellow.
Metabolic Complications—Metabolic complications can occur during or after the administration of TPN. These complications (see Table) are often related to electrolytes and dextrose in the TPN reacting with the body.
Teaching TPN to patients will take some time. You will need to teach the underlying disease process as well as all aspects of monitoring and administration. Key factors include purpose of TPN, signs of catheter complications, pump troubleshooting, infection control, biohazard handling and TPN storage.
Other factors are aseptic technique, handwashing, pump alarms, daily weight, monitor blood glucose, check expiration, emergency numbers for nurse, check temp q p.m., access-device care, complications and action to take, additive procedures, pump set up, check solution for cracked TPN, flushing procedure, record intake and output.
Social issues also are important to cover, especially since gatherings of family and friends with food are big social events in most cultures. Patients receiving TPN and their caregivers are therefore often excluded from social gatherings. With all the equipment needed to administer TPN in the home, it can start to take on the appearance of a hospital.
This was a big issue for Carrie's teenage daughter who felt she could not have friends over without needing to answer questions about what all the stuff in the refrigerator was.
After teaching Carrie, I sat down with her children and helped them sort through their feelings. We worked together to come up with some solutions like keeping the TPN in the vegetable drawer where they did not have to see it every time they looked in the refrigerator. We discussed strategies for talking with their friends that enabled them to feel more comfortable. Eventually the daughter invited several friends for a sleepover while her mom was on TPN. As nurses, we must be prepared to meet all of the patient's needs.
Carrie eventually had her pancreatic pseudocyst drained and she was able to come off TPN. She was able to return to work during her course of TPN. This occurred during the bowel/pancreas rest phase prior to surgery. After two days of twice-a-day nursing and one week of daily nursing, Carrie was independent in TPN take-down and administration. She progressed to nursing twice a week for labs, performance of routine site care and dressing changes to her Groshong. Care of the TPN patient can be very rewarding because nurses assist someone in becoming independent in his care. However, there are numerous complications and the nurse must be forever vigilant in monitoring for subtle changes that may spell trouble.
DeLegge, M. (1998). Home parenteral nutrition: A physician's perspective. Infusion, 4(7), 31-35.
Metheny, N. (1992). Fluid and electrolyte balance nursing considerations (pp. 180-191). Philadelphia: J.B. Lippincott.
Viall, C. (1995, April). Taking the mystery out of TPN. Nursing95, 34-41.
Jan Rayl is a home IV nurse with INOVA-VNA, Alexandria, VA, who has been specializing in home health for the past 14 years.