Parenteral Nutrition
Evaluate
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Evaluating the Nutrition Care Plan
After you have implemented your nutrition care plan, you need to follow-up and evaluate it to ensure that it has been effective in addressing your patient’s nutrition concerns. This can help you to decide on appropriate changes to make to the nutrition care plan moving forward.
When evaluating your plan in a inpatient setting, you will need to gather updated information from the same key areas of nutrition concern that you identified in your initial assessment. This will include, but is not limited to: parenteral feeding delivery/ tolerance, daily intake and outputs, laboratory values, medications, disposition, and any changes to the medical care plan. Also consider if PN is still indicated, or if your patient could transition to EN or an oral diet.
| Common Nutrition Issues | Evaluate effectiveness of NCP |
|---|---|
| Parenteral Nutrition |
|
| Daily Intake and Output |
|
| Malnutrition |
|
| Electrolytes and Laboratory Work |
|
| Medical Care Plan |
|
Evaluating Poppy’s Nutrition Care Plan
| Common Nutrition Issues | Evaluate effectiveness of NCP | Poppy’s outcomes |
|---|---|---|
| Parenteral Nutrition |
|
|
| Daily Input and Output |
|
|
| Malnutrition |
|
N/A |
| Abnormal Electrolytes |
|
|
| Medical Care Plan |
|
|
Poppy is on day 3 of PN administration with no complications, therefore it would be appropriate to advance her PN solution to 75%-100% of her estimated nutrition requirements. It is important that we still monitor closely for refeeding syndrome and complications that may result with this increase.
Poppy’s fluid balance is +5 L, which is an improvement from +10 L and she has a urine output of >2 L per day. Although Poppy is still considered fluid overloaded, she is moving in the right direction. For now, maintain fluid restriction in the nutrition care plan as per MD orders.
Poppy’s laboratory results reveal that her WBC, BG, Cr and BUN are elevated and her Hgb, K, and Mg are low. It would be important to liaise with the team regarding replacements for low K and Mg, and continue monitoring her laboratory values as PN volumes increase.
Lastly, Poppy continued to experience abdominal pain and distension. Taking the CT abdominal results into consideration, the GI surgery team schedules an OR and finds a 20 cm segment of necrotic bowel in the terminal ileum resulting in a 25 cm small bowel resection. Post operatively, the GI surgeon recommends continuing TPN for one week and then to trial enteral feeding upon evaluation of Poppy’s clinical status.
Weaning PN
There are various strategies for weaning PN. Patients may transition from PN to enteral feeding or an oral diet. The oral diet may consist of various textures and oral supplements are also taken into consideration.
Here is a general procedure for weaning PN for patients transitioning to enteral feeding:
- PN may be weaned when patient is able to tolerate oral intake/EN.
- PN should be reduced as oral intake/EN improves. PN should be reduced by an amount that is equal to the calories and protein provided via oral intake/EN.
- Calories counts can be used to assess adequacy of oral intake. Reduced oral intake can be expected if PN provides > 25% kcal requirements.
- PN may be discontinued when patient is tolerating 50-75% energy and protein requirements via oral intake/EN, unless impaired GI function precludes 100% absorption of nutrient needs.
- Some institutions do not gradually wean PN. PN is continued at goal rate and discontinued when the patient is receiving ~50% of their estimated nutrition requirements via enteral nutrition or oral intake.
Pause here and consider how you may start a trial of enteral nutrition for Poppy.
Weaning PN for Poppy
This is what you could do to start a trial of enteral nutrition for Poppy:
- Liaise with the GI surgery MD/ICU team to ensure they agree with restarting EN.
- Re-evaluate Poppy’s estimated nutrition requirements: energy, protein, fluid
- Complete a head-to-toe assessment
- If the team agrees to initiate EN, start conservatively to evaluate GI tolerance:
- Example (“trickle feed”): Isosource 1.5 @ 10 mL/hour × 24 hours = 240 mL/day
- Ask her RN to monitor closely for signs any of GI intolerance.
- If EN is well tolerated, decrease PN gradually as EN rate increases as described above. Review flow sheets or documented “ins and outs” in Poppy’s chart to assess PN & EN volumes received. Use this information to avoid overfeeding and continue to meet her estimated nutrition requirements, as you adjust and transition to EN.
Considerations: absorption of nutrients is likely to remain adequate as a small portion of poppy’s small bowel was removed (removal of 25 cm of ileum – vitamin B12 and bile salts absorbed in terminal ileum).
The Nutrition Care Process Model
As you use the Nutrition Care Process Model and the learning from this case study as a guide throughout your patient care in practicum, please keep in mind that the process is dynamic, and not step-by-step as all cases are different. You are encouraged to complete the recommended readings for this module and continue to expand your learning in this clinical area of practice.
PART 4: EVALUATE COMPLETE. Pause to reflect on the evaluation strategies discussed, and review the readings and resources in the following section for your information.
You’ve now completed the Parenteral Nutrition module. Please consider providing feedback through the embedded form in the next section.
Acknowledgements
Emily Opperman, MSc, RD
Michaela Kucab, MHSc, RD
Present Significantly
