Journal of Gerontological Nursing

Interdisciplinary Care 

Practical Uses of Peripheral Intravenous Nutrition: Three Case Studies

LuAnn R Gilmore, MS, RD; Jan Escobeo, RN; Linda Elliot, RN; Kim Spiller, RN, BSN; Jerry Strikland; Jeannie Jones, RN; Pat Allen, RN

Abstract

The nurse, dietitian, physician, pharmacist, and physical therapist must work as a team in the delivery of proper nutrition interventions.

Abstract

The nurse, dietitian, physician, pharmacist, and physical therapist must work as a team in the delivery of proper nutrition interventions.

Nutrition support has become more sophisticated during the past decade, and the advances in the science of nutrition continue to focus on optimal nutrient intake to enhance wound healing, boost immunity, and improve quality of life. Our mothers and their mothers before them knew the importance of providing wholesome foods to help us grow strong and keep us from becoming ill. One nutritional advancement is the delivery of nutrition intervention. Medical equipment and improved techniques provide a variety of choices for optimal delivery. In addition to regular intake of a daily diet, patients can receive high-calorie, high-protein supplements, enteral tube feedings, or parenteral infusions. Even within parenteral delivery there are choices of central versus peripheral delivery. There is no longer a reason for malnutrition. However, some health professionals are ignorant of nutrient delivery options or lack progressive thinking.

This article focuses on the nutritional intervention of peripheral parenteral nutrition (PPN) delivery. The successful orchestration of PPN is like that of the blended music of a symphony. It requires a team of health care members to properly assess, recommend, mix, deliver, and monitor PPN for optimal outcomes. See the Sidebar on this page for indications for PPN. The nurse, dietitian, physician, pharmacist, and physical therapist all play major roles in this orchestration.

With geriatric patients the nurse is usually the first to notice changes in appetite and weight. These changes should be reported to the physician and dietitian for assessment and recommendations. Peripheral parenteral nutrition is warranted whenever enteral intake is not possible for a short-term duration of up to 2 weeks. The dietitian and pharmacist should collaborate to determine the appropriate parenteral solution and admixtures to meet the nutritional goals set for the patient. The dietitian then should contact the physician to write the PPN order and review the nutritional goals with the nursing department to ensure proper delivery. Daily monitoring should be performed by the nurse and dietitian along with the physician to include an evaluation of PPN tolerance, appropriate electrolyte levels, nutritional parameters, and weight changes. The physical and occupational therapists also should be consulted to note improvements in strength and activity. Like an orchestra, the team should be in harmony when functioning together.

The following case studies illustrate this harmony. "The Use of Intravenous (IV) Nutrition in Improving Quality of Life" is a success story because of the proactive initiation of PPN therapy by the nurse. "The Use of IV Nutrition in Healing Pressure Ulcers" shows collaboration between the nurse, dietitian, and physical therapist in setting appropriate nutrition goals, monitoring therapy, and debriding wounds to promote wound healing. Finally "The Use of IV Nutrition in Preventing Malnutrition" reveals a study in the true purpose of nutrition - to prevent the problems of malnutrition before they occur and create irreversible patient decline.

One individual team member cannot provide everything just as a single flute cannot perform the full score of an opera.

THE USE OF IV NUTRITION IN IMPROVING QUALITY OF LIFE: CASE STUDY

Initial Evaluation

N.O. was a 78-year-old woman with anorexia and a noted 10-pound weight loss that occurred during the course of 30 days. At 5 feet, 8 inches tall and 102 pounds, she was severely underweight with a body mass index (BMI) of 15.6 kg/m2. A normal geriatric range for BMI is 21 to 28 kg/m2. Visceral protein stores were depleted with an albumin of 2.8 g/dL. Normal range is 3.5 to 5.0 mg/dL.

Nutrition Support

Because of N.O.'s anorexia she was unable to improve her oral intake to reverse her declining nutritional status. Peripheral parenteral nutrition was initiated with ProcalAmine® (BBraun/McGaw, Irvine, California) - a solution containing 3% amino acids, 3% glycerol, and maintenance electrolytes - and was delivered via a midline* catheter. ProcalAmine (1,000 cc) and 500 cc of a 10% lipid solution piggy-backed into the catheter were delivered for 14 days. This regimen added 29 g protein and 795 calories per day. (See Table 1 for a comparison of different solutions, including ProcalAmine, used for PPN).

Monitoring and Follow Up

Nurses reported the ProcalAmine regimen was well tolerated by the vein without infiltration or phlebitis. The midline catheter was used for the duration of the therapy. For suggested monitoring criteria for PPN, see Table 2.

Outcome of Initial Problem

At the initiation of the PPN therapy N.O. was lethargic and not talking or cooperating with the physical, occupational, or speech therapists. By the end of the PPN therapy N.O. was walking in the halls behind her wheelchair at least three times a day and eating the majority of her meals. Her nurse reported N.O. appeared much happier and livelier, smiling and joking with the nursing staff, and visiting with other residents.

Comments

Caring for people should mean improving their quality of life. Nutritional therapy has been shown to play a key role in improving quality of life (Inman-Felton, 1997; Ottery, 1997). Although laboratory test results and weight measurements were not available after the ProcalAmine therapy, the true results were achieved and evident by N.O.'s positive attitude and increased activity level. Nutritional repletion can lead to improved feelings of well-being (Morley & Kraenzie, 1994), which appears to have a role in improving appetite and maintaining adequate nutrition (Ryan & Shea, 1996). Therefore, nutritional support can provide the needed boost to improve patients' appetites and help them help themselves in the battle against malnutrition and its subsequent effects.

THE USE OF IV NUTRITION IN HEALING PRESSURE ULCERS: CASE STUDY

Initial Evaluation

RG. was an elderly man who had developed Stage II and IV pressure ulcers on the leg and right heel, respectively. His medical history was not significant.

Table

TABLE 1COMPARISON OF SELECTED SOLUTIONS USED FOR PERIPHERAL PARENTERAL NUTRITION (PPN)

TABLE 1

COMPARISON OF SELECTED SOLUTIONS USED FOR PERIPHERAL PARENTERAL NUTRITION (PPN)

Weighing 130 pounds and measuring 5 feet, 1 1 inches tall, F.G. was approximately 25% below desired body weight. His BMI was 18.2, indicating he was severely underweight.

His visceral protein status was moderately depressed with an albumin of 2,9 mg/dL.

Nutrition Support

F.G. consumed meals adequately but had developed significantly increased nutritional demands for healing two pressure ulcers. To meet the increased energy and protein requirements, PPN was started, using ProcalAmine. A regimen of 1,000 cc of ProcalAmine admixed by the pharmacy with 250 cc of 10% lipids per day was given for 14 days, as recommended by the American Society of Parenteral and Enteral Nutrition [ASPEN] Board of Directors (1993) for PPN delivery. This provided an additional 495 calories and 29 g protein per day. ProcalAmine was delivered via a midline catheter.

Monitoring and Follow Up

ProcalAmine therapy was tolerated well with normal blood sugar control and adequate vein tolerance. ProcalAmine was discontinued after the recommended 14-day course. F.G. received regular debridements from physical therapy on his heel, with progression of healing evident.

Table

TABLE 2MONITORING PERIPHERAL PARENTERAL NUTRITION

TABLE 2

MONITORING PERIPHERAL PARENTERAL NUTRITION

Table

TABLE 3COMPARISON OF COMBINED ENTERAL AND PARENTERAL NUTRITION SUPPORT INTAKE TO ENERGY AND PROTEIN GOALS FOR S.L.

TABLE 3

COMPARISON OF COMBINED ENTERAL AND PARENTERAL NUTRITION SUPPORT INTAKE TO ENERGY AND PROTEIN GOALS FOR S.L.

Outcome of Initial Problem

Within 3 weeks after initiation of the PPN therapy, the Stage IV ulcer on the right heel was reduced to Stage II and the leg decubitus had healed completely.

Comments

Protein energy malnutrition (PEM) is common in long-term care facilities. Even residents with apparendy healthy appetites and adequate intakes can become protein and energy depleted in the face of pressure ulcers, chronic infections, or following an elective surgery. Because of the increased metabolic demand these conditions create, nutritional deficits occur easily. If a resident such as RG. who maintained normal intake suffered the effects of PEM, even greater effects could occur in a resident with a poor appetite and suboptimal intake. Energy requirements may be increased to 35 kcal/kg/day (Ryan & Shea, 1996) and protein requirements to 1.2 to 1.5 g protein/kg/day (ASPEN Board of Directors, 1993). Multiple pressure ulcers may warrant even higher nutritional goals, if there is normal renal function. Careful attention to weight status is probably the most obvious clinical change that can be noted, but a thorough nutritional assessment by the dietitian should be performed every 3 months according to the Agency for Health Care Policy and Research [AHCPR] (Bergstrom, Bennett, & Carlson, 1994). Peripheral vein access often is difficult with geriatric patients. However, ProcalAmine was selected because it is tolerated more easily than standard PPN solutions, resulting in less phlebitis (Rypins, Johnson, Reder, Sarfeh, & Shimoda, 1990; Waxman et al., 1992). Clinical dietitians and nurses must work together to appropriately set nutritional goals for noted weight and medical changes residents are experiencing. Nutritional intervention through the use of PPN can produce positive clinical results in residents with increased needs that cannot be met orally or enterally.

THE USE OF IV NUTRITION IN PREVENTING MALNUTRITION: CASE STUDY

Initial Evaluation

S.L. was a 71 -year-old man residing in a nursing home. His medical history was significant for depression, back surgery, congestive heart failure, hypertension, chronic obstructive pulmonary disease, osteoarthritis, status post cerebrovascular accident with dysphagia, hypercoagulative state, lupus, and gastric tube (G-tube) placement. S.L. was noted to have lost more than 5% of his body weight in 2 weeks, decreasing from 128 pounds to 120 pounds, despite enteral G-tube feedings of ProBalance® (Nestle, Deerheld, Illinois). He had been experiencing a cough for the previous 2 months and severe pain in both lower extremities not relieved by propoxyphene (Darvocet).

Figure. Interdisciplinary team flow chart for nutrition intervention.

Figure. Interdisciplinary team flow chart for nutrition intervention.

The recent 5% loss represented a 20% drop from his usual body weight of 150 pounds and a 30% drop from a desired body weight of 172 pounds. His BMI was 17.9. With a height of 5 feet, 1 1 inches and actual body weight of 120 pounds, the facility's dietitian assessed S.L.'s nutritional goals to be 2,300 to 2,400 kcal per day, 60 to 65 g protein per day, with 1,700 to 1,900 cc of fluid per day. The energy and protein goals represented approximately 43 kcal/kg and 1 .2 g protein/kg of actual body weight. Visceral protein status was declining with a noted albumin of 2.8 g/dL and a prealbumin of 20 mg/dL (normal range 20 to 40 mg/dL).

Nutrition Support

Because of S.L.'s dysphagia, he was tolerating only pureed foods and thin liquids at the nursing home and was consuming only between 10% to 45% of meals. ProBalance enteral feedings were delivered via the G-tube at 60 cc per hour for 22 hours, providing 1,584 calories and 71 g protein. Despite this regimen, S.L.'s weight and visceral protein status continued to decline, and PPN was initiated. The PPN regimen consisted of 2 liters of ProcalAmine and 500 cc of 10% lipids admixed by the pharmacy and delivered at 104 cc per hour for 8 days (ASPEN Board of Directors, 1993). This provided an additional 1,040 calories and 58 g protein. PPN was delivered via a peripheral angiocatheter. The IV site was changed approximately every 3 days.

A comparison of the combined enteral and parenteral nutrition support intake to the energy and protein goals set for S.L. are shown in Table 3.

Monitoring and Follow Up

On the eighth day of PPN therapy, the line infiltrated. S.L. was sent to the hospital for further evaluation and a possible central line placement. There were no problems with site infection or monitoring during the 8 -day administration of ProcalAmine. During postProcalAmine therapy, an albumin of 3.7 was noted, with a weight increase to 129 pounds. S.L. started eating 90% to 100% of a mechanical soft diet, with enteral feedings being discontinued. Physical therapy noted a progressive increase in strength and endurance, and S.L. was able to sit upright in a wheelchair. Twenty days later, S.L. stated, "I feel like a new man."

At the time this article was written, the nurses reported S.L. was ambulatory and involved in physical activity for the first time in a long time.

Comments

Weight loss is common in elderly individuáis, men typically having lost 12 kg of lean body mass by age 70. However, any recent weight loss of more than 5% should not be ascribed to aging alone but should be evaluated carefully (Lipschitz, 1998). While enteral feeding should provide adequate supplementation or 100% of requirements, many patients cannot receive enough enteral nutrition to meet their requirements. Declining nutritional status results and worsens the condition, sometimes to the point that recovery is not possible. In S.L.'s case, PPN intervention was provided with ProcalAmine after a significant weight loss and decline in visceral protein status had been sustained but before more overt signs of malnutrition were evident. Preventive nutrition intervention always is more effective and will restore health quicker than waiting for signs of severe malnutrition and then treating the problem. Peripheral parenteral nutrition therapy is relatively simple and less expensive and less invasive than total parenteral nutrition. A short course of PPN therapy can boost protein status, improve enteral feeding tolerance, and has been noted to improve appetite. All three results were evident in S.L.'s case with an overall improvement in his quality of life (Inman-Felton, 1997) noted by the nursing staff, dietitian, and physical therapist.

CONCLUSION

The roles of the members of the health care team are vital to optimal patient care. Geriatric patients have unique needs which must be treated appropriately with both skill and love. The facts and outcomes of the above case studies are discussed in this article. However, the interaction of the team members in producing the positive outcomes of healing and improved quality of life is not adequately expressed.

Nutrition is an important element of nursing. However, when nutrition intervention is warranted, nurses may not be familiar with available nutrition solutions or delivery systems to correct the problem. The dietitian should be well versed in making nutrition assessments and appropriate recommendations. Unfortunately, in many nursing homes there is only one registered dietitian who may not be available on a daily basis. Thus, they may not be aware of a problem until alerted by nursing staff.

When properly consulted, dietitians can assess the level of malnutrition present and make recommendations for nutrient intake. However, when parenteral nutrition is warranted, the pharmacist must be contacted to determine the available formulary and admixtures that can be prepared safely (e.g., not exceeding safe osmolarity levels, pH).

All of these recommendations must be brought to the physician to determine fluid tolerance, level of aggressive measures warranted, and medication interaction considerations. A communication system must be established at each facility based on its level of team member staffing. The dietitian must establish criteria for nursing staff to know when to consult the dietitian and the types of interventions available. Flow charts for intervention and protocols for treatment should be designed together for optimal collaboration of the entire interdisciplinary team, with positive patient outcomes as the ultimate goal. See the communication model in the Figure for IV nutrition intervention suggestions.

Names in the case studies were changed for anonymity purposes.

REFERENCES

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  • American Society of Parenteral and Enteral Nutrition Board of Directors. (1993). Guidelines for use of parenteral and enteral nutrition in adult and pediatric patients.
  • Journal of Parenteral and Enteral Nutrition, 17(A), 9SA-11SA.
  • Bergstrom, N., Bennett, M.A., & Carlson, CE. (1994). Treatment of pressure ulcers. Clinical practice guideline, no. IS (AHCPR Publication No. 95-0652). Rockville, MD: United States Department of Health and Human Services, Public Health Service, Agency of Health Care Policy and Research.
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  • Ottery, F.D. (1997). Improving clinical practice with nutrition in a managed care environment. In Report of the seventeenth Ross Roundtable on Medical Issues (pp. 29-36). Columbus, OH: Ross Products Division, Abbott Laboratories.
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  • Rypins, E.B., Johnson, B.H., Reder, S.B., Sarfeh, J., & Shimoda, K. (1990). Threephase study of phlebitis in patients receiving peripheral intravenous hyperalimentation. American Journal of Surgery, 159, 222-225.
  • Waxman, K., Day, A.T., Stellin, G., Tominaga, T, Gazzaniga, A.B., & Bradford, RJL (1992). Safety and efficacy of glycerol and amino acids in combination with lipid emulsion for peripheral parenteral nutrition support. Journal of Parenteral and Enteral Nutrition, 16(4), 374-376.

TABLE 1

COMPARISON OF SELECTED SOLUTIONS USED FOR PERIPHERAL PARENTERAL NUTRITION (PPN)

TABLE 2

MONITORING PERIPHERAL PARENTERAL NUTRITION

TABLE 3

COMPARISON OF COMBINED ENTERAL AND PARENTERAL NUTRITION SUPPORT INTAKE TO ENERGY AND PROTEIN GOALS FOR S.L.

10.3928/0098-9134-20000101-10

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