Cuaderno de enfermería. Revista científica

Vol. 3(2), 29-56, 2025

https://doi.org/10.62574/f07hpn02

Nursing protocol for the management of total parenteral nutrition: Standards

of care and patient safety

Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Rosa Andrea Domínguez-Granda

rosa.dominguez.71@est.ucacue.edu.ec

Universidad Católica de Cuenca, Cuenca, Azuay, Ecuador

https://orcid.org/0009-0000-9429-2443

María Graciela Merchán-Coronel

maria.merchan@ucacue.edu.ec

Universidad Católica de Cuenca, Cuenca, Azuay, Ecuador

https://orcid.org/0000-0002-3884-2022

Isabel Cristina Mesa-Cano

imesac@ucacue.edu.ec

Universidad Católica de Cuenca, Cuenca, Azuay, Ecuador

https://orcid.org/0000-0003-3263-6145

ABSTRACT

Objective: To establish efficient and safe management of the clinical process related to parenteral

nutrition, both in its preparation and administration. Methodology: Systematic review of 32 scientific

documents. Results: The procedure for the preparation and administration of TPN, given that it is an

infusion that goes directly into the bloodstream and therefore the complications that may arise are of

vital importance, and thus ensure patient safety. Conclusion: There is a need to implement a

standardised protocol and consolidate this information in different healthcare facilities on the

preparation of TPN. This is of great importance in reducing the risk of complications and thus

contributing in general to recovery and reintegration into daily life, depending on the case or condition.

Descriptors: parenteral nutrition; enteral nutrition; diet, food, and nutrition. (DeCS).

RESUMEN

Objetivo: establecer un manejo eficiente y seguro del proceso clínico relacionado con la nutrición

parenteral, tanto en su preparación como en su administración. Metodología: revisión sistemática

de 32 documentos científicos. Resultados: El procedimiento en la preparación y administración de

la NPT, puesto que es una infusión que va directamente al torrente sanguíneo y por ende las

complicaciones que se pueden presentar son de vital importancia, y de esta manera garantizar la

seguridad del paciente. Conclusión: Existe la necesidad de implementar un protocolo

estandarizado y consolidar esta información en las diferentes casas de salud sobre la

preparación de la NPT es de gran importancia para reducir riesgos de complicaciones así

contribuir de manera general en la recuperación e incorporación a la vida cotidiana según sea

el caso o la condición.

Descriptores: nutrición parenteral; nutrición enteral; nutrición, alimentación y dieta. (DeCS).

Received: 02/04/2025. Revised: 12/04/2025. Approved: 18/04/2025. Published: 08/05/2025.

Original Article

Cuaderno de enfermería. Revista científica

Vol. 3(2), 29-56, 2025

Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

INTRODUCTION

Total parenteral nutrition (TPN) is a vital intervention that can save lives when

administered correctly, with the right equipment and under strict parameters.

However, its use remains largely restricted to critical care settings, with limited

application in other hospital wards. According to a systematic review by Eriksen (1),

very few hospitalised patients receive TPN, largely due to the associated risks, such

as serious complications that can lead to infections and increased mortality. TPN is

also linked to longer hospital stays and, therefore, higher healthcare costs. Despite

its effectiveness, more clinical evidence is needed to support its benefits and

potential complications. This makes it urgent to create standardised protocols for the

preparation and administration of TPN, as well as ongoing training for nursing staff.

Although many studies come from doctors and biochemists, it is crucial that nurses

are actively involved, as their role is fundamental in the care of these patients.

Parenteral nutrition, in contrast to enteral nutrition, must be adjusted to the clinical

condition, age and sex of the patient. It can be used either totally, when the aim is to

completely cover nutritional needs, or partially, when nutrients are supplied

according to the requirements established by the healthcare team. Venous access

for TPN infusion includes:

• Central venous catheter, indicated for long-term hyperosmolar TPN.

• Peripheral venous catheter, suitable for short-term TPN with lower osmolarity.

Both routes carry a risk of infection and thrombosis (2). Malnutrition causes

alterations in systemic functions, such as a decreased immune response, especially

in patients with a history of hypertension, type II diabetes mellitus or smoking. For

this reason, early administration of nutrients, either enterally or parenterally, has

Cuaderno de enfermería. Revista científica

Vol. 3(2), 29-56, 2025

Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

become an essential therapeutic method in critically ill patients and those with

sepsis. Although parenteral nutrition does not always shorten the duration of

mechanical ventilation, it does help to restore the intestinal mucosal barrier, stabilise

the gastrointestinal flora and reduce tissue damage associated with inflammation.

Higher mortality rates (1 in 3) have been observed in patients with late initiation of

artificial nutrition compared to those who receive it early (1 in 6) (3).

According to Wanden et al. (4), in adult hospitalised patients, the most frequent

indications for TPN are palliative cancer care. In Spain, it is also administered at

home when hospitalisation is not strictly necessary, ensuring nutritional intake in

patients with cancer treatment failure or oral intolerance. The NADYA group

recommends that home administration be regulated by the health authority, as

sterility and staff training may be compromised outside the hospital setting.

Nutrition is a fundamental biological process for the digestion and absorption of

nutrients. When oral intake is impossible, enteral nutrition (EN) or parenteral nutrition

(PN) is used to ensure nutritional stability in complex clinical situations (5). TPN

provides clinical benefits such as improved serum albumin and protein levels and

reduced hospital stay, but it also carries risks: catheter-related infections, electrolyte

imbalances, micronutrient deficiencies, intestinal mucosal atrophy and emotional

disorders (6).

In burn patients, the combination of TPN and EN allows the high caloric and

micronutrient requirements necessary for healing to be met, reduces the length of

stay in the ICU and facilitates the return to oral feeding (7). TPN administers aqueous

solutions of macronutrients (carbohydrates, proteins, lipids), micronutrients

(vitamins, minerals, electrolytes) and water through central or peripheral venous

access (8).

Nutritional intervention in the ICU is essential to preserve muscle mass and provide

Cuaderno de enfermería. Revista científica

Vol. 3(2), 29-56, 2025

Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

adequate protein. Nursing staff responsible for managing EN and PN must be

properly trained and follow strict protocols to ensure patient safety (9). TPN has

absolute contraindications (functional gastrointestinal tract, oral intake possible;

severe uncontrolled infections) and relative contraindications (haemodynamic

instability, immunocompromise, multiple organ failure, psychological disorders) (10).

Its complications are classified as metabolic, infectious, and mechanical (11).

Calcium and phosphate precipitation in TPN, favoured by high concentrations and

temperature, is particularly common in incubator-born neonates (12). The safety and

efficacy of TPN depend on the preparation environment, technique, and staff

training. A study in 40 ICUs in Spain (370 patients) showed that 65–85% of solutions

are prepared in hospital pharmacies using ‘all-in-one’ bags, highlighting the

importance of specialised management (13).

Calorie and protein requirements vary according to the condition and progress of the

patient in the ICU; after three days of admission, an average of 92.43% of the

prescribed kcal are administered (14). The proposed protocol will be implemented in

emergency departments, clinical areas, surgical wards, ICUs and paediatrics, where

TPN is prescribed. Nursing staff, with appropriate training, will be responsible for

preparing and administering TPN, ensuring asepsis and safety. The aim is to improve

the practice of the multidisciplinary team, reduce infectious and mechanical

complications, and optimise the quality of treatment and patient care.

The article aims to establish efficient and safe management of the clinical process

related to parenteral nutrition, both in its preparation and administration.

METHOD

Literature review: the search was conducted using five scientific databases with high

impact: PubMed, Scopus, Web of Science, CINAHL and Cochrane Library, selected

for their recognition and coverage in the field of health sciences.

Cuaderno de enfermería. Revista científica

Vol. 3(2), 29-56, 2025

Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

The search design was structured using controlled terms from the MeSH (Medical

Subject Headings) and DeCS (Descriptors in Health Sciences) thesauri. These

keywords were strategically combined with Boolean operators, such as ‘AND’ and

‘OR’, to maximise the efficiency of the results. Expressions such as ‘total parenteral

nutrition AND nursing protocol’ or ‘patient safety AND intravenous nutrition’ were

used to adjust the terms according to the objectives of the study.

RESULTS AND DISCUSSION

1.Cover

Title of protocol: Nursing protocol for total parenteral nutrition management:

standards of care and patient safety

Institution: Catholic University of Cuenca

Date of creation and/or revision: June 2025.

2. Introduction

which is why it is necessary to have knowledge not only of the procedure but also

of its components, active ingredients, and the effects they produce when mixed with

others, as well as being aware that they will be compatible and, above all, stable

when combined, in addition to the duration of each infusion to avoid the loss of the

effect of its components. Therefore, it is essential to have medical, nutritional, and

pharmaceutical evaluation, and above all, to have the physical prescription in the

TPN medical record with clear components and quantities, and for us, as

professional nursing staff, to have clear scientific knowledge of the different

components in order to prepare and administer TPN correctly. and, above all, a

physical prescription in the NPT medical record with clear components and

quantities. As professional nursing staff with clear scientific knowledge of the

Cuaderno de enfermería. Revista científica

Vol. 3(2), 29-56, 2025

Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

different components, we must be able to prepare and include the different

components according to their importance and effect, thus avoiding precipitation or

decomposition of certain drugs due to poor dilution with others that are generally

incompatible. It is also vitally important to be clear that TPN must be administered

through a central line, in a single lumen and infusion, avoiding mixing with additional

medications prescribed to the patient and thus avoiding complications due to these

(15).

According to some studies, there is not a great deal of evidence, and what evidence

there is has been of poor quality in terms of nutritional support having any effect on

mortality or the appearance of serious side effects in patients. However, there is

also no good-quality evidence to verify that nutritional support has contributed

significantly to weight gain in adults or children receiving this treatment, either

because they were considered to be nutritionally at risk or because their diagnosis

required them to remain for long periods without being able to start or resume oral

feeding. What has been observed instead is that in this population, what has been

achieved is to maintain the necessary nutritional requirements during this time,

although this will also depend on the type of patients we are dealing with, since the

majority of this population is usually clinically heterogeneous (16).

In the paediatric population specifically, it is said that, for example, there is no

significant difference in the duration or length of hospitalisation in terms of nutritional

support via nasogastric tube, since reintegration into natural oral feeding can be

achieved successfully in most children, especially on the first attempt, which

prevents or reduces the onset of complications or increases the length of hospital

stay. Therefore, enteral feeding, compared to the population group receiving

intravenous nutritional support or TPN, in the latter group of children, there will

always be additional risks of infections or complications derived from this, which will

consequently increase their hospital stay (17).

Cuaderno de enfermería. Revista científica

Vol. 3(2), 29-56, 2025

Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

The nutritional status prior to hospitalisation or surgery in each patient is essential

for a speedy recovery and, in turn, for the onset of complications during

hospitalisation, especially when the treatment involves gastrointestinal surgery.

This is because if the patient is already admitted with an established nutritional

deficit, it will be much more difficult to improve this during hospitalisation, and in the

case of surgery, the postoperative results will not be as expected, or it will be more

difficult to obtain good results. Weight loss, and especially muscle wasting in some

or most patients who are generally in terminal stages or in critical condition due to

their diagnoses, have been shown to be associated with both malnutrition and poor

clinical or surgical outcomes. For these patients at high risk of malnutrition, they are

often the main candidates for receiving parenteral nutrition or, failing that, enteral

nutrition or any type of nutritional supplement, whether oral or parenteral,

depending on their needs. Such interventions are costly and/or have unwanted

adverse effects, so it is important to conduct more studies to demonstrate more

accurately whether their use results in higher morbidity or mortality, or both, or

whether, on the contrary, they are unrelated to these outcomes, since it has not yet

been possible to verify or attribute the improvement to enteral or parenteral nutrition

or to an increase in the immune system. parenteral nutrition or an increase in the

immune system. What has been observed is that with the use of oral supplements,

there have been no infections in general; however, their use has not been well

received due to immediate unwanted effects such as nausea, vomiting, occasional

diarrhoea and, consequently, abdominal pain (18).

General objective

To determine the efficient management of a clinical process during the preparation

and administration of parenteral nutrition with the aim of establishing new and

instructive elements of the procedure that can be used by the healthcare personnel

in charge, thus avoiding complications arising from it, thereby improving the

Cuaderno de enfermería. Revista científica

Vol. 3(2), 29-56, 2025

Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

patient's current condition and, in turn, reducing the length of hospital stay.

Scope

This protocol is designed to be implemented in various areas of the hospital

environment, including clinical, surgical, and critical care units where Total

Parenteral Nutrition (TPN) is prescribed. Its application extends to paediatric and

adult patients who require intravenous nutritional support as part of their

comprehensive management. It also includes all phases of the care process, from

initial indication to monitoring and administration of TPN, ensuring safety and

quality standards. This protocol seeks to standardise nursing practices in these

areas, promoting evidence-based care that minimises associated risks and

optimises health outcomes.

3. Definitions and Key Terms

Important terms

Total Parenteral Nutrition: The provision of a compound or prepared infusion

containing various artificial components, generally micronutrients in addition to

medications and hyperosmolar substances, through an external device usually

inserted into a central line, although it may also be peripheral, which is used for a

long period of time (19).

Enteral Nutrition: This is the administration of nutrients directly into the digestive

system to correct nutritional problems or prevent malnutrition. This can be done

orally or via a nasogastric, orogastric or gastrostomy tube (19).

Central venous catheter: A thin, flexible device inserted into a large central venous

access in the chest or neck, through which the patient receives intravenous fluids,

blood transfusions at reduced rates or in large volumes, chemotherapy and other

medications, as well as being used for blood collection, especially in patients with

Cuaderno de enfermería. Revista científica

Vol. 3(2), 29-56, 2025

Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

difficult venous access. It is used in patients with prolonged stays or treatments

(20).

Acronyms: Explanation of relevant acronyms or abbreviations.

TPN: Total parenteral nutrition.

EN: Enteral nutrition.

CVC: Central venous catheter

CIP: Continuous infusion pump

4. Theoretical Framework and Scientific Evidence

TPN is considered a medication, as it is used for a specific indication, either

because the patient is malnourished or because they have total or partial

gastrointestinal dysfunction and cannot be fed orally or enterally. TPN is

administered specifically intravenously, through a central line, according to its

components, which are part of the nutrition group of medications. Each of these

must be evaluated separately, as they all have different mechanisms of action,

pharmacokinetics, pharmacodynamics, adverse effects, etc., which together can be

potentiated if not prepared properly and in quantities according to the needs of each

patient (21).

All procedures performed in a health service must be evaluated after they have

been carried out, and even more so in the preparation of TPN, since it is an infusion

that goes directly into the bloodstream and therefore the complications that may

arise are of vital importance. That is why it is essential to carry out quality control to

determine the level of errors being made, whether in preparation or administration,

in order to correct them with scientific feedback to the personnel responsible for the

initial evaluation, prescription, and preparation in the different health centres, as

appropriate, and thus ensure patient safety (22).

Cuaderno de enfermería. Revista científica

Vol. 3(2), 29-56, 2025

Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

This is why the need to implement a standardised protocol and consolidate this

information in the different healthcare facilities on the preparation of TPN is of great

importance in reducing such errors and thus contributing to improving the state of

health and helping to reduce the patient's hospital stay, improving their nutritional

status and, therefore, their physical condition, which will contribute in general to

their recovery and return to daily life, depending on the case or condition.

According to a study carried out in a department of the Specialty Hospital, Siglo XXI

National Medical Centre of the Mexican Social Security Institute, in this case the

Gastrointestinal Surgery Department, one of the main complications encountered

during the administration or initiation of parenteral nutrition was various infections,

which, after study, were associated with the placement and/or maintenance of the

central venous catheter depending on the length of time it had been in place. This

indicates that the longer the user remains with this central device, the greater the

incidence of infections associated with its use. Most infections occurred in the first

20 days after starting TPN, and these patients were hospitalised in critical areas

such as intensive care units. Therefore, this shows us that the earlier the return to

EN (enteral nutrition) or, if possible, to oral feeding, the greater the benefit and the

lower the risk of readmission or further surgery, if necessary. This highlights the

importance of proper preparation and, above all, a prior assessment of caloric and

nutritional needs in order to achieve improvement in the shortest possible time and

reduce the duration of TPN (23).

Hyperglycaemia is one of the main complications that can occur in patients on total

parenteral nutrition. The difference between hyperglycaemic and normoglycaemic

will depend greatly on the patient's age, previous comorbidities, the presence of

corticosteroids in the treatment (a normal side effect of which is hyperglycaemia,

especially if administered in high doses and at short intervals), the amounts

established in the preparation, especially the glucose intake, as well as the

Cuaderno de enfermería. Revista científica

Vol. 3(2), 29-56, 2025

Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

presence or absence of sepsis according to the initial diagnosis on admission and,

in particular, the length of time the patient has been on TPN (24).

5. Description of the procedure

Materials required (19, 20):

Human resources (nursing staff)

Laminar flow hood

Sterile compresses

Antiseptic solution (70% alcohol)

Sterile gloves

Sterile drapes

Cap

Mask

Sterile gown

50 ml, 20 ml, and 10 ml syringes

20-gauge needles

Intravenous access equipment

Transfusion equipment, preferably with a filter or according to institutional protocol

Card with instructions or prescription for NPT

All-in-one bag or NPT cover

Medication according to prescription:

50%, 10% or 5% dextrose

Amino acids

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Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

15% or 20% lipids

Trace elements

Electrolytes (sodium, potassium, magnesium, calcium)

B complex

Vitamin C

Infusion pump.

Support

Waste container

Sharps container

Prior preparation

Firstly, a medical indication and a prior assessment by the nutrition department are

required in order to determine the specific quantities of each component to be used

in the TPN, based on the assessment and the nutritional needs of the different

patients, according to their diagnoses and caloric requirements as mentioned

above.

Check that a central or peripheral venous access is in place and that it is sufficiently

permeable to begin the procedure.

Both the patient and their family members must be informed of the process and the

need for it, its benefits, possible complications, and warning signs that should be

reported to the staff if they occur.

Check for any allergies reported in the medication reconciliation.

Be familiar with the laboratory test results and the patient's metabolic status and,

based on your knowledge as a nursing professional, assess the quantities

Cuaderno de enfermería. Revista científica

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Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

prescribed in the TPN preparation and, if necessary, consult with the doctor and

nutritionist.

Step-by-step procedure (19, 20):

Gather the necessary equipment and take it to the laminar flow hood.

Place the medical instruction card in a visible place at the front, checking

beforehand that the medical instructions match the patient's details.

Disinfect the laminar hood before turning it on or prepare the sterile field in the area

designated for this purpose according to the medical conditions of each healthcare

facility.

Place the previously disinfected material in the sterile area, strictly complying with

all aseptic measures and without contaminating the area.

Wash your hands correctly in accordance with WHO guidelines.

Put on a mask, cap, gown and sterile gloves.

Begin preparation of the NPT. In the all-in-one bag, place the solutions and

medication in the following order:

Dextrose at 5%, 10% or 50% in quantities according to the medical instructions

transcribed on the card.

Lipids at 10% or 20% in quantities according to the medical instructions transcribed

on the card.

Amino acids at 3.5%, 5.4%, 8% or 10% in quantities according to the medical

instructions written on the card.

Electrolytes (sodium, potassium, magnesium, calcium) in quantities according to

the medical instructions written on the card.

Trace elements in quantities according to the medical instructions written on the

Cuaderno de enfermería. Revista científica

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Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

card.

Vitamins: B complex and vitamin C in quantities according to the medical

instructions written on the card. (The latter can be administered in the infusion

together or, preferably, separately once a day, as they can cause precipitation in

the general preparation due to the infusion time, since these medicines are usually

photosensitive and lose their effect if not protected from light).

Note: Each time a component or electrolyte is added, gentle shaking is

recommended to mix the components being added.

Once all the components of the TPN have been mixed, connect the infusion

equipment inside the laminar flow hood to prevent contamination, cover the bag

containing the preparation with a sterile drape and transport it to the patient for

connection.

Before administering TPN, check the condition of the catheter, including its patency,

condition, and whether there are any leaks or extravasation of fluid, as well as the

date of placement and healing. If this central catheter (CVC) has 2 or 3 lumens,

label each one for the different functions it will perform, with the distal lumen being

indicated as exclusively for TPN.

Check vital signs or start continuous vital sign monitoring as needed.

Check blood glucose before starting TPN and monitor QUID, TID or BID, as

needed, based on the patient's history and diagnosis.

Disinfect the catheter connector with an antiseptic solution before connecting the

infusion equipment, placing sterile gauze to protect the connection (catheter-

equipment) during connection.

Program the continuous infusion pump (CIP) with the total volume to be infused

and the infusion time, starting at a low drip rate of 30 to 40 ml/h and gradually

Cuaderno de enfermería. Revista científica

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Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

increasing the drip rate according to tolerance until the rate indicated for the patient

is reached, so that the preparation is infused within 24 hours.

Record on the nursing form (according to each institution's protocol): time, route,

solution administered, volume to be infused, infusion time, speed or drip rate as

programmed on the Continuous Infusion Pump, as well as the full name of the

person responsible for administration, including their role, i.e. nurse, doctor or

biochemist.

Provide safety and comfort to the patient.

Remove gloves and wash hands.

Monitor for adverse reactions at the start and during the infusion of TPN, and

discontinue if necessary.

Precautions and special considerations

General care to be taken during TPN infusion:

Monitor the infusion for precipitation, which may occur in the catheter or inside the

bag containing the preparation. This may depend on the infusion time or improper

preparation of the solution, so precipitation may occur at any time. Therefore, initial

observation and monitoring during administration are of vital importance. When an

administration pump sounds, it may be due to the presence of precipitates or the

infusion becoming cloudy, indicating an occlusion. For this reason, infusion

equipment with a filter should be used. If the healthcare facility does not have this

equipment, it should be replaced after inspecting the preparation, as it would be

very dangerous for the patient to continue the infusion under these conditions (19).

Maintaining aseptic technique is essential to ensure compliance with appropriate

standards for CVC management, guaranteeing the implementation and compliance

with the necessary safety measures both in the fixation process and in the ongoing

Cuaderno de enfermería. Revista científica

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Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

maintenance of the catheter, with the sole purpose of preventing associated

complications. It is recommended to label the lumens according to their use, for

example, the specific lumen for TPN infusion, infusions and other medications to

avoid precipitation due to unwanted mixtures. During biosafety procedures and

therefore when changing infusion equipment, first ensure that all flow accesses to

other solutions or return valves are closed, both on the catheter and on other

connections, and change the equipment and three-way valves in accordance with

each institution's biosafety standards. Perform wound care at the CVC insertion site

using aseptic techniques in accordance with each institution's biosafety standards

or when necessary, if the dressing is visibly dirty or moist, with an antiseptic solution

and a sealing dressing with a pad in the centre, labelled with the date of application

and dressing change, in order to prevent contamination and infections resulting

from improper handling of the CVC (20).

Verify daily electrolyte control to ensure that values remain within normal

parameters and to prevent imbalances, in addition to maintaining strict control of

intake and elimination and daily water balance to prevent water overload (19).

6. Roles and Responsibilities of Nursing Staff

Assignment of roles

Nursing assessment of patients must be constant and, above all, continuous, as

this is a crucial and very important aspect of nursing care, since it allows us to

accurately evaluate and determine the response of patients to the medications

administered and, in turn, facilitate the early identification and detection of the

presence or absence of possible adverse effects. If at any time the presence of an

adverse effect or reaction is suspected, the administration of the additional dose

should be avoided and the patient's primary care physician should be notified, and

the event should be reported in accordance with the rules and protocols of the

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Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

different institutions. Subsequent intervention will depend specifically on the type of

reaction presented and the clinical assessment of the patient's condition (25).

Required competencies

The administration of medication is a specific function of nursing staff and should

not be delegated to assistants or unlicensed personnel or personnel without

theoretical and scientific knowledge of the medication or solution to be

administered, or of the patient's condition or diagnosis, and even less so of the

effects that may occur during this infusion and how to respond to these events,

since they have not received adequate training to perform these functions, This is

even more important in the case of Total Parenteral Nutrition, where aseptic

technique must be maintained during preparation and administration (25).

The management and maintenance of central venous accesses must be carried

out by trained, qualified personnel with up-to-date theoretical knowledge in the field.

Training for both nursing staff and healthcare personnel in general who handle or

are in charge of patients who are carriers of the same conditions, both in terms of

management and, of course, prevention, must be continuous and constant over

time. In addition to ongoing training, this personnel must undergo frequent

evaluations to ensure that they have the necessary skills for such management

(26).

Education and training

It is currently vital to include content on general and specific nutrition in nursing

curricula, covering nutrition in terms of caloric needs, enteral nutrition

administration, planning, preparation and administration of parenteral nutrition (as

there is currently evidence that this is only a competence of biochemists and

pharmacists). in order to obtain professional and trained personnel working in

different health institutions and, in turn, improve both care and institutional capacity,

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Protocolo de enfermería para la gestión de la nutrición parenteral total:

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Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

so that it continues to be of high quality and warmth for the patient. At the same

time, training should not only be theoretical but also practical, and should be

scheduled and regular in the different health institutions where this activity is carried

out, in order to carry out an evaluation scheme in accordance with them and thus

avoid complications arising from poor preparation or administration of NPT, or from

the mishandling of a CVC. In turn, the person in charge of this training should seek

the best pedagogical strategy and teaching and learning methodology so that those

trained can obtain clear information and the results of the evaluations are

satisfactory. Although we, as nursing staff, must focus first on working to promote

health in order to maintain good nutritional status and thus avoid the need to apply

this therapeutic measure (27).

7. Compliance and Quality Indicators

Evaluation criteria (20).

Aseptic technique during the preparation of TPN and the management of the CVC

and its connections.

Hand washing before and after procedures.

Correct use of protective measures.

Information to the patient and family about the procedure to be performed.

Verification of local signs (such as bleeding, some infections that may be local or

general, such as bacteraemia, central venous catheter fractures, rupture of fixation

points, and others) and systemic complications (infections, thrombosis, embolisms,

and others).

Proper labelling of CVC lumens according to their use and verification of patency.

Dressing of the puncture site and catheter insertion site and, above all, verification

of the fixation of the central venous catheter according to institutional standards.

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Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

Recording of the procedure, including the date, time of initiation and, above all, the

name of the responsible staff member.

Frequency of evaluation

Evaluations should be carried out as necessary and, above all, according to the

frequency of total parenteral nutrition prescriptions available in each service, since

there are services where TPN is used more frequently than in other areas or other

health institutions. This frequency can be monthly or, depending on the need, this

time may be shorter or longer.

Measurement tools

As a specific tool or method, a checklist of compliance with various parameters can

be applied during the TPN preparation and administration process, which will serve

to average the level of compliance with this protocol.

8. Ethical and legal considerations

Ethical aspects

Informed consent: Generally, most healthcare institutions, whether public or private,

have some form of internal informed consent form that can be signed by the patient

before the start of total parenteral nutrition. although there is no standardised form

from the Ministry of Public Health, it is the duty of healthcare personnel to inform

the patient of the procedure to be adopted to improve their health, either to the

patient if they are conscious or to the family if the patient is not physically or mentally

capable of signing it. Information will be provided on the procedure, benefits,

possible complications, and their autonomy to make decisions regarding their

current condition will be respected, since life is unique and valuable and therefore

the principle of non-maleficence must be upheld regardless of the type of patient

we are dealing with (28).

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Protocolo de enfermería para la gestión de la nutrición parenteral total:

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Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

Confidentiality: Healthcare personnel must provide and guarantee the privacy and

confidentiality of patient information at all times, including all procedures performed

and treatments administered, in accordance with legal regulations relating to both

the protection of personal data and the confidentiality of the information contained

in the patient's medical records (29).

Legal aspects: Compliance with applicable local or national regulations, standards

and policies.

9. Contingency Plan and Complication Management

Identification of possible complications

Loss of sterility during the preparation of TPN, especially if there is no specific and

adequate area for this purpose, such as a laminar flow hood.

Contamination and precipitation of the solution due to incorrect addition of TPN

components, either due to lack of knowledge or lack of time due to the workload

and multiple activities that nursing staff must perform during a shift. Or, depending

on the area, the multiple TPNs that must be prepared.

Lack of professional nursing staff, due to the fact that in most healthcare institutions,

nursing staff is always insufficient to meet the high demand of patients in the vast

majority of healthcare centres. As a result, when special procedures such as these

are performed, due to the time required, they end up being performed mechanically,

losing the scientific basis and established standards for them (30).

Protocol for action in the event of complications

First, immediately notify someone if sterility is lost, as continuing with the procedure

involves a risk of contamination and additional complications for the patient.

Second, discard the preparation, as it is no longer safe, and request new doses to

start a new preparation.

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Protocolo de enfermería para la gestión de la nutrición parenteral total:

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Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

Third, establish a specific place to be used only for this function, preferably with the

appropriate conditions for the preparation of these solutions according to the

possibilities of each healthcare institution. The exclusive use of a laminar flow hood

is recommended.

Fourth, request professional nursing staff and assign them to perform this task

according to the needs of the healthcare institution, so that the conditions, time and

established protocol are complied with and thus avoid errors due to pressure.

Rotate this personnel periodically to ensure that all nursing staff are trained and

involved in this activity.

Finally, provide regular training and evaluation to identify and correct any

deficiencies (31).

10. Evaluation and Continuous Improvement

Periodic review of the protocol

This protocol should be reviewed at least once a year in each healthcare institution,

using the information obtained from the checklists, which should be consolidated

and will give us an idea of the weak points that need to be reinforced. At the same

time, this will serve to update the information with new ideas, forms or methods of

learning to improve the compliance rates obtained each year.

Updating the content

Monthly reports on the evaluations carried out should be prepared. This information

will be used to produce an annual summary of the information in order to develop

a report on the results obtained and design new teaching methods or provide

feedback to the healthcare team based on the evidence obtained, thereby

addressing the issues where the most errors or deficiencies are found.

12. Annexes and appendices

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Protocolo de enfermería para la gestión de la nutrición parenteral total:

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Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

EVALUATION QUESTIONS

PREPARATION OF PARENTERAL NUTRITION

Yes

Sometimes

Have the prescribed medical indication card available and

verify that the information transcribed for preparation

matches the medical prescription.

Prepare all the necessary equipment to begin preparing the

NP, which will be transported to the laminar flow hood or area

designated for this procedure.

Prepare the area and disinfect it to ensure it is sterile before

starting the procedure.

Wash your hands before starting the procedure.

Protective and safety clothing is put on in the correct order

and in compliance with aseptic measures and biosafety

standards, keeping the area sterile and avoiding

contamination.

Carry out the procedure following the order and quantities

indicated for each prescribed medication, and the safety and

sterility measures governed by the established protocol.

I rigorously apply all necessary and appropriate aseptic

techniques during the initiation and establishment of the

infusion set circuit.

Classify waste according to the biosafety standards

established by the health institution.

Hand washing was performed once the NPT preparation

procedure was completed.

I maintain the principle of sterility of the NPT prepared during

transport until it is connected to the patient.

ON THE ADMINISTRATION OF TOTAL PARENTERAL

NUTRITION TO THE PATIENT

Yes

Sometimes

Prepare and transport the necessary equipment to the

patient's room for connecting the NPT.

Explain the procedure to be performed and the benefits to be

gained, as well as possible complications, including warning

signs that may arise for the patient and family, using clear

and understandable language before connecting the NPT.

Take vital signs and check blood glucose levels prior to

connecting the NPT.

Hands are washed before starting to connect the NPT.

I verified the proper labelling of the CVC lumens according

Cuaderno de enfermería. Revista científica

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Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

to their use and checked their patency.

Check for local signs of complications at the CVC insertion

site, such as bleeding, signs of infection, fluid extravasation,

date of placement, and healing before connection.

Disinfect the catheter connector or three-way stopcock with

an antiseptic solution before connecting the catheter to the

infusion equipment.

Maintain strict aseptic techniques during the installation of

the catheter-sheath circuit and infusion equipment, checking

that the stopcocks or access points are closed to prevent

solution leakage or blood return, as appropriate.

Use the exclusive venous line or lumen for TPN

administration.

Check that the solution in the bag is the one previously

prepared and, above all, that it is free of precipitates.

Program the infusion pump according to medical

instructions, with the total volume and time to be infused.

Wash hands after completing the procedure.

Place the card with the information on the contents of the

TPN, as well as general information on the patient, such as

name, medical history, type of solution being administered,

date, time, total volume, infusion rate, and name of the

person responsible for both preparation and administration.

Once the infusion has started, check for side effects or

adverse reactions.

Provide comfort and convenience to the patient before

leaving the room.

Responsible:

Source: Data compiled in the study conducted by the author.

Diagrams or charts

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Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

Source: Adapted from Campus Vygon 2020 (32)

CONCLUSION

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Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

In writing this article, I have concluded that all nursing staff must be much more

involved in the preparation of total parenteral nutrition, but above all in demonstrating

this involvement, since, although it is true that the role of nursing is essential, given

that in many healthcare institutions nursing staff are responsible for both the

preparation and administration of parenteral nutrition, often without the appropriate

conditions to maintain the necessary sterility, they nevertheless adapt to the needs.

However, as we can see from the scientific evidence in articles and most books, the

only published evidence, or at least the majority of it, comes from doctors,

biochemists or even nutritionists, when in very few institutions are they responsible

for this.

For this reason, I believe it is very important to highlight our work with publications,

studies and percentages that demonstrate our reality within the healthcare system.

As nurses, we are trained in both scientific theory and practice to carry out this

activity. We have been doing it for years, but we have not been given the importance

or visibility that we should have as part of the medical team, and we as a profession

have not done so either, and if we have, it has been very few people.

FINANCING

Non-monetary

CONFLICT OF INTEREST

There is no conflict of interest with individuals or institutions linked to the research.

ACKNOWLEDGEMENTS

To the Catholic University of Cuenca, Ecuador.

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Protocolo de enfermería para la gestión de la nutrición parenteral total:

Estándares de cuidado y seguridad del paciente

Nursing protocol for the management of total parenteral nutrition: Standards of care and

patient safety

Rosa Andrea Domínguez-Granda

María Graciela Merchán-Coronel

Isabel Cristina Mesa-Cano

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