Steps to safe parenteral nutrition preparation and administration

1. Assessment¹:
During this first step in the PN use process, the dietitian and/or nutrition support team will:

• Review patient data
• Conduct a nutrition assessment including estimation of nutrient requirements
• Determine nutrition intervention and nutrition prescription based on therapy goals and clinical condition
• Communicate with the prescriber

2. Prescription¹:
When determining an appropriate prescription for PN, a clinician must decide²:

• Appropriate use
  What’s my patient’s indication for the use of PN?
• IV access
  How long will my patient be on PN? Will they need a peripheral line or a central line?
• PN ingredients
  How much protein, lipids, and dextrose will my patient need? What about vitamins, trace elements, electrolytes, and total volume?
• PN instructions
  What’s the infusion rate and the start and stop times?
  • A safety tool in prescribing PN is to use a standardized PN order format and sequence of PN components

3. Review, verification, and transcription^1,3:
Once the PN is prescribed, the pharmacist will review and verify that the received order is appropriate before any preparation or compounding begins. This process includes two steps:

• A clinical review to verify that the indication and the dosing of each nutrient is appropriate for the patient
• A pharmaceutical review to verify the compatibility of the PN components and the stability of the final preparation

After these steps are completed, the pharmacist will then transcribe the PN order from handwritten (although not recommended), printed, or CPOE system to the automated compounding device (ACD). An additional independent double check is performed to ensure accuracy of the PN prescription.

4. Preparation, compounding, and dispensing^1,3:
Once the prescription is deemed appropriate, the pharmacist and pharmacy technician will prepare and compound the PN following sterile compounding techniques. Before the final preparation goes out the door to be dispensed, the pharmacist must assure that it is properly labeled, delivered, and stored.

5. Administration¹:
Finally, the PN admixture has made it from the pharmacy to the nurse or caregiver who is responsible for its safe administration. They should be knowledgeable and acquire the skills needed to verify the correct PN order, avoid administration errors, and maintain infection control.

6. Monitoring¹:
The final step in the PN use process is monitoring. An experienced nutrition care team will closely monitor their patient to prevent and detect any complications that may occur throughout their patient’s journey with PN.