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3.  The American Dietetic Association defines nutritional assessment as “ a
comprehensive approach, completed by a registered dietitian, to defining
nutritional status that uses medical, nutrition, and medication histories,
physical examination, anthropometric measurements, and laboratory data.
 T he pulmonary system has a synergistic relationship with nutrition
throughout life, beginning with the fetus and extending through adulthood.
 a healthy pulmonary system supports the body through its ability to obtain
oxygen needed for cellular demands of the metabolism of the three
macronutrients: carbohydrates, proteins, and lipids.

4.  Nutrition Assessment is the first step of the Nutrition Care Process, which is defined as a systematic
process of obtaining, verifying, and interpreting data in order to make decisions about the nature
and cause of nutrition-related problems.
 Nutrition Assessment requires making comparisons between the information obtained and reliable
standards (ideal goals). Assessment provides the foundation for the nutrition diagnosis.

5.  Breathing provides the oxygen necessary for metabolism of nutrients to meet the energy needs of
individuals.
 Nutrition affects the efficiency of the metabolic processes and influences the amount of oxygen
needed and the amount of carbon dioxide exhaled.
 Nutrition influences the immune defense mechanisms, thereby affecting the patient’s susceptibility
to infection and ability to deal with physiologic stress.
 The ability to assess and interpret the role of and need for nutrition in maintaining normal
respiratory function and in combating pulmonary disease is important for today’s respiratory
therapist (RT)

6. The purpose of nutritional assessment:
 Identify individuals or population groups at risk of becoming malnourished.
 To obtain precise information about the prevalence and geographic distribution of nutritional
problems of a community.
 To develop health care programs that meet the community needs.
 To measure the effectiveness of the nutritional programs & intervention once initiated

7.  Gather data, considering:
 Dietary intake
 Nutrition-related consequences of health and disease condition
 Psycho-social, functional, and behavioral factors
 Knowledge, readiness, and potential for change
 Compare to relevant standards.
 Identify possible problem areas

8. Malnutrition and the Pulmonary
System
 Malnutrition adversely affects the structure, elasticity, and function of the lungs as well as the mass,
strength, and endurance of muscles involved in the respiration process.
 Malnutrition-altered lung function includes decreased strength, power, and endurance of
respiratory muscles and increased respiratory muscle fatigue. In addition, skeletal muscle relaxation
slows, and muscle mass is diminished due to specific reduction in muscle fiber size and type.
 During starvation or malnutrition, respiratory muscles and skeletal muscles are subject to
catabolism, providing energy to the body
 The resultant reduction in the mass of the diaphragm, diminished inspiratory and expiratory muscle
strength, and decreased vital capacity and endurance result in impaired pulmonary function

9.  Low levels of proteins in the blood (hypoalbuminemia) contribute to pulmonary edema as colloid
osmotic pressure is decreased, allowing a fluid shift into the interstitial space.
 Extravascular lung water increases, resulting in a decrease in functional residual capacity and
pulmonary reserve.
 Low serum albumin levels can result in an increase in extracellular fluid volume and a reduction in
the intracellular space.
 Surfactant provides the low surface tension at the air-liquid interface, preventing the atelectasis,
alveolar collapse, alveolar flooding, and severe hypoxia that result in respiratory distress.
 Even short periods of starvation result in a decreased synthesis and secretion of surfactant.
Reduced surfactant, which is synthesized from proteins and phospholipids, contributes to the
collapse of alveoli, resulting in an increased effort of breathing.

10.  This reduction in respiratory muscle function often coexists with increased energy requirements,
resulting in a deterioration of gas exchange and an increased work of breathing, which can lead to
pulmonary failure.
 Iron deficiency can result in low hemoglobin levels, thus reducing the oxygen carrying capacity of
the blood.
 Low levels of other micronutrients, such as potassium, phosphorus, calcium, and magnesium, affect
cellular processes.
 A reduction in 2,3-diphosphoglycerate (2,3- DPG) in the red blood cells due to reduced phosphorus
levels decreases oxygen delivery to tissues and decreases the contractibility of respiratory muscles

11.  Deficiencies in vitamin A, pyridoxine, and zinc may impair immune status and increase risk for
pulmonary infections.
 Patients with pulmonary disease usually present with a reduced nutritional intake attributed to fluid
restrictions, gastrointestinal discomfort, vomiting, anorexia, shortness of breath, and decreased
oxygen saturation when eating.

12.  In nutrition, energy is quantified in terms of kilocalories (kcal); 1 kcal is the amount of energy it
takes to raise the temperature of 1 kg of water 1° C.
 (Although kilocalories have been used most frequently in clinical nutrition, the kilojoule [kJ] is often
used in research because kJ is the international unit for energy.
 To convert kcal to kJ, multiply kcal by 4.184.)
 For approximately every 5 kcal burned, 1 L of oxygen is used by the tissues.
 Therefore, if a patient’s Vo˙ 2 is measured as 300 mL oxygen/minute, then 300 mL oxygen × 60
minutes × 24 hours equals 432 L of oxygen required per day and 5 kcal × 432 L oxygen/day equals
2160 kcal/day that should be given to the patient

13.  An IV solution of 5% dextrose running at 3 L/day will provide the patient with only 600 kcal/day
(0.05 × 3000 mL × 3.41 kcal/g of glucose)
 Blood sugar levels are maintained from liver glycogen (carbohydrate) stores between meals and
during fasting.
 The liver’s glycogen stores come from the carbohydrates (starches and sugars) that are eaten in the
diet and converted to glucose and stored as glycogen.
 liver glycogen will be depleted within 12 to 16 hours unless sufficient carbohydrate is provided
again.
 When the liver glycogen is depleted, the body obtains sugar by converting protein (amino acids) to
sugar. This process is called gluconeogenesis (gluco, meaning “glucose sugar”; neo, meaning “new”;
and genesis, meaning “to create”

14. STERVATION AND LUNG
 In starvation or semistarvation states, respiratory muscle strength can diminish, producing a
 decrease in forced vital capacity (FVC) and
 Decease forced expiratory volume in 1 second (FEV1)
 decrease in carbon monoxide diffusing capacity (Dlco)
 decreased creatinine-height index (CHI)
o If the calorie intake is less than needed, there will be a decrease in weight, as is commonly seen in
patients with COPD.
o Patients with emphysema are more commonly underweight, appearing thin and often cachectic

15.  protein energy malnutrition (PEM), also known as protein-calorie malnutrition (PCM), experience
higher morbidity and mortality rates.
 With loss of body protein, there is a subsequent loss not only of muscle and various enzyme
systems but also of immunoglobulins (IgA, IgG, and IgM). Thus, susceptibility to respiratory
infections is increased because of decreased immunocompetent

16. Nutritional Requirements
 The basic nutritional requirements include carbohydrate, protein, fat, vitamins,
minerals, and water
 The optimal amount of each of the nutritional components has not been determined precisely,
especially for those required in trace amounts.
 Water is the medium in which the various chemical reactions take place within cells. It is also
responsible for the fluidity of the blood, which allows blood to circulate.
 It is not surprising that 50% to 70% of the body’s weight is made up of water.

17. Energy
 Energy requirements of people with COPD are variable owing to differences in REE and levels of physical
activity.
 COPD, whether stable or in exacerbation, results in an increase in inflammation resulting in an increase in
REE.
 Carbohydrates are sometimes broadly classified as complex or simple. The complex carbohydrates are
starches
 (sugar molecules linked together in long branching chains)
 the best sources are grains, vegetables, and fruits. Foods high in complex carbohydrates usually contain the
vitamins required in the metabolic pathways for catabolism.
 In addition, these foods provide water, fiber, protein, and chemical components that are associated with a
decrease in chronic disease processes.

18.  Excessive glucose intake leads to an increase in carbon dioxide
production, and the respiratory system must work harder to rid the body
of this extra carbon dioxide.
 Generally, carbohydrates should make up about 55% to 60% of the caloric intake of enterally fed
patients.
 If a patient is having difficulty weaning from mechanical ventilation, a higher fat diet may be useful
during the weaning process, in particular those with high Pco2 and CO2 levels.
 Follow-up assessment of patients by a registered dietitian familiar with COPD allows proper dietary
adjustments.

19. Protein
 Protein should make up 12% to 15% of the caloric intake.
 The recommended dietary allowance (RDA) of protein for a healthy person has been set at 0.8 g/kg
of body weight each day. Thus, a 70-kg person should obtain about 56 g of protein each day.
 0.8 g/kg for the normal healthy adult
 1.2 to 1.5 g/kg for the initial provision of protein in the pulmonary compromised patient
 2.0 to 2.5 g/kg for severe catabolic conditions
 Because every 100 g of proteins contains approximately 6.25 g of nitrogen, grams of nitrogen can
readily be converted to grams of protein by multiplying by 6.25. Conversely, to find how much
nitrogen there is in a given amount of protein, in grams, divide by 6.25 (or the appropriate factor for
the specific protein)

20.  Soy protein is considered a high quality protein, along with milk or egg protein,
 soy protein has an additional benefit of lower insulin stimulation and a lowering of cholesterol.
 Plant-based proteins lower many of the risk factors for many chronic diseases.
 Most of the plant proteins have lower essential amino acid profiles than do animal proteins, but
when combined with other complementary plant protein, complete essential amino acid profiles
can be obtained

21.  A negative nitrogen balance is common in critically ill patients who are not able to eat and indicates
that more nitrogen is excreted than ingested.
 Body protein stores are being consumed in such cases, and muscle wasting is occurring.

22. Fat
 Dietary fat plays a number of important roles in the body. The fat-soluble vitamins, A, D, E, and K,
are carried in fats
 and oils.
 These vitamins are involved in immunity, antioxidant activity, blood clotting, and bone and arterial
health. Fat is energy dense and contains twice as many calories per gram weight as carbohydrate
or protein.
 fat is the best storage form of energy, and this is why the body stores excess calories in the form of
fat or triglycerides in the adipose tissue.
 Fat is also the most efficient way to provide more calories to hospitalized patients when they are
fluid restricted or cannot tolerate large volumes of food. Fat provides a feeling of fullness (satiety),
improves palatability of food, and is digested more slowly than proteins and starches.

23.  There are two essential fats, linolenic (omega-3) and linoleic (omega-6), that the body must obtain
from the diet. These fats are needed for modulation of inflammatory processes, nerve function, and
other essential chemical activities
 Excessive fat intake can decrease tissue oxygenation.
 Strive for a balance between fat and carbohydrate intake so that oxygenation is maximized and
carbon dioxide production is minimized

24. Vitamins, Minerals, Phytochemicals,
and Other Nutrients
 Vitamins can be classified into two main categories:
 Water-soluble vitamins are those of the B group and vitamin C.
 The fat-soluble vitamins are A, D, E, and K. Vitamins are cofactors in the enzyme systems needed for
various metabolic pathways and body processes.
 The minerals can be divided into either macronutrient elements or micronutrient (trace) elements.
 Minerals are used in all of the body chemical reactions and are part of numerous enzyme systems
serving as cofactors.
 It is just as important to supplement with minerals as it is with vitamins when there appears to be a
deficient food

25.  Data Gathering and Interpretation
 History
 Conditions that should be discovered in the medical history are as follows:
• Multiple surgical or nonsurgical trauma
• Fever
• Infection acute and chronic
• Burns
• Long bone fractures
• Hyperthyroidism
• Prolonged corticosteroid therapy

26. • Smoking or other tobacco habits
• Occupation and usual daily activity
• Use of supplemental oxygen
• Usual energy and nutrient intake through 24-hour recall, usual daily intake or food frequency pattern
• Special diet restrictions at home
• Food aversions, intolerances, and allergies
• Medications (prescription and over the counter), nutritional, botanical and herbal supplements
• Mechanical feeding problems (e.g., biting, chewing or swallowing, mouth sores)
• Changes in appetite
• Changes in food intake or food patterns
• Gastrointestinal problems (e.g., anorexia, nausea, vomiting, or heartburn)
• Elimination pattern and consistency of stool
• Maximal weight attained and how long ago it was attaine

27. Areas Requiring Assessment to Determine a Patient’s
Nutritional Profile
 PHYSIOLOGIC
• Types of diseases present
• Severity of illness
• Metabolic stress of disease
• Medications being used (both prescription and over the counter)
• Botanical and/or herbal therapies
• Genetic deficiencies
• Activity level
• Resting energy expenditure (REE)
• Food allergies and intolerances
• Current nutritional status
• Anthropometric
• Biochemical
• Immunologic

28.  PSYCHOSOCIAL
• Mental state (mood, alertness)
• Culture
• Food preparation skills
• Appetite
• Learned eating behaviors/habits (food preferences)
• Motivation
• Habits: alcohol, smoking
• Education
• Income
• Support system

29.  ENVIRONMENTAL
• Mechanical hindrances to eating (continuous mechanical ventilation and tracheostomy)
• Food availability
• Temperature
• Humidity

30.  SUGGESTED MEASUREMENTS
• Skinfold thickness
• Skinfold + arm circumference = arm, muscle circumference, muscle and fat area
• Body mass index (BMI)
• Percent body fat
• Percent lean body mass—body protein reserves (an indicator of protein energy nutrition)
• Body fat stores (an indicator of energy reserves)
• Result of long-term nutritional status

31. Body mass index
 The BMI is the primary method for assessment of the appropriateness of weight for a given height.
 The BMI is determined by weight (kg)/height (m2A BMI in the range of 20 to 25 is considered
optimal.
 A BMI from 25 to 30 is considered overweight, 30 to 35 is stage 1 obesity,
 35 to 40 is stage 2 obesity,
 and 40 to 45 is stage 3 obesity, also known as morbid obesity.
 As the BMI exceeds 27, the risk for weight-related problems begins to increase.
 BMIs that are below 19 are associated with malnutrition problems and increased

32. Anthropometric Methods
 Anthropometry is the measurement of body height, weight & proportions.
 It is an essential component of clinical examination of infants, children & pregnant women.
 It is used to evaluate both under & over nutrition.
 The measured values reflects the current nutritional status & don’t differentiate between acute &
chronic changes

33. Waist/Hip Ratio
 Waist circumference is measured at the level of the umbilicus to the nearest 0.5 cm.
 The subject stands erect with relaxed abdominal muscles, arms at the side, and feet together.
 The measurement should be taken at the end of a normal expiration

34.  Waist circumference predicts mortality better than any other anthropometric measurement.
 It has been proposed that waist measurement alone can be used to assess obesity, and two levels
of risk have been identified
 MALES FEMALE
 LEVEL 1 > 94cm > 80cm
 LEVEL2 > 102cm > 88cm

35. Hair

36. Mouth