How is a nutrition assessment relevant in the field of respiratory care? That’s probably what you’re thinking, right?
“I want to be a Respiratory Therapist, so why do I need to know about a patient’s nutritional status?”
And that is a valid question.
But, consider this. Nutrition is vital to life, just like oxygen. You can only go so long without oxygen. Additionally, you can only go so long without proper food and nutrients as well.
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What is a Nutrition Assessment?
A nutrition assessment is a process of analyzing and evaluating the overall nutritional status of a patient. A Registered Dietitian (RD) is typically the medical professional who is most involved in this process.
However, it’s important for Respiratory Therapists to develop an understanding as well.
That is because certain cardiopulmonary conditions may have increased energy requirements. This means that, without the essential nutrients, you may not be able to provide a patient with other important therapeutic modalities.
Nutrition is essential in respiratory care because oxygen is required for the cellular metabolism of carbohydrates, lipids, and protein. These nutrients are converted into the energy that the body needs to function properly. This includes all of the major organs and systems of the body.
What is the Best Diet for Patients with a Respiratory Condition?
Unfortunately, it’s impossible to provide a definitive answer to this question because each patient is different. Some patients may benefit from one diet, which could do more harm than good to others.
With that said, as a Respiratory Therapist, there are a few generalizations that can be made.
For example, a critically ill patient with a severe infection may require more protein intake than normal.
A patient with COPD may benefit from eating frequent smaller meals high in fat and low in carbohydrates. A patient with asthma may also benefit from smaller meals high in protein. They should avoid foods known to have allergens, as they may increase the likelihood of an acute attack.
Patients with cystic fibrosis are often malnourished. In general, they typically benefit from a diet that is high in fat and sodium.
Again, these are just a few general examples. Each patient is different, and a proper nutritional regimen should be implemented with the help of a qualified dietitian and physician.
Nutrition Assessment Practice Questions:
The process of collecting and evaluating data to determine the nutrition status of an individual
2. Nutrition assessment is the basis for developing what?
A nutrition care plan
3. What are the components of a nutrition assessment?
Dietary history, anthropometry, biochemical indicators, nutrition-focused physical assessment, and client history
4. What is BMI?
BMI is used to compare a patient’s weight and height to determine if they’re underweight, overweight, obese, or at a healthy weight.
5. What are the classifications of undernutrition, called protein-energy malnutrition?
Kwashiorkor, marasmus, and a combination of the two (lack of circulating protein, starvation, and a mixture of the two)
6. Laboratory values of albumin, transferrin, transthyretin, and retinal-binding protein may indicate what?
7. CRP may be elevated when?
During acute illness, indicating an inflammatory response and causing low values of serum proteins
8. The creatinine-height index reflects what?
Skeletal muscle mass
9. Nitrogen balance compares protein intake to what?
Nitrogen excretion in the urine
10. Observable signs in hair, eyes, lips, mouth and gums, skin, and nails may indicate what?
11. Resting energy expenditure (REE) may be determined by what?
The predictive equations or indirect calorimetry
12. Estimation of total caloric need involves what?
It involves multiplying the REE by a factor that accounts for activity and stressors.
13. An RQ greater than 1.00 indicates what?
Overfeeding and the need to decrease total calories
14. An RQ between the ranges of 0.67 to 1.3 should be used as what?
An indicator of test validity
15. What is malnutrition?
It is a state of impaired metabolism in which the intake of essential nutrients is less than the body’s needs.
16. What is marasmus?
Malnutrition associated with inadequate nutrient intake (starvation), and kwashiorkor is the hypercatabolic form
17. How can malnutrition affect the respiratory system?
By causing loss of respiratory muscle mass and contractility, decreased ventilatory drive, impaired immune response, and alterations in lung parenchymal structure
18. Approximately one-third of all patients with acute respiratory failure have malnutrition, mainly in the hypercatabolic form; these patients are prone to what?
Hypercapnia; and they can be difficult to wean from ventilatory support, and have higher mortality rates than patients with a normal nutrition status
19. In chronic lung disease, the combined effect of increased energy expenditure (secondary to increased work of breathing) and inadequate caloric intake contributes to what?
A marasmus-type malnutrition
20. The primary goal of nutrition support is to maintain or restore lean body (skeletal muscle) mass in what two ways?
(1) Meeting the overall energy needs of the patient and (2) Providing the appropriate combination of macronutrients (protein, carbohydrate, and fat) and micronutrients (vitamins and minerals); Nutrition support also attenuates the metabolic response to stress, prevents oxidative cellular injury, and modulates the immune response
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Most patients need 20% of their daily calories from protein, 50% to 60% from simple carbohydrates, and 20% to 30% from fat.
22. Nutrients can be supplied enterally (oral and tube feeding) or parenterally (peripheral or central venous alimentation). Which route is preferred?
The enteral route should be used whenever possible.
23. What is calorimetry, and when is it used?
It is the estimation of energy expenditure by measurement of oxygen consumption and CO2 production. It is used when you want to assess the patient’s metabolic state, to determine nutrition needs, or to assess response to nutrition therapy.
24. What is a comprehensive nutrition assessment?
The purpose of this is to gather data to develop a nutrition care plan that ensures adequate nutrition for health and well-being when implemented.
25. How to calculate and interpret BMI?
A healthy BMI is 18.5-24.9 for adults and between the 10th and 85 percentile for children. To calculate body mass index, BMI = actual body weight (kg)/ height^2 (in^2).
26. How to estimate daily resting energy expenditure?
By using predicted equations such as the Harris Benedict Equation
27. How can you avoid aspiration during enteral feedings?
To avoid pulmonary aspiration, raise the head of the bed 45 degrees; also, you can use saxing and the continuous drip method
28. How are the results of indirect calorimetry interpreted?
The results are used to assess the patient’s metabolic status and plan nutritional support. The first step is to compare REE. If it is within 10% predicted, it’s considered normometabolic. The second step is to interpret the RQ.
29. How can you obtain and evaluate a patient’s nutrition history?
Review the patient’s chart
30. How are resting energy expenditure values adjusted to reflect a patient’s actual energy needs?
Energy needs vary according to activity level and state of health
31. How does respiratory medication interact with food?
As a respiratory therapist, you should correlate treatments in between feedings.
32. What are the effects of malnutrition on the respiratory system?
One-third of patients with respiratory failure have malnutrition. This can cause a loss of diaphragmatic and accessory muscle mass and contractility, decreased hypoxic and hypercapnic response, decreased lung clearance mechanisms, decreased secretory IgA, increased bacterial colonization, and a reduced production of surfactant.
33. What is SIRS?
It stands for systemic inflammatory response syndrome. It underlies critical illnesses such as sepsis and ARDS. It can cause a 25% decrease in protein which leads to a lean body and anorexia.
34. What should the Respiratory Therapist observe clinically in malnourished patients?
Physical findings often appear first in selected tissues such as hair, eyes, lips, mouth, gums, skin, and nails. However, in addition to malnutrition, other causes of these abnormalities include medical therapies, anemia, allergies, sunburn, medication, and poor hygiene. Patients with severe malnutrition often appear very thin to the point where their bones are sticking out.
35. Which essential nutrients are important to monitor in patients?
Carbohydrates, protein, lipids, vitamins, minerals, and water
36. What is the purpose of a nutrition assessment?
To develop a nutrition care plan that ensures continual adequate nutrition for health
37. What is the BMI for a healthy adult?
38. What is the BMI for a healthy child?
39. What causes marasmus?
Prolonged, extreme lack of calories and protein associated with food shortage, early weaning, or infrequent feeding of infants
40. What are the characteristics of marasmus?
It is typically seen in children 6 to 18 months of age that are residing in impoverished areas of the world. They tend to have “matchstick arms” and a noticeable lack of muscle and fat.
41. What causes kwashiorkor?
The lack of eating enough protein and other essential vitamins, minerals, and nutrients
42. What are the characteristics of kwashiorkor?
A protruding belly and edematous face and limbs
43. What causes the protruding belly and edematous face and limbs in a kwashiorkor baby?
Decreased plasma proteins needed to maintain fluid balance and transport fat out of the liver
44. PEM may be reflected in low values for?
Albumin, transthyretin (prealbumin), and retinol-binding protein
45. What is a great prognostic indicator?
46. What is the largest constituent protein in plasma?
47. Why is the usefulness of albumin limited in monitoring the effectiveness of nutrition in the critical care setting?
Because its half-life is only 14 to 21 days
48. What is the most commonly used biomarker of inflammation?
C-reactive protein (CRP)
49. What happens to C-reactive protein when infection or inflammation is present?
50. What happens to albumin and prealbumin when infection or inflammation is present?
51. What reflects skeletal muscle mass?
The amount of creatinine excreted in the urine
52. The amount of nitrogen excretion in the urine is typically measured as what?
The 24-hour urinary urea nitrogen
53. What is common in malnutrition, especially the kwashiorkor type?
54. What is the classic measure of energy called?
Basal Metabolic Rate (BMR)
55. When is basal metabolic rate obtained?
It can be obtained after 10 hours of fasting.
56. How is basal metabolic rate measured?
The number of calories expended at rest per square meter of body surface per hour
57. The estimation of energy expenditure by measurement of oxygen consumption and CO2 production is called what?
58. What is the biggest problem with indirect calorimetry?
The machine has to be calibrated, and there are leaks.
59. Why can nutritional disorders not be diagnosed from a single laboratory value?
Because, by themselves, they are not sufficiently sensitive or specific to diagnose malnutrition. Instead, laboratory test results are used with other data as part of a holistic assessment of a patient’s nutritional status.
60. An increased metabolism associated with inflammation causes a 25% decrease in protein synthesis, which results in what?
It results in a loss of lean body mass.
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61. In a proinflammatory state, the combination of inflammation and hypoalbuminemia is linked to what?
Increased morbidity, mortality, and longer hospitalization
62. Although predictive equations are useful in calculating a patient’s energy expenditure needs, they do not always replace the need for performing what?
Indirect calorimetry, which is generally more accurate and provides additional information, including a calculation of the RQ.
63. Fifty percent of hospitalized patients present with what?
64. You should begin enteral nutrition within how long after intubation?
24 to 48 hours
65. How does malnutrition affect the respiratory system?
It causes a loss of respiratory muscle mass and diminishes the ability of the diaphragm to contract. It decreases the ventilatory drive and causes an impaired immune response.
John Landry, BS, RRT
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
- Faarc, Kacmarek Robert PhD Rrt, et al. Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020.
- Faarc, Heuer Al PhD Mba Rrt Rpft. Wilkins’ Clinical Assessment in Respiratory Care. 8th ed., Mosby, 2017.
- Jardins, Des Terry. Cardiopulmonary Anatomy & Physiology: Essentials of Respiratory Care. 7th ed., Cengage Learning, 2019.
- Rrt, Des Terry Jardins MEd, and Burton George Md Facp Fccp Faarc. Clinical Manifestations and Assessment of Respiratory Disease. 8th ed., Mosby, 2019.
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