13.2: Assess and Analyze the Impact of Nutrition on the Pulmonary System

Learning Objectives

By the end of this section, you should be able to:

• 13.1.1 Describe the normal function of the pulmonary system.
• 13.1.2 Identify cues of nutritional impact on the pulmonary system.
• 13.1.3 Analyze cues of nutritional impact on the pulmonary system.

Development of the pulmonary system spans from its initiation in the first trimester of pregnancy through to early adulthood (Arigliani et al., 2018). To assess and analyze the impact of nutrition on the pulmonary system, the nurse must understand the system’s normal function. The pulmonary or respiratory system comprises the upper and lower airways (passageways through which air moves), along with the lungs and alveolar sacs. The primary function of the pulmonary system is to ensure adequate oxygenation throughout the body. This occurs with gas exchange, which involves transporting oxygen to the cells and transporting carbon dioxide away from the cells. This process happens through ventilation, diffusion, and perfusion. Ventilation is the movement of atmospheric air that is higher in oxygen into the lungs and the removal of carbon dioxide. Ventilation is the number-one function of the respiratory system. Respiratory diffusion occurs when gases move down the concentration gradient across the alveolar sacs and capillaries. Perfusion is the process of the arterial blood moving through the tissue to the entire body. Adequate gas exchange is essential for all systems of the body. If the pulmonary system is inadequate, total health and well-being can be affected (Norris, 2019).

Normal Function of the Pulmonary System

The normal function of the pulmonary system is best understood when divided into the upper and lower respiratory tract. The respiratory system plays a significant role in ensuring all body systems adequately receive gas exchange for tissue perfusion (Figure 13.2).

Figure 13.2 The major respiratory structures span from the nasal cavity to the diaphragm. (credit: modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Upper Respiratory Tract

The upper respiratory system is responsible for inhalation and exhalation and also influences speech and the sense of smell. The upper respiratory tract is comprised of the:

• Nose—responsible for smell, which occurs via receptors from the olfactory nerve located in the upper areas of the nose
• Sinuses—give a fullness to speech and act as shock absorbers if facial trauma occurs
• Pharynx (throat)—a passageway for the respiratory and digestive tracts
• Larynx (voice box)—houses the vocal cords, which are responsible for speech

Lower Respiratory Tract

The lower respiratory tract is comprised of the airways, lungs, and accessory muscles of respiration. The lower respiratory system is responsible for gas exchange and perfusion.

The lower respiratory tract consists of the trachea, bronchi, bronchioles, alveolar ducts, and alveoli. Gases move to and from the lungs through the airways. The airways only allow for movement of gases, not gas exchange, because the airways are too thick to allow for diffusion. The actual respiratory gas exchange occurs in alveolar sacs that arise from the ducts and contain groups of alveoli. Surfactant is a fatty protein that lines the alveoli and reduces surface tension. Without surfactant, atelectasis, which is the collapse of the alveolar, will occur and gas exchange cannot happen, because the collapse causes a reduction of the alveolar area.

The lower airways consist of two elastic lungs located in the pleural cavity of the chest. The two lungs are not equal in size or gas exchange. The right lung is larger and consists of three lobes; the left lung has two lobes. Most of the function (55–60%) occurs in the right lung. If the client’s right lung is compromised, it will interfere with gas exchange and perfusion to a greater extent than a compromised left lung.

Respirations occur when changes in size of and pressure within the chest cavity take place. The diaphragm and chest muscles contract and relax to cause these changes. When the work of breathing is increased, back and abdominal muscles may be used in addition to chest muscles. When back and abdominal muscles are used, the client is said to be using accessory muscles to breathe.

Humans breath in and out approximately 22,000 times a day (Canadian Lung Association, n.d.). While environmental or contaminant factors impact pulmonary function, a natural degradation of function over time also occurs. The following Special Considerations box describes respiratory changes that occur with aging. Respiratory changes in older adults can be related to normal aging or respiratory disease. Age-related changes in the muscles and the cardiovascular system may also cause abnormal respirations (Schneider et al., 2021).

Special Considerations: Age-Related Changes in the Respiratory System

As individuals age, changes to the musculoskeletal, vascular, and respiratory systems that alter function and may require nursing interventions, as outlined in Table 13.1.

Table 13.1 Expected Changes in Respiratory Symptoms for Older Clients (sources: Dezube, R., 2023; Schneider et al., 2021; Sun et al., 2021)

Changes	Nursing Implications
Alveolar surface area decreases. Diffusion capacity decreases. Elastic recoil decreases. Bronchioles calcify and become rigid. Alveolar ducts dilate. Ability to cough decreases.	Encourage vigorous pulmonary hygiene (i.e., client to turn, cough, and deep breathe) and use of incentive spirometry, especially if the client is confined to bed or has had surgery, to reduce the risk for infectious respiratory or mechanical complications. Encourage upright position to minimize ventilation-perfusion mismatching; slumped and supine positioning allows the abdomen to compress the diaphragm and may limit full lung expansion.
Residual volume increases. Vital capacity decreases. Efficiency of oxygen and carbon dioxide exchange decreases. Elasticity decreases.	Include inspection, palpation, percussion, and auscultation in lung assessments to detect normal age-related changes. Assess client’s respirations for abnormal breathing patterns; Cheyne-Stokes respiration may occur in older adults without pathology. Encourage frequent oral hygiene to aid in the removal of secretions. Help the client actively maintain health and fitness to keep losses in respiratory functioning to a minimum.
Muscles atrophy. Laryngeal muscles lose elasticity. Vascular resistance in the pulmonary system increases. Pulmonary capillary blood volume decreases. Risk for hypoxia increases.	Have face-to-face conversations with the client when possible because the client’s voice may be soft and difficult to understand. Assess a client’s level of consciousness and cognition, because hypoxia from acute respiratory conditions can cause the client to become confused.
The body’s compensatory measures to avoid hypoxia and hypercarbia decrease. Respiratory muscle strength, especially in the diaphragm and intercostals, decreases.	Assess subtle manifestations of hypoxia to prevent complications. Encourage pulmonary hygiene and help clients actively maintain health and fitness to promote maximal respiratory system functioning and prevent respiratory illnesses.
Effectiveness of the cilia decreases. Alveolar macrophages are altered. Immunoglobulin A decreases.	Encourage pulmonary hygiene and help clients actively maintain health and fitness to promote maximal functioning of the respiratory system and prevent respiratory illnesses.
Anteroposterior diameter increases. Progressive kyphoscoliosis occurs. Chest wall compliance (elasticity) decreases. Mobility of chest wall may decrease.	Discuss the normal changes of aging to help reduce anxiety about symptoms. Discuss the need for increased rest periods during exercise, because exercise tolerance decreases with age. Osteoporosis is possible, leading to chest wall abnormalities. Encourage adequate calcium and vitamin D intake (especially during a client’s premenopausal phase) to help prevent or reduce later osteoporosis.

Assessment of Nutrition and the Function of the Pulmonary System

The nurse should complete an accurate assessment of the pulmonary system to identify the type and severity of breathing problems that may interfere with gas exchange and be positively impacted by nutritional support. This assessment should include a nutritional history and habits, fluid assessment, and barriers to nutritional goals. This assessment will provide cues to direct the client’s care and enable optimal nutritional intake.

Client History

Accurate client information is important to identify how food intake may interfere with pulmonary function. The nurse should be aware that age, gender, and race may affect nutritional needs and risks related to the respiratory system. The client history should include allergies (food and environment), dietary habits, special dietary needs and food sensitivities, food access and/or insecurity, smoking (tobacco and vaping), alcohol, illegal drug use (particularly inhaled substances), travel and environmental exposures, and residential conditions. The history should specifically include:

• Allergies—Include documentation of food, dust, pollen, bee stings, and medications. Document the onset of allergy and the specific allergic response, such as wheezing, difficulty breathing, cough, rhinitis, hives, swollen lips, or anaphylaxis. If the client identifies allergies, inquire as to number of prior reactions, treatments utilized, response to treatment, hospitalizations, and if the client has been prescribed and/or carries epinephrine. Food allergies are a risk factor for asthma along with asthma morbidity (daytime symptoms, increased rescue therapy, hospitalization, ventilator use, unplanned health care utilization) and mortality (Sherenian et al., 2018).
• Dietary habits—Assess initially with a 24-hour food recall, in which a client reports all their food and fluid intake on the last day (Figure 13.3). The 24-hour recall is used most often in dietary surveys and has been adapted and validated for use by adolescents and adults, as well as by adults in reporting their child’s intake (Arsenault et al., 2020). While not completely accurate for micronutrient evaluation, the 24-hour food recall can be reviewed and discussed to determine if the reported food intake is typical for the client’s normal routine. For example, if a client typically skips breakfast, eats mostly processed foods or fast food, drinks sugary beverages, and/or eats high-sodium food such as packaged and processed items, this information will assist the nurse in identifying areas for nutrition education.
• Special dietary needs—Include specific dietary preferences, religious requirements, or medically indicated restrictions, such as gluten free, diabetic diet, low salt, avoidance of tree nuts or peanuts, kosher, halal, or pork free. Dietary restrictions may put clients at increased risk for nutrient deficiency (vitamin E, magnesium, sodium, potassium, and calcium), resulting in increased presence of respiratory symptoms such as wheezing and airway hyperreactivity (Sherenian et al., 2018).
• Social determinants of health (SDOH)—Include conditions in the home, school, work, place of worship, and social environments that affect health, quality of life, and risks for illness (Office of Disease Prevention and Health Promotion [ODPHP], 2020). Economic and social conditions may limit or create uncertain access to adequate food, known as food insecurity. Restrictions may result from insufficient monetary resources, social support (for example, lack of school lunch during school breaks), or shortage of full-service supermarkets. Food insecurity is associated with increased obesity, asthma, COPD, and cancer(ODPHP, 2020).
• Smoking—Include status as a current smoker, having ever smoked, the age when the client started, and the number of cigarettes smoked daily. This should be recorded as pack-years, calculated as the number of packs smoked per day multiplied by number of years smoked. The nurse should also assess for use of chewing tobacco, hookah smoking, and vaping, including the product the client uses, such as nicotine or tetrahydrocannabinol (THC). For pediatric clients, any exposure to smokers should document relationship, frequency, location (home, car, or other) and duration of smoke exposure. According to the CDC (2022a), smoking is the leading cause of preventable death and is associated with increased risk for asthma, COPD, and immune-system damage or dysfunction. It is the primary cause of lung cancer, with 9 out of 10 lung cancer deaths caused by smoking or secondhand smoke exposure.
• Alcohol intake—Include the number of drinks in a single event in a day and the cumulative total per week. The Centers for Disease Control (CDC) (2022b) recommends that women have no more than 1 drink per day and that men have no more than 2 drinks per day; they further define binge drinking as consumption of 4 or more drinks during a single event for women and 5 or more during a single event for men. Alcohol use disorder affects the respiratory system and increases the incidence and associated risks of asthma, COPD, lung infection, aspiration pneumonia, and acute respiratory distress syndrome (ARDS) (Arvers, 2018).
• Illegal drug use—Include questions regarding any substance the client inhales, snorts, chews (edibles), or injects. This includes paint, markers, bleach, cleaning supplies, marijuana, cocaine, opioids (heroin and fentanyl), methamphetamines, gamma-hydroxybutyric acid (GHB), hallucinogens (ketamine, LSD, PCP, magic mushrooms), MDMA (ecstasy and Molly), and flunitrazepam (Rohypnol). Impact of drug use on the respiratory system involves respiratory sedation, risk of respiratory arrest, and immune-system suppression, increasing the potential for respiratory infections (Plein & Rittner, 2018).
• Prescription medications—Document the medication name, dose, frequency, and compliance; this will include medications taken for breathing problems and all other conditions. The nurse should be aware that clients may need prompting for the inclusion of medical cannabis in their medication list, as the number of states allowing for medical prescribing is increasing. Also assess the use of over-the-counter medications and herbal remedies. Certain medications may affect the respiratory system. For example, angiotensin-converting enzyme (ACE) inhibitors to treat hypertension may cause a dry nighttime cough. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) induce bronchospasm and should be avoided in clients with a history of sensitivity to these medications.
• Travel, geographic location, and environmental exposure—Assess to reveal exposure to diseases and pathogens found in certain areas that increase the risk for infection. Environmental exposures such as forest fires, pollution (often more common in lower socioeconomic or dense urban areas), gasoline fumes, or aerosolized chemicals (i.e., chlorine) increase upper and lower respiratory tract irritation and may worsen chronic respiratory conditions (Lee et al., 2021). Residential conditions influence the health of individuals; for example, substandard housing materials and overcrowding, along with biologic (molds, mites, roaches), chemical (lead, carbon monoxide), and physical (temperature, fine particles) hazards lead to respiratory disease (OASH, 2020). The nurse should document type of housing (single-family home, apartment, mobile home), setting (rural, suburban, urban), number of occupants, number of bedrooms, and any hazards or contributors to disease.

Figure 13.3 A 24-hour food diary provides clues about nutrients and how they may be impacting wellness. (CC BY 4.0; Rice University & OpenStax)

Clinical Tip: Allergies

The nurse should document any known allergies, especially to medications. The specific type of response the client experienced and what was done to correct it should be documented in a prominent place in the client’s medical record.

When conducting an assessment, the nurse should obtain a family history of respiratory disorders. This provides information regarding diseases that have genetic components, such as cystic fibrosis or emphysema. A family medical history of allergies is often present in clients with asthma. The nurse should ask about infectious diseases such as tuberculosis, because families have similar environmental exposures.

A client’s complete medical history including current conditions and diagnoses that impact the client’s health should be documented. In addition, the primary complaint or reason for the current health intervention (office visit or hospitalization) is necessary; this is often collected using the acronym OLD CARTS, referring to:

• Onset
• Location
• Duration
• Character
• Associated symptoms or aggravating factors
• Relieving factors
• Timing
• Severity or scale

In pulmonary diagnoses, primary concerns may include cough, wheezing, chest tightness, or shortness of breath. Examples include:

• Cough—A potential sign of lung disease. Questions that the nurse might ask include: Is it the same, better, or worse than when it started? Is the cough dry or does it produce sputum? Does anyone else you spend time with have a cough?
• Sputum—A large cue in the respiratory assessment. The nurse should note the color, consistency, and amount. The nurse should also ask about a time of day when coughing is more prevalent (in the morning, during or after meals, etc.). Sputum can indicate infection, pulmonary edema, or cancer.
• Wheezing—A sign of airway restriction. Does it occur with exercise or activity, or also at rest? Do you hear it while breathing in, breathing out, or both?
• Shortness of breath—May indicate different types of lung problems. The nurse should note dyspnea, difficulty breathing, or breathlessness. Another factor that should be determined is orthopnea, shortness of breath that occurs when lying down and is relieved by sitting up. These findings often occur with chronic lung disease.

To assess further, the nurse should ask if the complaint or problem has ever occurred before, if there are known triggers, and what treatments have been used to make it better (Dezube, 2023).

A client history provides awareness of risks and conditions that may shape nutritional interventions. This could include:

• Childhood illnesses—asthma, pneumonia, communicable diseases, hay fever, allergies, eczema, frequent colds, croup, and cystic fibrosis
• Adult illnesses—pneumonia, sinusitis, tuberculosis, HIV/AIDS, COPD, emphysema, sarcoidosis, obesity, obstructive sleep apnea, diabetes, hypertension, heart disease, influenza, and COVID-19
• Vaccinations—pneumococcal vaccine (PCV 13, PCV 15, and PPSV 23) influenza vaccine, COVID-19 vaccine, and bacille Calmette-Guérin (BCG) vaccine
• Past surgical history—surgeries of the upper or lower respiratory tract
• Injuries, hospitalizations, and tests—injuries to the upper or lower respiratory tract, hospitalizations related to pulmonary conditions, and dates of last chest x-ray, pulmonary function test, tuberculin test, or other diagnostic tests and their results
• Indications of infectious disease (tuberculosis)—recent weight loss, night sweats, sleep disturbances
• Travel, occupation, hobbies, and social history—geographic areas of risk for infection or pollutants, occupational hazards (aerosols or chemicals), tobacco, vaping, or other inhalants (Dezube, 2023)

Unfolding Case Study: Part A

Read the following clinical scenario and then answer the questions that follow. This case study will evolve throughout the chapter.

In this visit with Katrice and her parents, the health care team wants to collect a complete client history including Katrice’s medical and social history, family history, and current asthma symptoms. Katrice reports utilizing her asthma inhaler before exercise but has rarely needed the inhaler outside of exercise. They deny audible wheezing, nighttime cough, or asthma attacks that have required hospitalization. They are pleased overall with her asthma control. The provider notices on exam that Katrice’s body mass index (BMI) has increased since her last visit, taking her from overweight to obese.

1

Which statement indicates Katrice and her parents understand the normal function of the pulmonary system?

1. “It’s ok if I wheeze every day; as long as I use the inhaler, my lung function will stay the same for my whole life.”

• “The pulmonary system goes from my mouth through to the bottom of my lungs; it’s how my body gets oxygen.”
• “Wheezing is a sign that my airways have expanded too much, and air is moving through them too fast.”
• “Secondhand smoke doesn’t affect the lung tissue.”

2

What additional history information would signal the need for additional intervention by the nurse?

1. The family of five living in a four-bedroom single-family home
2. Wearing masks and playing inside when visiting family who live near a factory in a high-pollution area
3. Wheezing sometimes associated with taking NSAIDS before exercise
4. Having grandma smoke outside, away from the house, and covering her clothing with a “smoking jacket”

Physical Assessment

Physical assessment begins with vital signs. Blood pressure, heart rate, respiratory rate, pulse oximetry, height, weight, and BMI provide foundational information regarding respiratory effort, cardiovascular workload, oxygenation, and nutritional status (underweight or overweight). The respiratory tract exam should include the nose and sinuses; pharynx, trachea, and larynx; and lungs and thorax. Pulmonary assessment should include:

• Skin for color (cyanosis), pallor, and nail clubbing. These signs may indicate poor oxygenation from respiratory disorders.
• Visual inspection of the nose and sinuses for deformities, swelling, lesions, pain to palpation, and the presence of drainage or bleeding.
• Visual inspection of the mouth and throat. The health care provider should note the size and condition of the tonsils, erythema, postnasal drainage, symmetry of the neck, shape and size of the lymph nodes, and position of the trachea. Specific measures that may be documented are Mallampati score (an airway assessment scale to classify the visibility of the oropharyngeal structures) and neck circumference, both of which contribute to evaluation for obstructive sleep apnea. A specialist should examine the larynx if continued hoarseness is noted.
• Inspection, palpation, percussion, and auscultation of the lungs and thorax.

Clinical Tip: Assessing Airway Sounds

If the client is having difficulty breathing with secretions present in the upper airway, respirations would be loud and gurgling. Secretions may be present due to infection, allergies, or other issues. The nurse should instruct the client to clear their throat before proceeding with the assessment.

With inspection of the thorax, the nurse should visually observe the rate, rhythm, depth of inspiration, and symmetry of the chest. The adult respiratory rate at rest is 12–16 breaths per minute (Dezube, 2023). The nurse should also note the type of breathing, intercostal retractions, and the use of accessory muscles. Also, the nurse should observe the comparison of lateral or transverse diameter to anteroposterior diameter; the normal ratio is 2:1. These cues indicate lung disease such as COPD and advanced aging.

With palpation, the nurse should examine by touch and note for any abnormalities found, such as tenderness or swelling. The nurse might note crepitus (air trapped in and under the skin), which is typically felt as crackling. This should be reported to the health care provider. The nurse should also note fremitus (a vibration in the chest wall as the client speaks) during palpation.

Percussion is systematic tapping over the intercostal spaces, moving through the anterior, lateral, and posterior thorax. With percussion, the presence of abnormal fluid or air in the lungs may be detected, as noted by different sounds. Resonance is expected over lung areas; hyperresonance, dullness, or flat sounds may indicate concerning respiratory findings (Dezube, 2023).

With auscultation, the nurse should listen with a stethoscope for normal breath sounds, abnormal sounds, and voice sounds. These sounds provide information about the flow of air through the lungs and trachea, which help to identify fluid, mucus, or obstruction in the respiratory system (Dezube, 2023). Figure 13.4 shows the proper sequence for auscultation. The nurse should begin at the apex of the lung, moving from side to side in a systematic approach ending at the long bases.

Figure 13.4 Auscultation should be done posterior and anterior. (credit: modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Auscultating Lungs

Access multimedia content

The proper way to auscultate lungs, including the correct locations, can be seen in this video. This is of great importance to ensure that respiratory issues will not be missed and will be effectively monitored throughout the course of disease.

Psychosocial Assessment

A psychosocial assessment is important to determine how the client is coping with respiratory distress, either acute or chronic. The client’s emotions and responses may be based on concerns for normalcy, fitting in, bullying, cost of medications and health care, missed time from work or school, access to and cost of proper nutrition, safety, and support systems. In addition, the physical manifestations of disease may cause psychosocial symptom manifestation. A client with a high fever may be disorientated, a client with COPD may be depressed due to lack of cure, or a client with breathing difficulty may have anxiety caused by the sensation of not getting enough air.

The nurse should encourage clients to express their feelings and fears, allowing the health care provider to address their anxiety, depression, stress, or other concerns. The nurse should discuss coping mechanisms to enable the client to better handle the emotions and promote optimum disease and symptom management. The nurse may educate the client on coping mechanisms such as deep breathing, relaxation, and other techniques that decrease anxiety. Referrals to social, financial, educational, occupational, or mental health resources may be appropriate.

Diagnostic Assessment

The diagnostic assessment should include a laboratory assessment, imaging, and other noninvasive diagnostic tests. The laboratory assessment may include blood studies and arterial blood gases. Arterial blood gases are the best way to determine adequate oxygenation in hospitalized or unstable clients. An initial evaluation of albumin may indicate concern for dehydration or malnutrition. Prealbumin provides a valid evaluation of protein–calorie malnutrition. The example laboratory profile in Table 13.2 shows normal ranges and possible reasons for abnormal ranges.

Table 13.2 Pulmonary Laboratory Assessment Indications of Nutritional Concerns (sources: Castro et al., 2022; Padilla & Abadie, 2022; Pagana & Pagana, 2018)

Test	Normal Ranges (SI Units)	Significance of Changes from Normal
Complete Blood Count
Red blood cells	4.2–5.9 × 10^12 cells/L	Elevated levels (polycythemia): excessive production of erythropoietin in response to a chronic hypoxic state Decreased levels: possible anemia, hemorrhage, or hemolysis
Hemoglobin, total	Females: 120–160g/dL (12–16 g/dL conventional units) Males: 140–170 g/dL (14–17 g/dL conventional units)	Same as for red blood cells Based on hemoglobin and hematocrit levels, follow-up labs may include serum ferritin, iron, folate, and B12
Hematocrit	Females: 37–47% (conventional units) Males: 41–51% (conventional units)	Same as for red blood cells Based on hemoglobin and hematocrit levels, follow-up labs may include serum ferritin, iron, folate, and B12
WBC count (leukocyte count, WBC count)	Total:4.5-11 × 10^9 cells/L)	Elevated levels: possible acute infection or inflammation Decreased levels: an overwhelming infection, an autoimmune disorder, or immunosuppressant therapy
Differential White Blood Cell (Leukocyte) Count
Neutrophils	2.6–8.5 × 10^9 cells/L	Elevated levels: possible acute bacterial infection (pneumonia), COPD, or inflammatory conditions (smoking) Decreased levels: possible viral disease (influenza)
Eosinophils	0–0.55 × 10^9 cells/L	Elevated levels: possible COPD, asthma, or allergies Decreased levels: pyogenic infections
Basophils	0–0.22 × 10^9 cells/L	Elevated levels: possible inflammation; seen in chronic sinusitis and hypersensitivity reactions Decreased levels: possible in an acute infection
Lymphocytes	0.77–4.5 × 10^9 cells/L	Elevated levels: possible viral infection, pertussis, and infectious mononucleosis Decreased levels: possible during corticosteroid therapy
Monocytes	0.14–1.3 × 10^9 cells/L	Elevated levels: See lymphocytes; also may indicate active tuberculosis Decreased levels: See lymphocytes
Albumin	35–54 g/L (3.5–5.4 g/dL conventional units)	Elevated levels: dehydration Decreased levels: chronic disease, malabsorption, malnutrition with low protein, or dilution by IV fluids Follow-up diagnostics: prealbumin, blood urea nitrogen, or zinc (deficiency increases risk for pneumonia [Keller, 2019])
Prealbumin	180–450 mg/L (18–45 mg/dL conventional units)	Elevated levels: chronic kidney disease, steroid use, or alcohol use disorder Decreased levels: malnutrition, liver disease, infection, or inflammation Follow-up diagnostics: nutritional assessment, hemoglobin, and anemia evaluation (iron, transferrin, folate, and vitamin B12)
Arterial Blood Gases
PaO2	75–100 mm Hg	Older adults: Values may be lower Elevated levels: possible excessive oxygen administration Decreased levels: possible COPD, asthma, chronic bronchitis, cancer of the bronchi and lungs, cystic fibrosis, respiratory distress syndrome, anemias, atelectasis, or any other cause of hypoxia
PaCO 2	35–45 mm Hg	Elevated levels: possible COPD, asthma, pneumonia, anesthesia effects, or use of opioids (respiratory acidosis) Decreased levels: hyperventilation/respiratory alkalosis
pH	7.35–7.45	Elevated levels: metabolic or respiratory alkalosis Decreased levels: metabolic or respiratory acidosis
HCO3	22–26 mEq/L	Elevated levels: possible respiratory acidosis as compensation for primary metabolic alkalosis Decreased levels: possible respiratory alkalosis as compensation for a primary metabolic acidosis
SpO2	95–100%	Older adults: Values may be slightly lower Decreased levels: possible impaired ability of hemoglobin to release oxygen to tissues

The imaging assessment should include a chest x-ray and possibly a computed tomography (CT) scan. Chest x-ray is used to evaluate and assess the lungs. The x-ray may detect pneumonia, atelectasis, pneumothorax, and a tumor. If further evaluation is needed, a CT can be ordered, used in cases where suspicious lesions or clots are thought to be present. The CT will verify these findings.

Pulse oximetry, capnography, and pulmonary function tests are noninvasive tests that provide information about gas exchange in the client (Wood, 2022). Pulse oximetry identifies hemoglobin saturation with oxygen; the range should be 95–100%. A range below 91% in a client with no chronic respiratory problems is an emergency. The capnography measures carbon dioxide, and the pulmonary function test assesses breathing problems and lung function; they are utilized in both diagnosis and management of COPD and asthma.

Analysis of Nutrition and the Pulmonary System

With a complete pulmonary assessment, the provider must note any abnormal cues and analyze these findings. The abnormal findings typically are related to nutritional requirements and deficits. Depending on the indications from the initial 24-hour food recall, follow-up or repeated assessments would assist in determining any repeated calorie excesses or deficits. A focus on types of food intake, portions, meal patterns, and knowledge of nutrient content provide the initial clues for the physical exam findings that may be present in clients with pulmonary conditions.

A cursory consideration of weight and BMI may not be the best indication of the nutritional status and overall health for a client. In fact, a low BMI is linked to increased mortality for COPD clients due to the physiologic consequences of diaphragmatic weakness, decreased lung function, and systemic inflammation (McDonald et al., 2019). Malnutrition may result in clients with COPD or other chronic diseases from their increased energy expenditures, causing fatigue, less activity, muscle loss, and poor appetite. Weight loss can worsen with each exacerbation (McDonald et al., 2019). Diminished muscle mass is a sign of exercise intolerance and sedentary lifestyle for clients with chronic pulmonary disease. Malnutrition is a negative factor in the prognosis of COPD.

Obesity is a well-established health factor, recognized by the World Health Organization (2023) as a leading public health issue, with estimates in the 2016 data that 41 million children under age 5 and 240 million children ages 5–19 are overweight or obese. These children typically remain overweight or obese in adulthood. Obesity is a factor for increased asthma risk through its role in inflammation and pulmonary overreaction to environmental triggers (Calcaterra et al., 2021). Obesity alters the mechanics of the pulmonary system, leading to dyspnea, wheezing, and airway hyperresponsiveness (Dixon & Peters, 2018). Excessive weight reduces pulmonary and chest wall compliance, contributing to increased work of breathing in adults and children, but the inflammatory immunomodulatory impact of high-fat, high-sugar, and low-nutrient “Western” diets is the predominant obesity impact in children with asthma (Calcaterra et al., 2021). These physiologic responses are exacerbated by the low activity levels that are a natural consequence of pulmonary symptoms.

Table 13.3 lists key nutritional physical exam findings in clients with chronic pulmonary conditions.

Table 13.3 Nutritional Physical Exam Findings in Clients with Chronic Pulmonary Conditions (sources: Esquivel, 2018; Gea et al., 2018; Rolo; Silvestri et al., 2022)

Physical Exam Finding	Effect
Generalized nutrient deficiency	Low BMI Obesity or central obesity
Protein energy malnutrition	Poor physical performance in activities Lack of muscle strength Dull/dry hair or hair loss Banding of nails Bilateral edema
Anemia	Fatigue Decreased activity/exercise tolerance Weakness Palpitations Irritability Headaches Paresthesia Sore tongue Brittle nails or spoon-shaped nails Pallor Pica (ice, starch, clay)
Dehydration	Dry skin and mucous membranes Poor turgor Sunken eyes Decreased urine output Change in neurologic status
Poor oxygenation	Muscle retractions Tripod breathing Clubbing of nails
Micronutrient deficiency	Dim-light vision (vitamin A) Glossitis or inflammation of the tongue (iron, zinc, or riboflavin) Poor tooth health Lack of muscle strength; falls or fractures (vitamin D, calcium, magnesium) Excessive bruising or bleeding (vitamin K) Dermatitis and diarrhea (niacin) Muscle cramps (vitamin C or magnesium)