13.1 Assess and Analyze the Impact of Nutrition on the Pulmonary System

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).

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. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

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 and 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)

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.

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)

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.

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.