Case Study 26: Chronic Obstructive Pulmonary Disease

Alice Hsiaoling Ko
Nutrition Assessment
Patient Name: Stella Bernhardt
Age: 62 y/o
UBW: 145-150 ≈148lb; 67.13kg
CW: 119lb; 54kg
Ht: 5 ft 3 in; 160cm; 63 in
% weight change:
current weight-usual weight/usual weight x 100
((119 – 148)/148) x 100
=19.5% unintentional weight loss
BMI:
(119lb/(63in)^2) x 703
= 21.1; normal
RMR:
Female: (10xkg) + (6.25xcm) - (5xage) – 161
(10 x 54kg) + (6.25 x 160cm) – (5 x 62yo) – 161
540 + 1000– 310 – 161
= 1069kcal
TEE:
RMR X IF x AF
Injury factor: 1.4; She needs to increase energy intake by ~140%
above RMR because of her systemic inflammation
Activity factor: 1.1; she is not confined to bed, but she is not going to
do much exercise since it uses too much energy.
1069kcal x 1.4 x 1.2
= 1646kcal
Protein Requirement:
1.4g/kg protein
1.4g x 54kg
= 75.6 ≈ 76kg protein

Interpretation of Diet hx:

Usual dietary Intake
 Low levels of calorie(994kcal), protein(46g), fiber(12g),
fat(15%), calcium, potassium, copper, magnesium, and all
vitamins. High levels of carbohydrate (70%)
24 hour recall
  Low levels of calorie (555kcal), protein (7g), fiber(3g),
fat(7%), all essential vitamins and minerals. High levels of
carbohydrate (93%)

Drug Interpretation:
Ipratropium bromide 2.5mg q 30 minutes x 3 treatments
= None
Albuterol sulfate 130mcg q 2hr -> beta-2 adrenergic bronchodilator
= Adverse effects such as tachycardia, palpitation, peripheral
vasodilation, blood and pressure changes. Risk of hypertention. Limit
salt intake and other preventatives for hypertension.
Ancef (cefazolin) 500mg q 6hr:
=Risk of hypertension due to 46mg of sodium per each grams of
cefazolin activity. Reduce sodium intake to avoid fluid retention.
Solumedrol (methylprednisolone) 10mg/kg q 6 hr
=Grapefruit juice may increase blood levels and effects of solumedrol.
Limit grapefruit juice and gradefruit consumption during treatment.
=corticosteroids may cause fluid retention, hypernatremia,
hypokalemia, and elevation in blood pressure. Restrict dietary sodium
and potassium intake.
= Risk for high cholesterol with continuous treatment

Vitamin Supplement Intake:

Lab Normal Results None
Level
Protein, total (g/dL) 6-8 5.8↓ Lab Interpretations:
Albumin (g/dL) 3.5-5 3.3↓
WBC (x103/mm3) 4.8-11.8 15↑
RBC(x106/mm3) F: 4.2-5.4 4↓
Hemoglobin (Hgb, F: 12-15 11.5↓
g/dL)
Hematocrit (Hct, F: 37-47 35↓
%)
Lymphocyte (%) 15-45 10↓
Segs (%) 0-60 83↑
pH 7.35-7.45 7.29↓
pCO2 (%) 35-45 50.9↑
SO2 (%) ≥95 92↓
O2 content (%) 15-22 12↓
Base deficit <3 3.6↑
(mEq/L)
HCO3- (mEq/L) 24-28 29.6↑
Low levels of protein and albumin due to inadequate protein and
calorie intake
High levels of WBC due to inflammation of bronchi and excess mucus
build up
Low levels of hemoglobin, RBC, and hematocrit due to inflammation
from chronic bronchitis
High levels of pCO2 and HCO3- due to hypercapnia from emphysema
Low levels of SO2 and O2 content due to difficulty in breathing from
chronic bronchitis

Med/Social hx/Physical Assessment:

s/p acute exacerbation of COPD, increasing dyspnea, hypercapnia, r/o
pneumonia; dx stage 1 COPD (emphysema) 5y/a; hx bronchitis and
upper respiratory infections; family hx mother and aunt died from lung
cancer; smoker 1 PPD, 46 years; c/o shortness of breath (SOB),
coughing up phlegm, fatigue, and early confusion; 1+ bilateral pitting
edema, decreased breath sounds, percussion hyperresonant,
prolonged expiration with wheezing, pale, and using accessory
muscles at rest;

ADIME

A.
62y/o female s/p exacerbation of COPD; dx stage 1 COPD (emphysema)
5y/a; hx bronchitis and upper respiratory infections; family hx mother
and aunt died from lung cancer; smoker 1 PPD, 46 years; c/o shortness
of breath (SOB), coughing up phlegm, fatigue, and early confusion
PA: 1+ bilateral pitting edema, decreased breath sounds, percussion
hyperresonant, prolonged expiration with wheezing, pale, and using
accessory muscles at rest
Ht: 5’3”; UBW: 148lb; CBW: 119lb; %wt loss: 19.5% in 5y; BMI: 21.1
normal; TEE: 1646kcal; EPR: 76gm/day.

Diet hx:
Inadequate calorie, protein, fiber and fat intake.
Low levels of nutrient dense foods intake, with only sips of orange
juice and excess amount of coffee and Pepsi throughout the day

Labs:
Lab Normal Results
Level
Protein, total (g/dL) 6-8 5.8↓
Albumin (g/dL) 3.5-5 3.3↓
WBC (x103/mm3) 4.8-11.8 15↑
RBC(x106/mm3) F: 4.2-5.4 4↓
Hemoglobin (Hgb, F: 12-15 11.5↓
g/dL)
Hematocrit (Hct, F: 37-47 35↓
%)
Lymphocyte (%) 15-45 10↓
Segs (%) 0-60 83↑
pH 7.35-7.45 7.29↓
pCO2 (%) 35-45 50.9↑
SO2 (%) ≥95 92↓
O2 content (%) 15-22 12↓
Base deficit <3 3.6↑
Low levels of protein
(mEq/L)
5.8(NL6-8), albumin
HCO3- (mEq/L) 24-28 29.6↑
3.3(NL3.5-5), RBC 4
(NL4.2-5.4), hematocrit 53(NL37-47), hemoglobin 11.5 (NL12-15)

Dx.
PES#1:
Self-Feeding Difficulty (NB-2.6) related to lack of energy as evidenced
by shortness of breath, need of assistance, and 19% unintentional
weight loss.

PES#2:
Inadequate Protein-Energy Intake (NI-5.3) related to food and nutrition-
related knowledge deficit as evidenced by self-reported general
dietary intake, 24-hour recall and low levels of total protein and
albumin.
I.
PES#1:
Provide recipes for calorie dense, easier to prepare foods to reduce
amount of energy needed to prepare and consume the food. Such
foods can include high protein and calorie smoothies, milk shakes, and
puddings. Consuming easy high calorie snacks such as ice cream,
cookies, cheese, granola bars, and peanut butter can help reduce
fatigue in preparing and consuming foods.

PES#2:
Providing appropriate nutrition education on appropriate COPD diet,
such as the low carbohydrate and high fat diet. Educate patient on
small frequent meals instead of consuming 3 meals a day. Having
small frequent meals with help with calorie increase because it will
allow her to finish her small portions without feeling fatigue.

M/E.
Monitor ABG levels to make sure COPD symptoms are controlled.
Evaluate BMI to ensure there is no additional weight loss.
Monitor patient dietary recall to ensure patient is reaching her dietary
protein and calorie goal, and make sure patient is following COPD
nutritional guidelines of low carbohydrate, high fat and high protein
diet.

Case Study Questions

1. Mrs. Bernhardt was diagnosed with stage 1 emphysema/COPD five

years ago. What criteria are used to classify this staging?

 Stage 0 (at risk)

o Normal spirometry chronic symptoms (cough,
sputum production)
  Stage I (mild COPD)
o FEV1/FVC <70%
o FEV1 > 80% predicted
o With or without chronic symptoms
 Stage II (moderate COPD)
o FEV1/FVC <70%
o FEV1 <80% predicted
o With or without chronic symptoms
 Stage III (severe COPD)
o FEV1/FVC <70%
o FEV1 <50% predicted
o With or without chronic symptoms
 Stage IV (very severe COPD)
o FEV1/FVC <70%
o FEV1 <30% predicted or
o FEV1 <50% predicted with symptoms of chronic
respiratory failure

2. COPD includes two distinct diagnoses. Outline the similarities and

differences between emphysema and chronic bronchitis.
 Chronic Bronchitis:
o Continuous exposure of cigarette smoke and other
pollutants that causes generalized inflammatory
responses. Decreases cilia functions, increased
phagocytosis, and suppressed amounts of
immunoglobulin A (IgA). The damaged cilia are unable
to clean mucus from the airways, causing shortness of
breath. Chronic inflammatory also results in edema of
the bronchioles, and the walls of the airways thicken
and mucus glands become hyperplastic. This affects
the inhalation and prevents the patient from getting
enough oxygen. Patients also often to be normal or
overweight. This may also increase hematocrit levels
due to the body’s auto-response to create more
vehicles for oxygen.
 Emphysema:
o Also a result of continuous exposure of cigarette
smoke. This sign of COPD develops gradually over the
years, and usually as a late complication of chronic
 bronchitis. The type 2 cells get damaged causing a
decreased secretion of surfactant in the alveoli. The
bronchioles then lose its elasticity causes it to
collapse during exhalation and traps air in the lungs.
This is different from chronic bronchitis because it
affects the alveoli and the actual lung tissues get
damaged. This affects the exhalation and causes
dyspnea and hypercapnia. This will result in normal
hematocrit values.

3. What risk factors does Mrs. Bernhardt have for this disease?
Some risk factors that Mrs. Bernhardt have for COPD includes her
history of 1 pack a day (PPD) smoking for 46 years, diagnosed with
stage 1 COPD five years ago, have a medical history of bronchitis
and upper respiratory infections, and family history of mother and
aunt died from lung cancer.
4. A. Identify symptoms described in the MD’s history and physical
that are consistent with Mrs. Bernhardt’s diagnosis. Then describe
the pathophysiology that may be responsible for each symptom.

Symptoms Etiology
Confusion in the Complications from bronchitis and
morning (hypercapnia) emphysema cause her to have excess
CO2 in the blood.
Shortness of Breath Damaged cilia due to bronchitis and
(dyspnea) damaged alveoli due to emphysema
restrict her airway. Destruction of
alveoli due to emphysema also restricts
her breathing
Fatigue Because there are not enough oxygen
circulating the patients body, patient
will feel tired
Coughing up phlegm Damage cilia unable to clean mucus
that is dark brownish from the airways, causing body to
green cough up the thickened mucus with
bacteria growth.
Anorexia Decreased energy from lack of oxygen
causes her to not have energy to eat.
Appetite changing due to early satiety
with “I fill up so quickly-after just a few
bites”
Early Satiety Since eating requires a lot of energy,
patient will get tired of eating and start
to feel full because they lose the energy
to finish the meal.
Dysgeusia Increased coughing also creates a
bitter taste causing her to lose
appetite.

b. Now identify at least four features of the physician’s physical

examination consistent with her admitting diagnosis. Describe
the pathophysiology that might be responsible for each physical
finding.
 Physical examination
1+ bilateral pitting edema
Prolonged expiration with
wheezing
Decreased breath sounds
Percussion hyperresonant
Using accessory muscles at
rest
Pathophysiology
Fluid retention due to blood
flow obstruction
Harder to exhale due to
decreasing alveoli causing air
to be trapped
Breath sounds decrease due
to destruction of alveoli
(breathing becomes not as
smooth).
Loud and low pitched sounds
due to hyperinflated lungs
with excess air due to unable
to exhale.
Because it’s harder to exhale,
it increases accessory muscle
use to assist expiration.

Reference

Percussion (n.d.). In RnCeus. Retrieved February 4, 2015, from

http://www.rnceus.com/resp/respperc.html

5. Mrs. Bernhardt’s medical record indicates previous pulmonary

1
function tests as follows: baseline FEV = 0.7 L, FVC= 1.5 L,
1
FEV /FVC 46%. Define FEV, FVC, and FEV/FVC, and indicate how
they are used in the diagnosis of COPD. How can these
measurements be used in treating COPD?
 FVC: forced vital capacity
o Amount of air in which can be forcibly exhaled from
the lungs after taking the deepest breath possible.
 FEV: forced expiratory volume in 1 second
o Amount of air in which can be forcibly exhaled from
the lungs in the first second of a forced exhalation)
 FEV/FVC:
o The percentage of FVC exhaled in the first second
o FEV/FVC should be around 80% for normal airflow,
when the ratio is below 70%, the person can be
diagnosed with COPD
  Mrs. Bernhardt has a FEV/FVC ratio of 46% and can be
diagnosed with COPD.
 These measurements can be used in treating COPD
because it gives an assessment of airflow obstruction that
can be used to determine the severity of COPD. You can
use the measurements to identify what stage the patient is
on and determine the appropriate treatment and
recommendations for medications.

Pulmonary Function Tests (n.d.). In Meded UCSD. Retrieved February 4,

2015, from https://meded.ucsd.edu/isp/1998/asthma/html/spirexp.html

6. Look at Mrs. Bernhardt’s arterial blood gas values from the day she
was admitted.

a. Why would arterial blood gases (ABGs) be drawn for this

patient?
Arterial blood gases determines the blood pH, oxygen
content, CO2 content, partial pressure O2(PaO2), partial
pressure CO2(PaCO2). ABG is drawn for the patient in order
to determine how much oxygen and carbon dioxide the
patient has in her body. Because she has both chronic
bronchitis and emphysema, it is important to know what
kind of treatment is needed, whether she needs more
oxygen or more carbon dioxide.

b. Define each of the following and interpret Mrs. Bernhardt’s

values:

 pH
o Acidity level of the blood. Too much oxygen in the
blood will cause the blood to be basic, while too
little oxygen will cause the blood to be acidic.
o Mrs. Bernhardt’s value was at 7.29↓ (NL 7.35-7.45)
when she first arrived, but went to 7.4 in 2 days.
Her blood pH level is stabilized due to oxygen
therapy.
 PCO2
o Partial pressure of carbon dioxide measures how
well CO2 moves out of blood into the airspaces of
 the lung, and then out with the exhaled air
o Mrs. Bernhardt’s value was 50.9↑ (NL 35-45) when
she first arrived, but went to 40.1 at recall. This
indicates the flow of CO2 out of the blood and
exhaled is normalizing and the oxygen therapy is
working.
 SO2
o Changes in SaO2 measures the amount of oxygen
carried by the red blood cells (RBC). In COPD, fewer
RBC carry the usual load of oxygen, thus oxygen
saturation is decreased.
o Mrs. Bernhardt’s value was at 92↓ (NL ≥ 95), but her
value was lower at 90.2 ↓ after the recall. Because
all of her other values are normal, this lack of
oxygen carried in the RBC can be because of her
increased activity and increase oxygen usage.
2,
 HCO3
o Bicarbonate acts as a buffer. This is measured in
conjunction with other blood gases. The ratio of
carbonic acid to bicarbonate helps keep the body
pH normal.
o Mrs. Bernhardt’s value was at 29.6↑(NL 24-28), but
her value went to normal at 24.7 after the recall.
This indicates a good ratio of carbonic acid and
bicarbonate in the blood.

c. Mrs. Bernhardt was placed on oxygen therapy. What lab

values tell you the therapy is working?
The lab results suggest that the therapy is working because
everything went to normal except the SO2 level. Her CO2
level also stabilized to normal from 31↑ to 29.8, indicating
that she is exhaling the appropriate amount of CO2.

7. Mrs. Bernhardt has quit smoking. Shouldn’t her condition now

improved? Explain.
Even though Mrs. Bernhardt quit smoking, she only quit for one year
and she was a 1 PPD smoker for 46 years. The effects on her lungs
and respiratory system from her long time smoking are irreversible.
Because smoking is the primary risk factor for COPD, even after
 cessation of smoking, the inflammatory stress continues to damage
the lung tissues. The damage on the lung tissue caused irreversible
structural changes to the lungs and can ultimately decrease lung
function. (Barnett et al) However, with the cession of smoking, the
rate of decline in lung function and disease progression can be
reduced. (Fletcher et al)

- Barnett, M. (2008). COPD: Smoking cessation. Journal of Community Nursing,

22(11), 36.
- Fletcher, C.M., Petro, R. (1977) The natural history of chronic flow obstruction'.
British Medical Journal. 1:1645-1648.

8. What is a respiratory quotient? How is this figure related to

nutritional intake and respiratory status?
Respiratory quotient is the ratio of CO2 produced to O2 consumed.
Having a COPD patient receive proper nutrition can help reduce the
amount of CO2 produced and thus improving breathing. It is
important to know the percentage of total carbohydrate, fat, and
protein that a patient consumes to see how it impacts their
respiratory quotient. (RQ) The nutritional intake influences the RQ
because the metabolisms of macronutrients convert them into CO2
and water in the presence of O2. Different macronutrient produces
different RQ. Carbohydrate is a macronutrient that produces the
most CO2, while eating fat produces the least CO2. This relates to
nutritional intake because having a high fat, low carbohydrate diet
would reduce the RQ level and CO2 production. A patient with
dyspnea or hypercapnia would benefit from a high fat and protein
diet.

Florian, Ilaria S. "Nutrition and COPD - Dietary Considerations for Better

Breathing." Today's Dietitian: The Magazine for Nutrition Professionals 11.2
(2009): 54. Web. 4 Feb. 2015.

Understanding Nutrition Therapy

9. What are the most common nutritional concerns for someone with
COPD? Why is the patient diagnosed with COPD at higher risk for
malnutrition?
The most common nutritional concerns include anorexia, early
 satiety, dyspnea, bloating, and fatigue. A patient diagnosed with
COPD is at a higher risk for malnutrition because they may
experience shortness of breath and fatigue while trying to eat, thus
causes a loss of appetite. Malnutrition can happen because of
weaken respiratory muscles, resulting in altered ventilation, poor
muscle strength, and impaired immune function. Patient with may
only eat for a little bit at a time, thus providing a high calorie diet is
important.

10. Is there specific nutrition therapy prescribed for these patients?

There is no specific nutrition therapy for COPD patients. However,
there are guidelines that can be followed for such patients. Patient
may have a major increase in REE of up to 10-15% because of an
increase in the energy cost of breathing. In addition, certain
medications used to treat COPD may have thermo-genic effect on
the patient. This is why maintaining energy balance to preserve
body weight and lean body mass is every important. Some
guidelines are:
 Providing a high fiber of 20-35 grams diet to help move food
along the digestive tract, and reduce the level of
cholesterol in the blood
 Drink plenty of non-caffeinated fluid to help keep the mucus
thin and easier to cough up
 Low sodium diet to prevent fluid retention, causing
breathing to be more difficult.
 High calcium and vitamin D diet to prevent osteoporosis
caused by the side effects of glucocorticoid
 Avoid gas or bloating inducing foods because having a full
stomach or a bloated abdomen might make breathing
uncomfortable. Some foods that causes bloating or gas are:
o Carbonated beverages
o Fried, greasy or heavily spiced foods
o Apples, avocados, and melons
o Beans, broccoli, Brussels sprouts, cabbage,
cauliflower, corn, cucumbers, leeks, lentils, onions,
peas, peppers, pimentos, radishes, scallions,
shallots, and soybeans.

Nutrition Guidelines for People with COPD (n.d.). In Cleveland Clinic.

Retrieved February 4, 2015, from
http://my.clevelandclinic.org/health/diseases_conditions/hic_Understand
 ing_COPD/hic_Coping_with_COP

Nutrition Assessment

11. Calculate Mrs. Bernhardt’s % UBW and BMI. Does either of these
values indicate she is at nutritional risk? How would her 1+
bilateral pitting edema affect evaluation of her weight?
UBW: 148lb; 67.13kg
CW: 119lb; 54kg
%UBW: (current weight/usual weight) x 100
(119lbs/148lbs) x 100
= 80.4%
BMI:
(119lb/(62in)^2) x 703
= 21.1; normal
The value that indicates she is at nutritional risk is her current
body weight of 119lbs and the %UBW. The BMI is normal and the
%UBW is at moderate depletion. Mrs. Bernhardt’s 1+ bilateral
pitting edema can affect the evaluation of her weight because
there is excess water weight from the edema that included in her
current body weight. There could be an overestimate of her BMI
and %UBW.

12. Calculate arm muscle area using the anthropometric data for
mid-arm muscle circumference (MAC) and triceps skinfold (TSF).
How would this data be interpreted?
AMA= [MAC – (π x TSF)]2 /4π) – 6.5
AMA = [MAC – (3.14 x TSF)]2 /12.56)
AMA= [19.05cm – (3.14 x 1.5cm )]2 /12.56)
AMA= [19.05cm – (4.71 )]2 /12.56)
AMA= 16.4cm2
Mrs. Bernhardt is between the >15th but ≤ 85th percentile, which is
in the average category. This could mean that her estimate energy
reserves, both fat and somatic protein is within the normal ranges.

Percentile Category
≤ 5th Wasted
>5th but ≤ 15th Below average
>15th but ≤ 85th Average
>85th but ≤95th Above average
 >95th High muscle

13. Calculate Mrs. Bernhardt’s energy and protein requirements.

What activity and stress factors would you use? What is your
rationale?
Total Energy Requirement:
RMR X IF x AF
Injury factor: 1.4; She needs to increase energy intake by ~140%
above RMR because of her systemic inflammation
Activity factor: 1.1; she is not confined to bed, but she is not
going to do much exercise since it uses too much energy.
1069kcal x 1.4 x 1.1
= 1646kcal
Protein Requirements:
1.4g/kg protein
I put Mrs. Bernhardt at 1.4kg because COPD patients requires a
high protein need in order to maintain their muscle mass. Mrs.
Bernhardt is at stage 1 of COPD, but experienced 19.5%
unintentional weight loss. It is important for her to be on a high
protein diet to prevent further unwanted weight loss.
1.4g x 54kg
= 75.6 ≈ 76g protein/day

14. Using Mrs. Bernhardt’s nutrition history and 24-hour recall as a

reference, does she have an adequate oral intake? Explain.
Usual dietary intake
Based on her usual dietary intake, it was estimated that Mrs.
Bernhardt only consumed 994 calories total. However, within this
report, she admits that she eats very small amounts of even her
largest meal of the day containing with only meat, vegetables, and
rice potato or pasta. Mrs. Bernhardt obtained 400 of her calorie
intake from Pepsi, which she usually drank 3 cans a day. A large
part of her diet is from empty calories. She is not consuming
enough nutrients for the amount of energy expended.
 24-hr recall
After the 24-hour recall, her dietary intake is even less than what
she usually ate. She did not consume any solid foods besides the
oatmeal and the chicken noodle soup. Most of her diet consisted of
fluids. She also had coffee, which is not recommended for COPD
patients. She is not receiving an adequate diet for her current
condition. She is only consuming 555kcal out of the target calorie
of 1796. She is also only consuming 7grams of protein where her
target protein intake is 75.6grams. Her carbohydrate levels are
also too high for a COPD diet since carbohydrate produces more
carbon dioxides in the body. Patient needs to increase caloric
intake with a high protein and fat diet. According to the nutrients
report:
 Total calories: 555kcal
 Protein: 7g
 Carbohydrate: 128g
 Dietary Fiber: 3 g
 Total Fat: 7% calories
15. Evaluate Mrs. Bernhardt’s laboratory values. Identify those that
are abnormal. Which of these may be used to assess her nutritional
status?
Lab Result Normal Level
s
Protein, total (g/dL) 5.8↓ 6-8
Albumin (g/dL) 3.3↓ 3.5-5
WBC (x103/mm3) 15 ↑ 4.8-11.8
RBC(x106/mm3) 4↓ F: 4.2-5.4
Hemoglobin (Hgb, 11.5 ↓ F: 12-15
g/dL)
Hematocrit (Hct, %) 35↓ F: 37-47
Lymphocyte (%) 10↓ 15-45
Segs (%) 83↑ 0-60
pH 7.29↓ 7.35-7.45
pCO2 (%) 50.9↑ 35-45
SO2 (%) 92↓ ≥95
O2 content (%) 12↓ 15-22
Base deficit (mEq/L) 3.6↑ <3
Some HCO3- (mEq/L) 29.6↑ 24-28 values that
can be used to assess her nutritional status include the protein,
 albumin, and hematology values, such as RBC, hemoglobin, and
hematocrit. Her total RBC and hemoglobin count is low could be
because possible inadequate iron intake. Her arterial blood gases
(ABGs) could also be used to assess the nutritional status. The
ABGs can be used to determine what kind of food is needed to
minimize RQ levels. She also has a total protein and albumin
deficiency that can be caused by her lack of protein consumption
due to difficulty in eating.

16. Why may Mrs. Bernhardt be at risk for anemia? Do her laboratory
values indicate that she is anemic?
Anemia is frequently found in COPD patients, and this could be
related to the presence of systemic inflammation. (Parveen et al)
The increased level of inflammatory cytokines from COPD
ultimately leads to a shortened RBC survival and a demand for
increasing RBC production. (Hoernig et al) The excess level of
some inflammatory cytokines also inhibits the production and the
effect of erythropoietin and iron in the bone marrow. This is
because of the erythropoietin resistance due to the impaired
ability of RBC progenitors to respond to erythropoiethin. In a study
conducted by Kollert et al, they confirmed the high prevalence of
anemia of 14.9% and it’s association with reduced survival of
COPD. If anemia does occur in patients with COPD, it could
worsens their dyspnea and also limit their exercise tolerance. Mrs.
Bernhardt is at risk for anemia and her low levels of RBC at 4
(NL4.2-5.4), hemoglobin at 11.5 (NL12-15), and hematocrit at 35
(NL37-47). Because Mrs. Bernhardt has stage 1 COPD and her lab
values are low, she is at risk for anemia.

Parveen, S., Rangreze, I., Ahmad, S. N., Mufti, S. A., & Khan, S. S. (2014).
Prevalence of anemia in patients with COPD and its potential impact on
morbidity of COPD patients. International Journal of Clinical Medicine, 5(8), 452-
458.

Kollert, F., Tippelt, A., Müller, C., Jörres, R. A., Porzelius, C., Pfeifer, M., &
Budweiser, S. (2013). Hemoglobin levels above anemia thresholds are maximally
predictive for long-term survival in COPD with chronic respiratory failure.
Respiratory Care, 58(7), 1204.

John, M., Hoernig, S., Doehner, W., Okonko, D. D., Witt, C., & Anker, S. D. (2005).
Anemia and inflammation in COPD. Chest, 127(3), 825-829.
 17. What factors can you identify from her nutrition interview that
probably contribute to her difficulty in eating?
One of the factors that contribute to her difficulty in eating is
fatigue due to meal preparation. It is also noted that she drinks
more than she eats. Mrs. Bernhardt consumes coffee, sips of
orange juice, chicken noodle soup, and Pepsi. Her usual intake also
consists of very little amount of solid foods, consisting of only
oatmeal, meat, vegetables and rice, are all in extremely small
portions. This indicates that she gets fatigue while eating and it is
less energy consuming to take in fluid. She also complains of bitter
taste of her food due to constant coughing up of phlegm. Another
factor is that she avoids milk, because she thinks it increases
mucus production. This will make it difficult for her to get enough
calcium, protein and fat in her diet.

Nutrition Diagnosis
18. Select two high-priority nutrition problems and complete the PES
statement for each.

 Self-Feeding Difficulty (NB-2.6) related to lack of energy as

evidenced by shortness of breath, need of assistance, and 19.5%
unintentional weight loss.

 Inadequate Protein-Energy Intake (NI-5.3) related to food and

nutrition-related knowledge deficit as evidenced by self-reported
general dietary intake, 24-hour recall and low levels of total
protein and albumin.

Nutrition Intervention

19. What is the current recommendation on the appropriate mix of

calories from carbohydrate, protein, and lipid for this patient?
The current recommendation from the commercial enteral formulas
contains a low carbohydrate content of 30% and high lipid content
of 50%. The protein intake should be 1.2-1.7grams/kg/body weight
(20%) to avoid muscle losses. Consuming too much carbohydrate is
harmful to patients with COPD because of increase CO2 production
during metabolism. Because of this, the recommended
carbohydrate levels should be 30%. Fat metabolism produces the
 least CO2, thus requiring a higher fat content of 50%.

20. For each of the PES statements you have written, establish an
ideal goal (based on the signs and symptoms) and an appropriate
intervention (based on the etiology).
 Self-Feeding Difficulty (NB-2.6) related to lack of energy as
evidenced by shortness of breath, need of assistance, and
20lb weight loss in the past year.
o Provide recipes for calorie dense, easier to prepare
foods to reduce amount of energy needed to prepare
and consume the food. Such foods can include high
protein and calorie smoothies, milk shakes, and
puddings. Consuming easy high calorie snacks such
as cheese, granola bars, pudding, popcorn, and peanut
butter can help reduce fatigue in preparing and
consuming foods.

 Inadequate Protein-Energy Intake (NI-5.3) related to food

and nutrition-related knowledge deficit as evidenced by
self-reported general dietary intake, 24-hour recall and low
levels of total protein and albumin.
o Providing appropriate nutrition education on
appropriate COPD diet, such as the low carbohydrate
and high fat diet. Educate patient on small frequent
meals instead of consuming 3 meals a day. Having
small frequent meals with help with calorie increase
because it will allow her to finish her small portions
without feeling fatigue.

21. What goals might you set for Mrs. Bernhardt as she is
discharged and beginning pulmonary rehabilitation?
Some goals that I would set would be increase total calorie intake.
Decrease carbohydrate intake and increase fat and protein intake.
Another goal would be to eat healthy high calorie and high protein
snacks and limit empty calorie snacks such as potato chips, candy
bars, and soda. Mrs. Bernhardt consumes 3 cans of Pepsi a day,
and this unwanted carbohydrate would worsen her COPD condition.
Consume more non-caffeinated fluid to help thin the mucus Mrs.
Bernhardt has been coughing up.
 Nutrition Monitoring and Evaluation

22. You are now seeing Mrs. Bernhardt at her second visit to
pulmonary rehabilitation. She provides you with the following
information from her food record. Her weight is now 116 lbs. She
explains adjustment to her medications and oxygen at home has
been difficult, so she hasn’t felt like eating very much. When you
talk with her, you find she is hungriest in the morning, and often by
evening she is too tired to eat. She is having no specific
intolerances, but she does tell you she hasn’t consumed any milk
products because she thought they would cause more sputum to
be produced.

Monday

Breakfast: Coffee, 1 c with 2 tbsp nondairy creamer; orange 1⁄2 c;

1 poached egg; 1⁄2 slice toast

Lunch: 1⁄4 tuna salad sandwich (3 tbsp tuna salad on 1 slice

wheat bread); coffee, 1 c with 2 tbsp nondairy creamer

Supper: Cream of tomato soup, 1 c; 1⁄2 slice toast; 1⁄2 banana;

Pepsi—approx 36 oz

Tuesday

Breakfast: Coffee, 1 c with 2 tbsp nondairy creamer; orange

juice, 1⁄2 c; 1⁄2 c oatmeal with 2 tbsp brown sugar

Lunch: 1 chicken leg from Kentucky Fried Chicken; 1⁄2 c mashed

potatoes; 2 tbsp gravy; coffee, 1 c with 2 tbsp nondairy creamer

Supper: Cheese, 2 oz; 8 saltine crackers; 1 can V8 juice (6 oz);

Pepsi, approx 36 oz

a. Is she meeting her calorie and protein goals?

No, she is not meeting her calorie and protein goals.
On Monday, she only consumed 1055 calories, with 76%
from carbohydrate (Pepsi). Her protein consumption was
only 29 grams with the goal of 76grams.
 On Tuesday, there was a slight increase in calorie intake
from the KFC chicken leg and the mashed potatoes. But
overall, she is not consuming an adequate amount of
protein and calories.

b. What would you tell her regarding the use of supplements

and/or milk and sputum production?
It is common to think that milk causes the body to produce
more mucus. Milk does not cause the body to produce more
mucus, but instead it thickens the phlegm. Having thicker
mucus makes it harder for the damaged cilia to remove,
thus making it harder to cough up. This may cause the
patient to cough even more excessively. However, milk
plays an important part in a balanced diet because it is a
good source of calcium and vitamin D. There are ways to
thin the mucus to make it easier to remove, such as
drinking more water or club soda because the carbonation
can help loosen the mucus. Drink low-fat milk and dairy
product or consuming ice cream while drinking water or
club soda is a good way to increase consumption of milk
products. I would also recommend taking a multivitamin to
make up for nutrients that is lacking from her daily diet.
Another recommendation is adding medical food
supplement such as protein powder as an addition to the
regular diet can help increase calorie and protein intake per
meal.

Milk Products an Mucous in COPD (2012, March 21). In COPD

Foundation. Retrieved February 6, 2015, from
http://blog.copdfoundation.org/milk-products-and-mucous-in-copd/

c. Using information from her food diary as a teaching tool,

identify three interventions you would propose for Mrs.
Bernhardt to increase her calorie and protein intakes.
 Limit empty calorie intake such as Pepsi and coffee,
and substitute with club soda and decaffeinated
coffee.
 Eat small frequent easy prepared high calorie and high
 protein foods and snakes to maximize calorie intake.
 Because she is the hungriest in the morning, make
this the biggest meal of the day. Preparing high
calorie and high protein shakes or smoothies.

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