NCP Copd PBL Clinic SMST 5 MM 2014

NCP FOR COPD PATIENT
Mira Mutiyani
PSIG 2014
MNT for Lung Disorder
NCP for COPD Patient/PBL Clinic/MM/2014
10/23/14
CD 33. Design and implement

nutrition care plans as indicated
by the patient`s/client`s health
status (perform)
Implementation of NCP for COPD Patient

Scenario Smoking or Caffeine
10/23/14
Gambaran umum dari COPD (definisi,

epidemiologi, patofisiologi, etiologi, sign and
symptoms, serta manifestasi klinis?
Kuliah pakar oleh dr. TRIWAHJU ASTUTI, M.Kes., Sp.P

LAB. PULMUNOLOGI & ILMU KEDOKTERAN RESPIRASI FKUB
10/23/14
The Pulmonary System
Upper
respiratory
track
The nose
Pharynx
Larynx
The
respiratory Trachea
system
Bronchi
include:
Bronchioles
Alveolar ducts
Alveoli
Lower
respiratory
track
Krauses, 2012
10/23/14
The Pulmonary System

u
Normal lung anatomy
Selected airways disorders
10/23/14
Gas Exchange
Major function of the

pulmonary system
Obtain O2 to meets its
cellular metabolic
demands
Remove CO2 produced
Krauses, 2012
10/23/14
Other functions
u
Regulate the bodys acid-base balance
Synthetize arachidonic acid prostaglandins or leukotrients

(possible cause of bronchoconstriction in asthma
The alveolar cells secrete surfanctant, a compund synthetized

from proteins and phospolipids that serves the stability of
pulmonary tissue by reducing the surface tension of fluids
that coat the lung.
Part of the bodys immune defense system
Mucus
Cilia
Macrophages : Phagocytosis
10/23/14
Pulmonary System Disorder
Lung disorder
Primer
TB
Bronchial
asthma
Secondary
Lung
cancer
Associated
with CVD
Obesity
Acute
HIV
Pneumonia
Chronic
COPD
Cystic
fibrosis
(CF)
Lung
cancer
10/23/14
10
Pulmonary condition with nutrition implications
Neonate
Broncho pulmonary
dysplasia (BPD)
Respiratory Failure
Acute respiratory failure
Lung transplantation
Obstruction
Cystic fibrosis (CF)
Chronic obstructive
pulmonary disease
(COPD): Emphysema,
Chronic bronchitis, Asthma
Neuro-muscular
Abnormalities
Tumor
Lung cancer
Cardiovascular
Pulmonary edema
Infection
Pneumonia
Tuberculosis (TB)
Endocrine
Severe obesity
Muscular dystrophy
Paralysis
10/23/14
11
Pulmonary diseases
Sign and symptoms

Cough
Early
satiety
Anorexia
Weight
loss
Dyspnea
(shortness
of breath)
Fatigue
10/23/14
12
Pulmonary function test

u
Pulse Oximetry
Monitor a persons blood level
Uses the light waves to measure

the 02 saturation of arterial blood
Normal: 95% to 99% (young,

healthy)
Spirometry
Information on lung volume and

the rate at which air can be
inhaled and exhaled
10/23/14
Chronic Obstructive Pulmonary

Disease (COPD)
13
Characterized by airway obstruction
Type 1: Emphysema : abnormal, permanent

enlargement of alveoli, accompanied by destruction
of their walls without obvious fibrosis
Type 2: Chronic bronchitis: chronic, productive

cough with inflammation of one or more of the
bronchi and secondary changes in lung tissue
Bronchospasm: asthma
Etiology
Tobacco smoking
Continual contact second-hand smoke
Environmental pollution: cooking a confined,

unventilated space
10/23/14
14
Characteristics COPD
Emphysema
u
Patients are thin, often cachectic;

older, mild hypoxia, normal
hematocrits; Cor Pulmonale (heart
condition characterized by right
ventricular enlargement and failure
that results from resistance to
passage of blood through the lungs)
develops later.
Chronic bronchitis
Patients are normal weight; often
overweight; hypoxia; high hematocrit;
cor pulmonale develops early.
10/23/14
15
Emphysema
Chronic bronchitis
10/23/14
16
Treatments for COPD

u
Bronchodilatorstheophylline and aminophylline
Antibioticssecondary infections
Respiratory therapy
Exercise to strengthen muscles
10/23/14
17
NCP for COPD Patients

STEPS OF NCP
Nutrition
Assessment
Nutrition
Diagnosis
Nutrition
Intervention
Nutrition
Monitoring and
Evaluation
10/23/14
Bagaimana interpretasi dari hasil

assessment antropometri, biokimia,
fisik klinis, dietary history, client
history, dan data pendukung
lainnya?
19
Anthropometric Measurements
u
Tinggi Lutut (TL) = 54 cm

= 64.19 + (2.02 TL) (0.04 U) *
= 64.19 + (2.02 x 54) (0.04 x 68 thn)
= 170.55 cm
Lingkar Lengan Atas (LLA) = 27 cm

% deviasi dari standar
= LLA aktual x 100%
Nilai standar
= 27 x 100%
33.0 (laki-laki usia 60-69 thn)*
*Chumlea W, Roche A, 1988, J Am Geriatric Soc
= 81.8% status gizi kurang (60 90%

standar)**
Increased morbidity and mortality (3rd cause of death in
2020 in US)
*NHANES III, 1998-1994
** Kriteria SG berdasarkan LLA/U
10/23/14
20
3rd cause of death worldwide in 2020
Underweight in COPD patient
Mortality
(22 studies consist of 21.150 participants). Body mass index and mortality
in COPD: A Meta-Analysis (Chao Cao, et al, 2012. Plos One)
10/23/14
Biochemical Data, Medical Test, and

Procedure
Albumin: 2.9 g/dL (3.5 5.5 g/dL)
21
: Hipoalbuminemia
HGB: 11.4 g/dl (N: 13.4-17.7)
: Anemia
RBC: 4.82 106/UL (N: 45.5)

WBC: 10.15 103/UL (N: 4.3-10.3)
Hematocrit: 33.90% (N: 40-47)
Thrombocit: 475 103/UL (N: 142-424)
: Infeksi
MCV: 70.30 FL (N: 80-93)
: Anemia
MCH: 23.00 pg (N: 27-31)
: Anemia
MCHC: 32.70 g/dL (N: 32-36)

RDW: 15.20% (N: 11.5-14.5)
: Anemia Fe
10/23/14
22
Analisa Gas Darah

u
PH: 7.28 (N: 7.25-7.45)
PCO2 / PO2 (4 Maret 2014)
PCO2: 57.4 mmHg (N: 3545)
= 57.4 mmHg / 113.2 mmHg
= 0.51 Metabolic fuel : Ketone

bodies (0.66) (hypo caloric) why?
PCO2 / PO2 (5 Maret 2014)
= 64.5 mmHg / 60.7 mmHg
= 1.06
PO2: 113.2 mmHg (N: 80-100)
HCO3: 27.3 mmol (N: 2128)
Saturasi O2: 97.3% (N: >95%)
Metabolic fuel : CHO
10/23/14
Apa definisi dari RQ

(respiratory quotient?
24
Respiratory Quotient (RQ)

When oxygen consumption and
carbon dioxide production are
measured.
The RQ indicates the fuel mixture

being metabolized
RQ = 2 /
CHO : amout of CO2 produced and O2

consumed same
CHO: C6H1206 + 6O2 6CO2 + 6H2O
Fat : more oxygen required for oxidation
(-CH2-units)
-CH2 + 11/2O2 CO2 + H2O
Protein: The amount of protein being

oxidized can be determine separately by
measuring the excretion of urea (the end
product of amino acids metabolism.
10/23/14
25
Apakah zat gizi (CHO, protein, lemak)

akan mempengaruhi RQ dan bagaimana
perbandingan RQ dari masing-masing zat
gizi (CHO, Protein, Fat)?
10/23/14
Oxygen consumption and CO2 production in

oxidation of metabolic fuels
26
David A. Bender, 2008

10/23/14
27
Respiratory Quotient (RQ) cont...

u
Measurement of RQ and urinary excretion of urea: permit

calculating the relative amounts of CHO, fat, and protein
In the fasting state, when a relatively large amount of fat being

used as a fuel The RQ: 0.8-0.85
After meal, when there is more CHO available to be metabolized

the RQ: 0.9-1.0
If a significant amount of lipid being syntesized from CHO The

RQ > 1.0
10/23/14
28
10/23/14
Metabolic
fuels in the fed
states
29
The Fed State

u
During 34 h after a meal, there is an enough supply of metabolic fuel entering

the circulation from the gut.
Glucose from carbohydrate digestion and amino acids from protein digestion
are absorbed into the portal circulation, and to a considerable extent the liver
controls the amounts that enter the peripheral circulation.
By contrast, the products of fat digestion are absorbed into the lymphatic
system as chylomicrons and are available to peripheral tissues first; the liver
clears chylomicron remnants.
Much of the triacylglycerol in chylomicrons goes directly to adipose tissue for

storage; when there is a plentiful supply of glucose, it is the main metabolic fuel
for most tissues.
10/23/14
30
10/23/14
Metabolic
fuels in the
fasting states
31
The Fasting State

u
In the fasting or post absorptive state (beginning about 45 h after a meal,

when the products of digestion have been absorbed), metabolic fuels enter
the circulation from the reserves of glycogen, triacylglycerol, and protein laid
down in the fed state
Muscle and other tissues can utilize fatty acids as a metabolic fuel, but only to
a limited extent, and not enough to meet energy requirements completely.
By contrast, the liver has a greater capacity for the oxidation of fatty acids
than is required to meet its own energy needs. Therefore, in the fasting state
the liver synthesizes ketone bodies (acetoacetate and -hydroxybutyrate),
which it exports to other tissues for use as a metabolic fuel.
10/23/14
The Result Of These Metabolic Changes
33
Nutrition
Intervention
Nutrition Diagnosis
Nutrition
Monev
Critical Link
Nutrition intervention targeted to address Etiology or Sign and

symptoms
Nutrition
Diagnosis
10/23/14
Nutrition
Assessment
34
Nutrition Diagnosis (PES) Set Priority

u
Inadequate energy intake due to decreased ability to consume

sufficient energy, as evidence by underweight (A), Albumin , Hb ,
MCV , MCH , RDW (B), goes down position (C), Estimated
energy intake from diet less than need (890 kcal) (D), appetite loss,
dyspnea, coughing.
Malnutrition due to increased energy expenditure (REE), as evidence
by underweight, albumin , Estimated energy intake from diet less
than need (890 kcal)
Decreased nutrient needs (CHO), due to respiratory impaired (COPD),
as evidence by dyspnea, coughing.
10/23/14
35
Nutrition Intervention (GOAL)

Ideal nutrition needs for formation, development,
growth, maturity, and protection of healthy lungs and
associated processes throughout life.
Optimal pulmonary system enables the body to

obtain the oxygen needed to meet its celular demans
for energy from macronutrients, and to remove
metabolic byproducts.
10/23/14
36
Effect Malnutrition on the Pulmonary System

Affects: lung structure, elasticity, and function;
respiratory muscle mass, strengths, and endurance; lung
immune defense mechanism; and control of breathing.
Example:
Protein and iron deficiency low hemoglobin levels which
diminish the O2-carrying capacity of the blood.
Hypoproteinemia pulmonary edema, by decreasing colloid
osmotic pressure body fluids to move to interstitial space.
10/23/14
37
Adverse effect of Lung Disease on Nutrition Status
Krauses, 2012
10/23/14
38
MNT for COPD Assessment

u
Fluid balance and requirements
Food drug interactions
Energy needs, both energy intake

and energy expenditure
Fatigue
Anorexia
Difficulty chewing/swallowing
because of dyspnea
Impaired peristalsis secondary to

lack of oxygen to the GI tract
Underweight patients have the

highest morbidity/mortality
Food intake (decreased intake

common)
Morning headache and confusion

from hypercapnia (excessive CO2 in
the blood) food preparation and
intake
Fat free mass
10/23/14
39
Nutrition Intervention (Goal)

u Maintaining
optimal energy
balance in order to
preserve body weight
(adequate nutritional
status), lean body mass,
and general well being.
10/23/14
40
Measure Energy Expenditure

u
u
u
u
u
Can be determined from the rate of

consumption of oxygen (indirect
calorimeter).
Using spirometer : portable
Output or expenditure of approximately
20 kJ for each liter of oxygen
consumed, regardless of whether the
fuel being metabolized is carbohydrate,
fat, or protein
1 kj = 0.24 kcal 20 x 0.24 = 4.8 kcal
1 kcal = 4.2 kj 4.8 kcal x 4.2 = 20.16
10/23/14
Direct calorimetry (DC)
Energy/Basic Nutrition/MM/PS Ilmu Gizi
41
Directly measuring heat from the body
Requires a thermally insulated chamber

temperature can be controlled possible to
measure the amount of heat produce
No information on the kind of fuel being

oxidized
Not reprensentatif of free living (normal daily

activities) limited
Expensive equipment, scarcity uses around the

world
23 October
2014
Indirect calorimetry (IC)
42
Energy expenditure determines from the rate

of consumption of oxigen.
Measurementof both O2 consumption and

CO2 production at the same times provides
information of metabolic fuels being
metabolized
More common in used
An output or expenditure from each O2

consumed: (20 kJ) depend on the fuel
being metabolized (CHO, fat, protein)
23 October
2014
Spirometer (IC)
43
Quite simpe in used
Portable: can carry on more or less

normal activities for several hours at a
time to estimate energy expenditure
23 October
2014
Doubly Labeled Water

u
The gold standard for energy requirements

and energy balance
Principle: CO2 production can be

estimated from the difference elimination
rates of body H dan O2
Giving oral dose of water labeled with

deuterium oxide (2H20) and oxygen-18
(H218O) 2H20 is eliminated from the body,
and H218O is eliminated as as water and
CO2.
The elimination: 10-14 day.
The difference between two elimination

rates is a measure of CO2 production.
CO2 production then be equated to TEE

using standard IC to calculate energy
expenditure
44
23 October
2014
45
Principle
High calorie 125% to 156% (average 140%) above BMR

Had higher REE (energy expenditure) due to increased
work of breathing, greater respiratory muscle effort
Account for under nutrition
10/23/14
46
Resting Energy Expenditure (REE) or Resting Metabolic
Rate (RMR)
u
The energy expended in the activities necessary to sustain normal body

function and homeostasis.
Include respiration and circulation, the syntesis of organic compound, and the
pumping of ions across membran.
It includes energy required for CNS and maintanance of body temperature.
For practical reason: BEE now rarely measured REE (most cases higher than
BEE by 10-20%)
23 October
2014
47
Percentage of resting energy expenditure by different organ
u
u
The heart beats: circulate the

blood; respiration continues
The brain: involved in
transporting sodium and
potassium ions across nerve
membranes, against their
concentration gradient, to
maintain electrical activity.
Adipose tissue: reserve of fat
and CHO

23 October
2014
REE and CHO oxidation are higher in elderly

patients with COPD: a case control study
48
Bruna et al. 2012. Nutrition Journal

10/23/14
49
Higher REE
The greater energy expenditure of individuals with COPD
- Due to increased respiratory muscle effort and inflammatory mediators

- the effects of medication (oral or systemic corticosteroids, theophylline,
hormones, benzodiazepines and antipsychotics)
10/23/14
50
Higher CHO oxidation

Increased carbohydrate oxidation in the COPD group
Caused by increased anaerobic metabolism due to reduced ability to capture

oxygen.
When carbohydrates are oxidized in the absence of oxygen, only 2 ATP molecules
per milli mol of carbohydrates are generated, while the presence of oxygen
increases ATP/milli mol generation to 36 ATPs.
Hence, individuals with COPD need to oxidize greater amounts of carbohydrates
than healthy individuals to generate similar amounts of ATP molecules, because
COPD patients present a higher ATP cost
10/23/14
51
Principle
Low-carbohydrate diet (30%) high fat diet (50%)

Metabolized carbohydrate yields the greatest amount of
CO2 than other macronutrients
Higher CHO increased CO2 production complicate
ventilation (shortness of breath / worsen dyspnea)
Negative effect of higher fat diet: delayed gastric emptying
abdominal discomfort, bloating, early satiety.
10/23/14
Nutrient needs in stable COPD

(Intervention)
v
Protein: 1.2-1.7 grams/kg (15-20% of calories) to

restore lung and muscle strength and promote immune
function
Fat: 30-45% of calories
Carbohydrate: 40-55% of calories
Maintain appropriate RQ from substrate metabolism
Address other underlying diseases (diabetes, heart

disease) affect the total amount of nutrients
52
10/23/14
Nutrient needs in stable COPD

(Intervention)
u
Vitamins: intakes should at least meet the DRI
Smokers may need more vitamin C (+16-32 mg)

depending on cigarette use
Minerals: meet DRIs and monitor phosphorus and

magnesium in patients at risk for refeeding during
aggressive nutrition support
Sodium and fluid restriction: Patients with cor pulmonale

and subsequent fluid retention
53
10/23/14
54
Intervention and Monev

u
Routine care Collaboration health care team
Anticipatory guidance: 90% IBW
Supportive intervention: 85% to 90% IBW
Resuscitative/palliative: below 75% IBW
Rehabilitative care: consistently below

85% IBW
JADA1997
10/23/14
55
Intervention : Feeding strategies

u
GI motility: adequate exercise, fluids, dietary fiber
Abdominal bloating: limit foods associated with gas

formation
Fatigue: resting before meals, eating small portion of

nutrient-dense foods, arrange assistance with
shopping and meal preparation
10/23/14
56
Intervention : Feeding strategies

Suggest that patient
u
Use oxygen at mealtimes
Eat slowly
Chew foods well
Engage in social interaction at mealtime
Coordinate swallowing with breathing
Use upright posture to reduce risk of aspiration
Enteral tube feeding to increase total caloric and nutrients intake
10/23/14
Thank You
and
See u again...
58
References
u
David A. Brown. 2008. Introduction to Nutrition and Metabolism. 4th

edition. CRC Press. Boca Raton.
Donna H. Mueller. 2012. Krauses Food and the Nutrition Care Process.
13rd edition. Elsevier.
Sylvia Escott-Stump. 2012. Nutrition and Diagnosis-Related Care. 7th

edition. Wolters Kluwer, Lippincott & Wilkins.
Marcia Nelms, et al. 2011. Nutrition Therapy and Pathophysiology. 2nd

edition. Wadsworth, Cengage Learning.
10/23/14

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NCP Copd PBL Clinic SMST 5 MM 2014

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NCP FOR COPD PATIENT

MNT for Lung Disorder

NCP for COPD Patient/PBL Clinic/MM/2014

CD 33. Design and implement

Implementation of NCP for COPD Patient

Gambaran umum dari COPD (definisi,

Kuliah pakar oleh dr. TRIWAHJU ASTUTI, M.Kes., Sp.P

NCP for COPD Patient/PBL Clinic/MM/2014

The Pulmonary System

The Pulmonary System

Normal lung anatomy

NCP for COPD Patient/PBL Clinic/MM/2014

Selected airways disorders

Major function of the

Regulate the bodys acid-base balance

Synthetize arachidonic acid prostaglandins or leukotrients

The alveolar cells secrete surfanctant, a compund synthetized

Part of the bodys immune defense system

NCP for COPD Patient/PBL Clinic/MM/2014

Pulmonary System Disorder

NCP for COPD Patient/PBL Clinic/MM/2014

NCP for COPD Patient/PBL Clinic/MM/2014

Sign and symptoms

NCP for COPD Patient/PBL Clinic/MM/2014

Pulmonary function test

Monitor a persons blood level

Uses the light waves to measure

Normal: 95% to 99% (young,

NCP for COPD Patient/PBL Clinic/MM/2014

Information on lung volume and

Chronic Obstructive Pulmonary

Characterized by airway obstruction

Type 1: Emphysema : abnormal, permanent

Type 2: Chronic bronchitis: chronic, productive

Continual contact second-hand smoke

Environmental pollution: cooking a confined,

NCP for COPD Patient/PBL Clinic/MM/2014

Patients are thin, often cachectic;

NCP for COPD Patient/PBL Clinic/MM/2014

NCP for COPD Patient/PBL Clinic/MM/2014

Treatments for COPD

Bronchodilatorstheophylline and aminophylline

Exercise to strengthen muscles

NCP for COPD Patient/PBL Clinic/MM/2014

NCP for COPD Patients

NCP for COPD Patient/PBL Clinic/MM/2014

Bagaimana interpretasi dari hasil

Tinggi Lutut (TL) = 54 cm

Lingkar Lengan Atas (LLA) = 27 cm

*Chumlea W, Roche A, 1988, J Am Geriatric Soc

= 81.8% status gizi kurang (60 90%

NCP for COPD Patient/PBL Clinic/MM/2014

** Kriteria SG berdasarkan LLA/U

3rd cause of death worldwide in 2020

Underweight in COPD patient

Biochemical Data, Medical Test, and

HGB: 11.4 g/dl (N: 13.4-17.7)

RBC: 4.82 106/UL (N: 45.5)

MCV: 70.30 FL (N: 80-93)

MCH: 23.00 pg (N: 27-31)

MCHC: 32.70 g/dL (N: 32-36)

RDW: 15.20% (N: 11.5-14.5)

Analisa Gas Darah