chapter 21 nutrition assessment copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973,...
TRANSCRIPT
![Page 1: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/1.jpg)
Chapter 21
Nutrition Assessment
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 2: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/2.jpg)
Learning Objectives
• Describe how a comprehensive nutrition assessment is conducted.
• Describe how to calculate and interpret body mass index.
• Describe how to distinguish two forms of protein-energy malnutrition from each other.
• List the biochemical indicators of nutritional status.
2Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 3: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/3.jpg)
Learning Objectives (cont.)
• State what to observe clinically in the malnourished patient.
• Describe how to obtain and evaluate a nutrition history.
• Describe how to estimate daily resting energy expenditure.
• List the indications, contraindications, hazards, and limitations of indirect calorimetry.
• Describe how to properly prepare a patient for indirect calorimetry.
3Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 4: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/4.jpg)
Learning Objectives (cont.)
• Describe how to interpret the results of indirect calorimetry.
• Describe how REE values are adjusted to reflect a patient’s actual energy needs.
• State the effects of malnutrition and on the respiratory system.
• Describe how to identify patients at high risk for malnutrition.
• Identify the effect on a patient of too much protein, carbohydrate, or fat.
4Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 5: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/5.jpg)
Learning Objectives (cont.)
• State when enteral nutrition and parenteral nutrition are needed.
• Describe how to identify and minimize the common respiratory complications of enteral feedings.
• State specific nutritional guidelines that apply to patients with a specific pulmonary disease.
• Explain how common pulmonary medications affect nutrition.
5Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 6: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/6.jpg)
Nutrition Assessment
• Process of collecting & evaluating data to determine nutritional status of patient
• Performed by registered dietician or physician trained in clinical nutrition
• Compares social, pharmaceutical, environmental, physical, & medical factors to evaluate nutrient needs of patient
• Done to develop nutrition care plan• Data is collected from anthropometrics,
biochemical tests, & clinical observations
6Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 7: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/7.jpg)
7Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
The ABCDs of nutritional assessment include all of the following:
A. Airway, breathing, circulation, and defibrillation
B. Assessment (physical), BMI calculation, caloric count, and diet (intake/output)
C. Anthropometric, biochemical tests, clinical observations, and dietary analyses
D. Albumin, Bilirubin, Creatinine, and Deoxycortisol
![Page 8: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/8.jpg)
Anthropometrics
• Refers to measurements of bodyHeight & weightSkinfold thicknessArm muscle measurementsWaist & hip measurementsHead circumference Wrist diameter
8Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 9: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/9.jpg)
Anthropometrics (cont.)
• Height & weightUsually measured to determine weight status using
body mass index (BMI) & ideal body weight (IBW)BMI between 18.5 & 24.9 kg/m2 for adults is
considered healthyBMI of 25 to 29.9 kg/m2 = overweightBMI > 30 kg/m2 = obese
9Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 10: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/10.jpg)
BMI Categories
10Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 11: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/11.jpg)
BMI Categories
11Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 12: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/12.jpg)
Anthropometrics (cont.)
• Ideal Body Weight: Ideal body weight may also be determined using
Hamwi formulas:• Men: 106 pounds for first 5 feet, plus 6 pounds for each inch
over 5 feet• Women: 100 pounds for first 5 feet, plus 5 pounds for each
inch over 5 feet
12Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 13: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/13.jpg)
13Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
The IBW for a 25 year-old female patient whose height is measured at 5'5" would be:
A. 155 lb.
B. 125 lb.
C. 100 lb.
D. 130 lb.
![Page 14: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/14.jpg)
Anthropometrics (cont.)
• Kwashiorkor & marasmus Marasmus - typically seen in children ages 6 to18
months in deprived areas of world chronically malnourished
Kwashiorkor results from more sudden lack of protein & calories in infant (seen as protruding belly & edematous face)
14Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 15: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/15.jpg)
Weight Classification According to BMI
• Healthy weight:BMI between 18.5 & 24.9 for adults or BMI-for-age
between 10th & 85th percentiles for children• Overweight:
BMI 25.0 to 29.9 in adult & BMI-for-age in children between 85th & 95th percentiles
• Obesity:BMI greater than 30 in adults & greater than 95th
percentile in boys & girls ages 2 to 20 years• Underweight:
BMI of less than 18.5; underweight children score in bottom 10th percentile for BMI-for-age
15Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 16: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/16.jpg)
Biochemical Indicators
• Albumin measured for long-term trends in nutrition because it has half-life of 21 days
• Transthyretin has half-life of 2 to 3 days & therefore responds to nutritional changes much quicker than albumin
• Total lymphocyte count may be reduced with malnutrition due to lack of protein intake
16Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 17: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/17.jpg)
Biochemical Indicators (cont.)
• Creatinine-height index measures amount of creatinine excreted in urine over 24 hours60% to 80% of normal = mild deficit of muscle mass40% to 60% = moderate deficit<40% = severe depletion of muscle mass
• Nitrogen balance used to assess protein balance because 16% of protein is nitrogen
17Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 18: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/18.jpg)
18Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
Biochemical indicators are important element of nutritional assessment because:
A. They are use to determine ideal body weight
B. Can predict nutritional outcomes
C. Indicate the level of protein synthesis in the body
D. Help to calculate predicted body weight
![Page 19: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/19.jpg)
Pulmonary Function
• Protein malnutrition has been linked to reduced function of diaphragm & other muscles of breathing
• Leading to reduced vital capacity & peak inspiratory pressures
• Represents significant problem in ICU when trying to wean patient from mechanical ventilation
19Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 20: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/20.jpg)
Clinical Indicators
• Examination of hair, eyes, lips, mouth & gums, skin, & nails provides clinical indication of nutritional status
• Chronically malnourished patient will appear thin; appearance of protruding ribs; patient is cachexic in such cases
20Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 21: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/21.jpg)
Common Dietary Measures
• 24-hour recall• Usual intake recall• Food diary or food record• Food frequency questionnaire• Evaluation of nutrition history
21Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 22: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/22.jpg)
22Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
All of the following are economic benefits of a well-designed, multidisciplinary nutritional intervention plan, except:
A. Decreased nosocomial infections
B. Reduced hospital stays
C. Reduced need for medication or medical care
D. Increased years of productivity
![Page 23: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/23.jpg)
Macronutrients & Energy Requirements
• Macronutrients supply the body’s energy requirements:ProteinCarbohydrateFat
• Classic measure of energy expenditure is basal metabolic rate (BMR)
• Alternatively, predictive equations like Harris-Benedict Equation can be used to estimate daily resting energy expenditure (REE)
23Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 24: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/24.jpg)
Indirect Calorimetry
• Estimation of energy expenditure (caloric needs) by measurement of O2 consumption & CO2 production
24Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 25: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/25.jpg)
Indirect Calorimetry
25Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 26: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/26.jpg)
Interpretation of Calorimetry (cont.)
• Results are used to assess metabolic status & plan nutritional support
• First step is to compare results to predicted normal using Harris-Benedict equations
• Resting energy expenditure (REE) >10% above normal indicate hypermetabolic state
26Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 27: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/27.jpg)
Interpretation of Calorimetry (cont.)
• REE results <90% of normal predicted indicate hypometabolism
• Next, interpret RQ, which is ratio of CO2
produced to O2 consumed
• RQ of carbohydrates = 1.0; protein = 0.82; & fat = 0.7.
27Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 28: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/28.jpg)
Interpretation of Calorimetry (cont.)
28Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 29: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/29.jpg)
29Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
During indirect calorimetry a steady-state condition is reached when:
A. Patient remains still for 1 minute
B. REE results are within normal limits
C. No artifacts are detected during the test
D. Five consecutive 1-min averages have a variability of 5% or less
![Page 30: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/30.jpg)
Nutritional Support
• Malnutrition results from insufficient energy (calorie) intake over time
• Protein-energy malnutrition (PEM) has adverse effects on patient’s immune system & on respiratory musculature
• PEM can be result of starvation or disease
30Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 31: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/31.jpg)
Respiratory Impairment & Malnutrition
31Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 32: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/32.jpg)
Respiratory Consequences of Malnutrition
32Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 33: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/33.jpg)
Providing Substrates
• Protein should provide about 20% of patient’s caloric needs
• Carbohydrates should provide about 50% of patient’s caloric needs
• Fat should provide about 20% to 30% of patient’s caloric needs
33Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 34: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/34.jpg)
Routes of Feeding
• Enteral (oral & tube feeding) feeding is route of choice; safer, healthier, & easier than parenteral route
• Potential complication of enteral feeding is aspiration
• Parenteral (intravenous) feeding can be done through peripheral or central vein
34Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 35: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/35.jpg)
Pulmonary Patient
35Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
![Page 36: Chapter 21 Nutrition Assessment Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc](https://reader036.vdocuments.site/reader036/viewer/2022062421/56649d355503460f94a0ca17/html5/thumbnails/36.jpg)
36Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
All of the following can help decrease the risk of pulmonary aspiration for tube-fed patients, except:
A. Aspiration of subglottic secretions
B. Endotracheal intubation
C. Keep head of bed at 45 degree angle
D. Placement of feeding tube beyond the pylorus