CASE PRESENTATION ON:-PROTEIN ENERGY MALNUTRITION

BIOGRAPHICAL INFORMATION

Name : Master Durga prasad

Age : 3 years

Sex : Male

Address :Satna

Religion : Hindu

IP No. : 61739

Admission unit : B Unit

Date of admission : 11/01/13

Diagnosis : Protein Energy Malnutrition Grade – III

CHIEF COMPLAINTS

Patient had complains of Fever Since 8 days, Abdominal Distention since 2 days, Edema in the limbs since 2 days

PRESENT ILLNESS

Mas. Durga Prasad came to the hospital with the complaints of fever of intermittent type which is moderate in nature associated with chills, abdominal distention and abdominal girth is 50cm and swelling of the lower extremities with dry and scaly skin. Patient was admitted with the above complaints & was Diagnosed PEM and there is no any surgical intervention being done.

PAST HEALTH HISTORY

CHILDHOOD – ILLNESS:- There is no significant history of childhood illness, trauma, or immunization

patient doesn’t have any experience of previous hospitalization. PAST MEDICAL-SURGICAL HISTORY:

Patient is known case of dehydration as diagnosed 2 yrs back. No Diabetes, or other chronic illness& has not undergone any surgical interventions. MEDICATION & ALLERGIES:

As a known PEM, he regularly takes the medication diet according to standard body requirement., No history of any habitual OTC medications, not habituated to any herbal preparations or self preparations.

PERSONAL HISTORY PERSONAL STATUS: he holds up an cute place in his family along with his mother & family.

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EATING HABITS: He takes fruit as well as milk & includes plenty of water.

ALCOHOL HABITS: not a known alcoholic.

SMOKING HABITS: not habituated.

LIFE STYLE: well playing with other children.

SLLEEPING HABITS: Sleeps 8hrs/night & 2hrs/day, doesn’t have any problems in sleeping.

RELIGION&FAITH: He is a Hindu by religion and is involved in traditional and cultural activities frequently.

FAMILY HISTORY

34 years 27years

1year 5years 3years

No history of any communicable diseases & genetic disoders, patient’s father has a history of blood pressure.

S.No Name Relation Age Healthstatus Occupation

1 Shaikhar Father 34yrs Healthy merchant

2 Sunita Mother 27yrs Healthy housewife

3. Durgaprasad Son(patient) 3 yrs Admitted nil

4 shithil Son 1 yr Died -

5 manoj son 5 yrs Ukg studying

PSYCHO SOCIAL HISTORY

Patient maintains good relations with family members, relatives and friend.

NUTRITIONAL HISTORY

Recent Weight : 7kg,Expected Weight: 14kg .Appetite: Poor

24 Hours Diet Recall:

Child taken only two meals in last 24 hours and each meal contains 2 idly with chatni. Water intake approximately 400-500 ml.

Degree of Malnutrition :

=actual weight/expected weight X 100

2

= 7/14 X 100

50%

III Degree malnutrition

Menu plan for Mas. Durgaprasad as per standard daily requirement

Time Item Calorie Protein

8Am

10Am

12pm

2pm

5pm

7pm

9pm

!/2 cup milk+1 tsp ghee+2 biscuits+

1 tsp sugar

1 cup cooked rice+2 spoon Dhal sambar+1 tsp ghee

1 egg+1 Chapati+3 spoon sugar+1 tsp ghee

1 cup rice+2 spoon dhal Sambar+ 1 tsp ghee

1 bread+1/2 cup milk+ 1 tsp sugar

1 cup rice+1 tsp ghee+ 2 spoon dhal

1 Banana+ ½ cup rice+1/2 spoon ghee+ Sambar

136 Kcal

220Kcal

300Kcal

220Kcal

150Kcal

220Kcal

214Kcal

3gm

4gm

4gm

8gm

8gm

4gm

4gm

Total 1460Kcal 35gm

ENVIRONMENTAL HISTORY

Patient lives in rural area. The housing condition is rural but according to the family members they live in a hygienic condition. Drainage system is present. They get water from borewell supply.

GROWTH AND DEVELOPMENT

Child’s growth and development has not achieved to normal extent.

Gross Motor development: child was unable to take steps on tip of toe.

Fine motor development: not able to hold spoon properly to take food.

Sensory development: able to identify geometric figures, accommodation well developed.

Vocalization: able to understand simple comments, and asks about objects for name

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Psychosocial development: child is in the sense of autonomy.

Psychosexual development: child is in the anal stage and bladder control not yet achieved

Intellectual development: child is in sensory motor stage.

Spiritual development: child is in intuitive projective faith.

ELIMINATION PATTERN

Bowel : bowel sounds are dull

Bladder : bladder control not yet achieved.

PHYSICAL EXAMINATION

General Observation

Mas. Durgaprasad is a 3 years old male baby, poorly built, undernourished, conscious and oriented to time, place and person.

Vital SignsTemperature : 100o F

Pulse : 92bts/min

Respiration : 30breaths/min

Skin And Mucus Membrane

Color : Normal brown

Edema : Present

Moisture : Dry

Temperature : Increased

Turgor : Normal

Any Abnormal Discharges : No

HeadSkull/Cranium Size, Shape : Normal

Movements : Normal movements

Forehead : No scars

Hair

Changes in Texture : Hypo-pigmented

Characteristics : Brown in color, sparse and not distributed densely

Lice : Absent

Nails

4

Changes in Appearance : Clubbing of nails

Cyanosis : Absent

Texture : Softening of nails

Face

Appearance : Presence of facial puffiness

Color : Normal brown

Symmetry : Symmetrical

Movements : Normal

Eyes

Expression : Normal

Eye Lids : Normal

Lacrimation : Poor

Conjunctiva : Pale

Sclera : Clear

Pupil : Equally reactive and accommodate light.

Ears

Appearance : Symmetrical

Discharges : Nil

Lesions : Nil

Any Abnormalities : Nil

Nose

Appearance : Normal

Discharges : Nil

Patency : Patent

Sense of Smell : Normal

Mouth And Throat

Lips : Dry

Tongue : Not coated

Teeth : Deciduous teeth are present

Gums : Normal

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Buccal Mucosa : Normal

Palate : No cleft palate

Tonsils : Not inflamed

Taste : Normal

Neck

General Appearance : Normal

Trachea : Centrally located

Lymph Nodes : No palpable lymph nodes

Thyroid Glands : No thyroid enlargement

Cysts and Tumors : Nil

Gastro-Intestinal System

Diarrhea : Absent

Constipation : Absent

Bleeding : Absent

Worm Infestation : Suspected

Psychosocial History

General Status of the Family: Mas. Durga Prasad belongs to poor class family with a monthly income of 1000/-. His father is a daily wager. He is living with his father, mother and two elder sisters. They are living in their own house. Electricity supply is available in the house. There is no proper sanitary facility.

Activities of Daily Living : Mas. Durgaprasad lost his interest in daily activities and looks dull.

Sl. No.

Investigation Results Normal values Remarks

1.

2.

3.

4.

5.

6.

Hemoglobin

TLC

Lymphocyte

Monocyte

Eosinophils

RBC

5.2gm/dl

12,700cells/mm

62%

02%

04%

3.53mil cells/mm

12-16gm/dl

4000-11000cell/mm

20-45%

2-10%

1-8%

3.5-5.5 mil cell/m

Severe anemia

Inflammation present

Increased

Normal

Normal

Normal

Play Activities : Child has less interest to play with peers and siblings.

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Special investigations

Ultrasonography: The findings from the images obtained through Ultrasonography suggest that the liver is infiltrated with excessive triglycerides.

MEDICATIONS

Medication name Dosage Frequency

Route Actions Side effects Nursing responsibilities

1. Inj. Amikacin

2. Tab. B complex

225mg

50 mg

Bd

Od

IV

Oral

Binds to 30s ribosomal subunits of susceptible bacteria, thus inhibits protein synthesis.

Vitamin B complex and Vitamin C supplement

Tinnitus, vertigo, ataxia and deafness

Nausea and vomiting

Perform test for hearing acuity.

Avoid concurrent use of ototoxic drugs

Monitor for the signs of hypervitaminosis.

7

DESCRIPTION OF DISEASE

PROTEIN ENERGY MALNUTRITION

The term malnutrition can be applied to any disorder that prevents an individual from achieving an optimal nutritional state.Protein energy malnutrition is the state occurs due to insufficient or imbalanced consumption of protein and energy.

INCIDENCE:

Malnutrition is the one of the major health problem in the world in children with in 5 years of age.It is estimated that 80% of preschooler suffer from various degrees of malnutrition.At any given time there are 78 million children suffering from various degrees of malnutrition.

NORMAL PROTEIN AND ENERGY REQUIREMENT OF CHILDREN

Age group Energy (in kcal/day) Protein (in grams/day)

0-6 months 108/ kg 2.0/kg

6-12 months 98/kg 1.65/kg

1-3years 1240 22

4-6years 1690 30

TYPES OF PROTEIN ENERGY MALNUTRITION

1.Marasmus: Weight less than 60% of expected weight to the age. It is a clinical syndrome

characterized by loss of subcutaneous fat and muscle wasting.

2.Marasmic Kwashiorkor: Weight less than 60% of expected body weight for the age with features

of Marasmus with edema.

3.Kwashiorkor: Weight below 60-80% of expected weight with growth retardation and generalized

body edema.

GRADING OF PROTEIN ENERGY MALNUTRITION

a) Gomez Classification:

Grade I - 76-90% of average of weight.

Grade II - 61-75% of average weight.

Grade III -60% and below 60% of average weight.

b) The Water Loo classification

Nutritional Marasmus- below 60% of average weight without edema

Kwashiorkor - 60-80% of reference weight with edema.

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Marasmic Kwashiorkor - below 60% of reference weight and edema

c) Indian Academy of Pediatrics:

Above 80% of expected weight - Normal

70-80% of expected weight - Grade I

60-70% of expected weight -Grade II

50-60% of expected weight - Grade III

Less than 50% of expected weight - Grade IV

MARASMUS

A severe form of malnutrition caused by inadequate intake of protein and calories, and it usually

occurs in the first year of life, resulting in wasting and growth retardation. Marasmus accounts for a

large burden on global health.

Nutritional Marasmus is a nutritional disorder results due the gross deficiency of energy though protein

deficiency accompanies it.

It is the common problem in developing countries in the time of draught. It occurs chiefly in first year of

life.

ETIOLOGY:

a) Primary Cause: Primary cause is the dietary cause. Inadequate diet both qualitatively and

quantitatively.

b) Secondary Causes:

Age: Marasmus is more common in infant than in other ages. It is because of high nutritional

requirement of infant (Protein: 2-3gm/kg/day; Calorie: 1200 Kcal/day) and hence Marasmus

develops soon in infancy

Congenital Disease: Congenital disease which limits the intake and digestion of food.

Chronic Vomiting: Disease like pyloric stenosis and relaxed cardiac sphincter, which increase

the risk of vomiting there by, decreases the absorption of the nutrients from the GI tract.

Chronic Infection: Chronic infections like Congenital syphilis, tuberculosis and respiratory

infection which results in protein loss.

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Repeated episodes of chronic diarrhea will impair the digestion and absorption of nutrients

from the mucosa of the Gastro Intestinal tract and results in deficiency of the nutrients.

Serious organic disorders of heart, brain and kidney and some metabolic disorders and juvenile

diabetes mellitus.

Other causes include Transition from breastfeeding to nutrition, poor foods in infancy.

GRADING OF THE MARASMUS:

Grade I : Loss of fat in axillae and groin

Grade II : Grade I + loss of fat in abdomen and gluteal region.

Grade III : Grade I + Grade II + loss of fat in chest and Para spinal area.

Grade IV : Grade I + Grade II + Grade III + loss of fat in buccal pad.

CLINICAL MANIFESTATIONS

Appearance of toothless old man and a monkey look.

Growth retardation as evidenced by marked loss of weight and subnormal height.

Gross muscle wasting

Absence of edema.

Eyes will be sunken

Disappeared subcutaneous fat.

Face will be round, till the loss of subcutaneous fat.

Skin over the buttocks becomes wrinkled and saggy due to loss of adipose tissue.

Bones will be prominent.

Anemia

Subnormal temperature.

Skin becomes ashen gray because of anemia

Atrophy and wasting of body tissues especially subcutaneous fat.

The child will be apathetic and lethargic.

Recurrent infections

DIAGNOSIS

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History collection : Regarding the dietary habits and recurrent attacks of diseases.

Physical examination : To rule out the signs of the Marasmus.

Biochemical Investigation : Biochemical investigation to estimate the plasma protein level.

Plasma protein levels will not be noticeably reduced.

Pathological references : Liver does not show pathological fatty infiltration.

Reduced organ weight of lung and heart

MANAGEMENT:

Calorie requirement of the undernourished infants are greater than those of normal infants it

almost doubled.

The aim of treatment is to provide sufficient proteins, calories, and other nutrients for nutritional

rehabilitation and maintenance.

In case of severe PEM, restoring fluid and electrolyte balance parentally is the initial concern. A

patient who shows normal absorption may receive enteral nutrition after anorexia has subsided.

When possible, the preferred treatment is oral feeding. Foods are introduced slowly.

Carbohydrates are given first to supply energy, and then high-quality protein foods, especially

milk, and protein-calorie supplements, are given.

Start with the concentrated food of about 200 Cal/kg body weight gradually 2-3 weeks and

continued till the weight gain.

Protein requirement should be 4gm/kg body weight /day.

No of feeds should be increased usually 7 feeds a day.

A patient who’s unwilling or unable to eat may require supplementary feedings through a naso-

gastric tube or Total Parenteral Nutrition (TPN).

Secondary causes should be treated

Accompanying infection must also be treated, preferably with antibiotics that don’t inhibit protein

synthesis.

KWASHIORKOR

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Kwashiorkor is one of the more severe forms of protein malnutrition and is caused by

inadequate protein intake. It is, therefore, a macronutrient deficiency.

It is type of severe protein-energy malnutrition refers to a combination of edema, lethargy

(mental apathy) and growth failure.

INCIDENCE:

It is a major problem in South India (Andra Pradesh) and Orissa, Bengal and some parts of

Maharashtra.

In India it is estimated that about 1-2% of preschooler suffer from Kwashiorkor.

ETIOLOGY:

Book Picture Patient Picture

Unavailability of suitable protein rich foods

Faulty feeding habits

Super imposition of infection and infestations

Age Incidence

Higher incidence is found between 1 to 3

years.

Prolonged breast feeding

Seasonal Incidence

Family size

Lack of Accessibility and availability of Health

Services

-

-

Suspected case of worm infestation

Age is 3y, peak age of incidence

Breast feed till 2 years of age.

-

-

Lack of awareness of health services

CLINICAL MANIFESTATION

Book Picture Patient Picture

Onset: Insidious in onset over periods of weeks and months.

Apathy: Gradually loss of interest and activity. The degree unresponsiveness will be proportional to severity of the disease.

Diarrhea: Nearly 2/3rd of Kwashiorkor cases will be presenting with the complaints of loose stools with infective in origin.

Insidious in onset

Has less interest in play activities.

Absent

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Edema: Edema is a constant feature and is extremely variable in degree. Inspite of gross edema, ascites will be minimal.

Muscle wasting: Due to degeneration and reduction in the anterior horn cells may lead to weakness and hypotonia as suggested by one postulate (Kwashiorkor myelopathy). Protein deficiency also causes muscle wasting.

Skin changes: 40% to 60% of the florid kwashiorkor will have skin changes. Dry and scaly skin: Common over skin

Pavement dermatosis: Jet black, later exfoliate exposing underlying and also there will be peeling.

Petichae and ecchymoses.

Arabinoflavinosis

Hair changes: The hair is scanty, lusterless commonly brownish. The light color hair is known as dyschromotrichia.

Hepatomegally with fatty infiltration.

Face: Moon face due to edema

Associated Avitaminosis

Anemia of moderate degree.

Growth retardation

Psychomotor changes: Earlier the onset of the malnutrition; severe will be the psychomotor changes (mental deprivation)

Pedal edema with ascites

No muscle wasting

Skin is dry and scaly

Absent

Absent

Absent

Hairs are scanty and brown in color

Liver is enlarged 4cm below the RCM

Moon face is present

No symptoms

Hb 5.2gm/dl

Absent

Irritable and restless

Kwashiorkor sufferers show signs of thinning hair, edema, inadequate growth, and weight loss. The stomatitis on the pictured infant indicates an accompanying Vitamin B deficiency

DIAGNOSIS:-

Book Picture Patient Picture

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History and Physical examination

Anthropometric measurements

Biochemical investigation

o Low serum albumin (<3.5-5gm/dl)

o A/G ratio will be reversed(1:1.5)

o Decreased serum amino acid level.

o Decreased blood cholesterol level.

o Decreased pancreatic enzymes.

o Decreased serum Iron and Copper.

Organ Changes elicited by Imaging studies:

o Fatty liver

o Atrophy of acinary cells of pancreas

o Atrophic changes in stomach and intestinal villi.

Done

MAC-14cm

Not done

Not done

Not done

Not done

Not done

Not done

Present and enlarged 4cm below RCM

Not elicited

Not elicited.

MANAGEMENT

1. Dietary modifications

2. Control and Treatment of infections

Book Picture Patient Picture

Management: 1.Dietary modifications

Dietary Management:

Liberal protein rich foods to be given with adequate calories.

Proteins:

About 5 to 6 gms of protein/kg/day.

The total average protein intake of child is 50-60gm/day.

Calories:

Calories should be in range of 120-150 Kcal/kg/day.

1. Control and Treatment of infections

2. Correction of Vitamin deficiencies

High protein diet with 7-8 feeds a day

On antibiotic therapy (Inj. Amikacin 225mg BD)

On Becosule capsule for

Vit-B and C Supplementation

3. Correction of Vitamin deficiencies

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NURSING CARE PLAN

SR.NO.ASSESSMENT

NURSING

DIAGNOSIS

PLANNINGIMPLEMENTATION EVALUATION

OBJECTIVE INTERVENTIONS

1 Subjective data:

Mother says “My son

is not gaining weight

adequately”

Objective data:

Weight:7kg

(expected wt 14 kg)

Grade III

malnutrition:

Imbalanced nutrition;

less than body

requirement related

to decreased

utilization of

nutrients secondary

to fatty infiltration of

the liver.

Child will achieve

and maintain normal

nutritional status as

evidenced by weight

gain.

-Assess the nutritional

status and degree of

malnutrition.

-Assess the causes for

malnutrition.

-Prepare diet plan and

educate mother to

serve food

accordingly.

- Identify for the signs

of vitamin

deficiencies

-Administer Vitamin

Supplements

-Child is severely

malnourished. i.e. 3rd

degree malnutrition.

-Decreased utilization of

nutrients due to fatty

infiltration of liver.

-Prepared diet menu plan

based on the child

condition.

-Vitamin deficiency

present.

-Provided oral Vitamin

Supplements.

Nutrition of child is

improved to some

extent as evidenced

by increased interest

to take food and

mild increase in

weight. i.e. 8.2kg.

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SR

NO.ASSESSMENT

NURSING

DIAGNOSIS

PLANNINGIMPLEMENTATION EVALUATION

OBJECTIVE INTERVENTIONS

2.

Subjective data:

Mother says “My son’s

skin is somewhat hot”

Objective data:

Temperature: 100oF

Pulse: 92bts/min

Hyperthermia

related to

inflammatory

reaction secondary

to Hepatomegally.

Child will achieve

and maintain

normal body

temperature as

evidenced by

temperature

within normal

limits.

-Monitor vital signs

-Loosen the clothing

and switch on the

fan.

-Provide plenty of

fluids to drink

-Apply cold

compress

-Provide tepid

sponge.

-Administer

prescribed

antipyretics

Body Temperature is

100oF.

Loosen the clothing

and provided proper

ventilation.

Advise the mother to

provide plenty of water

and fluids.

Advised mother to

keep wet cloth on fore

head to reduce the

temperature.

-----

Administered Inj

Paracetamal

Intramusularly.

Child’s body

temperature is

within normal

limits

Temperature:

98.6F

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SR NO.ASSESSMENT

NURSING

DIAGNOSIS

PLANNINGIMPLEMENTATION EVALUATION

OBJECTIVE INTERVENTIONS

3. Subjective data: The

mother complaint

that her son is having

swelling of face.

Objective data:

The child is having

puffiness of face,

periorbital edema

and edema at feets.

Fluid volume

excess related to

fluid

accumulation in

tissues as

evidence by

puffiness of face,

periorbital and

pedal edema, and

abdominal

distension.

To maintain fluid

volume in the

body and to

reduce the

edema.

-Assess the child for

sites of edema.

-Assess the signs of

ascities and measure

abdominal girth.

-Assess the dietary

pattern of the child.

-Provide small and

frequent meals.

- Increase food items

that contain protein.

-Consider likes and

dislikes of the child.

-Child is having facial

puffiness, periorbital

edema, & pedal edema.

-Abdominal girth is

49cms

-

-Advised mother to give

small and frequent

meals.

-Provided the list of

protein rich foods to

mother.

- Instructed mother to

serve food in utensils

which the child used to

have food.

Child’s edema has

reduced as

evidenced by

abdominal girth

reduced to 45

cms.

17

18

SR NO. ASSESSMENT

NURSING DIAGNOSIS

PLANNINGIMPLEMENTATION EVALUATION

OBJECTIVE INTERVENTIONS

4. Subjective data

Mother says they have

not taken child for

immunization.

Objective data

Child not received

immunization vaccines

and food pattern was

inappropriate

Deficient

knowledge of the

parents related

to nutrition and

immunization

need of child

Parents will gain

knowledge

regarding the

nutritional

requirement of

the child and

immunization

need of child.

-Assess the level of

understanding of

parents.

-Educate the parents

regarding the

causes and

symptoms of

malnutrition.

-Explain the parents

regarding the daily

nutritional

requirement of the

child.

-Educate the parents

regarding the

importance of

immunization of the

under-five child.

-Educate regarding

the measures to

prevent

complications of

malnutrition.

-Understanding level of

the parents is

poor.ucated mother

regarding the condition

of their child.

-Educated parents

regarding the measures

to improve the nutrition

status and prescribed

menu plan.

-Explained the

importance and

schedule of vaccination

and encouraged for

future immunization.

-Educated parents

regarding the

prevention and

management of

complications.

Parents gained

knowledge

regarding the

nutritional

requirements of

the child, and its

management and

immunization

need of child.

SR

NO.ASSESSMENT

NURSING

DIAGNOSIS

PLANNINGIMPLEMENTATION EVALUATION

OBJECTIVE INTERVENTIONS

5. Subjective data: The

mother complaint that

my son is having edema.

Objective data:

Child having facial

puffiness and pedal

edema.

High risk for

impaired skin

integrity related

to fluid overload.

Child will achieve

and maintain

good skin texture

and integrity.

-Assess the risk

factors for the

impairment of skin

integrity.

-Provide meticulous

skin care.

-Avoid tight clothing.

-Cleanse and powder

opposing skin

surfaces several

times per day.

-Change the position

frequently.

-Use pressure

relieving mattresses

as needed to prevent

ulcer.

-Facial puffiness and

pedal edema present.

-Provided the skin care.

-Advised mother to

avoid tight clothing.

-Cleansed and

powdered skin

surfaces.

-Advised mother to

change the position

frequently.

-------

The child‘s skin

display no

evidence of

redness and

irritation. The

mother is applying

cream to the child

HEALTH EDUCATION

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I educate them (patient & family member) to – Take high caloric diet and iron rich diet. To avoid activities which causes fatigue. To take proper rest and sleep. Do not perform any heavy work. Take the medicine on time and care for the follow up.

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BIBLIOGRAPHY:

1. Marlow DR, Redding BA. Text Book of Pediatric Nursing. 6 th ed. New Delhi: Elsevier India Private Limited; 2006.

2. Wilson D & Hockenberry MJ. Nursing Care of Infants and Children. 8th ed. New Delhi: Elsevier Private Ltd; 2007.

3. http://en.wikipedia.org/wiki/Marasmus

4. http://www.faqs.org/nutrition/Kwa-Men/Marasmus.html

5. http://wrongdiagnosis.com/m/marasmus/intro.htm

6. http://social.jrank.org/pages/378/Marasmus.html

7. http://en.wikipedia.org/wiki/Kwashiorkor

8. http://www.umm.edu/ency/article/001604.htm

9. http://www.wrongdiagnosis.com/k/kwashiorkor/intro.htm

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