A CASE STUDY ON PROTEIN ENERGY MALNUTRITION(MODERATE)

Acknowledgement

This case study report is prepared during my Community Health Nursing clinical practicum in Chapagaun VDC,ward no 3.  The report is prepared as a practical fulfillment of post basic PBN curriculum. I realized that the requirement to do complete case study in the community area has been an important opportunity for me to gain new experience and knowledge in this field.

I got myself complete involved in the care and management of the patient during this period. However the work would not have been accomplished successfully with my effort alone.

I would like to express my sincere gratitude to all teachers of my colleges for providing valuable guidance, supervision and suggestions in the clinical field area.

I am also thankful to my colleagues and my patient and her family who gave me their valuable time for providing necessary information and kind cooperation during this period.

Finally, I would like to thank all of them who gave me their precious, valuable time and suggestions directly or indirectly while preparing this case study.

Background

PEM is one of the most common causes of childhood morbidity and mortality around the world. In 1995, the World Health Organization and UNICEF produced this diagram with the most important causes of childhood mortality. At that time they estimated that of the 10.4 million deaths in children under five, practically half of them were associated with malnutrition.

Nepal is one of the developing countries with the high maternal mortality rate and infant mortality rate. Nepal has the highest maternal mortality rate in the world. One woman dies every two hour from the child birth related cases and 80% of all maternal death is as a result of preventable obstetric complications.

Nepal has one of the highest mortality rate of 281/100,000 live birth. One of the main causes of maternal mortality and morbidity is that the women are married at an early age, and estimated 40% of women between 15 to 19 years have given birth to at least one child. So most of the nepali culture prefers early marriage, this can lead to early pregnancy which can further lead to various problems and then to the death of women and fetal.

According to post Basic Nursing curriculum to function effectively and independently in the field at community health nursing required to do 4 weeks of practical in. During the period, I selected maternal and child health centered disease “protein energy malnutrition” (PEM) which is the most common cause of infant mortality and morbidity in under five children. So this case study was designed to gain and provide comprehensive knowledge of protein energy malnutrition (PEM) and care to the patient.

Yours Sincerely

SMRITI MANANDHAR

B. N. First Year

Roll No: 37

 

 

Objectives of high risk case study:

                          

This case study was done during the community field practicum of 4 weeks in Chapagaun VDC,ward no 3,Lalitpur. The objectives of this case study are to provide holistic approach of care to patient, applying nursing theory and gain detail knowledge about a particular disease or case. The case that I have chosen for my case study was Protein Energy Malnutrition(PEM).

The specific objectives of this case study are as follows:-

1.      To upgrade knowledge about Protein Energy Malnutrition(PEM), it’s diagnosis, treatment and management including nursing management.

2.      To develop harmonious relationship among the patient & the family.

3.      To provide holistic nursing care to my patient by using nursing process and nursing theories.

4.       To gain the detail knowledge about one specific case and it’s nursing management.

5.      To identify the causes, path physiology, clinical features and diagnostic investigation of Protein Energy Malnutrition(PEM). To obtain detail history & perform physical examination of my patient.

6.      To compare the causes, clinical features, diagnosis and treatment applied on the own residental area  of patient regarding  Protein Energy Malnutrition(PEM)between the patient & book.

7.      To identify and compare normal developmental task of my patient.

8.      To apply knowledge from the basic science, nursing theory, nursing care plan, pharmacy and pharmacology and other related courses to plan and implement nursing care.

9.      To prevent the patient from further complication of disease.

10.  To provide the health education and preventive measures to client and his family about betterment of health to maintain and promote health and prevent other common illness and infection.

11.  To minimize the stress of the patient and his family by using appropriate divers ional therapy.

12.  To involve the patient and his family members in improvement and regular follow up.

13.  To precede information and knowledge about Protein Energy Malnutrition(PEM) through case presentation.

 

PART I

Biography data

Summary of History Taking and Physical Examination

History taking and physical examination helps to reveal information about the patient. They are the tool in obtaining subjective and objective data and thus helps to assemble information about patient.

About 80% of the information in the assessment is obtained by history taking. It is therefore essential to take history in systematic manner. About 15% of the information is revealed by physical examination. It helps to identify the health status of the patient. Physical examination is performed to gather objective data and to correlate them with subjective data. It also reveals additional problems that the patient have not recognized. When doing physical examination, cephalo-caudal approach is followed, that is head to toe approach.

After performing history taking and physical examination following things were found:.

·         Patient belonged to middle class family.

·         No history of any disease.

·         Vitals are stable

·         Nutritional status-low--rule out mild to moderate malnourished

·         No any abnormalities found in other regions

·         Appetite-slightly decreased

According to book	Seen in my patient
7 – 9 Months  Ø  Sits without support Ø  Crawls Ø  Emotional attachment to parents Ø  Separation anxiety Ø  Distinguishes between living and non-living objects Ø  Aware that objects exist even when out of sight (object permanence)	Ø All these development task were present in my client’s case
I.            Motor: ·         Sits alone ;stands holding onto furniture ·         Has good hand to mouth coordiantion ·         Developing pincer grasp,with preference for use of one hand over the other ·         Crawls ,may go backward at first     II.            Sensory: ·         Dispalys interest on small things  III.            Socialization and vocalization: ·         Definite social attachment is evident(e.g.stretches out arms to loved ones);shows anxiety with strangers(e.g. turns or pushes away and cries) ·         Responds to own name;is seperating self from mother by desire to act on own ·         Reacts to adult anger;cries when scolded ·         Has imitative and repetative speech,using vowels and consonants such as “dada”,no true words as yet ,but comprends words such as “bye bye”	All these development task were present in my client’s case

 

         

PART II

PROTEIN ENERGY MALNUTRITION:

A condition in which there is inadequate consumption,poor absorption or excessive loss of nutrition .

The World Health Organization (WHO) defines malnutrition as "the cellular imbalance between the supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions."

PEM is also referred to as protein-calorie malnutrition. It develops in children whose consumption of protein and energy (measured by calories) is insufficient to satisfy their nutritional needs. While pure protein deficiency can occur when a person's diet provides enough energy but lacks an adequate amount of protein, in most cases deficiency will exist in both total calorie and protein intake. PEM may also occur in children with illnesses that leave them unable to absorb vital nutrients or convert them to the energy essential for healthy tissue formation and organ function.

Epidemology:

Underlying cause of death under five is 35%

11% of total Global Disability Adjusted Life Year

In 2000, the WHO estimated that malnourished children numbered 181.9 million (32%) in developing countries. In addition, an estimated 149.6 million children younger than 5 years are malnourished when measured in terms of weight for age. In south central Asia and eastern Africa, about half the children have growth retardation due to protein-energy malnutrition. This figure is 5 times the prevalence in the western world.

Approximately 50% of the 10 million deaths each year in developing countries occur because of malnutrition in children younger than 5 years. In kwashiorkor, mortality tends to decrease as the age of onset increases.

According to NDHS 2006,49%of children under the age of five yearss are affected by stuntung,39% are of underweight and 13% of are wasted in nepal Likewise 48%of underfive children are suffered from anemia.

Indication of malnutrition:

Indicators	Interpretation	Indicator
Stunting	Low height for age	Indicator of chronic malnutrition,the result of prolonged food deprivation and/or disease or illness
Wasting	Low weight of height	Suggest acute malnutrition,the result of more recent food deficit or illness
Underweight	Low weight for age	Combined indicator to reflect both acute and chronic malnutrition

The causes of malnutrition

                                  I.            Immediate determinants:

·         Inadequate dietary intake and illness

                                 II.            Underlying determinants:

·         Food

The accesibity of the food,health benefits,quality, quantity of food intake including the attention of energy,protein and micronutrient

·         Health

The availabilty of curative and preventive health services,the hygienic and sanitary environment including the accessible to water

·         Care

Its  the process taking place between a care giver and the reciever  of care.This includes

ª  Care given by the mother to the child

ª  The breastfeeding pattern

ª  The time period of introduction to complementary food and its quality

ª  Home health practices

ª  The health hygiene practices

ª  The psychosocial care

ª  The food preparation pattern

                                III.            Basic determinants:

·         Poverty

·         Political status

·         Economic structure of the family and the nation

·         Sociocultural environment

Fig:conceptual frame work of the causes of malnutrition

Pathological changes:

Upper Gastro Intestinal Tract	Mucosa shiny and atrophic;Papillae of the tongue flattened
Small and Large intestine	Mucosa and villa atrophic;brush boarder enzyme reduced;hypotonic,rectal prolapse
Liver	Fatty liver;deposition of triglycerides
Pancrease	Exocrine secretion depressed;excessive functionless severely affected;glucagon production reduced;insulin level low;atrophy and degranulation or hypertrophy of islets seen
Endocrine System	Elevated growth hormone;thyroid involution and fibrosis;adrenal glands atrophic and cortex thinned,increased cortisol;catecholamine activity altered
Lympho recticular System	Thymus involuted;loss of distinction between cortex and medulla;depletion of lymphocytes paracortical areas of lymph nodes depleted of lymphocytes;germinal centers smaller and fewer
Central  Nervous System	Head circumferences and brain growth retardation;changes seen in dendrite arborization and morphology of dendritic spines;cerebral atrophy on CT/MRI;abnormality in auditory brainstem potentials and visual evoked potentials.

 Classification of malnutrition:

Definitions of malnutrition

Classification	Definition	Grading		In Ms.Susma’s case	Presentaion
Gomez	Weight below % median WFA	Mild (grade 1) Moderate (grade 2) Severe (grade 3)	75%–90% WFA 60%–74% WFA <60 o:p="o:p" wfa="wfa">

75%

Mild malnutrition

 Waterlow

z-scores (SD) below
median WFH

Mild
Moderate
Severe

80%–90% WFH
70%–80% WFH
<70 o:p="o:p" wfh="wfh">

70-80%

Moderatre malnutrition

 WHO (wasting)

z-scores (SD) below
median WFH

Moderate
Severe

-3%</= z-score < -2
z-score < -3

Moderate malnutrition

 WHO (stunting)

z-scores (SD) below
median HFA

Moderate
Severe

-3%</= z-score < -2
z-score < -3

Normal

Abbreviations: BMI, body mass index; HFA, height for age; MUAC, mid-upper arm circumference; SD, standard deviation; WFA, weight for age; WFH, weight for height; WHO, World Health Organization.

Gomez Classification:  The child's weight is compared to that of a normal child (50th percentile) of the same age. It is useful for population screening and public health evaluations.

• Percent of reference weight for age = [(patient weight) / (weight of normal child of same age)] * 100

Waterlow Classification: Chronic malnutrition results in stunting.  Malnutrition also affects the child's body proportions eventually resulting in body wastage.

• Percent weight for height = [(weight of patient) / (weight of a normal child of the same height)] * 100
• Percent height for age = [(height of patient) / (height of a normal child of the same age)] * 100

Classification of Malnutrition in Children

	Mild Malnutrition	Moderate Malnutrition	Severe Malnutrition
Percent Ideal Body Weight	80-90%	70-79%	< 70%
Percent of Usual Body Weight	90-95%	80-89%	< 80%
Albumin (g/dL)	2.8-3.4	2.1-2.7	< 2.1
Transferrin (mg/dL)	150 - 200	100 - 149	< 100
Total Lymphocyte Count (per µL)	1200 - 2000	800 - 1199	< 800

Wellcome Classification: evaluates the child for edema and with the Gomez classification system.

Weight for Age (Gomez)	With Edema	Without Edema
60-80%	kwashiorkor	undernutrition
< 60%	marasmic-kwashiorkor	marasmus

 Who classification of malnutrition:

The current WHO classification of protein-energy malnutrition is presented here. With this classification we only need to know the age, weight and height of the patient and look for edema. If the patient has edema, he or she has severe malnutrition regardless of the weight deficit. If the Wt/Ht deficit is between 2 and 3 SD is moderate malnutrition, if the deficit is > 3 SD then is severe malnutrition. The same criteria are used for Ht/Age deficits.Recommends use of Z-score or standard deviation score for evaluating anthropometric  data so.as to accurately classify individual with indices below the extreme percentiles

	Moderate	Severe
Edema	No	Yes
Wt / Ht Deficit1 (%)2	2-3 (70-79)	>3 (<70 nbsp="nbsp" o:p="o:p">

Ht /Age Deficit¹ (%)² 

    2-3 (85-89)  

    >3 (<85 o:p="o:p">

¹ Standard deviation from median of reference population

²  Percentage of the median of reference population: NCHS/WHO

IAP (Indian Academy of paediatrics) classification:

This classification is based on weight for age value.The standard used in this classification for references population was the 50^th percentiles of the Havard satandards.The classification scheme is used in the ICD’s programme

                        IAP classification of malnutrition

Grade of manutrition	Weight for age of the satndard(%)	In Ms.Pujari state
Normal	>80	75% of malnutrition,refers to mild malnutrition
Grade  I	>80(mild nutrition)
Grade II	61-70(moderate malnutrition)
GradeIII	51-60(severe malnutriton)
GradeIV	<50 malnutrition="malnutrition" p="p" severe="severe" very="very">

 Catagories of malnutrition :

According to the deficiency of protein and energy in varying degree,PEM is catagorized into

1.       MILd PEM

2.       Moderate PEM

3.       Severe PEM: (kwashiorkor,Maramus,Maramusmic Kwashiorkor)

1)      Mild PEM:

This is common in children betweem\n 9 month to 3 years of age , characterised by growth failure,repaeted infection and lethargic.Main cause of mild PEM is deficit dietary intake for a short period

Clinical manifestations of protein energy malnutrition

Mild to moderate malnutrition

S.N	Clinical features	In Ms.Pujari’s case
1.	Curtailing physical activity	Present
2.	Slow and less energetic	Present
3.	Growth lag more pronounced in weight than in height	Present
4.	Prolonged deprivation may lead to stunted height	Height stunting at 86th percentile
5.	Head circumferrence isnot reduced;chest circumference usually exceeds head circumference	Present
6.	Abdomen wall is thin and therefore abdomen appears distended	Present

2)      Moderate protein enrgy manutrition:

If food deficit persists for a longer period,the child will develop moderate PEM. This is also known as Runche which is the local language used foe moderate PEM.The meaning of Runche is crying baby,this describes miserable thinning child who is always crying.Common age for moderate PEM is between 1 to 4 years.The presentation of moderate PEM are similar to mild PEM but it is more easily recognizable forms which includes children appear more slow and less energetic,growth failure(more in weight),thin limbs flatterned buttocks with wrinkling of skin over the front thighs,winged scapula,distended abdomen,repeated infection and loss of subcutaneous fat beneath the skin

3)      Severe PEM:

Severe form of malnutrition are kwashiorkor,Maramus,Maramusmic Kwashiorkor

Kwashiorker:

The term kwashiorkor is taken from the Ga language of Ghana and means "the sickness of the weaning." Williams first used the term in 1933, and it refers to an inadequate protein intake with reasonable caloric (energy) intake. Edema is characteristic of kwashiorkor but is absent in marasmus.

Kwashiorkor typically presents with a failure to thrive, edema, moon facies, a swollen abdomen (potbelly), and a fatty liver. When present, skin changes are characteristic and progress over a few days. The skin becomes dark, dry, and then splits open when stretched, revealing pale areas between the cracks (ie, crazy pavement dermatosis, enamel paint skin). This feature is seen especially over pressure areas. In contrast to pellagra, these changes seldom occur on sun-exposed skin.

This is primarily a deficiency of protein with adequate supply of calories; more subsequent to an infectious outbreak of measles and dysentry

Marasmus:

The term marasmus is derived from the Greek word marasmos, which means withering or wasting. Marasmus involves inadequate intake of protein and calories and is characterized by emaciation.

In marasmus, the child appears emaciated with marked loss of subcutaneous fat and muscle wasting. The skin is xerotic, wrinkled, and loose. Monkey facies secondary to a loss of buccal fat pads is characteristic of this disorder. Marasmus may have no clinical dermatosis. However, inconsistent cutaneous findings include fine, brittle hair; alopecia; impaired growth; and fissuring of the nails. In protein-energy malnutrition, more hairs are in the telogen (resting) phase than in the anagen (active) phase, a reverse of normal. Occasionally, as in anorexia nervosa, marked growth of lanugo hair is noted.

Marasmic kwashiorkor:

Deficiency of both protein and energy in nutritionshows th signs and symptoms of both.

Severe malnutrition

As the nutritional deficit exaggerate with the onset of infections,the child may develop marasmus and kwashiorkor

Comparison of marasmus and kwashiorkor (Heimburger, 2006, p.833)

	MARASMUS	KWASHIORKOR
Clinical setting	Low energy intake	Low protein intake during stress state
Time course to develop	Months or years	Weeks
Clinical features	-Starved appearance -gross wasting of muscles -emaciation -marked stunting but no edema -Weight < 80 % standard for height -Triceps skin fold < 3 mm -Midarm muscle circumference < 15 centimeter (cm) -wrinkled skin -Dry,scaly and inelastic skin -Hypopigmented hair -voracious appetite	-Well-nourished appearance -Easy hair pluckability -puffy and moon shaped face -Edema in lower extremities and muscles in upper limb wasted Deficit in height is less in compare to marasmus -lethargic,listless and apathetic child Impaired appetite and difficult to feed the child
Laboratory findings	Creatinine-height index < 60 % standard	Serum albumin < 2.8 g/dL Total iron-binding capacity < 200μg/dL Lymphocytes < 1,500/cubic millimetre (mm3) Anergy
Clinical course	Reasonably preserved responsiveness to short-term stress Infections	Poor wound healing, decubitus ulcers, skin breakdown
Mortality	Low, unless related to underlying disease	High

Treatment:

In both children and adults, the first step in the treatment of protein-energy malnutrition (PEM) is to correct fluid and electrolyte abnormalities and to treat any infections. The most common electrolyte abnormalities are hypokalemia, hypocalcemia, hypophosphatemia, and hypomagnesemia. Macronutrient repletion should be commenced within 48 hours under the supervision of nutrition specialists.

The second step in the treatment of protein-energy malnutrition (which may be delayed 24-48 h in children) is to supply macronutrients by dietary therapy. Milk-based formulas are the treatment of choice. At the beginning of dietary treatment, patients should be fed ad libitum. After 1 week, intake rates should approach 175 kcal/kg and 4 g/kg of protein for children and 60 kcal/kg and 2 g/kg of protein for adults. A daily multivitamin should also be added

The child with mild and moderate mild PEM will be treated through:

v  Nutritional education including demonstration on preparing food.e.g sarbottam pitho,litho

v  Increase the calories and protein in diet by taking small meals often throughout the day.Eat or drink a nutrition supplement if any trouble in eating roght food

v  Supervised feeding

v  Food supplemantation

Diet (Formula) Composition

1. Energy provided by:                                     Protein                                    8-10 %                                     Fat                                            45 %                                     Carbohydrate                        45 % 2. Volume:    Marasmus                            100 - 120ml/kg/day                                     MK - K                                      75 ml/kg/day

The child with mild severe protein energy malnutrition will be treated through

Basis of Management

1. Restore and maintain hydro electrolytic balance.

2. Aggressive diagnosis and treatment of infections.

3. Nutritional therapy: oral feeding.

4. Prevention and treatment of complications.

5. Physical and psychological stimulation.

6. Parental education and social evaluation.

Useful Diets for the Treatment of Severe Malnutrition

DIET                                                         COMMENT

Breast Milk                                            Use it when available

Cow’s Milk                                            Lactose-malabsorption possible

Lactose - Free Formulas                  Expensive- Not available

Milk- Staple + Oil                               Safe, inexpensive, available

Cereal – Legume                                 Inexpensive, available

Chicken Based                                   Also Useful

WHO: F75, F100                                No kitchen , out-patient

Preventive management:

8^th FAO/WHO expert committee

A.  Health promotion:

1.      Measure directed to pregnabt abd lactating women(education,distribution of supplements)

2.      Promotion of breastfeeding

3.      Development of low cost of weaning food.the child should be made to eat more food at frequent interval

4.      Measures to improve family diet

5.      Nutritional education,promotion of correct feeding practices

6.      Home economics

7.      Family planning and planning and spacing of the birthings

8.      Family environment

B.  Specific protection

1.      The child’s diet must contain protein and energy rich foods,milk,eggs,fresh fruits should be given if possible

2.      Immunization

3.      Food fortificaion

C.  Early diagnosis and treatment

1.      Periodic surveillence

2.      Early diagnosis of any lag in growth

3.      Early diagnosis and treatment of infection and diarrhoea

4.      Development of programmes for early rehyr\dration of children with diarrhoea

5.      Development of supplementary feeding  programmes during epidemics

6.      Deworming of heavily infested to children

D.  Rehabilitation:

1.Nutritional rehabilitation services

2.Hospital treatment

3.Followup care

Complications of severe Malnutrition

These are usually seen in kwashiorkor and marasmic kwashiorkor:

• Serious infections, especially septicaemia or pneumonia. Gastroenteritis, tuberculosis, measles and AIDS often precipitate kwashiorkor.
• Hypoglycaemia due to loss of energy stores
• Hyothermia
• Heart failure due to a small, weak heart
• Bleeding, usually purpura
• Anaemia due to protein and iron deficiency
• Electrolyte imbalances, especially potassium deficiency
• Malabsorption
• Tremors (‘kwashi shakes’)
• Sudden death

About 25% of children with kwashiorkor die despite treatment. The long-term effect of severe malnutrition on growth and mental development remain uncertain as these children are also affected by a deprived environment.

Hypoglycaemia, hypothermia, infection and heart failure are the main causes of death in severe malnutrition.

Children with kwashiorkor have a low serum albumin, potassium, magnesium, sodium, copper and zinc. Also low glucose, transferrin and clotting factors.

PART III

Nursing process

Nursing process is defined as a systematic way of assessing the patient’s needs, planning care, implementing and evaluating the outcome of care given. It is a scientific and problem solving approach in nursing. In this caring science, our concern is the patient and his/her family, prevention of disease and promotion of health.

In my case study, I have provided care on the base of nursing process. I have address the patient by collecting subjective and objective data analysis and valid them. Then I detect some nursing diagnosis such as she was prone to malnutrition due to knowledge deficiency about nutrition, poor personal hygiene due to home health practices .So keeping those conditions of the patient I applied Nightingale’s environmental theory while caring my patient.

Florence Nightingale:The Environment Theory of nursing

The Environment Theory of nursing is a patient-care theory. That is, it focuses on the care of the patient rather than the nursing process, the relationship between patient and nurse, or the individual nurse. In this way, the model must be adapted to fit the needs of individual patients. The environmental factors affect different patients unique to their situations and illness, and the nurse must address these factors on a case-by-case basis in order to make sure the factors are altered in a way that best cares for an individual patient and his or her needs.

The ten major concepts of the Environment Theory, also identified as Nightingale's Canons, are:

S.N	Nightingale's Canons	Implementation in my client
1.	Ventilation and warming:	Well ventilation and warming was maintained by placing the client on warm environment and well instrusting the parents
2.	Light and noise:	Since ,the house was poorly gr
3.	Cleanliness of the area:	Since the area wasn’t well hygiened so the resident were encouraged for sanitation.
4.	Health of houses:	The well housing pattern was well explained and encouraged to maintained as far as possible.
5.	Bed and bedding:	The bed and beddings were maintained comforted as per child requirement
6.	Personal cleanliness:	Poor hygiene of the child was observed.the hygiened was maintained with the involvement of the care takers.
7.	Variety	The variety of needs regarding child’s regular needs,developmental milestonewere considered and the simliar environment like playing toys,interacting with mother were encouraged.
8.	Offering hope and advice	The hope via regular prgress of the child was given similiarly the regular advice for the improvement of the health status was given.
9.	Food	The child was encouraged for nutritious food,as the child was more prone to sever malnutrition anf risk for infection
10.	Observation	Continious observation was done in child’s state.Regular monitoring of nutritional satatus,height, weight,hygiene,health sate were done.

According to Nightingale, nursing is separate from medicine. The goal of nursing is to put the patient in the best possible condition in order for nature to act. Nursing is "the activities that promote health which occur in any caregiving situation." Health is "not only to be well, but to be able to use well every power we have." Nightingale's theory addresses disease on a literal level, explaining it as the absence of comfort.

The environment paradigm in Nightingale's model is understandably the most important aspect. Her observations taught her that unsanitary environments contribute greatly to ill health, and that the environment can be altered in order to improve conditions for a patient and allow healing to occur.

The nurse uses one or more nursing systems to promote a patient self care.        

Nursing Diagnosis done in my patient

·         Imbalanced nutrition:less than body requirement related to inadequate food intake

·         Impaired parenting

·         Risk for injury.

·         Diarrhoea:

Nursing Interventions

Maintaining Nutritional Status

·         Providing adequate and appropriate food intake

·         Instruction about the supplementary food and its fooding pattern

·         Breastfeeding ought to be encouraged

·         In 6- to 18-month-old children, the minimum energy density of the diet, assuming three daily meals and a functional gastric capacity of 30 g/kg body weight, has been calculated as between 1.00 and cal/g . If the child receives five meals per day, the minimum values are from 0.60 to 0.65 kcal/g.

Promoting parenting

·         Instructing about the child rearing practicesvia build up advantage of practiacal health education in domicillary setting for mother

.

Preventing Injury

·         Promoting the homley safety

·         Ehancing the immunity of the child via nutritonal updates and immunization

Protection from infections

• Improvement of sanitary homely environment
• Proper instruction for skin care and protection
• Assessment of source of malnutrition and cure it;if any disease prevalent

Promoting knowledge

• Explain the state of child to the care taker and family
• Explore the physiological need of the child and the technique for its achievement..
• Instruct family to arrange for easy access to TV, phone, computer, and stereo to limit woman getting out of bed.
• Instruct family to arrange for community support (eg, church, women's groups).

Provide sensory stimulation and emotional support

·         Regular emotional support was given enhancing the child angd the family mambers with the child improving state

·         Sensory stimulation was done by encouraging the child with activities via play therapy

Regular follow up and monitoring

·         The child was kept under survillence by instructing the parent about growth monitoring via growth chart and effort not to slip down to severe nutrition

Parent teaching on

·         Birth spacing

·         Child care

·         Maternal health status

·         Periodic health check up

NURSING    CARE     PLAN

S.N	Nursing Diagnosis	Goal of Action	Plan of Action	Rationale	Implementation	Evaluation
1.	Imbalance nutrition,less than body requirement related to ins\adequate food intake	-Estabilish dietary pattern with calorie inatke adequate to regin/maintain appropiate weight -Demonstrate weight gain to the client’s expected range	-to establish minimun weight gain and daily nutritional requirement -to provide diet with substitution,administer nutritional diet with supplementary food -to provide small frequent diet with consistence approach with pleasant environment and selectiveness	-Provide comparative  basline for effectiveness of the therapy -it will be more effective for providing ffod in enjoyable manner and treating  malnutrition -this enhance manipualtion in eating,body adjustment and likely for preferred food.	-establish minimun weight gain and daily nutritional requirement -provide diet with substitution,administer nutritional diet with supplementary food -provide small frequent diet with consistence approach with pleasant environment and selectiveness	The client nutrional status wa quite improved in daily assement. The height for weight ranges at 90th percentile at the end of 3rd week.
2	Fluid volume deficit related to diarrhoea	Improve fluid balance evidenced by adequate urine output,vital signs,good skin turgor and moist mucous membrane	-to asses the amount and frequency of diarrhoea -to assess the vital signs and capillary refill and skin turgor -tomonitor the amount and type of fluid intake(oral rehydration solution) output measuring accurately and replacing it with fluid intake	-it helps to determine the intensity of dehrdartion level -this is the indicator of circulatory volume -dehydration results in electrolyte imbalance so,the monitoring helps to identify the alteration in electrolyte balance	-asses the amount and frequency of diarrhoea -assess the vital signs and capillary refill and skin turgor -monitor the amount and type of fluid intake(oral rehydration solution) output measuring accurately and replacing it with	The hydration level of the client was established.
3	Impaired parenting  related to issue of family concern and inadequate knowledge	Family will actively involve in managing the nutritional state of the client	-to provide the adequate knowledge about the disease and its management -to involve the parents in providing care to their child -to help the family assesing the improvement pattern of their child	- it help the client to have the care in her own family with effective parenting and continious care	-provide the adequate knowledge about the disease and its management -involve the parents in providing care to their child -help the family assesing the improvement pattern of their child	The knowledge level of the parents was enhance shows by the active participation on caring the child.
4	Risk for infection related to general weakness	The infection will be prevented.	-Promoting hygeinic measures and general cleanliness -avoid exposure to cold and infection -maintain aseptic technique and hand washing practices during care -	-It helps to prevent the communicable disease cause by poor hygiene	Promoted hygeinic measures and general cleanliness -avoided exposure to cold and infection -maintained aseptic technique and hand washing practices during care	The client wasn’t symptomised with any infection.the prevention fron infection was done.
5	Knowledge deficit related to child care	The effective child care will be done involving the parents	-explain about importance of food  hygiene -informing about signs of detoriation -dicussing about support facilities available in the community to improve family income	-the knowledge help the client to have the care in her own family with effective parenting and continious care	-explained about importance of food  hygiene -informed about signs of detoriation -dicussing about support facilities available in the community to improve family income was done	The knowledge level of the parents was enhance shows by the active participation on caring the child.
6	Need for health education	To assist her in self care by upgrade knowlede	-to provide teaching about the importance of rest and exercise, nutrition diet, breast feeding and medications and regular follow up. -to provode knowledge about Immunization of baby, avoid lifting heavy and weighty. Sign and symptoms of high risk of mother and baby etc.	-upgrade knowledge awareness of health and provide self care and self dependence.It helps to self satisfaction.	-teach about the importance of rest and exercise, nutrition diet, breast feeding.continuous with medicines and regular follow up. -Immunization of baby, avoid lifting heavy and weighty. Sign and symptoms of high risk of mother and baby etc.	She can state about the importance of dofferent topics of the health care.She has positive response of health teaching so my goal was fulfilled

                                                                                                                             

  PATIENT AND FAMILY TEACHING DURING THE PERIOD

OF PROVIDING CARE

Health education is a vital part of nursing care of patient during hospitalization. It is a basis for providing preventive, promotive, curative as well as rehabilitative services to the patient including the visitors. As an approach of providing health education to my patient & visitors, I have included the following points.

About the nutrition and suplementary diet,

       I had explained the care taker of the client about the nutritionala requirement for the child and the necessity of the supplementary food(Sarbottam pitho)

About the disease

       I gave detail information to the care taker of the client about the disease including causes, signs & symptoms, treatment, prevention & health promotion.

About Treatment

       I gave health teaching to the patient about the progress of disease & the purposeof treatment

About possible complications

       The client was more liable to develop complications.The care taker were seemed worried about the state of the client so, the possible complications were explained with its preventive measures.

Daily progress and management of my case

Date:  2069/02/03

History taking about the family was done.

Ms.Sushma  Pujari’s assessment done with history taking and physical examination.

Mild to moderate malnutrition identified.

The family was well informed about the disease condition, well instructed of its management  and suggested for PHC visit for any health problems.

Height:74 cm

Weight:9kg

Head circumference:41.5cm

Chest circumference:43cm

Vital Signs:

Temperature:           97degree Fahrenheit

Respiration:              28/minute

Pulse:                         110/min

Activity level:

Well active according to the developmental milestone

  IV.            Motor:

·         Sits alone ;stands holding onto furniture

·         Has good hand to mouth coordiantion

·         Developing pincer grasp,with preference for use of one hand over the other

·         Crawls ,may go backward at first

     V.            Sensory:

·         Dispalys interest on small things

  VI.            Socialization and vocalization:

·         Definite social attachment is evident(e.g.stretches out arms to loved ones);shows anxiety with strangers(e.g. turns or pushes away and cries)

·         Responds to own name;is seperating self from mother by desire to act on own

·         Reacts to adult anger;cries when scolded

·         Has imitative and repetative speech,using vowels and consonants such as “dada”,no true words as yet ,but comprends words such as “bye bye”

Date:  2069/02/04 to Date:  2069/02/10

Unable to asses client due to banda.

Date:  2069/02/10

Ms. Pujari  was suffering from diarrhoea since last day.

Her vital signs represents normal findings.

The hydration level was normal while assessment.

She was slightly iritable .

Height:74 cm

Weight:9kg

Head circumference:41.5cm

Chest circumference:43cm

Vital Signs:

Temperature:           97degree Fahrenheit

Respiration:              28/minute

Pulse:                         110/min

Activity level:

Alert and active.

Management done:

·         Oral rehydration therapy was done.

·         The client was instructed to go to health post but diarrhoea was well managed by 7/8 hours so,not visited.

·         The instruction for hygienic environment was done

·         Reassurance was done

Date:  2069/02/11

Ms.Pujari was alert and active.NO any fresh complains were notified.

Continous monitoring and encouagemwnt about the nutrion of the child,sanitation,hygiene was given

Date:  2069/02/16 - Date:  2069/02/18

Ms.pujari seems to be well groomed.Her family seems to be more aware about he clients condition.

The sanitary laterine was built.The daily hygenic behaviours were well established.

The mother was more conscious for the feeding pattern of the child,sarbottam pitho was encouraged.

The marked development wasn’t identified in height and weight of the client.

Date:  2069/02/21

Progressively development was being observed,Ms.pujari seems to be alert as before with increasingly appetite.Her family seems to have assertive opinion about the clients condition.

The constant teaching about the improvement of the client state was given.

Height:76cm

Weight:9.5kg

Vital Signs:

Temperature:           97.8degree Fahrenheit

Respiration:              32/minute

Pulse:                         100/min

Date:  2069/02/26

Ms.Pujari was well improved in compared to the last 3 weeks.She was brought to health post for her vaccination of measles

Her percentile ranges upto 90^th percentile.

The mother was well informed about the client’s state and encouraged for continuity of care,and futher prevention af any complications

Height:76cm

Weight:10 kg

Head circumference:42cm

Chestcircumference:43cm

Vital Signs:

Temperature:           98.4degree Fahrenheit

Respiration:              22/minute

Pulse:                         88/min

Date:  2069/02/28

Ms.Pujari seems to be well active and nourished. Her family was well known about her appetite and hygienic status.Her examination revealed improved finding as follows

Height:76cm

Weight:10 kg

90 th percentile

Head circumference:42 cm

Chestcircumference:43cm

Vital Signs:

Temperature:           97degree Fahrenheit

Respiration:              28/minute

Pulse:                         92/min

Activity level:

Well active according to the developmental milestone

VII.            Motor:

·         Stands alone for short time and walks with help

·         Can sits down from a standing position without help

·         Can eat with spoonand cup but needs help

VIII.            Sensory:

·         Can discriminate between simple geometrical forms

  IX.            Socialization and vocalization:

·         Shows emotions such as jealousy,affection,anger

·         Enjoys familiar environment and will explore away from mother

·         Fearful in strange situation or with strangers,clings to mother

·         May develop habit of “security” blanket

·         Can say two words “dada” and “mama” with meaning;understands simple verbal requests such as “give it to me”

DIVERSIONAL THERAPY USED IN MY PATIENT

Everyone experiences stress and accompanying anxiety; this anxiety is increased during illness and the recovery process.

Since my client is an infant,she doesn’t represent more stress.Despite her illness,her appears to be normal,because she was more prone to be severe manourished and to the complications.

So,in order to avoid the risk of infection and promote the psychosocial development of the client,here are some of the ways that I implied on my patient.

Meeting Basic Needs

There is a close relationship between basic physiological needs and stress.

The infant’s basic need fulfillment is the prior need,so the mother was well instruction of nutritional supply,breastfeeding,warmth and affection.

Environmental Strategies

The environment was rule out unhygenic,poorly sanitized.thus the environmental hygiene was enhance so as the child will be less prone to infection due to poor hygiene.

Verbalization

Encouraging clients’ family to express their feelings is especially valuable in stress reduction. Freud (1959) used the term catharsis to describe the process of talking out one’s feelings. People instinctively know the value of “getting things off their chest” through verbalization.  Verbalization promotes relaxation primarily in two ways.  First, when a feeling is described it becomes real. Once the problem is identified, the person can begin to deal effectively with it. Also, the actual activity of talking uses energy and, therefore, reduces anxiety.

I encouraged the familyt to verbalize their feelings about disease process, family background, economical status & the care provided to child. They explained their feelings to me & experienced that their stress was minimized.

Involvement of Family and Significant Others

The family of the client are the primary source for providing care to the client so,their involvement is the priority.So,the family members were involved in each and every management of the client.

Stress Management Techniques

There are a variety of stress management techniques that can easily be taught to clients, families, and significant others. Many of these techniques are considered to be complementary modalities

as they are used in conjunction with traditional medical treatment methods (i.e., medication, radiation therapy). Some of the most common approaches for managing stress are discussed below.

Despite many stress mangement techniques,since my patient is an infant the most used appoarch was play therapy for the

Play therapy:

Play therapy enhance the child’s physical and psychological development.The play therapy involves educational,recreational sensorimotor,social and emotional adjustment of the child.

Play therapy helps a child to adapt socially,enhance motor activities,physical development and enjoyment.

I encouraged the client to play the preferred involving the family.

Health teaching

Health teaching plays an important role to prevent disease, promote health as well as to cure disease more rapidly with out any complications. One of the most important roles of the nurse is to provide health education. So I, being a nurse, I had also given health education to patient and family.

·         To promote the health

·         To motivate for early diagnosis and treatment

·         To help limit the disability

·         To keep in relationship

Keeping above objectives in mind I had given health education to the clients family about following topics.

Topics

Nutrition:

The physical development of the client is determined by the nutrional status of the client.since the client was malnourished,the nutrition was to be improved,Thus in order to improve the state the client’s family was instructed about the daily nutritional requirement of the infant.

The sarbottam pitho was encouraged with the mother breast feeding.The attractive way of presenting the food was implied so as to improve the appepite of the client.

Prevention fron injury and infection:-

The malnourished children are more likely to injury due to their rough and weak skin intregrity associated with diminished immune function related to altered body nutritional level.So,the client was well supervised for the activitites in own home area with precautious action(as every child are prone to injury) like avoiding fire,height to prevetn fall etc. In additon,diarrhoea was treated and to avoid furthe infection,the client was well cared for any signs for infection,fever,chest complications etc.

Rest and activities-

The rest and sleep

Personal hygiene-.

The family seems to be poorly hygiened.thus the requirement of the personal hygiene of the client and the family was clearified including its demerits of being unhygenic like infection,transmission of feco-oral disease etc

Care of the client-

The infant are the delicate state of the human life to rear.the client was the first child in the family,thus the family ws quite curious about the care of the client.The Fmily was encouraged for the pattern of their caring and further teaching about the care regarding physical state,psychological development,  family caring and affection was clearified.

Breast feeding of the baby including supplementary feeding:

After the weaning period,the child should be fed with appropiate foods and continue breatfeeding up to 2 years of age as far as possible.

Immunization:

There close relationship between incidence of communicable disease and malnutrition,each affecting other.So.the child should be immunized timely against vaccine preventable disease to reduce the burden of malnutrition.

Others:

·         Growth monitoring:

Regular monthly checking as in under five clinic or MCHclinic or even as home to identify any weight loss or failure to gain weight in the child.Thus ,it will helps mother to improve her feeding practise.

·         Oral rehydration therapy:

Diarrhoea is the major cause of malnutrition and mortality of the children.Repeated attacks of diarrhoea as in chronic form increases the sevirity of malnutrition.Treatment of diarrhoea with timely ORT helps to prevent dehydration and malnutrition.

 

What I learn from case study

 

    Case study is a very good approach for the students to learn about the disease & nursing practice in depth. It gives us comprehensive knowledge about a specific disease& relate with real situation. It is the suitable way of applying theory in practice in real situation. Here are some points which I learned from this case study.

1)            About the disease

               I studied about this disease in depth by the resources available in, literatures, research, internet and some journals. I also obtained information from doctor, sisters. I know about the disease, it’s causes , predisposing factors, pathophysiology, signs & symptoms, diagnosis, therapeutic management, conservative management, nursing management, complications & get a chance to compare all these with  real case.

2)  About the patient

                Through this case study I got the opportunity to know the history of patient, his personal, family,social ,occupational ,educational as well as present & past health history, his habit, way of living, ways of thinking and its influence on health and illness. I also got chance to  compare normal developmental task with the patient.

3) About the family and environment

                  I also got the information about my patient’s family background, socio-cultural and education background, concept about health and illness, nutrition, economic status, religion, traditional beliefs and general attitude of family toward the disease and treatment

4) About the nursing care

               I applied Nightingale environmental theory while proceeding nursing care to the patient, The client was given care regarding the individual care in focus.The promotion of the health was quite remarkable on the basis of nursing care provided.

 Summarization

Within the curriculum of the PBBN Nursing,4 weeks community health nursing practical was at chapagaun VDC,ward No.3,where I have selected a case for the detail study in high risk group.the summary of the case is given below:

Sushma Pujari,9month female was diagnosed as mild malnourished by her physicla examination with anthropometric comparision. In the residental setting,she was given care to improve her nutritional state and physiologic stability.

Her care takers were well instructed about her disease,its complications and its treatment .The home halth practices were improved considering the basic determinants as underlying cause of malnutrition.

The client was treated for diarrhoea.The further intervetnions were done to avoid the injury and infection.The effectiveness of the care provided and improvement is done by the regular monitroing of the client’s physical state.

During the period of providing nursing care, I had provided holistic care to them considering physical, mental, social, spiritual and economic aspect. I had provided care on the base of Nightingale Environmental theory.

In almost 3 weeks of the continuous conservative treatment pattern,the general physical state of the client seems quite more stable.the client was active as usual,with optimal weigth gain minimal exposure to injury,cure frequent diarrhoea,good appetite,immunization and hygeinc habits.

.

Conclusion

When I found this case ‘for the high risk case study’ to be very important for me, gaining new knowledge, experience about PEM (Protein Energy Malnutrition), physiology changes, complication and management and rehabilitative and health promotive state in  such types of patient care.

This case study helps me to explore out about the disease condition PEM with effective practicable management techniques.

While providing care,the Nightangle environmental theory was quite applicable in the community setting with efficient involvement of the family to provide the care to the client and progress on wards.

Thus the case study was accompanied with the nursing process. I learnt various new experiences. E.g.: theory application, conservative managementof the disease condition, knowledge about the disease and its prevention and health promotion in the residental setting etc.

At last I am satisfied with this case study because the goals (Objectives) are met.

~ THE END ~

 

 

Bibliography:-

1.        Wong’s Nursing Care of Infants and Children,

8^th edition,Hockenberry Wilson,

Mosby Elsevier

Page no:579-582

2.       Park’s textbook of preventive and social medicine

K.Park, 20^th edition,

M/S banarsid Bhanet 2009

Page no:552-555

3.       Community Health Nursing

B T Basavanthappa,1^st edition,

Jaypee

Page No:135-137

4.       Ghai Essential Paediatrics

Ghai OP,Paul Vinod K.,Arvind Bagga

7^th edition

CBS Publishers and distributions

Page No:62-77

5.       http://emedicine.medscape.com

6.    Child health Nursing,uprety kamala,pradipa printing and publishing 1^st edition pg no: 446-453

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