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
|
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.
|
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">60> |
75%
Mild malnutrition
Waterlow
z-scores (SD) below
median WFH
median WFH
Mild
Moderate
Severe
Moderate
Severe
80%–90% WFH
70%–80% WFH
<70 o:p="o:p" wfh="wfh">70>
70%–80% WFH
<70 o:p="o:p" wfh="wfh">70>
70-80%
Moderatre malnutrition
WHO (wasting)
z-scores (SD) below
median WFH
median WFH
Moderate
Severe
Severe
-3%</= z-score < -2
z-score < -3
z-score < -3
Moderate malnutrition
WHO (stunting)
z-scores (SD) below
median HFA
median HFA
Moderate
Severe
Severe
-3%</= z-score < -2
z-score < -3
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">70>
|
Ht /Age Deficit1 (%)2
2-3 (85-89)
>3 (<85 o:p="o:p">85>
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 50th
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">
50>
|
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:
8th
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 90th 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.
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.
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
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.
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,
8th edition,Hockenberry Wilson,
Mosby Elsevier
Page no:579-582
2. Park’s
textbook of preventive and social medicine
K.Park, 20th edition,
M/S banarsid Bhanet 2009
Page no:552-555
3. Community
Health Nursing
B T Basavanthappa,1st edition,
Jaypee
Page No:135-137
4. Ghai
Essential Paediatrics
Ghai OP,Paul Vinod K.,Arvind Bagga
7th edition
CBS Publishers and distributions
Page No:62-77
6.
Child health Nursing,uprety kamala,pradipa
printing and publishing 1st edition pg no: 446-453
.
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