BIOGRAPHICALINFORMATION

Name : Abhiyaan Sharma

Age : 3years
Sex : Male
Address : Satwari Jammu
Religion : Hindu
IPNo. : 555680
Admission unit :ward 22
Date of admission :13-04-24
Diagnosis :Protein Energy Malnutrition Grade –III

CHIEF COMPLAINTS

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

PRESENT ILLNESS

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

PAST HEALTH HISTORY

CHILDHOOD–ILLNESS:-
There is no significant history of childhood illness, trauma, or immunization patient doesn’t
have any experience of previous hospitalization.
PASTMEDICAL-SURGICALHISTORY:
Patient is known case of dehydration as diagnosed 2yrs back .No Diabetes, or other
chronic illness & has not undergone any surgical interventions.
MEDICATION & ALLERGIES:
As a known PEM, he regularly takes the medication diet according to standard body
requirement. No history of any habitual OTC medications, not habituated to any herbal
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preparations or self preparations.

PERSONAL HISTORY PERSONAL STATUS: he hold acute place in his family along
with his mother & family.

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

ALCOHOL HABITS: not a known alcoholic.

SMOKING HABITS: not habituated.
LIFESTYLE: well playing with other children.
SLLEEPING HABITS: Sleeps 8hrs/night & 2hrs/day, doesn’t have any problems in sleeping.
RELIGION & FAITH: He is a Hindu by religion and is involved in traditional and cultural
activities frequently.

FAMILY HISTORY

34years 27years

1year 5years 3years

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

S. No Name Relation Age Health status Occupation

1 Sunil Father 34yrs Healthy merchant
2 Sushmita Mother 27yrs Healthy housewife
3. Abhyaan Son(patient 3yrs Admitted nil
t)
4 Suraj Son 1yr Died -
5 Chaman Son 5yrs Ukg studying
2
PSYCHOSOCIALHISTORY
Patient maintains good relations with family members, relatives and friend.
NUTRITIONAL HISTORY
Recent Weight: 7kg, Expected Weight: 14kg. Appetite: Poor
24Hours
Child taken only two meals in last 24 hours and each meal contains 2 idly with chatni.
Water intake approximately 400-500 ml.

Degree of Malnutrition:
=actual weight/expectedweightX100
=7/14X100 50%
III Degree malnutrition
Menu plan for Durga Prasad as per standard daily requirement
Time Item Calorie Protein
8Am !/2cupmilk+1tspghee+2biscuits+ 136Kcal 3gm

1tspsugar

10Am 1 cup cooked rice+2 spoon Dhal+1 tsp ghee 220Kcal 4gm

12pm 300Kcal 4gm

1egg+1Chapati+3spoonsugar+1tspghee

2pm 220Kcal 8gm

1cup rice+2spoon dhal+1tsp ghee

5pm 150Kcal 8gm

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

7pm 220Kcal 4gm

1cup rice+1tsp ghee+2spoon dhal

9pm 214Kcal 4gm

1 Banana+ ½ cup rice+1/2 spoon ghee+
Vegetables
Total 1460Kcal 35gm

3
ENVIRONMENTAL HISTORY

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

GROWTHANDDEVELOPMENT

Child’s growth and development has not achieved to normal extent. Gross
Motor development: child was unable to take steps on tip of toe. Fine motor
development: not able to hold spoon properly to take food.

Sensory development:

Able to identify geometric figures, accommodation well developed.

Vocalization: able to understand simple comments, and asks about objects for name
psychosocial development: child is in the sense of autonomy.
Psychosexual development: child is in the anal stage and bladder control not yet achieved
Intellectual development: child is in sensory motor stage.
Spiritual development: child is in intuitive projective faith

ELIMINATIONPATTERN
Bowel :bowel sounds are dull

Bladder :bladder control not yet achieved.

PHYSICALEXAMINATION
General Observation

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

Vital Signs
Temperature : 100oF
Pulse : 92bts/min
Respiration : 30 breaths/min

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Skin And Mucus Membrane
Color : Normal brown

Edema : Present

Moisture : Dry

Temperature : Increased
Turgor : Normal
Any Abnormal Discharges : No

Head
Skull/Cranium Size, Shape : Normal Movements :
Normal movements : Normal
Forehead :No scars
HAIR
Changes in Texture : Hypo-pigmented

Characteristics : Brown in color, sparse and not distributed densely

Lice : Absent
Nails
Changes in Appearance : Clubbing of nails
Cyanosis : Absent
Texture : Softening of nails

FACE
Appearance : Presence of facial puffiness

Color : Normal brown

Symmetry : Symmetrical

Movements : Normal

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 :Normal

EYES

Eye Lids : Normal

Lacrimation : Poor

Conjunctiva : Pale

Sclera : Clear

Pupil : Equally reactive and accommodate light.

EARS
Appearance : Symmetrical

Discharges : Nil

Lesions : Nil

Any Abnormalities : Nil

NOSE
Appearance : Normal

Discharges : Nil

Patency : Patent

Sense of Smell : Normal

Mouth And Throat

Lips : Dry

Tongue : Not coated

Teeth : Deciduous teeth are present

Gums : Normal

Buccal Mucosa : Normal

Palate : No cleft palate

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Tonsils : Not inflamed

Taste : Normal

NECK
General Appearance : Normal
Trachea position : Centrally located
Lymph Nodes : No palpable lymph
Thyroid Glands : No thyroid enl.
Cysts and Tumors : Nil
Gastro-Intestinal System
Diarrhea : Absent
Constipation : Absent
Bleeding : Absent
Worm Infestation : Suspected
Psychosocial History
General Status of the Family: Durga Prasad belongs to poor class family with a monthly
income of 1000/-. His father is a daily wager. He is living with his father, mother and two
elder sisters. They are living in their own house. Electricity supply is available in the
house. There is no proper sanitary facility.

Activities of Daily Living: Durga Prasad lost his interest in daily activities and looks
dull.
Sl. Investigation Results Normal values Remarks
No.
1. Hemoglobin 5.2gm/dl 12-16gm/dl Severe anemia
2. TLC 12,700cells/mm 4000-11000cell/mm Inflammation
present
3. Lymphocyte 62% 20-45% Increased
4. Monocyte 02% 2-10% Normal
5. Eosinophils 04% 1-8% Normal
6. RBC 3.53milcells/mm 3.5-5.5milcell/m Normal

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 MEDICATIONS;
Medication name Dosage Frequenc Route Actions Side effects Nursing
y responsibilities
Inj. Amikacin 225m Bd IV Binds to 30s Tinnitus, Perform test for
g ribosomal vertigo, ataxia hearing acuity. Avoid
subunits of and deafness concurrent use of

1. Tab.B Od Oral susceptible ototoxic drugs Monitor

Complex 50mg bacteria, thus Nausea and for the signs of

inhibits vomiting hypervitaminosis.
protein
synthesis.
Vitamin B
complex and
Vitamin C
supplement

8
 DESCRIPTION OF
DISEASE
PROTEIN ENERGY MALNUTRITION

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

INCIDENCE:

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

NORMALPROTEINANDENERGYREQUIREMENTOFCHILDREN

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

0-6months 108/kg 2.0/kg
6-12months 98/kg 1.65/kg
1-3years 1240 22
4-6years 1690 30

TYPESOFPROTEINENERGYMALNUTRITION

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

a clinical syndrome characterized by loss of subcutaneous fat and
muscle wasting

2. Marasmic Kwashiorkor: Weight less than 60% of expected body

weight for the age with features of Marasmus with edema.

3. Kwashiorkor: Weight below 60-80% of expected weight with

growth retardation and generalized body edema.

GRADING OF PROTEIN ENERGY MALNUTRITION

a) Gomez Classification:
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Grade I -76-90%ofaverageofweight.

Grade II -61-75%ofaverageweight.

Grade III -60%andbelow60%ofaverageweight.

b) The Water Loo classification

• Nutritional Marasmus -below60%ofaverageweightwithoutedema

• Kwashiorkor -60-80%ofreferenceweightwithedema.
• Marasmic Kwashiorkor -below60%ofreferenceweightandedema

c) Indian Academy of Pediatrics:

• Above 80% of expected weight -Normal

• 70-80% of expected weight -Grade I
• 60-70% of expected weight -Grade II
• 50-60% of expected weight -Grade III
• Less than 50% of expected weight -Grade IV

MARASMUS

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

and it usually occurs in the first year of life, resulting in wasting and growth
retardation. Marasmus accounts for a large burden on global health.

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

energy though protein deficiency accompanies it.

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

chiefly in first year of life.

ETIOLOGY:

a) Primary Cause: Primary cause is the dietary cause. In adequate diet

both qualitatively and quantitatively.

b) Secondary Causes:

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 • Age: Marasmus is more common in infant than in other ages. It is
because of high nutritional requirement of infant (Protein: 2-
3gm/kg/day; Calorie: 1200 Kcal/day) and hence Marasmus
develops soon in infancy

• Congenital Disease: Congenital disease which limits the intake and

digestion of food.

• Chronic Vomiting: Disease like pyloric stenosis and relaxed

cardiac sphincter, which increase the risk of vomiting there by,
decreases the absorption of the nutrients from the GI tract.

• Chronic Infection: Chronic infections like Congenital syphilis,

tuberculosis and respiratory infection which results in protein loss.

• Repeated episodes of chronic diarrhea will impair the digestion and

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

• Serious organic disorders of heart, brain and kidney and some

metabolic disorders and juvenile diabetes mellitus.

• Other causes include Transition from breastfeeding to nutrition,

poor foods in infancy.

GRADINGOFTHEMARASMUS:

Grade I : Loss of fat in axillae and groin

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

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

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CLINICALMANIFESTATIONS

• Appearance of toothless old man and a monkey look.

• Growth retardation as evidenced by marked loss of weight and

subnormal height.

• Gross muscle wasting

• Absence of edema.

• Eyes will be sunken

• Disappeared subcutaneous fat.

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

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

• Bones will be prominent.

• Anemia

• Sub normal temperature.

• Skin becomes as hen gray because of anemia

• Atrophy and wasting of body tissues especially subcutaneous fat.

• The child will be apathetic and lethargic.

• Recurrent infections

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

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

Biochemical Investigation : Biochemical investigation to estimate the plasma
protein level.
Plasma protein levels will not be noticeably reduced.
Pathological references : Liver does not show pathological fatty infiltration.

Reduced organ weight of lung and heart

MANAGEMENT:
❖ Calorie requirement of the undernourished infants are greater than
those of normal infants it almost doubled.

❖ The aim of treatment is to provide sufficient proteins, calories, and

other nutrients for nutritional rehabilitation and maintenance.
❖ In case of severe PEM, restoring fluid and electrolyte balance parentally is the

Initial concern . A patient who shows normal absorption may receive

enteral nutrition after anorexia has subsided.

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

introduced slowly. Carbohydrates are given first to supply energy, and
then high-quality protein foods, especially milk, and protein-calorie
supplements, are given.

❖ Start with the concentrated food of about 200 Cal/kg body weight
gradually 2-3 weeks and continued till the weight gain.

❖ Protein requirement should be 4gm/kg bodyweight/day.

❖ A patient who’s unwilling or unable to eat may require supplementary feedings through a
naso-gastric tube or Total Parenteral Nutrition (TPN).
❖ Secondary causes should be treated
❖ Accompanying infection must also be treated, preferably with antibiotics that don’t inhibit
protein synthesis.

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KWASHIORKAR:

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

caused by inadequate protein intake. It is, therefore, a macro nutrient deficiency.

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

lethargy (mental apathy) and growth failure.

INCIDENCE:

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

In India it is estimated that about1-2% of pre schoolers suffer from Kwashiorkor.

ETIOLOGY:
Book Picture Patient Picture
• Unavailability of suitable protein rich -
Foods

• Faulty feeding habits -

• Super imposition of infection and Suspected case of worm infestation

Infestations

• Age Incidence Age is 3y, peak age of incidence

Higher incidence is found between1

To 3y ears.
Breastfeed till 2 years of age.
• Prolonged breastfeeding
-
• Seasonal Incidence
-
• Family size
Lack of awareness of health services
• Lack of Accessibility and availability
Of Health Services

13
Book Picture Patient Picture
• History and Physical examination Done
• Anthropometric measurements MAC-14cm

• Biochemical investigation
o Low serum albumin(<3.5-5gm/dl) Not done
o A/G ratio will be reversed(1:1.5) Not done
o Decreased serum amino acid level. Not done
o Decreased blood cholesterol level. Not done
o Decreased pancreatic enzymes. Not done
o Decreased serum Iron and Copper. Not done
• Organ Changes elicited by Imaging studies:
o Fatty liver Present and enlarged
4cmbelow RCM

o Atrophy of acinary cells of pancreas Not elicited

Not elicited.
o Atrophic changes in stomach and intestinal villi.

14
 MANAGEMENT

1. Dietary modifications

2. Control and Treatment of infections

Book Picture Patient Picture

Management: 1.Dietary
modifications Dietary
Management:
Liberal protein rich foods to be given with adequate
calories. Proteins:
About5to6gmsofprotein/kg/day. Highproteindietwith7-
8feedsada
Thetotalaverageproteinintakeofchildis50-60gm/day.
Calories:
Caloriesshouldbeinrangeof120-150Kcal/kg/day.

1.ControlandTreatmentofinfections On antibiotic therapy

(Inj. Amik
225mgBD)

On Becosule capsule
2.CorrectionofVitamindeficiencies
for
Vit-B and C
Supplementation

15
NURSING CARE PLAN
SR.N NURSI PLANNING
O ASSESS NG OBJECTIVE INTERVENT IMPLEMENTAT EVALUA
MENT IONS ION TION
. DIAGN
OSIS
1 Subjective Imbalanced Child will Assess
- achieve
the and Child
maintain
is severely
normal nutritional
Nutrition of
data: nutrition; status as nutritional
- evidenced by
malnourished
weight gain. child is
Mother less than - status and .i.e. 3rd degree improved to
says “My body degree of malnutrition. some extent
son is not requiremen malnutrition. as evidenced
gaining t related to Assess the Decreased by increased
weight decreased - causes for utilization of interest to
adequately” utilization malnutrition. nutrients due to take food
of nutrients fatty infiltration and mild
Objective secondary - Prepare diet of liver. increase in
data: to fatty plan and Prepared diet menu weight. i.e.
Weight:7kg infiltration educate plan based on the 8.2kg.
(expectedwt1 of the liver. mother to child condition.
4 kg) serve food
accordingly. Vitamin
Grade III Identify for deficiency
malnutrition: the signs of present.
vitamin Provided oral Vitamin
Supplements.
deficiencies
Administer
Vitamin
Supplements

16
 SR NURSI PLANNING
ASSESSM NG OBJECTI INTERVEN IMPLEMEN EVALUATI
NO. ENT VE TIONS TATION ON
DIAGN
OSIS
2.
Subjective Hypertherm Child will Monitor vital Body Child’s body
data: ia Temperature
Mother says Related to Achieve signs Is Temperature
“My and is
son’s skin is Inflammator Maintain Loosen the 100oF. Within normal
y
Some what Reaction Normal Clothing and Loosen the Limits
hot” body
Secondary temperatur switch on the Clothing and
to e
Objective data: Hepatomega As Provided Temperature:
lly. evidenced fan. proper
Temperature:10 Provide 98.6F
0oF By plenty Ventilation.
Pulse:92bts/mi temperatur Off fluids to Advise the
n e drink mother
Within Apply cold To provide
normal plenty
limits. Of water and
compress
fluids.
Advised
mother to
Provide Keep wet cloth
tepid on
sponge. Forehead to
Administer Reduce the
prescribed temperature.
antipyretics
-----

Administered
Inj PCM

17
 SR NURSI PLANNING
ASSESSM NG OBJECTI INTERVEN IMPLEMEN EVALUATI
NO. ENT TATION ON
DIAGN VE TIONS
OSIS
3.
Subjective Hypertherm Child will Monitor vital Body Child’sbody
data: ia Temperature
Mother says Related to Achieve signs Is Temperatureis
“My and
son’s skin is Inflammator Maintain Loosen the 100oF. Withinnormal
y
Some what Reaction Normal Clothing and Loosen the Limits
hot” body
Secondary temperatur switch on the Clothing and
to e
Objective data: Hepatomega As Provided Temperature:
lly. evidenced fan. proper
Temperature:10 Provide 98.6F
0oF By plenty Ventilation.
Pulse:92bts/mi temperatur Off fluids to Advise the
n e drink mother
Within Apply cold To provide
normal plenty
limits. Of water and
compress
fluids.
Advised
mother to
Provide Keep wet cloth
tepid on
sponge. Forehead to
Administer Reduce the
prescribed temperature.
antipyretics
-----

Administered
Inj PCM

18
 SR NURSI PLANNING
NO. ASSESS NG OBJECTI INTERVEN IMPLEMEN EVALU
MENT DIAGN VE TIONS TATION ATION
OSIS
4. Subjective Deficient Parents Assess the Understandin Parents
data g gained
will level of knowledge
- gain
Mother says Knowledge Level of the Knowledge
they of Regardin understand parents
ing
Have not the parents g the- is poor. Regarding
taken child related to nutrition of parents. uneducated the
Educate the mother
for nutrition al parents nutritional
immunization and require regarding the regarding the requirement
causes and condition of
. ment of symptoms of s
their child.
the Malnutrition.
Immunizati Of the child,
on Explain the
child
Parents
Objective data Need of And its
and regarding Educated
child
parents
Child not immuniza the daily Manageme
tion- nutritional Regarding the
received nt
immunization need of requirement Measures to And
Vaccines and child. of the child. Improve the Immunizati
food Educate the on
pattern was parents Nutrition Need of
regarding status and child.
inappropriate
the prescribed
- importance menu plan.
of Explained the
immunizati Importance
on of the and schedule
of vaccination
under-five
and
child. encouraged
Educate for future
Regarding the Immunization.
measures to Educated
prevent
complications parents
of Regarding the
malnutrition. prevention
and
management
of
complications.

19
 HEALTHEDUCATION
• Educate them (patient & family member)to–
• Take high caloric diet and in on rich diet.
• To avoid activities which causes fatigue
• To take proper rest and sleep.
• Do not perform any heavy work.
• Take the medicine on time and care for the follow up.

BIBLIOGRAPHY:
1. MarlowDR,ReddingBA.TextBookofPediatricNursing.6thed.NewDelhi: Elsevier India
Private Limited; 2006.
2. Wilson D & Hockenberry MJ. Nursing Care of Infants and Children. 8 th ed. New
Delhi: Elsevier Private Ltd; 2007.
3. http://en.wikipedia.org/wiki/Marasmus
4. http://www.faqs.org/nutrition/Kwa-Men/Marasmus.html
5. http://wrongdiagnosis.com/m/marasmus/intro.htm
6. http://social.jrank.org/pages/378/Marasmus.html
7. http://en.wikipedia.org/wiki/Kwashiorkor
8. http://www.umm.edu/ency/article/001604.htm
9. http://www.wrongdiagnosis.com/k/kwashiorkor/intro.htm

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