PROTIEN ENERGY MALNUTRITION: NURSING MANAGEMENT.pptx
Protein‑Energy Malnutrition (PEM) Definition: PEM is an energy deficit caused by inadequate intake of macronutrients, commonly seen as marasmus, kwashiorkor, and marasmic‑kwashiorkor. Forms of PEM: Marasmus: Severe calorie and protein deficit → extreme wasting, “monkey-like” face, thin limbs. Kwashiorkor: Protein deficit post-weaning → edema, fatty liver, skin/hair changes. Marasmic-Kwashiorkor: Features of both. Classification Systems: Gómez (Wt/Age): >90% normal, ≤60% = 3rd-degree malnutrition Waterlow (Ht/Age): >95% normal, ≤85% = 3rd-degree IAP (Wt/Age): >80% normal, ≤50% = Grade IV WHO Terms: Stunting = Height-for-age < -2 SD Underweight = Weight-for-age < -2 SD Wasting = Weight-for-height < -2 SD Clinical Features: Marasmus: Wasting of fat and muscle, no edema, low serum proteins, anemia Kwashiorkor: Edema, fatty liver, low albumin, anemia, skin/hair changes Diagnostic Evaluation: Clinical: History, physical signs Anthropometry: Wt/Ht/age z-scores, MUAC Lab: CBC, serum albumin, electrolytes Dietary: 24-hour recall Imaging: If comorbidities suspected Management Phases: Initial (1–2 weeks): Stabilize – manage hypoglycemia (10% dextrose), hypothermia (warmth), infections (antibiotics), dehydration (ORS/ReSoMal), correct electrolytes, give vit A, K, folate. Small, frequent feeds (milk-based); NG if needed. Rehabilitative (2–6 weeks): Increase diet to 150 kcal/kg/day, give fluids (100–125 mL/kg/day), structured stimulation. Follow-Up: Discharge when Wt/Ht ≥85–90% expected. Train caregivers for home care and follow-up. Hospitalization Needed: Children with weight <60% expected, <1 year, or complications. Nursing Management: Assess for malnutrition, complications Monitor vitals, weight, glucose, electrolytes Administer feeds and supplements (vit A, iron, zinc) Rehydrate with ORS/IV fluids Educate caregivers on protein-rich diets and hygiene Involve parents for better home continuity Prevention Strategies: Promote breastfeeding and timely complementary feeding Nutritional counselling for mothers Regular growth monitoring and immunization Improve sanitation, clean water access, food security Implement feeding programs for at-risk children Possible Nursing Diagnoses: Imbalanced nutrition: less than body requirements Risk for infection Fluid volume deficit Impaired skin integrity Delayed growth and development Knowledge deficit regarding nutrition
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PROTIEN ENERGY MALNUTRITION: NURSING MANAGEMENT.pptx
- 1. PROTIEN ENERGY MALNUTRITION Mr. Pradeep Abothu, M.Sc (N), PhD Scholar, Associate Professor, Dept. of Child Health(N) ASRAM College Of Nursing
- 2. DEFINITION Protein-energy malnutrition, is an energy deficit due to deficiency of macronutrients. The term protein- energy malnutrition refers to a group of related disorders that include Marasmus, Kwashiorkor and Marasmic – Kwashiorkor.
- 3. Marasmus: means withering or wasting. Marasmus occurs due to inadequate intake of proteins and calories and is characterized by emaciation. Kwashiorkar: means sickness of weaning. Kwashiorkar involves inadequate intake of protein and is characterized by presence of edema.
- 4. Classification of PEM: a. weight for age classification by Gomez: Weight for age Nutritional status >90% normal 76–90% 1st degree malnutrition 61–75% 2nd degree malnutrition ≤60% 3rd degree malnutrition Weight for age (%) × 100
- 5. b. Waterlow’s classification on the basis of height for age: height for age (%) × 100 height for age nutritional status >95% normal 90–95% 1st degree malnutrition 85-90% 2nd degree malnutrition ≤85% 3rd degree malnutrition
- 6. c. Classification given by Indian Academy of Pediatrics on the basis of weight for age: Weight for age Nutritional status >80% normal 71-80% Grade I malnutrition 61-70% Grade II malnutrition 51-60% Grade III malnutrition ≤50 Grade IV malnutrition
- 7. C. Who classification Who recommends 3 terms for describing malnutrition in under five children 1. Stunting: it is defined as, height for age being 2 standard deviation below from median height for age, given in NCHS reference population. 2. Underweight: it is defined as, weight for age being 2 standard deviation below from median weight for age, given in NCHS reference population. 3. Wasting: it is defined as, weight for height being 2 standard deviation below from median weight for height for age, given in NCHS reference population.
- 8. Marasmus • Growth failure • Wasting of all tissues including muscles and adipose tissue • Oedema present • No hepatic enlargement • Serum proteins low • Anaemia present • Monkey-like face , • Protuberant abdomen, • Thin limbs Clinical Features:
- 9. Kwashiorkor • Periorbital edema & sunken eyes, pot belly • Growth failure • Wasting muscles but preserved adipose tissue • Edema , localized or generalized, present • Enlarged fatty liver ,Serum proteins low • Anemia present • Alternate bands Of light and dark hair Clinical Features:
- 11. • Clinical assessment: diet history, growth trend, edema, skin/hair changes • Anthropometry: Wt/age, Ht/age, Wt/Ht z scores; mid upper arm ‑ ‑ ‑ circumference • Laboratory: CBC, serum albumin & total protein, electrolytes • Dietary assessment: 24 h recall / food frequency ‑ ‑ • Imaging (as needed): USG or X ray for comorbid conditions ‑ Diagnostic evaluation:
- 12. MANAGEMENT: Management of PEM primarily involves nutritional rehabilitation, which can be conducted at home, in nutritional rehabilitation centers (NRCs), or in hospitals, depending on the severity of the condition. Children with mild to moderate malnutrition without infections or complications can be effectively managed at home. Children weighing less than 60% of their expected weight, those with complications or age under one year should be admitted.
- 13. Care in the Hospital: Hospitalization is essential for children with severe PEM, primarily to address life-threatening complications and to stabilize their condition. Children may need admission due to critical issues such as severe edema, dehydration, or infections, which require close monitoring and intensive care.
- 14. Treatment progresses in three phases: i. Initial Phase: Stabilization and Intensive Care (1-2 weeks) In this phase, immediate medical attention is crucial. The focus is on stabilizing the child by managing complications and initiating feeding. Treating Complications: Complications such as edema, severe dehydration, persistent diarrhea, hypothermia, hypoglycemia, shock, infections, jaundice, or bleeding should be treated promptly. • Hypoglycemia: The child may have seizures or become unconscious due to hypoglycemia (blood glucose < 54 mg/dL). Administer 10% glucose at 5-10 ml/kg body weight to prevent death.
- 15. Hypothermia: Infants under 1 year with marasmus are prone to hypothermia. Use the kangaroo mother technique or keep small babies in an incubator. Older children should be covered with warm blankets, and rectal temperature should be monitored. Infections: Children with PEM are at risk for infections like septicemia. Antibiotics are given based on blood culture results, and aseptic techniques should be observed.
- 16. Electrolyte Disturbances: Common issues include hypernatremia and hypokalemia. Limit salt intake initially to prevent sodium overload. Treat hypokalemia with potassium supplementation (30-40 mEq/L). Dehydration: Correct dehydration slowly over 12 hours using ORS or ReSoMal (70-100 mL/kg). For severe cases, use Ringer's lactate (30 mL/kg in 2 hours). Deficiencies: Administer vitamin A (50,000 to 200,000 IU) based on age, folic acid (5 mg first day, 1 mg/day), and vitamin K (2.5 mg IM). Immediate Feeding: If oral intake is not possible, nasogastric tube feeding is initiated promptly. The child should receive frequent, small amounts of a milk-based diet to kickstart recovery.
- 17. ii. Rehabilitative Phase: Nutritional Restoration (2 – 6 weeks) Once stabilized, the child enters the rehabilitative phase, characterized by intensive feeding and recovery efforts. The goal is to reverse the malnutrition and regain weight through consistent and intensive feeding. Nutritional Support: The dietary regimen consists of high-protein, high-calorie foods, starting at 80 to 100 kcal/kg/day and gradually increasing to 150 kcal/kg/day. Fluid Management: Ensuring fluid intake remains at 100 to 125 ml/kg/day is vital to prevent dehydration while facilitating recovery.
- 18. iii. Follow-Up Phase: Transition to Home Care As the child’s condition improves, a transition plan is developed: Preparation for Discharge: Before leaving the hospital, the child should reach 85 to 90% of the expected weight for height. Parents are trained in ongoing nutritional support and care routines to continue at home. Continued Monitoring: Regular medical check-ups are arranged to ensure the child maintains growth and to prevent relapse.
- 19. Nursing Management: • Assess nutritional status and identify signs of malnutrition. • Identify and manage complications such as electrolyte imbalances, hypoglycemia, and hypothermia. • Administer therapeutic diets to stabilize and catch-up growth. • Provide micronutrient supplementation (e.g., zinc, iron, vitamin A). • Monitor vital signs, including temperature, pulse, respiration, and blood pressure. • Regularly track weight gain and growth parameters.
- 20. • Administer prescribed medications. • Manage dehydration with oral rehydration salts (ORS) or intravenous fluids. • Educate parents on feeding techniques and nutritional requirements. • Guide parents on providing a balanced diet rich in proteins, calories, vitamins, and minerals. • Advise on the inclusion of nutrient-dense foods like eggs, milk, meat, fish, legumes, and nuts. • Involve parents in the care process to ensure continuity at home.
- 21. Prevention: • Conduct community education programs on the importance of nutrition, breastfeeding, and complementary feeding. • Offer nutritional counseling services to pregnant and lactating mothers. • Ensure routine vaccinations to prevent common childhood diseases. • Implement regular growth monitoring and screening programs. • Encourage routine health check-ups for early detection of malnutrition.
- 22. • Advocate for programs aimed at improving food security and reducing poverty. • Promote supplementary feeding programs in vulnerable populations. • Ensure access to clean drinking water to prevent waterborne diseases. • Promote the use of proper sanitation facilities to reduce the risk of infections. • Educate the community on basic hygiene practices to prevent infections.
- 23. Possible Nursing Diagnosis: • Imbalanced nutrition less than body requirements related to inadequate dietary intake and malabsorption. • Risk for infection related to compromised immune function due to malnutrition. • Fluid volume deficit related to dehydration from diarrhea or insufficient intake. • Impaired skin integrity related to edema, dry skin, or pressure ulcers. • Delayed growth and development related to inadequate nutritional intake. • Deficient knowledge regarding nutrition and dietary needs related to lack of education or resources.
- 24. THANK YOU…