This essay is based on a patient who was admitted to Gondar university Hospital in the paediatric ward with a diagnosis of sever acute malnutrition (SAM). The essay will discuss the assessment and management of a patient by using the holistic care approach that focuses the rehabilitation issues. After analysing the patient’s assessment and rehabilitation aspects will be discuss with its rational supported by literature, guidelines and standards. Finally recommendation will be given based on the evaluation of the care to improve the quality of nursing practice to nurses in the Hospital based on its rule and regulations

1. MSc Advanced in Clinical Pediatrics Nursing
Name of Student- Sileshi Mulatu
ID NO---5955/07
Specialty - Pediatric Track
Name of assignment- Psychosocial Case Study
Date of assignment JUN, 12, 2015
Student declaration- this assignment has been written
by me and I have not copied any words or phrases
without acknowledging the author
Signed: Sileshi Mulatu: Dated: Jun, 12, 2015
UNIVERSTY OF GONDAR
COLLEGE OF MEDICINE AND HEALTH
SCIENCE
DEPARTMENT OF NURSING

2. i
ACKNOWLEDGMENT
I extend my sincere appreciation and gratitude to Mr. Tesfaye Demeke (RN, BSc, and
MSc) for his valuable and fruitful lecture, for his provision and support at a time of doing
this essay on rehabilitation of malnutrition patient starting from the beginning to the
end. Finally, I want to thank department of nursing for their facilitation of this program and
for their all contribution throughout the time in the ward and at the time of all my doing.

3. ii
TABLE OF CONTENTS
ACKNOWLEDGMENT...................................................................................................................................i
TABLE OF CONTENTS..................................................................................................................................... ii
ESSAY ON REHABLITATION ON A PATIENT WITH MALNUTRATION..............................................................1
INTRODUCTION.............................................................................................................................................1
DESCRIPTION.................................................................................................................................................1
DISCUSSION...................................................................................................................................................2
THE REHABILITATION NURSING CARE OF A CHILD WITH MALNUTRATION .................................................3
NUTRITIONAL REHABILITATION....................................................................................................................3
NUTRATION AND EDUCATION TO THE PARENT ...........................................................................................5
DISCHARGE AND FOLLOW UP.............................................................................................................6
EXERCISE .......................................................................................................................................................7
PSYCHOSOCIAL ISSUES OF MALNUUTRATION..............................................................................................7
NURSING IMPLICATION.................................................................................................................................8
CONCULSION.................................................................................................................................................8
RECOMMANDATION.....................................................................................................................................9
REFERENCE..................................................................................................................................................10
APPENDIX I = .............................................................................................................................................12
NURSING CARE PLAN ..................................................................................................................................12

4. 1
ESSAY ON REHABLITATION ON A PATIENT WITH MALNUTRATION
INTRODUCTION
This essay is based on a patient who was admitted to Gondar university Hospital in the
paediatric ward with a diagnosis of sever acute malnutrition (SAM). The essay will discuss
the assessment and management of a patient by using the holistic care approach that
focuses the rehabilitation issues. After analysing the patient’s assessment and
rehabilitation aspects will be discuss with its rational supported by literature, guidelines
and standards. Finally recommendation will be given based on the evaluation of the care
to improve the quality of nursing practice to nurses in the Hospital based on its rule and
regulations.
DESCRIPTION
The name of the patient has been changed to B, MD for confidentiality purpose in this
essay. B, MD is a 13 months old female patient who came from Kola diba 35 Km far from
Gondar university Hospital. This child was relatively healthy until 1 week of admission.
She was with abdominal distension, loss of appetite, weight loss, vomiting and nausea.
She had oedema of lower extremity. As I took information from her mother, the mother
feed her child exclusive breast feeding till 6 month and after 6 months she was started
complimentary feeding and started from age of 6 the child was with poor appetite and
developed abdominal discomfort, vomiting and nausea at the time of feeding.
In the last 1 month the condition of the child was worsen and this condition put the family
in stress and her family brought the child in this hospital on 24.09.2007.
Her family are farmers and they are with low economic status and they can’t feed the child
especial food and the mother feed simplify the family food like enjera, Kita and other
common dry food. They are not educated and they don’t have any information about how
to care and feed the child.
On Assessment, I have been assess her vital sign and which indicated that the RR, PR,
temperature and BP is normal range. But the anthropometry; weight = 4.7kg which is
underweight MUAC=9cm this also shows the patient is malnourished, height =65 cm this
show the patient stunted and HC= 43 cm.

5. 2
This all anthropometry value indicate the patient is with SAM. In addition to that when the
weight for height is analyzed by using the Harvard curve; it became below the 5th
percentile, it is 52% meaning that the child is sever west, weight for age is less than 60
which is Marasmus, and height for age is less than 85-90 % and the patient is moderately
stunted.
Most of the time children in their first 3 years of life are particularly vulnerable for
malnutrition. This is not surprising given that this is a period when children are growing
fast and have high nutritional requirements per unit of body mass (Martorell et al. 1995;
Martorell 1999; Hoddinott and Kinsey 2001). In case of this patient since she is in the age
of 1 year, she is highly vulnerable for malnutrition (1).
DISCUSSION
Malnutrition is defined as a nutrient deficiency state of protein, energy or micronutrients
(vitamins and minerals) and a serious public-health problem that has been linked to a
substantial increase in the risk of mortality and morbidity(2).
Is “a state in which the physical function of an individual is impaired to the point where
he/she can no longer maintain adequate bodily performance processes such as growth,
pregnancy, lactation, physical work, and resisting and recovering from disease” (3).
In children who are 6–59 months of age, severe acute malnutrition is defined by a very
low weight-for-height/weight-for-length, or clinical signs of bilateral pitting edema, or a
very low mid-upper arm circumference. Severe acute malnutrition affects an estimated
19 million children under 5 years of age worldwide and is estimated to account for
approximately 400,000 child deaths each year. In most developing countries, case fatality
rates in hospitals treating SAM remain at 20–30% and few of those requiring care actually
access treatment (4).
Although data are imprecise, it is known that the risk of mortality in acute malnutrition is
directly related to severity, with moderate wasting associated with a mortality rate of 30–
115/1000/ year and severe wasting associated with a mortality rate of 73–187/1000/year.
This is equivalent to approximately 1.5 million child deaths associated with severe wasting
and 3.5 million with moderate wasting every year(4, 5).

6. 3
Severe acute malnutrition (SAM) remains a major killer of children as mortality rates in
children with severe wasting - a widespread form of SAM - are nine times higher than
those in well-nourished children (6).
Many studies show that this problem is associated with different factors like improper
weaning practice (early abrupt weaning with dilute and dirty formula), infections (diarrhea,
measles, tuberculosis, pertussis, etc.), harmful traditional practices (age bias in feeding,
sex bias, in feeding, food prejudices- omission from family diet), and child neglect (7).
Over 50% of deaths in children aged 0-4 years are associated with malnutrition, and high
priority is therefore given to its prevention and treatment. Unfortunately, hospital treatment
of severely malnourished children is often poor and old-fashioned and consequently case-
fatality rates are high. To improve treatment and reduce mortality, the World Health
Organization has published guidelines for the management of severe malnutrition in first
referral facilities (8).
THE REHABILITATION NURSING CARE OF PT’ WITH MALNUTRATION
NUTRITIONAL REHABILITATION
The aim of this phase is to restore wasted tissues and promote a rapid rate of catch-up
growth through administration of high energy and protein. Severely malnourished
children requiring inpatient care, because they have medical complications.
Nutritional Rehabilitation is mandatory for this patient to restore a healthy body weight
and improve eating behaviors of malnourished patients in order to maximize the response
to nursing intervention and to maintain healthy body weight over time, to integrate medical
treatment in patients with chronic infections(9).
In this case the patient is severely malnourished patients with medical complications, and
she admitted in the Ward. Feeding was began after admission with ‘Starter diet’ until the
child is stabilized as supported with the literatures(10).

7. 4
As the patient admitted in the hospital rehabilitation center, the care provider manage this
patient by providing 24 hour care and monitoring the child condition, treatment of medical
complications with antibiotic, assess emotional care, social assessment of the family to
identify and address contributing factors, counselling on appropriate feeding, and the
nurse feeding the patient (F75) to promotes recovery of normal metabolic function and
nutrition-electrolytic balance 100kcal/ kg/day in 24-hour care with a trained staff who
prepare and distribute the feeds 5-6 feeds per day for five days and this is evidenced by
the protocol of management of severe acute malnutrition, eight or more feeds should be
given. As evidenced by protocol for the management of severe acute malnutrition
Patients without an adequate appetite and/or a major medical complication are initially
admitted to an in-patient facility for Phase 1 treatment and the formula used during this
phase (F75) promotes recovery of normal metabolic function and nutrition-electrolytic
balance(11).
On the six day the child moves to the Transition Phase from Stabilization Phase when the
edema is absence, return of appetite, NGT is removed, reduce of medical complication
and after the patient was active. And there was gradual transition from F75 to catch up
diet (F 100). After 06 day the care giver transfer the patient from transition phase to
rehabilitation phase, Guidelines recommend that the patient transfer to rehabilitation
phase after 3-7 days of transition phase, if the patient recovered their appetite and
received treatment for medical complications they enter. The aim is to promote rapid
weight gain, stimulate emotional and physical development and prepare the child for
normal feeding at home.

8. 5
NUTRATION AND EDUCATION TO THE PARENT
The patient’s family come from the rural area and illiterate, they have no concern about
the feeding or nutritional habit of them and their child. From the literature education is one
of the most important resources that enable women to provide appropriate care for their
children (Armar-Klemesu et al. 2000).
Women who receive even a minimal education are generally more aware than those who
have no education of how to utilize available resources for the improvement of their own
nutritional status and that of their families. In Ethiopia, children whose mothers have some
primary education were 1.9 times more likely to be stunted compared to children whose
mothers had a secondary or higher education. so combined with the diets, the patients
and patient’s family are also offered Nutrition Education, to correct misinformation about
food and help family to acquire a basic understanding of the nutritional requirements of a
growing child (12).
Other studies in Ethiopia have also indicated the importance of woman’s education in
improving nutritional status (Save the Children Fund (UK) 2002, Christiaensen &
Alderman 2004). Maternal education may function in improving child nutrition through
changing caring practices, health seeking behavior and recognition of the symptoms of
malnutrition (WHO et al. 1999) or through improving caregiver’s status and enabling
decision on family’s resources. Smith and Haddad (2000) show from evidence elsewhere
that improved woman’s education has made the largest (43 percent) contribution to
reducing childhood malnutrition in recent decades (13).

9. 6
DISCHARGE AND FOLLOW UP
Many hospitals discharge children before they reach 90% weight-for-height and there is
evidence that many of these children remain malnourished and have repeated infections,
or relapse and die (14).
Early discharge is because of the relatively long duration of rehabilitation, families may
request that their children be discharged early from hospital. Reasons include concern
for the care of other family members and loss of incomes. So to prevent this problem the
nurse must monitor the patient’s condition wither the patient gain the needed amount of
weight and s/he recover from his/her nutritional problem. Requests for early discharge
may also come from hospital managers in response to bed shortages or budgetary
constraints. But as stated with literatures the dangers associated with sending children
home before they have recovered are they may remain malnourished because their home
diet is inadequate for catch-up growth, their immune function remains impaired and they
are prone to repeated infections and continuing malnutrition and repeated infections lead
to relapse and death (15, 16).
The average stay in a hospital setting in malnourished patient is varies between 10 to 15
days, but can be longer if the patient progress is not well. However according to the WHO
guideline the patient requires follow up for another 4-6 months for full recovery, depending
upon the child’s progress at home. Therefore parent/caregivers must be prepared for
discharge and follow up and before being discharged from the facility, child must become
accustomed to eating family meals (9).
Throughout in-patient care, keep the patient’s family informed of the patient’s progress
and the discharge plan. If possible, during Phase 2 conduct cooking demonstrations with
parents/caregivers on how to use local foods and maintain balanced diets because this
is an effective way to transfer knowledge, especially where literacy is an issue like this
case (3).
All SAM children should be followed up by health providers in the program till s/he reaches
weight-for-height of – 1SD. Make a plan with the parent for follow-up visits. Regular
check-ups should be made at 2 weeks in first month and then monthly thereafter until
weight for height reaches -1 SD or above. If a problem is detected or suspected, visit/s
can be made earlier or more frequently until the problem is resolved (15, 17).

10. 7
EXERCISE
Evidences thought that exercise is important for the patient with malnutrition. Emotional
and physical stimulation can substantially reduce the risk of permanent mental retardation
and emotional impairment of the patient and patient’s family and in order to reduce this
problem after the first few days of treatment, the child should spend prolonged periods
with other children on large play mats and with the mother include language and motor
activities, activities with toys, encourage the child to perform the next appropriate motor
activity (18).
Physical activity promotes the development of essential motor skills and may also
enhance growth. For immobile children, passive limb movements should be done at
regular intervals but for mobile children, play should include such activities as rolling or
tumbling on a mattress, kicking and tossing a ball, and climbing stairs etc. Duration and
intensity of physical activities should increase as the child’s condition improves (9).
PSYCHOSOCIAL ISSUES OF MALNUUTRATION
This is an important part of management and should be offered to the family as required
and this patient’s family are in distressed for how to manage their child at home and they
worry about the feature life of their child. Eevidences show there is disability related to
malnutrition and that the prevalence of moderate/severe disability was 0.7%. Physical
impairment was the most common type (42% of diagnoses), followed by intellectual
impairment (22%). Epilepsy, hearing impairment and visual impairment were less
common. Psychosocial adjustment especially family support in the home and in addition
Community awareness about the nutrition helps for social adjustment and early detection,
So as a nurse should give psychosocial care and support for these family (15, 19).

11. 8
Malnutrition is associated with depressed mood, cognitive impairment and preoccupation
with food, weight and shape. In a classic study published in 1950, Keys et al (51) studied
the effects of starvation and refeeding in healthy male volunteers who underwent 6
months of semi-starvation) and the patient who are malnourished need psychosocial
support (20).
NURSING IMPLICATION
Rehabilitation in a malnourished child should focus in the whole aspects of the child
status. The nurse should assess the child by using the WHO guideline and Malnutrition
in children can be assessed using anthropometry, biochemical indicators (e.g. a decrease
in serum albumin level) and clinical signs of malnutrition. The advantage of anthropometry
is that body measurements are sensitive over the full spectrum of malnutrition, whereas
biochemical and clinical indicators are useful only when a child is at least moderately
malnourishedinjury type (15, 21).
From these the nurse used evidenced based methods for treating, managing and
teaching children and families for better understanding and outcome of malnourished
patients
CONCULSION
Regardless of all of the efforts to address malnutrition in Ethiopia, the problems are
increasing with time. This can only be addressed through interventions focusing on food
security, better caring practices for the vulnerable, and adequate healthcare together with
a healthy environment. Many studies show that this problem is associated with different
factors like improper weaning practice (early abrupt weaning with dilute and dirty formula),
infections (diarrhea, measles, tuberculosis, pertussis, etc.), harmful traditional practices
(age bias in feeding, sex bias, in feeding, food prejudices- omission from family diet), and
child neglect.

12. 9
For the prevention of this problem the care giver play a role on awareness creation to the
community, as they need someone to feed them, counsel and guide them, and take them
to receive healthcare. The reason for the low level of proper caring practices in Ethiopia
is that most of the actions that government can take to improve caring practices have to
take place at the household and community levels through interactions with caregivers.
Moreover, these activities are not as sector specific.
After the patient come to the hospital according to the criteria the care giver should admit
as inpatient and treat this patient based on the WHO gridline and the nurse should give
holistic nursing care.
RECOMMANDATION
To the nurse
 Should be admitted the patient according to the admission criteria
 The nurse should treat and manage the patient according to the guideline
 They should be monitor patient’s condition before discharge the patient
 The nurse should give health education for parent’s about feeding practice
 They appoint the patient and the patient’s family for follow-up

13. 10
REFERENCE
1. Tesfu ST. Essays on the Effects of Early Childhood Malnutrition, Family Preferences
and Personal Choices on Child Health and Schooling. 2010;8(18).
2. Shinji Iizaka ETaHS. Comprehensive assessment of nutritional status and associated
factors in the healthy, community-dwelling elderly. 2008;8;24-31.
3. Dr. Francis Kimani Dr. S.K. Sharif OGW M, M.Med. National Guideline for Integrated
Management of Acute Malnutrition. 2009.
4. Collins S. Treating severe acute malnutrition seriously 2007;92:453–61.
5. Hidetaka Wakabayashi MaHS, MD. Malnutrition is assoc iated with poo r rehabilitation
outcom e in elderly inpatients with hospital-associated deconditioning: a prospective
cohort study. Foundation of Rehabilitation Information. 2014;46:277-82.
6. K SINGH NB, A RANJAN, HO DIXIT, A KAUSHIK, KP KUSHWAHAAND VM
AGUAYO. Management of Children with Severe Acute Malnutrition: Experience of
Nutrition Rehabilitation Centers in Uttar Pradesh, India. 15, 2014; 51.
7. Tefera Belachew CJ, Kebede Faris, Girma Mekete,, Asres aT. Protein Energy
Malnutrition For the Ethiopian Health Center Team. 2001.
8. Marko Kerac MM, Andy Seal. Management of Acute Malnutrition in Infants (MAMI)
ProjectTechnical Review: Current evidence, policies, practices & programme
outcomes Management of Acute Malnutrition in Infants (MAMI) Project. January 2010.
9. Welfare MoHaF, Government of India. Operational Guidelines on Facility Based
Management of Children with Severe Acute Malnutrition. 2011.
10.L. Ma P, P. Poulin , PhD CPsych et al. The association between malnutrition and
psychological distress in patients with advanced head-and-neck cancer. 2013;20.
11.Grellety PMGaDY. protocol for the management of severe acute malnutrition. ethiopia
– federal ministry of health 2007.
12.Benson T. An assessment of the causes of malnutrition in Ethiopia. International Food
Policy Research Institute Washington, DC, USA. November 2005.
13.Sheila Reed EC, Kouam PPea. Evaluation of Community Management of Acute
Malnutrition (CMAM): Pakistan Country Case Study. 2012.

14. 11
14.Ashworth A. Community-based rehabilitation of severely malnourished children: a
review of successful programmes London School of Hygiene and Tropical Medicine.
July 2001.
15.Akram DS. Community based nutritional rehabilitation of severely malnourished
children 2010;60(3).
16.Ashworth A. Efficacy and effectiveness of community-based treatment of severe
malnutrition. 2005.
17.al. Me. Mortality and morbidity patterns in under-five children with severe acute
malnutrition (SAM) in Zambia: a five-year retrospective review of hospital-based
records Archives of Public Health. (2015) 73:23.
18.Christophe M Pison NlJCea. Multimodal nutritional rehabilitation improves clinical
outcomes of malnourished patients with chronic respiratory failure: a randomised
controlled trial. 2011.66:953-60.
19.James Kisia VM, Velma Nyapera, David Otieno, Hellen Mwangovya. Research
Summary: Childhood Disability and Malnutrition in Turkana Kenya. International
center for evidence in disablity.
20.Neville H. Golden MaWM, MS, RD. Nutritional rehabilitation of anorexia nervosa.
Goals and dangers. 2003.
21.Blössner M, Onis Md. World Health Organization Nutrition for Health and
Development Protection of the Human Environment Geneva Environmental Burden
of Disease Series, . 2005;12.

15. APPENDIX I =
NURSING CARE PLAN
No Nursing diagnosis Goal/Expected outcomes Interventions Evaluation
1  Imbalanced nutrition (Less than
body requirements, related to
lack of knowledge and
inadequate food intake)
 Verbalize understanding of
nutritional requirements and
identify strategies to
incorporate requirements into
daily diet after discharge.
 Put the patient in phase 1, phase 2 and
rehabilitation
 Teach about nutritional requirements, and
plan an eating program
 Encourage small, frequent meals.
 understanding of nutritional
requirements
 The patient Gain the
weight evidenced by the
increment of the weight
from 4.7-to 5.2 Kg.
2  Dehydration related to
vomiting and diarrhea
evidenced by poor skin turgor
and sunken eyes
 Maintain patient’s body
fluid
 Put the patient in fluid maintenance
as prescribed by the physician
 The patient body fluid is
normal evidenced by fast
skin turgor
3  Impaired social interaction
and stress of patient’s family
related to child illness
 Relief the patient’s family
from stress
 Emotional support of the families
 Encouraged the child and family for
appropriately feeding
 Counseling and participating in child
feeding practice.
 The patient and the
family had decreased
anxiety evidenced by
good interaction with the
others
4  Risk for infection, related to
protein-calorie malnutrition
 The patient will free from
infection during
hospitalization.
 Monitoring for early detection of
infection
 Apply infection prevention measures
 Provide antibiotic as prescribed by
the physician
 Remained infection free,
evidenced by normal vital
signs.
5  Pain related to infections as
manifested by verbalization
 The patient will free from
pain
 Give anti-pain provided by the
physician
 The patient has no pain
as evidence of patient
verbalization.