2. Specific objectives
• By the end of lesson learner should be able
to:
Define nutritional disorders
Define malnutrition
State the causes of protein energy
malnutrition
3. CONT
State the predisposing factors of protein
energy malnutrition
List clinical features of protein energy
malnutrition
Describe management of protein energy
malnutrition
Explain preventive care of protein energy
malnutrition
5. MALNUTRITION
• Malnutrition- This is lack of nutrients or poor
nutrition. The cellular imbalance between
supply of nutrients & energy and the body's
demand for them to ensure growth,
maintenance and specific functions”.
• Malnutrition may be due to an excess, deficit
or imbalance in the essential components of a
balanced diet.
6. MAIN CAUSES OF MALNUTRITION
1) Direct causes
2) Underlying causes
10. PROTEIN ENERGY
MALNUTRITION (PEM)
• This condition is also referred to as protein
calorie malnutrition (PCM).
• It is the most common form of under nutrition
in children.
11. Clinical Forms of Protein Energy
Malnutrition
• The two clinical forms of protein energy
malnutrition are:
Kwashiorkor - main deficient nutrient is
protein
Marasmus- the deficiency is caloric
12. KWASHIORKOR
• There is a lack in protein relative to calories,
often associated with a normal growth pattern
until six to eight months of age when the
weight of the child begins to decrease.
14. CLINICAL FEATURES OF
KWASHIORKOR
Growth failure
Edema of the face, hands, anus, feet
and bulging abdomen
The hair becomes thin, straight and
brownish in color
The child has poor appetite and is
irritable
15. CONT
There is mental apathy and lack of
interest in the surroundings
Diarrhea
Hepatomegaly and anemia
Reduced plasma proteins lead to ascites
16. MARASMUS
• Refers to starvation. The disease is
caused by lack of food of any kind, which
includes proteins, carbohydrates, fats and
vitamins.
17. CLINICAL FEATURES OF MARASMUS
Muscular atrophy, with loss of
subcutaneous fat and legs and arms are
thin
Wrinkled, thin and flaccid skin
The face of the child usually looks old
and anxious
18. CONT
The child may have diarrhea or
constipation
The child has very good appetite when
being fed but does not put on weight
19. PREDISPOSING FACTORS OF PEM
Knowledge about the nutritional values
Cultural norms
Poverty
21. MANAGEMENT OF PEM
• The moderate and severe types of protein
energy malnutrition must be investigated
to enable the health care worker to
establish the origin or cause of
malnutrition in different children
22. INVESTIGATION TO ESTABLISH
CAUSE OF MALNUTRITION
Take history that is family and social
history
Conduct a physical examination
A blood test for white blood cells,
hemoglobin and malarial parasites
should also be conducted.
23. cont
• Stool test should be carried out to
exclude the possibility of intestinal
worms.
24. CONT
• If the child is very sick, cold or
collapsed, then they should be
hospitalized and an IV infusion of
glucose should be commenced.
•
25. CONT
• Any infection should be managed with
appropriate antibiotics.
• The child should be kept warm and a
doctor has to be called urgently.
26. cont
• Severe cases should used tube feeding.
• As the condition of the patient
improves, undiluted milk, sugar, oil
and vitamins should be given.
• Staple foods are gradually introduced.
27. CONT
• As the condition of the child
gradually improves the feeding tube
should be removed and a cup or a
cup and spoon should be used to feed
the child.
28. CONT
• The parent/guardian should be
involved in the feeding of their child
under the supervision of the nursing
staff.
• A high calorie feed should be
commenced after two to four days,
with solids being cautiously and
slowly introduced
29. cont
• Feeds should initially be given at two
to three hour intervals and later, as
the child's condition improves, the
quantity of food should be increased
and given after every four hours.
30. CONT
• The amount given each time must be
documented on the fluid and feeding
chart. Urine output must also be strictly
monitored
31. NURSING CARE OF PATIENTS
ADMITTED IN THE WARD
Vital signs
Sanitation and hygiene
Counseling by nutritionist on diet
Health education on discharge
Drugs advice
Prevention of complications
32. VITAMIN A DEFICIENCIES
Risk Factors
Low availability of vitamin A-rich foods
Lack of breastfeeding
High rates of infection (measles, diarrhoea)
Malnutrition
33. CAUSES OF VITAMIN A DEFICIENCY
Some diseases may increase the risk of
VITAMIN A DEFICIENCY because they:-
Reduce appetite so that a person eats less
vitamin A
Decreased absorption vitamin E.g. due to
diarrhea, worms
Increased vitamin A needs in disease
conditions e.g. measles.
34. CLINICAL FEATURES
Reversible dryness of the conjunctiva and the
cornea
Night blindness during early stages
Keratomalacia
Bitot's spots (white 'foamy' areas) often seen near
the lateral part of the sclera of the eye
35. MANAGEMENT
• Supplementation
Vitamin A deficiency can be treated by
administering 200, 000 i.u. orally.
Start a second dose the following day.
Administer a third and fourth dose of
200,000 i.u. orally one to four weeks later.
In children below the age of 12 months,
the vitamin A dosage is 100, 000 i.u.
orally.
36. MANAGEMENT
As pre-formed vitamin A in foods from animals
e.g. Liver, fish
As pro-vitamin A in some plant foods e.g. red
palm oil, carrots, yellow maize, liver, mangoes
Health education on diet
Treat infections and malnutrition
TCN eye ointment to apply on the active lessions
Eye shield to cover the eye
37. PREVENTION
• Measles immunization
• High dose of vitamin A supplements
• Encouragement of breast feeding, which should
be continued during illness including diarrhea
• Promotion of local production and consumption
of green leafy vegetables and also animal
products
• Environmental sanitation and personal hygiene
measures especially those designed to prevent
diarrheal disease.
38. Vitamin D Deficiency
• Vitamin D is essential for the development of
strong bones and teeth.
• A deficiency in this vitamin affects the
epithelial structures of the skin, the mucous
membrane and eye.
39. Clinical Forms of Vitamin
Deficiencies
• These are of two types namely :
Rickets
Osteomalacia
40. RICKETS
• Rickets can be described as a failure in the
mineralization of rapidly growing bone or
osteoid
tissue.
• It occurs in infants, toddlers and adolescents as
a result of vitamin deficiencies.
41. OSTEOMALACIA
• Osteomalacia is defined as a failure in the
mineralisation of the mature bone.
• It occurs in adults whose bones are already
fully grown.
42. PREDISPOSING FACTORS
Premature babies
Hereditary factors
Failure to expose infants to sunlight may also
result in deficiencies.
Failure to breastfeed or mother taking
inadequate vitamins
Diseases in infants
43. CLINICAL FEATURES OF RICKETS
Dentition is also delayed and teeth are
defective when they grow
The pelvic bones may become flattened.
The abdomen may protrude
Sweating, diarrhoea and vomiting may
occasionally be present
The child is often miserable and sleeps less at
night
44. Signs and symptoms in babies
Soft skull bones
Fontanelle take long to close
Swelling of bones in wrists and ankles
Muscle weakness, floppy can’t stand
Greenstick fractures
45. Signs and symptoms in children
Late walking
Bow legs
Knock knees
Adolescents’ pain in legs and back
Pelvic deformities causing difficult childbirth
46. The Management of Rickets
Giving an adequate amount of vitamin D and
minerals in the diet.
Vitamin D supplements should be continued
daily at the dose of 500-50,000 I.V., either
orally or by intramuscular injection.
The child should be exposed to sunlight daily.
The parents should be advised to avoid the use
of thick nappies, as these tend to bow the
femur by separating them.
47. CONT
The infant should be nursed flat on a hard
mattress during the acute stage with restriction
of walking or crawling.
Where splints are used to correct the bowing,
care should be taken to prevent sores.
In a few cases surgical intervention may be
required.
Rehabilitative care is essential.
48. Preventive Care
Exposure of babies to sunlight for a few hours
a day
Provision of Well balanced diet which includes
vitamin D supplements
Health education should be extended to
schools so that all members of the community
who interact with children on a regular basis
49. OSTEOMALACIA
• Failure in the mineralisation of the mature
bone.
• Occurs mostly in women with D deficiency
54. MANAGEMENT
• Infants should be kept warm and
comfortable because they tend to feel
cold.
• Provide the necessary care to prevent the
skin from breaking.
• The parents should be given health
education about the need for the child to
maintain lifelong use of thyroid
medication.
55. CONT
• The infant’s vital signs should be
monitored
• A general physical observation for
manifestations such as diarrhea,
vomiting, sweating, weight loss,
insomnia and personality changes.
56. Zinc Deficiency
Causes
Reduced dietary intake
Chronic conditions such as cancer, alcohol
addiction, celiac disease and chronic liver
disease.
Losing excess amounts of zinc from the body
through poor absorption
60. MANAGEMENT
Regular zinc supplements can greatly reduce common
infant morbidities in developing countries
Given in treatment of:
diarrhea
• 20mg/ kg for 10 days
Dietary diversification
• Animal protein (oysters, red meat)
61. B1 DEFICIENCY(BeriBeri)
Deficiency of vitamin B1results in
Delay growth in children
Difficulty walking and paralysis of the legs
Progressive, severe weakness and wasting of
muscles
Edema of legs, trunk and face
Polyneuritis- degeneration of nerves
Susceptibility to infections
62. TYPES OF BERIBERI
Dry Beri Beri
Wrist & foot drop
• Weakness
• Weight loss
• Disturbance of sensation
• Progressive ascending paralysis of the toes,
fingers, and limbs.
63. CONT
Wet Beri Beri
Edema
• Heart enlargement and failure leading to
acute swelling (edema)
• Increasing in breathlessness and sudden death
64. INFANTILE FORM OF BERIBERI
• Occurs after an acute infection with loss of
appetite, vomiting, restlessness, and pallor.
The infant becomes breathless, cyanotic with
a weak rapid pulse. In severe cases aphonia
occurs. In older infants CNS signs of spasmodic
contraction of facial muscles and convulsions
as well as fever.
65. Treatment
Give thiamine orally or injection
Give other vitamins, may be deficient too
Prevention
Cut down or quit alcohol
Give fortified foods
Thiamine supplements
66. B2 DEFICIENCY(RIBOFLAVIN)
Deficiency of vitamin B2 leads to:
Cracking of the skin commonly around the
mouth
Blurred vision
Cataract formation
Corneal ulceration
Glossitis-Inflammation of the tongue
67. B3 Deficiency( Niacin)-Pellagra
• Deficiency of vitamin B3 leads to pellagra and
it occurs within 6-8weeks of severe deficiency.
It is characterized by 3 Ds:
Dementia
Dermatitis
Diarrhea
68. MANAGEMENT
Niacin supplement 300mg to500mg orally or
100mg parenteral
If there’s encephalopathy give injectable form
of Niacin 100-250mg
Give other B vitamins
Foods rich in vitamin B3
69. Vitamin C Deficiency(Ascorbic acid)
• A deficiency in vitamin C leads to scurvy.
• It occurs in children between six to sixteen
months of age, chronic alcoholic people, drug
users.
70. CLINICAL FEATURES
Small blood vessels fragile
Gums reddened and bleed easily
Teeth loose
Joint pains
Dry scaly skin
Lower wound-healing, increased susceptibility
to infections, and defects in bone development
in children
71. MANAGEMENT
• Treatment involves a course of ascorbic acid
tablets
• Vegetables, fruits and fruit juices are also
useful to prevent deficiencies.
72. IRON DEFICIENCY (ANEMIA)
CAUSES
• Nutritional deficiencies
• Malaria
• Intestinal parasitic infections
• Chronic infections e.g. HIV
• Malabsorption.
• Not breastfeeding
• Diet rich in caffeine or cereals which inhibit iron
absorption.
73. OBESITY
• Causes of obesity
• Food and activity-people gain more weight
when they eat more of calories than they
burn through activity. This imbalance is the
greatest contributor to weight gain.
• Genetics
• Environment –food advertising encourages
people to buy unhealthy foods such as high-
fat snacks sand sugary drinks.
74. CONT
• Health conditions and medications- some
hormone problems may cause overweight and
obesity such as underactive thyroid, Cushing
syndrome and polycystic ovary syndrome.
• Stress , emotional factors and poor sleep- some
people eat more than usual when they are upset
,bored, angry or stressed. Less sleep also causes
obesity in that, hormones that are released
during sleep control appetite and body’s use of
energy.
76. Reference/Further Readings
• Basavanthappa, B.T. (2013). Community
Health Nursing practice (7th ed.) New
Delhi: Jaypee Brothers Medical Publishers
• 2. Dude, K. (2014). Nutrition Essentials
for nursing practice (7th ed.). Wolters
&Kulwer.
• www.health grades. Com>right-care/food-
nutrition-and –diet/zinc-deficiency
