NURSING CARE PLAN

 Identification Data :
 Name of the Child – Master ABHISHEK
 Age/Sex – 4 year/ male
 Address- Khajrana Indore (M.P)
 Diagnosis – Protein Energy Malnutrition
 Educational Level –not applicable
 Religion - Muslim
 Parent’s Occupation – workshop
 Family Income –approx. 70000thousand /annum.
 Present complains – Pt is looking weak and pale. Lethargy and anorexia also.
 History of present illness – As narrated by his mother, her economic conditions were not good therefore they are unable to feed properly to their child resulting loss of
weight as well as bossing of head and developed delayed milestones also.
 Socio economic Status –
Socio economic status of my patients family is poor .he is from a lower class family. Interaction with society is normal.
 Past Medical History -
Pt is not having any past medical history of hospitalization for any particular problem nor having problem during or after the delivery.
 Family History of any illness –
Type of family:- Nuclear
S. No. Name Relationship Age/Sex Health Status
1. Akbar Head of the family 30 yr normal
2. Sakina wife 27yr normal
5. MAST ABHISHEK son 4yr PEM

Family Tree:-

27 yrs 30 yrs

4yrs
 Birth History :
 Antenatal History –mother was immunized for TT while in pregnancy.
 Natal History – delivery normal vaginal and birth weight was also normal and was of the weight 2.5 kg.
 Immediate Post Natal History –baby cried just after the birth and was all right and not having any abnormality .no evidence for any complication or abnormal birth was
noted.
Feeding History –
Child had normal feeding and was having weight and height up to the mark and no difficulty in feeding and nutritional level of child noted by his close observer his mother.
 Immunization Status – immunization of child done till now with out omission and skipping he is fully immunized up to his age.
 Functional health Patterns :
 Hygiene – hygiene maintains daily as he go for toilet and bath timely but some time skip the bath and oral hygiene is poor observed.
 Dietetic History – dietary pattern of the family is poor, diet is not sufficient or adequate and vegetarian and he ate when he want unless not. no extra diet is given
 Activity exercise –as he is weak he doesn’t play much and tired too early also.
 Sleep & Rest – as he is very weak he doesn’t sleep well and most of the time he take rest.
 Cognitive / Perceptual –understand the talks of elder and perception is also developed, try to complete the task but tired early
 Values & Beliefs – follows customs and beliefs the family use to do .imitate the act of elder and involve in family assembly for worship.
 Physical Examination :
 General Appearance –looking demarceated and very weak.
 Height – 101 cm
 Weight – 15 kg.
 Mid arm circumference – 15cm
 Head circumference - 50cm
 Chest circumference - 55cm
 Vital Signs :
Temperature -98.6
Pulse -100 beats / min.
Respiration -26/min
Blood Pressure -100/60
 Head –hair distribution is normal , no any scare marks or dandruff ,fontanels complexity closed and circumference of head is 52cm and no any evidence of any head
related alteration.
 Eyes –eyes of patient are clear and no any discharge, visualization is normal, lacrimal gland functioning in normal pattern. There is no evidence of swelling.
 Ears –no ear discharge, hearing is normal and external structure is also symmetrical and normal.
 Nose –nose is clear , absence of DNS, shape is symmetrical
 Oral Cavity –oral cavity is normal in structure , bad odor is coming not hygiene properly and absence of dental caries
 Neck –symmetrical, thyroid also normal, range of motion of head and neck is slow, palpable carotid artery, not any enlargement of lymph node is detected.
 Chest & Respiratory System –rhythm is regular, chest moment up and down.
 Abdomen & Inguinal Areas –no distension, no scar, skin color same in whole body, bowl sound and peristalsis movement present.
 Upper & Lower Extremities –dislocation is not present, no deformities In extremities , range of motion is not proper.
 Nervous System –good reflexes and well developed cognition and motor activities.
 Genital & Rectal Examination –urethral opening is in middle of the penis , bladder normal urine passed ,bowl function is normal
 Skin –color: brownish in color, elasticity and texture is absent, no skin rashes are evident, and birth mark is present.
 Systemic Examination :
All system functions work properly. No hepatic enlargement is present
 Mile stones / Growth & Development :
 Biological Development –
Weight:
By 2year:-12kg
 By 3 year: 14 kg.
By 4 year: 16kg.
Height:
By 2year :-89cm
By 3 year: 95cm
By 4 year: 100cm
Gross motor development:-
 6month:- support own weight on hands and extended elbow
 1yr :- walks with a broad based gait & steps of unequal length
 2yr :- run and walks without support
 3yr :- goes up stairs one foot per step
 4yr :- goes down stairs one foot per step
Fine motor development:-
 1yr :- release an object on command
 15month:- can drink from one cup
 2yr :- can feed himself and can build a tower of 6 block
 3yr :- can dress undress himself
 4yr :- copies a cross +
Social /cognitive milestone:-
 1yr :- comes when called
 16month:-mimics action of others
 2yr :- wears simple garments/socks/shoes
 3yr :- unbutton dress
 4yr :- play with other children
Language milestone:-
 1yr :- speaks 1-2 meaning full words
 2yr :- speak 2-3 word sentences
 3yr :- good vocabulary
 4yr :- can tell a story
INVESTIGATIONS:-
S.NO INVESTIGATIONS PT. VALUES NORMAL VALUES REMARKS
1. Blood test;
CBC 9% 13-17% Decreased
Neutrophils 50% 50-70% Normal
Basophils 20% 20-40% Normal
Lymphocyte 22% 60-70% decreased
Platelet counts 1 lacs 1- 4 lacs decreased
2. Biochemistry report
Sr. albumin 3.5 4-6mg/dl Decreased
Sr. creatinine 0.4 0.5-1.5mg/dl Decreased
 3. Chest X- Ray:- reports reveals no significant problem is seen.
Medications:-
S.NO MEDICATIONS
1. Syp. Zincovit
2. Syp. PotKClor
ASSESSMENT
Subjective data:
Patient mother verbalized
me that he got easily tired
and look too weak also
objective data
I assessed that pt’s looks
very weak and his weight
is also less as compared to
height and age ; i.e; 7.5
kg
Subjective data:- patient
mother states that PT. is
very inactive and easily
get tired.
DOSE ROUTE TIME ACTIONS
2.5 mg oral BD Multi vitamin
5ml oral BD Potassium supplement.
NURSING EXPECTED PLANNING INTERVENTIONS RATIONAL EVALUATION
DIAGNOSIS OUTCOME
Imbalanced nutrition Short term goal:- to Assess the body Body weight is assessed i.e; 7.5 Helps in PT. weight is
less than body’s increase diet of patient weight of the kg comparision and increased slightly
requirement related or remove anorexia. patient. planning. by 200 gm.
to improper intake of
food. Long term goal:- To Provide the Nutritious diet including fat and
increase weight nutritious diet to protein diet is given as skimmed It covers the need
him according to milk, dalia etc. of body. Child developed
his choice. And provide diet as he wants. complains with
medicine.
Advice them to Diet is given to patient in Frequent diet
provide feeding at frequent intervals and in an increase appetite.
frequent interval. attractive manner
Monitor intake and Intake and output chart is Helps to detect the
output of the monitor. current status and
patient. any deviation .
Monitor the daily Daily weight is assessed.
weight. For further
interventions.
assess the level of Assessed the level of activity
activity of javed. tolerance.
For full co-
Involve the parents Prepared schedule of activity for operation of
for planning the him with the involvement of parents.
schedule of parents.
Activity intolerance Short term goals:- to activity for javed. Client’s capacity
related to fatigue, reduce or decreased For providing of carrying out
lack of nutrients in fatigue Helps him in Helped him in carrying out support or sense of different
diet and low body carrying out of different activities. loved for him activities are
mass. Long term goal:- to daily activities. increased.
Objective data:- I
observed that patient
activity is very slow and
dull and looks very
lethargic.
Subjective data:- pt.
mother verbalize that
randomly he s fever also.
Objective data:- I
observed that pt. is very
weak and due to this
immunity of patient is
very low that’s why he
gets easily ill.
Subjective data:
Patients verbalized me
many questions as when I
am going my home as
well as his parents also
asked many questions
objective data:
I assessed that pt’s facial
expressions are anxious
or strips of anxiety looks
on his forehead.
increase activity tolerate Assess the health Complete health history is Helps in further
level. status of the assessed. intervention and
patient includes all evaluation.
investigations.
Medications are given in time Chances of risk
of infections are
Short term goal:- Provide It reduces the risk decreased . no
Risk for infection educate them about the medications on Cleanliness of the ward as well of infections. other infections
related to immature protein energy time. as patient is properly maintained. will come or
immunity and malnutrition and reason Prevent cross seen.
decreased health status. of early infections Maintain proper infection.
cleanliness of the Teach them about the nutrition
Long term goal:- pt patient. of him.
should be free from any
infection Advice to take care I played with child to gain his To maintain good
of him related to confidence health
diet.
Assess the level of Now child is
anxiety of them. To gain his adjusted with the
I avail him toys so that he can confidence as they environment .
Anxiety and fear play with them fear with hospital
related to changes in Short term goal:- to employees.
environment and increase their Advice the mother I switch on his favorite cartoon
prolonged knowledge to stay with programme on TV. To divert his To divert his mind. Parents anxiety
hospitalization mind. level will be
decreased.
Long term goal:- to .
reduce anxiety
HEALTH EDUCATION
Health teacing is given to the family on balanced diet and high protein and energy diet.

Energy serving foods:- Cereals, Rice, Wheat, Gyegre, Potato, Sugar-cane, fruits, banana etc.
Body building foods:- Milk and milk products, Pulses, gram, legumes, eggs, paneer, etc.
CEREALS→ rice, Wheat Flore, Juwar, millets are the major sources of the energy contain both carbohydrate and protein.
PULSES→ They are the source of the protein. They do not contain fat but are the major sources of protein. They also contain Vit-B and Vit- B complex in some amount.
NUTS AND OIL SEEDS→ Nuts and oil seeds are the sources of both protein and fats.
GEEN LEAFY VEGETABLES → Green leafy vegetables are the sources of minerals, carbohydrates, protein and it also contain vitamins.
FRUITS→ Fruits are the sources of minerals and vitamins. They also contain energy in addition.
MILK AND MILK PRODUCT → Milk and milk products are good sources of protein, fats and minerals specially calcium.
FISH AND MEAT→ Fish is the protein sources and also have biological value as it contain vitamin- B complex. Meat and chicken are the Chief sources of Protein.

IMPORTANCE
Food is the prime requirement of the life. Many people maintain their heath only by the maintenance of the diet. Physician and health agency also indicate the importance of diet
in the daily life. A balance diet is prepared to meet for maintaining of health, vitality and general well-being. A balance diet is accepted mean of safeguard the population from
nutritional deficiency.

FUNCTIONS OF BALANCE DIET

1. It provide energy for daily activity.
2. It has food stuff which help in body growth and regeneration and repairing of body tissue.
3. It helps in the regulation of body functions.

STUDENTS EVALUATION-
During caring the patient I learnt many things about protein energy malnutrition in children and common problems faced by the patient with PEM, the management used to treat
such patients and also various nursing diagnosis and interventions used to care the patient.