LESSON PLAN ON

PEM(PROTEIN ENERGY MALNUTRITION)

SUBJECT- NUTRITION

PREPARED BY
RITA BHARGAV
NURSING TUTOR
GENERAL INFORMATION:

NAME OF THE STUDENT : RITA BHARGAV

SUBJECT : NUTRITION

TOPIC : PEM

DURATION : 1Hr

PLACE : LECTURE HALL

METHOD OF TEACHING : LECTURE CUM DISCUSSION

LANGUAGE : ENGLISH & HINDI

A-V AIDS : HAND OUT, BOOKLET, FLASHCARDS

PREVIOUS KNOWLEDGE OF GROUP: GROUP HAS PREVIOUS KNOWLEDGE ABOUT PEM.

GENERAL OBJECTIVES:

AT THE END OF THE TOPIC THE STUDENT GAIN KNOWLEDGE ABOUT PEM.

SPECIFIC OBJECTIVES:

 Explain about the definition of PEM.

 Explain about the clinical symptoms of PEM.
 Explain about the classification of PEM.
 Explain about the Kwashiorkor.
 Explain about the marasmus.
 Explain about the Miasmic kwashiorkor
 Explain about the severe acute malnutrition.
S.No TIME SPECIFIC OBJECTIVE CONTENT TEACHER STUDENT A-V AIDS EVALUATION
ACTIVITY ACTIVITY

1. 5min Explain about the Definition-Protein energy Lecture cum Listening Flash-cards, What is the
definition of PEM. malnutrition is a term used to describe discussion leaflet, definition of
clinical disorders, resulting from poster PEM?
deficiency of protein and energy. It
mostly occurs in preschool children
and diarrhoea is the main cause of it.

Explain about the clinical Lecture cum Listening Flash-cards, What are the
5min symptoms of PEM.  Clinical symptoms of PEM- discussion
2. leaflet, clinical
Failure to grow, thinning, poster symptoms of
weakening and wasting of PEM?
muscles.
 Edema which is due to
accumulation of fluids in the
tissue.
 Irritability and apathy.
 Change in skin colour, peeling
and ulceration.
 Change in hairs which become
dry and sparse and take on a
 characteristic red colour.
 Loss of appetite, vomiting,
diarrhoea resulting in
dehydration.
 Anaemia, increased
susceptibility of infection.

5min Explain about Lecture cum Listening Flash-cards, What is the

classification of PEM. Classification of PEM-Classification of discussion leaflet, classification
PEM is as follows- poster of PEM?
3.
1. Kwashiorkor
2. Marasmus
3. Miasmic kwashiorkor
4. Severe acute malnutrition

8min Explain about the Lecture cum Listening Flash-cards, What is the
Kwashiorkor. discussion leaflet, Kwashiorkor?
Kwashiorkor-Kwashiorkor is a severe poster
form of malnutrition characterized by
4. is too much fluid in the body’s tissues,
which causes swelling under the skin.
Kwashiorkor is a debilitating and life
threatening condition caused by a lack
of protein in diet.

SIGN AND SYMPTOMS OF

KWASHIORKOR –
 Pitting edema is a characteristic
sign.
 Weight loss or decreased
 muscle mass in arms and legs.
 Swollen abdomen due to fatty
liver and increased capillary
permeability resulting in
ascites.
 Peripheral edema resulting
from decreased oncotic
pressure.
 Anaemia, desquamative rash
on flexures and buttocks, skin
pigmentation.
 Thinning of hair.
 Failure to gain body weight and
retarded growth.
 Lethargy or apathy and inability
to fight infections due to poor
immunity.
 Change in hair colour.
 Diarrhoea
 Shock
 Loss of teeth
 Anorexia
 Poor renal function
 Behavioural changes
DIAGNOSIS OF KWASHIORKOR - The
physical examination shows general
swelling, protruded belly and
hepatomegaly.
TREATMENT OF KWASHIORKOR -
 In the early stage of disease,
 treatment revolves around
providing an adequate diet for
Child , with more calories and
protein.
 Carbohydrate in the form of
simple sugars and fats, are
given.
 Proteins are given after other
sources of energy have been
8min Explain about the provided.
marasmus.  Vitamins and minerals are also Lecture cum Listening Flash-cards, What is
essential to restore the discussion leaflet, marasmus?
nutritional status of the poster
patient.

Marasmus-Marasmus is a type of
malnutrition primarily caused by a
deficiency in calories and energy.
5.
There is a severe deficiency of nearly
all nutrients, especially proteins,
carbohydrates and lipids.
CAUSES OF MARASMUS -
 Decreased energy intake
 Increased loss of ingested
calories due to emesis
 Chronic diarrhoea
 Burns
 Increased energy expenditure
 Viral, bacterial, parasitic
 infections
 Bottle feeding
 Combination of the above
factors
SIGN AND SYMPTOMS OF
MARASMUS
 Shrunken, wasted appearance
is the classical presentation of
marasmus.
 Prominence of ribs, slow
growth and drastic loss of
adipose tissue.
 Chronic diarrhoea, muscle
atrophy especially in the upper
arms and buttocks.
 Skin folds, ‘old man’ face.
 Unusual body temperature.
 Anaemia, dehydration.
 Corneal lesions due to vitamin
A deficiency.
 Dermal manifestations, otitis
and rhinitis.
 Tachypnea and paralysis of the
lower extremities.
 Weak bladder and bowel
control.
 Blood or mucus in the stool.
 Lethargy and fainting or
alteration of awareness and
persisting vomiting.
DIAGNOSIS OF MARASMUS–
 Blood glucose
 Haemoglobin
 Examination of blood smear
 Albumin value
 Electrolytes
TREATMENT OF MARASMUS–
 Correct water and electrolyte
balance. Use of nasogastric
tube , continuing breastfeeding
as soon as possible,
contraindicated in shock and
coma. Start other food after 3-
4 hours of rehydration.
 Treat infection.
 200cal/kg of body weight/day.
 Counsel the parents and plan
the future, including the
immunization and
supplements.
 Add frequent small meal.
 Use the liquid diet and prevent
hypothermia.
 Give vitamin A and folic acid.
 In case of shock, provide
intravenous rehydration With
RL solution and 5% dextrose.
 Encourage the child to eat
frequently.
 Stimulate the emotional and
 physical development of the
child.
PREVENTION OF MARASMUS -
HEALTH PROMOTION –
1. Health education and
nutritional supplements for
pregnant and lactating
mothers.
2. Development of low3 coast
weaning food.
3. Improvement of family diet.
4. Nutrition education.
8min Explain about the severe 5. Home economics.
acute malnutrition. 6. Family planning and spacing of
birth. Lecture cum Listening What is severe
discussion acute
SPECIFIC PROTECTION – malnutrition?
1. Provide a diet rich in calories,
protein and other dietary Flash-cards,
essential such as milk, eggs and leaflet,
fruits to pregnant and lactating poster
mothers and children.
2. Immunization against disease.
3. Early diagnosis and treatment
REHABLITATION – Nutritional
rehabilitation services formula given
by NIM Hyderabad that is
“NUTRITIOUS LADDU” with the
following method-
1. Green gram- 100g
2. Bengal gram- 100g
6. 3. Whole wheat flour- 100g
4. Jaggary- 100g
5. Desi ghee- 150g

Severe acute malnutrition-

Severe acute malnutrition is defined as

the presence of oedema of both feet
and severe wasting or mid –upper arm
circumference less than 115mm.

DIAGNOSIS OF SEVERE ACUTE

MALNUTRITION –
 Mid –upper arm circumference
less than 115mm.
 Oedema of both feet
( kwashiorkor with or without
severe wasting)
Children
with severe malnutrition should first
be assessed with a full clinical
examination to confirm whether they
have any general danger sign, medical
complications and an appetite.
Children
with severe acute malnutrition with
loss of appetite or any medical
complications have complicated
 severe acute malnutrition and should
be admitted for inpatient care.
CLINICAL MANIFESTATION ON
PHYSICAL EXAMINATION –
 Shock
 Signs of dehydration.
 Signs of dehydration.
 Severe palmer pallor.
 Bilateral pitting oedema.
 Eye sign of vitamin A
deficiency.

SEVERE ACUTE MALNUTRITION IN

INFANTS AGED LESS THAN 6 MONTH
–
General danger signor serious clinical
condition for infants six months or
older-
 Recent weight loss or failure to
gain weight.
8min Explain about the nursing  Ineffective breastfeeding
care of patients with directly observed separated Lecture cum Listening Flash-cards, What is the
PEM. area. discussion leaflet,poster nursing care
 Pitting bilateral oedema of the for Pem?
feet.
 Any medical problem.
TERATMENT OF SEVERE ACUTE
MALNUTRITION –
  Give parenteral antibiotics to
treat possible sepsis, and
appropriate treatment for
other medical complications.
 Re-establish effective exclusive
breastfeeding by mother or
other caregiver.
 For infants with severe acute
malnutrition with no oedema,
give expressed breast milk.

Nursing care of patients with PEM-

ASSESSMENT –
 Assess the normal growth and
7. development of child.
 Assess skin, hair, and
musculoskeletal system.
 Assess neurologic and
cardiovascular status for
alertness, attentiveness,
developmental delay etc.
 If feasible, observe the parent
feeding the child.
 Assess child’s overall tone,
sucking pattern, oral sensitivity,
lip and tongue function, and
swallowing function.
 Obtain nutritional history
 regarding eating pattern.
 Measurement should be
plotted on growth chart.
 Birth measurement should be
obtained and entered for
comparison.
NURSING INTERVENTIONS –
 Administer multivitamin
supplements as prescribed.
 Demonstrate proper feeding
techniques including details on
how to hold and how long to
feed the child.
 Provide a quiet, non-
stimulating environment for
eating.
 Develop individualized teaching
plan to instruct parents of child
dietary needs.
 Specify type of diet, essential
nutrients, serving size, and
method of preparation.
 Promoting adequate nutrition.
 Advice family that some
nutritional intervention will be
continued until appropriate
height for age reached.
 Maintain high – nutrient diet
until weight is appropriate for
height (usually age 4 to 9
 months).
 Maintain intake and output.
 Gradually increase nutrients,
and use small, frequent
feedings with adequate fluids
to ensure hydration.
 Assess child’s age appropriate
milestones.
 Assess child’s growth by using
age-and gender –appropriate
growth chart.
 Make regular visits to
community and home care
considerations.
 Parents participating in child’s
care, using appropriate feeding
technique.