COLLEGE OF NURSING Silliman University Dumaguete City Resource unit on Nutrition and Malnutrition

August 22, 2008 Submitted to: Ms. Rochelle Ellen B. Reyes, R.N. Prepared by: Bayawa, A.I. Antonette N. Bermudez, Grace Judith V. Umbac, Leah Marie B. NCM101-H2

1st Semester SY, 2008-2009 Topic: Placement: Time Allotment: Unit Description: Nutrition and Malnutrition Level III, First Semester 90 mins. This unit deals with the basic concepts of nutrition, the 5 basic types of nutrients and its other areas. It also includes a brief discussion of the proper nutrition during childhood in terms of adequate energy, protein, vitamins and minerals and planning for childrens meals. It also deals with the concepts of malnutrition; its types, causes, treatments & ways of prevention, and the important nursing responsibilities. At the end of our 2 hours discussion, our listeners shall have gained knowledge about the basic concepts, types and effects of nutrition and malnutrition, at the same time, manifest beginning skills and positive attitudes to support nutrition and integrate proper nursing interventions to malnourished patients. Content Prayer Introduction of the Topic 1. Define nutrition and its related terms. 1.0 Nutrition 15 mins. A. Nutrition - is the study of food in relation to health of an individual, community or society and the process through which food is used to sustain life and growth. B. Nutrients - is a chemical component needed by the body for one or more of these three general functions: (1) to provide energy, (2) to build and repair tissues, and (3) to regulate life processes. Warm-up questions T.A. 2 mins. 3 mins. Claudio, V. and Dirige, O. (2002). Basic Nutrition for Filipinos. 5th edition. Manila, Philippines: Merriam & Webster Bookstore, Inc. Nutrition:Conce Oral Evaluation T-L Activities Resources Evaluatio n

Central Objective:

Specific Objectives Within 90 minutes, the learners shall:

Enumerate and differentiate the types of nutrients.

1. Carbohydrates - are a big group of organic compounds prominent in plants which contains the elements carbon, hydrogen, and oxygen. The simplest unit is the saccharide or sugar, including glucose and sucrose. Polysaccharides are carbohydrates of much greater molecular weight and complexity; examples are starch, glycogen, and cellulose. . Carbohydrates perform man vital roles in living organisms. Sugars, notably glucose, and their derivatives are essential intermediates in the conversion of food to energy. Starch and other polysaccharides serve as energy stores in plants, which provide a major energy source for animals, including man. Carbohydrates also act as a protein-sparer. To save or spare protein for this unique function of body-building, carbohydrates must be adequate in the diet. If energy is not sufficiently supplied by carbohydrate sources, fat catabolism is excessive at a rate the body cannot handle. Carbohydrates prevent incomplete oxidation of fat. The brain and the nerve tissues utilize only glucose for energy. A constant supply of glucose must reach these important tissues. Unlike fat storage in adipose tissues, glycogen provides immediate source of energy. Commonly called fiber or roughage in the diet, cellulose, an indigestible polysaccharide acts as a broom and regulates intestinal peristalsis. 2. Lipids - any of a diverse group of organic compounds, occurring in living organisms that are insoluble in water, but soluble in fat solvents. A fat molecule has the elements carbon,

pts and Controversies. 9th Ed. Copyright 2003. Thomson Learning ,Inc Whitney and Sizer Carol Matson Porth. (1998).Concept s of altered health status. Lippincott, Philadelphia, New York. Claudio, V. and Dirige, O. (2002). Basic Nutrition for Filipinos. 5th edition. Manila, Philippines: Merriam & Webster Bookstore, Inc. Understandi ng Nutrition 8th Ed. Whitney and Rolfes Copyright 1999. Wadsworth

hydrogen and oxygen. Lipids have a variety of functions in living organisms. Fats and oils are a convenient and concentrated means of storing food energy in plants and animals. As adipose tissue, fat is the largest reservoir of potential energy. Moderate deposits of fat beneath the skin and around internal organs act as protective pad and give support to the organs. If adequate energy is supplied by fat and carbohydrate sources, protein is spared or saved for its unique function of tissue-building and repairing. Fats are suppliers of essential fatty acids, one that cannot be synthesized in the body and should be ingested preformed or ready-made from food sources. It is also a carrier of fat-soluble vitamins (A, D, E, and K) since these needs a fat-soluble medium to keep them in solution and to facilitate reactions. 3. Proteins are large complex organic compounds composed of amino acids as the building units linked together in peptide bonds. Proteins comprise carbon, hydrogen, oxygen, and nitrogen. Proteins accomplish all three functions of a nutrient: body-building, regulating process and supplying energy. They are also essential for growth since all living cells in the body need them plus the available EAA and nitrogen to synthesize new protein. Without these, there will be loss of weight and emaciation. Proteins are also good source of essential amino acids. In addition to maintaining the bodys structure,

Publishing Company. Kozier, E. (2004). Fundamentals of nursing: concepts, process, and practice. 7th edition. Philippines.

Edelman and Mande.(2002). Health promotion throughout the lifespan.5th ed. USA: Mosby,Inc.

proteins speed up chemical reactions in the body, serve as chemical messengers, fight infection, and transport oxygen from the lungs to the bodys tissues. 4. Vitamins - are potent organic compounds of unrelated chemical composition which occur in minute quantities in foods and are needed in small amounts for specific regulatory functions and for the maintenance of life and normal growth. They differ; however in that the body does not extract usable energy from vitamins, rather it uses vitamins as helpers in metabolic processes. Vitamins can function only if they are intact, but because they are complex organic molecules, they are vulnerable to destruction by heat, light, and chemicals agents. This is why the body handles them carefully. The strategies of cooking foods at moderate temperatures, in or over a small amount of water, and for short times all help to preserve the vitamins. There are 13 different vitamins, each with its own special roles to play. One vitamin enables the eyes to see in dim light, another helps protect the lungs from air pollution, and still another helps make the sex hormones. When you cut yourself, one vitamin helps stop the bleeding and another help repair the skin. Vitamins busily help replace old red blood cells and the lining of the digestive tract. Almost every action in the body requires the assistance of vitamins. 5. Minerals - In contrast to vitamins, which are

Describe the nutrition during childhood.

organic compounds, the minerals are pure inorganic elements. That means minerals occur in the simplest of chemical forms, as atoms of a single element. Some minerals are put together in orderly are fluids rays in such structures as bones and teeth. Some minerals are found in the fluids in the body and influence their properties. Whatever their roles, minerals are not metabolized, nor they yield energy. Some 16 minerals are known to be essential in human nutrition. Others are still being studied to determine whether they play significant roles in the human body. Still other minerals are not essential nutrients, but are important nevertheless because they are environmental contaminants that displace the nutrient minerals from their workplaces in the body, disrupting body functions. 6. Water - If the importance of a nutrient is judged by how long we can do without it, water ranks as the most important. A person can survive only eight to ten days without water, whereas it takes weeks or even months to die from a lack of food. Water circulates through our blood and lymphatic system, transporting oxygen and nutrients to cells and removing wastes through urine and sweat. Water also maintains the natural balance between dissolved salts and water inside and outside of cells. Our joints and soft tissues depend on the cushioning that water provides for them. While water has no caloric value and therefore is not an energy source, without it in our diets we could not digest or absorb the foods we eat or eliminate the bodys digestive waste.

The human body is 65 percent water, and it takes an average of eight to ten cups to replenish the water our bodies lose each day. How much water a person needs depends largely on the volume of urine and sweat lost daily, and water needs are increased if a person suffers from diarrhea or vomiting or undergoes heavy physical exercise. Water is replenished by drinking liquids, preferably those without caffeine or alcohol, both of which increase the output of urine and thus dehydrate the body. Many foods are also a good source of waterfruits and vegetables. C. Nutrition During Childhood: Energy and Nutrient Needs 1.Energy Intake and Activity - Individual childrens energy needs vary widely, depending on their growth and physical activity. A one year 10 mins. old needs about 1000 kcalories a day; a three year old needs only 300 kcalories more. By age ten, the child needs about 2000 kcalories a day. Total energy needs increase slightly with age, but energy needs per kilogram of body weight actually decline gradually. Inactive children can become obese even when they eat less food than the average. They would do well to learn to enjoy physical play and exercise. Some children, notably those adhering to a strict 20 mins. vegetarian diet, have difficulty meeting their energy needs. Grains, vegetables, and fruits provide plenty of fiber, adding bulk, but too few Lecture Discussio n Oral Evaluation

2. Define malnutrition and its related terms.

Lecture Discussio n

Oral Evaluation

Differentiat e acute from chronic malnutrition.

kcalories to support growth. Differentiat e undernutrition from overnutrition and give examples each. 2.Protein - Like energy needs, total protein needs increase slightly with age but when the childs body weight is considered, the protein requirement actually declines gradually. The estimation of protein needs considers the requirements for maintaining nitrogen balance; the quality of protein consumed and added needs of growth. 3.Vitamins and Minerals - The vitamin and mineral needs of children increase with their ages. A balanced diet of nutritious foods can meet childrens needs for these nutrients, with the notable exception of iron. 4.Planning Childrens Meals - To provide all the needed nutrients, childrens meals should include a variety of foods from each food group in amounts suited to their appetites and needs. Serving sizes increase with age. To ensure that children have healthy appetites and plenty of room for nutritious foods when they are hungry, parents and teachers must limit access to candy, cola and other concentrated sweets. If such foods are permitted in large quantities, the only possible outcomes are nutrient deficiencies, obesity, or both. The preference for sweets is innate; most children do not naturally select nutritious foods on the basis of taste. Overweight children need help in selecting nutrient-dense foods that will meet their nutrient needs within their energy allowances.

Sweets need not be banned altogether. Children who are exceptionally active can enjoy highkcalorie foods such as ice cream, pudding or pancakes. As for sedentary children, they need to become more active, so they can also enjoy some of these foods without unhealthy weight gain. 2.0 Malnutrition A. Malnutrition - a pathological state resulting from a relative lack or absolute deficiency or excess of one or more essential nutrients. B. Types of Malnutrition 1. Acute Malnutrition - That which relates to present state of nutrition. An indicator for this is weight-for-height. 2. Chronic Malnutrition - That which relates to past state of nutrition. An indicator for this is height-for-age or stunting of growth. C. Forms of Malnutrition 1. Undernutrition - It is a pathological state resulting from the consumption of inadequate quantity of food over an extended period of time. Protein-Energy Malnutrition (PEM) - is the most common and wide spread form of malnutrition in the developing country such as the Philippines. It is manifested in two forms: marasmus and kwashiorkor.

 Marasmus - The word marasmus comes from a Greek word which means wasting. A marasmic child has the appearance of a shrunken wizened old man, a living skeleton with skin and bones. The child has no fat accumulation in his liver, and little or no fat under h is skin to insulate against the cold. Unlike the kwashiorkor child who has been usually fed with milk until weaning, the marasmic child may have been neglected from early infancy, thus is found to be low both in calories and protein. Kwashiorkor - Kwashiorkor was first used in Ghana, Africa. It comes from Ghana language that means the evil spirit infects the first child when the second child is born. Nutrition scientists find the name appropriate because it often develops in a child, who after weaning from breast on the birth of the second child. is given a diet consisting mainly of starchy food or sugar water. The first child begins to sicken and die, just as if an evil spirit accompanied the new baby and set out to destroy the older child. What actually happens is that protein deficiency follows soon after weaning. Breast milk provides a child with sufficient protein, but if weaned with a diet starchy food or sugar water that is generally a protein poor diet, the child is then unable to receive enough amino acids to maintain a childs body, much less enough to enable it to grow. Hence, the child may get enough calories but not enough protein. The classical

syndrome consists of depigmentation of hair and skin, edema in the limbs and flabby moon-like face. Marasmus-Kwashiorkor Mix - is an advanced and calorie deficit together with increased protein requirement or loss. This results in rapid decrease in anthropometric measurements with obvious edema and wasting and loss of organ mass. Vitamin A Deficiency (VAD) - is another important deficiency found in the country. Vitamin A is essential for growth, vision, healthy skin and mucous membrane. The deficiency is due to the low intake of the vitamin both from animal sources and its precursors like green leafy and yellow vegetables, as well as low fat intake needed for its transport. It results in increase susceptibility to infections and xeropthalmia characterized by eye lesions; it may lead to retarded growth and permanent blindness. In the Philippines, 3.5 % of the estimate 11 million Filipino pre-school children have xeropthalmia, 10% whom are corneal related cases. Fifty percent of those with corneal damage become blind, 70% of whom may die within a few months after becoming blind. Night blindness - A condition making it difficult or impossible to see in relatively low light or poor dark adaptation. It is a symptom of several eye

diseases. Night blindness may exist from birth or may be caused by injury or malnutrition. Bitots spot - are the 20 mins build-up of keratin debris located superficially in the conjunctiva. It is associated with night blindness. Bitots spot can be treated by adequate intake of vitamin A and Beta carotene. Keratomalacia - is drying and clouding of the cornea due to vitamin A deficiency and insufficient protein and calories in the diet. Xeropthalmia - Dry eyes. Also called conjunctivitis arida. This can be associated with systemic diseases (systematic lupus eryhtematous, rheumatoid arthritis, hypothyroidism) or deficiency of vitamin A. Xeropthalmia results from inadequate function of the lacrimal glands which supply water to produce ears. Oral Evaluation Lecture Discussio n

Identify and explain the factors that cause malnutrition.

Iron Deficiency Anemia (IDA) - is common among infants three months to two years of age, born of as mother with depleted iron stores caused by multiple pregnancies and poor dietary history. It is a condition in which the hemoglobin concentration of the blood is below accepted values. Iodine Deficiency Disorder (IDD) - refers to a group of clinical entities caused by

inadequacy of dietary iodine, which include goiter, cretinism, hypothyroidism, fetal wastages and increased morbidity and mortality. Some foods such as cassava, cabbage, cauliflower, red-skinned peanuts, sweet potatoes, lima beans and bamboo shoots are found to cause goiter thus called goitrogenic foods. Females are more commonly affected by goiter than males. Thyroid enlargement tends to coincide with puberty and the reproductive years in females. The pregnant and lactating women are most affected for more than 10 in every 100 had goiter. While goiter may affect all age groups, the serious effect of this deficiency is on brain development in the fetus and in the young child. The effect on brain development may be manifested as mental retardation, speech impairment, deafmutism, squint loco motor problems or physical retardation. Some products of pregnancy are either aborted or still born. Myxedema - is the characteristic sign of severe or long standing hypothyroidism. It is histologically similar to the pretibial myxedema deposits that often occur with graves disease. Cretinism - a condition of severely stunted physical mental growth due to untreated congenital deficiency of thyroid hormones 10 mins. (hypothyroidism).

Oral Evaluation

 Cretinism

Neurological

Lecture Discussio n

Hypothyroidism results from suboptimal levels of thyroid hormone which may be caused by iodine deficiency or iodine excess. Discuss the general effects of malnutrition. 2. Overnutrition - pathologic state resulting from the consumption of an excessive quantity of food over an extended period of time. Obesity - a symptom of some underlying difficulty that may have many causes such as metabolic hormonal abnormality, genetic and family environment, failure to get enough daily exercise, neurotic problems, poor food habits and fads and fallacies. Evidence seems to indicate that the course of obesity starts in childhood and persists up to adulthood. Diabetes Mellitus - is a chronic systemic disease characterized by either a deficiency of insulin or a decrease ability of the body to use insulin. Diabetes mellitus is sometimes referred to as high sugars by both clients and health care providers. Cardiovascular Disease - is used to describe conditions of the coronary arteries that may cause damage to the heart. The risk factors are diet, lack of exercise, blood cholesterol and triglycerides, diabetes, high blood pressure, smoking, age (between 35-45 in men), sex (more common among men until

age 55) and overweight. Hypertension - is a consistent elevation of systemic arterial blood pressure. Hypertension is caused by increases in cardiac output, total peripheral resistance. Cardiac output is increased by any condition that increases heart rate or stroke volume, whereas peripheral resistance is increased by any factor that increases blood viscosity or reduces vessel diameter, particularly arteriolar diameter. D. Factors that Cause Malnutrition 1. Poverty - Generally, groups with low income have inadequate food intake both in quality and quantity. It has been a widely held view that the nutritional status is improved significantly with income. Intakes are usually high in carbohydrates and low in protein. 2. Faculty Food Intake - Food consumption surveys revealed inadequate intake of nutritious foods such as green leafy and yellow vegetables, vitamin C rich food, milk, eggs, dried beans, fats, and oils and etc. resulting too inadequacy of most of the essential nutrients. 3. Poor distribution of Supply - Food balance sheet (a rough estimate of supplies available for consumption) should not be interpreted as signifying food self-sufficiency. Actual needed supply to meet nutritional standards would much be higher if one to consider the inequality in the distribution of income and of food. It has been

Describe the physical signs of malnutrition in children.

suggested that the food production planners target a production a level at least 25 percent and over the RDA to satisfy nutrition requirements, but even this is a conservative estimate. 4. Large Family Size - As the number of family members increases, the less amounts of food are available to each member. This particularly is true when the buying capacity of the family is low having been limited by income levels and food prices. 5. Low-level of Education Among Household Members - Giving the family breadwinner a lions share of the food available in the family decreases the share of the growing child or of a pregnant and lactating mother within the family. Thus, an important factor determining individual food security is the relationship between members of the household. Some food insecure households restrain the consumption of some members of the household to protect the vulnerable individuals. However, some distribute food in according to power, status or earning capacity of the household members. 6. Intra-familial Food Distribution - Giving the family breadwinner a lions share of the food available in the family decreases the share of the growing child or of a pregnant and lactating mother within the family. Thus, an important factor determining individual food security is the relationship between members of the household. Some food insecure households restrain the consumption of some members of the household

3. Identify and discuss nursing responsibilities.

Describe nursing responsibilities as a hospital nurse and community or school nurse.

to protect the vulnerable individuals. However, some distribute food in according to power, status or earning capacity of the household members. 7. Urbanization - When urbanization is faster than industrialization, unemployment increases and wages are low. This affects the buying power for food and food intake. 8. Widespread Evidence of Infectious Diseases and Parasitism due to Poor Sanitation Morbidity and mortality statistics show that water-borne diseases continue to be a significant 10 mins. health problem. A close correlation was noted to exist between the lack of adequate water supply and sanitation facilities and the incidence of water borne diseases. 9. Wrong Infant Feeding and Weaning Practices - Empirical studies show that breastfed and properly weaned children were found to have better nutritional status as compared to those who were not. It is a known fact that breast milk provides the following advantages: nutrient adequacy, sterility, immunization against infection, anti-allergic properties, psychological bonding and low cost. E. General Effects of Malnutrition 1. Increase Susceptibility of Infection - It is generally recognized that malnutrition arises not only from inadequate nutrient intake but also from impaired efficiency of absorption and utilization due to infectious diseases and

Socialized Discussio n

Final Evaluation : Pick a Name, Pick a Question Game

illnesses. Infectious diseases and illnesses affect nutritional status through: reduced nutrient consumption due to loss of appetite; nutrient absorption due to impaired production of digestive enzymes, etc. and nutrient wastage due to fever and other metabolic processes. 2. Impaired Physical and Mental Development - Malnutrition among the young children in particular could have socially significant long term effects on their mental and physical development, personality traits and performance. These consequences are difficult to reverse. Severe malnutrition among the very young can result in adverse structural changes in the brain or impairment of various biochemical or metabolic processes. The normal functioning of the brain is altered either totally or partially. 3. Impaired Rational Development - Aside from loss of life as a consequence of severe malnutrition, nutritional status has serious consequence for economic development which drains the national economy in various sectors: a. In health, additional burden of medical services, hospitalization, etc. have to be given. b. In education, more school drop outs, absences, etc. occur which reduce the number and quality of our manpower. c. In agriculture and industry we experience losses through poor performance, absenteeism and processes. F. Physical Signs of Malnutrition in Children

1. Hair - dull, brittle, dry, loose, falls out. Possible nutrient deficiency: PEM. 2. Eyes - pale membranes, spots, redness, adjust slowly to darkness. Possible nutrient deficiencies: Vitamin A, the B vitamins, zinc and iron. 3. Teeth and gums - missing, discolored, decayed teeth, gums bleed easily and are swollen and spongy. Possible nutrient deficiencies: Minerals and vitamin C. 4. Face - off-color, scaly, flaky, cracked skin. Possible nutrient deficiencies: PEM, vitamin A and iron. 5. Glands - swollen at front of the neck, cheeks. Possible nutrient deficiencies: PEM and iodine. 6. Tongue - sore, smooth purplish, swollen. Possible nutrient deficiency: B vitamins. 7. Skin - dry, rough, spotty, sandpaper feel or sores, lack of fat under skin. Possible nutrient deficiencies: PEM, essential fatty acid, vitamin A, B vitamins and vitamin C. 8. Nails - spoon-shaped, brittle, ridged. Possible nutrient deficiency: Iron. 9. Internal Systems - abnormal heart rate, heart rhythm, or blood pressure; enlarged liver, spleen; abnormal digestion; burning, tingling of hands, feet; loss of balance, coordination; mental confusion, irritability, fatigue. Possible nutrient deficiencies: PEM and minerals.

10. Muscles and Bones - wasted appearance of muscles; swollen bumps on skull or ends of bones; small bumps on ribs; bowed legs or knock-knees. Possible nutrient deficiencies: PEM and vitamin D. 3.0 Nursing Responsibilities A. Hospital Nurse 1. Maintain and improve the patients appetite. 2. Assist patient to eat when necessary. 3. Ingredients needed for proper feeding. 4. Check whether the actual tray served is the prescribed diet for the patient. 5. Supplement meals served to the patient, when necessary. 6. Use feeding principles for various age groups. 7. Plan and implement health teaching in nutrition to suit individual needs of the patient. B. Community/School Nurse - The main goal for nurses who work with school age children is to maintain the childrens normally healthy status and prevent the development of illness when possible. This task is accomplished through a variety of health-promotion mechanisms, such as examinations, guidance, education and legislation. The nurse, either from the community or within the school is frequently in a position to plan and direct comprehensive health care services for school age children. These services should include the following:

1. Planning direct health maintenance. 2. Screening and providing health care for problems that interfere with the learning process. 3. Providing nursing services for children with health problems. 4. Coordinating referral services. 5. Planning and implementing actions to ensure a healthy physical and emotional milieu for the school. 6. Planning and participating in the health education that teaches children skills and methods for making wise decisions about their health and about their environment. Planning the health maintenance for the children of a school varies depending on the type of health maintenance program. In one of the system, the school nurses may try to ensure that each child has primary sources of health care, whereas in another system, the schools nurse practitioners may be the primary providers. In either setting, the school nurse must work collaboratively with the schools physician, community physician, and parents in meeting childrens health needs. In most school settings, school nurses can work with community leaders and parents to improve the quality of education, including health education for all children. School nurses frequently work closely with other school professionals in evaluating. Children whose school performance appears to indicate a problem that is physical in nature.

The school nurse can also play a role in developing a health environment for children at the school. Program for prevention of accidents in and around the school should be planned by the health care team. Open Forum Evaluation

Bibliography: Claudio, V. and Dirige, O. (2002). Basic Nutrition for Filipinos. 5th edition. Manila, Philippines: Merriam & Webster Bookstore, Inc. Nutrition:Concepts and Controversies. 9th Ed. Copyright 2003. Thomson Learning ,Inc Whitney and Sizer Carol Matson Porth. (1998).Concepts of altered health status. Lippincott, Philadelphia, New York. Understanding Nutrition 8th Ed. Whitney and Rolfes Copyright 1999. Wadsworth Publishing Company. Kozier, E. (2004). Fundamentals of nursing: concepts, process, and practice. 7th edition. Philippines.

Edelman and Mande.(2002). Health promotion throughout the lifespan.5th ed. USA: Mosby,Inc.