Case in Point—Gary: Fending for himself

Gary, a 7-year-old Caucasian boy, was discovered searching a garbage can

by a police officer. The officer noticed that Gary was dirty, unkempt, and thin.
His skin was pale. Gary was taken to the police station, where he was turned
over to social services. Gary told social services that his mother had been sick
and was taken to the hospital; he had not seen her for many months. He did not
know what hospital she was in, and he had been alone all this time. He told the
social worker that he had run out of food immediately after she left; he had
been able to survive by searching for food behind restaurants and in garbage
bins. Social services brought Gary to the local hospital, and upon examination, it
was found that Gary had a distended abdomen, serosanguinous sores on his
body, and swollen and painful lower limbs. Gary limped and found walking very
tiring.

ASSESSMENT

1. Identify three distinguishing signs of malnutrition.

a. Swollen and painful lower limbs

Edema can be associated with low protein levels in the bloodstream caused by
malnutrition, as well as renal and liver dysfunction. The proteins aid in the
retention of salt and water within the blood arteries, preventing fluid from
leaking into the tissues. When a blood protein called albumin becomes
depleted, fluid is managed to retain and edema develops, particularly in the
lower extremities.

b. Distended abdomen

The abdomen is swollen due to a lack of abdominal muscular strength. This

leads the innards of the abdomen to expand out rendering the abdomen
bloated.

c. Body sores

Vitamin and Nutritional Deficits can cause dermatological conditions in the skin
and nails, this is mainly due to the lack of Vitamin C and B. Body sores can
develop if patients do not receive sufficient micronutrients or macronutrients.
The skin grows dehydrated and hair may grow dry, lifeless, and straw-like in
texture.
d. Easily fatigued

Reduced energy levels and a tendency to tire more frequently than other
children. Vulnerability of muscles and weariness. The muscles of the body look
likely to fade away and could be left with little or no strength to perform out
regular duties. This might also be attributed to malnutrition-induced anemia.

2. What would you introduce first into Gary’s diet?

a. Essential nutrients

A better and healthier, balanced diet is the most effective method for avoiding
malnutrition. Improvements in diet, such as consuming foods rich in energy and
vitamins. Supplements with vitamins and minerals are recommended. Gary must
consume foods from all of the major dietary categories, including:

 a variety of fruits and vegetables

 abundance of starchy meals such as toast, rice, potatoes, spaghetti
 a few other kinds of milk and dairy products, as well as nondairy
alternative solutions
 several examples of protein, like as beef and pork, fish, eggs, and beans
 sufficient liquid intake (water)

It is also advisable that we make sure to include all six of the Essential Nutrients in
Gary’s new and improved dietary plans.

3. How frequently would you offer nutrition and how large a portion?

a. Small meals frequently throughout the day

Small meals can help to satisfy hunger, maintain blood sugar levels, and provide
nourishment to the body all through the day. Smaller, more frequent meals in
Gary's regular eating patterns can also assist in a faster metabolism when
contrasted to a slower metabolism whenever meals are missed. Recommend
that Gary eat short and frequent meals, preferably in 3 small meals and 2-3
snacks in between.
4. What other signs of malnutrition would you expect to find?

a. Spindly arms

Malnutrition precludes your body of the energy it requires to function. As a result,

it begins to degrade its very own tissues and halt its operations. This starts with its
fat storage and progresses to musculature, skin, hair, and nails. People suffering
from protein-energy malnutrition are frequently noticeably malnourished.
Children's growth and development may be impeded.

b. Poor hair quality

Protein deficiency, as seen in kwashiorkor and marasmus, can cause hair

changes such as thinning and loss. A lack of biotin is also to be anticipated if
Gary has poor hair quality. Biotin, often known as vitamin B7, aids the body in the
conversion of food into energy. Biotin deficiency is extremely rare, but when it
does develop, the most apparent signs are fragile, receding, or breaking hair
and nails.

c. Low immune system

The immune system is one of the initial systems to shut down. This renders
undernourished persons more susceptible to disease and infection, as well as
longer to recover. Wounds heal more slowly. The cardiac activity also
decreases, resulting in a decreased heart rate, blood pressure, and body
temperature. Individuals may feel faint, feeble, and uninterested in life. They
may lose their appetite and sections of their gastrointestinal process may
deteriorate.

DIAGNOSIS

5. Write a nursing diagnosis for Gary.

Altered nutrition related to inadequate intake of balanced diet and water-

soluble vitamins (thiamine, folic acid, and pyridoxine) in subnormal living
conditions
PLAN/GOAL

6. What two changes can you predict will occur with the introduction of a good,
nutritionally sound diet?

a. Improved skin conditions

Dietary changes can result in much better skin, faster healing, and the
prevention of additional skin disorders such as skin cancer and premature aging
of the skin. In others, the dermatological condition may be connected to
malnutrition, and dietary adjustments, and may alter health outcomes. Finally,
systemic drugs used to treat dermatological problems, including steroids, and
the lack of nourishment that our body needs are known to increase the
likelihood of other diseases, which can be reduced by dietary changes.

b. Abdominal bloating to decrease

The treatment for edema caused by malnutrition is to replace the body with
nutrients that have been depleted. To attain normal blood pressure, simple
carbs and lipids are commonly administered before proteins. Malnourishment
signs, such as a bloated belly, may take several days to resolve.

7. Whom can you refer to for assistance?

a. Social services

With adequate training and instruments, social service workers may assist nurses
and other medical health workers in preventing malnutrition in young groups.

b. Possible family members

The great majority of children who are not being cared for by their parents have
existing families, along with at a minimum one parent or perhaps another
relative. In truth, the vast majority of children who are abandoned by their
parents are put in blended families or family-based alternative care.
IMPLEMENTATION

8. Name at least three methods that could be employed to improve Gary’s

nutrition.

a. Offer small amounts of nutritious foods frequently

Gary, as I stated in the previous question, should eat little but frequently, with
three smaller meals a day and two or three snacks in between. Protein should
be included in each meal, such as meat, fish, poultry, eggs, beans, or lentils.
Avoid low-fat, sugar-free, dietary meals and beverages, such as skimmed milk.

b. Identify the foods Gary likes

Gary may have more appetite if we include the food that he likes. We can do
this by identifying what food he associates with good and fond memories. Thus,
enables his healing and treatment from malnutrition to be further effective than
just offering or ordering him to eat what is on his plate.

c. Prepare the foods in an appetizing way

The phrase "appetite" most frequently refers to the desire to consume food.
There are a plethora of factors that could lead to a decline in appetite, notably
developmental stages or health complications, such as malnutrition. A decline
in appetite might result in a reduction in eating. We may all circumvent this by
presenting the meal in an appealing or interesting manner that a child will find
appealing.

9. Could a food diary be helpful?

No, because of Gary's maturity level and potential anxiety of publicly

acknowledging what he ended up eating. He might not be particularly
comfortable with others examining him and this may prompt the child to eat
less.

10. Would a home visit be beneficial for Gary and a caregiver?

Yes, for reinforcement that Gary is doing well and that he would never have to
scavenge for food in the gutters anymore.
EVALUATION/OUTCOME CRITERIA

11. What could the doctor measure at the next appointment to see if the plan is
working?

a. Weight and Height (BMI)

Weight, height, and BMI for age are indicators used to evaluate children's
nutritional health. Because of its simplicity of measurement, bodyweight for age
is among the most commonly used indicator for assessing nutritional status.

b. Prealbumin blood test

A prealbumin blood test determines the amount of prealbumin in your blood.

Prealbumin is a protein produced by the liver. Prealbumin aids in the transport of
thyroid hormones and vitamin A into circulation. It also aids in controlling how
your body uses energy. If your prealbumin concentrations are lower than
average, this might indicate malnutrition. Malnutrition is a condition in which
your body does not receive sufficient nourishment for proper health, including
protein, vitamins, and minerals.

c. Overall appearance

Appearance can be a good start in general assessment of a patient. In Gary’s

case, the doctor should see that his skin, hair and nails are locking much
healthier, and that he will not appear emaciated, abdomen distended and the
other characteristics of a malnourished or unhealthy child.

12. What observations could the caregiver offer about the success of the plan?

a. Change in Gary’s appearance

Again, appearance can be a good start in general assessment of a patient. In

Gary’s case, the doctor should see that his skin, hair and nails are locking much
healthier, and that he will not appear emaciated, abdomen distended and the
other characteristics of a malnourished or unhealthy child.

b. Mental status changes

According to a research conducted in Bombay, 129 children who had recently

experienced malnourishment had poorer IQ and a 60% risk of attention deficit
hyperactivity disorder (ADHD) opposed to 15% in control children from the same
schools. It is of consideration that these dilemmas remained unchanged into the
adult years.
13. What could be an important piece of information from Gary?

Gary's consumption of protein, carbs, water, minerals, and vitamins has

progressively increased, and he feels stronger and is eating properly. Vitamin
and mineral supplements are frequently recommended. Protein bars or
supplements may be required to compensate for protein-energy malnutrition.
Children who are very malnourished must be nourished and rehydrated with
extreme caution. They cannot be quickly provided a normal diet. They will
almost always require specialized hospitalization for care. When they are well
enough, they can progressively resume ingesting a standard diet and do so at
home.

THINKING FURTHER

14. How could the Internet be of benefit to the caregiver?

Research for treatments that best suits Gary’s situation, and ways on how to
further encourage him to do better for himself. Also, look for strategies to assist
Gary in adjusting to his newfound living environment.

15. Who would also benefit from this information?

Malnutrition influences the immune system and leads to muscle and weight loss.
Malnutrition can also arise following hospitalization when patients are required
to adhere to tight diets or refrain from eating. This might make it more difficult for
them to recuperate adequately. We understand how critical it is to raise public
awareness about malnutrition. Children who are experiencing or who have
experienced it should be properly treated and be educated that consuming all
of the six essential nutrients is vital to their health and their growth, if the child
does not have the means, make them understand that they can always call for
help, give them the contact information and address of the nearest Social work
office that can cater to them.
RATE THIS PLATE

Gary has been through a lot of heartache for a child his age. Gary is placed in a
foster home, and his foster mother asks him what he would like to eat for his first
dinner with them. He thought and thought and finally decided on the following
plate. Rate this plate. Take into consideration that Gary is malnourished, has not
eaten much lately, and is lacking many nutrients.

 Fried chicken—leg and thigh

 1/2 cup mashed potatoes and 2 Tbsp gravy
 1/2 cup corn with butter
 Biscuit with butter
 2% milk—8 oz

Can Gary eat all of this, and should he? Does this plate need to be changed,
and how would you change it?

Gary hasn't eaten much, but this platter is overflowing. Gary should begin taking
a minerals and vitamins supplement once a day, with no more than 100% of
each nutrient. Carbohydrates, simple sugars, and lipids are the first sources of
calories. Proteins are consumed after all other caloric substances have
delivered the required energy. The plate's calorie density is excessive. Minimal
amounts of food must be supplied at the beginning. Gary may have believed
this was what he desired, but his body could not manage the amount of the
food. Numerous children suffer from malnutrition, develop lactose intolerance,
and must consume milk containing the enzyme lactase to start breaking down
the lactose (the milk sugar).