Kwashiorkor is a severe form of protein-energy malnutrition characterized by a significant protein deficiency, despite a potentially adequate caloric intake. It is most commonly seen in developing regions where diets often consist of starchy, low-protein foods. This condition particularly affects children who have recently been weaned from breast milk, often when a new sibling arrives, and transitioned to a diet lacking essential protein. Nurses play a crucial role in the management and recovery of patients with kwashiorkor, from the initial stabilization phase to long-term nutritional rehabilitation. This process is guided by specific nursing diagnoses that address the patient's complex needs.
Primary Nursing Diagnoses for Kwashiorkor
Nursing diagnoses for a patient with kwashiorkor are multifaceted, reflecting the systemic impact of severe protein and micronutrient deficiencies. The following are among the most critical diagnoses addressed by the nursing care plan:
Imbalanced Nutrition: Less than Body Requirements
This is a foundational diagnosis for kwashiorkor patients, directly addressing the underlying protein and nutrient deficits. The nursing care plan focuses on restoring nutritional balance without inducing life-threatening complications like refeeding syndrome.
- Related to: Inadequate protein and nutrient intake, poor absorption due to gastrointestinal mucosal atrophy, and decreased appetite (anorexia).
- As evidenced by: Muscle wasting (often masked by edema), depleted serum albumin, loss of subcutaneous fat, fatigue, and hair changes.
Fluid Volume Excess
Protein deficiency leads to a decrease in plasma proteins, particularly albumin, which is essential for maintaining fluid balance in the bloodstream. This results in edema, the hallmark sign of kwashiorkor.
- Related to: Low plasma protein concentration (hypoalbuminemia) causing a shift of fluid from the intravascular space to the interstitial spaces.
- As evidenced by: Bilateral pitting edema of the ankles, feet, and potentially the face, as well as a distended, bloated abdomen from ascites.
Impaired Skin Integrity
Kwashiorkor often presents with distinctive skin changes, including dermatosis, hyperpigmentation, and peeling. This is due to poor tissue growth and repair resulting from nutritional deficiencies.
- Related to: Protein and micronutrient deficiencies (e.g., zinc), edema, and frequent diarrhea.
- As evidenced by: Flaky, peeling, and cracked skin lesions (particularly on pressure points and folds), skin breakdown, and poor wound healing.
Risk for Infection
The weakened immune system is a major complication of malnutrition, leaving patients highly vulnerable to severe and opportunistic infections. In kwashiorkor, the usual signs of infection, such as fever, may be absent.
- Related to: Depressed immune response, low immunoglobulin levels, skin breakdown, and unsanitary living conditions.
- As evidenced by: Weakened immune system function, delayed wound healing, and a high susceptibility to bacterial, fungal, and parasitic infections.
Developing a Comprehensive Kwashiorkor Care Plan
Effective nursing interventions for kwashiorkor follow a structured, cautious approach, often guided by the World Health Organization (WHO) guidelines for managing severe acute malnutrition.
The World Health Organization's 10-Step Protocol
This widely-used protocol is divided into stabilization, nutritional rehabilitation, and follow-up phases. Nurses implement key steps to manage immediate and long-term needs:
- Treat/prevent hypoglycemia: Give glucose solutions initially.
- Treat/prevent hypothermia: Keep the patient warm due to poor thermoregulation.
- Treat/prevent dehydration: Use a special low-sodium rehydration formula (ReSoMal) cautiously.
- Correct electrolyte imbalance: Supplement with potassium and magnesium.
- Treat/prevent infection: Administer broad-spectrum antibiotics, as infection signs may be masked.
- Correct micronutrient deficiencies: Provide vitamin and mineral supplements.
- Initiate cautious feeding: Begin with small, frequent feeds to avoid refeeding syndrome.
- Achieve catch-up growth: Gradually increase caloric intake once stable.
- Provide sensory stimulation and emotional support: Engage children in play and provide comfort.
- Prepare for follow-up: Educate caregivers on nutrition and hygiene.
Nursing Interventions by Diagnosis
- For Imbalanced Nutrition: Monitor weight and anthropometric measurements. Administer prescribed therapeutic formulas (e.g., F-75, F-100) slowly, possibly via nasogastric tube if appetite is poor. Progressively increase the caloric and protein density as tolerated. Encourage breastfeeding where applicable.
- For Fluid Volume Excess: Carefully monitor intake and output. Measure weight and abdominal circumference daily. Avoid diuretics, as the edema is related to low protein, not fluid overload. Fluid restriction may be necessary during the stabilization phase. Assess for signs of overhydration, like increasing respiratory or pulse rate.
- For Impaired Skin Integrity: Keep skin clean and dry, especially in areas with lesions. Apply topical treatments as prescribed, such as zinc paste. Reposition immobile patients frequently to relieve pressure. Use soft, clean linens. Monitor for secondary infection.
- For Risk for Infection: Maintain strict aseptic technique. Monitor vital signs for changes indicating infection (e.g., hypothermia). Administer prescribed antibiotics. Protect the patient from exposure to infectious individuals.
- For Impaired Parent/Child Attachment: Facilitate maternal involvement in the child’s care, including feeding and emotional stimulation. Encourage skin-to-skin contact. Teach caregivers about the patient's condition and recovery process. For more resources on managing severe malnutrition, visit the WHO website.
Key Differences Between Kwashiorkor and Marasmus
Nurses must be able to distinguish between different forms of severe acute malnutrition to tailor care effectively. While both are severe forms of undernutrition, their clinical presentations differ notably.
| Feature | Kwashiorkor | Marasmus |
|---|---|---|
| Primary Deficiency | Protein, despite sufficient calories. | Overall energy and protein. |
| Hallmark Sign | Edema (swelling) of the extremities and abdomen. | Severe muscle and fat wasting, without edema. |
| Appearance | Appears bloated or 'puffy,' masking the true state of malnutrition. | Looks emaciated, with a 'skin and bones' or 'old man' appearance. |
| Physical Signs | Skin lesions, hair discoloration, fatty liver. | Loose, wrinkled skin, extreme thinness. |
| Cause | Often follows weaning when diet becomes low-protein, high-carbohydrate. | Inadequate intake of all nutrients over a prolonged period. |
Conclusion
Kwashiorkor requires a diligent, systematic nursing approach to correct severe nutritional, fluid, and metabolic imbalances. The primary nursing diagnoses of imbalanced nutrition, fluid volume excess, impaired skin integrity, and risk for infection guide the creation of a comprehensive care plan. By following protocols such as the WHO's 10 steps, nurses can effectively stabilize patients, facilitate nutritional rehabilitation, manage complications, and support the patient's emotional well-being. Early and meticulous nursing intervention is critical for improving outcomes and preventing the potentially fatal consequences of this severe malnutrition disorder.
