A Family Case Study

Presented to the
College of Nursing

In Partial Fulfillment of the Requirements

In
CHN

FAMILY CASE STUDY

Submitted by:
II. TABLE OF CONTENTS

Title Page……………………………………………………………………………………..1
Table of Contents…………………………………………………………………………….2
Acknowledgement……………………………………………………………………………3
Introduction……………………………………………………………………………………4
Objectives of the Study………………………………………………………………………5
Identification of the Case…………………………………………………………………….6
Family Background…………………………………………………………………………..7
Socio-economic Background………………………………………………………………..8
Family Medical & Health History……………………………………………………………9
Genogram…………………………………………………………………………………….10
Family Apgar………………………………………………………………………………....11
Family Coping Index…………………………………………………………………………12
Family Nursing Assessment Tool………………………………………………………….13
Nursing Theory………………………………………………………………………………14
Management…………………………………………………………………………………15
A. Medical
B. Nursing Management
B.1 Problem List ( Maslow’s Hierarchy)
B.2 Problem identification (Health Threat/ Deficit/ Foreseeable Crisis Situation)
B.3 Family Nursing Care Plan
B.4 Health Teachings (Three Levels of Prevention)
Referrals……………………………………………………………………………………...22
Summary/ Evaluation……………………………………………………………………….23
Implication…………………………………………………………………………………...24
Health Updates……………………………………………………………………………...25
References……………………………………………………………………………….….26
Appendices………………………………………………………………………………..…27

AKNOWLEDGEMENT

The study has provided our group opportunities to know the different problems and
needs of the family in order for them to develop more in terms of their environment and
especially with their health status. But all of these could not be done without the help of those
significant people that help us throughout the study.

The group would like to thank the following:

First of all, To the Lord Almighty, we thank you for giving us a chance to live and
experience this opportunity. Thank you for making all things possible, for giving us all we
needed, a n d f o r m a k i n g u s e a r n i n s i g h t s i n t h i s w a y k n o w i n g t h e w o r t h o f o u r
life. For His guidance and safety which He gives every
d a y , f o r a l l t h e b l e s s i n g s t h a t H e h a s showered upon us, and for giving us the strength
to pursue everything.
Next To our loving parents, family and supporters, thank you so much for helping us with your
prayers, for allowing us to be exposed in the community, and for helping us with our needs
especially financial matters.
To our dear Clinical Instructors ______________________ who were always there
to help and support us especially in our activities and programs, and in making our case
presentation successful. We are grateful for the encouragement you gave us every time we feel
discouraged especially for the outcome of our activities, for the patience,
for understanding our differences, for the concern, and for the guidance you gave us. We
appreciate it and it inspires us more to continue and pursue and we are happy and
blessed to have you as our clinical instructors.
We would also like to thank the Barangay Officials in _____ including PHN
_________, PHM and the Barangay Health Workers that organized and find a proper and
appropriate place for us to have our community exposure.
 We would also like to extend our gratitude to the family of Mrs. No
Space for accommodating, welcoming, and for trusting us to share their
basic and personal information that made our case study successful.

Introduction

Children in their middle years treasure their families and feel they are special and
irreplaceable. Family is not just define as two or more people who live in the same household,
share a common emotional bond, and perform certain interrelated social tasks (Allender &
Spradley, 2008) but it is also a source of emotional support, comfort, warmth, nurturing,
protection and as well as security. It is composed of a male and a female being molded to be as
one, working hand in hand to have a good atmosphere among the family members. Almost all
families, regardless of type, share common activities (Cherlin, 2008).

The status of each family will always affect the status of the community as a whole.
Community health nursing is a response to the health needs of the people. It does not focus on a
particular class or family. It is a comprehensive and general approach. Community health service
is not an episodic as it requires continuous observation and monitoring of the community as a
whole. Promotion and preservation of different clients (individuals, families, population groups
and community) is the primary goal of community health nursing.

Every family is unique. Nurses that are exposed to the community learn how to interact
and adapt to the different kind of people living in a community. It is in the family who develop
health values, beliefs and practices. Family influences the health and activities of their member
(Chen, Shiao, & Gau, 2007). With this, it is important that families in the community are aware
of the things and practices pertaining to their health.

Conducting a case study is a way where student nurse improve and apply all the concepts.
It is a tool in determining the health status of family through assessment and critical inspection
because of this, health related problems are identified which gives an indication to the student
nurse on how to intervene just to give a holistic care and improve the deficiency.
 The family that was chosen by the researcher is one of the important concerns of the
Philippines – Malnutrition. Malnutrition now a day is rampant and it is one of the problems
identified in the community. A family living in a poor environmental condition without enough
resources and lack of knowledge on vital health information and also experiences socio –
economic related problems. Tiring as it is, but reaching out to this family and mingling with
them makes the researcher feel the sense of fulfillment as they share knowledge, skills and time
to support in uplifting the condition of family.
GENERAL OBJECTIVES
At the end of the student – family relationship, the adopted family will
be able to improve their health status and become self – reliant in
maintaining their health through appropriate interventions in a given time
frame.

SPECIFIC OBJECTIVES
After 1 month of home visits and student nurse – family interaction, the student will be
able to:

1. Establish rapport and trust with the family

2. Trace the family medical and health history
3. Illustrate the genogram of Mrs. No Space that will help visualize hereditary pattern
4. Explain the family Apgar score that shows the relationship of family function
5. Determine the different nursing theories that are related to Mrs. No Space condition,
concerns, and problems
6. Give health teachings about possible risk factors
7. Identify actual and potential problems which may be a hindrance in attaining optimum health
8. Categorize the identified health problems as health threat, health deficit or foreseeable crisis
9. Plan possible solutions or nursing actions to the prioritizes health problem
IDENTIFICATION OF THE CASE

Patient’s Code Name: Mrs. No Space

Age: 29 years old
Nationality: Filipino
Civil Status: Single
Occupation: Vendor
Date of Last Admission: year 1994 due to Asthma
Sources of Information: Mrs. No Space

FAMILY BACKGROUND

Mr. and Mrs. No Space living together for 13 years without a benefit of a legal marriage.
They have 5 children, 3 girls and 2 boys, 4 were studying and she is six month pregnant. They
are currently living at Purok 8 Brgy. 76 - A Bucana, Davao City. Mrs. No Space is a High
School Graduate same as with her husband. She is a vendor and her husband is a “trisikad”
driver.
As what she said, her pregnancy is unwanted and they were facing financial problem due
to the school expenses of their children. They were only depending on her small income, support
coming from her mother-in-law and her husband.
Mrs. No Space experienced varicella infection (chicken pox) when she was three months
pregnant. She never submitted herself for medical check-up and even never visited the health
center for prenatal check up due to financial constraints and unwanted pregnancy.

SOCIO – ECONOMIC BACKGROUND

No Space is 29 years old, she is a vendor and her husband is a “trisikad” driver. They
have combined daily income of Php250 and combined estimated monthly income of Php7000.
Mrs. No Space’s mother in – law was sometimes helping them in terms of financial
needs. The money coming from her mother-in-law & their own income is budgeted by her. But
according to Mrs. No Space it is not enough for them but she managed it appropriately so that
they can eat at least thrice a day.
They don’t own the house but they managed to rent it. Their house is made up of mixed
materials like a bamboo and plywood and their house is an inadequate space for them all.
 Furthermore, her house is prone to fire because it is made of light materials. They are
using a charcoal for cooking in their common kitchen. The foundation of their house is not good
or strong, since it is made of wood and bamboo. So, when we are to describe it, it could not stand
by strong winds when there is typhoon. There is a high possibility that their house might
damaged during strong typhoon.

FAMILY MEDICAL & HEALTH HISTORY

The parents of Mrs. No Space are still both alive. According to Mrs. No Space, her 5
children already completed their vaccination. The fourth (4 th) child of the family, Ms. O
experienced hospitalization for 1 week at Southern Philippines Medical Center due to
Pneumonia. And also her husband was confined for two (2) days at Southern Philippines
Medical Center due to ulcer.
On 1994, Mrs. No Space stated that she experienced asthma and she was only 10 years
old back then. On April, 2014 she also experienced varicella infection (chicken pox) and she was
three (3) months pregnant at that time and she only took it for granted and does not seek for
health care provider or having prenatal check – up to know if there is any complication, because
according to her, her pregnancy is unwanted.
Furthermore, Mrs. No Space also stated that during labor she experienced preeclampsia
and severe bleeding after delivery. This occurrence started to happen from giving birth of their
first child up to their fifth child.

X.GENOGRAM
FAMILY APGAR
Component Score Definition Justification
Adaptation Use of intra and extra familial No enough resources. Needs
1 resources for problem solving assistance coming from both
when family equilibrium is parents if occurrence of
under stress. unexpected financial matters.
 Sharing of decision making Client always insists that her
Partnership 1 and nurturing responsibilities own idea is right.
by family members.
Physical and emotional The client herself wishes to do
1 maturation and self- something for herself like
Growth fulfillment achieved by family working DH abroad.
members through natural
support and guidance.
Caring or loving relationship Caring and loving in the family
Affection 2 among family members. can be witnessed.
Commitment to devote time Both spouses are pre occupied
to other members of the on ways to earn a living.
family for physical and
Resolve 1 emotional nurturing; usually
involves a decision to share
wealth and space.
Total Score 5
Moderatel -Inadequate coping or decision making skills
Interpretatio y -Emotional Immaturity
n Dysfunctio
nal

Legend: Total Score:

0- Hardly Even 0-3 Severely dysfunctional family
1- Sometimes 4-6 Moderately dysfunctional family
2- Almost Always 7-10 Highly functional family
Analysis and Interpretation

A healthy family unit is considered by Smilkstein to be a nurturing unit that demonstrates

integrity in five components. Adaptation, Partnership, Growth, Affection and Resolve. This tool
is useful in suggesting areas to be assessed relative to family functioning and potential areas of
family strengths and resources. Various types of family strengths which are scored as follows:
“Almost always” (2 points), “Sometimes of the time” (1 point’0, or “Hardly even” (0 point). The
scores for each of the components are totaled; a score 7-10 suggests a highly functional family.
4-6 points a moderately dysfunctional family; and 0-3 points a severely dysfunctional family.
This helps determine the family’s ability to acquire resources and productive use of money or
social support, the ability to communicate in depth with each other with openness and support
and consensual decision making; the presence of encouragement, support, prairie recognition,
respect for individuality and flexibility of family functions and roles.(David, E.et.al,2007)
With regards to our client’s family, in terms of adaptation the score is 1, this means that
family don’t have intra- and extra familial resources for problem solving when family
equilibrium is under stress. Mrs. No Space mentioned that whenever they have financial
problems, her parents or mother in-law sometimes help them if there’s a need to. In terms of
partnership, the family scored 1 because sharing of decision making and nurturing
responsibilities by family members are merely observed because usually Mrs. No Space always
insist that her own idea is right. Third component is Growth, the family scored 1 because
physical and emotional maturation and self-fulfillment achieved by family members through
mutual support and guidance is occasionally observed. Fourth component is Affection; the
family is scored 2 because caring or loving relationship among family member can be witnessed.
The last component is resolve the family scored 1 maybe, there is no commitment to devote time
to other members because they are preoccupied on ways to earn a living. The total score is 6
which mean their family is moderately dysfunctional; this implies that the family needs to
improve their sense of adaptation, partnership, growth, and commitment to devote time to other
members of the family.

FAMILY COPING INDEX

Family Coping Areas Point Scale Assessed Problems Justification System

No Problem “Ako may mulihok sa tanan
Physical Independence 5 diri sa balay ug mag asikaso
 sa mga bata”
Lack of Financial “Dili ko ganahan mag pa
Therapeutic 2 resources to seek check-up kay wala ko
Component medication kwarta”
Able to identify “Kabalo ko na delikado mag
Knowledge of Health 2 health status but chicken pox ang buntis pero
Condition don’t have any action dili ko ganahan magpa
check-up”
Taken improper “wala mi basura diri, dili
Application of Principle 2 garbage disposal & pud mi naga segregate”
of General Hygiene segragation
Failure to visit HC “Naga adto ko ug Health
for current prenatal Center sauna pero karon
Health Attitudes 3 check up due to lang ko na pag buntis na
idleness and wala koy adto-adto sa
unwillingness. hospital”
Good relationship “Magkasinabot man mi sa
between the family akong pamilya pag may
Emotional Competence 3 members; but client problema, Panagsa maglagot
always insist what ko sa akong asawa”
she thought is right
Client is sometimes “Lagot ko niya nga sige
Family Living moody with husband pugos patsek up, di man ko
3 because of her ganahan pa”
pregnancy
1 Inadequate space Based on our observation, a
Physical Environment family of seven with 1 room
is not adequate for them to
live toghether. And they
shared the kitchen and
comfort room with the other
 renters as well.
They are aware of Based on our observation,
Use of Community avail ability of they house is near in the
Response 3 community lesomes Health Center but they don’t
but they are not utilize the resources that
utilizing it health center offered
Comments:

They are friendly, cooperative, willing to open up or share information regarding their family
status and health.

Analysis & Justification

This table presents the Family Coping Index of “No Space”. The coping capacity of the
family correspond a point scale according to the family level of competence. 1 No Competence,
3 Moderate Competence and 5 Complete Competence. As the result the family coping area
which is Physical Independence is scaled 3. This means not all the family members are able to do
their activity of daily living independently, on the other hand physical environment scaled 1
which means that the family has no competence in relation to work environment because they
have inadequate living space, knowledge of health condition, application of principles of general
hygiene and therapeutic competence scale 2, this means that in this area the family coping is
poorly competent in terms of their health condition. Emotional competence, Family Living is
scaled 4 it implies that the family is close knit to each other. They support each other in terms of
decision making but in sometimes they do not understand each other. On the other hand, Health
Attitudes is scaled 3 this means that in this area of family coping capacity they are moderately
competent because the pregnant woman is not going to the health center for prenatal check up.
Use of Community Facilities- is scaled 3, this means that the coping capacity of the family is
moderately competent because the family is not utilizing the community facilities.
XIII. FNAT
XIV. NURSING THEORY

The following nursing theories are applicable in their client family:

The Nightingale’s Environment model where in, Nightingale viewed the manipulation of
the physical environment as a major component of nursing care. She identified ventilation and
warmth light, noise, variety, bed and beddings, cleanliness of rooms and walls, and nutrition as
major areas of the environment the client could control. When one or more aspects of the
environment are out of balance, the client must are use increased energy to counter the
environmental stress. In Nightingale notes in nursing, she discussed the importance of the health
of homes as being closely related to the presence of pure air, pure water, efficient drainage, and
cleanliness that it’s an adequate space for their family, sufficient lighting, and pure clean air are
what they are experiencing now.

Dorothea Orem’s combination of three theories, theory of self care, theory of self care
deficit and theory of nursing system also applies. In the self care theory, it explains the
activities carried out by the individual to maintain their own health. While self care deficit is the
inadequacy of the self care requisites.
According to Orem’s Theory, these areas are important for prioritizing nursing diagnosis:

-Air
-Water
-Food
-Elimination
-Solitude/Interaction
-Prevention of hazards
-Promotion of normality
-Maintain a developmental environment
-Prevent or manage the developmental threats
-Maintenance of health status
-Awareness and management of the disease process
-Adherence to the medical regimen
-Awareness of potential problem
-Modify self image
-Adjust life style to accommodate health status changes

XV. MANAGEMENT

A. Medical

MALNUTRITION

Malnutrition is a serious condition that occurs when a person’s diet does not contain the
right amount of nutrients.

It means "poor nutrition" and can refer to:

 undernutrition – when you don't get enough nutrients

 overnutrition – when you get more nutrients than you need

Signs of Malnutrition

- Most common symptom of malnutrition is unplanned and unexplained weight loss.

Signs of Malnutrition in Adults

 feeling tired all the time and lacking energy

 taking a long time to recover from infections
 delayed wound healing
 irritability
 poor concentration
  finding it hard to keep warm
 persistent diarrhea
 depression

Signs of Malnutrition in Children

 failure to grow at the expected rate, both in terms of weight and height (known as "failure
to thrive")
 changes in behavior such as appearing unusually irritable, sluggish or anxious
 changes in hair and skin color

Causes

- lack of nutrients in your diet

Social factors

Social factors that can contribute to malnutrition include:

 living alone and being socially isolated

 limited knowledge about nutrition or cooking
 reduced mobility
 alcohol or drug dependency
 low income or poverty

Physical factors

Physical factors can contribute to malnutrition. For example:

 If your teeth are in a poor condition, or if dentures don't fit properly, eating can
be difficult or painful.
 You may lose your appetite as a result of losing your sense of smell and taste.
 B.Nursing Management

Treatment usually consists of replacing missing nutrients, treating symptoms as needed,

and treating any underlying medical condition.

B.1 PROBLEM LIST (MASLOW’s)

Deficits

The Maslow’s Hierarchy of needs comprises of five (5) stages including Physiologic
needs, Safety needs, Belongingness and Lobe needs, Esteem needs and self – actualization.
 A. Physiologic Needs
 Food – insufficient nutrients due to financial constraints
 Shelter – inadequate living space for a family of seven members sharing one room
B. Safety and Security
 Unstable employment – leads to inadequate family resources
 Cohabitation family – situation of the couple is not in a legal basis that put their
family at risk in terms of legality
 Prone to fire – the materials of the house used are made of light materials
C. Self – esteem
 Inferior – having low self-esteem
D. Self – actualization
 Unfulfilled- client verbalized the need to earn more than what they currently have

B.2 PROBLEM IDENTIFICATION

Health Threat
● Lack of Food Storage- Lack of Food Storage
- They don’t have refrigerator that would keep their food safe from microorganism.
● Inadequate Living Space
- One room for a family of seven is a substandard space for the family
● Prone to Fire
- Their house is made of light materials like wood and bamboo.
● Possible Pregnant Complication
- Because Mrs. No Space never seek medical help even when she was having varicella virus
during her 3 months gestation.

Health Deficit
● Malnutrition
- Food prepared is lack of nutrients
Foreseeable Crisis
● Unwanted pregnancy
- Interest of taking maternal and child health is at risk
● Unwillingness to go to the health center
- Possible complications may occur during pregnancy until child birth
B.3 FAMILY NURSING CARE PLAN
B.4 HEALTH TEACHING

Pregnancy Management
- Instruct to take proper nutrition
- Advice to have Prenatal Check-up
- Instruct the importance of doing light exercise

Medical Management
- Adherence to the medical regimen
- Awareness of potential problem
- Promotion of normalcy
- Awareness and management of the disease process

Malnutrition
- Need to have guidelines to proper nutrition
- Encourage to buy nutritious foods that the family can afford

Home Management
- Maintain a developmental environment t
- Teach the importance of an adequate space
- Prevention of hazards

3 LEVELS OF PREVENTION
 Primary Prevention
1. Health Promotion

- Health education to mothers about good nutrition and food hygiene health
workers
- Distribution of supplements (distribution of iron , folic acid and vitamin a).
- Promotion of breastfeeding
- Development of low cost weaning foods
- Measures to improve family diet
- Nutritional education
- `Home economics
- Family planning and birth spacing
- Family environment

2. Specific Protection
- Specific protein diet, eggs, milk, fresh fruit
- Immunization
- Fortification of food
Secondary prevention; early diagnosis and adequate treatment
1. Periodic nutrition surveillance.
2. Early diagnosis of any lag of growth.
3. Early diagnosis and treatment of infection including diarrhea.
4. Developing the program for early dehydration of children with diarrhea.
5. Developing supplementary feeding program during epidemics.
6. Regular deworming of school and preschool children.

Tertiary prevention; nutritional rehabilitation

1. Nutritional rehabilitation services.
2. Hospital treatment
3. Follow up of cases
XVI. SUMMARY / EVALUATION
XVII. IMPLICATION
XVIII. HEALTH UPDATE

More than half million Pinoy kids suffer from severe malnutrition
By: CLAIRE DELFIN ; February 27, 2013 1:43pm

CALUYA ISLAND, Antique – The drizzle halted, and the sun finally took over. As it
shone higher and brighter, it made the sea even more inviting. Its clear waters glittered like fine
diamonds and its white sands offered an immaculate, spectacular landscape equivalent to what
people call paradise. Undeniably, it’s a good morning to dip. And brothers Adrian and Arvin
Malano rushed to the sea as soon the school bell rang to signal the start of lunch break. They
went farther and farther from the coastline, lingering at the part where the water was deep
enough for them to swim, gyrate and even whirl underneath. At first glance, the brothers aged 12
and 7 seemed to be simply enjoying the moment, frolicking underwater. But playing and having
fun is not exactly the reason why they were there in the sea at a time when they should be eating
lunch and resting before going back to school for the afternoon sessions.

Each time they rose up fast from the seabed, their hands were full with long lines of green
seaweed. Some tattered shanks of styrofoam were afloat, waiting for the fill of their harvest. This
is a usual day for the young brothers. A kilogram of seaweed will sell eight pesos.
 For a 30-minute harvest, they both would usually gather up to three kilograms, which will
earn them about P24 or a little over half a US dollar. There are bad days, though, when they get
no harvest. “We want to help our parents. It’s for our food,” said 12-year-old Arvin.

At home, the Malano brothers joined their parents and three other siblings for lunch, their
first meal for that day. The entire family only had five small pieces of dried fish and rice to share.
Their parents would rather have the five kids take the fish. They would have to satisfy
themselves with sprinkling their rice with salt to give it flavor.

Rovelyn and her husband earn a living also by harvesting and selling seaweed. They said
they would not want their children to work, but they claimed that they are left with no better
options. The choices to make have always just been either hunger or extreme hunger, they said.

“Hunger has always been with us since I was a kid. And now that I am a mother, I still
experience it. My kids are still experiencing it, and it’s even worse,” a tearful Rovelyn said as she
looked at her children eating. “There are nights when they would just go to sleep with empty
stomachs. Sometimes, they wake up in the middle of the night with their stomachs aching,” she
added. It may be weird, but she couldn’t help but feel relieved whenever she would think of one
of her children who died and another one whom she gave up for a childless couple to adopt. “At
least, they do not suffer the same hard fate we are having,” Rovelyn sighed.

REFERENCE

http://www.gmanetwork.com/news/story/296884/news/specialreports/more-than-half-million-
pinoy-kids-suffer-from-severe-malnutrition

SUMMARY

Adrian is 7 years old and Arvin Malano is 12 years old. They live in Caluya Island,
Antique. At the very young age they usually rushed to the sea as soon as the bell rang to signal
the start of lunch break. They went farther and farther where the water was deep enough for them
to swim and even whirl underneath. At first, you will just think that they are just simply playing
and enjoying the moment but playing and having fun is not exactly the reason why they were
there in the sea at a time of lunch and when they should be eating lunch and resting before going
to school for the afternoon sessions. But instead they were there to harvest green seaweed where
a kilogram of seaweed will sell 8 pesos.

For 30 minutes harvest, they both usually gather up to 3 kilograms which will earn them
for about 24 pesos. As what Arvin said “we want to help our parents. It’s for our food.” The
entire family has 5 small pieces of dried fish and rice to share. Rovelyn and her husband earn a
living also by harvesting and selling seaweed. As they said they don’t want their children to
work but they claimed that they are left with better options.

Their mother said “Hunger has always been with us since I was a kid. And now that I am
a mother, I still experience it. My kids are still experiencing it, and it’s even worse.” There are
nights when they would just go to sleep with empty stomachs. Sometimes, they wake up in the
middle of the night with their stomachs aching,” she added.

REFLECTION

World has always been facing poverty. Health status of every child here in the universe is
at risk. Innocent children suffered from different illnesses due to poverty or financial constraints.
Do they deserve to experience this kind of problem or it is their fate or destiny to have this kind
of problem.

Malnutrition is one of the problems of Philippines. Many people say that money is the
only solution. Do you think that money is the only solution to fight against malnutrition? I guess
not, money is just one of the factors that help to eliminate malnutrition but the most important
thing is education. Money can’t buy the education we have because if people are just educated it
seems that they already have the idea how to handle things and at least this problem will be
lessen. But we can’t blame them because of the poverty, lot of people are lack of education.

As what the story of Adrian and Arvin, I can’t imagine that at the very young age they
already working and harvesting green seaweed at the sea for their meal while studying. It only
shows that not all people are lucky enough to eat at least thrice a day. In their situation, I can’t
take it that they would just go to sleep with empty stomach. And I guess, hunger will affect
children’s education. How they suppose to focus their attention to their lesson if they are hungry?

And now, one thing come up into my mind, as long as we are fully supported by our
loved ones don’t waste any chances because it is one of the reason to avoid this situation and
always put into our mind be responsible in our studies.

REFERENCES:

http://www.nhs.uk/Conditions/Malnutrition/Pages/Causes.aspx

http://www.nhs.uk/Conditions/Malnutrition/Pages/Symptoms.aspx

http://www.nhs.uk/Conditions/Malnutrition/Pages/Introduction.aspx
- http://raystudent.blogspot.com/2011/12/prevention-of-malnutrition.html