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A. DEFINITIONMarasmus is a form of protein-calorie malnutrition is mainly due to severe calorie deficiency and chronic mainly occurred during the first year of life and care of subcutaneous fat and muscle. (Dorland, 1998:649).Marasmus is a disease caused by deficiency of protein calories. (Suriadi, 2001:196).Marasmus is severe malnutrition in infants often exist in areas with insufficient food or lack of hygiene. Synonym marasmus applied to clinical disease patterns that emphasize one more sign ayau protein and calorie deficiency. (Nelson, 1999:212). B. EtiologyThe main causes of marasmus are less calorie protein that may occur due to: inadequate diet, eating habits are not exactly like the parent-child relationship with a disturbed, because of metabolic abnormalities, or congenital malformations. (Nelson, 1999).Marasmus can occur at any age, but are often found in infants who are not getting enough milk and are not fed often attacked his successor or diarrhea. Marasmus may also occur due to various other diseases such as infections, gastrointestinal disorders or congenital heart disease, malabsorption, metabolic disorders, chronic kidney disease and also in the central nervous disorders. (Dr. Solihin, 1990:116). C. ANATOMY PHYSIOLOGY Mouth, Throat & EsophagusThe mouth is the entrance to the digestive system. The inside of the mouth covered by mucous membrane. Taste perceived by the sensory organs located on the surface of the tongue. Taste is relatively simple, consisting of sweet, sour, salty and bitter. Perceived by the olfactory nerves in the nasal olfactory and more complicated, consisting of a wide range of odors.Food is cut into pieces by the front teeth (incisors) and in chewing by the back teeth (molars, molars), into smaller parts that are easier to digest. Saliva from the salivary glands will be wrapped around the parts of the food with digestive enzymes and begin to digest it. Saliva also contains antibodies and enzymes (eg lysozyme), which break down proteins and attack the bacteria directly. The process of consciously swallowing begins and continues automatically. StomachStomach is a hollow muscular organ shaped like a cage large and donkey, consists of three parts: the cardia, fundus and antrum. Food into the stomach of kerongkonan through a ring-shaped muscle (sfinter), which can open and close. Under normal circumstances, sfinter blocking re-entry of gastric contents into the esophagus. Rectum & AnusThe rectum is a room that starts from the tip of the large intestine (the sigmoid colon) and ends at the anus. Rectum is usually empty because stool is stored in a higher place, namely in the descending colon. If the full descending colon and feces into the rectum, then the desire to defecate. Adults and older children can resist this desire, but infants and younger children have less control of the muscles that are important to delay bowel movements.The anus is a hole at the end of the digestive tract, where the waste material out of the body. Anus is formed partly from the body surface (skin) and some eat it from the intestine. A muscular ring (anal sphincter) keeping the anus remains closed.Stomach serves as a storehouse of food, which contract rhythmically to mix food with enzymes. The cells lining the stomach produces three important substances:- mucus- hydrochloric acid (HCl)- precursor of pepsin (an enzyme that solves protein)The mucus protects the stomach cells from damage by stomach acid. Any abnormalities in this mucus layer, can cause damage that leads to the formation of peptic ulcers.Hydrochloric acid creates an atmosphere that is very acidic, which is required by pepsin to break down proteins. High gastric acidity also acts as a barrier against infection by killing many

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bacteria. Intestinal SmoothThe stomach releases food into the duodenum (duodenum), which is the first part of the small intestine. Food into the duodenum through the pyloric sphincter in the amount that can be digested by the small intestine. When full, the duodenum to the stomach sends a signal to stop flow of food.Intestinal wall is rich in blood vessels that carry substances that are absorbed into the liver via the portal vein. Intestinal wall mucus release (which lubricates the intestinal contents) and water (which helps dissolve the fragments digested food). The walls of the intestine also releases a small amount of enzymes that digest proteins, sugars and fats. D. CLINICAL MANIFESTATIONSIn the beginning there is a failure to gain weight, accompanied by loss of body weight to result in thin, with a loss of turgor of the skin to become wrinkled and loose because subcutaneous fat is lost from the cheek pads, baby's face may still appear relatively normal during beberaba time before it becomes shrunk and wrinkled . Abdominal bloating and can be flat. Muscle atrophy occurs with the result hipotoni. Temperature is usually normal, the pulse may be slowed, at first the baby may rewe, but then lethargy and appetite loss. Babies usually constipation, but may appear what is called a type of starvation diarrhea, with frequent bowel movements, stool contains mucus and a little bit. (Nelson, 1999).Additionally manifestation marasmus are as follows:1. Emaciated body looks like a parent2. Lethargi3. Irritable4. Wrinkles (poor skin turgor)5. Sunken fontanel in infants6. Jaingan subcutaneous missing7. Malaise8. Hunger9. Apathetic E. PATHOPHYSIOLOGYLess calories protein will occur when the body's need for calories, protein, or both are not fulfilled by the diet. (Arisman, 2004:92). In case of lack of food, the body is always trying to preserve life by meeting basic needs or energy. The body's ability to use carbohydrates, proteins and fats are essential to sustain life, carbohydrates (glucose) can be used by all tissues of the body as fuel, unfortunately the body's ability to store carbohydrates is very little, so that after 25 hours had to be a shortage. As a result of protein catabolism occurs after a few hours to produce amino acids that immediately converted into carbohydrates in the liver and kidneys. Selam fasting fat tissue is broken down into fatty acids, glycerol and ketone bodies. Muscles can use fatty acids and ketone bodies as an energy source that is running chronic food shortages. The body will defend itself not to break down proteins more seteah lost roughly half of the body. (Lubis's Nuuhchsan Arlina Mursada, 2002:11). F. MANAGEMENT1. This situation requires a diet that contains sufficient quantities of protein biologiknya good quality.Diit high in calories, protein, minerals and vitamins.2. Fluid and electrolyte therapy.3. Management immediately any acute problems such as severe diarrhea problems.4. Assessment of a history of socio-economic status, review the history of dietary, anthropometric assessment, review the clinical manifestations, laboratory results monitoring, weigh weight, assess vital signs. Handling heavy CTFBroadly speaking, the handling of heavy CTF grouped into early treatment and rehabilitation.The initial treatment is aimed to overcome life-threatening condition, while the phase of rehabilitation is directed to restore the state of nutrition.Treatment efforts, including:- Treatment / prevention of hypoglycemia, hypothermia, dehydration.- Prevention of septic shock if there ancamanperkembangan- Treatment of infections- Provision of food- Identification and treatment of other problems, such as vitamin deficiency, severe anemia and heart trouble. According Arisman, 2004:105- Composition ppemberian CRO (Oral Rehydration Fluids) of 70-100 cc / kg is usually sufficient to correct dehydration.- How to start giving as much as 5 cc / kg every 30 minutes during the first 2 hours orally or NGT then increase to 50-10 cc / kg / hour.- The liquid as much as it should be discharged within 12 hours.- Breastfeeding should not be discontinued when the provision of ORS / intravenous rehydration is given in the activity.- Give him a liquid diet containing 75-100 kcal / cc, respectively referred to as the F-75 and F-100. According Nuchsan LubisManagement of marasmus patients treated in hospitals are divided into several stages, namely:1. The initial phase of the first hour :24-48 is a critical period, ie action to save lives, among other things to correct dehydration or acidosis with IV fluid administration.- Fluid given was Darrow's solution or Ringer's Lactate-Glucose Dextrose 5%.- At first given 60 ml / kg in the first 4-8 hours.- Then the remaining 140ml given in the next 16-20 hours.- Fluids given 200ml/kg BW / day.2. Phase adjustment to the provision of food- In the first days of a given number of calories as much as 30-60 calories / kg / day or an average of 50 calories / kg / day, with 1 to 1.5 g protein / kg BW / day.- 1-2 days then gradually increased up to 150-175 calories / kg / day, with 3-5 g protein / kg BW / day.The time required to achieve this High Calorie High Protein diet approximately 7-10 days. G. DIAGNOSTIC EXAMINATION1. Physical examinationa. Measuring Height and Weight b. Calculate body mass index, ie weight (in kilograms) divided by the Height (in meters)c. Measuring skinfold thickness dilengan on the back (triceps fold) is pulled away from the arm, so that the layer of fat under the skin can be measured, generally view using a caliper (calipers). Amount of fat under the skin is 50% of body fat. Normal skin fold approximately 1.25 cm in males and about 2.5 cm in women.2. Basic Concepts Nursing Care.I. Assessment 1. Biodataa. The identity of patientsb. The identity of responsible2. Medical historya. The main complaintb. Medical history nowc. Past medical history Patients never get Rs for allergiesd. Family health history3. Patterns of health functionsa. Pattern perception of healthWhen sick, regular clients in TKO membeliobat atauapabila terdeat drug does not change the patient push yourself to the nearest

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clinic or hospital.b. Exercise activity patternsExercise activities during the illness:Activity: 0 1 2 3 4 Eating Bathroom Dress Elimination Mobilization in bedc. The pattern of bed restNo metabolic disturbances in nutrition.d. Pattern elimnesiClients Chapter 1x a day, with mushy consistency, characteristic odor and yellow color of urine 4-5x a day, with a clear yellow color characteristic odor.e. The pattern of cognitive perceptualWhen sober assessment Kien, speaking clearly, hearing and normal vision.f. The pattern of role relationshipsClients religion of Islam, worship is done routinely.g. Self-concept pattern1. Self-esteem: not bothered2.Ideal self: do not disrupted3. Identity: disturbed, because they feel embarrassed due to illness4. Self-image: not bothered5. The role of self: do not disruptedh. Patterns of Sexual Reproductioni. Coping Patterns4. Nutritional status can also be obtained by measuring the LLA to estimate the amount of skeletal muscle in the body (lean body mass, lean body mass).5. Laboratory tests: albumin, creatinine, nitrogen, electrolytes, hemoglobin, hematocrit, transferrin. II. NURSING DIAGNOSIS Alteration in nutrition less than body requirements related to inadequate food intake (decreased appetite). (Wong, 2004) fluid volume deficit related to diarrhea. (Carpenito, 2001:140) Impaired skin integrity related to impaired nutritional / metabolic status High risk of infection associated with damage to the body's defense Lack of knowledge related to its lack of information (Doengoes, 2004) Changes in growth and development associated with physical melemahnyakemampuan and dependence secondary to caloric intake or inadequate nutrition. (Carpenito, 2001:157). Intolerance activities associated with impaired oxygen transport system secondary to malnutrition. (Carpenito, 2001:3) Excess fluid volume related to lower protein intake (malnutrition). (Carpenio, 2001:143). III. NURSING INTERVENTION1. Impaired nutrition less than body requirements related to inadequate food intake (decreased appetite). (Wong, 2004)Objectives:Patients receive adequate nutritionExpected outcomes:improve the oral input.Intervention:a. Get a history of dietingb. Encourage parents or other family member for feeding the children or there while eatingc. Ask the children to eat over the kitchen in the group and make mealtime a pleasantd. Use a familiar cutlerye. Nurses must have at meals to provide assistance, prevent nuisance and praise the child to eat themf. Serve makansedikit but ofteng. Serve small portions of food and give each portion separately 2. Fluid volume deficit related to diarrhea. (Carpenito, 2001:140)Objectives:Prevent dehydrationExpected outcomes:Lip mucosa moist, there was no increase in temperature, good skin turgor.Intervention:a. Monitor vital signs and signs of dehydrationb. Monitor the amount and type of fluid intakec. Accurately measure urine output 3. Impaired skin integrity related to impaired nutritional / metabolic status. (Doengoes, 2000).Objectives:No disruption of skin integrityExpected outcomes:skin is not dry, not flaky, normal elasticityIntervention:a. Monitor reddish, pale, ekskoriasib. Encourage 2xsehari bath and use lotion after a showerc. Massage the skin over bony hasilususnya Criteriad. Rather lie 4. High risk of infection associated with damage to the body's defenseObjectives:The patient showed no signs of infection Expected outcomes:Normal body temperature is 36.6 C-37, 7 C, leucocytes within normal limitsIntervention:a. Washing hands before and after the actionb. Make sure all equipment in contact with the patient clean / sterilec. Instruct health care workers and family in the infection control proceduresd. Give antibiotics according to program 5. Lack of knowledge related to its lack of information (Doengoes, 2004)Objectives:increased knowledge of patients and familiesExpected outcomes:Stating awareness and lifestyle changes, identify the relationship of signs and symptoms.Intervention:a. Determine the level of knowledge of the patient's parentsb. Assess dietary needs and answer questions as indicatedc. Encourage the consumption of foods high in fiber and fluid intake is adequated. Provide written information to parents of patients 6. Changes related to growth and development of physical and dependence melemahnyakemampuan secondary to caloric intake or inadequate nutrition. (Carpenito, 2001:157).Objectives:Children are able to grow and develop in accordance with his age.Expected outcomes:There was an increase in personal behavior, social, language, cognitive or motor activities in accordance with his age.Intervention:a. Teach the parents about the developmental tasks appropriate to the age group.b. Assess the child's developmental level with the Denver IIc. Provide an opportunity for a sick child meet developmental tasksd. Provide age-appropriate toys. 7. Activity intolerance related to impaired oxygen transport system secondary to malnutrition. (Carpenito, 2001:3)Objectives:Children are able to indulge in accordance with its capabilities.Expected outcomes:Demonstrate ability to do the activity again.Intervention:a. Provide games and activities according to ageb. Help all children's needs by involving the patient's family 8. Excess fluid volume related to lower protein intake (malnutrition). (Carpenio, 2001:143).Objectives:Excess fluid volume did not occur.Expected outcomes:Mention the factors that cause and prevention methods edema, peripheral edema showed decreased and sacral.Intervention:a. Monitor skin against signs of pressure soresb. Change position at least 2 hoursc. Review input and dietary habits

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that can support the retention of fluids IV. IMPLEMENTATION OF NURSINGa. Obtaining a diet historyb. Encourage parents or other family member for feeding the children or there while eatingc. Asking children to eat over the kitchen in the group and make mealtime a pleasantd. Using a familiar cutlerye. Nurses must have at meals to provide assistance, prevent nuisance and praise the child to eat themf. Presenting makansedikit but ofteng. Presenting a small portion of food and give each portion separately V. EVALUATION OF NURSINGPatients say the problem is resolved when getting adequate nutrition and are able to improve the oral input