A REPORT ON FIELD ATTACHMENT AT MATUNGU

SUB- COUNTY HOSPITAL

PERIOD : 13th Sep TO 13th Dec 2021

INSTITUTION : BUMBE TECHNICAL TRAINING

INSTITUTE

DEPARTMENT : INSTITUTIONAL

MANAGEMENT

PRESENTED BY : JEMUTAI FLORENCE

PROGRAMME : DIPLOMA IN NUTRITION AND

DIETETICS MANAGEMENT

ADM NO : 5017

NAME OF THE SUPERVISOR: FAITH NANJIRA

Table of Contents
Declaration
Acknowledgement
Abcractive
Introduction1
Objectives1
Overall Objectives1
Specific Objectives1
Historical Bachground2
Vision2
Mission2
Policy3
Mandate3
Organizational Structure4
Acronyms/Abbreviations5
CHAPTER ONE8
1.1 METHODS AND MATERIALS USED DURING ATTACHMENT8
1.1.1 METHODS8
1. Nutrition Counseling8
2. Use of Demonstration8
3. Nutrition Education9
4. Health Talks9
5. Nutritional Assessment9
1.2 MATERIALS10
1.2.1 Anthropometric Equipment10
1. Mid Upper Arm Circumference (MUAC) Tapes10
2. Real Objects (Food Samples and Food Models)10
3. Growth Charts for Children10
4. Weighing Scales11
5. BMI for age Reference Chart for Children 5-17 years11
6. Flip Charts11
7. Pamphlets11
8. Stadiometers11
9. Recording Tools12
10. Nutrition Supplements12
11. Working Materials13
DUTIES OF A NUTRITIONIST13
CHAPTER TWO14
2.1 MEDICAL WARDS14
Departments14
2.1.1 Female Medical Ward14
2.2 Male Medical Ward18
CHAPTER THREE22
3.1 Paedriatic Ward/NBU (Ward 4)22
3.1.1 Objectives22
3.1.2 My roles and activities23
3.1.3 Experience Gained23
3.1.3.1 Phase 1 Treatment23
3.1.3.2 Dehydration in Malnutrition24
3.1.3.3 The Transition Phase25
CHAPTER FOUR27
4.1 Surgical Ward (Ward 5)27
4.1.1 Roles and Activities27
4.1.2 Experience Gained27
4.1.2.1 Comprehensive Nutrition Care for Patients in Surgical Ward27
CHAPTER FIVE30
5.1 Mother and Child Health Care30
5.1.1 Objectives30
5.1.2 My Roles and Activities30
5.1.3 Experience Gained31
CHAPTER SIX33
6.1 Maternity Ward (Ward 1)33
6.1.1 Objectives33
6.1.2 Positioning and Attachment33
6.1.3 Proper Hygiene and Sanitation34
6.1.4 Exclusive Breastfeeding34
6.1.5 Experience Gained35
6.1.5.1 Post-Partum and Ante-Partum Rooms35
6.2 Gynecology Ward (Ward 2)35
CHAPTER SEVEN36
7.1 Kitchen36
Conclusion/Challenges37
Recommendation38
RECOMMENDATIONS TO THE HOSPITAL38
References39
Appendix 140
Appendix 242
Declaration
I have declared that this work is my own original and has not been done by anyone else or
presented by any institution.

Name : JEMUTAI FLORENCE

Date : 13 th DEC, 2021

Signature :

5
Acknowledgement
I have made great effort to write this practicum however it would not have been possible
without the kind of support and help of many.

I would like to extend my sincere thanks to all of them.

Sincere appreciation to the nutrition-in-charge in Matungu sub-county Hospital for priceless

appreciation in this great facility as well as their great support and being a rich source of
information.

I am highly indebted to my lecturers for their guidance and constant supervision as well as for
providing necessary information to ensure I gain maximum field conscience.

Thanks to my fellow colleagues at the facility who were not only a pool of information but also
for their emotional and moral support.

Appreciation to my parents for their support to see me through my schooling. Finally, I give
thanks to the Almighty God for the grace and strength He has given me throughout the
practicum.

6
Abstract
My three months attachment program was held at Matungu sub-county Hospital. The facility
has this ward male & female wards; maternity ward, obstetric paedriatric ward; surgical and
psychiatric wards respectively. Each ward has an approximately 25 bed capacity. I had the
following objectives to achieve during the attachment period to gain more knowledge and skills
on inpatient nutritional management of various nutrition related conditions by providing
appropriate intervention; to gain more leadership skills and smooth running of nutrition support,
to establish a good working relationship with fellow professionals and the patients and to gain
more nutrition counseling skills at the inpatient and outpatient level through the help of the
medical professionals including the doctors, nurses, clinical officers and other nutritionists. I
managed to achieve most of my pre-set objectives. I gained much experience in handling
patients both in the inpatient setting and at the outpatient settings. This was achieved through
engaging me in several nutrition interventions such as modification of therapeutic feeds,
prescription of nutrition supplements, nutrition counseling and education. The attachment also
exposed me to several challenges. One of the main challenges I experienced during the
attachment period was the strike by the county health workers. Another challenge was the
shortage of blood for the patients with severe anaemia in the hospital. Boosting the hemoglobin
levels depended mainly on the dietary supplements and the prescribed drugs. The lack of
stipend was also a challenge as I had to depend on parents for money. In conclusion, the
attachment program in Matungu sub-countyHospital proved to be so essential in improvement
of my knowledge and skills in providing nutrition interventions for various disease conditions
and I thank all the medical team that made this happen. The three months program enabled me
to transform my theoretical knowledge I gained in the college into skills and I can now
comfortable handle patients with different medical conditions with no supervision.

7
Introduction
I carried out my attachment at the Matungu sub-county Hospital on 13th Sep to13 th Dec, 2021.
The aim of the attachment was to familiarize and put in practice theoretical part I learnt in class.
In the process, I managed to carry out the task given under the objectives.

Objectives

Overall Objectives
1. To understand the overall organization of the hospital facility.
2. To understand the management of the hospital.
3. To understand the mission, vision and core values of the hospital.

Specific Objectives
To understand the practical session; I had specific objectives;

i) Conduct practical nutrition education and counseling to patients with various

nutrition related conditions.
ii) Nutrition assessment of patients is a core part of my nutrition. Given in classroom
settings, It was mostly thought in theory; my biggest objective was to get to see how
assessment is conducted and learn to do it myself.
iii) Apply nutrition intervention method to help prevent, rehabilitate and solve nutrition
related diseases.
iv) Interacting with the other nutrition students to learn different perspectives of
nutrition. I also exchanged learning materials and experienced in them.
v) Observe as well as incorporate the relationship between nutrition and other
discipline in the medical set up to work collectively to bring about positive.
vi) To understand and use various nutritional tools and equipments used.
vii) Administering of therapeutic diets to patients under various conditions.

8
Historical Bachground
The facility was established around 1900 during the construction of Kenya-Uganda Railway. It
acted as an army barracks facility for the colonial government serving the entire Western
Region for some time until it was turned into a native hospital where they trained health
workers more specifically on wound dressing. During this time, It was serving as a regional
hospital and was commonly known as Old Matungu Provincial Hospital until the year 1969,
when the New matungu Provincial Hospital – Russia was built with the help of the Russian
Government.

The establishment of the New Matungu Provincial Hospital did not render the former
functionless, instead they worked in collaboration for quite a long time until around 1992 when
the agency was made a sub-countyt hospital being separated from the New Matungu Provincial
Hospital. This was due to its central location within the district headquarters making it more
accessible, (By then known as Matungu sub-county Hospital).

After devolution, the hospital was transformed to a county hospital, presently known as
Matungu County Hospital.

Vision
An efficient and high quality health care system that is accessible, equitable and affordable for
every Kenyan.

Mission
Provide integrated accessible and quality health care services through effective and efficient
structure, training, research and partnership.

Policy
Treat any patient whose life or health is at risk and ask questions later. Down payments will be
accepted and patients will be given time to find the balance.

9
Mandate
Implement policies, set standards, provide health care services, create an enabling environment
and regulate provision of health services delivery within our area of jurisdiction.

10
Organizational Structure Medical Superintendent

Medical and Health Administrative Hospital Matron

Paramedical Services Officer

Radiography, Nutrition Non-Medical Services Nursing and Outpatient

Services Services

Supplies Medical Account and Welfare Personal

Officer Technology Billing Services Services and
Engineering Registry

Nutrition Officer In- Nutrition Supervisors Nutrition Interns Nutrition Attachees

Charge

Kisumu County Referral Hospital Organogram

11
Acronyms/Abbreviations
M.S.CH : Matungu sub-county Hospital

RESOMAL : Rehydration Solution for Malnutrition

B.M.I : Body Mass Index

F.B.F : Fortified Blended Flour

M.U.A.C : Mid Upper Arm Circumference

M.A.M : Moderate Acute Malnutrition

S.A.M : Severe Acute Malnutrition

F 75 : Special Milk for Stabilization of Malnutrition

F 100 : Formula 100

O.R.S : Oral Rehydration Salt

PAEDS : Peadriatic Ward

N.G. TUBE : Nose Gastric Tube

SEP : Supplemental Feeding Programme

MCH : Mother to Child Health care

C.W.C : Child Welfare Clinics

OPD : Outpatient Department

CCC : Comprehensive Care Centre

ANC : Antenatal Clinic

M.O.H : Ministry of Health

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K.M.C : Kangaroo Mother Care

PMTCT : Prevention of Mother To Child Transmission

EBF : Exclusive Breastfeeding

RVD : Retroviral Disease

PEM : Protein Energy Malnutrition

DM : Diabetes Mellitus

HTN : Hypertension

CKD : Chronic Kidney Disease

AKI : Acute Kidney Injury

PUD : Peptic Ulcer Disease

PEM : Protein Energy Malnutrition

IFAS : Iron Deficiency Anemia

CD4 : Clustered of differential

BS : Blood Sample

CME : Continuous Medical Education

TCA : To Come Again

SD : Standard Deviation

RUTF : Ready to Use Therapeutic Food

RUSF : Ready to Use Supplementary Food

DOA : Date of Admission

WHZ : Weight for Height Z-score

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MOS : Medical Officer

COS : Clinical Officer

CHAPTER ONE

1.1 METHODS AND MATERIALS USED DURING ATTACHMENT

1.1.1 METHODS

1. Nutrition Counseling
Dissemination of nutrition information to recipients to impact knowledge and positive change to
their behavior and attitudes.

Here, the client is greatly involved in making right nutrition choices as the nutritionists act
majorly to guide him/her into making sound nutrition decisions. The patient is asked questions

14
to stimulate an interactive session as the nutritionist make notes on relevant issues and finally
leading the clients into making final decision. However, the sole decision making lies with the
client being counseled.

The application of nutrition counseling was in all wards and outpatient units including the
comprehensive care clinic. Nutrition counseling on its own has proved to be an effective tool in
assessing client’s level of knowledge in nutrition.

2. Use of Demonstration
Modeling and explaining a particular procedure to show a specific method of applying the
skills. Use of demonstrations was applied extensively in the maternity wards (Ward 1 & 4).
Here, the following demonstrations were carried out:

- Positioning and attachment of the infants during breastfeeding.

- Family planning methods.
- Proper hygiene and sanitation.

This method allowed the mothers and listeners to engage in the session actively hence
increasing the knowledge retention.

This method has a demerit in that it takes a lot of time in the preparation and demonstration as
well.

3. Nutrition Education
Nutrition education is a process whereby clients/patients are enlightened on nutrition to acquire
skills, attitude and knowledge for the sole purpose of developing healthy dietary habits and
choices.

This method was advantageous in the sense that it can be used to disseminate nutritional
knowledge in a hospital setting for both inpatient and outpatients as well as in a community
setting.

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4. Health Talks
Consists of nutrition education to a number of clients, which involves choosing a topic on
relevant areas based on the audience majorly health talks were given in the mother and child
health clinic.

5. Nutritional Assessment
Anthropometric and clinical methods of assessment were majorly used in determining the
nutritional status of clients/patients.

Anthropometric measurements used included MUAC, weight, height and length.

Clinical assessment methods included checking for presence of edema, oral thrush in the mouth,
baggy pants and temperature.

1.2 MATERIALS

1.2.1 Anthropometric Equipment

1. Mid Upper Arm Circumference (MUAC) Tapes

These tapes were used in the nutrition assessment of patients in pediatric wards, maternity
wards, mother and child clinic, outpatient nutrition clinic and the chest clinic.

Children below six months and patients whose weight and height could not be easily obtained
e.g. bedridden patients also had their MUAC reading taken to determine their nutrition status.

MUAC is a tool used to measure the level of wasting in patients with readings being taken on
the middle of the upper left arm using a special tape.

2. Real Objects (Food Samples and Food Models)

Use the actual objects in giving nutrition counseling or education. Most of the real objects that
were being used were food samples. This helped to make the learners identify with the foods

16
being reffered to and also made sessions more interesting. Example of food samples included;
beans, wheat, flour, groundnuts, peas, French beans and omena.

These materials were majorly wards, mother and child clinic and the nutrition outpatient
department.

3. Growth Charts for Children

The growth charts were used in the pediatric wards and mother child health clinics. These charts
were found in the mother-child booklets. From the charts, by measuring the weight of the child,
one could determine the level of nutrition in terms of standards deviations. With +24D meaning
the child is overweight and -25D denoting underweight.

4. Weighing Scales
These were used in the wards to determine the weight and nutritional status of the patient,
calculate the amount of protein and calorie intake and level of edema. Weight also showed the
level of wasting in the patient. Example of weighing scale that was used include the tarred scale.

5. BMI for age Reference Chart for Children 5-17 years

This chart was used in determining the level of nutrition in the above named age bracket. Most
of its application was in the comprehensive care clinic.

6. Flip Charts
Flip charts were used to show BMI for age charts, Age for weight charts and other nutrition
information. The child had step to step counseling information for HIV/AIDs patients.

7. Pamphlets
These are nutrition messages printed in small pocket size print publications. Use of pamphlets
was among the diabetic patients where they were issued with the pamphlets as a reminder of
what was discussed with them pertaining nutrition. The pamphlets were however in limited

17
number and at times, we were forced to write nutrition messages on sheets of paper. However,
their use was very effective in passing of the information.

8. Stadiometers
These were used to measure the height of patients and determine the level of stunting. The data
dot from here (height) was also used as input in calculating the BMI of patients and clients.

9. Recording Tools
a) Nutrition care plan forms – were specialized forms for writing the nutrition care process
that a patient had been put on.
b) Feeding regime forms – were used in the pediatric wards to indicate the types of feeds,
nutrition status and assessment details of the patient and the amount of the feed being
administered.
c) Pen.
d) Tallying sheets.
e) Register books for clients – SEP, OTP MOH 409, MOH 407A.
f) Growth monitoring graphs.
g) Clinic cards/books.
h) Tally books.
i) Patients’ medical files.

10. Nutrition Supplements

i. B-Immune – Given to those patients with compromised immunity like the RVD, TB and
cancer patients.
ii. Fresubin – Prescribed for patients with poor and low appetite which is also high in
proteins.
iii. Febrin – Prescribed for children/patients with poor appetite also high in protein.

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 iv. F-100 – Therapeutic milk given for the treatment of SAM in children below the age of
two years. It is given during the transition phase and phase two of treatment.
v. F-75 – Therapeutic feed given to children below the age of two years during the initial
phase for the treatment of SAM.
vi. Foundation Plus – Given to wasted RVD and TB patients together with RUTF
depending on severity of wasting to provide extra energy and calorie.
vii. Advantage Plus – Given to pregnant and lactating mothers to provide extra energy.
viii. Vitamin A – Given to specific target disease groups such as TB, measles patients, those
with eye problems and children of six months and between one year up to five years and
lactating mothers four weeks postpartum.
ix. Formula Milk e.g. Nan, Pre-Nan, cow’s milk especially to the abandoned children.

11. Working Materials

 Lab coat.
 Sterilizer.
 Gloves.
 Syringes.

Duties of a Nutritionist
i. Nutrition assessments and counseling to patients.
ii. Nutritional reviews.
iii. Admissions and discharges to various nutrition programs.
iv. Monitoring and evaluating the level of nutrition programs.
v. Preparation and prescription of therapeutic feeds.
vi. Diet prescription and management, issuance of supplements.
vii. Management of disease conditions both inpatient and outpatient.
viii. Compiling daily and monthly reports
ix. Admission and discharges to various nutrition programs.
x. Documentations and office organization.

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CHAPTER TWO

2.1 MEDICAL WARDS

This hosted varying conditions with most being; Diabetes mellitus, hypertension, peptic ulcers,
tuberculosis, pneumonia, cancer, anemia and HIV/AIDs. The activities done in this;

- Prepare a diet requisition sheet for patients.

- Nutrition assessments, counseling and reviews.
- Meal management and diet prescription.
- Reviewing their files daily to monitor their progress.

Departments

2.1.1 Female Medical Ward

Case Study

Assessed a female patient aged 65 years with a condition of pulmonary embolism in known
diabetes mellitus (DM).

Name - Patient Z

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Age - 65 years

Sex - Female

Principle of Diagnosis

Pulmonary embolism in known DM

Anthropometric

Height - 1.62 m

IBW - 71

BMI - 21.1 Kg/m2

Biochemistry

RBS = 18.6 mmol/L

Clinical

Sick 100 king

Nutritional status

Overweight.

Diet History

Patient feed on small frequent meals, but not following diabetic diet and not taking medication
on time.

Taboos, allergies, intolerance

21
Meat

Food Intake

Poor

Breakfast : Tea + Bread

Lunch : Ugali + Fish

Supper : Ugali + Vegetables

Physical Activity

Sedentary

Nutrition Diagnosis

N
/Dx – Elevated blood sugar levels related to excessive intake of carbohydrates as evidenced by
diet history and RBS of 18.6 mmol/L.

Diet Care Plan

Prescribed diet – Calorie restricted diet / high fiber diet.

Activity Level

24 X 71 = 1704 Kcals

Protein Carbohydrates Fats

20
/100 X 1704 / 4 55
/100 X 1704 / 4 25
/100 X 1704 / 9

= 84 g = 234 g = 47 g

Consistency of diet = solid/liquid diet.

Route of administration = Oral

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NUTRITION MANAGEMENT INTERVENTION

- Intake of calorie restricted diet to help in weight reduction.

- Take foods high in fibre to bind excess fats in the body.
- Avoid sugary foods to prevent elevation of sugars.
- Encourage physical activity to help in weight reduction.
- Take water at least 8 glasses per day.

Food Exchange List

Patient - Z Carbohydrates - 234 g

Height - 1.62 m Proteins - 85 g

IBW - 71 Kgs Fate - 47 g

BM - 27.1 Kg/m2 Total Kcals - 1704 Kcals

Food Exchange List

List Serving Carbohydrates Proteins Fats Kcals

Milk 2 24 16 16
Fruits 4 60 - -
Vegetables 5 25 10 -
Starch 8 125 16 -
Meat 3 - 21 24
Fats 2 - - 10

Food Groups No. of Breakfast Snack Lunch Snack Supper

servings

23
 Meat 3 1 - 1 - 1
Milk 2 1 - - 1 -
Vegetables 5 - - 3 - 2
Starch 8 2 2 1 2 1
Fruits 4 1 1 1 1 -
Fats 2 - - 1 - 1

Meat Pattern Menu

Breakfast Snack 1 Snack 2

1. 1 egg boiled. 1. Porridge ½ cup. 1. 2 cups of

tea (250 mls)
2. 2 cups of tea (250 milk) 2. 1 small fruit. 2. 2 slices of
brown bread.
3. 2 slices 3. 1 small
fruit.
4. 1 small orange

Lunch Supper

1. 1 matchbox-sized meat. 1. 1 piece of chicken.

2. 3 cups of vegetables. 2. 2 cups of vegetables.
3. 1 cup of ugali. 3. 1 cup of rice.
4. 1 small fruit.

2.2 Male Medical Ward

Management of a male patient, aged 49 years with a diagnosis of anaemia in RVD.

24
Case Study

Name : Patient X

Age : 49 years

Sex : Male

Principle of diagnosis

Anaemia in RVD

Anthropometric Assessment

Height - 1.64 m

Weight - 41 Kgs

BMI - 15.2 Kg/m2

N/Status - Underweight (SAM)

Biochemistry

Hb of 5.6 g/dl

Clinical

Weak

Pale

Dehydrated

Diet History

Feeds on small meals three times a day and has a poor appetite.

25
Taboos, allergies, intolerance

Meat

Food Intake

Poor

Breakfast : Tea + Bread

Lunch : Rice

Supper : Ugali + Mala

Physical Activity

Sedentary

Support system – Lives with sister

Nutrition Diagnosis

N
/Dx – Inadequate dietary intake related to poor appetite as evidenced by the diet history and Hb
of 5.6 g/dl.

Diet Care Plan

Prescribed diet – High protein, high caloric diet.

Activity Level

35 X 4 = 1435 + 500

= 1935 Kcals

Carbohydrates Protein Fats

60
/100 X 1935 / 4 15
/100 X 1935 / 4 25
/100
X 1935 / 9

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= 290 g = 73 g = 54 g

Consistency of diet = Solid/Liquid foods

Route of administration = Oral

Nutrition Intervention/Plan

- Intake of foods rich in iron such as beans, liver, dark green leafy vegetables to increase
iron levels in the body.
- Take high calorie diet to provide extra energy in the body.
- Take foods rich in vitamin B12 which helps in the formation of RBS in the body which
prevent anaemia.
- Avoid intake of tea leaves and coffee because they contain polyhedral that hinder
absorption of iron.
- Fruits rich in vitamin C help in iron absorption.

27
CHAPTER THREE

3.1 Paedriatic Ward/NBU (Ward 4)

It is a ward specifically for children below 12 years.

The ward is divided into three sections, i.e.

Acute Room: This is where children with medical conditions that require close monitoring by
the nurses and doctors were stationed.

General Room: This room was reserved for the children who were already recovering from
their conditions and required minimal monitoring.

Malnutrition Room: This room was reserved for the children with severe acute malnutrition
with complications. Beside the room is the small diet kitchen for the ward and the nutrition
station for close monitoring by the nutritionists. The various medical conditions encountered in
the ward included:

- Pneumonia - Neonatal sepsis - Respiratory

- Asthma - Gastroenteritis disorders
- Malaria - Dehydration - Menengitis
- Marasmus - Febrile convulsions - Juvenile DM
- Kwashiorkor - Anemia - TB

28
3.1.1 Objectives
i. To learn how to manage severe acute malnutrition with complications at the inpatient
setting.
ii. To learn the criteria for enrolling malnourished children for inpatient care.
iii. To learn how to manage severe acute malnutrition in children below 6 months of age.

3.1.2 My roles and activities

 Attending the daily morning reports sessions and the ward rounds.
 Nutrition assessments: antropometrics, dietary, clinical and biochemical assessments.
 Prescription and preparation of therapeutic feeds, i.e. F75, F100 & RUTF.
 Preparation of the Oral Rehydration Solutions (ORS) and the Rehydration Solutions for
Malnutrition (ReSoMal).
 Nutrition counseling and education to the mothers and caretakers of the sick children.
 Conducting daily nutrition reviews and monitoring to the malnourished children in the
wards.
 Documentation of nutrition registers e.g. MOH 407B.

3.1.3 Experience Gained

The main experience I gained in this ward was based on my main objective in this ward, that is,
management of SAM with complications among the sick children.

3.1.3.1 Phase 1 Treatment

The F75

F75 contains 75Kcal/100mls. It is used in the stabilization phase i.e. until the medical
complications stabilizes and the appetite has improved, edema subsides from at least grade +++
to grade ++, IV fluids and NGT feeding completed. The patient is then graduated to the
transition phase of the treatment. Phase 1 usually takes about two days. Quantity administered
per feeding involved depended on the weight of the child, number of feeds per day and on
presence/absence of oedema.

29
In presence of oedema: Weight X 100/8 (mls)

In absence of oedema: Weight X 130/8 (mls)

For the malnourished children below 6 months of age, the main aim of treatment was to
promote exclusive breast milk alongside dilute F100 (prepared by addition of extra 35mls of
water per 100ml F100). Supplemental Suckling Technique (SST) was used in those that were
too weak to suckle.

For a commercially made F75, I leveled scoop diluted in 25 mls of water. Local preparation
involved.

- 300mls of whole - 1000mls of boiled - 2 vials of mineral

Milk and cooled water solution
- 100g of sugar

3.1.3.2 Dehydration in Malnutrition

I gained experience in diagnosis and management of dehydration in malnutrition. Replacing the
lost fluids through dehydration and correction of electrolyte imbalances. This mostly happened
during the stabilization phase.

ReSoMal

Administration of ReSoMal was done cautiously to avoid over hydration and treatment for
dehydration involved the use of the below protocol:

 For the first 2 hours: 10mls/kg/hour of ReSoMal.

 Then: 75ml/kg over 1 hour then first feed introduced with F-75 and ReSoMal alternated
with F-75 each hour at 7.5ml/kg/hour for 10 hours.
 The fluid can be increased/decreased as tolerated between 5-10ml/kg/hour.
 And at 12 hours switch to 3 hourly oral/NG tube feeds with F-75.

30
3.1.3.3 The Transition Phase
The objective for this phase was to gradually increase the amount of calorie intake for catch-up
growth with the weight gain during this phase expected be about 6g/kg/day.

The criteria for transfer to this phase included:

o Appetite has improved and taking all prescribed quantity of milk.

o Edema, if present, reduced from severe +++ to moderate ++ or mild +.
o Treatment for any medical complication has commenced and patient is recovering.
o IV fluids and NG feeding completed and cannula/tube removed in case the child was
under NG tube feeding.

The F100

This is a special therapeutic milk for catch up growth and resolve micronutrients deficiencies
for severe malnourished children and with higher kilocalories (100kcals/100mls). Same amount
of fluids used in the Phase 1 was used in the transition phase after which it was gradually
increased by 20mls to a maximum of 220mls depending on tolerance.

For a commercially made F100, I leveled scoop diluted in 25mls of water. Local preparation
involved the following ingredients:

 880mls of whole milk.

 1000mls of boiled and cooled water.
 75g of sugar.
 2 vials of mineral solution.

The RUTF

This was used (if the child accepted it) interchangeably with the F100 in this phase i.e. RUTF at
night, F-100 at daytime. They were being substituted on the basis that about 100ml of F100 =
20g of RUTF.

When given alone, the RUTF was provided at between 150 and 220kcal/kg BW/day.

31
The phase 2 treatment was done in the OTP and the criteria for discharge to the OTP included:

 A good appetite: if the child passes the appetite test and takes 75% of the daily ration of
RUTF.
 Bilateral pitting edema reducing to moderate ++ or mild +.
 Resolving medical complication.
 Clinically well and alert.

32
CHAPTER FOUR

4.1 Surgical Ward (Ward 5)

This was patient ward who were admitted due to surgical conditions. The condition encountered
were burns, fractures and trauma and theatre conditions.

4.1.1 Roles and Activities

 Carry out nutrition assessment, review of patients especially those with increased
nutrition requirements and are risk of under nutrition.
 Carry out nutrition counseling and education to the patients.
 Formulate diet plans and feeding regime for patients especially post-operative patients
who had surgeries affecting the gastrointestinal tract.
 Carry out supplementation to patients with increased nutrient needs.
 Prescribe supplements and parenteral feeds where there is need.
 Enroll patients to nutrition support programs on discharge those who need further
nutrition care.

4.1.2.1 Comprehensive Nutrition Care for Patients in Surgical Ward

Pre-Operative

In pre-operative cases, the rationale for nutrition care is;

 To avoid aspirations during surgery.

 To prevent complications during surgery.
 Nutrition care also determines outcome.

The pre-operative nutrition care includes;

 Put patient on fiber restricted diet 2-3 days preceding surgery.

 Ensure patient in Nil Per Oral (NPO) for at least 6 hours before surgery.

33
  Ensure patients meet their energy needs during the pre-operational period.

Burns, Chronic Wounds

The conditions in the surgical wards have various nutrition implications i.e. increased calories,
protein requirements, increased fluid requirements and vitamin requirements. Therefore
nutrition support is essential to prevent deficiencies and for promoting healing and ensuring
optimum nutrition status.

Burns usually come with a traumatic experience and increased energy requirement depending
on the Total Burn Surface Area (TBSA). The nutritional concerns of the burn victims addressed
are as outlined below,

Hyper metabolism and increased nitrogen losses

a) Loss of water and risk of infection due to loss of body’s first line of defense.
b) Loss of protein through leakage of protein rich fluid.
c) Improper consumption of food due to depression, pain and discomfort.
d) Acute ulceration of the stomach and duodenum.

As an intervention, nutritional counseling to the clients and the caretakers available was done.
They were encouraged to increase the energy and protein requirements to promote a faster
recovery of the burn victim. The metabolic rate of burn victim is said to increase
proportionately to the TBSA up to 50-60%, after which there is an inconsiderable increase. An
increase in caloric intake is thus necessitated.

Proteins of high biological value especially those from animal sources are emphasized to
promote tissue repair, compensate protein losses due to increased muscle catabolism and wound
losses. The clients were also encouraged to drink plenty of water and fruit juices so as to
maintain circulatory volume, electrolyte balance and prevent renal failure.

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For a TBSA of between 1-10%, protein should provide 15% of the total caloric requirement of
the patient while for a TBSA of greater the 10% (adults and children); protein should contribute
20% of the total caloric needs of the patient. Children below 1 year of age need to consume 3-
4g protein/kg since they cannot tolerate high renal solute loads.

The curreri formula was used (Adults)

Daily calorie requirements = (24Kcal X kg usual body weight) / (40Kcal X TBSA (% burn))

Daily protein requirements = (1g X body weight) / (3g X TBSA)

Caloric and protein needs for the children are as follows;

Daily calorie requirements = (60Kcal X kg usual body weight) / (35Kcal X TBSA)

Daily protein requirements = (3g X kg usual body weight) / (1g X TBSA)

Vitamin A is essential for the regeneration of the epithelial tissue of the skin; vitamin C is
essential for synthesis of collagen and acts as an antioxidant while zinc is essential for the
maintenance of body tissues.

CHAPTER FIVE

5.1 Mother and Child Health Care

The MCH involves both the antenatal and post-natal clinics. It is composed of the Antenatal
Clinic (ANC) room, Nutrition Room, Laboratory, Mentor Mothers Room, The Triage,
Conference Room, Family Planning Room and the ART Room.

The department is an outpatient dealing with children 6 to 59 months of age (5 years and
below). The services offered include immunization, nutritional services, prevention of mother to
child transmission (PMTCT), family planning and growth monitoring.

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5.1.1 Objectives
 To gain more skills on enrolling and managing SAM & MAM children in the OTP ans
SFP.
 To learn and gain more monitoring skills in children.
 To familiarize myself and offer the general nutrition care for the antenatal mothers.

5.1.2 My Roles and Activities

 Nutrition assessment and diagnoses to children brought to the clinic i.e. weight, height,
MUAC.
 Growth monitoring by plotting the growth charts.
 Nutrition education (health talks) on various topics related to nutrition of the mother and
child.
 Enrolling and giving nutrition support to SAM & MAM children through OTP and SEP
programs, involving prescriptions and dispensing of the FBF (First Food, Advantage,
CSB) and the RUTF.
 Nutrition counseling to caretakers of the malnourished children.
 Vitamin A supplementation and deworming children with antihelminths i.e.
Albendazole.

5.1.3 Experience Gained

During the antenatal clinics, the following are done; HIV screening for PMTCT, Iron and Folic
Acid supplementation. In postnatal clinics, the children underwent growth monitoring,
immunization, supplementation and other medical checklists.

Nutrition counseling is done to mothers during ANC visits on. They were encouraged to have
one extra meal, additional 500Kcals per day. Besides that, the pregnant mothers were sent to the
lab for urinalysis to check for the presence proteins in urine which would otherwise confirm risk
of preeclampsia. Presence of glucose or ketones would suggest presence of gestational diabetes.
My experience was on the counseling I did to the mothers with such conditions before they
were referred to the gynecological outpatient clinic (GOPC).

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Pregnant women attended the monthly Focused Antenatal Care (FANC) visits which was aimed
at helping them maintain the normal progress of pregnancy through timely guidance and advice.

The teachings and counseling they get during the visits include:

 Birth preparedness.
 Nutrition counseling.
 Immunization and supplementation with IFAS.
 Personal hygiene.
 Family planning.

For the malnourished children, the RUTF was prescribed as shown below;

Quantity per day = 200g X kg / 500. The follow up visits was after every two weeks.

1 pouch containing 15 sachets of First Food and 2 pouches each containing 15 sachets of
advantage was prescribed to the malnourished pregnant/lactating mother respectively. Follow
up visits was after 1 month.

Immunization of thechildren was also done in and the immunization schedule was as follows:

 BCG – at birth or within 2 weeks.

 Oral Polio Vaccine (OPV) – at birth or before 2 weeks, at 6 weeks, at 10 weeks and at
14 weeks.
 DPT/Hep B – It was given at the left thigh at 6 weeks, at 10 weeks and at 14 weeks.
 PCV10 (Pneumococcal Vaccine) – Given at the right thigh at 10 weeks and at 14
weeks.
 AT 9 months Measles and Yellow Fever Vaccines were given, or soon after.

Vitamin A supplementation was done as shown in the table below.

Table, Vitamin A Supplementation & Deworming Dosages and Frequencies

VITAMIN A DEWORMING
TARGET GROUP DOSAGE FREQUENCY DOSAGE FREQUENCY

Infants 6 months 100,000 IU Once - -

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 Children 12 months 200, 000 IU Every 6 months 200mg Once

Children 2 years and 200, 000 IU Every 6 months 400mg Every 6 months
above

CHAPTER SIX

6.1 Maternity Ward (Ward 1)

6.1.1 Objectives
- To promote, protect and sustain exclusive breastfeeding.
- To endure mothers and help prevent diseases and any other nutritional complication on
the mother and child, improving their well-being.
- To promote feeding tolerance.
- To promote neurodevelopment, organ maturity and functioning through exclusive
breastfeeding.
- To prevent infectious diseases and promote development of immune system.

Activities done in these two wards include:

 Vitamin A supplementation to lactating mothers.

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  Nutrition assessment of neonates taking their weight and monitoring their feeding
progress.
 Showing their mothers how to express milk for the ones who were weak to suckle.
 Nutrition education which involves hygiene, family planning, exclusive breastfeeding,
breastfeeding techniques and growth monitoring.
 Update diet distribution book which helped to know the number of patients in wards and
their condition e.g. PET mothers who need a low salt diet mothers who have undergone
C/S who need soft light diet e.t.c.
 Observing and educating mothers on causes and management of breast conditions such
as mastitis, breast engorgement, inverted and flat nipples.

6.1.2 Positioning and Attachment

Proper positioning and attachment was noted as a major challenge not only to the new mothers
but also to the older mothers with some being unreceptive due to arrogance.

The counseling on positioning and attachment consisted of the following;

- Proper positioning meant that the mother sat in a comfortable upright positioning with a
back rest if necessary; the buttocks, back and head of the infant were supported by both
hands of the mother; the infant shows signs of being relaxed by staying still.
- Proper attachment to the breast meant that the infant’s mouth covered a large part of the
areola with more of it showing in the upper lip than the lower lip; there was no suckling
sound apart from the sound due to swallowing; the mother did not strain during
breastfeeding; there was no pain on the mother’s breast during breastfeeding.

Demonstrations were shown to the mothers who came with their infants. The mothers were
asked to show how they normally breastfed their infants and corrections made where the mother
did not do right.

Mothers who were accompanied by their spouses were congratulated and the men encouraged
supporting the mothers during the lactation period by giving conducive environment and
providing enough food. It was so nice counseling both the mother and father of the infant.

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6.1.3 Proper Hygiene and Sanitation
The mothers were advised to maintain high standards of sanitation to prevent the vulnerable
infants to disease and infections.

6.1.4 Exclusive Breastfeeding

All mothers, save for the HIV positive mothers who had decided not to breastfed, were
encouraged to exclusively breastfeed their infants for six months without giving any other foods
or liquids unless under a qualifies physician’s prescription.

6.1.5 Experience Gained

6.1.5.1 Post-Partum and Ante-Partum Rooms

Some of the key experiences I gained in the maternity involved management of complicated
breast conditions such as engorged breasts by expressing the milk by hand or use of a breast
pump. This was preceded by rubbing using a warm wet cloth. Inverted nipples was corrected by
use of syringes to pull out the nipple. I also learnt about the Cabbage Therapy that was aimed at
reducing the milk let-down where a frozen cabbage is pressed on the breast to ease the tensed
milk ducts. This was especially done for those who had neonatal death after delivery. I gained
more skills on teaching the mothers on good positioning and attachment during breastfeeding.

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CHAPTER SEVEN

7.1 Kitchen
Menu Planning

Is done using S11 which is a government document showing menu requisition from the store.

General ward menu

 Ugali and kales for lunch.

 Green grams and rice for supper.
 Porridge for breakfast.

Total number of patients were 132

Calculating food per patient: different food have different quantity of consumption as listed
below per patient.

Kales – 200g Sugar – 15g Maize flour – (120 X 132) / 1000

Maize flour – 120g Tomatoes – 40g = 15 + 7 = 22Kgs

Green grams – 60g Onions – 20g Green Grams – (60 X 132) / 1000

Rice – 100g Wimbi – 30g = 7 + 3 = 10Kgs

Rice = (100 X 132) / 1000 Wimbi = (30 X 132) / 1000

= 13 + 8 = 21 Kgs = 3 + 7 = 10 Kgs

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Kales = (200 + 132) / 1000

= 26 + 9 = 35 Kgs

Determining the total amount to be consumed per food.

The calculation helps in determining the total quantity of food required.

Conclusion/Challenges
The challenge I faced during the field practice was language barrier, ignorance from pregnant
mothers, early feeding to children who were under 6 month

Recommendation

Recommendations To The Hospital

1. The hospital should launch a special nutrition awareness campaign that involves both the
staff and the public to tackle major injuries brought to the hospital such as high incidents
of malnutrition.
2. The frequency of the nutrition based Continuous Medical Education (CME) should be
increased to help students and the nutritionists have a better understanding of their
profession through sharing and getting updates from the same.
3. As a kind request to the nutritionists, they should spend more time with the students in
their workstations for close monitoring and assistance.
4. The hospital should work to ensure that therapeutic feeds are ordered on time especially
for the formula feeds to avoid shortages and consequently negative effect on the
patients.
5. The other hospital staff especially nurses should not overlook the work done by the
nutritionist since it plays a key role in improving the health of the patient

References
 Kenya National Clinic Nutrition and Dietics Reference Manual. 1st edition 2011
 Nutritional pamphlets

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 National Guidelines for Management of Diabetes Mellitus
 Ministry of Medical Services, Division of Human Nutrition; The Kenya National
Manual for Clinical Nutrition and Dietetics; May 2009
 Manual of Clinical Nutrition Management; 2013; Compass Group
 Ministry of Medical Health; National Guideline for Integrated Management of Acute
Malnutrition; June 2009
 Ministry of Health, Kenya; Maternal, infant and young child nutrition: National
Operational Guidelines for Health Workers; 2013; Division of nutrition

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Appendix 1

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