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A Clinical Report On Field Attachment at Matungu Sub - County Hospital
A Clinical Report On Field Attachment at Matungu Sub - County Hospital
INSTITUTE
DEPARTMENT : INSTITUTIONAL
MANAGEMENT
DIETETICS MANAGEMENT
ADM NO : 5017
Signature :
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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 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.
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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.
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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;
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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.
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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.
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Organizational Structure Medical Superintendent
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Acronyms/Abbreviations
M.S.CH : Matungu sub-county Hospital
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K.M.C : Kangaroo Mother Care
DM : Diabetes Mellitus
HTN : Hypertension
BS : Blood Sample
SD : Standard Deviation
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MOS : Medical Officer
CHAPTER ONE
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
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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:
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.
Clinical assessment methods included checking for presence of edema, oral thrush in the mouth,
baggy pants and temperature.
1.2 MATERIALS
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.
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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.
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.
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
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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.
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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.
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
Departments
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
Anthropometric
Height - 1.62 m
IBW - 71
Biochemistry
Clinical
Nutritional status
Overweight.
Diet History
Patient feed on small frequent meals, but not following diabetic diet and not taking medication
on time.
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Meat
Food Intake
Poor
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.
Activity Level
24 X 71 = 1704 Kcals
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/100 X 1704 / 4 55
/100 X 1704 / 4 25
/100 X 1704 / 9
= 84 g = 234 g = 47 g
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NUTRITION MANAGEMENT INTERVENTION
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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
Lunch Supper
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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
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.
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Taboos, allergies, intolerance
Meat
Food Intake
Poor
Lunch : Rice
Physical Activity
Sedentary
Nutrition Diagnosis
N
/Dx – Inadequate dietary intake related to poor appetite as evidenced by the diet history and Hb
of 5.6 g/dl.
Activity Level
35 X 4 = 1435 + 500
= 1935 Kcals
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
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.
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CHAPTER THREE
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:
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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.
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.
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In presence of oedema: Weight X 100/8 (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.
ReSoMal
Administration of ReSoMal was done cautiously to avoid over hydration and treatment for
dehydration involved the use of the below protocol:
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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 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:
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.
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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.
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CHAPTER FOUR
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Ensure patients meet their energy needs during the pre-operational period.
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,
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.
Daily calorie requirements = (24Kcal X kg usual body weight) / (40Kcal X TBSA (% burn))
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
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.
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:
VITAMIN A DEWORMING
TARGET GROUP DOSAGE FREQUENCY DOSAGE FREQUENCY
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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
6.1.1 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.
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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.
- 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.
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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.
Calculating food per patient: different food have different quantity of consumption as listed
below per patient.
Green grams – 60g Onions – 20g Green Grams – (60 X 132) / 1000
= 13 + 8 = 21 Kgs = 3 + 7 = 10 Kgs
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Kales = (200 + 132) / 1000
= 26 + 9 = 35 Kgs
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
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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