THIKA SCHOOL OF MEDICAL AND HEALTH SCIENCES

PRESENTER: AVRIL JOYCE OTOTO

ADMISSION NO: DND/J-0003/24

DEPARTMENT: NUTRITION AND DIETETTICS

COURSE NAME: DIPLOMA IN NUTRITION AND DIETETICS

REPORT ON CLINICAL ATTACHMENT AT KISUMU COUNTY REFERRAL HOSPITAL FROM 8TH

SEPTEMBER 2024 TO DECEMBER 2024.

APRIL 2025

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ACKNOWLEDGEMENT

I thank the Almighty God for His guidance and power for this far.I thank my supervisors for the support and
guidance during the [Link] goes to Kisumu County Referral Hospital and Thika School of Medical
and Health Sciences for the attachment opportunity would also like to thank my friends, fellow nutritionists,
other health care workers and family for their support throughout the attachment period.

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TABLE OF CONTENTS

Contents
DECLARATION...........................................................................................................................................i
ACKNOWLEDGEMENT............................................................................................................................ii
TABLE OF CONTENTS.............................................................................................................................iii
ABSTRACT..................................................................................................................................................7
ACRONYMS................................................................................................................................................8
CHAPTER ONE...........................................................................................................................................1
INTRODUCTION.........................................................................................................................................1
Historical Background...................................................................................................................................1
Vision...........................................................................................................................................................1
Mission.........................................................................................................................................................1
Policy............................................................................................................................................................1
Mandate.........................................................................................................................................................2
HOSPITAL ORGANOGRAM.....................................................................................................................2
CHAPTER TWO..........................................................................................................................................3
CLINICAL EXPERIENCES.........................................................................................................................3
Maternity ward..............................................................................................................................................3
New Born Unit..............................................................................................................................................4
Postpartum and antepartum rooms................................................................................................................5
Gynecology ward..........................................................................................................................................5
Diet kitchen...................................................................................................................................................5
CASE STUDY..............................................................................................................................................6
SURGICAL WARD......................................................................................................................................8
Management of burns....................................................................................................................................8
Nutritional management of burns..................................................................................................................9
The Curreri formula was used.....................................................................................................................10
SURGERY..................................................................................................................................................11

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Goal of nutritional management..................................................................................................................11
Objectives....................................................................................................................................................11
Preoperative nutrition care..........................................................................................................................11
Postoperative nutrition care.........................................................................................................................12
CASE STUDY............................................................................................................................................13
Kitchen........................................................................................................................................................14
: MATERNAL AND CHLD HEALTH (MCH).........................................................................................16
Importance of IFAS supplementation during pregnancy............................................................................17
Vitamin A supplementation and deworming...............................................................................................18
Immunization..............................................................................................................................................18
Immunization table......................................................................................................................................18
Table showing ABZ deworming for children between 12-60 months........................................................19
PEDIATRIC WARD (WARD 4)................................................................................................................19
Management of severe acute malnutritionAdmission criteria into inpatient care.......................................20
10 steps of management of SAM................................................................................................................21
Stabilization phase......................................................................................................................................21
Transition phase..........................................................................................................................................21
Rehabilitation phase....................................................................................................................................22
Discharge criteria........................................................................................................................................22
CASE STUDY............................................................................................................................................23
2.12 MEDICAL WARDS (MALE AND FEMALE).................................................................................24
WHO ENERGY REQUIREMENT PER BODY WEIGHT CLASSIFICATION......................................25
Management of hypertension......................................................................................................................25
Implications.................................................................................................................................................25
Aims of nutritional management.............................................................................................................25
Nutritional management..........................................................................................................................26
CASE STUDY............................................................................................................................................26
CHAPTER THREE.....................................................................................................................................30
CHALLENGES, RECOMMENDATIONS AND CONCLUSION............................................................30
Challenges faced.........................................................................................................................................30
Recommendations.......................................................................................................................................30

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Conclusion...................................................................................................................................................30
REFERENCE..............................................................................................................................................31

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ABSTRACT
This report is a summary of the work I undertook during my clinical attachment at Kisumu county Referral
Hospital for a period of three months beginning from 8th January2025 to April 2025.
It entails all the departments I rotated in and the work which I did. The various medical conditions and their
nutritional managements are also highlighted in this report. The challenges that I encountered and their
possible remedies have also been outlined.

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ACRONYMS
BMI : Body mass index

F-100 : Formulae 100

F-75 : Formulae 75

ReSoMal : Rehydration Solution for Malnutrition

FBF : Fortified Blended Flour

MAM : Moderate Acute Malnutrition

MCH : Maternal child health

MUAC : Mid upper arm circumference

OPD : Outpatient Department

OTP : Outpatient Therapeutic Programme

PLWHA : people living with HIV/AIMOPC: maternal outpatient clinic

PEM : Protein energy malnutrition

POPC : pediatrics outpatient clinic

RBS : random blood sugar

RUTF : ready to use therapeutic

food SAM : Severe Acute Malnutrition

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 CHAPTER ONE

INTRODUCTION

Historical Background
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 Nyanza Provincial General Hospital until the year 1969, when the New
Nyanza Provincial General Hospital – Russia (presently known as Jaramogi Oginga Odinga
Teaching and Referral Hospital) was built with the help of the Russian government.

The establishment of the New Nyanza Provincial General 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 district hospital being separated from the New Nyanza ProvincialGeneral
Hospital. This was due to its central location within the district headquarters making it more
accessible. (By then known as Kisumu East District Hospital)

After devolution, the hospital was transformed to a county referral hospital, presently known as
Kisumu County Referral 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 service 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.

HOSPITAL ORGANOGRAM

Medical Superintendent

Medical and paramedical Health administrative Hospital matron

services officer

Radiography, Nutritional Nursing and

Non-medical services
services outpatient services

Supplies Medical Accounts and Welfare Personal

officer technology billing services services
engineering and registry

Nutrition officer Nutrition attachees.

Nutrition supervisors Nutrition Interns
in charge

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 CHAPTER TWO

CLINICAL EXPERIENCES
Kisumu county referral Hospital has eight wards, that is; male & female wards; maternity ward;
obstetric gynecology; pediatric ward; surgical ward, MCH and psychiatric ward

Maternity ward
The maternity ward is divided into various sections which are:

 Post-partum and ante partum rooms- this is meant for mothers who have delivered
(either through spontaneous vaginal delivery or through caesarian section) and those who
have not delivered respectively.
 NBU- this admits neonates who are pre-term, underweight and those who have medical
complications.
 Labor ward-admits mothers who are in labor and ready for birth.
 Maternity theatre-where caesarian surgery is done for mothers with complications. The
theatre is however out of the maternity department.
 OBS/Gynecology ward- deals with mothers who have already delivered and they have
medical complications e.g. DM, anemia, cervical cancer. The ward is generally meant for
women with medical complications affecting their reproductive system. These included
conditions like PV bleeding, anemia, fibroids, fistula, cervical cancer etc.

While I was in this ward I was involved in the following activities;

 Nutritional assessments of the prenatal and postnatal mothers.

 Breast milk expression to mothers who have neonates with poor suckling reflex.
 Conducted cabbage therapy to mothers to stop milk production and breast engorgement
after neonatal deaths.
 Promotion of rooming in, kangaroo mother care (KMC), good positioning and attachment
while breast feeding this was to promote sufficient breast milk production. This happened
in the NBU.
 Supplementation of post-partum mothers with the FBF (Advantage) to improve
production of breast milk.
 Supplementation of the SAM cervical cancer patients with RUTF.

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  Nutrition counselling and education to mothers with severe anemia resulting from PV
bleeding and other medical complications affecting the female reproductive system. They
were counseled on consumption of iron-rich foods and foods with high vitamin C content
to boost iron absorption.

 Supplementation of vitamin A 200,000 IU to postnatal mothers to boost immunity.

I was able to learn and gain experience in the following areas.

New Born Unit

The New born Unit (NBU) is an intensive care unit specializing in the care of ill or premature
newborns/neonates. Moreover, this unit is responsible for rehabilitating the newborns until they
attain the proper weight and optimum health status for recuperation either at the pediatric ward
or for normal care at home.

The daily routine care of the newborn in the NBU entails the following:

 Assessment of health and nutritional status.

 Giving the newborn a shower.
 Care of the umbilical cord.
 Changing diapers.
 Recording of any changes in the newborns.
Newborns at the NBU are either fed orally (breastfeeding/cup feeding) or through nasogastric
tube feeding for those who lack suckling reflex, preterm babies or those on oxygen treatment. I
learnt and helped initiate Kangaroo Mother Care (KMC) and cup feeding. Kangaroo Mother
Care is a method of care of preterm infants which involves skin-to-skin contact of the
newborn and the mother.

Nutrition activities I was involved in the NBU included:

 Assessing and monitoring the nutritional status of newborns by taking their weight on
daily basis.
 Preparing the infant formula for those babies whose mothers were not present, those
mothers who didn`t have enough breast milk or abandoned newborns.

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 Giving health talks to mothers on hand expression of breast milk and supporting them
when expressing breastmilk, importance of exclusive breastfeeding, and maternal
nutrition during lactation and hygiene.
 Managing different health condition such as cracked nipples, inverted nipples, engorged
breasts and mastitis.
 Documentation in Kangaroo mother care register, admission book and updating patients
files.

Postpartum and antepartum rooms

Some of the key experiences I gained in the maternity involved management of complicated
breast conditions such as engorged breast by expressing the milk by hand or use of a breast
pump. This was preceded by rubbing using a warm wet cloth. Inverted nipples ware
corrected byuse 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 breasts 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.

Gynecology ward
The experiences and skills I gained from this ward include the knowledge of different
gynecological conditions and their appropriate nutrition interventions. Some of the conditions
include cervical cancer, fibroids, incomplete abortion. They resulted into abdominal uterine
bleeding casing anemia. I counseled the patients on ways to prevent and treat anemia
nutritionally. This involved increased consumption of iron-rich foods and vitamin C rich foods.

Diet kitchen
The main work in this department involve preparation of diet to patient presenting with different
condition this eased the feeding of patients that needs bland diet and those that presents with
different condition I also managed to fill the government requisition sheet serial number 11.

When I was in the diet kitchen I managed to carry out the following activities;

 Preparation of FBF to patient presenting with low weight

 Calculation of diet requisition sheet the namber of patients and amount of food to be
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given to patients

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  Carrying out organoleptic this involves observing and testing the food prepared for
patients
 To file the requisition sheet after every issuing of commodities.

I was able to learn and gain some experiences while at the diet kitchen some of which includes;

 Preparation of fortified blended floor FBF

 preparation of diet sheet
 Ordering food items from the store
 Preparation of eggs for patients with low HB

CASE STUDY
Patient w, aged 21rs old has a diagnosis of Day 4 post emergency as with septic wound; has a
muac of 15.5cm. Gave birth to a live infant baby weighing 3050g.

I. Nutrition Assessment
a. Anthropometric assessment
MUAC -15.5CM
The patient is SAM
b. Biochemical assessment
HB-11.4g/dl
c. Clinical assessment
Not pale
Not dehydrated
No oedema
d. Dietary assessment
Baby
Suckling reflex present
Baby is being exclusively breastfed on demand

Mother
Patient reports to be taking t e a + c h a p a t i for breakfast, ugali and
vegetables for lunch and ugali + fish
e. Socio-economic status
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 The patient lives with parents who are elderly, she is unemployed thus depends on
parents and siblings. She is not food secure.
f. Functionality test
Patient has a reduced physical activity because of the C Section and the septic
wound on the surgical site.
II. Nutrition diagnosis
Increased nutrients needs related to hypercatabolism as evidenced by septic
wound on the surgical site and MUAC of 15.5cm.
III. Nutrition intervention
Supplements with 3 sachets of RUTF daily
Take small frequent meals
Take high calorie-high protein diet to promote wound healing and meet caloric
needs
Supplement with an egg daily and 2 cups of FBP
Take foods rich in vitamin A zinc and selenium to boost immunity
Take foods rich in iron to boost HB levels
Take foods rich in vitamin C to aid in the absorption of iron
IV. Nutrition monitoring and
evaluation Monitor dietary intake
Monitor weight
Monitor HB levels

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 SURGICAL WARD
This was a ward where patients with surgical conditions were admitted. The conditions
encountered were burns, fractures, and trauma, diabetic foot, septic wounds, head injuries,
intestinal wounds and theatre condition. The ward is divided into two sections with one side
being for male patients and the other side being for female patients.

While I was at the surgical ward I was able to carry out the following activities;

 Carry out nutrition assessment, review of patients especially those with increased
nutrition requirement and are at risk of under nutrition
 Carry out nutrition counselling 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.

During my rotation in this ward I was able to manage several patients with burns.

Management of burns
Aims of Nutrition management in burns

 To improve wound healing.

 To replace fluids and electrolytes that was lost during burning.
 To prevent infections and rapid severe weight loss.
 To achieve and maintain optimum body weight.
 Attaining normal hydration status and electrolyte balance.
 Meeting nutritional needs by providing adequate calories to prevent weight loss of >10%
of usual body weight.

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  Providing adequate protein for positive nitrogen balance and maintenance or depletion of
visceral protein stores.

Nutritional management of burns

 Give high calorie high-energy foods to cater for the increased nutrient needs and to allow
protein to perform its functions.
 Take high protein diet for healing of wounds at least 1.5g – 3.0g/kg/day, but excessive
intake of proteins should be discouraged because it will lead to azotemia, hyper-
ammoniuria or acidosis.
 Encourage the intake of fruits and vegetables that are rich in vitamin C and zinc that
fastens/quickens the healing of the wound.
 Discourage the intake of empty calorie foods such as chips, Crips, beverages to help the
client to maintain ideal body weight.
 Take foods that are low in fats.
 Take at least eight glasses of water or more to prevent dehydration.
Children younger than 1 year of age, recommend 3g – 4g of proteins/kg/day because the infant is
unable to tolerate high renal solid loads.

Complications of burns include;

 Infections.
 Dehydration.
 Edema.
 Malnutrition.
 Anorexia.
 Blisters.
 Hyper metabolism

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

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Hyper metabolism and increased nitrogen losses

 Loss of water and risk of infection due to loss of the body’s first line of defense
 Loss of protein through leakage of protein rich fluid
 Improper consumption of food due to depression, pain and discomfort
 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 a 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.
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 than 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 3–4
g protein/kg since they cannot tolerate high renal solute loads.
The Curreri formula was used

Daily calorie requirements = (24 kcal X kg usual body weight) + (40 kcal X TBSA {% burn})

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

Caloric and protein needs for the children are calculated as follows:

Daily calorie requirements = (60 kcal X kg usual body weight) + (35 kcal X TBSA)

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

In addition to the aforementioned Curreri formula, a high carbohydrate diet with 82 %

carbohydrates, 15 % protein and 3 % fat is able to stimulate protein synthesis The clients were
further encouraged to consume foods that a rich in vitamin A (dark green leafy vegetables, eggs,
yellow and red fruits), vitamin C (oranges, lemons, green leafy vegetables), selenium (brown

11
rice, ginger, onions, milk, garlic) and zinc (milk, dairy products, beans, peas). All of these
nutrients were recommended since they aid in wound healing. 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.

SURGERY
Surgery like any other injury to the body elicits a series of reactions including release of stress
hormones and inflammatory mediators i.e. cytokines. This release of mediators to the circulation
has a major impact on body metabolism. They cause catabolism of glycogen, fat and proteins
with release of glucose free fatty acids and amino acids into the circulation so that substrate are
diverted from their normal purposes e.g. physical activities to the task of healing and immune
response. For optimal rehabilitation and wound healing the body needs to be in anabolic
state. Measures to reduce stress of surgery can minimize catabolism and support anabolism
throughout surgical treatment and allow patients to recover substantially better and faster even
after major surgical operation.
Goal of nutritional management
To enhance recovery of patients after surgery
Objectives
 To avoid long periods of pre-operative fasting
 To reestablish oral feeding as early as possible after surgery
 To integrate nutrition into overall managements of patients
 To control metabolic processes

Preoperative nutrition care

 Encourage patients who do not meet their energy needs from normal foods to take oral
nutrition supplements during the preoperative periods
 Administer preoperative enteral nutrition preferably before admission to the hospital
 Ensure the stomach is empty. It is important to empty the stomach at the time of operation
to avoid the danger of aspiration during the induction of anesthesia or upon awakening
 Use a chemically defined or elemental liquid diet with minimal residue pre-operatively for
patients with nutritional risks

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  Patients who are scheduled to undergo surgery and who are considered to have no specific
risk for aspiration may drink clear fluids until 2 hours before anesthesia. Solids foods are
allowed until 6 hours before anesthesia
 For elective cases, no food is allowed by mouth (nil by mouth) for at least six hours before
surgery
 Low fiber foods should be administered orally, a liquid diet for 2 – 3 days preceding
surgery

Postoperative nutrition care

The aim of postoperative nutrition care is to reduce nutritional deficiencies that ordinarily
develop in untreated patients during the period of post operation. Note;
 Length of nil by mouth after surgery may be influenced by the patients pre-existing
nutritional status, severity of operative stress and the nature and severity of the
illness.
 If the period of post-operative starvation is expected to be longer than one week,
parenteral nutrition support maybe beneficial even for a mildly malnourished
individual
 Introduction of solid foods depends on condition of the GI tract, oral feeding is often
delayed for the first 24 – 48hrs following surgery to await the return of the bowel
sounds or passage of flatus
 Initiate normal food intake or enteral feeding earlier after gastro intestinal surgery
 Oral intake including clear liquids can be initiated within hours after surgery to most
patients undergoing colon resections
 Oral intake should be adopted to individual tolerance and to the type of surgery
carried out
 Apply tube feeding in patients whom early oral nutrition cannot be initiated with
special regard to those undergoing major head and neck or gastrointestinal surgery for
cancer

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CASE STUDY
Patient w aged 11/2 years succumbed to 20% superficial bum that covered the left
arm, stomach and left lower limb
I. Nutrition assessment
a. Anthropometric assessment
Wt-11kg
Ht-87cm
W/h- -1SD (Normal)
b. Biochemical assessment
HB-10.8g/dl
RBS-5.1mmol/l
c. Clinical assessment
Not pale
Not dehydrated
No oedema
d. Dietary assessment
Exclusively breastfed for 6months, complimentary feeds introduced at 7months
with porridge
Currently on family diet
Patients has reduced appetite
e. Socio economic status
The child is a first born; mother is a house wife and father a casual worker
The family is food secure.
f. Functionality test
No disability
No delayed milestones
II. Nutrition diagnosis
Increased nutrient needs related to hypercatabolism as evidenced by 20%
superficial burn
III. Nutrition intervention
Supplement with 3 sachets of RUTF daily and take small frequent meals

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 Take plenty of fruits to boost appetite
Take high calorie high protein diet to meet the energy needs and promote wound
healing respectively
Take iron rich foods to boost the iron levels
IV. Nutrition monitoring and
evaluation Monitor HB levels
Monitor blood sugar levels
Monitor dietary intake
Monitor weight.

Nutrients requirements
Energy needs
(60kcals x Bwt)+(35kcals x TBSA)
(60 X 11)+(35 X 20)=1,360Kcals

Protein needs
(3g x Bwt)+(1g x TBSA)
(3 X 11)+(1 X 20)=53g

Kitchen
Menu Planning

Is done using S11, 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.
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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 flour – 30g = 7 + 3 =

10Kgs

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

1000 1000

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

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

: MATERNAL AND CHLD HEALTH (MCH)

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 (5years and below). The services offered include
immunization, nutritional services, prevention of mother to child transmission (PMTCT),
family planning and growth monitoring.

My objectives in this department included; to learn and gain more experiences in growth
monitoring of children, enrolling and management of SAM AND MAM children of the OTP and
SFP and to offer nutrition counselling and education to pregnant mothers.

Some of the activities I was able to carry out included;

 Nutrition assessment and diagnoses of the 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 such as breastfeeding and mixed feeding.
 Enrolling and giving nutrition support to SAM & MAM children through OTP and SFP
programs, involving prescription and dispensing of the FBF (First Food, Advantage,
foundation plus) and the RUTF.
 Nutrition counselling to caretakers of the malnourished children.
 Vitamin A supplementation and deworming children with anthelminths i.e. Albendazole

17
I learnt that during the antenatal clinics, HIV testing was done prevention of mother to child
transmission (PMTCT) and supplementation with iron and folic acid was also done.

Importance of IFAS supplementation during pregnancy:

 Maintain supply of blood in the body during pregnancy.
 Helps avoid neural tube defects and giving birth to preterm babies.
 for normal fetal development.

In postnatal clinics, the children underwent growth monitoring, immunization, supplementation

and other medical checklists.

Nutrition counseling is done to mothers during every ANC visits. 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 of proteins in urine which would otherwise confirm
risk of preeclampsia. Presence of glucose or ketones would suggest presence of gestational
diabetes.

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.
During those visits they were taught and counselled on the following:

 Birth preparedness
 Nutrition counselling
 Immunization and supplementation with IFAS

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  Personal hygiene
 Family planning

For the severely malnourished children the RUTF was prescribed. One pouch containing 15
sachets of First Food and 2 pouches each containing 15 sachets of Advantage was prescribed to
the malnourished pregnant/lactating mothers respectively. Follow up visits was after a month.

Vitamin A supplementation and deworming

At the clinic, there is routine vitamin A supplementation for all children from 6 months and
above. Children from 6 months to 11 months are given 100,000IU of vitamin A and those
from
12 months and above are given 200,000IU of vitamin A. The vitamin A supplementationhappens
after every 6 months until the child is above 5 years of age. The importance of vitaminA
supplementation is that it reduces mortality in children below the age of 5 years. (Boosts the
immune system)

Deworming is done from the age of one year whereby children 2 years and below are given
200mg of Albendazole tablet while those from 2years and above are given 400mg of
Albendazole tablet. Deworming also happens every 6 months for the under-five children.

Immunization
Children under five are immunized against different diseases and the table below summarizes the
immunization schedule.

Immunization table

BCG At birth

OPV Oral Polio Vaccine At birth, 6wks, 10wks, 14wks

DPT-HepB-Hib 6wks,10wks,14wks

Pneumococcal vaccine 6wks,10wks,14wks

Rota virus 6wks,10wks.2nd dose to be given not later than

32 weeks

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Measles 9 months

20
Yellow fever 9 months

TT Pregnant women

Vitamin A 6 months, 12, 18, 24,36,48,59

Measles 2nd dose 18 months

Malaria vaccine 6months,7months,9months,24months

Table showing vitamin A supplementation for children between 0-60 months

Age of the child Amount of vitamin A given

< 6 months 50,000 IU

6-11 months 100,000 IU

12-60 months 200,000 IU

Table showing ABZ deworming for children between 12-60 months

Age of the child Amount of ABZ given

12-23 months 200mg (half the tablet)

24-60 months 400mg (full tablet)

PEDIATRIC WARD (WARD 4)

It is a ward specifically for children below 12 years. The ward has different medical
professionals including medical officers, clinical officers, pediatric nurse specialist (in charge of
the ward) and the nutritionists. Management of the medical and nutrition related conditions
arean integrated approach involving all the professionals in the ward.

The ward is divided into 3 sections, i.e.

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Acute Room: This is where children with medical conditions that require close monitoring by the
nurses and doctors 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: malaria, PEM; kwashiorkor, marasmus, neonatal jaundice, asthma
&pneumonia, dehydration & anemia.

Some of my objectives included;

 To learn how to manage severe acute malnutrition with complications at the inpatient
setting.
 To learn the criteria for enrolling malnourished children for inpatient care.
 To learn how to manage severe acute malnutrition in children below 9 years of age.

When I was at pediatric ward I was able to carry out the following activities;

 Attending the daily morning reports sessions and the ward rounds.
 Nutrition assessments: anthropometrics, 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

Management of severe acute malnutrition

Admission criteria into inpatient care

 Any grade of bilateral pitting edema with severe wasting (MUAC < 11.5 cm or

22
  WHZ < -3 z-score)

 Presence of bilateral pitting edema

 Failing of appetite test

10 steps of management of SAM

 treatment/ prevention of hypo glycaemia

 treatment/ prevention of hypothermia

 treat/prevent dehydration

 correct electrolyte imbalance

 treat infections

 correct micronutrient deficiency

 initiate cautious feeding

 achieve catch-up growth

 sensory stimulation

 discharge preparation

Stabilization phase

The first five of the essential steps ae done at this stage of management

The child is started on F75 100ml/kg/day (in case edema is present) and 130ml/kg/day
distributed in 3 hourly feeds

This lasts 2-5 days until edema begin to subside

No weight gain is expected

Transition phase

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Micronutrient supplementation (vitamin A where necessary) is done at this stage

The child is transited to F100 given of the same amount as at stabilization phase

This stage may last up to 2 days

Rehabilitation phase

The child continues with F100 with the main aim being catch up growth

If the child is gaining weight and able to take and retain the full amount then the feed is increased
by 20ml/kg /day until, the maximum of 200ml/kg/day is attained

As the amount of feeds increase the frequency of feeding reduces

Other foods like RUTF and other modified foods are introduced at this stage as the child is
prepared for discharge.

Discharge criteria

Patient is gaining weight

Patient is having good appetite

>-2 - z score

The child is then discharged from SFP upon giving the caregivers nutrition advice

The child is supplemented with FBF or RUSF and given a TCA

N/B Infants 0-6 months are began on F75, or F100 diluted, and should not be given F100 due to
their fragile gastro intestinal tract and to avoid [Link] main aim of nutritional
intervention in FTT is to reinitiate breastfeeding

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CASE STUDY
I. Nutrition assessment
a. Anthropometric assessment
Wt-7.04kg
Lt-73cm
W/H-<-3SD
MUAC-11.3cm(SAM)
b. Biochemical assessment
HB-5.5g/dl
Albumin -17.33g/l
c. Clinical assessment
Oedema +++
Irritable
Thin brittle hair
d. Dietary assessment
Exclusive breastfeeding practiced for 6months
Complementary feeding introduced at 7months, currently on family diet
e. Socio economic status
Mother unemployed, father a casual worker, the family is food insecure
f. Functionality test
No disability, no delayed milestones
II. Nutrition diagnosis
Inadequate protein intake related to poor dietary practices as evidenced by the diet
history and Z scores of <-3SD
III. Nutrition intervention
Admit on inpatient therapeutic programme
Start F75 at 100ml/kg/day=(100 x 7.04) /8=88ml/3hourly
Give ReSoMal@5-10ml/kg per every loose stool
IV. Nutrition monitoring and
evaluation Monitor feeds tolerance
Monitor weight daily

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 Monitor oedema daily

2.12 MEDICAL WARDS (MALE AND FEMALE)

The medical wards are two, that is, ward 3 which is the female ward and ward 6 for the male
patients. Both wards are divided into two rooms i.e. A & B, whereby the A side are for those
patients that require close monitoring. In each ward I encountered different medical and nutrition
related conditions which enabled me to be able to learn. The two wards consist of the patients
with different medical conditions which nutritionists come review and give the necessary
nutritional interventions based on the diagnosis. At medical wards, as a nutritionist, I did
nutritional assessment of all the patient to determine their nutritional status, I gave nutritional
care for all the patients based on their medical conditions.

Some of my objectives included to familiarize with nutrition management of different medical

conditions while in the wards and do nutrition assessment, counseling and documentation of
work done.

There were different medical conditions in the wards included anemia, hypertension, peptic ulcers
disease, acute kidney injury, diabetes, HIV and related opportunistic infections.

My roles and activities included Nutrition assessments to the newly admitted patients. This
involved taking the weight, height, computation of the BMI; dietary assessments; biochemical
assessments; clinical assessments and the functional assessments. I also did nutrition counseling
and education with respect to patients’ condition. I was also able to order for Therapeutic and
Supplemental Feeds such as fortified blended flour and ready to use therapeutic feeds. I also
updated patients’ files and nutrition registers daily. I did daily nutritional reviews to the
continuing patients in both wards. I also attended daily morning ward rounds with the
nurses, consultant physician, clinical officer interns and with fellow nutrition and clinical
medicine students.

The daily ward rounds enabled me to gain more knowledge and experiences in management of
the various medical and nutrition related courses. I was able to learn the diet modification in and
every condition which included increasing and decreasing of micronutrients and macronutrients
based on the condition of a patient. Diet modification was in terms of the consistency of the diet
was also important especially in patients feeding through nasal gastric tube (NGT).
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WHO ENERGY REQUIREMENT PER BODY WEIGHT CLASSIFICATION

CLASSIFICATION SEDENTARY MODERATE ACTIVE

Overweight 20 – 25kcal/kg 25- 30kcal/kg 30-35kcal/kg

Normal 25 - 30kcal/kg 30-35kcal/kg 35-40kcal/kg

Underweight 30 - 35kcal/kg 35-40kcal/kg 45– 50kcal/kg

I was able to use this table to determine the energy requirements of different patients in the
medical wards using their level of activity and their nutritional status. After determining their
level of activity and nutritional status, the energy requirement according to the table is then
multiplied by the body weight to get the energy requirement of the patients. This helped me in
planning meals for the patients.

While I was in this ward I was able to manage patients with hypertension. I learnt a lot about the
diet modification of the patients with high blood pressure.

Management of hypertension
Hypertension is a cardiovascular disorder characterized by persistently elevated diastolic blood
pressure (BP) of above 95mmHg. Uncontrolled hypertension can affect various body organs and
can lead to impaired vision, kidney failure, stroke, paralysis, heart attack and brain damage. Risk
factors include; diet, race, stress, age, diabetes, obesity, smoking, atherosclerosis and heredity
among others.
Implications
 Strained cardiac and vascular function
 Cellular electrolyte imbalance
 Aneurysms (balloon out and busting of the arteries)
 Arterial lining injuries which accelerates the plaque formation

Aims of nutritional management

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  To control blood pressure within the normal ranges
 To achieve a gradual weight loss in overweight and obese individuals and maintain their
weight slightly below the normal
 To reduce sodium intake based on severity
 To maintain adequate nutrition
 Regulate fat intake

Nutritional management
 Provide low calorie diet if the patient is overweight until ideal body weight is achieved
 Regulate fat intake. Encourage intake of unsaturated fats (oils). The poly unsaturated
and monounsaturated fatty acids lower BP, the level of triglycerides and LDL
cholesterol and consequently lead to increase in HDL cholesterol that carries
cholesterol in the blood back to the liver for recycling or disposal. Fats should be 20%
of total kilo calorie
 Restrict alcohol intake
 Restrict sodium intake. To achieve this, encourage choice of food low in sodium and
limit the amount of salt added to food, restrict processed foods and use of sodium
containing spices
 Avoid stimulants e.g. caffeine and spirits
 Avoid cigarette smoking, which may lead to atherosclerosis
 In some cases it may be necessary to restrict fluid intake
 Encourage physical activity for those leading a sedentary lifestyle. Physical activity has
measurable biological effects affecting cholesterol levels, insulin sensitivity and
vascular reactivity. These effects are dose dependent such that the more the exercise,
the greater the health benefits

CASE STUDY
I. Nutrition Assessment
a. Anthropometric Assessment
Wt-45kg
Ht-1.69m

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 BMI-15.76kg\m2
The patient is severely malnourished
b. Biochemical Assessment
FBS-11.2mmol\L
Hb-12.5g\dl
c. Clinical Assessment
Not pale, wasted ,dehydrated

d. Dietary Assessment
The patient reports to be taking porridge and white bread for breakfast, ugali and
beef for lunch and rice and chicken for supper.
The patient takes large quantities of simple carbohydrates

e. Socio-economic status
The patient lives with his wife, he is a casual worker. The family is food secure.

II. Nutrition Diagnosis

Elevated blood sugar levels related to excessive intake of simple carbohydrates as
evidenced by RBS of 28.4mmol/L

III. Nutrition Intervention

Intake of complex carbohydrates to regulate the blood sugar levels
Intake of high fibre diet
Check on food portion size
Take small frequent meals
Take plenty of nutritious fluids to aid in rehydration
Prescribe Diben drink [1 drink per day]
Regular light exercise [30 mins walk/day]

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 Nutrition Monitoring and Evaluation
Monitor blood sugar levels
Monitor weight
Monitor dietary intake

Energy needs
35-40 Kcals/kg/day
40 x 45=1800 Kcals/day

T.E.R=1800Kcals
CHO; 247g
PRO; 90g
FAT; 50g
FOOD EXCHANGE LIST
Food groups Exchanges CHO PRO FAT Kcals
Vegetables 5 25 10 125
Fruits 4 60 240
Milk 4 48 32 20 480
Meat 4 28 12 220
Starch 8 120 16 640
Fat 3 15 135
TOTAL 253g 86g 47g 1,842kcals

FOOD DISTRIBUTION LIST

Food group Breakfast Snack Lunch Snack Supper Total exchange
Vegetables 1 2 2 5
Fruits 1 1 1 1 4

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Fat 1 1 1 3
Milk 1 1 1 1 4
Meat 1 2 1 4
starch 2 1 2 1 2 8

31
 CHAPTER THREE
CHALLENGES, RECOMMENDATIONS AND CONCLUSION
Challenges faced
During my practice at Kisumu referral hospital, I encountered some challenges which included;

Shortage of supplements and therapeutic feeds such as ready to use therapeutic feeds and
fortified blended flour which made it difficult to work.

It was difficult to take the weight of critically ill bed-ridden patients who could not move. For
such patients we would only estimate their weights in order to help determine their estimated
energy requirements as well as their protein requirements.

Language barrier especially with patients and caregivers who could not speak or understand
Kiswahili or English.

Some patients and care takers were unable to follow the feeding regime protocol due to
illiteracy.
Recommendations

The facility should build nutrition offices or stations in every department to carter for smooth
running of nutrition services.

The hospital should do a timely order of nutrition commodities to ensure the patients in need
of such commodities do not miss.

The county government should employ more nutritionists to reduce the work load at the
facility

The hospital and the county government should provide breakfast and lunch to the students to
motivate them.
Conclusion
The attachment period gave me an opportunity to apply my nutritional knowledge acquired in
class and apply it in different patients/clients with different nutritional status as well as different
medical diagnoses. I was also able to apply the critical thinking skills in the nutrition care
process for the different patients.

The continuous nutrition education presentations were a good learning platform and an
interactive learning process for all nutrition personnel. I managed to achieve most of my

attachment objectives and gained skills and experiences from practicing in the hospital and it will
help me in future when I am employed as a practicing nutritionist.
REFERENCE
Kenya National Clinical Nutrition and Dietetics Reference Manual, 2nd EDITION, 2015.

Ministry of Health, Kenya Integrated Management of Acute Malnutrition Guidelines, 2016,

WHO 2006 Infant and young child feeding.