MACHAKOS INSTITUTE OF TECHNOLOGY.

FACULTY OF PUBLIC HEALTH SCIENCES.

DEPARTMENT OF NUTRITION AND DIETETICS.

REPORT ON CLINICAL ATTACHMENT AT MACHAKOS LEVEL 5 HOSPITAL FROM 4 TH SEPTEMBERTO 8TH

DECEMBER 2023.

NAME:ELIZABETH MUTUA

ADMISSION: C/NUT/11134/22
DECLARATION
I hereby declare that this is my original work and has never submitted for the award of certificate in
Nutrition and Dietetics in any other institution.

Name: ELIZABETH MUTUA

Adm: C/nut/11134/22

Signature: ......................... Date.............................................

Nutritionist in-charge - MACHAKOS LEVEL 5 HOSPITAL

Name: GRACE MUTISYA

Signature: ................................. Date................................................

Head of Nutrition Department – MACHAKOS INSTITUTE OF TECHNOLOGY

Name: MAGRET NGANGA

Signature: .................................... Date.................................................

DEDICATION
I dedicate this work to God and to my family as well as friends who has made it a success through their
support and care.
ACKNOWLEDGEMENT
I acknowledge my work to the almighty God for the great care He has taken me through. I am also
grateful to my fellow colleagues for the cooperation they have shown during this period. I also
acknowledge my nutritionist for the good guidance and support through this period. I was able to learn
a lot through the great experience.
LIST OF TABLES

ACRONYMS
AIDS: acquired immuno- deficiency disease.

ARV: anti-retroviral therapy

BMI: body mass index

CCC: comprehensive care clinic

CHW: community health worker

CS: Caesarian system

CVS: cardiovascular system

EBF: excusive breast feeding

ERF: excusive replacement feeding

F-1OO: special milk for catch up growth for severe acute malnutrition

F-75: special milk stabilization of severe acute malnutrition

FBP: food by prescription

HIV: human immuno-deficiency virus

HT: height in centimeters

MAM: integrated management of acute malnutrition

MAM: moderate acute malnutrition

ANC: antenatal-clinic

MIYCF: maternal infant young child feeding

MUAC: mid upper arm circumference

PLWH: people living with HIV.

OPERATIONAL DEFINITION OF TERMS
Nutrient –a substance that must be consumed as part of the diet to provide a source of energy.

Opportunistic infection- disease that occurs when patients system is impaired.

Underweight- patients with BMI of below 18.5kg/m2

Nutrition status-is a state of health of an individual as affected by the intake and utilization of nutrients.

Nutrition care plan –is a formal process of nutrition goals and intervention prescribed for an individual
using the data obtained from nutrition assessment hence it include statement of nutrition goals,
monitoring and evaluation parameters.

Health education-actions to maintain best possible quality of life of members of community both
collectively and individually.

Edema –accumulation of fluid in the body tissues.

Overweight: patient with BMI over 30 kg/m².

SUMMARY : Machakos Level 5 Hospital is a government health care facility
which offers health services to the people living in Machakos county and
neighboring counties
It consist of different department which offers different services, they are as follows;

Medical ward which caters for both male and female patients with medical conditions and some
diseases affects different organs in the body.

Pediatric ward which deals with children and health condition attacking them. This conditions can affect
children mentally, physically socially.

Surgical ward which mostly catering for conditions that needs surgery, includes tumor, septic wounds,
burns, cancer etc.

Maternal and child health clinic which is an outpatient department and deals with the health condition
of the mother and the child.
CHAPTER 1

1.0 BACKGROUND INFORMATION

Machakos level 5 hospital is entrusted to provide services in the Eastern region. The facility is highly
equipped with modern medical equipment that handles various health matters.

Medical services offered at the facility include:

 Casualty and emergency services

 Surgery(general, orthopedics, neurosurgery and cardiothoracic)
 Pediatrics services
 Medicine(diabetic, cardiology clinics)
 Nursing
 Dental
 Nutrition
 Maternal and child health care/family planning
 Comprehensive care clinic for HIV/AIDS cases
 Physiotherapy
 Laboratory
 Pharmacy
 Outpatient Medical services
 Mortuary services
 Oncology clinic services
 Eye clinic
 Intensive care unit

1.1 MISSION
To provide high quality equitable, affordable, curative, preventive, promotive and rehabilitative
health services through out-patient, inpatient, teaching and training services.

1.2 VISION
Aspire to be ultra-modern hospital providing specialized healthcare to satisfy the customer needs.
1.3 Objectives
 To integrate the theoretical knowledge learnt from the course studies into practical skills in the
hospital wards and other departments, while gaining real time experience and exposure to help
me gain confidence in my profession.
 Understand the theory behind the skills acquired in hospital.
 To gain interpersonal skills
 Perfection of communication skills as I learnt in school.
 Put the knowledge learnt from school in practical.
 To learn how to carry out medication effectively.
 To gain more knowledge on how to manage different conditions nutritionally.

CHAPTER 2

2.0 MATERNAL AND CHILD HEALTH

Machakos level 5 hospital has done a commendable job in upholding excellent maternal and child health
care. The CWC is a clinic where children aged 0-59 months are brought for immunization, growth
monitoring and nutritional services.

Roles of a nutritionist in CWC Clinic

1. Nutrition Assessment to monitor growth which is done by taking weight, height and MUAC and
recording to Mother and Child Health booklet/card.

2. Preparing and giving health talks on the following;

 Proper attachment and positioning of the baby during breastfeeding.

  Importance of Exclusive breastfeeding for the first six months.
 Proper way to start on complementary feeding and weaning.
 Dietary diversification and food consumption for breastfeeding mother.

3. Referring the children for immunization at the nursing station.

- For severe cases, mothers were referred to pediatric wards to be monitored from there.

Antenatal Clinic
This is a clinic for pregnant women on regular basis so as to get pregnancy care and monitoring
pregnancy progress.

My role as a nutritionist in the ANC clinic was to carry out nutrition assessment and nutrition education
to pregnant mothers.

Nutrition Health and Education at the ANC Clinic

 Dietary diversification using the 10 food groups.
 Ensure adequate intake of iron rich foods both from plant and animal sources.
 Management of pregnancy related complications such anorexia, pica, heart burn and morning
sickness.
 Good personal hygiene and sanitation.

2.1 SPECIAL CLINIC

It is an outpatient department in the hospital designed to enable patients consult from the doctors. As a
nutritionist, I did an assessment for both children and adults who attended the clinic .I took their weight,
height, calculating their BMI, and Z-scores. For children who were found wasted with a Z-score of -3 SD
and MUAC less than 11.5 cm were referred to the nutrition room for nutrition counselling on nutrient
and energy-dense food and supplementation by giving FBFs. Also patients with chronic conditions such
as DM, HTN and others were given appropriate counselling.

CASE STUDY
Patient X

Sex; Female

Age; 55yrs

Address; Machakos

Dx; HTN
Anthropometric Assessment
Weight; 70 kg

Height; 158 cm

BMI:28kg/m2

The patient is overweight in relation to his BMI of 28 kg/m2

Biochemical Assessment
FBS 7.8MMOL/L high (3.5-5.5mmol/l - normal range).

Clinical Assessment
No pallor

No Jaundice

Edema present

Dietary Assessment
24hours recall

Breakfast; uji without sugar

Lunch; one plate of githeri

Supper; ugali+managu+milk

Economic Assessment
She is a farmer,married and has 5 children.

Functional Assessment
Patient is ambulant

NUTRITION INTERVENTION
1. I adviced the patient to do exercises on a daily basis to burn extra calories in order to lose
weight.
2. I also adviced the patient to limitthe inake of carbohydrates rich foods to minimize absorption of
more sugars in the body which will be stored inform of fats.
 3. The patient was advised not to skip meals especially breakfast as the body will start storing
more of the sugar in form of fats to use when meals have been skipped.
4. The patient was advised to limit intake of foods rich in fats to reduce accumulation of excessive
fats in the body.
5. The patient was advised on portion sizes to regulate absorption of sugars in the body.

2.2 COMPREHENSIVE CARE CLINIC (CCC)

This is a clinic where PLWHIV and TB patients are attended to.

Activities carried out in CCC include;

 Treatment of opportunistic infections associated with HIV/AIDS.

 Care of children who are HIV positive.
 Connections to support groups.
 Care of TB clients.
 Nutrition support to clients.

ROLES OF NUTRITIONIST IN CCC

 Carrying out nutrition assessment (weight,height and BMI).
 Take dietary history and social–economic assessment.
 Distribution of food and micronutrient supplements to patients.
 Holding Nutrition education and nutrition Counseling sessions. as follows:

BMI= weight in Kgs/height in meters square

The ranges for the BMI are as follows:

 If the BMI is between18.5–24.9 then the weight is normal.

 BMI of <18•5 is underweight
 BMI of 25.0-29.9 is considered overweight .
 BMI of >30 is considered obese.

Patients who were underweight or those who had a BMI of less than 18.5 were supplemented with
Fortified Blended Flour(FBF) and were also counseled on dietary diversification,modification and
increased intake of high protein high Calorie diet.Those who were overweight and obese were
counseled on weight management and healthy food choices.
Those who were overweight and obese were counseled on weight management and healthy food
choices.

Nutrition Management and counseling for PLHIV includes;

 Explaining the benefits of maintaining good nutritional status to PLWHIV.

 Nutrition counseling on drug food interactions and management of diet drug side effect.
 Counseling on dietary diversification using the 10 food groups.
 Counselling on Critical Nutrition Practices(CNPS)such as hygiene,and positive living behaviors.
 Nutrition supplementation for Severely malnourished patients.

2.3 MATERNITY
This is an inpatient ward in the facility that always deals with the pregnant mothers and all
complications they encounter during this period.

It's divided into different rooms, they include;

a) Antenatal room
This is a room allocated for mothers who have not delivered and sometimes encounter some pregnancy
complications e.g anemia, sickle cell e.t.c.
b) Postnatal room
This is where mother who are already delivered are placed as they are monitored on complications that
arises after delivery.

After some days, if there's no complications reported they are free for discharge to go home and come
back for follow up as indicated to her by the doctor.

c) Caesarian Section room

This a special room where mothers with complications that put there life in danger during the time of
delivery are placed. They are placed in this room for sometimes as they are waiting for surgery because
they can't give birth normally.

NEW BORN UNIT(NBU)

This was where preterm and term babies with complications are treated and monitored. It is divided
into 3 categories;

 NBU 1 : Includes babies born within the facility with medical conditions.
 NBU 2 : Includes babies who are referred from other facilities or were born from home with
complications.
 NBU 3 : Include babies who are stable from NBU 1 and 2 and this is where kangaroo mother care
is practiced.

Pre-nan and Lactodex was specific formula used for feeding the pre-term and low birth weight infants. It
has adequate protein and calories and is easily digested.

Supplementation of human milk with energy and protein has been shown to improve the rates of both
weight and length gain.

During my rotation I was able to know some terms used to classify new born babies and problems
associated with feeding them.

Classification by weight
 LBW <2500g
 VLBW <1500g
 ELBW <1000g and >700g

Problems associated with small babies such as:

 Low blood glucose.

 Feeding difficulty.
 Breathing difficulties
  Anemia
 Jaundice
 Inability to maintain normal body temperatures

Care and management of low birth weight

 Kangaroo Mother care (Skin to skin contact)
 Breast feeding on demand
 Educating mothers on how to express breast milk
 Monitor weight gain

Other Nutrition activities at the new born unit included;

1. Nutrition Assessment.
2. Teaching and demonstrating on proper positioning and attachment during breast feeding.

2.4 PAEDIATRICS WARD

Paediatrics is the branch of medicine department that deals with the medical care of infants, children,
and adolescents. It is where children are treated and diseases managed medically as well as
nutritionally.

The common diseases in the ward were;

 Pneumonia
 Malnutrition
 Meningitis
 Underweights

Roles of a Nutritionist in the Paediatrics Ward

 To carry out Nutritional assessments, that is anthropometric, dietary, clinical and biochemical
assessment filling all the data in the assessment forms for all new admissions.
 Developing a nutritional diagnosis from the data collected during assessment.
  Management of severe acute malnutrition using the available therapeutic feeds, which are F75
and F100.
 Taking the weight of the children in the program and plotting on a daily basis on the multi-chart
as well as reviewing the intakes of the prescribed feeds and updating in the feeding charts.
 Giving health talks in the paediatrics wards on proper infant and young child feeding practices.

Marasmus-Kwashiorkor rehabilitation guidelines

Most children shows wasting of muscles and loss of subcutaneous fats, severe acute malnutrition hence
infection. i.e in management of moderate and severe PEM.

Taking a careful social and family history to find out more about the real causes of the malnutrition.

 Nutritional assessment using the 24 hour dietary recall.

 Making a careful physical examination e.g. edematous, paleness
 Weighing, recording mid-upper arm circumference.
 MUAC criteria to identify severe acute malnutrition.
 W/L- <-3z–scores.

Management of severe acute malnutrition

The admission criteria for children with severe acute malnutrition are as follows;

1. W/H- <-3z–score
2. MUAC of <11.5
3. Bilateral edema

Nutrition intervention
The feed given at stabilization phase is F75 which contains 75 kcal and 9g of protein per liter.The
amount given is130ml per kg/bwt if the child has edema 100ml per kg/wt.the child is given 8 feeds per
day 3hourly.

The stabilization phase is 1 to 2 days or more depending on the child’s condition.

Children under 6 months

Children below 6 months who have SAM are given diluted F100 or infant formula and their mothers are
encouraged to breast feed on demand.

CASE STUDY
Name; patient Y

Age: 2 years
Sex: male

Anthropometric Assessment
Weight; 7.2 kg

Height; 72.5 cm

Dx; Severe acute malnutrition

Clinical Assessment
C/o: Wasting

Refuses to eat

Bilateral oedema.

Plan
Admission for nutrition therapy

Provision of F-75 100ml/kg bwt for rehabilitation

2.5 MEDICAL WARDS

This ward is divided into two i.e; male ward and female ward.

Roles of nutritionist in the ward

 Nutrition assessment
 Attending ward rounds
 Nutrition supplementation
 Food modification to meet client needs e.g.for NGT patientsNutrition review
 Nutrition education and counseling.

There are various conditions in the ward that I encountered during my rotation such as;

 Hypertension
 Diabetes
 Peptic Ulcer disease
 Congestive heart disease
Congestive heart failure
This is a condition resulting from a gradual weakening of the heart muscles,this strains the hearts ability
to supply adequate blood despite its own reduced supply.

Causes
 A coronary artery disease
 Heart attack
 High blood pressure.

Symptoms
 Shortness of breath (dyspnea)
 Congested lungs
 Anorexia,nausea,feeling of fullness,constipation,tenderness and enlargement of the liver.
 Reduced bloodsupplytothebrainhencementalconfusion,memoryloss,anxiety,headaches.
 Malnutrition can occur due to increased energy needs,disrupted blood flow,infections and
limited oral intake.

Dietary modification
Same as for CHD plus;

 Use foods that are less likely to produce gas.

 Adjust fiber carefully to prevent constipation
 Sodium restriction depending on the severity of the disease
 Fluid restriction varies; 500-2000ml/day.

Nutrition tips for congestive heart failure

 Check food labels and limit salt and sodium intake.
 Choose meat and other foods low in saturated fats to help lower cholesterol level.
 Avoid alcohol
 High fiber foods
 Maintain a healthy body weight.
DIABETES

Classification of diabetes
 Type 1-It develops when insulin producing cells in the body have been destroyed and the body is
unable to produce insulin.
 Type 2-Develops when insulin producing cells in the body are unable to produce enough insulin
or when the insulin that is produced does not work properly (insulin resistance).

Symptoms of Diabetes
 Frequent urination (polyuria).
 Excessive thirst(polydipsia)
 Excessive hunger(polyphagia)
 Extreme fatigue
 Cuts/bruises that are slow to heal.

Nutrition recommendation for the management of diabetes

 Less intake of starch and fats
 Low sodium use/intake
 Moderate/avoid alcohol and smoking
 Intake of high fiber diet
 Consumption of healthy diet
 Intake of water at-least 2 liters per day
 Physical activity
 Diabetic plate education

2.6 SURGICAL WARD

It is divided into 2;

 Male and
 Female surgical.

Patients dealt with here are those who had to undergo a surgical procedure.They include patients with:

 Burns
 Fractures
 Head injuries
  Intestinal operation(colostomy,appendectomy & ileostomy)
 Cancer/ tumors
 Diabetic foot.

Aim of management:
 Prevent malnutrition
 Maintain or improve nutrition status of patients.

Duties and responsibilities of a nutritionist:

1. Preparation of a diet sheet for the patient in the ward

2. Performing nutritional assessment and diagnosis to patients which included:

 weighing of the ambulant patients to get their BMI

 getting MUAC for non-ambulant patients.

3. Nutritional counselling to patients/caregivers depending on their nutritional status

4. Nutritional supplementation to those patient who needed to be supplemented.

5. Preparation of feeding regimes for patients feeding through NGT.

6. Reviewing of patients on a daily basis.

7. Preparation of burn management diet (BMD).

Pre-operative diet:
1. The patient should be encouraged to lose weight if overweight. They not be able to recover
from anaesthesia and also difficulty in wound healing.
2. The stomach should be empty at the time of operation. No food is allowed by mouth atleast six
hours prior to operation as this will reduce vomiting and aspiration.
3. Consumption of iron rich foods since haemoglobin of less than 10g/dl is not allowed
4. Underweight patients need to gain weight so as to withstand the anaesthesia, hence they are
nutritionally stabilized first.

Post-operative diet:
1. Consume 35-45 kcals/kg/day once a normal diet is tolerated so as to facilitate wound healing.
2. Consume1-1.5g/kg/day protein for patients who were well nourished and 1.52g/kg/day for
patients with poor absorption.
3. Consume plenty of fresh fruits and vegetables rich in vitamin A and C so as to promote wound
healing and prevent gastric ulceration.
 4. Q Consume foods rich in minerals like zinc,iron,and potassium and phosphorus.

CASE STUDY
NAME: Patient Z

AGE: 3 years

RESIDENCE: Machakos

DX: 36% Burn.

Anthropometric Assessment
Weight: 8.2 kgs

Height:76.1cm

MUAC:11.2cm

The child is severely malnourished related to his MUAC of 11.2cm.

Biochemical Assessment
White blood cells:4.4mmol slightly L (4.4-14.5mmol)

Haemoglobin - 13.1 g/dl (13.4 - 16.5 g/ dl).

Clinical Assessment
Pealing of the skin on the burnt area.

Poor appetite

No vomiting.

No diarrhea.

Dietary assessment
Patient feed orally

Patient feed in high protein high calorie diet

Patient report good appetite

No allergies.

Functional Assessment
Patient is bed ridden

Patient can move all the limbs

Nutrition diagnosis
Low minerals in the body related to loss of minerals through the open wound as evidenced by sodium
ion of 122mm,potassium ion of 2.2mg/dl and calcium ion of 5.6mg/dl.

Nutrition Intervention
 The caregiver was advised to give the child food rich in proteins to compensate for the lost one
through the wound area and promote wound healing.
 The caregiver was advised to give the child high carbohydrate diet due to high energy
requirements.
 The caregiver was advised to give the child variety of fruits to provide more minerals to the
body.
 The caregiver was advised to give the child alot of fluids to compensate the lost one through the
open wound.
 CHAPTER 3: LESSONS LEARNT, EXPERIENCE AND SKILLS

Many new cases arised during my rotation in different departments and I was able to learn a lot of new
skills and lessons.

While I was in maternity ward I gained a lot of skills and experience like;

How to express milk from a mothers breast while I was in the new born unit

 The calculation of EBM and the additional feeds(NAN)

 Insertion of an NG tube
 I became familiar with many new born complications and how they are managed or treated
 Management of pregnancy related complications.

Paediatric ward was also full of experience as I attended and participated in the ward rounds. As
nutritionists we were involved in various activities in order to manage different nutritional related
conditions. As nutritionists we also took and recorded weight of the children which was a great
experience. There was a lot of malnourished children an so we participated in the preparation of;

 F75 for stabilization phase

  F100 for transition phase
 ReSoMaL for rehydrating the malnourished
 ORS for rehydrating other children who were not malnourished.

Comprehensive care clinic had numerous skills and experiences that I gained during my rotation there.
We dealt with the HIV infected patients and I was able to know the following;

 The difference types of ARVs given

 How to fill the MOH tool 361 A and 361 B
 Supplementation of the patients with ABZ and Vitamin A
 Counselling and care of PLWHIV.

In the Medical ward I had a wide opportunity to learn and gain alot of experience since this is where all
the medical conditions were treated. During the ward rounds I became familiar with different skills like ;
the insertion of catheters , Nasal Gastric tubes and oxygen tubes. I gained alot of skills considering the
many different cases. The skilks incude;

 Preparation of blenderized foods .

 Insertion of NG tubes
 Checking for blood sugar levels of patients
 Checking for the blood pressure of patients .

In maternal and child health care clinic I learnt how to take anthropometric measurements of children,
specifically weight, height and length. I also gained experience on the supplementation of children at 6
month with vitamin A. I gained skills on the following;

 Injection of the birth, first, second and third doses for infants
 Counselling mothers on proper attachment of their babies
 Counselling on how to practice complementary feeding correctly.
CHAPTER 4

4.0 CHALLENGES, ISSUES, ANALYSIS AND LIMITATIONS

Despite being good and full of experience and new skills, I encountered different challenges as I rotated
the different departments in the facility. The challenges encountered in general includes;

 Language barrier– some patients could not understand neither Kiswahili nor English and it was
hard for me to communicate to them.
 Negligence and non-adherence to recommended diets among patients.
 Limited rooms and space to offer nutrition counseling leading to poor privacy
 Faulty machines like the weighing scales
 A small number of nutritionists in the whole facility compared to the high demand
 Shortage of food supplements especially the RUTF and RUSF.

CHAPTER 5: CONCLUSION AND RECOMMENDATIONS

5.0 CONCLUSION
The whole attachment session was informative and of good experience as I was able to relate the theory
work learnt in class into practical session. I was able to work in different departments and I gained skills
as a team player. The entire nutrition department was a humble area and provided me with technical
guidance during my attachment.

5.1 RECOMMENDATIONS
Machakos level 5 hospital should employ more nutritionists to facilitate effective delivery of nutrition
services.

 The hospital should increase rooms for effective nutrition counseling.

 Alternative meals to be availed to patients having food allergies or intolerance to specific meals
provided during meal times.
 Nutrition department should be well financed to purchase enteral and parenteral feeds for
critical patients where oral nutrition is not possible.
REFERENCES
Kenya National Guidelines in the nutrition management of HIV/AIDS

Kenya National Guidelines in the management of Diabetes

Handbook for Integrated management of acute malnutrition

Guideline for the management of heart failure

Integrated Management of Acute Malnutrition National guide lines(IMAM)