AN INTERNSHIP REPORT SUBMITTED TO KENYA

NUTRITIONISTS AND DIETICIANS INSTITUTE FOR

THE PURSOSE OF REGISTRATION AS CLINICAL
NUTRITIONIST.
NAME OF INTERN
KEVIN OCHIENG NGARE
INDEXING NUMBER
KNDI-00608-2015
INSTITUTION FOR INTERNSHIP
KENYATTA NATIONAL HOSPITAL
YEAR OF INTERNSHIP
2016
FACULTY MEMBER
DR. KYALO
SUPERVISORS
MRS.EDNA WARENTHO-CHIEF NUTRITION OFFICER,
KENYATTA NATIONAL HOSPITAL
MRS. IRENE MAKORI-STUDENTS COORDINATOR,
NUTRITION DEPARTMENT, KENYATTA NATIONAL
HOSPITAL
 ACKNOWLEDGEMENTS
Special thanks to almighty God for taking care of me during whole year of internship.

Thanks to Chairperson of Kenya Nutritionists and Dieticians Institute, Prof. Julia Ojiambo,
CEO of KNDI, Dr. David Okeyo and the Technical Manager, for their continuous seminars
and workshops during internship.

Thanks to Dr Kyalo of JKUAT, for the continuous assessments and updating us on the
requirement of KNDI.

I would want to acknowledge the following people whose contribution facilitated the
successful completion of my internship. Special thanks to my supervisors, Chief nutrition
Officer KNH Mrs. Edna Warentho and Assistant Chief Nutrition Officer Mrs. Irene Makori.

I am also grateful to the following people;

Mrs. Mary Kamwana-Nutritionist in-charge of medical wards, KNH

Mr. AggreyMakua-Nutritionist in-charge of Critical care Unit, KNH

Mr. Richard Ogendo-Nutritionist Reproductive Health Unit, KNH

Mrs. Winnie Atieno-Nutritionist in-charge Kenyatta private care center, KNH

Mrs. Mercy cherono- Nutritionist in-charge General surgery, KNH

Mr. Evans kosgei-Nutritionist special surgery, KNH

Mrs. Gladys Muchini-Nutritionist Diet kitchen, KNH

Staffs such as Doctors, nurses, social workers, physiotherapists, adherence counselors,

Occupational therapists, records officers and the subordinate staffs also contributed towards
my achievements during internship.

Thanks also go to my fellow interns who their assistance and teamwork played key role my
internship.

Lastly, thanks to family members who gave financial support and encouragement during the
whole year internship.

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 DEDICATION
This internship report is dedicated to my brothers Tom Ngare, Kennedy Ngare, Geoffrey
Ngare, phelix Ngare and My sister Millicent Ngare.

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Table of Contents
ACKNOWLEDGEMENTS ....................................................................................................... ii
DEDICATION .......................................................................................................................... iii
ABBREVIATIONS .................................................................................................................. vi
ABSTRACT............................................................................................................................ viii
INTRODUCTION ..................................................................................................................... 1
INTERNSHIP OBJECTIVES .................................................................................................... 2
INTERNSHIP TOOLS .............................................................................................................. 2
THE ORGANIZATION STRUCTURE .................................................................................... 3
VISION .................................................................................................................................. 3
MISSION ............................................................................................................................... 3
MOTTO ................................................................................................................................. 3
WORK AND ACTIVITIES ....................................................................................................... 4
1. REPRODUCTIVE HEALTH UNIT............................................................................... 4
Nutrition Assessments ....................................................................................................... 4
Nutrition counseling for preoperative and postoperative mothers ..................................... 4
Nutrition regime writing .................................................................................................... 4
SAMPLE FEEDING REGIME ......................................................................................... 5
Nutrition review ................................................................................................................. 5
Diet prescription................................................................................................................. 5
Breastfeeding ..................................................................................................................... 6
2. COMPREHENSIVE CARE CENTER .............................................................................. 6
3. KENYATTA PRIVATE CARE CENTER ........................................................................ 7
DIETARY MANAGEMENT AND RENAL DISEASES ........................................................ 8
What Caused my Kidneys to Fail?..................................................................................... 9
Other causes: ...................................................................................................................... 9
What are the symptoms of the kidneys not working? ........................................................ 9
4. MEDICAL WARDS. ......................................................................................................... 9
6. ARTHOPAEDIC WARD ................................................................................................ 11
7. DIET KITCHEN .............................................................................................................. 12
Preparation of special milk (F100 and F75) ........................................................................ 12
F100 Preparation for 100 litres ........................................................................................ 12

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 F75 preparing 1 litre......................................................................................................... 13
Recipe for preparing special soup .................................................................................... 13
Recipe for preparing special uji ....................................................................................... 14
8. GENERAL SURGICAL WARDS .................................................................................. 14
9. SPECIAL SURGICAL WARDS ..................................................................................... 15
10. PAEDIATRIC WARDS ............................................................................................... 15
11. ONCOLOGY WARDS ................................................................................................. 15
12. DIETARY ADVISORY CLINIC ................................................................................. 16
13. BURNS UNIT ............................................................................................................... 16
14. CRITICAL CARE UNIT (CCU) .................................................................................. 16
15. OPTHALMOLOGY WARD ........................................................................................ 16
16. NEWBORN UNIT (NBU) ............................................................................................ 16
17. PAEDIATRICS INTENSIVE CARE UNIT(PICU) ..................................................... 17
18. NEUROLOGICAL INTENSIVE CARE UNIT(NICU) ............................................... 17
ACHIEVEMENTS .................................................................................................................. 17
CHALLENGES ....................................................................................................................... 18
CONCLUSION ........................................................................................................................ 18
RECOMMENDATIONS ......................................................................................................... 18
APPENDICES ......................................................................................................................... 19
APPENDIX 1; INSERTING FEED TO A PATIENT WITH NASOGASTRIC TUBE ......... 19
APPENDIX 2: EXAMPLES OF ENTERAL FEED IN KNH (SURVIMED
PREDIGESTED). ................................................................................................................ 20
APPENDIX 3:ENTERAL FEED-TRESUBIN ORIGINAL FIBRE ................................... 20
APPENDIX 4: ENTERAL NUTRITION FEED-FRESUBIN ORIGINAL ........................ 21
APPENDIX 5:READY-TO-USE THERAPEUTIC FOOD ................................................ 21
APPENDIX 6:INFANT FORMULA .................................................................................. 22
APPENDIX 7 :FOOD PYRAMID IN KNH ....................................................................... 22
APPENDIX 8: PAEDIASURE CHILDREN ENERGY SUPPLEMENT .......................... 23
APPENDIX 9: SAMPLE REGIME..................................................................................... 23
APPENDIX 10: ENTERAL FEEDING REGIME .............................................................. 24
APPENDIX 11: INTERSHIP TIMETABLE....................................................................... 24

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 ABBREVIATIONS
NBU-NEWBORN UNIT

PICU-PEDIATRICS INTENSIVE CARE UNIT

ICU-INTENSIVE CARE UNIT

CCU-CRITICAL CARE UNIT

NICU-NEUROLOGICAL INTENSIVE CARE UNIT

KPCC-KENYATTA PRIVATE CARE CENTER

KNH-KENYATTA NATIONAL HOSPITAL

KNDI-KENYA NUTRITIONISTS AND DIETICIANS INSTITUTE

DR-DOCTOR

PROF-PROFFESSOR

RHU-REPRODUCTIVE HEALTH UNIT

DAC-DIATARY ADVISORY CLINIC

KMTC-KENYA MEDICAL TRAINING COLLAGE

AMREF-AFRICA MEDICAL AND RESEARCH FOUNDATION

NASCOP-NATIONAL AIDS AND STIs CONTROL PROGRAMME

KEMRI-KENYA MEDICAL RESEARCH INSTITUTE

NACC-NATIONAL AIDS CONTROL COUNCIL

NPHLS- NATIONAL PUBLIC HEALTH LABORATORIES SERVICES

VVF-VASICO VAGINAL FISTULA

CDC-CENTER FOR DISEASE CONTROL

MEAK- MEDICAL AND EDUCATIONAL AID TO KENYA

NBTS- NATIONAL BLOOD TRANSFUSION SERVICES

JKUAT-JOMO KENYATTA UNIVERSITY OF SCIENCE AND TECHNOLOGY

WHO-WORLD HEALTH ORGANISATION

BMI-BODY MASS INDEX

MUAC-MID UPPER ARM CIRCUFERENCE

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CHO-CARBOHYDRATE

KCAL-KILOCALORIES

AIDS-ACQUIRED IMMUNODEFICIENCY SYNDROME

HIV-HUMAM IMMUNO VIRUS

CKD-CHRONIC KUDNEY DISEASE

ESRD-END STAGE RENAL DISEASE

CCC-COMPREHENSIVE CARE CENTER

PLWHIV-PEOPLE LIVING WITH HUMAN IMMUNO VIRUS

DIETARY APPROACHES TO STOP HYPERTENSION

GFR-GLOMERULAR FILTRATION RATE

AKI-ACUTE KIDNEY INJURY

CNE-CONTINUOUS NUTRITION EVALUATION

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 ABSTRACT
Internship is part of the requirement for the Bachelor of Science of nutrition, food and dietetic
sciences. KNH is the public hospital of choice in Kenya and beyond. It offers quality
specialized health care to patients from the Great Lakes Region, Southern and Central Africa.
These services include nutrition services, open heart surgery, neurosurgery, orthopaedic
surgery, reconstructive surgery, burns management, critical care services, new born services,
ophthalmology (cornea transplant), oncology, palliative care and renal services (including
kidney transplantation), among others. Internship objectives included, to acquire knowledge
on leadership and management skills, to learn more on medical nutrition therapy and put
theoretical part learnt from university, to apply Nutrition Care Process in the management of
medical conditions, to learn about reporting, monitoring and evaluation in context of store
keeping and to satisfy the requirement of Kenya Nutritionists and Dietician Institute (KNDI)
for registration. The following areas were covered during internship period reproductive
nutrition, medical nutrition,orthopaedic nutrition, surgical nutrition, critical care nutrition,
oncology nutrition, renal nutrition, cardiac and hepatic nutrition, pediatrics nutrition and
preparation of special diets. The ward attached to included, Reproductive Health Unit(RHU),
Oncology, Kenyatta Private Care Center(KPCC), medical wards, orthopaedic wards, surgical
wards both general and special, Critical care unit, Burns Unit, pediatrics wards, Newborn
Unit, Pediatrics intensive care unit, renal unit, Diet kitchen, Diet Advisory clinic(DAC),
orthopaedic clinic, surgical clinic, Gaenecology clinic, pediatrics clinic, diabetic clinic, Ear,
nose and throat clinic, and Accident and Emergency section. Achievements were practical
application of nutrition care process, nutrition counseling and education. learnt and knew
more about all medical conditions, experienced on medical nutrition therapy, acquired
practical knowledge and skills on leadership and management, acquired practical skills on
teamwork, social networking skills improved, become experienced on parenteral, Enteral and
partial nutrition support, writing reports and reporting techniques. Monitoring and evaluation,
financial generation and management. In any institution there are challenges, these were the
challenges faced in KNH, financial constrains, many patients compared to staffs and duration
of internship too long. Recommendations for internships includes, internship period to be
reduced to a minimum of 6 months, interns to be given amount of money for sustainance by
the Government of Kenya, More time to be allocated to specialized wards and medical wards,
and institution to come up with standard nutrition guidelines to all wards. In conclusion,
Internship is a very important component of nutrition training as it equips interns with
practical knowledge and skills on the management of medical conditions through nutrition
care process and medical nutrition therapy.

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 INTRODUCTION
Kenyatta National Hospital (KNH) was established in 1901 with a capacity of 40 beds. The
Hospital operated as a department of the Ministry of Health until 1987 when its status
changed to a State Corporation through Legal Notice No. 109 of 6th April 1987. Over the
years KNH has grown to its present capacity of 2,000 beds and attends to an annual average
of 70,000 inpatients and 500,000 outpatients.

KNH is the public hospital of choice in Kenya and beyond. It offers quality specialized health
care to patients from the Great Lakes Region, Southern and Central Africa. These services
include nutrition services, open heart surgery, neurosurgery, orthopaedic surgery,
reconstructive surgery, burns management, critical care services, new born services,
ophthalmology (cornea transplant), oncology, palliative care and renal services (including
kidney transplantation), among others.

The Hospital provides training facilities for the University of Nairobi (College of Health
Sciences) and the Kenya Medical Training College (KMTC). The institution also works
closely with the Kenya Medical Research Institute (KEMRI), Government Chemist, National
Radiation Protection Board, National Public Health Laboratories Services (NPHLS), National
AIDS and STIs Control Programme (NASCOP), National AIDS Control Council (NACC),
National Blood Transfusion Services (NBTS) and African Medical and Research Foundation
(AMREF), among others.

The Hospital has established linkages and collaborations with other institutions in providing
various clinical services, outreach programs and research. Collaborations have been
established with Operation Smile International, Neurosurgical Mission of St. Louis (USA),
Plastic Surgical Project of the late Prof. Platt, Open Heart Surgery through Medical and
Educational Aid to Kenya (MEAK) of Guys Hospital (UK), Renal Transplant Programme of
University of Barcelona/NOVARTIS, Vesico Vagina Fistula (VVF) Project with AMREF
and Spinal Surgery with Nuvasive Spine Foundation (USA) among others. Outreach
Programmes include Nyeri Neurosurgical Programme and Cancer Treatment Programme in
Mombasa and Kisumu. There are various research projects with University of Washington,
CDC, University of Nairobi, Grand Challenges Canada, among others.

According to the Kenya Gazette Supplement No.114 (Acts No.18), the nutritionist and
Dieticians Act, 2007, page 823, provides for an internship for the graduates. The internship is
a way of putting into practice the theories learnt in University into practical under the
supervision of the registered nutritionist or Dietician. As the requirement of the Act, I
undertook internship in Kenyatta National Hospital for duration of one year.

During internship in KNH, I learnt the following;

I. Nutrition Care Process that is nutrition assessment, nutrition diagnosis, nutrition

intervention, monitoring, evaluation and documentation.

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 II. Management and leadership skills
III. Medical nutrition therapy
IV. Burns nutrition
V. Intensive Care nutrition
VI. Teamwork
VII. Nutrition management of various medical conditions.

INTERNSHIP OBJECTIVES
I. To acquire knowledge on leadership and management skills.
II. To learn more on medical nutrition therapy and put theoretical part learnt from
university.
III. To apply Nutrition Care Process in the management of medical conditions.
IV. To learn about reporting, monitoring and evaluation in context of store keeping.
V. To satisfy the requirement of Kenya Nutritionists and Dietician Institute (KNDI) for
registration.

INTERNSHIP TOOLS
 Log book.
 Interns’ assessment forms.
 Interns register book
 Diet/Milk list
 Patients’ assessment forms.
 Patient regime form
 Diet requisition sheet
 Pediatrics weight charts
 Revenue sheet

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 THE ORGANIZATION STRUCTURE

VISION
A world class patient-centred specialized care hospital.

MISSION
To optimize patient experience through innovative healthcare; facilitate training and research;
and participate in national health policy.

CORE VALUES

Customer focus
Professionalism & Integrity
Teamwork
Equity and Equality
Employee empowerment
Environmental safety

MOTTO

We Listen, We Care

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 WORK AND ACTIVITIES

1. REPRODUCTIVE HEALTH UNIT

Reproductive Health Unit is a section in the hospital that is dealing with the new borns,
breastfeeding, initiation of breastfeeding, nutrition counseling, diet prescription, nutrition
assessments, nutrition talks and lectures, nutrition review, breastfeeding complications and
supplementation.

Nutrition Assessments
The weight and the length of the babies were taken using weighing scale and length board.
The weight and length were then compared with the reference then classified.

The weights and heights of the mothers were taken and Body Mass Index (BMI) were
calculated and classified as per the WHO guidelines.

<18.5-underweight

18.5-24.9-normal

25-29.9-overweight

30.0-34.9-Obese class I

35.0-39.9-Obese class II

>40.0-Obese class III

Nutrition counseling for preoperative and postoperative mothers

The mothers who were about to go and from caesarian sections, were counseled on
appropriate foods that is full liquid diet immediately after surgery, followed by mechanically
soft diet and then regular diet.

Nutrition regime writing

A regime is a plan of feeding that includes time, type of feed, amount of food and the flow
rate to guide you when feeding a patient. Feeding regime include Oral feeding regime,
Enteral Feeding regime, parenteral feeding regime and Partial feeding regime.

In the Reproductive Health Unit, Enteral feeding regime was written to a patient with Brain
Hypoxia. The regime was being changed after every 24 hours after doing a nutrition review
on the biochemical and anthropometric measurements.

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SAMPLE FEEDING REGIME
PATIENTS NUTRIENT REQUIREMENTS

PROTEIN (g) 72CHO (g)276FAT(g)64FLUID(mls)2480TOTAL KCALS2000

TIME FEED AMOUNT FLUID FLOW RATE

6.00AM FRESUBIN 1000MLS 1000 MLS 83MLS/HR

ORIGINAL
FIBRE

6.00PM FRESUBIN 1000MLS 1000MLS 83MLS/HR

ORIGAL FIBRE

WARM WATER 480MLS 480MLS 80MLS/4HRLY

Comments/Recommendations please monitor feed tolerance and feed as per the regime.

Nutritionist Name Kevin Ochieng Sign………………..Date 4/5/2016

Nutrition review
Nutrition review is done to patients daily to determine the progress of the patients in terms of
nutrition, weight, biochemical and the functionality of gastrointestinal tract.

Review was done to all patients in the wards to determine the nutritional status and corrected
where necessary.

Diet prescription
Kenyatta National Hospital requires that all patients in the wards are prescribed for a diet
which is appropriate according to the conditions.

Diets prescribed in the Reproductive Health Units includes; High protein High calorie diet for
postoperative patients, low fat diet for patients with Cardiac problems, diabetic diet for
hyperglycemia patients

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Breastfeeding
Breastmilk is the natural food for newborns. It contains everything your baby needs. No
question, no debate, no doubt.
The breastfeeding mothers were counseled on the following importance of breastfeeding to
newborns, mothers and the community;
Breastfeeding matters because, everyone benefits from breastfeeding that the baby, mother
and the community, Breastmilk is convenient, always at right temperature and available
anytime,Breastmilk is free, promotes bonding between the mother and the baby,
environmentally friendly, and reduces the cost of health care for your family and society.
Breastfeeding matters to your baby because it protect your baby from many infections and
illnesses, build healthy eating habits, promotes proper jaw development, promotes proper
brain development.
Breastfeeding is important to mothers because, it controls postpartum bleeding, help in losing
weight gained during pregnancy very fast and slows down the return of period.

2. COMPREHENSIVE CARE CENTER

Comprehensive Care Center is healthcare center which provides concurrent prevention and
management of multiple physical and emotional health problems for all patients at all stages
of life of people living with HIV.
This support is provided over a period of time in relation to family, life events and
environment. The goal of this type of healthcare is usually to encourage people to address
medical needs as soon as they arise, rather than waiting for them to become serious. The
following are the services provided in Comprehensive Care Centres in Kenya;
 HIV testing services and diagnosis
 Nutrition assessment, care and support
 Adherence counseling
 Initiation of antiretroviral treatment care
 Routine patient monitoring and treatment of opportunistic infections
 Psychosocial support for children, adolescents and adults
 Access to reproductive health information, services and support
 Access to maternal and childcare information and service
 Tuberculosis screening and diagnosis
 Facilitate linkages to community care support
In CCC, I did the following;
Nutrition Assessment
Nutrition review
Issuing vitamin A
Nutrition Counseling HIV positive patients
Issuing plumpynuts and foundation plus to HIV and tuberculosis patients
Taking anthropometric measurements that is weight and height and calculating BMI
Compiling daily report in the IQ form.

Nutrition AND HIV/AIDS management

Nutrition is a very important component in the management of HIV/AIDS.
The patients were counseled on the following points on diet management;
 Have periodic nutritional status assessment, especially weight, at least every 2nd
month for symptomatic clients and every 3rd month for asymptomatic clients.

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  Increase energy needs according to disease stage. PLWHIV with no AIDS symptoms
require 10% more energy(equivalent to one snack) per day than the recommended
daily allowance for HIV-negative healthy individuals of the same sex, age, physical
activity level and physiological status. PLWHIV with AIDS symptoms require 20-
30% more energy (equivalent to 2-3 snacks) per day than the recommended daily
allowance for HIV-negative individuals.
 Malnourished PLWHIV (BMI<18.5) were supported with supplementary foods such
as foundation plus and plumpynuts. Severely malnourished (BMI<16kgm/m2)
PLWHIV were treated with appropriate therapeutic foods.
 Maintain high levels of sanitation, food hygiene and food/water safety at all times. If
living in hookworm endemic areas one should be de-wormed semi-annually with an
appropriate broad-spectrum anti-helmithic drug, like Albendazole or mebendazole.
 Practice healthy living behaviours,including safer sex, avoiding or moderating use of
alcohol and cigarettes, moderating consumption of junk foods, and managing
depression and stress.
 Engage in physical activity or exercises to strengthen or build muscles, and increase
appetite and health.
 Drink plenty of clean water (8 glasses in a day).All water used to swallow medicines
and to prepare juices should be clean and safe e.g. filtered and boiled, or treated with
waterguard.

3. KENYATTA PRIVATE CARE CENTER

KPCC also called Level 9 and Level 10. Level 9 and Level 10 in Kenyatta National Hospital
consists of general medicals wards, maternity and labour ward, pediatrics wards and surgical
ward.
These were my responsibilities as nutrition intern;
Nutrition assessment, the weight of all children and infants were taken twice in a week that is
Monday and Friday. Height and length were also taken and BMI for ages were also referred.
The anthropometric measurements plotted appropriately in the weight charts. Biochemical,
dietary and clinical assessments were also done.
Ordering of supplements from private wing, the supplements were ordered for patients who
were on enteral nutrition, parenteral nutrition or those who were on oral nutrition but needed
nutritional supplementation. The supplements ordered included Fresubin Original,
Fresubinoriginal fibre, diben,Survimed, and Gravity sets for patients on enteral nutrition
support. Parenteral nutrition supplements included Kabiven (three-in-one), Intralipid, soluvit,
vitalipids and adittrace. Fresubin protein energy drinks, Energy drink, provide extra, Ensure
and paediasure were examples of oral supplements.
Nutrition Counseling; all patients in the wards counseled according to their conditions. The
conditions counseled on were, renal, diabetes, gastrointestinal problems, liver disorders,
cardiac and immunological disorders. Counseling was done to patients who were new and
had not be counseled before or have forgotten points counseled on.
Nutrition Review; reviewed patients on parenteral and enteral nutrition support. The regimes
were reviewed almost daily to make appropriate nutritional changes according to the change
in the status. Patients who were orally feeding were reviewed too.
Writing nutrition regime.i.e parenteral and enteral nutrition; this involved nutritional
assessments, biochemical, clinical assessments and functional assessment of the patients.
Calculated a nutritional requirement that is energy, protein, carbohydrate, fluid and fat
requirements.

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Compiling weekly and monthlyreports; weekly reports composed of daily reports that
included nutritional services, regime writing and nutrition supplements. Monthly reports
consisted of weekly reports. The compiled reports were forward to nutrition officer in-charge.
Monitoring and evaluating patients on parenteral and enteral, nutritional support; patients on
artificially nutrition support and those on special diets were monitored. Evaluated the
progress of the patients by checking on the biochemical, anthropometric, dietary, clinical and
functional parameters.
Diet Prescription; In the wards the following diets were prescribed for the patient based on
the severity of the diseases and the physiological status; Renal diet, diabetic diets, bland diets,
DASH diets, low fat diet, High protein, High Calorie diet ,low salt diet, low and high fibre
diet, mechanically soft diets, full liquid diet, and regular diets.
Menu planning; patients assisted to choose on the correct diet according to tastes, hospital
menu, and their conditions. Menu planning was also done to patients who were discharged
home so they could follow the prescribed diets completely.
Follow up on the diet prescribed; follow up done to patients in the wards to check on the
changes on the nutritional status. These was done by taking weights, checking on food
tolerance, blood pressure charts, fluid charts, feeding charts and inquiring from the patients,
relatives and other health staffs.

DIETARY MANAGEMENT AND RENAL DISEASES

The kidneys are made up of thousands of tiny filters called nephrons. When these filters are
damaged, this causes less waste products and fluid to be cleaned from the blood.
When the kidneys fail, waste products build up in your blood stream causing you to feel ill.
This is an immediate sign that treatment is needed.

STAGE DESCRIPTION GLOMERULAR

FILTRATION RATE
At risk Risk factors for kidney (GFR) More than 90
disease (e.g., diabetes, high
blood pressure, family
history, older age, etc.)

1 Kidney damage (protein in More than 90

the urine) and normal
filtration rate.

2 Kidney damage and mild 60 to 89

decrease in filtration rate

3 Moderate decrease in 30 to 59
filtration rate

4 Severe decrease in filtration 15 to 29

rate

5 Kidney failure (dialysis or Less than 15

kidney transplant needed)

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What Caused my Kidneys to Fail?
Sometimes we just don’t know but there are several reasons your kidney may not work. The
two most common causes are:
1. Diabetes (Sugar in the blood)
2. Hypertension(High Blood pressure)
These both affect the blood vessels slowly over time and cause damage to the nephrons or the
filters of the kidneys.

Other causes:
1. Infections that affect the nephrons
2. Birth defects – these can cause blockages of the urine flow that cause damage to the
kidney.
3. Trauma- Caused by accidents or from a medication or poison ingested or inhaled into the
body.

What are the symptoms of the kidneys not working?

1. Urinating more than normal or less than normal
2. Feeling tired
3. Loss of appetite – bad taste in the mouth
4. Nausea, vomiting
5. Swelling in face, hands and feet
6. Increased difficulty in breathing
7. Itchy Skin
A new diet is essential part to your treatment process. Not only will it help you feel better, it
can also help you avoid complications of your renal disease such as fluid overload, high
blood potassium, bone disease, and weight loss.
Because every individual is different and their needs unique, the following dietary advice
were given depending on a number of factors and discussion with patients. These factors
include: stage of your renal disease, type of treatment you are on, laboratory results, and
presence of other medical conditions.
Kidney function is essential for removing the waste material from food that you eat. The
kidneys excrete a dietary protein called urea, as well as sodium, potassium, and phosphate.
These substances can build up in the body if kidney function is impaired.
Following a strict diet can lessen this accumulation and its effects.
Hemodialysis Patients should monitor and limit their intake of the following:
 Control level of Potassium
 Control level of Phosphate
 Control level of Sodium
 Control level of Fluids

4. MEDICAL WARDS.
Medical wards in Kenyatta National Hospital include Level 7 and level 8. Medical wards are
the most populated ward in the hospital and consist of both male and female patients. The
wards admits cancer, diabetic, liver disorder, Gastrointestinal disorders, cardiac , neurological
disorders, renal, skin problems, ear, nose and throat problems, blood disorders,
immunological disorders patients and other medical problems.
Responsibility in the medical wards included;
Nutrition Assessment of patient; patients assessed on the basis of biochemicals,
anthropometry, dietary, clinical and physiological statuses.

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Collection and Distribution of supplements; the supplements required were being ordered by
the nutritionists in –charge. Collection and distribution of the nutritional supplements was
done by the nutrition intern and nutrition attaché in liaison with other medical staffs that is
doctors, nurses, physiotherapists.
Attended Continuous Nutrition Evaluation (CNE); continuous nutrition evaluations was on
weekly basis. There was internal and external CNES. External CNES were being conducted
by nutritionist/dieticians from outside Kenyatta National Hospital such as ASPEN
Nutritionals, WHEITH Nutrition, and LIPTIS Nutrition. Internal CNES were organized by
the department and collaboration with various nutrition subcommittees. During CNES, we
learnt more about nutrition and renal diseases, nutrition and liver diseases and nutrition and
non communicable diseases, infant formulae,growth-catch formulae, and other nutrition
supplements i.e. anti-regurgitation formulae, lactose free formulae, high calorie-high protein
supplements.
Parenteral and Enteral nutrition;thisrefers to provision of food and nutrients to the patient
when the conventional feeding methods are not adequate and cannot meet nutrition needs.
Enteral nutrition is a way of providing nutrition to patients who are unable to consume an
adequate oral intake but have at least a partial GI tract. Recommended for patients who have
problems in chewing, swallowing, prolonged lack of appetite, an obstruction, a fistula or
altered motility in the upper GIT, in coma or have very high nutrition needs. Parenteral
nutrition refers to nutrition directly into systemic circulation, by-passing the gastrointestinal
tract and the first circulation through the liver. Parenteral nutrition was done with qualified
nutritionist, nutrition intern ,nurse and a doctor.
Nutrition Counseling patients; nutrition counseling was done on a day basis. Counseling was
individualized to patients depending on the medical conditions and patient’s nutritional
status. It takes between 30 minutes to one hour per patient. Three to four patients were
counseled daily.
Diet prescription; diet was prescribed depending on the patient’s nutrition needs and medical
conditions, with recognition to nutrition assessment results. It was also being done daily by
filling milk/diet list and taking it to kitchen before the actual day.
Diet requisition; this is legal way of ordering diet from the kitchen through a diet requisition
sheet. Diet requisition was done to all patients in the ward. It was done daily indicating
number of patients, type of diet, those on artificial nutrition, number of children, those on
special diets and those in need on milk/mala.
Documented on the patients files; documenting on patient’s file gives away for a continuous
care. All patients counseled, reviewed, on parenteral and enteral nutrition care were
commented on their files .Comments were in form of Problem, Etiology and
symptoms/signs(PES) statement.
Written nutrition regimes; Wrote regimes to patients with Nasogastric tube, parenteral
nutrition support, gastrotomy, and those on oral nutrition support.
Presented about renal and nutrition management.
Diet planning for patients; planned diet to all patients in the ward as per the requirements of
the patient and the availability of food in the kitchen.
Supervision of students on attachments; Kenyatta National Hospital enrolls students on
attachment programme quarterly. An intern was being allocated two attaches per ward. An
intern oversees all the activities done by attaches and approves them in liaison to qualified
nutrition officer in-charge of the ward.
Monitoring and Evaluation;in medical wards monitoring was done to all patients on enteral
and parenteral nutrition.Monitored patients on hourly, daily, weekly and monthly basis.It was
done too to patients on special diets such as those on diabetic diet, renal diet, cardiac diet,

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hepatic diet. Evaluation was done using the following parameters; anthropometrics,
biochemicals, physiological, and clinical.
Weekly report; Reports from Monday to Friday was summarized and handed over to
nutritionist in-charge of the ward.

5. RENAL UNIT
This is a specialized ward in KNH that was designed to handle renal problems. The renal
problems handled were acute kidney Injury (AKI), Acute Renal Failure (ARF), Chronic
Kidney Disease (CKD), End Stage Renal Disease (ESRD) and others.
In Renal Unit, nutrition is the key in the management of renal problems. Nutritional services
provided included diet counseling, nutrition review, advising porters and cooks on
appropriate diet, diet prescriptions, regime writing, diet requisition, nutrition assessment,
documentation, supplementation, compiling reports and reporting , attending ward rounds
,updating patients register book and nutrition diagnosis.
Diet counseling was the most important activity done in the renal unit. Patients and their
relatives were counseled on correct nutrition for the management of renal diseases. They
were counseled on potassium, sodium, calcium and phosphate as nutrients, their food sources,
and amount to consume, safe ways to prepare and their functions in the body. Counseling
also tackles amount fluid consumed per day, amount of protein, fat and carbohydrates and
physical activities. It was based on the type of kidney problem, stage of the kidney disease
and socioeconomic factors. As the counsel was on consultations was made with the doctors,
physiotherapists, nurses and the registered nutritionists in-charge of the ward. Where
appropriate write-ups, bronchures and guidelines were given out.
Review being a tool used to assess the progress of the patients was employed to judge the
effectiveness of counseling and the diet given. Nutrition review was daily activity done on
individual basis.Checking on biochemicals, fluid charts and clinical apparatus and
documenting the progress and outcome in the files.
Regime writing was a daily activity which involved oral, Enteral and parenteral nutrition. It
was key because it involved nutrition diagnosis, calculations of caloric, fluid and nutrients
requirements. Renal patients were provided with special foods and supplements.
Nutrition assessment consisted of biochemical assessments which were indicated in the
patients file, anthropometric assessment which was done to all new patients and to all patients
in the ward at least once every week. Clinical assessment was day-to-day activity used in
judgment of the patients progress nutritionally.
Compilation of reports and reporting was done daily and weekly. The final report handed to
handed to nutritionist in-charge who later handed them to the departmental head.
Ward rounds, these rounds were twice in a week that’s Monday and Thursday. During ward
rounds, the patients were identified and quick assessment done to come up with the patients
final report. In ward rounds I learnt more on team work. All staffs were present that’s
nutrition officer, nurses, doctors, medical interns, clinical officers, social worker, adherence
counselor, physiotherapist, nutrition intern and nutrition attaches. The rounds were a good
learning time as staffs from different professions presented their cases.

6. ARTHOPAEDIC WARD
This is a general ward for both male and female patients bone and fracture problems.
In the orthopaedic ward patients with all types of injury were admitted. The injuries included,
head injury, hands injury, legs injury, general body injury.
Nutrition was a very core in the management and treatment of various types of injuries. High
protein high calorie was part of diet prescription because of the tissue repair.

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Activities engaged in were nutrition assessment, nutrition interventions, nutrition diagnosis,
writing reports and reporting, documentation in the files, diet prescription and requisition,
ordering and distribution of the supplements, writing of feeding regime, supervision of
nutrition attaches and nutrition review.
During counseling process almost 90% of the patients were counseled on foods rich in
calcium, phosphorus, protein and calories. These foods consisted of high biological value
proteins, carbohydrates and fats.
The remaining 10% had more than one complication so other diet prescriptions were included
appropriately.
Patients who were not able to feed individually were assisted by both nutrition intern and the
primary nurse in the ward.

7. DIET KITCHEN

This is part of production unit in Kenyatta National Hospital that is used to prepare special
diets for the patients with special conditions. These conditions include diabetes, renal,
respiratory diseases, sexually Transmitted diseases, those on enteral nutrition support, Toto
diet and special feeds.
Special feeds prepared in the diet kitchen included special milk that F100 and F75, special
soup, renal diet and Toto diet.
Nutrition intern had the following duties in the diet kitchen; preparation of special milk,
special soups, special uji renal diet, Toto diet, receiving diet requisition orders from the
kitchen, preparing diet master guide , serving the special diets, receiving special requests
from the wards, follow-up of the special requests.

Preparation of special milk (F100 and F75)

F100 Preparation for 100 litres

Ingredients
Milk-100litres
Sugar-5kgs
Corn oil-3.2litres

Procedure
Boil 100 litres of milk in a clean sufuria.
Put 3 litres of boiled milk sufuria used for mixing.
Add 5 kgs of sugar into the milk.
Add 3.2 litres of corn oil.
Blend the mixture for 15 minutes.
Put the mixture in 97 litres of milk remaining in the sufuria.
Stir to mix.
Then serve special milk to the wards.
The special was served in the evening and morning.

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F75 preparing 1 litre

Ingredients
Warm water-700 mls
Boiled milk-300mls
Sugar-50gms
Corn oil-20mls.

Procedure
Pour 700mls warm water in bowl or clean container.
Add 300mls of boiled milk.
Add 50gms of sugar.
Add 20 mls of corn oil.
Put the mixture in a blender to mix thoroughly.
Serve anytime there is need in the wards.

Recipe for preparing special soup

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Recipe for preparing special uji

8. GENERAL SURGICAL WARDS

This is also known as level 5.Theseare wards which were established in KNH to serve for the
general surgery.
Intern was tasked with the following duties; nutrition assessment, diet prescription, diet
requisition, nutrition counseling, nutrition intervention, feeding regime writing, distribution
of the supplements, nutrition review, charging for the services provided, attending ward
rounds, nutrition diagnosis and documentation.
Nutrition counseling tackled the following areas, nutrition during preoperative and post
operative surgery.
Diet prescription was done according to nutrition guidelines during surgery.
Compilation of reports and reporting was done as per the previous wards.
Assessment, documentation, review, supplementation, ward rounds, nutrition interventions
were also done as previous ones.

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 9. SPECIAL SURGICAL WARDS
Also known as level 4.
Special surgical wards are wards where special surgeries takes place. The special surgeries
consisted of the following wards, cardiothoracic surgery, plastic surgery, special surgery and
neurosurgery.
In cardiothoracic surgery ward, cardiac and thoracic are the main problems. Special surgery
ward, deals with special conditions such as birth deformities that is conjoined twins.
Neurosurgery ward deals with brain and spinal problems while plastic surgery ward deals
with burnt patients and those with skin problems.
Nutrition intern play a major role n nutrition assessment, nutrition diagnosis, nutrition
interventions, feeding regime writing, supplementation, report writing and reporting,
charging for the services, nutrition review and diet prescription.
Diet prescribed was as per the patient’s conditions. Cardiac surgical patients were prescribed
for clear liquid diet low in fat for 1-2 days, mechanically soft diet for 3 days and regular diet
onwards. Thoracic surgical patients, brain and spinal and plastic surgical patients were
prescribed for the same diet for the specified period of time.
Nutrition counseling was done to caretakers, counseling points included diet prescription,
hygiene and physical activities.

10. PAEDIATRIC WARDS

Also known as level 3 in Kenyatta National hospital.
These are wards that deal with infant and children. Pediatrics wards involve all medical
conditions affecting infant and children. These conditions are acute and chronic diarrheas,
constipation, vomiting, lower and upper gastrointestinal bleeding, obesity, ascites, neonatal
cholestasis, neonatal sepsis, gastroenteritis, kwashiorkor, marasmus and marasmickwash.
The following were the responsibilies of intern in the wards; nutrition supplementation,
nutrition assessment, nutrition interventions, feeding regime writing, writing reports and
reporting, monitoring and evaluation.
Nutrition assessments that are clinical assessments were done daily and anthropometric
assessments were done three times in a week. Measurements included MUAC, weight and
height. Biochemical assessments were rarely used as method of assessment.
Nutrition supplementation was an important responsibility in the ward as almost all children
required supplements. Infants who were also not able to breastfed were supplemented with
infant formulae. The formulae given were threptin for energy giving, lactose free, paediasure,
high protein energy, high energy, infacare, fibrin, laptomama, laptomil formula 1 and
laptomil formula plus 2.
Nutrition counseling provided to the caretaker of the child or infant. They were counseled on
appropriate nutrition practices that’s exclusive breastfeeding for 6 months, complementary
feeding practices and balanced nutrition.

11. ONCOLOGY WARDS

Also known as GFD and 1E in Kenyatta National Hospital.
These are ward dealing with cancer patients.GFD deals with both male and female adults
patients while 1E deals with pediatrics cancer patients.
As an intern, I was responsible for the following duties, nutrition assessments, nutrition
diagnosis, nutrition interventions, diet prescription, diet ordering, feeding regime writing,
monitoring and evaluation, documentation.

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Nutrition interventions included nutrition counseling, nutrition planning, nutrition reviews
and regime writing.

12. DIETARY ADVISORY CLINIC

Dietary Advisory Clinic is a clinic for giving nutrition counseling to out-patients in KNH.
It deals with all nutrition related conditions most diabetes, renal and eating disorders.
Intern was tasked with the following nutrition counseling, monitoring and evaluation and
follow up.

13. BURNS UNIT

This is a special unit established in KNH to take care of the burnt patients. It handled all
patients that’s infant, children, and adults.
The work of intern was to do; nutrition assessments, nutrition counseling, compiling reports
and reporting, documentation, feeding regime writing, nutrition supplementation, nutrition
diagnosis, monitoring and evaluation, follow up and charging for the services provided.

14. CRITICAL CARE UNIT (CCU)

Also called intensive care unit (ICU).

Critical care unit is a special unit established for patients who are in critical conditions.
In ICU an intern worked under the supervision of nutrition officer in-charge. Under the
supervision of qualified nutritionist, an intern was able to carry out the following duties;
nutrition assessments, nutrition diagnosis, feeding regime writing, parenteral and Enteral
nutrition support, documentation, monitoring and evaluation and nutrition reviews.

15. OPTHALMOLOGY WARD

Also know as level 9D.

Ophthalmology is ward that deals with eye problems.
In this ward, I learnt more about eye problems and their nutrition management.
An intern was tasked with the following duties, nutrition assessments, nutrition diagnosis,
nutrition interventions, diet prescription, monitoring and evaluation, report writing and
reporting, follow up, diet ordering and documentation.

16. NEWBORN UNIT (NBU)

NBU is a ward in Kenyatta National Hospital which was designed to infants with
complications immediately after birth. The complications includes premature birth, mothers
with breastfeeding problems, infants are not able to breastfeed, infants with medical
complications and infants with low birth weight.
During attachment in the newborn unit, I carried out the following tasks; taught mothers on
the important of exclusive breastfeeding, taught mothers how to express and store breastmilk,
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wrote parenteral, Enteral and oral nutrition feeding regimes, supplemented infants who were
on infant formula and mothers on supplements, nutrition assessment, nutrition review and
documented in the patients’ files.

17. PAEDIATRICS INTENSIVE CARE UNIT(PICU)

PICU is a critical care unit for children. This section in the hospital handles children with
emergency problems. Emergency problems involved accidents, children with medical
conditions that need critical care.
In PICU, the following nutrition care were given ; composed feeding regime that’s parenteral,
Enteral, partial and oral, nutrition counseling to the care givers, nutrition assessment that’s
taking weights, heights/lengths, taking mid upper arm circumference(MUAC), comparing
weights and heights/lengths with age or body mass index(BMI), prescribed diets for children
and their care givers, supplemented patients. Mother who were still breastfeeding were
counseled on exclusive breastfeeding for 180 days, mother who were HIV positive were also
counseled on exclusive breastfeeding with no mixed feeding for up to 6 months, those who
were about to start on complementary feeding were advised on better food options to give
their children at stages of life. Nutrition was done daily and nutrition care given as per the
outcome of the review.

18. NEUROLOGICAL INTENSIVE CARE UNIT(NICU)

NICU is an intensive care unit designed to take care of the patents with neurological
disorders. These disorders included brain and spinal injury, psychiatric patients.
Nutrition plays a key role in the treatment and management of these medical problems. The
diet prescribed included high protein high calories diets and those that matched the personal
requirement of the patients.
All patients were supplement with protein and energy rich supplements that’s Fresubin
protein energy drinks, provide extra, Ensure and paediasure for children. They were also
supplemented with therapeutic foods such as special milk, fermented porridge, special
porridge and mala/fresh milk.
Nutrition assessment that’s anthropometric, biochemical, clinical and physiological were
done daily to the new and old patients.
Artificial nutrition that’s parenteral and enteral nutrition support were part of the daily and
weekly activities as part of the internship requirement. This involved writing regimes, and
diet prescription.

ACHIEVEMENTS

The following are the internship achievements;

I. Become more experienced on practical application of nutrition care process.
II. Nutrition counseling and education.
III. Learnt and knew more about all medical conditions.
IV. Gained experienced on medical nutrition therapy.
V. Acquired practical knowledge and skills on leadership and management.
VI. Acquired practical skills on teamwork.

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VII. My social networking skills improved.
VIII. Become experienced on parenteral, Enteral and partial nutrition support.
IX. Learnt on Writing reports and reporting techniques.
X. Monitoring and evaluation.
XI. Experience on financial general and management.

CHALLENGES

As an intern, I had several challenges. These challenges included the following;

I. Financial constrains; working with no pay I could not manage to cater for the basic
needs.
II. Many patients in the wards; each in KNH more than 60 patients in one ward.
III. Duration of internship too long; doing internship for one was too long with no pay.

CONCLUSION

Internship is a very important component of nutrition training as it equips interns with

practical knowledge and skills on the management of medical conditions through nutrition
care process and medical nutrition therapy. During internship, interns also gained experience
on financial, social and leadership management skills. As an intern, I was able to be
knowledgeable and skilled in the following areas, reproductive nutrition, oncology nutrition,
medical nutrition, ophthalmology nutrition, orthopaedic nutrition, surgical nutrition,
pediatrics nutrition, psychiatric nutrition, intensive care nutrition and outpatient nutrition.

RECOMMENDATIONS
I. Internship period to be reduced to a minimum of 6 months.
II. Interns to be given amount of money for sustainance by the Government of Kenya.
III. More time to be allocated to specialized wards and medical wards.
IV. An institution to come up with standard nutrition guidelines to all wards.

REFERANCES
Kenya national clinical nutrition and dietetics reference manual, first edn, 2010.
Manual of clinical nutrition management, 2013.
Patient’s files and charts.

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APPENDICES

APPENDIX 1; INSERTING FEED TO A PATIENT WITH NASOGASTRIC TUBE

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APPENDIX 2: EXAMPLES OF ENTERAL FEED IN KNH (SURVIMED
PREDIGESTED).

APPENDIX 3:ENTERAL FEED-TRESUBIN ORIGINAL FIBRE

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APPENDIX 4: ENTERAL NUTRITION FEED-FRESUBIN ORIGINAL

APPENDIX 5:READY-TO-USE THERAPEUTIC FOOD

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APPENDIX 6:INFANT FORMULA

APPENDIX 7 :FOOD PYRAMID IN KNH

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APPENDIX 8: PAEDIASURE CHILDREN ENERGY SUPPLEMENT

APPENDIX 9: SAMPLE REGIME

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APPENDIX 10: ENTERAL FEEDING REGIME

APPENDIX 11: INTERSHIP TIMETABLE

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