CHAPTER ONE

1.1 INTRODUCTION

The Dietetics internship program is a year program designed for graduates of Nutrition and Dietetics.

The program is set to expose graduates of Nutrition and Dietetics to the practical aspect of the

profession and so as to be able to put all the theoretical aspect of the knowledge acquired in various

institutions into practical application. The program is coordinated by the Dietetics department of

Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife and all the interns are being taken

through all the postings in the hospitals in which presentations are conducted at the end of each posting

using a patient as a case study.

1.2 Brief Historical Background of the Obafemi Awolowo University Teaching Hospital Complex

Obafemi Awolowo University Teaching Hospital Complex is one of the generation of Teaching

Hospitals established by the Federal Government to provide qualitative health care delivery to its people.

1976, the defunct Western State Government of Nigeria resolved to establish a medical school in its

state University at Ile-Ife (which was then five (5) years old to provide manpower to tackle the health

problem of the state, after a period of careful planning faculty of Health Sciences was created in the

then University of Ife ( now OAU) ON 8th of May ,1972.The initial corporate name of the institution

was Ife University Teaching Hospitals Complex was changed to Obafemi Awolowo University

Teaching Hospitals Complex in 1987.In honor of the late distinguished ,elderly statesman Chief

Obafemi Awolowo, who died that year.

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1.3 Metamorphosis

While the Teaching Hospitals Complex ,as a dynamic institution ,had undergone various changes in

its government ,administration ,management ,physical resources and services load during its 25

years of existence ,its founding philosophy to concept of provision of comprehensive health care

based on integrated ,primary ,secondary and tertiary health care delivery has remained

constant ,Currently, it provides these services through six health care units as given below:

Ife Hospital Unit, Ile – Ife. 342 Bed Complement

Wesley Guild Hospital, Ilesha. 212 Bed Complement

The Dental Hospital, OAU, Ile-Ife. 36 Dental Chairs

Urban Comprehensive Health Centre Eleyele, Ile-Ife. 12 Bed Complement

Rural Comprehensive health Centre, Imesi –Ile. 4 Bed Complement

Multipurpose Maternal and Child Health Centre, Ilesha. 3 Bed Complement

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1.4 Catchment Area

By virtue of its location and the scarcity of health care facilities in neighboring area of the Obafemi

Awolowo University Teaching Hospitals Complex is extremely large ,including the whole of Osun

Ekiti and Ondo State and some parts of Oyo,Kwara ,Kogi ,Lagos and Edo State while the primary base

is the Ife/Ijesha Senatorial District ,the institution provides tertiary, secondary and primary health

care services to the area mentioned above.

1.5 Brief Description of the Department

Dietetics department is under the clinical service unit of Obafemi Awolowo University Teaching

Hospital Complex. The department started in 1981 under Dr (Mrs) I.F Smith, a consultant

Nutritionist/Dietitian of the department of community Health and Nutrition, Obafemi Awolowo

University Teaching Hospital complex, Ile Ife. The department started with a dietitian, two dietetic

assistants and two cooks, who are trained to prepare various therapeutic diets.

The Dietetic unit at Wesley Guild Hospital started to function in 1990 with the designation of diet cooks

to prepare therapeutic diet under the supervision of a dietitian. The department as at today has 7

dietitians and 23 cooks. Dietetics internship is a professional training designed for graduates of Dietetics.

It involves service experience between registered professions in dietetic fields and dietetic graduates in

which it exposes us to the practical aspect of the profession and also to put all the theoretical

aspect of the knowledge acquired during studies into practical application. The program is

coordinated by the Dietetics department in the teaching hospital and all dietetics interns are being taken

through different postings in which Presentations are conducted at the end of each posting using one

patient as a Case Study.

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1.6 Duties of the Dietitians in OAUTH

The service rendered by the dietitians in the department include:

1. Draw up monthly menu plan for in-patients (both normal and therapeutic).

2. Planning and implementing nutritional care for all in-patients

3. Providing nutritional counselling to patients and significant others.

4. Attending medical team meeting on the new development and research studies with physicians

on the effect of different diets on the prognosis of certain disease states.

5. Attend food procurement meeting.

6. Supervise of food items purchased and meals prepared in the kitchen.

7. Attend to referral written for in-patients.

8. Attend outpatient clinic to follow patients up and.

9. Also go on ward rounds with the Medical Consultants.

10. Dietary modification based on different disease condition.

11. Planning and implementation of nutrition care process for all in- patients.

12. Menu planning for different energy requirements.

13. Comprehensive Nutrition Education/Nutrition Rehabilitation.

14. Designing menus as indicated by the patients’ health status.

15. Participating in research studies with physicians on the effect of different diets on the prognosis

of certain disease state, for instance, Diabetes mellitus, HIV and other current health research

studies.

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1.7 Staff Profile of the Dietetics Department

The following is the staff profile of the dietetics department of the Obafemi Awolowo University

Teaching Hospital.

 Deputy director and Head of Department

 Chief dietitian

 Assistant chief dietitian

 Principal dietitian

 Senior dietitian

 Dietitian

 Dietitian assistant

 Interns

 Dietetic aides

1.8 Schedule of the Training Program

The internship training program was sectioned into:

1. Food service system/GIT Lab

2. Medical posting

3. Surgical posting

4. Peadiatric posting

5. Obstetrics and Gynecology posting

6. Clinic/IHVN (outpatient)

7. Community Health posting (Nutrition Rehabilitation Centre)

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 Kitchen Experience

The goal of this section was to learn how to make both therapeutic and normal diet, and to have a basic

understanding of therapeutic diet and disease conditions. Other knowledge also acquired from this

section includes:

 Food portioning and presentation.

 Writing of menu sheet and drawing up a menu plan.

 Modification of menu to suit each disease condition.

 Procurement process of all food items.

 Storage techniques of different type food groups.

The food service system unit popularly referred to as the gastrointestinal laboratory (GIT LAB) is where

various types of therapeutic diets prescribed for patients on admission are being prepared and served by

the cooks under the supervision of dietitians.

1.9 Diet Requisition Sheet

Diet requisition sheets are sheets brought from wards, written by nurses on duty, showing the total

number of patients to cater for and the particular type of diets each individual is being placed on. It also

indicates bed number of the patients.

1.10 Meal Ticket

This is the label use to identify the type of meal that will be given to the patient based on their disease

condition.

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1.11 Therapeutic Diets

These are diets modified for the management and treatment of diseased conditions. It is the alteration

and modification of normal diet to provide changes in dietary intake, increase in energy value, greater

and lesser amount of one or more nutrient.

The common rationale behind therapeutic diet includes any of the following;

1. To maintain, restore/ rehabilitate nutritional status of people.

2. To reduce calorie for weight control in overweight/ obese people.

3. Also to provide exact calories for optimal weight gain.

4. To balance amounts of carbohydrates, fat and protein for control of diabetes.

5. To reduce the amount of nutrient in food such as fat, sodium etc.

6. To increases amount of a nutrient such as protein, carbohydrate according to patient’s

requirement.

7. To provide texture modifications due to problems with chewing and/or swallowing.

8. To exclude foods due to allergies or food intolerance.

1.12 Practical Rules for Good Sanitation in The Kitchen

1. Tie hair neatly before starting food preparation use white hair tie or cap if necessary wash hands

thoroughly with soap and water before starting preparation.

2. Wash fruits, vegetables, cereals, and beans thoroughly before preparation with portable water

and milk in a clean container as soon as possible after receipt and keep covered.

3. Use portable water in food preparation.

4. Boil water for drinking or for preparation of cold beverages, if the purring of water is not

guaranteed.

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 5. Utensils and equipment used for preparation should be scrupulously cleaned.

6. Cooked food should be stored covered, preferably in the container in which it is cooked.

7. Left over foods such as rice, vegetables should be stored in a refrigerator reheating before

use is advisable.

8. Finger nails should be kept neat and well-trimmed

THE POSTINGS ARE AS FOLLOWS:

a) Food service system/ Dietetics Kitchen

b) Surgical Posting

c) Medical Posting

d) Pediatrics Posting

e) Obstetrics and Gynecology

f) Clinic Posting (out –patient and IHVN)

g) Community Health Posting (Nutrition Rehabilitation Centre)

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 CHAPTER TWO

2.1 FOOD SERVICE SYSTEM POSTING/ DIETETICS KITCHEN

The dietetics kitchen is the place where therapeutic diets prescribed for patients on admission are being

prepared, cooked and served. This posting I had the opportunity of learning about the various

therapeutic diets available in the hospital, the modifications made to the diets available in the hospital,

the modifications made to the diets as well as the clinical conditions for which each is prescribed. I also

had the opportunity of taking part in the preparation and serving of the meals under supervision of

Registered Dieticians. I related with the cooks who prepare the meals to learn about the ingredients used

in preparation of meals as well as the cooking methods. I also learnt about storage methods, inventory

taking, menu planning. Etc.

2.2 DIET REQUISITION LIST

This is a sheet containing the list of the different therapeutic diets prepared in the kitchen and it is used

to make requisition for diets by different wards.

2.3. DIFFERENT THERAPEUTIC DIET

The different types of therapeutic diets include;

 CLEAR FLUID:

It is planned to require minimum digestion, to maintain the body fluid and electrolyte balance along with

the situation of gastrointestinal functions and to help maintain water balance. It reduces colonic residual

to minimal; the liquid is prepared on fire. The component is plain pap.

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  FULL FLUID

This is a progression diet between clear fluid and soft diet. It supplies more nutrient then clear fluid it

components include 6 heaped desserts spoon of milk, 3 spoons of sugar added to moderately thick pap

and is served to 10 patients. Each patient is given 500mls.

 HIGH PROTEIN FLUID

This is similar to full fluid in its components only that it is higher in protein by the addition of 3 eggs to

the component of full fluid and it is also for 10patients. 500mls each.

 SOFT DIETS

This is a texture –modified diet. It is used as a transition diet between liquid and regular diets. It is low

in cellulose and residue. It is often prescribed for patient with dysphagia, poor dentition and post-

operative patients. Such foods as prepared in the kitchen include Kamala, Porridge, Moi Moi, etc.

 BLENDERIZED DIETS

Patients with functioning GIT but who cannot be adequately nourished through oral intake are fed

through nasogastric tube and their diets, according to prescription are blended and served to the patients.

 LOW RESIDUE DIET

This is usually soft in texture and is used when a reduction in stool frequency and volume is required. It

is indicated in diarrhea, colitis, and diverticulitis. E.t.c

 LOW CALORIE DIET

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This is a weight reducing diets reducing diet. It is adequate in other nutrients but reduced in energy

value. Vegetables and fruits are given to increase the bulk of the diet.

 HIGH CALORIE DIET

This is an energy-dense diet used to manage weight loss, under nutrition or convalescence.

 LOW PROTEIN/LOW SALT DIET

This is a diet used to manage renal impairment. The protein and salt intake is reduced below the normal

intake (0.3-0.6g protein per kg body weight).

 DIABETIC DIET

This is given Diabetic patients to ensure a controlled blood glucose level and ideal body weight. The

patients’ caloric intakes are individualized. An average of 1600kcal is given to females and 1700kcal for

males. Their meals are served with vegetables.

 HIGH PROTEIN DIET

This diet indicated in cases where the normal protein requirement is insufficient to meet the need at hand.

The protein intake is therefore increased above normal. E.g. Burns, protein energy malnutrition, post-

surgical cases etc.

 LOW FAT DIET

This is a fat restricted diet (25g per day) given to patients with liver, pancreatic or gall bladder diseases.

It is also indicated in the management of obesity and malabsorption syndrome.

 FAT FREE DIET

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No fat is added to this diet and it is indicated in severe cases like steatorrhea (fatty stool) and

hepatomegaly.

 KETOGENIC DIET

This therapeutic diet comprising a high fat is prescribed to epileptic patient for alleviation of convulsion.

This is achieved by making the body use fat as the major source of fuel and the use of fat as energy

source produces ketone bodies.

 LOW SALT DIET

A low salt diet restricts a patient’s salt intake to half levelled teaspoon of salt per day. It is indicated to

regulate hypertension and promote loss of excess fluids as in edema and ascites.

 SALT FREE DIET

No salt is added to this diet and no salt is added at the table.it is often prescribed in the management of

stage II hypertension.

2.4 MEASUREMENTS FOR MEAL PLANNING

1 bowl of beans to 8 patients

1 bowl of garri to 10patients

1 bowl of yam flour to 8 patients

1 bowl of rice to 10 patients

1 pack of meat which is 20 pieces to 20 patients

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 400g of yam to 1 adult

200g of yam to 1 child

0.8g of fish/kg body weight to a normal patient

1 crate of egg to 30 patients

1 egg to 3 patients (High protein fluid diet)

2.5 MENU TIMETABLE

Day Breakfast Lunch Dinner

Monday Pap + Moi - Moi Amala+ ewedu+Fish Rice+Fish+stew

Tuesday Bread + Fish stew Beans/Rice+ stew + fish Semo+Egusi soup+fish

Wednesday Pap+ Akara/Moi Moi Eba/Amala+ Rice+stew+fish

Ewedu/Okro+meat

Thursday Yam/Yam Pottage + fish Beans/Rice+ Stew+ fish Semo+Egusi soup+fish

stew

Friday Pap + Moi - Moi Amala +o k r o +f is h Yam pottage +fish stew

Saturday Pap+ Akara/Moi Moi Eba/Amala+ ewedu+fish Rice+Beans+stew+fish

Sunday Bread + Fried Eg g Jollof rice + chicken Amala + ewedu + fish

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____________________

DTN T.F kushigbagbe

Intern coordinator

CHAPTER THREE

3.1 SURGICAL POSTING

The surgical posting comprises of the male surgical ward 1 and 2, Female Surgical Ward 1and 2, Sub-

Specialty Surgical Ward (Male and Female), Intensive Care Unit, ENT (Ear, Nose and Throat),

OPTHAL (Ophthalmology), Male and Female Orthopedic Ward. These Wards specializes in the

treatment of both operative and post-operative patient e.g. Patients with cases like prostate cancer, breast

lymphoma, ovarian carcinoma, goiter and other surgical cases.

During this posting, I was able to monitor and follow up the dietary management of patients with

different types of pre and post- surgical illness. One of the cases managed is presented below;

3.2 DIAGNOSIS:

Diabetes mellitus with right diabetic foot ulcer and pyomyositis

Ward: female sub-specialty ward

Sex: Female

Date of admission: 15/03/2019

Date of discharge: 30/03/2019

Origin: Ile –Ife in Ife Central L.G.A of Osun state

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Religion: Islam

Occupation: Trader

Age: 52 years

Residence: Abayagani, Ile-Ife

Dietitian: Dtn Ogunniyi and Dtn Oladipo

3.3 WHAT IS DIABETES MELLITUS?

The term diabetes mellitus is one of the most common endocrine disorder s that is characterised by

blood glucose increase and caused by deficient secretion or function of insulin or both. High blood

glucose in diabetic patients is accompanied by the disorders and dysfunctions of different organs,

especially eyes, feet, kidneys, nerves, and blood vessels in the long term.

The abnormalities of carbohydrate, fat and protein metabolism are due to deficient action of insulin on

target tissues resulting from insensitivity or lack of insulin.

3.3.1 BLOOD GLUCOSE LEVELS IN DIAGONIZING DIABETES

TEST NORMAL PRE-DM DM

Random <11.1mmol/l - >11.1mmol/l

Fasting 2.8-5.0 mmol/l 5.1-6.9 mmol/l >7.0 mmol/l

2 hour post-prandial <7.8 mmol/l 7.8-11 mmol/l >11.1 mmol/l

3.3.2 COMPLICATIONS of DM

 Retinopathy

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  Nephropathy

 Neuropathy

 Ketoacidosis

 Coronary artery disease

 Peripheral vascular disease

 Cerebrovascular disease

3.3.3 SYMPTOMS OF DIABETES MELLITUS

• Polyphagia

• Polydipsia

• Polyuria

• Significant weight loss

• Hyperglyceamia

3.4 WHAT IS A DIABETIC FOOT ULCER?

Foot ulcer can occur in anyone, and refer to a patch of broken down skin usually on the lower leg or feet.

When the blood sugar levels are high or fluctuate regularly skin that would normally heal may not

properly repair itself because of nerve damage. People with diabetes may have reduced nerve

functioning due to peripheral diabetic neuropathy.

3.5 PATHOPYSIOLOGY OF TYPE 2 DIABETES MELLITUS

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T2DM is characterized by a combination of peripheral insulin resistance and inadequate insulin

secretion by pancreatic beta cells. Insulin resistance which has been attributed to elevated levels of free

fatty acids and proinflammaory cytokines in plasma, leads to decreased glucose transport into muscle

cells, elevated hepatic glucose production and increased breakdown of fat. T2DM is an islet

paracrinopathy in which the reciprocal relationship between the glucagon- secreting alpha cells and

insulin-beta cells is lost leading to hyperglucagonemia and hence the consequent hyperglycemia.

Therefore, T2DM only occur when there is insulin resistance and the body cannot produce enough

insulin to compensate for the resistance. i.e.

Increased carbohydrate intake

Increased hepatic blood glucose production

Increased blood glucose

Decreased insulin secretion

Decreased peripheral glucose uptake

3.6 MEANING OF PYOMYOSITIS

It is a bacterial infection of the skeletal muscle, considered to only occur in damaged muscle or in

immunosuppressed patients, as in patients with prior trauma, diabetes mellitus, chronic steroid use,

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connective tissues disorders, malignancy and malnutrition as well as concurrent infection with human

immunodeficiency virus (HIV) or varicella that can lead to abscess formation. It is usually caused by

staphylococcus aureus.

Early in its course, the differential diagnosis includes musculoskeletal aches, osteomyelitis, septic

arthritis, muscle hematoma, muscle rupture, thrombophlebitis, or deep venous thrombosis.

3.6.1 CAUSES OF PYOMYOSITIS

 The primary bacterium responsible for pyomyositis has been identified to be staphylococcus

aureus which constitutes to about 95% of cases of pyomyositis

 Group A streptococcus also is responsible for development of pyomyositis in around 10% cases

3.6.2 RISK FACTORS FOR PYOMYOSITIS

 Strenuous activity

 Muscle trauma

 Skin infections

 Infected insect bites

 Illicit drug injections

 Connective tissue disorder

 Diabetes

 Consumption of poor cooked meats

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  Tick bites

3.7 PATIENT’S FAMILY/SOCIAL HISTORY

She is a trader who resides in Ile-Ife, divorced, a Muslim from Yoruba ethnic group. There is no family

history of diabetes mellitus

3.8 MEDICAL HISTORY

Patient is a recently diagnosed T2DM. Patient has right diabetic foot ulcer with pyomyositis. The sore is

said to be discharging pus and foul smelling, there is no loss of sensation. There is positive sign of

polyphagia, polydipsia, polyuria and weight loss evidenced by loosening at previously well-fitting

clothes in spite of normal appetite.

3.9 VITAL SIGNS

Date FBS (Mmol/L)

15/3/19 13.6

16/3/19 12.8

18/3/19 7.5

19/3/19 10.2

20/3/19 11.8

21/3/19 8.6

22/3/19 8.2

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23/3/19 7.7

24/3/19 6.3

25/3/19 7.2

26/3/19 6.6

3.10 MEDICAL NUTRITION THERAPY

3.11 Nutrition Assessment

3.12 Anthropometry

Due to the fact that the patient cannot ambulate, her knee length was measured to get the height.

Using this formula;

Ht(cm) = {1.85× kl (cm)} – {0.2×age(yrs)} + 82.21

{1.85×52} – {0.21×50} + 82.21

93.6-10.5+82.21

83.1+82.21= 165.31cm~ 165cm

(using Broka’s index) IBW = 65kg

Required calorie = 1600kcal

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3.13 CLINICAL

A young woman met sitting on the bed, conscious, not febrile, not pale, not jaundiced, nil pedal edema

3.14 DIETARY

Patient eats from all food groups and does not have any food dislike or allergy however, she is a

moderate eater, she takes fruits and vegetables frequently although she takes the sweetened ones without

restriction. She also takes offals & and other fatty meat. She takes Bf 10am. she prefers oily stew,

ogbono, and egusi soup to other Vegetables. she takes lunch around 2-3pm, and takes dinner around 6-

7pm. She takes no alcohol and does not smoke.

3.15 Nutrition Diagnosis

Excessive/inappropriate carbohydrate intake RT food and nutrition knowledge deficit AEB suboptimal

glycaemic control over a period of time (FBS 13.6mmol/L) on admission.

3.16 Nutrition Intervention

GOALS

 To achieve an optimal glycaemic control

 To educate the patient on portion sizes of foods to achieve/maintain a close to normal blood

glucose level.

 To prevent further complications

INTERVENTION

 Patient was placed on 1600kcal DM/ High protein diet

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  Patient was counselled on types of food and fruit portion and the importance of daily intake of

fruits and vegetables

 Patient was advised to adhere to dietary counselling

 The likes and dislikes of the patient were noted and communicated to the nurse and dietetics

kitchen staffs.

 The importance of diet therapy adherence was reinforced to the patient

3.17 Monitoring and Evaluation

 Monitored patient’s meal from the diet kitchen to ensure that the meals were prepared and served

as appropriate

 I visited the ward regularly for adequate follow up of patient’s compliance to intervention,

tolerance and improvement.

3.18 Evaluation

 Improved Glycemic Control

 Patient’s fasting blood glucose reduced from 13.6mmol/l to 6.1mmol/l

 Patient complied with dietary modification

 Patient was discharged on the 30/03/2019

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________________________

DTN Oladipupo/O. T Ogunniyi

Surgery Coordinator

CHAPTER FOUR

4.1 MEDICAL POSTING

The following units are under the medical posting;

 ENDOCRINOLOGY UNIT- This is the unit that deals with all endocrine system

related conditions such as Diabetes, goitre etc.

 GASTROENTEROLOGY-This is the unit that deals with all medical conditions

along the gastrointestinal tract.

 NEUROLOGY UNIT- This is the unit that takes care of all conditions related to

the nerves and nervous system.

 CARDIOLOGY- This unit attends to diseases of the cardiovascular system.

 IMMUNOLOGY UNIT- This unit deals with medical conditions related to the
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immune system e.g HIV/AIDS

 RENAL/NEPHROLOGY UNIT- This is the unit that deals with all the diseases of

kidney such as renal failure and renal surgery.

4.2 The Wards Under This Posting Are:

 Male Medical Ward

 Female Medical Ward 1 and 2

 Renal Ward

 Mental Health

In these wards, patient seen are with cases such as Diabetes Mellitus, hypertension, liver disease,

Myocardial Infarction, HIV/AIDS, Renal disease etc.

During, my posting I was able to monitor patients with different types of diseases and give adequate diet

therapy under the supervision of Registered Dietitians in the unit. One of the disease condition managed

is presented below;

4.3 DIAGNOSIS:

Congestive cardiac failure 20 to decompensated cardiomyopathy

Ward: Male Medical Ward

Sex: Male

Date of admission: 10/5/2019

Date of discharge: 20/5/2019

Origin: Igbokoda, Ondo state

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Religion: Christianity

Occupation: Farmer

Age: 50 years

Residence: Ikare Akoko

Dietitian: Dtn Olulana and Dtn Kushigbagbe

4.4 What is Heart failure?

Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac

disorder that impairs the ability of the ventricle to fill with or eject blood.

4.5 What is congestive cardiac failure?

Congestive Cardiac Failure describes a condition where the heart muscle is weakened and cannot carry

out its normal function properly.

4.6 What is Decompensated cardiomyopathy?

Decompensated cardiomyopathy is any of several structural or functional diseases of heart muscle

marked especially by hypertrophy and obstructive damage to the heart.

4.7 What are the causes of DCM?

DCM can be inherited, but it is caused by other things;

 Ischemic heart disease

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  Hypertension

 Heart valve disease

 Viral infections of the heart

 Drugs that damage the heart

 It can also happen in women after they give birth. (postpartum cardiomyopathy)

4.8 HYPERTENSION

Hypertension refers to a chronic elevation in blood pressure. A measurement of blood pressure is

expressed using the reading for systolic pressure as the first (higher) number and the reading for

diastolic pressure as the second (lower) number. A reading greater than or equal to 140/90mmHg is

considered to be hypertensive. However, it is not necessary for both systolic and diastolic blood pressure

to be elevated for an individual to be considered hypertensive; thus, readings of 140/80 mmHg or 120/90

mmHg are both high—i.e., they represent elevations in either systolic BP or diastolic BP.

4.9 PATHOPHYSIOLOGY OF CONGESTIVE CARDIAC FAILURE

The progression of HF is similar to that of atherosclerosis because there is an asymptomatic phase when

damage is silently occurring. HF is initiated by damage or stress to the heart muscle either of acute MI

or insidious (hemodynamic pressure or volume overloading) onset. The progressive insult alters the

function and shape of the left ventricle such that it hypertrophies in an effort to sustain blood flow, a

process known as cardiac remodelling. Symptoms do not usually arise until months or years after

cardiac remodelling begins. There is compensatory enlargement in the form of cardiac hypertrophy,

cardiac dilatation or both.

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Tachycardia (i.e increased heart rate) due to activation of neurohumoral system e.g norephinophrine and

atrial natrouretic peptide, activation of renin angiotensin aldosterone mechanism. Another substance, B-

natriuretic peptide (BNP), is secreted by the ventricles in response to pressure and is predictive of the

severity of HF and mortality at any level of BMI (Horwich et al., 2006).

Eventually overuse of compensatory systems leads to further ventricle damage, remodelling, and

worsening of symptoms. Heart failure results in DEPRESSION of the ventricular function curve.

COMPENSATION in the form of stretching of myocardial fibers results. Stretching leads to cardiac

dilation which occurs when the left ventricle fails to eject its normal end diastolic volume.

Compensatory mechanism

 Sympathetic nervous system stimulation

 Renin - angiotensin system activation

 Cytokines system

 Myocardial hypertrophy

 Altered cardiac rhythm

 All these are activated to restore normal haemostatic function

Renin angiotensin system

Renin + angiotensinogen

Angiotensin 1

27
Angiotensin II

Peripheral Aldosterone secretion

Vasoconstriction Salt &water retention

After load Increased plasma Volume

Cardiac output Increased Preload

Increased cardiac workload

Heart failure

4.10 PATIENTS FAMILY/SOCIAL HISTORY

He is a Christian of Yoruba ethnicity and a farmer and married in a monogamous setting with four

children. There is family history of hypertension in both parents.

4.11 MEDICAL HISTORY

He is a known hypertensive patient diagnosed 5years ago. Also a known patient in cardiology unit being

managed for heart failure, presented with pedal edema, dyspnea and cough but has poor clinic and drug

compliance.

Date Blood pressure Pulse rate (bpm) Respiratory

(mmHg) rate(cpm)

14/05/2019 102/80 98 28

15/05/2019 110/90 96 26

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17/05/2019 100/70 100 24

18/05/2019 100/70 80 24

19/05/2019 100/80 98 40

20/05/2019 110/90 92 36

4.12 MEDICAL NUTRITION THERAPY

Nutrition Assessment

4.13 Anthropometry

Skin fold thickness = 6mm (underweight)

4.14 Biochemical

Fasting lipid profile, S/E/U/Cr and urinalysis were noted

4.15 FASTING LIPID PROFILE (MMOL/L)

INVESTIGATIONS READINGS REFERENCE RANGES

Total cholesterol 4.13mmol/L 3.6 – 6.2

HDL 1.0mmol/L 0.8 – 1.7

LDL 1.34mmol/L 1.9 – 3.6

Triglycerides 2.34mmol/L 0.5 – 1.0

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4.16 CLINICAL

Physical examination

A middle aged man, conscious, not in obvious respiratory distress, not dehydrated, bilateral pitting pedal

edema extending to the thigh.

4.17 DIET HISTORY

Patient eats from all food groups and does not have any food dislike however, he uses more bouillon

cube and little salt in cooking, he rarely takes fruit and vegetables. He stopped alcohol intake a year ago

but doesn’t smoke. He takes Bf 10am in the morning and its usually swallow. He prefers oily stew,

ogbono, and egusi soup to other Vegetables. He did not usually take lunch, and takes dinner around 6pm.

4.18 NUTRITION DIAGNOSIS

Excessive sodium intake RT inadequate nutritional knowledge AEB bilateral pitting pedal edema

4.19 NUTRITION INTERVENTION

Goals:

 To achieve a reduction in Weight

 To prevent further complications

 To discourage alcohol intake

 To preserve the pleasure of eating

Intervention

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  Comprehensive nutrition Education

 He was placed on low salt diet

 lifestyle modification

4.20 Monitoring and evaluation

 Patient’s diet was monitored from the dietetic kitchen to ensure that he gets the right diet at the

right time.

 Patient was visited regularly to review from time to time and to ensure compliance with the

therapeutic diet.

Evaluation

 Patient tolerated his meal very well

 Optimum blood pressure of 100/80 mmHg was achieved.

 Edema was resolved

 Patient was discharged on 20/5/2019

31
_________________________

(DTN T.F Kushigbagbe/Olulana)

Medicine coordinator

CHAPTER FIVE

5.1 OBSTETRICS AND GYNEACOLOGY POSTING

This posting unit is concerned with care of women during pregnancy, child birth and the disease of the

female reproductive organs respectively.

There are four wards under this unit, Antenatal, Labour, Postnatal and Gynaecology Wards. The role of

a Dietician is to provide adequate nutrition in all medical conditions relating to female reproductive

health. The experience I had in this unit afforded me the opportunity to know different medical

condition such as;

 Pre-eclampsia in Pregnancy is a condition that can develop during pregnancy characterized by

high blood pressure (hypertension) greater than 140/80mmHg and protein in the urine

(proteinuria).

 Eclampsia: If pre-eclampsia is not properly managed it leads to this condition.

32
 This is characterized by hypertension, proteinuria, edema and the development of seizure, and it

is life threatening to both the mother and baby.

 Placenta Previa: Implantation of the placenta in the lower part of the uterus.

 Gestational Diabetes Mellitus: Diabetes that develops during pregnancy. Only by observing what

happens at the end of the pregnancy can it be decided whether or not

the condition is persistent. Gestational diabetes is a routine screening process at the

antenatal appointment. It is important to diagnose the condition as uncontrolled blood

sugar have adverse effect on the fetus as well as mother.

 Nephrotic Syndrome: This is a kidney disorder that causes urinary protein loss (proteinuria)

exceeding 3.0-3.5grams per day.

 Anemia in Pregnancy: Several types of anemia can develop during pregnancy. These includes:

Iron deficiency anaemia, Folate deficiency anaemia, Vitamin B12 deficiency anaemia.

5.2 DIAGNOSIS:

Elevated blood glucose (gestational diabetes)

Ward: Antenatal Ward

Sex: Female

Date of admission: 21/03/2019

Date of discharge: 21/07/2019

Origin: Ifetedo in Ife East L.G.A of Osun state

Religion: christianity

Occupation: Trader

Age: 35 years

Residence:22, orilonise, Moore, Ile-Ife

33
Dietitian: Dtn Awofolaju

5.3 WHAT IS GESTATIONAL DIABETES

Gestational diabetes is referred to as abnormally elevated blood glucose that exist only during pregnancy.

Gestational diabetes is a condition in which a woman without diabetes develops high blood sugar levels

during pregnancy and it is most common at the last trimester. Babies born to mother with poorly treated

gestational diabetes are at increased risk of being too large, having low blood sugar after birth and

jaundice, it can also result to still birth. Long term children are at higher risk of being overweight and

developing type 2 diabetes.

5.4 WHAT ARE THE CAUSES OF GESTATIONAL DIABETES

The cause of gestational diabetes is insulin resistance and not enough insulin to compensate for it.

5.5 WHAT ARE THE RISK FACTORS OF GESTATIONAL DIABETES

 Overweight

 Previously having GDM

 Family history of T2DM (especially first degree relative.

 Having a polycystic ovarian syndrome

 Maternal age: woman over the age of 35years

 Previous poor obstetric history

5.6 WHAT ARE THE COMPLICATIONS OF GESTATIONAL DIABETES

 Excess birth weight

 Early (preterm) birth and respiratory distress syndrome (a condition that makes breathing

difficult)

 Hypoglycemia: sometimes babies of mothers with GDM develop low blood sugar shortly after

birth

34
  They have higher risk of developing Type 2 diabetes later in life

5.7 PATIENT’S FAMILY/SOCIAL HISTORY

Patient is the first child in the family of six (all are alive). She is married in a

polygamous setting with her first pregnancy.

5.8 MEDICAL HISTORY

She was diagnosed to have GDM in 2017. No history of blurring of vision, gestation sweating, chest

pain, orthopnea, dyspnea, no intermittent claudication. Not a known hypertensive and no known family

history of DM

5.9 VITAL SIGNS

Date Blood pressure Pulse rate (bpm) Respiratory

(mmHg) rate(cpm)

3/07/2019 130/60 92 20

5/07/2019 130/90 88 22

6/07/2019 130/80 86 20

10/07/2019 100/70 92 21

12/07/2019 100/60 90 23

17/07/2019 110/70 80 22

5.10 MEDICAL NUTRITION THERAPY

5.11 Nutrition Assessment

35
5.12 Anthropometry:

Height:161cm

Weight: 91kg

Pre Pregnancy Weight: 75kg

Ideal Pre Pregnancy Weight: (using broka’s index) = 61kg

BMI: 33.17kg/m2

Ideal Pregnancy Weight: 0.3 x 35 (gestational age) + 61

= 71.5kg

Weight gain per week= 0.3kg

Expected weight gain= 10.8kg

Pregnancy history

G10P2+7 (NA)+2PNM + 1PROM

EDD: 22/07/19

EGA: 35weeks and 6days

5.13 BIOCHEMICAL

DATE FBS 2 HPP RBS

21/3/2019 9.1

5/7/2019 4.9 7.3 4.9

6/7/2019 5.3 6.9 6.9

7/7/2019 5.4 5.4 3.8

10/7/2019 5.5 3.7 7.2

12/7/2019 5.0 4.8 5.1

13/7/2019 5.4 3.6 5.7

36
14/7/2019 5.6 8.4 7.1

16/7/2019 4.7 7.3 5.7

17/7/2019 5.2 7.3 6.0

5.14 CLINICAL

A young woman met sitting on the bed, conscious, not febrile, not pale, not jaundiced, nil pedal edema.

5.15 DIETARY

Patient eats from all food groups and does not have any food dislike or allergy however, she is a

moderate eater, she takes fruits and vegetables frequently although she takes the sweetened ones without

restriction. She also takes offals & and other fatty meat. She takes Bf 10am. she prefers oily stew,

ogbono, and egusi soup to other Vegetables. she takes lunch around 2-3pm, and takes dinner around 6-

7pm.

5.16 NUTRITION DIAGNOSIS

Nutrition related knowledge deficit RT consumption of calorie densed foods AEB pre-pregnancy

weight of 75kg and FBS of 9.1mmol/L

5.17 NUTRITION INTERVENTION

GOALS

 To achieve an optimal healthy Weight

 To achieve optimal glycaemic control

 To prevent further complications

 To preserve the pleasure of eating

INTERVENTION

 Comprehensive nutrition Education

37
  Advice on portion sizes of food, fruits and vegetables

 she was placed on DM diet (1800kcal)

 She was also advised to take a lot of rest

 Patient was advised to exercise moderately (brisk walking)

 Patient was advised to adhere strictly to the therapeutic diet served

5.18 MONITORING AND EVALUATION

 Daily monitoring of blood glucose

 Patient’s diet was monitored from the dietetic kitchen to ensure that she gets the right diet at the

right time.

 Patient was visited regularly to review from time to time and to ensure compliance with the

therapeutic diet.

5.19 EVALUATION

 Patient tolerated her meal very well

 Her blood glucose got reduced to 5.2mmol/L.

 She delivered a bouncing baby girl with birth weight of 3.1kg

 Patient was discharged on the 22/07/2019.

38
_________________________

DTN Awofolaju

O&G Coordinator

CHAPTER SIX

6.1 PAEDIATRICS POSTING

The pediatrics posting which includes children Ward 1and 2, Children Orthopedic Ward, Paediatrics

surgical ward and Children Emergency Ward. The department specializes in the diagnoses and treatment

of various disease conditions affecting the children. The role of a dietitian is to help attain and maintain

adequate nutritional status.

6.2 DIAGNOSIS:

Sickle cell nephropathy

Ward: children ward 1b

Sex: Male

Date of admission: 5/09/2019

39
Date of discharge: 20/09/2019

Origin: Ile –Ife in Ife Central L.G.A of Osun state

Religion: Christianity

Occupation: pupil

Age: 10 years

Residence: Moore, Ile-Ife

Dietitian: Dtn Akinnifesi

6.3 WHAT IS SICKLE CELL

Sickle cell disease is an inherited disorder of the hemoglobin in the blood, the abnormal hemoglobin

causes distorted (sickled) red blood cells. The sickled red blood cells are fragile and prone to rupture. It

requires the inheritance of two sickle cell genes.

6.4 WHAT IS SICKLE CELL NEPHROPATHY

The renal manifestations of sickle cell disease range from various tubular and glomerular functional

abnormalities to gross anatomic alterations of the kidneys. The hypoxic, acidotic and hyperosmolar

environment of the inner medulla are known to promote sickling of RBCs with resultant impairment in

renal medullary blood flow, ischemia, micro infarction and papillary necrosis. The underlying

mechanisms of SCN relate mainly to hypoxia and

ischemia.

6.5 WHAT ARE THE CAUSES OF NEPHROPATHY

Diabetes

Hypertension

Excessive protein intake

40
6.6 WHAT ARE THE RISK FACTORS OF NEPHROPATHY

 High blood pressure

 Hyper cholesterolemia

 Chronic kidney disease

 Acute kidney disease

 Nephrotic syndrome

6.7 PATHOPHYSIOLOGY OF SICKLE CELL NEPHROPATHY

The renal medulla contains the vasa recta (i.e the capillaries that are derived from the efferent arterioles

of the juxtamedullary glomeruli). These capillaries have a hairpin configuration similar to that of the

loops of Henle. The low oxygen tension or relatively hypoxic, hyper tonic and acidotic environment of

the inner medulla predisposes RBCs in the vasa recta to sickle, particularly in the settings of severe

intravascular volume depletion. The resulting increased blood viscosity contributes to ischemia and the

eventual infarction that involves the renal microcirculation. Medullary ischemia and infarction cause

papillary necrosis. Sloughed papillae may obstruct urinary tract outflow, leading to obstructive uropathy.

Nevertheless, the current data suggest that hematuria and papillary necrosis do not portend greater risk

for renal failure. The clinical manifestations are determined by the predominant site of tubular

involvement.

RBC sickling and congestion in the vasa recta leads to ischemia and associated impairment of solute

reabsorption by the ascending limb of the loop of Henle and impairs urinary concentrating ability. More

distal tubular dysfunction may impair renal acidification and potassium secretion leading to an

incomplete form of distal renal tubular acidosis and hyperkalemia.

6.8 PATIENT’S FAMILY/SOCIAL HISTORY

41
Patient is a 10year old girl of Yoruba ethnicity, she is a Christian and from a monogamous family, the

mother being the only wife and she is the last child of four children. The mother is a 32year old trader

and father, a 46year old engineer and they are both educated. Child is currently in primary 5 and of

average performance.

6.9 MEDICAL HISTORY

Patient was diagnosed of sickle cell anemia 5 years ago following complaint of bone pain. Child has not

been compliant with clinic attendance and medication as family is said to have relocated to Ilorin.

6.10 Vital signs

Date Temperature Blood pressure Pulse rate (bpm) Respiratory rate

(OC) (mmHg) (cpm)

05/9/2019 36.9 110/70 124 29

06/9/2019 36.9 110/70 122 27

07/9/2019 37 100/70 124 28

08/9/2019 38 110/80 126 27

09/9/2019 36.9 110/70 108 28

10/9/2019 37 90/50 110 30

11/9/2019 37 90/50 102 28

12/9/2019 37 90/60 105 27

13/9/2019 37.1 100/60 110 30

14/9/2019 37.3 110/80 108 28

15/9/2019 36 90/60 115 30

16/9/2019 37 100/60 110 28

17/9/2019 37 100/60 108 30

42
18/7/2018 36 90/60 110 26

19/7/2018 36.6 90/60 28

20/9/2019 36.8 90/60 28

6.11 MEDICAL NUTRITION THERAPY

6.12 Nutrition Assessment

6.13 Anthropometry

Height: 1.30m

Expected body weight:

Age :10years

Expected weight gain 7n -8/2

= 31kg

6.14 BIOCHEMICAL

Urine profile, urinalysis and S/E/U/Cr were noted

6.14.1 Urine profile

Date Intake Output Balance

05/9/2019 900 500 400

06/9/2019 400 700 300

07/9/2019 600 400 200

08/7/2019 300 700 400

09/9/2019 1000 700 400

10/9/2019 1250 1600 350

11/9/2019 1500 1300 200

43
12/9/2019 2900 1600 1300

13/9/2019 1000 700 300

14/9/2019 400 600 200

15/9/2019 1200 1300 100

16/9/2019 1800 2000 200

17/9/2019 2000 2550 550

18/9/2019 2800 3100 300

19/9/2019 2800 3500 700

20/7/2019 4800 3200 1600

6.14.2 Urinalysis

 Blood - 2+

 Urobilinogen – normal

 Bilirubin - negative

 Protein - 1+

 Nitrite – negative

 Ketone – negative

 Ascorbic acid – negative

 Glucose – normal

 pH – 8

6.14.3 S/E/U/Cr

 Creatinine - 78mmol/L

 Bicarbonate - 20mmol/L

44
  Potassium - <2.8mmol/L

 Sodium - 136mmol/L

 Urea - 4.6mmol/L

6.15 CLINICAL

Patient met on bed, conscious and communicating, generalized body Oedema present, not dehydrated,

not pale, anicteric, and afebrile.

6.16 DIETARY

Patient eats from all food groups. However, she likes tasty food and protein dense food and would not

eat without that and she dislike pap.

6.17 NUTRITION DIAGNOSIS

Renal dysfunction RT physiological function AEB altered laboratory value (proteinuria: 1+).

6.18 NUTRITION INTERVENTION

Goals

 To prevent further complications

 To resolve oedema

 To achieve optimum nutrition

 To preserve the pleasure of eating

 Comprehensive dietary counseling was given to the care giver

 He was placed on a low salt maintenance protein diet of 0.8g/kg body weight.

6.19 MONITORING AND EVALUATION

 Daily monitoring of blood pressure

 Daily monitoring of urine profile

 Monitored acceptance and tolerance of dietary regimen

45
  Monitored adherence to dietary regimen

6.20 EVALUATION

 Patient accepted, tolerated and adhered to dietary regimen.

 Electrolyte balance was achieved

 Patient was discharged on the 14/07/2018.

_______________________

DTN Akinnifesi

(Supervisor)

CHAPTER SEVEN

7.1 COMMUNITY HEALTH/NUTRITION REHABILITATION CENTER

This is situated at Eleyele Quarters in Ile-Ife it is a unit in the urban comprehensive health Centre of

OAUTHC where issues relating to nutrition rehabilitation, personal hygiene and community health is

addressed.

Categories of those referred to the nutrition clinic are:

 Malnourished children

 Anaemic women

 Motherless babies

46
When mothers bring their children for immunization, the weight of the child is taken and the

malnourished children are referred to the nutrition clinic. The clinic day is Tuesday but malnourished

children are referred on other days for counselling, the nutritionist attends to them. Mothers (care-giver)

are given health talks on how to prepare adequate diets for their children and how to ensure that their

children are well nourished.

Food demonstrations are conducted. This is a medium whereby mothers are shown how to prepare

nutrient dense diet for their children. The mothers do the preparation and cooking under the guidance of

the Nutritionist. They are taught how to combine various food groups to help their children achieve

optimal nutrition.

An evaluation is done after the meals have been served and fed to the children by the mother. The

mothers note the proper cooking method that ensure adequate tolerance by their children and also ensure

conversation of the nutrient present in the food. It is expected that each mother apply the new things

learnt and prepare the food demonstrated for her child to eat before the next clinic visit.

Pregnant women are found to be anemic (PCV <29%) are also referred to the nutrition clinic for

counselling and taught on how to prepare a meal that would help boost their PCV with demonstration.

Their own clinic is always on Thursdays. Motherless babies who have low weight for age are also

attended to; the care givers are counselled on adequate nutrition care for the child and are sometimes

referred to NGOs for further help.

47
 CHAPTER EIGHT

INSTITUTE OF HUMAN VIROLOGY IN NIGERIA (IHVN) CLINIC

8.1 AIMS OF NUTRITIONAL COUNSELING IN IHVN

1. To strengthen and boost the immune system of the patients through adequate nutrient Intake.

2. To reduce the severity of the infection in the patients.

3. To prevent any further wasting in patients.

4. To reduce the risk of opportunistic infections.

5. To understand the suitable diet at each stage (in pediatrics) of the patient’s life.

6. To encourage the patients to feed adequately.

8.2 GUIDELINES FOR COUNSELING PATIENTS IN IHVN

48
 1. Reviewing and counseling patients on adequate diet in terms of carbohydrate, protein, fat,

vitamins, minerals and water as well as fruits and vegetables.

2. Educating the patients on the importance of using the locally-available foods in their right

proportion.

3. Laying emphasis on the importance of rest after work.

4. Educating patients on good personal and environmental hygiene in order to avoid or reduce the

risk of opportunistic infections.

8.3 NUTRIENTS OF CONCERN IN THE MANAGEMENT OF HIV/AIDS

Protein

The need for protein cannot be overemphasized. Infected patient require protein for maintenance of lean

body mass, body cells and tissues. Adequate protein intake also contributes to the strengthening of the

body’s immunity through the production of antibodies.

Good protein sources are animal products and legumes.

Selenium

Selenium has been implicated in the protection of body tissues against oxidative stress, maintenance of

defenses against infection, and modulation of growth and development. The early preclinical stages of

development of human immunodeficiency virus (HIV) infection are accompanied by a very marked

decline in plasma selenium. Subclinical malnutrition assumes increased significance during the

development of acquired immune deficiency syndrome (AIDS).

Foods sources of Selenium include: meats, eggs and sea foods.

Zinc

Zinc is present in all body tissues and fluids and plays a central role in the immune system, affecting a

number of aspects of cellular and humoral (relating to body fluids) immunity.

49