MINISTRY OF EDUCATION

ACADEMIC YEAR: 2016-2017

LEVEL II FULL TIME
BACHELOR’S OF SCIENCE IN HONOR WITH NUR

FROM: 05thDecember to 30th December 2016

MEMBERS OF THE GROUP: KALISA Claude
KUBAHONIYESU Linea
MUTIMAWASE Marlene
UWINEZA Jeanine

SUPERVISORS: NSHUTIYUKURI Claudine

BAZAKARE M.Leatitia ISHIME

CORDINATOR: Sister UWAMARIYA Marie Grace

Done at RWAMAGANA 20th/jan/2017

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I.INTRODUCTION

As the nurses students of second year BScN in General Nursing full time at Rwamagana school
of nursing and midwifery we are interesting in making report of our clinical practice done at
GISHALI Health Center which help us to put into practice what we have learning theoretically in
the classroom and to improve our knowledge and skills.
Our clinical practice at GISHALI Health Center began on 05thDecember to 30th December 2016.

.1.1. Presentation of clinical practice placement

Health center of GISHALI
 Geographic location: GISHALI Health Center is located in Shaburondo Village,
Bwinsanga Cell, Gishali sector, Rwamagana District in Eastern province.

 Description of surroundings of the health center (limits, beneficiary population):

EAST: Gishali police training center

NORTH: Ruhunda health center
WEST: Kigali city
SOUTH:Rwamagana hospital & health center and AVEGA health center
It is limited to serve two sectors such as Gishali, Mwurire and one cell from Muhazi
sector(Nsinda). With total beneficial population of 15903 population

i. Various services and minimum package of activities

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. Nursing Consultation 10. Management of Integrated

2. Laboratory Children’s Disease (PCIME)
3. Pharmacy (distribution and store) 11. Data Management
4. VCT 12. Tuberculosis services
5. PMTCT 13. Vaccinations
6. Family Planning 14. Health insurance service
7. Maternity 15. Nutrition
8. Dressing and Injection 16. Community health services
9. Financial Management 17. maintenances service IT
18.ARVS-services

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 ii. Various minimum packages of activities
 Curative consultation
 Follow up the patient with HIV/AIDS
 Community health and hygiene
 Voluntary counseling test (VCT)
 family planning
 Vaccination
 Pharmacy
 Minor surgery
 Laboratory

CARE STAFF AND THEIR QUALIFICATIONS

No Name Qualification/level Function/ SERVICE

01 NSABIMANA Martin General Nursing A0 TITULARIAT
02 GASIRABO Midwifery General Duties
03 Muhinka Rene General Nursing A1 General Duties
04 Gilbert General Nursing A1 General Duties
MUKASINE
05 SERAPHINE BIOCHIMIE A2 Customer care
HABIMANA Jean Marie
06 Vianney IT A2 Data Manager
MUKAMUCYO
07 JEANNETTE Sociologue A1 Superviseur CHW
MUNGANYINKA
08 CHRISTINE Infirmier A2 PCIME,EYES &TB
09 BINTU JACKY Infirmier A2 PMTCT
MUREKATETE
10 ESPERANCE Infirmier A2 Pharmacie & ART
11 MUTESA Egide Infirmièr A2 Vaccination & Nutrition
12 HAKIZIMANA Elvis InfirmièrA2 PF & Distribution &Circoncision
13 NYIRAMANA Libelle Biochimie A2 Laboratory
14 BIGIRIMANA ERIC Lab A0 Laboratory
15 IMANISHIMWE Midwifery Maternity &CPN & PMTCT

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 Immaculée
16 SHINGIRO Jean Marie Accountant A2 Comptable
Vianney
17 NYIRANSHIMIYIMANA Infirmier A2 Consultation & Hospit & Psmt
PRISCILLE
18 UWIMANA Alice Biochimie A2 Caissiere
19 BANKUNDIYE Floride Human Science A2 Receptionist
20 Michel S4 Chauffeur Ambulance
21 Mark Reparateur Moto
22 Pascal Reparateur eau & Electricity

iii. Work organization

Monday: curative consultation; family Planning; maternity; minor surgery.VCT (Voluntary

Counseling Test),
Tuesday: curative consultation; family planning; Antenatal consultation of old case; maternity;
minor surgery, VCT, vaccination
Wednesday: curative consultation; maternity; minor surgery; Family planning; VCT
Thursday: CD4 count and viral load; family planning; curative consultation; maternity; minor
surgery, VCT
Friday: curative consultation; minor surgery, maternity and antenatal consultation; Family
planning, vaccination, VCT
Saturday: curative consultation and maternity and minor surgery.
Sunday: curative consultation; maternity and minor surgery

 Main cause of morbidity (5 causes):

i. respiratory tract diseases
ii. Malaria
iii. Gastro-intestinal disorders (gastritis, intestinal
parasites)
iv. Urinary tract infection
v. Skin infections
.

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II.DEVELOPMENT (BODY OF REPORT)

2. 1. Activities carried out or in which the student took part.

2.1.1. Basic Nursing Care of the Client

Implemented List of nursing care techniques/ procedures carried out

 Wound dressing
 Drug administration : (Intramuscular injection, intradermal and subcutaneous injections)
anal and oral route
 Bed making
 Monitoring vital signs

2.1.2. Health education Session

 Hygiene about person hygiene, environment hygiene and material hygiene and food
hygiene.
 Malnutrition
 Vaccination program in Rwanda
 Malaria
 Importance of voluntary HIV/AIDS test
 Mutual health insurance(mutuelle de santé)
2.1.3. Nursing care process for a client
 Identification:
Names: NYIRAMANA Agnes
Age:29
Sex: female
Marital status: married
Religion :cathoric church
 Short description of consultation progress
Date of Admission: 18th June, 2015 at 09h30 min
Chief complain: fever severe, headache, vomiting, abdominal pain

Past History: family history: some of her family members they suffered from asthma
Personnel history: she had suffered from malaria in January 2014.
Present illness history
N.A had headache, vomiting, chills, fatigue, rapid respiration, high fever
Actual state
General state alteration, temperature of 40.30c
Blood pressure (91/52 mmHg), weight (64kg),
Respiration is 24breath /min, Pulse is 110 beats/min.

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Physical examination: Normal
Differential Diagnosis:
 Simple malaria with minor digestive disorder
 exclude other infection
 Typhoid fever

Investigations:
TDR and Blood smear tests as quick as possible

Management:
 Nursing interventions: Wet sponging, aeration of the ward
 give Paracetamol per os 1gr unique dose
 Treatment adjustment after laboratory results

Follow up and evaluation:

At 10h00 min, laboratory results: TDR: positive, Blood smear: p. f Trophozoites ++++
Vital signs: temperature decreased to 370c

Prescription: Artesunate 2.4 mg/every twelve hours

Day two: General state improved
Decision: discharge home with provision of coartemR 2x4tablets/day/3days and paracetamol
3x500mg/day/5days.

 Descriptive table of the care process

Data collection Nursing Goals/outc Intervention Evaluation

diagnosis omes

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 Subjective data: N.A has N.A will Cooling the body After administer
-headache hyperthermia not by applying cold paracetamol the
-fever related to experience packs and aellating temperature has
-weakness
impaired fever after room been reduced from
-Abdominal pain
thermoregulatio administra Monitoring body 40.3oC to 37oc
-Chills
-Vomiting n as tion of temperature in each within 30 min
-Diarrhea manifested by paracetam 15 minutes and other
Objective data: body ol with in vital signs.
-fever 40.3oc temperature of 30 min Monitoring body
-intestinal 40.3oc fluids
parasite
- hemoglobin Administering
13g/dl paracetamol tablet
-malaria 500mg
3x1/day//3days as
prescribed
Documenting my
interventions

Acute N.A will Giving spine After

abdominal pain not position administration of
related to experience Reassuring the client mebendazole pain
intestinal acute Administer has been reduced
parasite as abdominal mebendazole tablet
manifested by pain after 2*100mg/3 day as
entomoeba administer prescribed by nurse
Document my
hystolitica in of
interventions
her stool Mebendaz
ole within
three days

2.2 STUDY OF A TOPIC OR PROBLEM OF CHOICE(MALARIA)

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Definition

Malaria is serious infectious disease transmitted by a female anopheles as a mosquito.

Causes of malaria

Malaria is caused by the bites from the female Anopheles mosquito, which then infects the body
with the parasite Plasmodium. This is the only mosquito that can cause malaria.

Signs and symptoms of malaria

Uncomplicated malaria typically has the following progression of symptoms through cold, hot
and sweating stages:

 Sensation of cold, shivering

 Fever, headaches, and vomiting (seizures sometimes occur in young children)
 Sweats followed by a return to normal temperature, with tiredness.

Severe malaria is defined by clinical or laboratory evidence of vital organ dysfunction. This form
has the capacity to be fatal if left untreated. As a general overview, symptoms of severe
malaria include:

 Fever and chills

 Impaired consciousness
 Prostration (adopting a prone or prayer position)
 Multiple convulsions
 Deep breathing and respiratory distress
 Abnormal bleeding and signs of anemia
 Clinical jaundice and evidence of vital organ dysfunction.

Pathology of Plasmodium
It is linked with the parasite density and is more severe in P. falciparum. Fever is caused
by massive liberation of merozoites due to antigenic stimulation of macrophage. The later
causes the Tumor Necrosis Factor (TNF) emission. The decrease in RBC plasticity,
cytoadherence of RBC to vascular endothelium and eventual formation of rosettes
(adhesion of RBC parasitized and non-parasitized) blocks the capillaries of brain,
kidneys. They also affect the viscosities of placenta (in pregnant woman). This blockage
results in the anoxy (lack of oxygen) of organs. In addition, the massive hemolysis
blocks the kidneys by hemoblobine and results in “black water fever”. The situation can
be worsened by the administration of quinine. Moreover the precipitation of immune

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 complex give rise of the lay on the vascular endothelium of kidney. This results in the
nephritis in case of P. malariae.
The typical pathological change appears in the spleen, liver, bone marrow, brain and other
visceral organs.
Spleen: enlarged, especially in chronic infection and may rupture. Tropical splenomegaly.
Liver: enlarged, kupffer cells and parenchyma cells are filled with parasites, malaria pigment
and debris.
Bone marrow: hyperplasic
Kidney: enlarged and congested, containing malaria pigments and hemoglobin casts.
Lungs: pigmented and show hemorrhagic patches, infected RBCs.
Brain: congested, capillaries plugged parasited RBCs; small foci of hemorrhage are found. In
severe hypoxia, neurons show degeneration and occasional inflammation infiltrate in the
meninges.
Hematological changes
Anemia: caused mainly by increased destruction of erythrocytes and reduced erythropoesis in the
bone marrow. Leukocyte count is decreased and Hemoglobin level is reduced.
MIP: Malaria in Pregnancy
At least 30 million pregnancies occur among women in malarious areas of Africa, most of whom
reside in areas of relatively stable malaria transmission”. It has been shown that Pregnancy leads
to an altered immunity due to new organ: placenta which favors the malaria parasite to flourish
because the parasites sekwester in the placenta. MIP has different effects on the mother, the
foetus and the infant.
On Mother: Malaria can become severe and leads to death. This is more severe in
primigravidae. The acute infection can lead to severe anemia due to placental infection.
On fetus: malaria can lead to abortion/perinatal death, intrauterine growth restriction (IUGR),
prematurity and congenital infection.
On infant: Increased risk of death and Increased/decreased susceptibility to malaria.
People who are at high risks of being affected by malaria are: children Under 5 due to low
immunity, Pregnancy, HIV with <500 CD4/μL and Non-immune travelers
Severe malaria

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The definition of criteria of severity are: Coma due to severe anaemia; Renal failure; Acidosis,
Respiratory distress; Hypoglycemia;Shock (hypotension), Repeated generalized convulsions;
Haemostatic abnormalities; Massive intravascular haemolysis (Black water fever), Altered
consciousness; Prostration or weakness; Jaundice and hyperparasitemia, Hyperthermia
Diagnostic of malaria
The commonly confirmatory tests to detect the presence of malaria parasites are microscopy or
rapid diagnostic tests (RDTs). Quality assurance of microscopy and RDTs is vital for the
sensitivity and specificity of the results.
Control and prevention:
- Early diagnosis & treatment
- Insecticides Treated Nets
- Strategies to control Malaria in Pregnancy (MIP)
-Intermittent preventive treatment: administration of a curative dose of an effective antimalarial
drug (currently sulfadoxine-pyrimethamine) to all pregnant women whether or not they are
infected with the malaria parasite.
-Nutritional supplements
-Vectors control: Indoor spraying with long acting insecticides.
Similarities of the reading and what we observed
The similarities the treatment of simple malaria is the coartem of combination of arthmeter 20mg
and lumenfantrine 120mg hence dosage for both adults and children are the same . Also malaria
can be prevented through the use of mosquito net especially for pregnant women.
Differences of the reading and what we observed
The difference is that we ask whether administration of a curative dose of an effective
antimalarial drug (currently sulfadoxine-pyrimethamine) to all pregnant women whether or not
they are infected with the malaria parasite is done but this action nowadays is not done.

References:
1. Jeffrey C. Pommerville (2011), Alcamo’s fundamentals of Microbiology.
2. Gerald D. Schmidt and Larry S. Roberts (2009), Foundations of parasitology.

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 3. Abhay R. Satoskar, Gary L. Simon, Peter J. Hotez and Moriya Tsuji (2009), Medical
Parasitology.
4. Fritz H. Kayser, Kurt A. Bienz, Johannes Eckert and Rolf M. Zinkernagel (2005),
Medical Microbiology.

2.3 NEW ACQUISITIONS

During clinical practice we learnt many things include:
 We learnt to be patient, how the patient seen to behave for any particular situation for our
daily endeavor
 We have seen the authenticity about many diseases and its etiology
 We have seen the new environment with different myths
 We learnt to possess the punctuality
 Vaccine injection like subcutaneous injection and intra-dermal injection
 Proper using of anti-tetanus vaccine schedule for women
 Increasing ability to take vital signs
 We have learnt and know more about the importance of hand washing
 Increasing sense of empathy and responsibility
 Increasing of critical thinking
 We learnt more about how to make daily nursing care plan based on prioritization based upon
fourteen Virginia Henderson’s needs using NANDA list
 We learnt more about collection of data related to the patient and how to present him/her to
supervisors and other senior nurses
 We have performed vein puncture
 We have administered the IV-medication severally
 We have known way of prescriptions according to the dosages and indications of many
medicines
 Prescription and administration of drugs accordingly to the ministry of health of Rwanda
protocols.

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III.CONCLUSION
3.1. Questioning on the achievement of the learning objectives.
In our clinical practice, many objectives were achieved particularly in vein puncture;
consultation, drug administration by oral tract, injections (IM, S/C, and I/D), educating the
families about role of vaccination, prevention measures of HIV and family planning, not only
that was done we have performed health assessment, took vital signs and parameters at huge.
These objectives are according to the need and priority of the health promotion, diseases
prevention and alleviate suffering. These objectives make an improvement in human health
especially women who are in action of giving vaccine to their babies because they learn more
which can help in their daily life as they have told us.

3.2. Difficulties and constraints encountered

In the problems we encounted are the following:

 Lack of enough materials for wound dressing
 Hospitalization of only 24hours, no enough linens
 No enough intradermal injection

3.3 SUGGESTIONS
3.3.1 As regard the organization
We suggest that GISHALI HEALTH CENTER for reinforcement of social services in order to
know well and monitor the problem of their clients. Also to improve the services of minor
surgery due to that we saw that it is difficult to perform wound-dressing for the patients, while
there no patient’s set and kits. In factor they have to recruit skilled worker about sterilization.

3.3.2 As regard to the experience of the clinical practicum.

In order to achieve our objective for increasing the improvement of our skills, we suggest that
the time of being with supervisor may be increased meanwhile ,this can be better for us.

ACKNOWLEGDEMENT

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So, we are very happy to thank our Lord who has been with us in the life we was in GISHALI,
also we appreciate the leaders of Rwamagana school of nursing and midwifery who allocated us
in GISHALI for clinical practice and sent us a special and excellent supervisor who helped us to
know more. And then, we thank the staff members of GISHALI health center and the ministry of
health.

GISHARI HEALTH CENTER PHOTO

WE LEARN FROM PRACTICES

THANK YOU!

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