SCHOOL OF NURSING

BSCN UPGRADING PROGRAMME

WEEKEND PROGRAM
LEVEL IV
ACADEMIC YEAR 2015-2016

CLINICAL PLACEMENT REPORT FROM 19TH

August TO 10TH SEPTEMBER 2016 DONE AT
NDERA

PRESENTED BY: MUMUKUNDE M Bernadette

SUPPERVISOR:

HARUNA
ROSE MARY

CLINICAL PRACTICE COORDINATOR: KINARA ERIC

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CLINICAL PLACEMENT REPORT

1.INTRODUCTION

Mount Kenya university organized clinical practice to strengthen the skills and knowledge of
its students whereby learners put theories covered in class into practices. This clinical
placement takes place at different health settings including referral hospitals, district hospitals,
and healthcenters and in communities. That’s why the level five Students areallocated atNdera
Neuropsychiatric hospital in the clinical placement period from 19 thAugust to 4thSeptember
2016 in order to enhancetheir knowledge, skills and performance in mental health.

2.HISTORICAL BACKGROUND OF NDERA NEUROPSYCHIATRIC HOSPITAL

Before independence, patients with mental diseases from Rwanda and from Burundi were
enclosed in form of prisons to Bujumbura where they used to beneficiate primary health care.

At the begging of 1959 independence manifestations, the two countries were separated and
there was no specialized centre for patients with mental diseases. They faced a number of
problems among which being ejected by families, living in forests considered as wild animals
etc.

The foundation of a specialized centre for mental health seems to be clearer and the problem
had been felt by Rwandan government in collaboration with Catholic Church through
Brothers of charity.

In 1964, the project of construction of the hospital took place and begun in 1968-1972.

It is in 1972 that the hospital was officially inaugurated with a capacity of 120 beds. It had
improved till 1994 and with all other institutions in Rwanda,Ndera hospital underwent
consequences of 1994 Genocide.

In 1995, the hospital restarted its activities after having been rehabilitated by Brothers of
charity in collaboration with Rwandan government, Swedish corporation and International red
cross committee. Today there are trained personnel and patients receive care of quality.

3.Geographic situation

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Neuropsychiatric hospital of Ndera is located in Kinunga cell, Ndera sector, Gasabo district in
KIGALI CITY. It is in 17.6 kilometers from the city centre.

Its limits are: Bumbogo sector in North, Masaka sector in South, Kimironko sector in west,
Rusororo sector in East

4.Activities

Activities of the hospital had started progressively with means and are situated in the
following fields:

a) Curative domain
 Consultations are done by specialists, General practitioners and psychiatric
nurses
 Follow up for hospitalized patients
 Care of patients with HIV/AIDS
 Care of patients with neurological problems

b) Prevention
 Sensitization in secondary schools about mental illness
 Supervision of district hospitals for mental health care reintegration

c) Promotional medicine

 Home visits to patients with HIV/AIDS

 Inspection of places in terms of hygiene
 Reintegration of patients abandoned by their families

5.Organization of the institution

Administrative function

A) Domain of health care

In relation to national politics of health institutions, the general director ensures responsibility
and coordination in collaboration with finance director, medical director and director of
nursing.

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In general the hospital comprises of different services:

PSYCHIATRIC PART

 Ward A: ward for men in crisis

 Ward B: ward for improved men
 Ward C: ward improve women
 Ward D: ward for women in crisis
 Ward K: ward for children(centrekundwa)

NEUROLOGY PART

 Ward for men

 Ward for women
 Ward for children
 Intensive care unit

PAEDIATRIC PART

 It is for infants and adolescent patients with mood disorders

CENTRE FOR CHRONIC PATIENTS

 Called also Home Saint Jules, is reserved for patients with no families and who have
lost abilities to live in society

B) Domain of general administration

General administration comprises of all activities related to hospital functioning.

Hence the hospital personnel are formulated as follows:
Administrative personnel, health care personnel as the table below indicate it:

FONCTION QUALIFICATION NUMBER

ADMINISTRATION Director 1
Accountant A0 2
Cashier A2 1
Invoice officer A0 1
Accountant A2 3
Secretary A1 1
Secretary A2 2
Archive officer A2 1

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 HEALTH CARE Psychiatrists Specialists 2
Neurologist specialists 2
General practitioner Medical doctors 3
Nurses A0 1
Nurses A1 42
Nurses A2 22
Sociologists A0 3
Social workers A0 3
Social workers A2 3
Physiotherapist A0 2
Physiotherapist A1 1
Pharmacist A0 1
Hygiene department Hygiene officer A1 1
Technicians 67
Technique Technicians and 6
drivers
Yes ,Ndera Neuropsychiatric hospital meet the standards of health care in Rwanda
COMMON CASES IDENTIFIED WHILE IN CLINICAL PLACEMENT
-Schizophrenia
-Manic disorders
-depression
-PTSD(post traumatic stress disordes)
-toxicomanie
-TPAT(troubles psychotiqueaiguetransitoire)
-epilepsia

WEAKNESES AND STRENGTHS ON VARIOUS DEPARTMENTS

1. Strengths:

-good hygiene of buildings and environment of the hospital

-commitment of nurses and other personnel of the hospital for teaching and orient the students

-all nurses do report beforeleaving the service

-almost all informations of patients are documented in the patients file

-team workingspirit(nurses,doctors,paramedics,…)

-services wellorganized and posted on the board

-the hospitalprovidesfoods for patients and other basic needs

-no need of care takers(abarwaza)

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2. Weakneses:

-some buildings are old

VI. RECOMMENDATIONS

To the hospital:

- To avail missing materials and equipments so that to facilitate the patients care and
protection to the care givers
- To renovate the oldest building ward

To school :

- To increase the number of clinical instructors at least 1 instructor per service where
students are located

VII. CONCLUSION

The clinical placement doneatNdera neuro psychiatrichospital from19th/08/2016 to 4th/09/2016

isvery important to me because have contributed to improvemyskills and to put in practice
the theorieslearnt in the 3rd semesterespecially mental healthcourse.Almost all clinical
objectives wereachieved.

Clinical placement report done by UZABAKIRIHO Manasseh; REG NO BSCN/38974/2015.

CLINICAL CASE PRESENTATION

6.IDENTIFICATION

Name and surname:M.E

Date of birth:1989
Age:27years
Place of birth: Southern Province
KAMONYI district

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 KAYENZI sector
Sex: female
Marital status: single
Profession: Household
Religion: catholic
Nationality: Rwandese
Date of admission: 19th JULLY 2016

MEDICAL DIAGNOSIS : MANIC EPISODE

7.GENOGRAM

8.ANTECEDENTS

Personal psychiatric antecedents: the 2nd crisis

Family psychiatric antecedents: none

Medical and surgical antecedents: not identified

Judicial antecedents:none

Notion Dependency: none

9.CHIEF COMPLAINTS

The patient was brought atNeuropsychiatric CARAES NDERA hospital by the police for :

 Euphoric and expensive mood

 Logorrhea
 Agitation

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  Verbal and physical aggressively
 Incoherent speech
 Instability
 Running away preaching the word of God

10.Context of recentcrisis:

 Beginning: the recent crisis started when she was in the household works
where manifested excess of pray, insomnia, logorrhea, preaching and
wandering .
 With circumstance:the recent crisis started when she was in the household
works
 Predisposing factors:failure in final exam to end primary school, family
conflicts and family poverty which prohibited her to continue her studies in
private school.
 precipitating factors:misunderstanding and conflict with her boss because
they were in different religions and she didn’t copy with this stressors

11.PERSONAL AND FAMILY HISTORY

The patient was born eutocically at home without problem in 1989, she was born the second
in the family of seven children but her father has another wife to whom he has got four
children(prenatal history). She was grown well even if her family was poor(childhood and
preschool history). Her father experienced physical and verbal aggressively towards his
wife and his children. She has studied until primary six(P6),she did not continue her studies
because she has failed in the national final examination of primary school,and due to her
family’s poverty she did not get access to private school(school age history). Her brother
succeeded the national examination and attended secondary school .This made the patient
happy.The patient used to help her mother to seek for school fees of her brother but later
they find NGO(Non Governmental organization) to pay for him(adolescent stage
history).The patient gave up her family and went to Kigali seek for the job where she acted
as house girl.She used to wake up early in the morning sing and pray but she had
misunderstanding with her boss because they belonged to different churches and religions,the
patients was catholic and the boss was protestant. She was pushed away without getting her
money(youngadult stage history).

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12. DISEASE HISTORY

The patient started manifesting inappropriate behavior after being pushed away from the job
and missing her money .She travelled along the road stopping the vehicles, preaching
.Sometimes she manifested verbal and physical aggressively. Wandering and insomnia.She
was brought at home by his boy friend, Arrived at home they mistreated her saying that she is
mental patient. She was abandoned there .The patient left her home and went to Nyamagabe
police station which brought her at CARAES Butare where she was treated using haldol
2.5mg twice a day and largactil 50mg twice a day .After getting improved she was discharged
and returned to her family but she did not respect the appointment given which led to poor
compliance to treatment.

The second crisis started when she left her family and returned to Kigali to look for the
occupation where she become a house girl.she started praying continuously ,manifesting
insomnia, wandering,preaching ,logorrhea .She was picked and brought at CARAES Ndera
by the police .She was admitted in ward D and given haldol5mg 2ptimes a
day,nozinan100mg 2times a day

Now she is on : Haldol5mg once a day

Largactil100mg once a day

Tegretol200mg 2times a day

13.CLINICALEXAMINATION

Physical: Vital signs taken on 19th August 2016

Blood pressure:12/6mmHg

Temperature: 36.80c

Pulse: 88beats/min

Respiratory rate: 16beats/min

Vital parameters

Height:1.65m,weight:60kg

Review of Systems :

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Respiratory system: By auscultation no problem identified in the lungs. Respiration rate
was in normal range intervals.

Cardiac system: Using the stethoscope no heart problem was identified.

Vascular system: Pulse, BP werefound in normal range.

Gastrointestinal system: Using palpation and percussion no abdominal pain localized or

generalizedidentified and no hypersialorrheawasidentified.

Musculosqueletal system: no particilarity

Nerve system: no tics of hand, legs and neck were identified. But according to the sign and
symptoms she presented , she is mentally ill

Urinary system: No problem was identified.

Integmentary system: non problemidentified

Paraclinical Exam: serological test and was found normal (negative ).

14.Psychiatric examination (Mental Status Examination)

General appearance: the patient is well dressed and groomed, combed and well cleaned.

Behavior: psychomotor agitation, but she is easily distractible

Cooperation: she is very cooperative

Mood: normal but during a conversation it becomes expensive

Affect: labile affect

Speech: she is talkative (pressured speech)

Thought :flit of ideas(grandiosity ideas),grandiose delusions

Perception :normal perception(no hallucinations,)

Orientation :she is oriented in time, place and person

Memory:normal(no problem with recent and remote memory)

Insight: positive

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Judgment: normal judgment

Vegetative functioning:

 sleep: normal sleep but sometimes she sleeps a day and insomnia in the night and
verse verse
 Appetite: normal but sometimes refuse to eat saying that there is no need for eating
 Strength of the body: the patient is very strong
 Sexuality:normal(no sexual arousal, no abnormal libido)

15.PSYCHOPATHOLOGICAL ANALYSIS

A.Positive elements in her life:

 She is still alive

 Her parents and her relatives (siblings) still alive
 Her young brother has succeeded national examination and he has found NGO to pay
for him school fees andnow he is ready to finish secondary school (this makes the
patients very happy)

B. Negative elements in her life:

 The patient was born in the poor family

 There was misunderstanding in her family (family conflict)
 She failed in the national examination in primary school
 She took responsibility while she was too young where she used to help her mother to
seek for her brother’s school fees
 She faced illegal marriage of her father with another woman which brought conflicts
in the family
 She gave up her parents and went to Kigali
 She experienced mistreating when she reached in Kigali

16.MULTIAXIAL DIAGNOSIS

Axis I: Manic episode

Axis II: not identified

Axis III: none

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Axis IV: family conflity

o Poverty in her family

o Failing at national examination
o Inadequate social support
o Inadequate financial support

Axis V:she functions well but sometimes,she is distractible 80%(with minimal symptoms,
distractibility and instability)

17.PROBABLE DIAGNOSIS

 Manic episode
 Hypomania
Nursing diagnoses
1. Non compliance on treatment related to her mental status secondary to lack of
knowledge to her mental illness, importance of medication as evidenced by
interruption of medication, no respect of the follow up, and relapse

2. Ineffective individual coping related to inadequate support system, negative role

model, and dysfunctional family system as evidenced by inappropriate use of coping
mechanism.

3.Disturbed thought process related to stress sufficiently severe to threaten a weak ego as
evidenced by delusional thinking, impaired ability to make decision, problem solve and
inappropriate social behavior

17.1. Favorable elements of manic episode :

Expansive mood
Insomnia with less need of sleeping
No need for eating
Instability
Logorrhea
Psychomotor agitation
Distractibility

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Notice: the disturbance lasts for long period(more than one week) and impairs her ability to
perform her job.

17.2. Favorable elements of hypomania

Are the same of manic episode but the difference is the duration.
The disturbance lasts more than four days.

18. Retained diagnosis: Manic episode

Bipolar mania - or a manic episode as part of a bipolar illness - is a condition most

commonly characterized by having an abnormally elevated mood, along with such
other symptoms as an excess of energy, extravagant behavior, rapid speech, reckless
spending and hallucinations.A person experiencing a manic episode shows persistent
and often inappropriate enthusiasm which may involve taking on new projects for
which he or she is ill suited. It might also involve engaging strangers in detailed
conversations, acting without concern for consequences of one's actions, or increased
sexual activities. Less commonly, a person may be abnormally irritable during a manic
episode

On average, the episodes begin before age 25, this means that some individuals
experience their first episode while in their teens and others during middle age.

18.1.CAUSES

There are many theories which talked about the cause of Manic episode. Some
suggestthat the problem can bebased of a person’senvironment or life experience,
basically meaningthat certain events, hardships, stress or otheroutsidefactorscan have
an impact on a person’spsyche and inducemanicdepressivesymptoms. However, manic
episode is more widely considered to be a biological disorder, and that environmental
factors mainly act as triggers for symptoms or work to exacerbate the condition.

Evidence also exists to suggest that manic episode is inherited, and that the children of
parents who are manic depressive are more pre-disposed to developing the condition
themselves.

18.2.SYMPTOMS OF MANIC EPISODE

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 1.  Inflated self-esteem or grandiosity

2.  Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

3.  More talkative than usual or pressure to keep talking

4.  Flight of ideas or subjective experience that thoughts are racing

5.  Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
stimuli), as reported or observed 6.  Increase in goal-directedactivity (eithersocially,
atwork or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal
directedactivity).

7.  Excessive involvement in activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or
foolish business investments ).

General behaviorsassociatedwith a manicepisodeinclude:

An abnormally happy, irritable, or energetic mood. Other characteristics that often

occur with this mood include:

 Unrealistic feelings of self-importance.

 A decreased need for sleep.

 Increased talkativeness.Racing thoughts.

 Being easily distracted by things that are not important.

An intense focus on reaching a goal.

 Dangerous or irresponsible behavior, such as driving too fast, spending too

much money, or having unprotected sex.

 Extreme behavior that causes problems on the job, at school, in social

situations, or at home.

18.3.Treatment

The main goals of treatment are to:

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  Avoid moving from one phase to another

 Avoid the need for a hospital stay

 Help the patient function as well as possible between episodes

 Prevent self-injury and suicide

 Make the episodes less frequent and severe

 The health care provider will first try to find out what may have triggered the mood
episode. The provider may also look for any medical or emotional problems that might
affect treatment.

 The following drugs, called mood stabilizers, are usually used first:

 Carbamazepineoral 200mg-600mg 2-3times daily

 Lamotrigine

 Lithiumoral 20mg/kg/day in divided doses

 Valproate (valproicacid)oral 200mg-500mg TID

You can add:

 Halopelidol IM,IV 5mg-10mg once or loranzepam IM,IV 1mg-2mg

 Other antiseizure drugs may also be tried.

19.THERAPEUTIC PROJECT AND MY INTERVENTIONS

19.1. Chemotherapy: I administered medications as prescribed by doctors (examples: Haldol

5mg once a day, Largactil100mg once a day, Tegretol 200mg 2times a day)

19.2. Biological aspect:

 I assessed and document a physical status of the patient and monitoring vital signs

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  I provided psycho -education and support for taking medication and monitor side
effects using Akeneton as a medicine.
 I assisted the patient to meet some basic needs such food, changing clothes,
environmental safety and medical care
 I involved the patient in music therapy
 I assisted the patient in the occupational therapy

19.3.Psychological care

o I assessed and document mental status

o Being available and active listening to the patient

20.NURSING CARE PLAN

Nursing assessment Nursing diagnosis planning Nursing Evaluation

interventions

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The patient said that Non compliance on The patient -I created the client- After 2days of
she did not take all treatment related to will get nurse therapeutic nursing
drugs; she did not her mental status enough relationship. interventions
return to health facility secondary to lack of informatio -I assessed the the patient
for follow up, this led knowledge to her n about her client,understanding understood
to relapse. mental illness, illness, and of her illness. her mental
Mental status importance of medication -I administered illness as
examination results medication as within prescribed evidenced by
Expansive mood, evidenced by 2days medication. her positive
insomnia with less need interruption of -I explained her insight,
of sleeping, no need for medication, no respect about her mental
eating, instability of the follow up, and illness.
,logorrhea, relapse -I explained her
Psychomotor agitation, about treatment
Distractibility The patient regimen.
Clinical examination will
Vs: maintain As these are
BP:120/60mmHg, prescribed -I explained her the process
pulse:88beats/min medication about the importance the
,temperature:36.90c, regimen of maintenance of involvement
RR:16breath/min and regular prescribed of the family
Vital parameters follow up medication, regular members will
Height:1.65m,weight: follow up, and the help in the
60kg consequences of the follow up of
medication the patient to
interruption. see if there
-I made involved her will be no
family members in interruption to
her therapy for better treatment or if
management. there will be
-I performed psycho no relapse.
-education with other
patients who
responded well to

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 treatment

21.Prognosis and evolution

The evolution is good on treatment during hospitalization but the problem rises after
discharge where the patient does not respect the follow up and not adhere adequately to
treatment

The prognosis is bad because:

 The mood disorders are chronic

 The patient does not adhere to treatment
 The patient does not respect the follow up
 The patient has not adequate financial and social support

22.CONCLUSION

As conclusion,this is the case of a young adult girl who developed a manic episode without
any specific factor or event and no other direct medical condition that caused this disorder.
But she passed through stressful life thatcan play a big role in her illness, and her illness has a
bad prognosis because mood disorders can not be treated completely,the patient is not
adhering to treatment and disrespect the appointment given by health providers .

23.SUGGESTIONS

 In the patient’s treatment you may add lithium as a mood stabilizer

 Any time she is stabilized the care provider must provide enough sessions of
psychotherapy to empower her coping mechanism.
 Her father should and her mother should be involved in the care
 As the patient sometimes experience insomnia in the night stilnoct drug should be
added in her treatment

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24.REFFERENCES

 American Psychiatric Association. (2000).Diagnostic and Statistical Manual of

Mental disorders. 4th edition. Washington, DC,
 Mary C. Townsend. (2011).Essential of Psychiatric mental Health Nursing: Concept
of Care in Evidence based Practices 5th edition. Philadelphia
 LeanaU. (2004). Mental health nursing a South African persipective, 4thedition,Cape
Town .

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