COLLEGE OF MEDICINE AND HEALTH

SCIENCES

SCHOOL OF NURSING AND MIDWIFERY

DEPARTMENT OF GENERAL NURSING

ADV.DIPLOMER IN GENERALNURSING

HUYE CAMPUS

YEAR THREE

ACADEMIC YEAR:2020 -2021

CLINICAL AREA: RANGO HC

NAME: MUTUYIMANA ELISABETH

REG NUMBER:220002450

Clinical supervisor: Poline

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1.INTRODUCTION

Clinical portfolio is tool designed to help student in clinical placement to make reflection about
what they did in clinical placement, is very crucial as it make us to reflect about clinical
placement, simply it is like mirror of clinical placement, as it helps as to identify our strength and
weakness during and after clinical placement, this led us to know gap and where to put more
effort. It is a well formatted written report which shows what a student has covered as his/her
objectives, what’s not covered during his/her clinical placement journey. This clinical portfolio
comprises and covers whole activities taken place within RANGO HC during my clinical
placement. I and my colleagues welcomed at RANGO HC on 12th September 2022, and we were
introduced and oriented in services where we were supposed to be rotating during clinical
placement. During this clinical placement, I and my colleagues was supposed to cover five
services which are; maternity, family planning,,consultation,vaccination,and minor surgery. and I
tried hard to achieve almost of all my objectives. This portfolio highlights my self-assessment with
the known skills and the gaps to guide the clinical learning. It also includes the clinical learning
contract, clinical learning activities/case studies, reflective journals, my group clinical report and
signed code of conduct, attendance list as well, all as an evidence. I regularly worked with
registered nurses/midwives and doctors to achieve my clinical objectives simultaneously providing
health services to community. Briefly, clinical placement was good at all.

2.SELF-ASSESSMENT IDENTIFYING THE KNOWN AND THE GAPS TO GUIDE

CLINICAL LEARNING
Student self-assessment helps the students identify their achieved and non-achieved objectives so
that we may seek the way of achieving them. In addition, student self-assessment involves the
students in evaluating their own work and learning progress which help them in seeing where to
focus their attention in learning. The table below summarizes the covered, partially covered as well
as non-covered objectives. Therefore, within the table, the explanations are given for partially
covered and non-covered objectives.

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A TABLE SHOWING THE COVERED, PARTIALLY COVERED AND UNCOVERED
OBJECTIVES DURING THE CLINICAL PLACEMENT AT BYUMBA DISTRICT HOSPITAL
CLINICAL LEARNING OBJECTIVES COVERED NOT OBSERVATIO MEANS OF
COVERED N VERIFICATIO
N
MATERNITY
1. Assess the expectant mother using the √ Good Consult my daily
nursing process. activities

2. Incorporate the family in the plan of care of √ Excellent Signed log book
the expectant mother.

3. Uses Leopold’s maneuver in the assessment √ Nice Consult patient

file
of the expectant Mother’s abdomen.

4. Auscultate and count fetal heart rate. √ Good Consult my

nursing care plan
5. Give health education to the mother and √ Good Consult patient
family according to stage of pregnancy. file

6. Administer vaccines and supplements as √ Nice Consult patient

prescribed. file

7. Ensure the mother undergoes the √ Nice Consult my

recommended laboratory tests (HIV, nursing care plan

STI’S, HB, blood group)

8. Manage and monitor a mother in labor √ Excellent Signed log book

using a partograph.

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9. Manage and assist the first, second and third √ Good Consult patient
stages of labor. file

10. Assess and perform episiotomy when √ Good Signed log book
indicated.

11. Use correct techniques to repair √ Good Consult my

Episiotomy and tears. daily activity
note

12. Receive and assess newborn using the √ Excellent Consult patient
APGAR score. file

13. Resuscitate the newborn, if necessary. √ Good Consult patient

file
14. Assess the mother and newborn before √ Good Consult patient
transferring to the postnatal ward. file

15. Give education concerning the importance √ Very good Consult patient
of breast-feeding file

16. Assess the mother for presence of any √ Nice Consult patient
gynecological condition. file

17. Advise mother for regular screenings √ Good Consult patient

(pap smear, SBE, mammography) file

18. Teach mother on selfbreast √ Nice Consult my

examination. nursing care
plan

19. Make use of appropriate positions during √ Good Consult patient

different procedures (ultrasound, speculum file

assessment).

20. Use partograph to monitor mother in √ Excellent Consult patient

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 labor. file

21. Give health education using a teaching √ Good Consult patient

plan (one on one or group session) file

22. Provide a pre-transfer immediate care of √ Good Consult patient

clients with obstetric complication (breech file

presentation, shoulder dystocia, PPH, and

cord prolapse)

LEARNING CONTRACT

Student Clinical learning contract

Student’s Identification (names): MUTUYIMANA Elisabeth

Student registration
number:220002450
Department: AD.DIPLOMA Nursing
Year of study: Year 3
Semester/Trimester: II Period of clinical placement: from12/09 /2022 to 14/10/2022

A learning contract is an agreement between student and clinical supervisor/mentor which

determine the explicit of what a student has to achieve. It is completed before the starting of
clinical placement by the student with supervisor/mentor's help and then signed after agreement by
both sides. Purpose: To engage the students in clinical learning process that provides opportunities
to make behavioural improvements and meet nursing/academic standards.

1. MATERNITY

Student’s learning Clinical learning Timeline Indicators Means of Observation/comment

goals activities verification of the supervisor/
Mentor

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 in I will assess 17 Nurse, log
I will assess mother Material preparation 1 weeks clients as will be book,
using Nursing Self-preparation documented in patient file
process for every Vital signs patient my note book and daily
mother will receive assessment activity
nursing care plan sheet

In I will perform 6 Nurse log

Material preparation 1 weeks Leopold’s book,
I will perform Self-preparation manoeuvre as patient file
Leopold’s Vital signs written on and daily
manoeuvre for every Preform portogram activity
mother will care in Leopold’s sheet
labour ward manoeuvre

Patient preparation In I will auscultate 9 Nurse log

1. Auscultate and Material preparation 1 weeks patients book,
Auscultation and as patient file
count fatal and daily
counting of fetal Documented in
heart rate. heat beat patient file and activity
log book sheet

Material preparation In 5 days I will offer this Nurse log

Give health Vital signs care to 8 mother book,
education to the Health education as will be patient file
mother and family Counseling documented and daily
according to stage of activity
pregnancy sheet

1weeks I will vaccinate 6 Nurse log

Administer vaccines Material preparation patient as will be book,
and supplements as vaccination documented patient file
prescribed Proper waste and daily
management activity
sheet

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  Ensure the Material preparation In I will offer this Nurse log
sampling 1 weeks care to 10 book,
mother
patient as will be patient file
undergoes the Counseling if documented in and daily
file and my note activity
recommended recommended
book sheet
laboratory
tests (HIV,
STI’S, HB,
blood group)

Manage and monitor Vital signs 1 weeks in Nurse log

I will offer this
a mother in labour monitoring Close labour book,
care to 10 patient
using a partograph monitoring Ward as will patient file
be
Fill portogram documented in and daily
appropriately portogram activity
sheet
Manage and assist Close monitoring 1 weeks in I will provide Nurse log
the first, second and Manage and assist labour this Care to 10 book,
third stages of labor the second and third Ward mothers to patient file
stage of labor and daily

Drug administration patient as will be activity

documented sheet

Assess and perform Material preparation 1weeks in I will perform Nurse log
episiotomy when Position of patient labour episiotomy to 5 book,
indicated Perform episiotomy Ward patients as will patient file
be documented and daily
activity
sheet
Use correct Material preparation 3weeks in I will offer this Nurse log
techniques to repair Positioning of labour care to 7 mothers book,
Episiotomy and tears patient Ward as will be patient file
Preform correct and documented in and daily
repair episiotomy portogram activity
sheet
1. Receive and Self-preparation 1week in I will receive 9 Nurse log
labour to newborns as book,
assess
Receive new born Ward will be patient file
newborn Score APGAR score documented and daily

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 using the correctly in file and book activity
APGAR sheet

score.

Resuscitate the new Preparation of In I will offer this Nurse log

born, if necessary material 1weeks care to 7 new book,
Resuscitation of new borns as will be patient file
born documented and daily
Close monitoring activity
sheet
Give education Patient preparation 1WEEks I will offer this Nurse log
self-preparation care to 15 book,
concerning the
Health education patients as will patient file
importance of about breast feeding be documented and daily
and its important in patient file activity
breastfeeding
sheet

2. Provide Material preparation In I will offer this Nurse log

Postpartum weeks in care to 22 book,
postpartum
assessment postpartum patients as will patient file
care Postpartum care ward be documented and daily
activity
sheet
3. Assess the Material preparation 1weeks I will offer this Nurse log
mother for Vital signs care to 13 book,
monitoring patients as will patient file
presence of Assessment mother be documented and daily
for any activity
any
gynecological sheet
gynecological condition
condition.

Teach mother on Patient preparation 1weeks I will offer this Nurse log
selfbreast Heath education care to 20 book,
examination about self-breast patients as will patient file
examination be documented and daily
activity
sheet
Use partograph to Self-preparation 1weeks in I will offer this Nurse log
monitor mother in Fill portogram labour care to 12 book,
labor accordingly Ward mothers as will patient file
be documented and daily
in portogram activity

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 sheet

I MUTUYIMANA ERISABETH commit to comply with the above commitments and code of
Professional Conduct for Nursing/Midwifery. Failure to do so, the CMHS academic regulation
and clinical training guidelines will be applied.

Date and signature of student Date and signature of Clinical Supervisor

4.CLINICAL LEARNING ACTIVITIES (CASE STUDIES)

1st clinical learning activity (case study)

Name: N,G Age:1996, Sex: Female, Marital status: Married, Religion: Catholique, Occupation:
Cultivator
Admitted on 19th September2022

Gestity :2 parity:1 and Abortion: 0, Gestational age:39 weeks

HOME ADDRESS DISTRICT: huye SECTOR:tumba
CELLULE: rango VILLAGE: inkambi

Chief complains
Lumbopelvic pain, Dizziness and headache.
History of present illness
The lumbopelvic pain started in past 24hours while dizziness started within past two months.

Past medication
She was taking Nifedipine 20mg*2/day/30days.

Vital signs were

Temperature=36.7 o C blood pressure=140/99mmhg, Respiratory rate=20 breaths/min,
Pulse=78beats/min

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Current status Chief complains
Lumbopelvic pain and Dizziness.
Vital signs
Temperature=36oc, Blood pressure=148/100mmhg, Respiration rate=18 breaths/min,
Pulse=84beats/min FHR=148beats/min Contractions=2 lasts between 20-40 seconds

Current medication/care
Mgs04 (4 grams) loading dose infused in 200ml of normal saline to flow in 15 minutes.

Physical examination/review of system Hair, ears, eyes, nose, tongue

Hair is black as normal, no problem with smelling, hearing, seeing and taste

Respiratory system
By inspection no problem on respiration, respiratory rate is 18 breaths/minute even palpation,
percussion and auscultation no abnormalities.
Cardiovascular system
For inspection is normal even apical pulse is 84 beats/min, palpation, percussion and when you
auscultate all S1 and S2 are audible, all show that patient is normal for this system
Also, capillaries refills are less than 3 seconds

Gastrointestinal system
Is normal because patient told me she defecates normally also bowels sounds are audible and are
normal.
There is abdominal distension due to pregnancy
Genital urinary system
Is normal by external appearance but she feels pain during urination.
There is no abnormal discharge
Muscoskeletal system
Is normal because patient can move and no problem in articulation
And there is no complain about weakness
Integumentary system
In normal because skin is colored black as normal and its integrity not impaired

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B. A’S NURSING CARE PLAN

DATE ASSESSM NURSIN EXPECTED INTERVEN RATIO EVALUA

ENT G OUTCOMES TIONS NALE TION
DIAGNO (OBJ
SIS ECTIVES)

Subjective -Labor pain -patient pain -labor - -Pain

data related to will be reduced support by massaging reduced to
04th
contractions as from 9/10 to massaging ng on lower 3/10 after
oct Lumbopelvi
evidenced by 3/10 within 6 on lower back help delivering
c pain, and
2021 patient hours after back of in of baby
dizziness
verbalization on. nursing mother until relaxation n
Objective And pain score of interventions her delivery of
data 9/10 ligament s
-Bp
:148/100mm

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hg hypertension -patient blood - -MgS04 -blood
- related to pressure will be administrati helps in pressure
RR:18breat vasoconstrictions reduced from on of reducing of reduced to
hs/min as evidence by 148/99mmhg to Mgs04 blood 132/84
BPof 130/80 mmhg 4grams in pressure for mmhg
-P:84 pregnant
beat/min 148/99mm after nursing 200ml of within 20
hg intervention within normal women minutes
to:37 oc
-pain 20 minutes saline flow
scole:9/10 in 20
minutes as
loading
doses and
5grams of
MgS04 in
500ml of
normal
saline flow
in 5 hours as
maintenance
dose

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 Anxiety related patient anxiety Have Have Achieved
to contraction ns will be relieved in conversation conversa
and 1 hour after n with client tion with
hospitalization as nursing and patient patient help
evidenced by intervention counseling in reducing
facial expression anxiety

-Impaired -To make patient -teach client - lying on -After

comfort related comfortable within importance left side 1hours-
to lying on left 1 hour of lying on only help in patient is
side only as left side and maintaining comfortab
evidence by continue FHR
le able as
normal and
patient’s claims labor she
protection
monitoring understand
g from fetal
Teach and reason to
distress.
change lying on
different leftside
position

Pre-eclampsia
Pre-eclampsia: is a condition in pregnancy characterized by abrupt hypertension and albuminuria.
It is diagnosed as preeclampsia when there is hypertension after 20 weeks of gestation when it
comes before 20 gestational weeks it is called gestational hypertension. For preeclampsia blood
pressure systolic is between 140-159 mmhg and diastolic 90-109 mmhg

PATHOPHYSIOLOGY
During normal pregnancy, the villous cytotrophoblast invades into the inner third of the
myometrium, and spiral arteries lose their endothelium and most of their muscles fibers. These
structural modifications are associated with functional alterations, such that spiral arteries become
low-resistance vessels, and thus less sensitive, or even insensitive, to vasoconstrictive substances.

Management of preeclampsia
Always after confirming preeclampsia we administer MgS04

Loading dose of MgS04

Give MgS04 20% solution, 4g IV flow in 5-20 minutes

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When you have 50% MgS04 and 1 ml of MgS04 of 50% contain 2 grams To
make 20% of MgS04 with 4 grams.
1. Take one 20ml sterile syringe
2. Draw 8ml (4g) of MgS04 50% into syringe
3. Add 12 ml of sterile water for injection to make a 20%solution
After administering loading dose we have to assass for toxicity of MgS04 before administering
maintenance dose
Signs of MgS04 toxicity include

• Respiratory rate less than 16 breaths per minutes

• No patellar reflex
• Urinary out put less than 30 ml per hour averaged over preceding 4 hours
If found any sign of toxicity withhold medication if continue administer antidote of MgS04 which
is calcium gluconate 1 g (10 ml of 10% solution) IV slowly in 3 minutes
If there is no sign of toxicity, we continue by administering maintenance dose
Maintenance dose
On maintenance dose 1g of MgS04 must flow in one hour by IV infusion and we have to
administer 5 grams.
To admister it, we have to prepare 500 ml IV bag and put 10 ml of 50% MgS04 and infuse 50 ml
per hour after administering of maintenance dose you continue to check for MgSo4 toxicity.
CASE 2 BIRTH ASPHYXIA
Baby M.J he is a male born on 15th 0ctober 2021 to His mother M.S and B.A .They are
Rwandans, Northern province, Gicumbi district, byumba sector, rukoma cell and Gikoma village.
They are Adventist of 7th day. They use mutuelle de santé as a health insurance. No known
allergies or chronic diseases.

MATERNAL HISTORY

Mother has 43 years old, gravidity 5 and parity 5, living children 5, no abortion and no prematurity
delivered. Last menstrual period of mother is on 9th January 2021. She gives birth by vaginal
delivery on 15thOctober 2021. Mother HIV status is negative, has no chronic condition, and no
sexual transmitted diseases. Baby born with APGAR Score of 6/10; weight is 2,300kg. After birth
baby had received vitamin K and ophthalmic ointment (tetracycline ointment)

NURSING ASSESSMENT ON ADMISSION

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Date of admission: 15th January 2021 Times: 11h00

Reason of transfer: baby has a poor APGAR score of 6/10

Chief complaint: baby has ineffective breathing pattern

Evaluation of ABCD (A: Airway, B: Breathing, C: Circulation and D: Disability):

A: Clear airway

B: Tachypnea

C: Cyanosis of extremity

D: Blood glucose level 69mg/dl

Vital sign on admission: temperature is 37.1OC, pulse is 131beat/min, oxygen saturation is 92%,
respiratory rate is 74breath/min and weight is 2,300kg and height is 51cm

PHYSICAL ASSESSMENT

 GENERAL APPEARANCE: baby is weak and asthenia, altered

 HEAD: presence of fontanels, no scar in head, no hydrocephalus and has black hair

 EARS, EYES, NOSE AND MOUTH: pineal of ears are soft, no discharge from nose and
ears, and no cleft palate, nose are symmetrical

 CHEST, LUNG AUSCULTATION: respiratory rate of 65 breaths/min, oxygen saturation

of 92% and tachypnea

 HEART: rate, rhythm are normal, heart sound S1&S2 are audible no murmurs, and
capillary refill are normal and no jugular vein distension

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  ABDOMEN: no scar on abdomen, presence of four quadrants, no infection on umbilical
cord

 GENITAL: presence of penis, and two testis are descended

 EXTREMITIES: cyanosis of extremity and has five finger and five toes and leg and arm
are symmetric

 SKIN: no scar on skin, presence of hair and soft skin, and no jaundice baby present

 NEURO AND REFLEX: baby has poor sucking, and poor reflexes

 MUSCULAR SKELETAL SYSTEM: temperature is 37.1OC , no skin rash, no fracture,

poor muscle tone, no laceration, bruising or wound.

Danger sign: tachypnea

First emergency care: is to administer oxygen

Current vital sign: oxygen saturation is 96% under oxygen therapy, respiratory rate is
70breath/min, pulse is 116 breath/min temperature is 36.5OC

Medical diagnosis: Hypoxic ischemic encephalopathy (HIE) grade I

Investigation done

 Full blood account

 CRP

Treatment received:

 Aminophylline 115mg BID

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  Gentamycine 11.5mg OD

 Total fluid (IV + Enteral) 60ml/kg/day

 Maintenance IV Fluid Dextrose GD10% 140 ml/kg

N.B: If convulsion appear, give Phenobarbital IV 46 mg loading dose

 Full blood count: Test if white blood cell, red blood cell, hematocrit, platelets and
hemoglobin are normal. To see if baby need transfusion or need platelet. this measures the
level of hemoglobin in blood. If it is low means you could be anemic

 CRP: this exam is done to know if baby has infection and plan for protection infection by
using antibiotics.

DRUG DESCRIPTION

AMINOPHYLLINE is dissociates into theophylline, which is a xanthine derivative. Its main

action is bronchial smooth muscle relaxation, thereby relieving bronchospasm.

PRESENTATION

250 mg in 10 mL ampoule (25 mg/mL)

MECHANISM OF ACTION:

Theophylline has two distinct actions in the airways of patients with reversible obstruction; smooth
muscle relaxation (i.e., bronchodilation) and suppression of the response of the airways to stimuli
(i.e., nonbronchodilator prophylactic effects). While the mechanisms of action of theophylline are
not known with certainty, studies in animals suggest that bronchodilation is mediated by the
inhibition of two isozymes of phosphodiesterase (PDE III and, to a lesser extent, PDE IV), while
nonbronchodilator prophylactic actions are probably mediated through one or more different
molecular mechanisms, that do not involve inhibition of PDE III or antagonism of adenosine

17
 receptors. Some of the adverse effects associated with theophylline appear to be mediated by
inhibition of PDE III (e.g., hypotension, tachycardia, headache, and emesis) and adenosine
receptor antagonism (e.g., alterations in cerebral blood flow). Theophylline increases the force of
contraction of diaphragmatic muscles. This action appears to be due to enhancement of calcium
uptake through an adenosine-mediated channel.

INDICATIONS AND USAGE

Treatment of bronchospasm associated with chronic bronchitis, emphysema, bronchial asthma and
obstructive pulmonary disease.

ADMINISTRATIONS GUIDELINES

Note: Dose is calculated on lean (ideal) body weight. Administer by slow intravenous infusion at a
rate not exceeding 25mg/min.

NURSING CARE PLAN OF BABY M.J

NURSING NURSING EXPECTED INTERVETION RATIONALE EVALUATIO

ASSESSMENT DIAGNOSIS OUTCOME N

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SUBJECTIVE Ineffective Neonate Provide nasal Nasal wash up will Baby
DATA breathing respiration rate wash up every 45 help to remove any respiratory
pattern related will be reduced min blockage in airway rate is
to poor APGAR from 74 62breath/min
score as breaths/min to within 3o min
. baby is not evidenced by 60 breaths/min
feeding Apgar score of in 30min after Give CPAP . CPAP keep alveoli’s
6//10(RR:74 nursing (Continuous open so gaseous
. baby is weak breaths/min and intervention Positive Airway exchange occur
weak reflexes) Pressure)
. baby is not
breathing well
Keep baby breath well
Administer by increasing oxygen
oxygen if concentration in air
saturation is
below 90%
OBJECTIVE
Monitor vital sign . Note any change in
DATA every 1 hrs. respiratory rate for
further intervention

high change in
TO: 37.1OC Keep the baby temperature lead
warm/ maintain to apnea
the temperature
PSO2: 92% on
oxygen

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RR: 74breath/min Interrupted Baby will be Insert nasalgastric nasal gastric tube will
breastfeeding able to receive tube help to breast feed
breast milk
Pulse: 131beat/min related to baby
during
inability to hospitalization
Weight: 2300kg coordinate period
sucking and Health education
Blood sugar: breathing as about breast will help to breastfeed In progress
69mg/dl evidenced by feeding to his rich milk (balanced
poor response to mother diet) to baby
stimulus

. cyanosis on
extremity

. tachypnea

Apgar score :6/10

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BIRTH ASPHYXIA

A 2008 bulletin from the World Health Organization estimates that 900,000 total infants die each
year from birth asphyxia, making it a leading cause of death for newborns

In the United States, intrauterine hypoxia and birth asphyxia was listed as the tenth leading cause
of neonatal death.

Definition: Birth asphyxia is defined as a reduction of oxygen delivery and an accumulation of

carbon dioxide owing to cessation of blood supply to the fetus around the time of birth.

This is pathologic condition referred to neonate who have no spontaneous breathing or represented
irregular breathing movement after birth.Usually caused by perinatal hypoxia. It is emergency
condition and need quickly treatment (resuscitation

PATHOPHYSIOLOGY

When fetal asphyxia happens, the body will show a self-defended mechanism which redistribute
blood flow to different organs called “inter-organs shunt” in order to prevent some important
organs including brain, heart and adrenal from hypoxic damage.

Hypoxic cellular damages:

a. Reversible damage(early stage): Hypoxia may decrease the production of ATP, and result
in the cellular functions . But these change can be reversible if hypoxia is reversed in short time.

b. Irreversible damage: If hypoxia exist in long time enough, the cellular damage will become
irreversible that means even if hypoxia disappear but the cellular damages are not recovers. In
other words, the complications will happen.
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Asphyxia development:

Primary apnea: breathing stop but normal muscular tone or hypertonia, tachycardia (quick heart
rate), and hypertension happens early and shortly, self-defended mechanism could not be damage
to organ functions if corrected quickly

Secondary apnea: Features of severe asphyxia or unsuccessful resuscitation, usually result in

damage of organs function

CAUSE OF BIRTH ASPHYXIA

Some of the causes of decreased oxygen before or during the birth process may include:

 Inadequate oxygen levels in the mother's blood due to heart or respiratory problems or
lowered respirations caused by anesthesia

 Low blood pressure in the mother

 Inadequate relaxation of the uterus during labor that prevents oxygen circulation to the
placenta

 Early separation of the placenta from the uterus, called placental abruption

 Compression of the umbilical cord that decreases blood flow

 Poor placenta function that may occur with high blood pressure or in post-term
pregnancies, particularly those past 42 weeks

Pathologically, any factors which interfere with the circulation between maternal and fetal blood
exchange could result in the happens of perinatal asphyxia. These factors can be maternal factor,
delivery factor and fetal factor.

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Maternal factor:

 Hypoxia, anemia, diabetes, hypertension, smoking, nephritis, heart disease, too old or too
young,

Delivery condition:

 Abruption of placenta, placenta previa, prolapsed cord, premature rupture of membranes,

Fetal factor:

 Multiple birth, congenital or malformed fetus

RISK FACTORS OF BIRTH ASPHYXIA

• Elderly or young mothers

• Prolonged rupture of membranes

• Meconium-stained fluid

• Multiple births

• Lack of antenatal care

• Low birth weight infants

• Malpresentation

• Augmentation of labor with oxytocin

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 • Ante partum hemorrhage

• Severe eclampsia and pre-eclampsia

• Ante partum and intra partum anemia

SIGN AND SYMPTOMES

Each baby may experience symptoms of birth asphyxia differently. However, the following are the
most common symptoms.

Before delivery, symptoms may include:

• Abnormal heart rate or rhythm

• An increased acid level in a baby's blood

At birth, symptoms may include:

• Bluish or pale skin color

• Low heart rate

• Weak muscle tone and reflexes

• Weak cry

• Gasping or weak breathing

• Meconium — the first stool passed by the baby — in the amniotic fluid, which can block
small airways and interfere with breathing
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DIAGNOSIS OF BIRTH ASPHYXIA

The following test are used to diagnose birth asphyxia:

• Severe acid levels — pH less than 7.00 — in the arterial blood of the umbilical cord.

• Apgar score of zero to three for longer than five minutes. The Apgar test is used just after
birth to evaluate a newborn's color, heartbeat, reflexes, muscle tone and respiration.

• Neurological problems, such as seizures, coma and poor muscle tone.

• Respiratory distress, low blood pressure, or other signs of low blood flow to the kidneys or
intestines.

Problems with a baby's circulatory, digestive and respiratory systems may also suggest that a baby
has birth asphyxia.

TREATMENT OF BIRTH ASPHYXIA

Birth asphyxia is a complex condition that can be difficult to predict or prevent. Prompt treatment
is important to minimize the damaging effects of decreased oxygen to the baby.

Specific treatment for birth asphyxia is based on:

• The baby's age, overall health and medical history

• Severity of the baby's condition

25
 • The baby's tolerance for specific medications, procedures or therapies  Expectations for

the course of the condition

Treatment may include:

• Giving the mother extra oxygen before delivery

• Emergency delivery or Caesarean section

• Assisted ventilation and medications to support the baby's breathing and blood pressure

• Extracorporeal membrane oxygenation (ECMO)

• A= Establish open airway: Suctioning, if necessary endotracheal intubation

• B= Breathing: Through tactile stimulation, PPV, bag and mask, or through endotracheal
tube

• C= Circulation: Through chest compressions and medications if needed

• D= Drugs: Adrenaline .01 of .1 solution

• Hypothermia treatment to reduce the extent of brain injury

• Epinephrine 1:1000 (0.1-0.3ml/kg) IV

• Saline solution for hypovolemia

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 CASE STUDY 3
N S is woman of 32 years old. She is married She is Rwandan come from southern province, huye
district, and Mpare sector.
She is G3P2, Living children two, no death child, no abortion and no premature delivery. She was
admitted on 04h October 2022 in health center, for the reason of premature rupture of membrane
and twin pregnancy, with complain of abdominal pain and gush of fluids since five hours. on
admission head neck and limbs are normal, no bleeding and no quickening. Neither known
allergies nor chronic diseases. Her last menstruation period was on 15/03/2022 expected date of
delivery was 22/12/2022. Gestation age was thirty-one weeks (31wks).
Vital signs are: blood pressure 110/75mmhg, pulse 84 beat/min, temperature 36.4oC, respiration
rate 20 breath/min. Weight 66kgs, height 165cm, number of antenatal care visit two times, ant
tetanus vaccine was taken and she had passed through ultra-sound . Fundal height 36cm, Fetal
heart rate was 140-142 beat/min, on vaginal exam cervix is open at three centimeter (3cm).
position of cervix is mild, Amniotic membrane is ruptured and are clear.
Physical examination:
central nerve system (Glass gown, reflex, muscle power and tonicity, sensitivity and multicity) are
normal
HEAD AND NECK
No mass on head, scalp is normal, colored hairs, colored conjunctiva
No discharge from the noise, No tongue trash
No tonsillitis, No lymphadenopathy, No goiter
CARDIOVASCULAR SYSTEM:
No hypotension (110/75mmhg), Audible heart sound S1&S2 are audible no murmurs no other
added sound, Palpable peripheral pulse, Capillary refill <2 second, No jugular vein distension
RESPIRATORY SYSTEM:
Wheezing sound during auscultation, Chest movement 20 breath/min, no trachea deviation.
GASTRO- INTESTINAL SYSTEM:
Gravida uterus, fundal height is 36cm
GENITO- URINARY SYSTEM:
Cervical dilatation at 3cm, descent on four to five (4/5)
MUSCLO- SKELETAL SYSTEM
Fever 38.90C, Cool, no skin rash, no fracture, normal muscle tone and endurance no
laceration, bruising or wound

27
INVESTIGATION DONE WAS:
Full blood count, blood group and rhesus, urinalysis, RPR, Toxoplasmosis, Rubella, Hep B and C
virus.
Ultra-sound show that mother has twin pregnancy. Ultrasound presentation is cephalic on twin A
and breech on twin B. fetal heart rate is 131 beat/min to twin A and 141 beat/min to twin B. fetus
with weight of 3090grams twin A and weight of 3010grams twin B

 Blood group and rhesus: when woman is pregnant it’s important to know blood group; in
case you or your baby need to have a blood transfusion, so health care provider know if
you and your baby have the same RHD blood group. Women blood group might be the
same as your baby’s, but it can be different. If blood group are different it may mean that
women need extra care.

in most case, your blood will not mix with your baby blood until delivery. But if you get
pregnant again with a Rh-positive baby, the antibodies already in your blood could attack the
baby’s red blood cells. This can cause the baby to have anemia, jaundice or more serious
problems.
 Full blood account: this measures the level of haemoglobin in blood. If it is low means
you could be anaemic
 Congenital infections are due to pathogens that are transmitted from mother to child during
pregnancy or delivery. They can have a substantial negative impact on fetal and neonatal
health. That why they request CPR, toxoplasmosis, rubella and hep B and C virus

TREATMENT PLAN:
 Dexamethasone IM 6mg BID
 Cefotaxime 1g IV TID

DRUG DESCRIPTION
DEXAMETHASONE

Dexamethasone is a corticosteroid (acts like a hormone the body normally makes, called cortisol).
USE OF DEXAMETHASONE
Dexamethasone is used to treat many conditions.
 cancer treatment, where it is usually given along with other anticancer medications as part
of a treatment regimen,
 To control nausea and vomiting from cancer treatment.

28
  Severe and high risk of chronic lung disease
 Prevention and management of post-extubation stridor

PRESENTATION:
 4mg/1ml vial
 0.5mg/ml suspension

ROUTE: IV injection, IM injection, oral

INDICATIONS
Allergic states: Control of severe or incapacitating allergic conditions intractable to adequate trials
of conventional treatment in asthma, atopic dermatitis, contact dermatitis, drug hypersensitivity
reactions, perennial or seasonal allergic rhinitis, and serum sickness.
Dermatologic diseases: Bullous dermatitis herpetiformis, exfoliative erythroderma, mycosis
fungoides, pemphigus, and severe erythema multiforme (Stevens-Johnson syndrome).
Endocrine disorders: Primary or secondary adrenocortical insufficiency (hydrocortisone or
cortisone is the drug of choice; may be used in conjunction with synthetic mineralocorticoid
analogs where applicable; in infancy mineralocorticoid supplementation is of particular
importance), congenital adrenal hyperplasia, hypercalcemia associated with cancer, and
nonsuppurative thyroiditis.
Gastrointestinal diseases: To tide the patient over a critical period of the disease in regional
enteritis and ulcerative colitis.
Hematologic disorders: Acquired (autoimmune) hemolytic anemia, congenital (erythroid) hypo
plastic anemia (Diamond-Blackfan anemia), idiopathic thrombocytopenic purpura in adults, pure
red cell aplasia, and selected cases of secondary thrombocytopenia.
Miscellaneous: Diagnostic testing of adrenocortical hyper function, trichinosis with neurologic or
myocardial involvement, tuberculous meningitis with subarachnoid block or impending block
when used with appropriate ant tuberculous chemotherapy.

S INDICATIONS AND CONTRAINDICATIONS FOR USING CORTICOSTEROIDS IN

ANTENATAL PERIOD
Indications
1. True preterm labour
2. Following conditions that lead to imminent delivery:
 Antepartum haemorrhage
 Preterm premature rupture of membrane
 Severe pre-eclampsia

29
Contraindications
Frank chorioamnionitis is an absolute contraindication for using antenatal corticosteroids.
Following signs and symptoms in the mother suggests Frank ammonites:
 History of fever and lower abdominal pain
 On examination: Foul smelling vaginal discharge, tachycardia and uterine tenderness 
Fatal tachycardia

N.B: Maternal diabetes, pre-eclampsia and hypertension are NOT contraindications for using
injection corticosteroid in pregnant women. Dexamethasone can be administered if otherwise
indicated with a careful watch on blood sugar and blood pressure [If chorioamnionitis is suspected,
consider delivering the baby].

NURSING CARE PLANE OF U.N

30
NURSING NURSING OBJEC INTERVETION RATIONALE OUTCOME
ASSESSMENT DIAGNOSIS TIVES

SUBJECTIVE Acute pain Patient . positioning . different Patient have

DATA related to pain will patient in position can been
. abdominal
pregnancy/co be comfortable help like semi understood
pain
ntraction as reduced position sitting position the reason
. gush of fluid
evidenced by from . give prescribed or left lay as it she has a pain
. Pelvic pain
patient verbal 7/10 to medication(painki can increase And pain has
. nausea
and pain score 3/10 ller) decent so been reduced
OBJECTIVE
DATA 7/10 after progress of to 4/10
1hour of . reassure a labor will be
TO: 36.4OC
nursing patient quick so pain
PSO2: 95% RR:
20breath/min intervent relieved
Pulse: ion Sooner
84beat/min
BP:
110/75mmhg
.patient know
Pain score of
7/10 the cause of
pain

anxiety Client Health education Get more

related to will about labor information
appear
perceived process and about labor
relaxed
disturbance to appropri progression of and
ate until progression
emotional labor and Information
she
status as receive counseling will comfort has given to
evidenced by babies patient and patient and
crying relieve anxiety be reassured

31
32
 .asssess level and
cause of Provided
anxiety .monitor baseline
pattern of uterine information .h
contraction .monit ypertonic or
or vital sign (BP hypotonic
and Pulse as contractile
indicated pattern may
. Reassure patient develop if
stress persists
and causes
prolonged
catecholamine
release .
stress, fear,
and anxiety
have a
profound
effect on the
labor process

. monitor vital
sign every . change in
Risk of Patient
30min . give
infection will be vital sign may In progress
prescribed
free of
related to antibiotics .clean be caused by
infection
environment infection .to
premature during
hospitali prevent the
rapture of
zation
membrane period infection
.

33
PROLONGED LABOR

Prolonged labor, also known as failure to progress, occurs when labor lasts for approximately 20
hours or more if you are a first-time mother, and 14 hours or more if you have previously given
birth.
Prolonged labor is the inability of women to proceed with childbirth upon going into labor. Failure
to progress can take place during two different phases; the latent phase and active phase of labor.
The latent phase of labor can be emotionally tiring and cause fatigue, but it typically does not
result in further issues, the active phase of labor, on the other hand, if prolonged can result in term
complication.

CAUSES PROLONGED LABOR

Fetal malpresentations
Fetal malpresentations are irregular positions of the crown of the fetal head in relation to the
mother's pelvis (the fetus is in an abnormal position. Some important ways to manage fetal
malpresentation are making rapid evaluations of the condition of the women pertaining to vital
signs as well as the heart rate of the fetus. If fetal heart rate is abnormal, and if membranes have
ruptured and amniotic fluid is atypical, it is important for medical professionals to determine the
presenting part of the fetus and the position of the fetal head. Possible delivery methods, if this
is the case, are compound presentation, Vaginal breech delivery, or caesarean section for breech
presentation depending upon the severity of the malposition. Uterine contractions
This refers to uterine conditions that result in the uterus not having enough coordination or strength
to dilate the cervix and push the baby through the birth canal. Issues with uterine contractions are
the main cause of prolonged labor during the latent phase. Contractions may not occur as of a
result of uterine tumors. In addition, if the uterus is stretched, usually due to previous pregnancies
or the birth of twins, contractions may be difficult. Irregular or weak contractions can be fixed
through stimulation of the uterus or oxytocin infusions. Lack of contractions may be caused by an
overwhelming amount of painkillers or anesthesia, by which the medications should be
34
discontinued. In this case, it is appropriate for assisted vaginal delivery to be conducted. Cervical
stenosis
Cervical dystocia, or stenosis, occurs when the cervix fails to dilate after a practical amount of
time during positive uterine pains. The main problems in cervical dystocia is the lack of uterine
inertia and cervical abnormalities, which prevent the cervix from fully dilating. It is very typical of
patients that have hypopituitarism. There are many preexisting complications that may result in
stenosis. Common conditions that lead to stenosis are tumors, a full bladder, large size of the
infant, multiple pregnancies, delay in rupture of membranes, or problems with the cervix.High
stress may interfere with the progression of pregnancy in cases such as these, leading to prolonged
labor.
Cephalopelvic disproportion
Cephalopelvic disproportion is the issue that arises when the fetus' body or head is to large to pass
through the mother's pelvis. Common conditions that lead to CPD are diabetes, multiple
pregnancies, small or abnormally shaped pelvis, atypical fetal positions, hereditary factors, and
first time pregnancies. Medical professionals can usually estimate if fetal size is too large based
on ultrasounds, but they are not always entirely accurate. Doctors typically determine CPD when
labor begins and the use of oxytocin is not effective. The safest way for delivery to take place
when CBD is a factor is through cesarean sections.

DIAGNOSIS
Protracted cervical dilation (dilation progresses less than 1 cm/hour during the active phase);
or
– The fetus has failed to engage after more than 1 hour of complete dilation in a multipara
and 2 hours of complete dilation in a primipara; or
– The active pushing phase until birth of the infant is longer than 30 minutes in multipara
and 1 hour in primipara.
MANAGEMENT
Notes:
– Oxytocin is contra-indicated in case of frank foeto-pelvic disproportion (risk of uterine rupture).
– In case of fetal distress (prolonged deceleration of the fetal heart rate to less than 100 beats per
minute after each uterine contraction) and if the fetus is viable:
• At complete dilation, with the presenting part engaged: instrumental delivery
• Prior to complete dilation, or at complete dilation with presenting part not engaged: consider
caesarean section earlier than in the algorithms, but the context needs to be taken into
account when deciding a caesarean section for exclusive fetal indication In either case, do
not use—or stop, if already using—oxytocin.

35
– If the foetus is dead, avoid caesarean section whenever possible. Allow more time for dilation
and engagement. Consider embryotomy
In terms of medical care, preventative treatment or assisted delivery are typically the first
options doctors consider. There is usually no quick fix to prolonged labor, especially if
preventative measures do not revert the mother back to normal labor. Often, medical
professionals resort to intervention methods. If the state of the fetus and mother are not
especially serious or threatening to their health, doctors will perform assisted vaginal deliveries.
Assisted vaginal delivery
There are two different methods of assisted vaginal delivery that medical professionals typically
utilize to aid in delivery in order to avoid surgical methods of fetal extraction. These procedures
are only applied if a vaginal delivery has proven to still be safe to the mother and the baby, based
their vital signs. Assisted vaginal delivery is usually only used in the latent phase.Delivery during
the active phase is usually associated with more complications for the mother.One approach to
assisted vaginal delivery is the use of forceps.The forceps doctors use resemble two large salad
spoons and are inserted into the cervix, around the baby's head and help to guide it out of the
birth canal. The other option is the use of vacuum extraction. Vacuums used have a cup on the
end and are inserted into the cervix. The cup attaches to the fetus's head by suction and aids in
guiding delivery. The choice between forceps and vacuum extraction is usually made by the
doctor based on preference. It is important that these methods are used properly, or else they can
cause severe birth injuries to the baby that may be permanent. Cesariansections
Cesarian sections, also referred to as C-sections are usually quick solutions to the issue of failure to
progress. Often times, C-sections are the best options to avoid harming the fetus or the mother,
especially if labor proves to be life-threatening. One third of C-sections occur as a result of
prolonged labor. C-sections are usually a necessary measure in prolonged labor to avoid serious
birth complications. If the mother reaches the active phase of prolonged labor, a C-section is the
safest solution. Cesarian sections need to be performed immediately if there are signs of fetal
distress, uterine rupture, or cord prolapse. It is important that medical professionals are equipped
and prepared in the case of an imperative C-section. There is a window of time by which cesarian
sections need to be executed if any warning signs present themselves. If there is a delay in the
Csection, permanent damage can result to the baby, such as cerebral palsy or hypoxic-ischemic
encephalopathy (HIE). Due to all the risk factors that are present in the event of prolonged labor, it
is extremely important that medical teams are well-suited and prepared to conduct a C-section if
needed.

SIGN AND SYMPTOMS OF PROLONGED LABOR

Symptoms include:

• Labor extends beyond 18 hours

• Dehydration and exhaustion of the mother

36
• Pain around the back, sides, and thighs of the mother as a result of extreme muscle pressure 
Severe pain when labor begins
• Increased heart rate of the mother
• Swollen large intestine on either side of the uterus as a result of gas build up
• Uterus sensitivity
• Ketosis
• Distress of the fetus
• Uterine ruptures

COMPLICATIONS

• Distress to the fetus as a result of decreasing Oxygen levels

• Internal bleeding of the fetus's head (intracranial hemorrage)
• Higher chance of operative delivery
• Risks of long term injuries to the infant such as hypoxic-ischemic encephalopathy (HIE) or
cerebral palsy
• Infection of the uterus
• Damage to the birth canal
• Postpartum infection
• Postpartum hemorrhage

PREVENTION OF PROLONGED LABOR

If the mother is being closely monitored and begins to show signs of prolonged labor, medical
professionals can take preventative measures to better the chances of the women delivering her
child within 24 hours.A precise initial diagnosis of prolonged labor based on signs and symptoms
is extremely important in applying proper precautionary treatment. Oxytocin infusions upon an
initial amniotomy is typically used to move normal labor back on track. The application of
oxytocin is only effective if administered on the basis of fetal distress. This treatment method only
pertains to specific states of the fetus. If the baby is experiencing malpresentation, for example, the
only safe and reliable method to proceed with childbirth is medical interference.

REFLECTIVE JOURNALS

Reflective journal 1

Control infection
37
Reflective journey 2

Introduction

Family is away family choose number of children and spacing between them and is voluntary
decision made by family no other party to involve in their decision. In family planning health care
providers teach family different method used in family planning it's benefit and consequence then
let family choose method which is better to them
Situation (what actually happen)

My first day in postpartum ward I was very interested on what's go on there in postpartum. After
orientation in ward, the next was health education about family planning, group education had
given well by nurse where she started by definition, importance and different method used in
family planning. After we approached every mother personally by asking method had been chosen,
honestly we wished that every mother to choose implants (jadelle) as we as student want many
case about it, but we reached to the mothers who decided to use other methods like pills, LAM,
condoms, etc., meanwhile nurse get angry to them and forceful she made decision to them some of
them refused to do so and nurse told to us to not give them pills or condoms. Actually patient
hadn't gotten their chance to decide method they wanted.

Affect and why I felt as I did (what was its impact on me personally and why)

I was not happy to see client can't decide her own method and other to be abandoned because they
didn't accept implants and nurse to decide to have them pills I felt like patient right is destroyed

Interpretation (what I learn from the experience)

I had approached a nurse and ask her to reconsider reason why that mothers don't want implants
and tell her that it's their right to decide beneficial methods to them I felt happy as nurse got what I
had told to her and let me gave them pills and condoms. what I learned is during family planning
education I have to explain well to patient until he /she got good and consequences for each
method but let her decide as is who face effects (good or bad) firstly

Decision (what I decided to do so as to become a better nurse)

38
I decided to do my job better by accept and obey patient right but put more effort in explain more
about service I providing to him/ her but let her full right to decide as its boost healing process as
patient is psychologically good.

Reflective journal 3

Situation (what actually happen)

It was in morning on 5th in labor ward where we received woman G1 P 0 was in labor she was been
transfed to the hospital because she refuses to push a baby during contraction she was with small
laceration because she had been beaten by some family members (husband, big sister, mother) and
health care providers it seems like everyone was happy for her honesty me also was sad to her
meanwhile we are straggling with her one nurse came and observe situation, kindly and politely
started to talk to the mother. Mother stared to tell her why she doesn’t want to push that it is
because she has fear to face pain and she need caesarian, nurse tried to explain for that according
to decent of baby that c section cannot done mother try to understand and start to push.

Affect and why I felt as I did (what was its impact on me personally and why)

My feeling was mixed, bad to see my refused to push baby until she got transfer from muhondo to
byumba hospital without other problem despite of her weakness of not trying to push. On other
hand my feeling was good as see patient started to collaborate with health care providers because
impact of sympathy showed by nurse to the patient. I was so excited when we received baby but
mother has many tears
Interpretation (what I learnt from the experience).
I have learned to never give up to any situation when you have not tried all you can. I have learned
to never leave behind because there one way or other he/she can collaborate. I have learned that
even if situation is hard you must obey and flow protocol as you can.
Decision (what I decided to do so as to become a better nurse)

This led to think twice, as good word had changed situation I decide to put more effort in
collaboration with patient and to try to be in shoes of patient. So as you showed sympathy to
patient have positive impact in curing process this will led to health society so wealth nation

Retained placenta 4
The retained placenta is defined as the placenta that has not undergone placenta expulsion within
30 minutes of the baby’s birth where the third stage of labor has been managed actively. A retained
placenta is a main cause post-partum hemorrhage both primary and secondary.

39
Situation (what actually happen).
In maternity ward we received the client called D.A she is 36 years old. About her antecedent she
is G3 P3 PD=0 LC=3, DC=O. three days ago she delivered a male health baby with 3600gr and his
APGAR was 10/10. After the third stage of labour the client experienced bleeding that was being
caused by the retained placenta. The midwife in charge injected oxytocin 10 IU to the client for
uterine contractions, hence he administered ampicillin as prophylaxis of infection and analgesic for
relieving pain, then he worn the sterile gynaecological gloves to remove the retained placenta.
Affect and why I felt as I did (what was its impact on me personally and why)
I hadn’t been confused about the procedure that was done because it had been practiced with
asepsis as we had studied.
After assisting in delivering the retained tissues, asked the registered midwife more about retained
tissues including their causes.
Interpretation (what I learnt from the experience).
The thing I learnt from that situation is that I have to always respect closely follow up and
monitoring to my clients. inform the senior health care provider while I meet with complicated
cases to me for a help.
Decision (what I decided to do, so as to become a better nurse).
After that event I decided to use critical thinking about the case happened and I decided to do more
research about retained placenta including its risk factors, causes, complications and how it can be
managed so that I couldn’t fail to manage it at the next time.
Reference: Duffy, James (2014)

Caput succedaneum 5
Caput succedaneum is a type of swelling around the skull, which can give an infant a” cone head”
appearance. Usually, it forms after difficult delivery or prolonged labor. At this condition an infant
skull is not hard and fused like an adult. it is soft and made up of section of bone which meet at
“suture lines”. These soft pieces of the skull will harden and join together as the child ages.

Situation (what actually happen).

40
In post-partum I performed the assessment of the new born, he had a swelling around the skull
(caput succedaneum). Her mother was frightened about that condition because she thought that it
was a kind of abnormality.
Affect and why I felt as I did (what was its impact on me personally and why)
I felt confused when the baby’s mom had been crying and talking that her baby was born with a
malformation, I assessed the baby and I found that he had born with caput succedaneum. At that
time, I counselled the mom about that situation of caput succedaneum including its causes, risk
factors and healing process. I explained her how it occurs with its phenomenon until she
understood it was not a malformation.
Interpretation (what I learnt from the experience).
The thing that I have learnt from this situation is that” as students together with health care
provider, we have to perform a complete assessment of the newborns and hence we communicate
the findings to their parents. The other thing I have learnt from this situation is that” it’s not good
to apply pressure or any other compression to the swelling area because it may cause brain
damage.
Decision (what I decided to do, so as to become a better nurse).
As a future nurse I decided to hold on professional codes of conduct by performing all procedures
as we have studied them and avoiding routines. Having a clear communication with the clients
including history taking, counselling and providing them health education. As a future nurse have
to conduct a good collaboration with clients, colleagues, supervisors and other health care
providers with the purpose of improving my knowledge.
References: -Kallen Gill, Lori Smith on 13 August2018.
-Google searching about cap succedaneum.

INTRODUCTION
This reflective journal is done on how to manage late term
pregnancy and induction of labor .Term gestation is
defined as a pregnancy between 37 and 42 completed
weeks (260 to 294 days) after the first day of the last
menstrual period (LMP). Postterm pregnancy begins
when 42 completed (menstrual) weeks have elapsed. The

41
first day of the LMP occurs approximately 2 weeks before
conception in a 28-day cycle (Sharon B., and Sindhu K.
S.2008)
Induction of labor: Stimulation of uterine contractions
prior to the onset of spontaneous labor for vaginal
delivery after the age of viability. (Mayor clinic staff
2017)

WHAT ACTUALLY HAPPENED.

Patient B.B, 21 Years old Gravida one party zero,
admitted from Bwisige health center on 12/10/2021at
10h00 for the reason of post term pregnancy management.
Her last menstruation period was on 27/01/2021 expected
date of delivery was 3/10/2021. Gestation age was fortyone
weeks (41wks).

Vital signs were: blood pressure 118/82mmhg, pulse 110

beat/min, temperature 36.0oC, respiration rate 18
breath/min. Weight 64kgs, height 166cm, number of
antenatal care visit four times. Fundal height 30cm, Fetal
heart rate was 140 beat/min, on vaginal exam cervix is
open at one centimeter (1cm). Amniotic membrane intact,
effacement 10% and her pelvis is adequate.
Chief complain on admission is lumborpelvic pain
contraction like on pregnancy of 41wks. Symptoms
started during the night and still on admission no progress
on late term labor. Differential diagnosis is late term
pregnancy of 41weeks of gestation on latent phase of
labor. on ultrasound presentation is cephalic, adequate
amniotic fluid and adequate placenta. fetus with weight of
3420grams.

42
Final diagnosis is late term pregnancy in latent phase of
labor.s
Investigations: FBC, BG &Rh RUBELLA, Hep B&C,
TOXOPLASMOSIS, RPR.

Treatment plan was: admit the patient in labor ward, fetal

and maternal monitoring, then induction of labor with
cytotec 50microgrma sublingual every four hours,
maximum 6 doses. She started the first dose at
11h45minute.

At 11h30 min FHR was 147bpm. At 12h00’ FHR WAS

140 bpm, at 12h27’ FHR was 150 bpm, at 13h00’ was
147pbm, at 13h37’ FHR was 148 bpm, at 14h00’ FHR W
was 137bpm, at 14h30’ FHR was 150bpm, at 15h07’
FHR was 152bpm, at 15h46’ FHR WAS 147bpm and she
take the second dose, on second dose, she started having
one contraction like lasting 20 sec in 20min. then at
16h00’ FHR was 148bpm, at 16h30 FHR was 146bpm,
and at 17ho5min, FHR was 145bpm. With few
contractions like that coming in every 15 to 10 minutes.

EFFECTS ON ME PERSONALLY
I feel happy due to the above case because all we did and
monitored is to save the life of mother with her fetal and
the labor progress well without any complication. Also
the mother was good collaborating and able to support the
contraction.

WHAT LEARNED FROM EXPERIENCE.

43
Form the above experience and knowledge I learned
about stage of term pregnancy which include early term
pregnancy from 37weeks zero day to 39weeks 6 days.
Full term pregnancy from 40weeks 0 day to 40 weeks 6 days. Then late term pregnancy from 41
weeks 0 day to 42weeks.

DECISION (WHAT I DECIDE TO DO SO AS TO BECOME A BETTER NURSE)

In order to became a good future Nurse, the better thing

to do is self-confidence and term work with medical term,
midwifes and nurses. Consult the literature for update is
also an important key never to left behind.

COLLEGE OF MEDICINE AND HEALTH SCIENCES

TITLE OF THE REPORT: CLINICAL PLACEMENT GROUP REPORT

COLLEGE OF MEDECINE AND HEALTH SCIENCES

SCHOOL OF NURSING AND MIDWIFERY

Department: GENERAL NURSING

Program: Advanced diploma in general nursing

44
Academic Year: 2021-2022

Year of study: LEVEL III

Name of Clinical site (institution): RANGO HEALTH CENTER

Period of clinical placement: from 12/09/2022 to 14/10/2022

CLINICAL PLACEMENT

REPORT OF RANGO HEALTH

CENTER

Prepared by:

Names Ref. e-mails phone

num numbe
ber r

MUTUYI 2200 Mutuyimanaerisabeth20 078638

MANA 0245
Elizabeth 0

45
 @gmail.com 4618

IRAGENA 2200 simbigise@gmail.com 078954

SIMBI 0139 8910
Gisele 5

DUSENGE 2200 dusengimana88@gmail.c 078933

Eric 0446 69169
om
6

2200 0livimugi@gmail.com 078048

MUGIRA 0587 8883
NEZA 8
Olivier

UWIHAN 2200 emmaculeuwihanganye 078439

GANYE 0526 @gmail.com 4406
Immaculee 0

CLINICAL SUPERVISOR: KABANYANA Pauline

ACKNOWLEDGEMENT

Firstly, we really thank God who helped us during our clinical practice of 5weeks giving us effort
and protect us. We thank school administration for giving the period of clinical practice, which
help us to put what we learned in theory into practice, to be familiar with our career and increase

46
our knowledge. Thanks to all supervisors who had been with us within this whole period of clinical
practice, you have helped us in learning more and achieving our objectives. Sincerely we thank
Rango health center staff to allow us to do our clinical practice in this heath center. Thanks to all
clients who allowed to collaborate with us and helped us to put into practice our theoretical
knowledge.

PRESENTATION OF THE CLINICAL PRACTICE SETTING

BRIEF DESCRIPTION OF THE SITE

Backg

round of RANGO Health Center

INTRODUCTION

Rango health center has four apartment houses and is one of seventeen health centers located in
Huye district and the only one in Tumba sector. This institution is public health supported by
government in its Ministry of health. Rango health center is situated in southern province, Huye
district, Tumba sector.

47
This institution is introduced in by the government of Rwanda in the behalf of taking care of
people’s life. Today this health center covers the population who are around 37847 who come in
Tumba sectors and neighbor’s sectors. The above number of people situated in 5 cells and 33
villages with 127 community Health workers, 8 nurses on A1 level, 5nurses with A2 level, one
environmental health with A1 level, one social assistant with an A2 level, four cleaners, three
biotechnologists with A2, and one of Biotechnology of A1 one accountant with A2 level, two
watch-gate, one EMR manager with A1, one customer care with A2 level, one nutritionist with A1
level , Data manager A2, one cashiers with A2 level and one Receptionist and customer care A2.

Aims of RANGO Health Center

There are five main aims of Rango Health Center which are following:

 To help people to achieve and maintain healthy lives and restoring community based health insurance
through the households
 To be well known as the best health center in the region
 To augment medical tools to facilitate the accessibility and the quality of health care to the
population of the area where the center situated
 To reduce maternal death and child mortality under five years in giving a good prenatal care and
vaccination
 To discharge best customer care services with the maximum quality as well as curative as preventive.
 To convey the innovations in health service and to be outstanding by helping people to get to the
improved lives

Mission and vision

 To reduce malnutrition
 To improve maternal health
 To reduce number of infant mortality under five years
 To promote family planning as the probable solution to the demography problem which increase
every day.

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  To give good care to people who live with HIV, TB and several chronic diseases
 To implement Government policies
 To promote solidarity and cooperation with other health center

DESCRIPTION OF ATTENDED SERVICES

During this clinical internship we have attended SIX services namely: family planning,
Vaccination, wound dressing, consultation, maternity and antenatal care services

CASE STUDY OF INTEREST

We have focused on malaria disease because in this area we have found many cases of malaria.
This the reason why we interested on this case in order to search more information about this
disease.

CASE STUDY

Client identification

Initial names: I.A Age:10 years old Sex: Female

Province: Southern District: Huye Sector: Tumba

Cell: Cyimana Village: Ubumwe

Marital status: Single Next of kin: Her mother Religion: catholic

Occupation: student

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Date of admission: 05th /October/ 2022

Chief complaints: Nocturnal fever, headache, chills, body weakness, anorexia, and joint pain

History of present illness: These symptoms above were started on 02th/10/2022. This time client’s
feel fever and chills and progressive with headache followed by loss of appetite. Today her mother
comes her to the health center for further management.

Past medical history: No history related to chronic diseases, and allergy medications.

Surgical history: No reported

Family history: She has both parents, brothers and sisters.

Socio-economic history: Her family is found in 2nd category of Ubudehe and lives with her family

Allergic history: no known allergy

PHYSICAL ASSESSMENT

1. Vital signs and parameters

Temperature: 38.10C Weight: 27kg
RR: 20 cycle/min Height: 1.35cm
Pulse: 78beats/min
2.REVIEW OF THE SYSTEM.
Head: Hair is black colored but she complaints headache since 2 days ago.

Ear: no discharge from ear and two ears are symmetry.

Eye: conjunctiva well colored no anemia or jaundice

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Nose: no flu, no nasal obstruction, bleeding, and nasal polyps

Neck: No stiffness, jugular vein heard and not distended.

Throat: swallow normally without dysphagia, no sore throat and tonsillitis seen during inspection.
No cleft lip and cleft palate in the mouth.

Central nervous system: She is alert and well oriented with Glasgow coma scale of 15/15.

Respiratory system: she breaths normally with 20 breaths/min, no cyanosis on extremities or

tongue, and no abnormal sound (wheezing and crackles).

Cardio-vascular system: Chest is symmetry and no discharge from the nipple. Peripheral pulse is
present with regular heart beat with pulse of 78 beats/min. On auscultation: S1 and S2 are audible
without heart murmurs.

Gastro-intestinal tract: Abdomen not distended or bloating, no constipation, vomiting and

diarrhea. Bowel movement and sounds are audible.

Genital-urinary: normal urination, urination frequency is normal, genital organs appear well
normal and no abnormal discharge from sex.

Muscle-skeletal: Joint Pain, upper and lower extremities well-functioning without fracture and
capillary refill is less than 2 seconds.

Integumentary system: No rashes on the skin, color of skin is normal, it is soft and moisture.

Suspected diagnosis: Simple malaria, septicemia.

Investigation: Blood smear results positive

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Final diagnosis: Simple malaria

Treatment plan: Paracetamol 500mg TIDs/3days

Coartem 2x3tablets/BIDs/3days

NURSING CARE PLAN FOR MRs I.A ON 05/10/2022

Nursing Nursin G Nur Ratio Ev

Assessment g oa sing nale alu
diagnos ls inte ati
is rve on
ntio
n

Subjective After 20 min

Hyperth Cl - -
data of
ermia ie Ope Openi
intervention,
Body
related nt’ ning ng
fever
weakness,
to s the doors
reduced from
headache,
disease fe door and
38.10C to
fever,
conditio ve s windo
37.30C
anorexia,
n r and ws
and chills
(malaria wi win impro
) as ll dow ve
Objective evidenc be s, ventil
data ed by re war ation
tempera du m then
52
Fever of ture of ce wate fever
T:38.10C, 38.10C d r reliev
Pulse:78bea fr appl ed.
ts/min, o icati
RR:20 m on -
cycles/min, 38 on Parac
.10 the etamo
Treatment C fore l act
plan to head as
Paracetamo 37 , antipy
l 500 mg .00 retic
TIDs/3days C -
wi adm
Coartem thi inist
3tabs n er
BIDs/3days 20 drug
mi as
n pres
aft crib
er ed.
nu (par
rsi acet
ng amo
int l
er 500
ve mg
nti TID
on s/3d
ays,

53
 Coa
rtem
3tab
s
BID
s/3d
ays)

Acute Cl Col Cold Still in

pain ie d applic process
related nt’ appl ation because our
to s icati reduc client is an
change pa on, e outpatient.
in body in reas pain,
function wi sure exerci
ing as ll the ses
manifes be clie increa
ted by rel nt, ses
client ie impr muscl
verbal ve ove e
report d RO relaxa
(pain fr M, tion
scale of o and leads
4/10) m adm to
4/ inist decrea
10 er se of
to drug pain
2/ pres
10 crib
wi ed.
thi

54
 n
2
ho
ur
s

Knowle Cl Heal This After health

dge ie th educat education
deficit nt’ educ ion client receive
related s atio helps and able to
to kn n client obey the
unfamili o abo to get information
arity wl ut infor provided.
with ed info matio
informa ge rmat n
tion as wi ion about
manifes ll relat physi
ted by be ed ologic
delay im to al
for pr sign chang
coming ov s e of
to ed and body
health wi sym functi
center thi pto oning.
at the n ms
first 15 of
sign of mi dise
disease. n ases
of and
ed role
uc of

55
 ati com
on ing
for
heal
th
facil
ity
earl
y.

THEORITICAL SKILLS FROM LITERATURE ABOUT CASE

Malaria is a disease caused by a parasite. The parasite is transmitted to humans through the bites of
infected mosquitoes. Is a potentially life-threatening disease caused by infection with Plasmodium
protozoa transmitted by an infective female Anopheles mosquito vector. Malaria is a serious and
sometimes fatal disease caused by a parasite that commonly infects a certain type of mosquito
which feeds on humans.

Malaria have three types:

 Simple malaria
 Simple malaria with minor digestive symptom
 Cerebral malaria

CAUSES

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There are the Different Types of Malaria Parasites can infect humans and cause illness which
are:

 Plasmodium falciparum (or P. falciparum)

 Plasmodium malaria (or P. malariae)
 Plasmodium vivax (or P. vivax)
 Plasmodium Ovale (or P. Ovale)
 Plasmodium knowlesi (or P. knowlesi

PATHOPTHYSIOLOGY

The natural history of malaria involves cyclical infection of humans and female Anopheles
mosquitoes. In humans, the parasites grow and multiply first in the liver cells and then in the red
cells of the blood. In the blood, successive broods of parasites grow inside the red cells and destroy
them, releasing daughter parasites (“merozoites”) that continue the cycle by invading other red
cells.

The blood-stage parasites are those that cause the symptoms of malaria; when certain forms of
blood stage parasites (gametocytes, which occur in male and female forms) are ingested during
blood feeding by a female Anopheles mosquito, they mate in the gut of the mosquito and begin a
cycle of growth and multiplication in the mosquito.

After 10-18 days, a form of the parasite called a sporozoites migrates to the mosquito’s salivary
glands. When the Anopheles mosquito takes a blood meal on another human, anticoagulant saliva
is injected together with the sporozoites, which migrate to the liver, thereby beginning a new cycle.

RISK FACTORS

 Young children and infants

 Older adults
 Travelers coming from areas with no malaria

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  Pregnant women and their unborn children

Poor immunity: The outcome of infection depends on host immunity; individuals with immunity
can spontaneously clear the parasites; in those without immunity, the parasites continue to expand
the infection.

Climate: Climate is a key determinant of both the geographic distribution and the seasonality of
malaria; without sufficient rainfall, mosquitoes cannot survive, and if not sufficiently warm,
parasites cannot survive in the mosquito.

SIGNS AND SYMPTOMS

 A sensation of cold and shivering.

 Fever, headache, vomiting, and seizures in young children.
 Sweating, anorexia, and tiredness.

DIAGNOSING

Blood smears: A diagnosis of malaria should be supported by the identification of the parasites on
a thin or thick blood smear, and Rapid diagnostic tests.

Medical diagnosis: Malaria

NURSING DIAGNOSIS

 Acute pain related to disease condition.

 Risk for infection related to weakened immune system.
 Hyperthermia related to increased metabolic rate and dehydration.
 Fluid volume deficit related to excessive sweating and dehydration.

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  Knowledge deficit related to lack of exposure and information about the disease process, its
treatment, and prognosis

NURSING MANAGEMENT

 Improve body temperature.

 Improve tissue perfusion
 Improve fluid volume.
 Educate the patient and family. Review the disease process and therapy, focusing on patient’s
concerns.

MEDICAL MANAGEMENT

Artemisinin-based combination therapies (ACTs). ACTs are, in many cases, the first line treatment
for malaria. There are several different types of ACTs. Examples include artemether-lumefantrine
(Coartem) and artesunate-amodiaquine. Each ACT is a combination of two or more drugs that
work against the malaria parasite in different ways.

Chloroquine phosphate. Chloroquine is the preferred treatment for any parasite that is sensitive to
the drug. But in many parts of the world, the parasites that cause malaria are resistant to
chloroquine, and the drug is no longer an effective treatment

PREVENTION

 Apply insect repellent to exposed skin. ...

 Wear long-sleeved clothing and long pants if you are outdoors at night.
 Use a mosquito net over the bed if your bedroom is not air-conditioned or screened. Spray an
insecticide or repellent on clothing, as mosquitoes may bite through thin clothing.

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THE COMPLICATIONS

 Cerebral malaria: If parasite-filled blood cells block small blood vessels to your brain (cerebral
malaria), swelling of your brain or brain damage may occur. Cerebral malaria may cause seizures and
coma.
 Breathing problems: Accumulated fluid in your lungs (pulmonary edema) can make it difficult to
breathe.
 Organ failure: Malaria can cause your kidneys or liver to fail, or your spleen to rupture. Any of
these conditions can be life-threatening.
 Anemia: Malaria damages red blood cells, which can result in anemia.
 Low blood sugar: Severe forms of malaria itself can cause low blood sugar (hypoglycemia), as can
quinine — one of the most common medications used to combat malaria. Very low blood sugar can
result in coma or death.

ANALYSIS OF THE QUALITY OF CARE PROCEDURE

WOUND DRESSING
Wound dressing is a protective covering placed on the wound. Dressing protect them from further
trauma and provide moist environment for healing.

IMPORTANCE OF WOUND DRESSING

Wound dressing protect the wound from mechanical injury, protect the wound from microbial
contamination, provide or maintain humidity of the wound and It absorbs drainage or debride
wound

POSITIVE POINTS BEARING IN MIND THE STANDARD OF THE PROCEDURE

We have seen that during nursing procedure they respect solution to be used, they have good
organized staff and they work as team, they know how to manage time and they use critical
thinking and analyzing skills

NEGATIVE POINTS BEARING IN MIND, THE STANDARD OF PROCEDURES

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They didn’t prepare patients before any procedure, they didn’t present themselves to the patients
and they didn’t respect sterility during material preparation

IMPLANON INSERTION
An implant is a small flexible rod that is placed just under your skin in your upper arm. It releases a
progesterone hormone similar to the natural progesterone that women produce in their ovaries and
works for up to three years.

IMPORTANCE OF USING IMPLANT

It works for three years, it does not interrupt sex, you can use it if you are breastfeeding, your
fertility will return to normal as soon as the implant is taken out and It may reduce heavy, painful
periods.

POSITIVE POINTS BEARING IN MIND THE STANDARD OF THE PROCEDURE

We have seen that during nursing procedure they respect solution to be used, they have good
organized staff and they work as team, they know how to manage time, they use critical thinking
and analyzing skills and they respect sterility
Negative points bearing in mind, the standard of procedures They didn’t prepare patients before
any procedure, they didn’t present themselves to the patients and they didn’t respect sterility
during material preparation

The student in put made for improving the quality of the PROCEDURE
 We try to perform procedure as we have studied and in case we get a challenge, we try to ask
questions
 We have tried to ask many questions about procedure and after getting more explanation we try join
it with we know. so our skills had been increased.
 We have tried to collect same mistake we have seen
 we tried to share information regard to this procedure to other health care provider

Challenges encountered during the period of clinical placement

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During our clinical placement we the learners in nursing met with different challenges. Those
challenges include the following: ineffective communication and emotional reactions.
The first challenge we faced in our clinical placement is the problem of ineffective communication;
the improper treatment and fear were one of the challenges that we met in dealing with clinical
learning environment and in interaction with instructors, patients, and department personnel.
Companions of the patients never trusted us again, one of the patients started to see us in another
manner (shape).
Finally, the other challenge we met is emotional reactions (stress). We were hoping for our
internship to be just finished as soon as possible.
Also we met with a challenge of insufficient of materials like in wound dressing and maternity
services which had affected our achievement of objectives but we have tried our best to fulfill our
expected objectives.

LESSON LEARNT
In this clinical placement we learnt that health care profession is a profession which needs
patience, empathy, honest, respect and adaptive. We also witnessed and participated in
multidisplinary team meeting, where we gained not only skills from the cases usually presented but
also gained skills of leadership skills and organization structuring. Within this clinical placement,
we have also learnt that communication in the health and social care underpins everything that
professionals do and can determine the quality of the service that the patient receives. Poor
communication between members of Interprofessional teams affects the quality of care patient
receive and can results in any number of bad experiences for the patient.

CONCLUSION AND RECOMMENDATIONS

CONCLUSION

In this clinical placement was very good and helpful because we tried to achieve our objectives but
because we faced some challenges, need to get the improvement and changes in order to prevent
other challenges in the next clinical placement. This clinical placement, it was very helpful

62
because we tried to put into practice of what we learned in theory and according to our objectives
we tried to achieve them on 90% with the help of our Supervisor and Nurses also tried their best to
help us and we thank them and in general we thank our school staff and RANGO health center for
giving the Opportunities of doing this clinical placement to put into practices what we learnt in
theories.

RECOMMENDATIONS

 we have recommended that during procedure performance, everyone should bear in mind asepsis as
well as use of available materials properly with the sole aim of provision and promotion of good care,
increasing collaboration level with the patients, promotion of both preventive and protection
techniques and we do recommend that wound dressing materials like forceps, kidney dishes and
sheets for individual set preparation should be increased prepared.
 Basing on what we have seen at RANGO HEALTH CENTER, there was a big difference compared
to what we studied in theory. So, we recommend them that they may improve the sterility in wound
dressing and maternity ward to improve quality of health service that will also prevent infections.

REFERENCES

1.Black, J. M., & Hawks, J. H. (2017). Medical-surgical nursing. Elsevier Saunders,

2. Kimberlin, D. W. (2018). Red Book: 2018-2021 report of the committee on infectious diseases (No.
Ed. 31). American academy of pediatrics.
3. Oshinsky, D. M. (2019). Polio: American story. Oxford University Press.
4. Willis, L. (2019). Professional guide to diseases. Lippincott Williams & Wilkins.
5. WHO Expert Committee on Malaria, & World Health Organization. (2017). WHO expert committee
on malaria: twentieth report (No. 892). World Health Organization.

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 6. RANGO health center annual report provided by health center Secretary and data manager in written
and printed document as done at in 2020.

References

Retrieved from
https://mayoclinic.org/testshttps://mayoclinic.org/tests-
procedures/labor-induction/about/pac-20385141 on 25 Dec
2018procedures/labor-induction/about/pac-20385141 on
25 Dec 2018.
Sharon B., and Sindhu K. S. (2008) ‘preterm labor’ in
Samantha M. and Pfeifer (ed) (2008) NMS Obstetrics and
Gynecology 6thedition, Lippincott Williams and Wilkins, university
of Pennsylvania school of medicine.
Gary F.S., at al 2007 Williams Obstetrics 22nd edition >

Section IV. Labor and Delivery > Chapter 22.

Induction of Labor, The McGraw-Hill Companies.

proof and evidence

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