5.

GROUP CLINICAL REPORT

COLLEGE OF MEDICINE AND HEALTH SCIENCES

GROUP CLINICAL REPORT DONE AT GISENYI DISTRICT HOSPITAL

SCHOOL OF NURSING AND MIDWIFERY

DEPARTMENT OF GENERAL NURSING

ADVANCED DIPLOMA PROGRAM

HUYE CAMPUS

YEAR OF STUDY: LEVEL TWO

NAME OF CLINICAL SITE: GISENYI DISTRICT HOSPITAL

PERIOD OF CLINICAL PLACEMENT: FROM 29th AUGUST, 2022 TO 21st OCTOBER,

2022.

s/n First name Surname Reg. number Units/wards

1 IRIMASO Antoine 221020641 MEDICAL,
2 MIZERO NSHUTI LAISSA 221004220 SURGICAL,
3 RUKUNDO JEAN PAUL 221011930 ACCIDENT&
4 MUKAMWIZA MARIE CHRISTELLA 221000335 EMERGENCY
5 IRADUKUNDA ERIC 221004005 AND
6 GATESI HENRIETTE 221008152 THEATRE
7 NIYINGABIRA OLIVIER 221021311
8 SIBOMANA JEAN CLAUDE 221030281
9 INEMAZACU JOSIANE 221008752
10 HAGENIMANA EMMANUEL 221005826
HISTORICAL BACKGROUND OF GISENYI HOSPITAL

GISENYI DH is localized in the Western Province, Rubavu District, in Gisenyi Sector few
meters from Kivu Lake. It is situated in a touristic town of Gisenyi bordering DRC. The hospital
attends a population of over 515083 persons spread over 12 sectors of the Rubavu district, 13
Health centers such as: Busasamana, Bugeshi, Mudende, Kabari, Nyakiliba, Karambo, Nyundo,
Murara, Byahi, Gacuba II, Gisenyi, Kigufi, and Busigari. It serves also some areas of Rutsiro,
Nyabihu Districts and Goma town/Democratic Republic of Congo (DRC).

Gisenyi DH started working during the colonial period in 1930 as a health post in Gisenyi. It was
engaged in promoting preventive and curative services at a primary level.
With population growth, it was necessary to improve the infrastructure and services arrival of a
Belgian surgeon called DEWILDE around the year 1950, Gisenyi health post became Gisenyi
Hospital.

Since 1972, Gisenyi Hospital was under leadership of a nurse who was replaced by a physician
in 1975.Under the leadership of a nurse, Gisenyi Hospital had seven services, radiology services
started in 1976.

By 1984, Gisenyi hospital expanded its buildings. Those include:

Operating theater,
Surgical ward,
Obstetrics and Gynecology ward.

During the tragic events of Rwanda genocide, Gisenyi Hospital stopped working until around
August, 1994. Now Gisenyi hospital has 249 personnel, 316 beds, beds occupation rate 73%.
And has expanded its buildings to:

Emergency ward.
 Internal medicine ward.
Pediatry
Ophthalmology.
Laboratory.
OPD
ARV
Isange one stop center.
Kinestherapy.
Mental health ward.
Radiograph and Echography buildings.

1.1.2 Mission

Gisenyi is committed to:

Continually improve the quality of health care by offering curative and preventive care
Coordinating all activities of partners at all levels
Supervising health centers thus contributing to the quality of service

1.1.3. Vision

Hospital's vision is to be the hospital of first choice in western province, to provide high quality
health care service, to comply with the international standards.

1.1.4. Core value

The mission of the Gisenyi Hospital will be supported by four values:

Quality: The constant search for quality and efficiency will guide the activities of each staff,
common ambition of the institution's staff will provide quality service for both medical and
administrative logistics accordance with national standards and guidelines for the health policy.
Compassion: The other value will be respect, listening and maintain confidentiality to clients.
Treat customers with compassion and dignity while satisfying the conditions of confidentiality.

Team working: The team will be bound by the staff interrelations; it will have an awareness of
belonging to the group and will pursue a common goal oriented towards a convergence of efforts
of the team of Gisenyi Hospital.

Efficiency: The efficiency value will affect the sound management of all the resources of the
hospital with the same responsibilities to achieve good performance from the production of all
the players in the hospital.

BRIEF DESCRIPTION OF ATTENDED SERVICES

1. SURGERY DEPARTMENT

1. MISSION OF SURGERY DEPARTMENT.

The mission of the department is to strive to be a Center of excellence in surgical service

delivery, medical education and research in the Southern Province and beyond.

We seek to be sensitive to the needs of our patients and their families during the course of
offering surgical services.

2. OBJECTIVES OF SURGERY DEPARTMENT.

1. Patient first in whatever we do.

2. Compassion for our patients

3. Teamwork helps us to achieve our mission.

4. Customer care for our patients

5. Integrity; transparency, honesty and sincerity governs our code of conduct.

6. Excellence; we never stop learning and working to improve our skills

7. Ownership of the departmental targets.

3. MAIN ACTIVITIES
 · Out patients clinics: Out patients consultations, minor surgery and Plaster
clinics
· Pre-operative management
· Theatres activities
· Post-operative management
· In patients consults (Ward rounds)
· Special investigations (ENT, Ophthalmology)
· Training and supervision of Referral and District Hospitals in CHUB
catchment areas
· Community based activities (Outreaches)
· Researches
2. INTERNAL MEDECINE

Gisenyi internal medicine is a department which is leaded by IRANKUNDA Delphin as Head

of Department. And it is one ward which is very organized with one senior doctor who is called
doctor BUTONZI John, one General Practitioner who is called NYANDWI Eugene and other
two interne doctors. And also, internal medicine has also 13 nurses (six of them they have A0 in
nursing, six has A1 in nursing and one them she has A2 in nursing).

Also, internal medicine department is divided into two ward one ward for male and other ward
for women and when you combine these can host 60 patients (30 male patients and 30 female
patients) at the same time but also internal medicine it one department which are in charge of
controlling a patient who are hospitalized in private chambers. Where those chambers can host
18 patients means it has 18 chambers. So, internal medicine can host 78 patients at same time.

Department offers different services to adult patients with age varying from 16years to old age.
Patients with different pathologies get the prevention, diagnosis and their care in a general
approach. As well as the staff is mainly composed by general practitioner and internists. The
department offers different services to adult patients with age varying from 16years to old age.
Patients with different pathologies get the prevention, diagnosis and their care in a general
approach. As well as the staff is mainly composed by general practitioner and internists.

We give daily follow up for the good recovery of the patients and for difficult cases transfer to
tertiary level is necessary for further management. It is staffed by certified nurses and physicians.
The tuberculosis service is included for a good follow up for the patients. Mental health service
is integrated in internal medicine to strengthen a good follow up of mental health care

PRESENTATION OF A CLINICAL CASE OF INTEREST

We have chosen fracture as clinical case of interest because GISENYI district is a region with
high rates of Road traffic accidents mostly due to traffic jam, and sometimes people driving with
falsified driving licenses from neighboring country (DRC). From the observation we have seen
that 80% of all patients received on emergency are cases of RTA, and among those 80% half of
them are having fractures.

FRACTURE

Names: N.S

Age: 55 years

Sex: Female

2. Address: Rubavu, Rugerero, Rwaza, Kiraji

Next of kin: her daughter

Religion: ADEPER

Marital status: Married

Health insurance: MUSA

Occupation: Subsistence Farmer

3. Chief complaints on admission

Swelling, and Right leg pain

4. History of present illness: The symptoms started that early morning when the patient had an
RTA caused by a motorcycle.

5. Past health history (antecedents): No known chronic condition.

Family and social history: She lives in a 6 membered family, and she is in 2 nd category of
UBUDEHE.

Date and time of Admission: 12/10/2022 at 8:00 AM

Review of body systems

  Central nervous system: GCS:15/15, ENT is normal.
 Cardio vascular system: S1 and S2 Audible with no murmurs.
 Respiratory system: Clear lung sounds, good air entry.
 Gastro-intestinal tract: no organomegaly, and no tenderness.
 Genital urinary system: no abnormal findings and no complaints reported by the client
 Muscular skeleton system: Thigh tenderness, decreased Range of Motion, swollen,
warm and tender.

Vital signs on the time of admission

Blood Pressure: 110/65mmHg

Temperature: 36.8℃ taken axially in the morning hours
Regular normal pulse rate of 102beats per minutes
Regular and effortless respiration rate 0f 17 breaths/min
Oxygen saturation: 95%

General overall health state: A 55 years old female patient admitted on 08/11/2021.presented
with left leg functional impairment, swelling and tenderness post to RTA.

Differential diagnosis

 Thigh muscle contusion

 Left Femur fracture

Investigation summary

• FBC

• Thigh X- ray

Medical diagnosis

 Left Femur Fracture

Treatment plan:

IM Diclofenac 75 mg
 Pct Po 1g TDS 7/7

Ibuprofen Po 400 mg Bid 5/7

Traction

NURSING CARE PLAN OF N.S ON 12/10/2022

NursingAss Nursing Objective Interventions Evaluation

essment Diagnoses s

subjective Acute pain Patient's -Instructing the The pain

data: related to pain will patient regarding reduced from
fracture, soft be proper methods to 7 to 3 after 1
Pain scale:
tissue injury, reduced control edema and hour of
7/10
and muscle from 7/10 pain intervention.
Left thigh spasm AEB to 3/10
-Elevate extremity.
swelling 7/10 pain within 2
The affected
and score. hours.
extremity is elevated
tenderness.
to minimize edema.

-Administer
objective prescribed pain
data: killers.

Body
temperature
of 36.80c Impaired Patient Teaching exercises to The patient is
physical will maintain the health of showing
Pulse of
mobility achieve a the unaffected functional
110beats/mi
related to pain-free, muscles and to body parts
n
fracture AEB functional increase the strength movement
Respiration inability to , and of muscles needed for after 3 days of
of stable transferring and for hospitalizatio
18cycles/mi move body part using assistive n.
n movemen devices.
t after 3
Therapies
days of
Prescriptio hospitaliz
n: ation.

IM Risk for Patient Wound management. After nursing

Diclofenac infection will be Wound irrigation and intervention
75 mg related to Prevented debridement are and close
Pct Po 1g opening in the from initiated as soon as monitoring,
TDS 7/7 skin in an infection possible the patient is
open fracture. during free from
•Ibuprofe Signs of infection.
hospitaliz infection.
n Po 400 The patient must be
ation
mg Bid 5/7 assessed for presence
period.
of signs and
Patient's symptoms of
vital signs infection.
will be
Monitoring vital signs
maintaine
frequently
d in
normal
range

.
Knowledge The client Providing health After 5
deficit about will be education about the minutes, the
disease r/t able to disease, medication. client is able
lack of know the to respond to
information causes, all questions
AMB preventio concerning
inability to n and the health
 answer treatment education
disease of disease given.
related in 5
questions. minutes.

Moral distress Relieving Psychological After nursing

related to long distress in reassurance of the intervention,
hospital stay 2 hours. client, give her the client is
AMB general medications and make free from
body her environment safe. stress.
weakness.

THEORITICAL INFORMATION ABOUT THE CASE

Injury to one part of the musculoskeletal system results in malfunction of adjacent muscles,
joints, and tendons.

A fracture is a complete or incomplete disruption in the continuity of the bone structure and is
defined according to its type and extent.

Fractures occur when the bone is subjected to stress greater than it can absorb.

When the bone is broken, adjacent structures are affected, resulting in soft tissue edema,
hemorrhage into muscles and joints, joint dislocations, ruptured tendons, severed nerves and
damaged blood vessels.

Classification

There are several kinds of fracture that may occur in a bone:

 Complete fracture. A complete fracture involves a break across the entire cross-section
of the bone and is frequently displaced.
  Incomplete fracture. An incomplete fracture involves a break through only part of the
cross section of the bone.
 Comminuted fracture. A comminuted fracture is one that produces several bone
fragments.
 Closed fracture. A closed fracture is one that does not cause a break in the skin.
 Open fracture. An open fracture is one in which the skin or mucous membrane wound
extends to the fractured bone.

Causes

Fractures may be caused by the following:

 Direct blows. Being hit directly by a great force could cause fracture in the bones.
 Crushing forces. Forces that come into contact with the bones and crush them could also
result in fractures.
 Sudden twisting motions. Twisting the joints in a sudden motion leads to fractures.
 Extreme muscle contractions. When the muscles have reached its limit in contraction, it
could lead to serious fractures.

Clinical Manifestations

The clinical signs and symptoms of a fracture may include the following but not all are present in
every fracture:

 The pain is continuous and increases in severity until the bone fragments are
immobilized.
 Loss of function. After a fracture, the extremity cannot function properly because normal
function of the muscles depends on the integrity of the bones to which they are attached.
 Displacement, angulation, or rotation of the fragments in a fracture of the arm or leg
causes a deformity that is detectable when the limb is compared with the uninjured
extremity.
 There is actual shortening of the extremity because of the compression of the fractured
bone.
  When the extremity is gently palpated, a crumbling sensation, called crepitus, can be
felt.
 Localized edema and ecchymosis. Localized edema and ecchymosis occur after a
fracture as a result of trauma and bleeding into the tissues.

Complications

Complications of fractures may either be acute or chronic.

 Hypovolemic shock resulting from hemorrhage is more frequently noted in trauma

patients with pelvic fractures and in patients with displaced or open femoral fractures.
 Fat embolism syndrome. After fracture of long bones and or pelvic bones, or crush
injuries, fat emboli may develop.
 Compartment syndrome. Compartment syndrome in an extremity is a limb-threatening
condition that occurs when perfusion pressure falls below tissue pressure within a closed
anatomic compartment.

Assessment and Diagnostic Findings

To determine the presence of fracture, the following diagnostic tools are used.

 X-ray examinations: Determines location and extent of fractures/trauma, may reveal

preexisting and yet undiagnosed fracture(s).
 Bone scans, tomograms, computed tomography (CT)/magnetic resonance imaging
(MRI) scans: Visualizes fractures, bleeding, and soft-tissue damage; differentiates
between stress/trauma fractures and bone neoplasms.
 Arteriograms: May be done when occult vascular damage is suspected.
 Complete blood count (CBC): Hematocrit (Hct) may be increased (hemoconcentration)
or decreased (signifying hemorrhage at the fracture site or at distant organs in multiple
trauma). Increased white blood cell (WBC) count is a normal stress response after
trauma.
 Urine creatinine (Cr) clearance: Muscle trauma increases load of Cr for renal
clearance.
  Coagulation profile: Alterations may occur because of blood loss, multiple transfusions,
or liver injury.

Medical Management

Management of a patient with fracture can belong to either emergent or post-emergent.

 Immediately after injury, if a fracture is suspected, it is important to immobilize the body

part before the patient is moved.
 Adequate splinting is essential to prevent movement of fracture fragments.
 In an open fracture, the wound should be covered with sterile dressing to prevent
contamination of the deeper tissues.
 Fracture reduction refers to restoration of the fracture fragments to anatomic alignment
and positioning and can be open or closed depending on the type of fracture.

Nursing Management

Nursing care of a patient with fracture include:

 The nurse should instruct the patient regarding proper methods to control edema and
pain.
 It is important to teach exercises to maintain the health of the unaffected muscles and to
increase the strength of muscles needed for transferring and for using assistive devices.
 Plans are made to help the patients modify the home environment to promote safety such
as removing any obstruction in the walking paths around the house.
 Wound management. Wound irrigation and debridement are initiated as soon as possible.
 Elevate extremity. The affected extremity is elevated to minimize edema.
 Signs of infection. The patient must be assessed for presence of infection.

REFERENCES

 Katherine, Abel (2013). Official CPC Certification Study Guide. American Medical
Association. p. 108.
 Medicine Net Fracture Archived 2008-12-21 at the Wayback Machine Medical Author:
Benjamin C. Wedro, MD, FAAEM.
  Compartment Syndrome". The Lecture Medical Concept Library. Retrieved 2021-06-25.
 Browner BD, Jupiter JB, Levine AM, Trafton PG. Skeletal Trauma: Fractures,
Dislocations, Ligamentous Injuries. 2nd ed. Philadelphia, PA: WB Saunders; 1998.
 Delee JC Jr, Drez D. Orthopaedic Sports Medicine: Principles and Practice. Philadelphia,
PA: WB Saunders; 1993.
 Lieurance R, Benjamin JB, Rappaport WD. Blood loss and transfusion in patients with
isolated femur fractures. J Orthop Trauma. 1992. 6(2):175-9.

ANALYSIS ON THE QUALITY OF CARE PROCEDURE

Two nursing care procedures/techniques as they are done in service with available
resources.

A. lipectomy

This procedure is done on the female patient who has lipoma near the clavicle bone.

It is the incision process where a benign neoplasm of adipose tissue composed of mature fat
cells have to be removed. It is a minor surgery where they use different surgical instruments.

When the procedure is going to be done you have to prepare yourself and prepare patient then
after material. Sterile procedure requires much attention because if not you can cause further
infections. After receiving consent to perform we washed our hand and rub, opened sterile
gloves, then inner cover is used as preparation sheet, we prepared 5 forceps, needle and syringe,
scissor, suturing materials, suturing materials, sterile surgical blades, local anesthesia(lidocaine),
disinfectant(povidone), dressing materials.

During procedure, we disinfect the site with povidone, we inject anesthesia, we took blade and
cut for separating skin, we applied forceps for fixing skin out of the suture, then after we
penetrated inside and removed lipoma as our purpose. Approaching to the end of procedure we
sutured the wound and dressing it then after we ambulance the patient to the best for taking a
short rest and recovery from anesthesia.

Highlights: positively they perform the procedure referring to standard measures even if sterile
sheet is insufficient they find another way of maintaining sterility and addition to that client are
aware about what they are doing, better material arrangement. Negatively, sometime they can
pass across the sterile field while they are serving him/herself otherwise there is high quality of
procedure as it is.

Student input made for improving the quality of the procedure: prepare the materials to be
sterile, prepare safe working environment, prepare patient for the procedure and assists during
the procedure then after the procedure they also prepare room and clean used material for next
use.

Student strength: curious of observing procedure, better in communication and provision of

some cares, sterile material preparation

Weakness is slow speed during procedure, some of them can have fear of the procedure,
mastering names and function of each instruments to be used.

B. Wound dressing

In the wards where wound dressing is performed it is done in this way: when performing wound
dressing first you have to greet the patient and ask a permission from the client after allowing
you, you have to put on gloves after you keep the privacy then position the client put
impermeable protection. this is followed by assessing the wound and remove gloves after you
disinfect hands with alcohol then you have to arrange materials and put normal saline in the
sterile cup and then put on protective gloves in order to remove the old dressing then you remove
them and disinfect hands and put on gloves then you put a sterile cloth on impermeable
protection in order to maintain the sterility then you dress a wound and after you thank client and
give him/her a health education.

Highlight positive and negative points bearing in mind the standards of the procedure:
Positive points to keep in mind include asking consent from client, keeping his privacy, to put a
sterile cloth and a protection, to use solutions like normal saline and hydrogen peroxide where
necessary and hand washing.

Negative points to keep in mind dressing without assessing the wound, failure to maintain
sterility as it should be done

Describe briefly the student input made for improving the quality of the procedure

Keeping privacy, asking a consent from the client, to know the wound type and appropriate
solution, and the way of arranging materials.

The student strength and weakness accounted in the described case in group

The strength includes preparing the materials, dressing a wound, and to know the solution to
use, to know the stage of wound healing and providing a health education to the clients. And the
weakness includes failure to maintain sterility hundred percent.

Lessons learnt based on clinical objectives

in this clinical placement based on clinical objective we learnt many different lessons like taking
quick exams (covid 19,glycaemia, HIV test, hepatitis test ) that we couldn`t learn in the class, we
assisted some different procedures like operations in minor surgery and casting, usage of
available resources to perform the different procedures depending on available resources, we
learnt to be self-confident and competent in apply theories skills into practice, improvement of
communication skills and friendship with the clients, well triage form filling and we learnt some
first aid that can be given appropriate to a certain case.

▪ challenges encountered by the group during the period of clinical placement

During period of clinical placement, we have been encountered by different challenges including
overcrowding of student in the hospital, and addition to this there are fewer number of cases to
be done so that to achieve all objectives is somehow complicated.

And also, we have found that the routine we studied in college as student nurse is somehow
different to routine the registered nurse they use.

Other challenge is there is no enough materials to perform some specific thing in its manner way
like in its sterile way. Other time we miss the cases in order to cover our objective 100% like
enema

▪ CONCLUSION AND RECOMMENDATIONS

We really thanking the hospital about how they accepted us for practicing in their field. They
have good administration and nurses who helped us to achieve our goals and we are saying that
stay ahead in the way you organize your service, so for the hospital side we got what we had to
get and all needed one are available. Recommendation is to continue in the way they are in, and
how they are working with clients or students in the hospital. We are also thankful to University
of Rwanda. Huye Campus leaders who had though to provide us this importance period to put
into practice what we had learnt into theories so we are encouraging them to increase this period
because it is really very importance and needed by the student to increase their knowledge and
skills, Thanks a lot.

We would like to recommend our institution that for promoting the quality learning, not only this
also we can recommend our institution to work with many district hospitals according to the
number of students they have, because we were a lot of students at the sites so it was hard for us
to perform many cases so that we can be fully know them.

Finally, we can say that the clinical placement lasting five weeks has gone well just no student
has failed this clinical placement but the objective is not achieved hundred per cent according to
different challenges we have highlighted above.

REFERENCES

 Gisenyi district hospital staff

 Patient file
 Fundamental of nursing and fundamental of community health
 medical l nursing notes level one 2019-2020
  www.who.int> health care

CONCLUSION FOR PORTFOLIO

In conclusion, according to the above detail’s information, this clinical portfolio includes/holds
different hints which helped me to identify my gaps in practices and where to put more efforts.
Among those hints includes daily activities record, case studies where there is one case on
pyumyostatitis, malaria. Three reflective journals one for better management of client with
wound, for good way of drug administration, poor management of client with bedsores and poor
follow up of vital signs as well as self-assessment where the covered and not covered objectives
found. This is important for my daily learning. Depending on the experience that I have acquired
from this portfolio, I would like to ask Huye campus, to help all students to have a common
understanding about the fulfilment of student clinical portfolio.