Clinical Porfolio

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College of Medicine And Health Sciences
Nursing and Midwifery
Pediatric Track
Clinical Porfolio
Supervisors:
Dr.GodfreyKatende
Mrs.Joselyne Reguma
SEPTEMBER 10,2021
CHILDREN ARE OUR FUTURE LEADERS.
JAMES VT. Tuckolon
MScN/Pediatric Nurse Specialist
(Candidate)
REF No: 220018335
jtuckolon@gmail.com

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TABLE OF CONTENTS
......................................................................................................................................................................1
List of Figures.................................................................................................................................................6
List of Tables..................................................................................................................................................7
List of Ancrynoms ..........................................................................................................................................8
General Introduction....................................................................................................................................11
CHAPTER ONE : CLINICAL ONE (RWANDA MILITARY HOSPITAL) .....................................................................13
1.1. Background.............................................................................................................................................. 13
1.2. Kanombe Military Hospital(November to December 2020)................................................................... 13
1.3. General Objectives .................................................................................................................................. 14
1.4. A Clinical case one(Tetrology of Fallot (TOF)....................................................................................... 15
1.4.1.Case Description..................................................................................................................................... 16
1.4.1. Nutrition service for te patient........................................................................................................... 16
1.4.2. Management plan and interventions.................................................................................................... 17
1.5. Clinical Case Two (A child with Acute kidney injury(AKI) ................................................................ 17
1.5.1.Case description...................................................................................................................................... 17
1.6. Clinical case three.................................................................................................................................... 18
1.7. Clinical Case Four................................................................................................................................... 18
1.8. SWOT Analysis RMH 2020................................................................................................................ 19
RECOMMANDATIONS:................................................................................................................................... 20
Reference:............................................................................................................................................................ 20
CHAPTER TWO:CLINICAL TWO CHUK TEACHING HOSPITAL............................................................................22
2.1. Introduction/Background......................................................................................................................... 22
2.2. Mission, Vision & Values ....................................................................................................................... 23
2.2.1. CHUK Vision...................................................................................................................................... 23
2.2.2. CHUK Mission Statement................................................................................................................... 23
2.2.3. CHUK Values...................................................................................................................................... 23

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2.3. Pediatric department................................................................................................................................ 23
2.4. Clinical Objectives .................................................................................................................................. 24
2.5. Week one activity Orientation and PICU (MAY 4th and 5th 2021) .................................................... 25
2.6. Week two activity PICU ( May 10,11 and 12,2021)............................................................................. 29
2.7. Case presentation/description(Jejunum atresia) ...................................................................................... 29
2.7.1. Definition............................................................................................................................................. 29
2.7.2. Case description................................................................................................................................... 30
2.8. Week Three General Pediatric Ward(May 17,18 and 19 ) ..................................................................... 31
2.9. Week Four General Pediatric Ward(May 24 25,and 26 )........................................................................ 31
2.10. Week five NICU( May 31, June 1 and 2,2021).................................................................................. 31
2.11. Case study on the management of the child diagnosed with Respiratory distress Syndrome ............. 32
2.11.1. Case presentation................................................................................................................................. 32
2.11.2. Health History of newborn and Mother............................................................................................... 32
Baby details......................................................................................................................................................... 32
2.11.3. Vital Signs Framemwork of Days of Life(DOL) ................................................................................ 33
2.11.4. Neonatal Nursing Assessment and Physical examination................................................................... 34
2.11.5. Nursing care plan................................................................................................................................. 37
2.11.6. Laboratory investigat ion framework Development.......................................................................... 39
2.11.7. Maternal Details , Family Centered Care and /Education .................................................................. 40
2.11.8. Past Medical/Pregnancy Details .......................................................................................................... 40
2.11.9. Nutritional Details ............................................................................................................................... 41
2.11.10. Surgical Details ............................................................................................................................... 41
2.11.11. Birth and Labor Details ................................................................................................................... 41
2.11.12. Psychosocial Details........................................................................................................................ 41
2.12. Findings/observation of the Management of the Case ........................................................................ 41
2.13. Framework of management................................................................................................................. 42
2.14. Gaps identified in managing the case.................................................................................................. 44
2.15. Effects of the Gaps on the baby........................................................................................................... 44
2.16. Strengths and weaknesses noticed in managing the case ................................................................ 45
2.17. SWOT Analysis of the pediatric Department.CHUK.......................................................................... 45
2.18. Recommendations ............................................................................................................................... 47
References ........................................................................................................................................................... 47
CHAPTER THREE: CLINICAL TWO REMERA HEALTH CENTER...........................................................................48

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3.1. Introduction/Background......................................................................................................................... 48
3.2. WEEK ONE June 7,8,9 2021................................................................................................................. 49
3.4. WEEK Two June 14,15 and 16 2021 ................................................................................................... 50
3.5. WEEK three June 21,22, and 23,2021................................................................................................ 51
3.6. Prevention of Mother-to-Child Transmission of HIV(PMTCT) ............................................................. 52
3.7. Packages of PMTCT................................................................................................................................ 52
3.8. Organogram of PMTCT Service at Remera Health Center.................................................................... 53
3.9. PMTCT Empirical studies conducted in Rwanda( 2014 and 2020)........................................................ 54
3.10. ANC PMTCT HMIS June /2021 Report ............................................................................................ 61
3.11. PMTCT Labor and Delivery............................................................................................................... 61
3.12. HIV exposed Infant Follow up ........................................................................................................... 62
3.13. Analysis of Exposed Infants Outcomes(June 2021)............................................................................ 64
3.14. Challenges noticed as per the questionnaire........................................................................................ 70
3.15. PMTCT UNIT,REMERA HEALTH CENTER 2021 ........................................................................ 71
CHAPTER FOUR : CLINICAL TWO (KABUGA PEDIATRIC PALLIATIVE CARE CENTER)..........................................75
4.1. Introduction ............................................................................................................................................. 75
4.1.1. Staffng ................................................................................................................................................. 75
4.1.2. Patients load at Palliative Care Center during the period.................................................................... 76
4.1.3. Palliative Care Case One Presentation ............................................................................................... 76
4.1.4. Nursing Care plan Case one developed for the patient....................................................................... 77
4.1.5. Palliative Care Case Two Presentation.............................................................................................. 79
4.1.6. Nursing Care Plan Case Two developed ............................................................................................ 80
4.2. Strengths and Best Practices During My Two Weeks Clinical Practice ................................................. 82
4.3. Things To Be Improved........................................................................................................................... 82
4.4. Challenges I Faced During My ClinicPractice........................................................................................ 82
4.5. Opportunities........................................................................................................................................... 83
4.6. Recommendations ................................................................................................................................... 83
4.7. Conclusion............................................................................................................................................... 83
Reference............................................................................................................................................................. 83
CHAPTER FIVE:CLINICAL TWO(KIREHE PEDIATRIC DEVELOPMENT CLINIC(PDC)...............................................85
5.1. Introduction ............................................................................................................................................. 85
5.2. Day one( August 30,2021) ...................................................................................................................... 87

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5.3. Day two August 31,2021......................................................................................................................... 93
5.4. Day three Sept 1,2021 ............................................................................................................................ 95
5.5. Day four September 2,2021................................................................................................................... 96
Figure 25:Mentorship At Mushikiri Health Center..........................................................................................97
5.6. Day five September 3,2021 .................................................................................................................... 97
Figure 26:Play and Communication Section of Children with Developmental Delay and Disability ..................98
5.7. Best practices at the Kirehe Pediatric Development Clinic..................................................................... 98
5.8. CHALLENGES....................................................................................................................................... 98
5.9. RECOMMENDATIONS ........................................................................................................................ 99
5.10. CONCLUSION ................................................................................................................................... 99
5.11. Lesson learnt........................................................................................................................................ 99
Attendance of Clinical Placement: .............................................................................................................102
References.................................................................................................................................................107

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List of Figures
Figure 1:Critical Care Nurse Specialist Educating on the use of Mechanical Ventilator........................................ 27
Figure 2: Guidiline of Sedation with Mecahaniacal Ventilator............................................................................... 28
Figure 3:Vital Signs Framework of DOL................................................................................................................ 33
Figure 4:Framework of laboratory investigation conducted,NICCU,CHUK,2021................................................. 39
Figure 5:PMTCT Service at Remera Health Center organigram ........................................................................... 53
Figure 6:HIV exposed infants outcomes at six weeks............................................................................................. 64
Figure 7:HIV exposed infants outcomes at 9 months.............................................................................................. 65
Figure 8: HIV exposed infants outcomes at 18 Months .......................................................................................... 66
Figure 9:HIV exposed infants outcomes at 24 months............................................................................................ 67
Figure 10:Exposed inffants follow up results.......................................................................................................... 68
Figure 11:Results on care providers for PMTCT .................................................................................................... 69
Figure 12:PCMT Unit At Remera Health Center................................................................................................... 71
Figure 13:The flow of patients for PMTCT ............................................................................................................ 72
Figure 14:CHWs ,Pediatric Track Students/UR and staff in Meeting..................................................................... 73
Figure 15: CHWs List ............................................................................................................................................. 73
Figure 17: Kirehe pediatric development clinic(PDC)............................................................................................ 86
Figure 18:Presentation of the Pediatric Development Clinic(PDC)........................................................................ 88
Figure 19:PDC Home Visit Report Form for the mother with HIE child ............................................................... 89
Figure 20: Social economic status of the mother with HIE child............................................................................ 90
Figure 21: PDC Home Visit Report Form for the mother with LBW child........................................................... 92
Figure 22: Home of the mother with LBW child ................................................................................................... 93
Figure 23: James V.T.Tuckolon (Mscn/Pediatric Student/University of Rwanda .................................................. 94
Figure 24: Social Worker educating mother on preparation of child’s food........................................................... 96
Figure 25:Training at Mushikiri HC........................................................................................................................ 97
Figure 26:Play and Communication section of children with developmental delay and disability......................... 98

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List of Tables
Table 1: Courses and Clinical placement Schedules..................................................Error! Bookmark not defined.
Table 2: SWOT anlysis ........................................................................................................................................... 19
Table 3: Neonatal Nursing Assessment................................................................................................................... 34
Table 4:Nursing Plan................................................................................................................................................ 37
Table 5:Framework of management provided......................................................................................................... 42
Table 6:SWOT Analysis.......................................................................................................................................... 45
Table 7: Immunization Schedules ........................................................................................................................... 50
Table 8:ANC HMIS ................................................................................................................................................ 61
Table 9:PMTCT Report........................................................................................................................................... 61
Table 10:HIV exposed on Infant Follow up............................................................................................................ 62
Table 11:Nursing Care Plan .................................................................................................................................... 77
Table 12:Nursing Care Plan Case two..................................................................................................................... 80

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List of Ancrynoms
AKI : Acute Kidney Injury
APGAR: Appearance Pulse Grimace Activity Respiration
ART:Antiretroviral Therapy
ARVs : Antiretrovirals
BCC: Behaviour Change Communication
BCG: Bacille Calmette-Guerin
CHUK: University Central Hospital of Kigali
CHW: Community Health Workers
CNS:Central Nervous System
CPAP: Continuous Positive Airway Pressure
CPT: Cotrimoxazole Prophylactic Therapy
CSB: Corn Soy Blend
DOL: Day of life
DPT: Diphtheria, Pertussis, and Tetanus
ECD: Early Childhood Development
EBM: Expressed Breast Milk
EBP: Evidence-Based Practice
ECG:Electro Cardio Gram
EPI:Expanded Program on Immunization

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HBB: Helping Baby Breath
HIV: Human immunodeficiency virus
HMIS: Health Management Information System
IEC :Information Education Communication
IMCI:Integrated Management of Childhood Illness
IPC: Infection Prevention Control
IPV: Inactivated Polio Vaccine
IV:Intravenous
HIE: Hypoxic Ischemic Encephalopathy
KMC:Kangaroo Mother Care .
LBW:Low Birth Weight
MCV: Measles containing –Vaccine
MSN: Master of Science in Nursing
NGO: Non-governmental Organization
NICU:Neonatal Intensive Care Unit
NGT: Nasogastric Tube
NPO:Nothing By Mouth
OPD: Out patient Department
OPV:Oral Polio Vaccine
ORS:Oral Rehydration Salt
PCC: Palliative Care Center
PCV: Pneumococcal Vaccine

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PDC: Pediatric Development Clinic
PICU:Pediatric Intensive Care Unit
PID :Pelvis Inflammatory Disease
PIH :Partners In Health
PMTCT: Prevention of Mother To Child Transmission of HIV
PPROM: Preterm Premature Rupture of Membrane
RDS: Respiratory Distress Syndrome
RMH:Rwanda Military Hospital
RUTF:Ready to Use Therapeutic Food
RV: Rota Vaccine
SOP:Standard Operating Procedure
SWOT: Strength,Weakness,Opportunity,Threat
TB: Tuberculosis
TOF:Tetrolgy of Fallot
TPN:Total Parenteral Nutrition
UR: University of Rwanda
WHO: World Health Organization
WNL: Within Normal Limit

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General Introduction
This document contains my clinical portfolio as a master of pediatric nursing student at the University of
Rwanda's College of Nursing and Midwifery.
It covers the first clinical placement term at Rwanda Military Hospital (November to December 2020).The
second clinical placement began in May 2021 at CHUK,and proceeded at Remera Health Center, where I
spent three weeks in June 2021 for my clinical placement. In July there was a total lackdown of COVID-
19 crisis where no clinical plcement was done and in some part of August 2021.I completed my remaining
weeks of clinical at Remera Health Center in August.I continued in August at Kabuga palliative care
center from August 17 to 25,2021.
Finally, my clinical placement at Kirehe Pediatric Development Clinic (PDC) came to a close on
September 3, 2021, after starting on August 30 and ending on September 3, 2021.
There were six health facilities and community my clinical placement was focused.Therefore those health
facilities that I practiced during my clinical placement were Rwanda Military Hospital,CHUK teaching
Hospital,Remera Health Center,Kabuga Palliative Care Center, Kirehe Padiatric Development Clinic,
Mushikiri Health Center and Community. I spent one day of practice at the Mushikiri health center, where
Partners In Health (PIH) operates.
This is to acknowledge supervisors and lecrurers who were there to provide me supervision and guidance
during my clinical placement.They provided supervision visits, conducted clinical evaluations, and
assigned case studies for each student in accordance with existing practice at several clinical settings in
Rwanda.

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Modules Clinical
Placement Covered
Objectives covered
Clinical Supervisors
and lecturers
Time Sites Overall
percentages of
clinical
placement
objectives
achieved
Advanced Pediatric
Health Assessment
and Essential
Pediatric Nursing
1.Dr.GodfreyKatende
2.Dieudonne
Kayiranga
9 Nov-Dec
2020
Kanombe Military
Hospital,Kigali
85%
Advanced Newborn
Care
1.Dr.GodfreyKatende
2.Mrs.Joselyne
Reguma
3.Dieudonne
Kayiranga
May 9- June
2,2021
CHUK Teaching
Hospital , Kigali
City ,Rwanda
90%
Pediatric Health
Promotion
Dr.GodfreyKatende
2.Mrs.Joselyne
Reguma
June 7 -
23,2021
Disruption of
COVID 19
Completed
August 9-
11,2021
Remera Health
Center,Kigali
City.Rwanda
90%
Pediatric Palliative
Care(PPC
Dr.GodfreyKatende August 17-
25,2021
Kabuga Palliative
Care Center
70%

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2.Evelyne
Nankundwa
Health
Promotion,Advanced
Pediatric Health
Assessnent and
Essential Pediatric
Nursing
2.Evelyne
Nankundwa
Dr.GodfreyKatende
2. Mr. Nemerimana
Mathieu
August 30 –
September
3,2021
Kirehe Pediatric
Development
Clinic(PDC)and
Community,Kirehe
District,Rwanda
91.6%
CHAPTER ONE : CLINICAL ONE (RWANDA MILITARY HOSPITAL)
1.1. Background
The University of Rwanda Postgraduate Studies,College of Medicine and Health Sciences, Nursing and
Midwifery, began her first clinical placement practice on November 9, 2020 for all 8 tracks. For the
pediatric track, there were two hospitals allocated for a total of nine students (Kanombe Military Hospital
and CHUK).However; four students were assigned at Kanombe Military Hospital while the other five
students were also assigned at CHUK respectively.
1.2. Kanombe Military Hospital(November to December 2020)
The hospital is one of the country referral hospitals built in 1968 at Kanombe, a Kigali suburb, as
a Military Referral Hospital. It continues to provide health care services to the military and their

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immediate families until after the 1994 genocide against the Tutsi when doors were opened to the general
population.
I understood that this hospital is a teaching hospital that is accepting students from variety of health
institutions across the country.I also noticed that the department of Pediatric at the Rwanda Military
Hospital has a total of five different units, which include: general Pediatric, neonatology, intensive care
unit, pediatric critical care and Pediatric outpatient department.There are ninety two hospital beds at the
department of Pediatric. The general Pediatric ward has total of forty-seven beds (47), neonatology thirty
(30), Intensive care unit six (6), Pediatric Critical Care four (4), outpatient department five (5)
respectively.
On the 9th
of November 2020, the pediatric along with ELM and Neonatology tracks assembled at the
hospital for orientation. Our supervisor, Dr Godfrey with other tracks supervisors were present during the
orientation day. We were taken around by the nursing director to orient us and to see the various
departments and units of the hospital.
Basically,I actually spent the period of two months at the Kanombe Military Hospital assigned at the
pediatric unit.With these,our clinical objectives are listed below:
1.3. General Objectives
 Create a SWOT analysis of the pediatric unit, based on observations of unit workflows and
discussions with staff and patient and together with the nurse in charge, to identify strengths,
weaknesses, opportunities, and threats, to optimize the strengths and opportunities, and address
the threats and weaknesses
 Articulate linkages among theory, research, and practice; and recognize limitations of the current
science base for specialized practice
 Correlate understanding of holistic, patient-centered, quality principles with the care of diverse
populations of patients across the lifespan and across the health-illness continuum in a variety of
healthcare settings.
 Employ an expanded use of the nursing process, as specialized care nurses, in the care of critically
ill patients and their families.
 Integrate principles of pharmacology, pain management, physical assessment, holistic care, and
international standards of practice to provide specialized nursing care for patients and their
families.

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 Along with nurse educator or nurse in charge, plan and conduct teaching sessions with A1 and A0
nursing students on topics of identified clinical need.
 Utilize information based on evidence as a foundation nursing practice.
 Utilize effective critical thinking, clinical reasoning and decision making skills to prioritize and
coordinate care for patients and their families.
 Incorporate effective use of invasive and non-invasive technologies and various diagnostic
procedures to promote physiologic stability for patients.
 Refine core competencies in physical assessment skills as well as selected advanced competencies.
 Apply knowledge of growth and development (G&D) in conducting history and physical
examinations of pediatric patients. Use growth charts, as applicable, and calculate z-scores to
determine patients’ nutrition status.
 Provide age and developmentally appropriate nursing care of the child that is tailored to the patient
and family-centered, including common procedures
 Interpret and track patients’ laboratory test results, compared with age-appropriate normals,
understanding the indications for testing, implications of the results, and applications and
limitations to care and treatment
 Familiarize self with common pediatric outpatient conditions, their presentation, and management,
e.g., simple malaria, pneumonia and other causes of cough, fever, diarrhea, anemia, injuries, ear
and skin infections
 Conduct clinical (skills) needs and strengths assessment of the unit staff (after adequate close
observation), discuss in clinical group, and present findings and recommendations to the nursing
leadership.
I had the opportunity to have achieved the above objectives required of my clinical placement during this
period.
During this clinical placement, I was provided key concepts of elimination,perfusion,intrcranial
regulation,oxygenation with clinical cases identified and further presented to my supervisors. The below
are clinical cases discussed as per each concept.
1.4. A Clinical case one(Tetrology of Fallot (TOF)
Tetralogy of Fallot (ToF) is the most prevalent type of congenital cardiac disease, affecting about one in
every 3000 live births( Z. Ealdadah et al 2001).

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1.4.1.Case Description
A (4) year-old male child was been admitted at Ngarama District hospital on November 22,2020, who
was seen in difficulty in breathing(distress), change in skin color for 5days.Mother alleged that she did
not know the cause of the child symptoms and did not give any home medication. She decided to seek
medical help at the district hospital. Due to the severity of his condition, the district hospital decided to
transfer them to the Rwanda Military Hospital for further investigations and to meet the cardiologists. The
child was transferred and admitted on November 25,2020 at RMH 9:00pm and admission chief complaint
were respiratory distress, TET spells.Vital sign showed:Temp:37C
, SPO2 90%,Respiration 25b/min,Heart
Rate; 100b/min,BP:130/80mmHg and Pain assessment: 5/15,Weight:31.5kg
According to mother, she had normal vaginal delivery with no complication. Visited all ANC as requested
by the attending midwife. She completed maternal vaccine(TT)as scheduled. No pregnancy related
complications.
1.4.1. Nutrition service for te patient
Nutrition was relevant for this child because a patient with TOF will have growth and developmental
problem. It was important to educate the parent about nutrition. Undernutrition is common in patient with
congenital heart disease. Adequate nutrition is critical to foster growth and development as well as to
reduce the risk for infection. Children with congenital heart defects typically have increased nutritional
needs due to the increased energy expenditure associated with increased cardiac and respiratory workload.
Firstly, the basic issue that I saw that went well in the care of this patient was diagnosing the patient
according to the clinical presentation and assessment of his condition. The main strengths of nursing and
interdisciplinary care of this patient condition was daily rounds and discussing patient condition with
students’ doctors and student nurses.
The main issue was the absence of the cardiologist to further assess the patient, but the patient was
managed symptomatically. The main strengths and interdisciplinary care that I observed, is that all patients
admitted, their conditions are discussed every morning to see their progress.

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The plan of care was 80%congruent with the delivery of care. As observed from the plan ECG,
echocardiograms were ordered for this patient but the tests were not done for this patient. Not all ordered
as planned were initiated, but treatment was given to the patient according to the symptoms and other
investigations conducted for the patient.
1.4.2. Management plan and interventions
IV line was opened, the child was kept knee to chest position,O2 @ 15L/Min, D5RLmaintanace 10mg/kg
and Morphine, propranolol were administered
I recommending that whenever a plan is made for patient according to his/her condition more especially
if the condition is life threatening, there is a need to implement the plan through effective intervention
1.5. Clinical Case Two (A child with Acute kidney injury(AKI)
Acute kidney injury (AKI) is a complex illness marked by a loss of renal function and linked to a variety
of etiologies and pathophysiological mechanisms(J. Gameiro et al 2018).
1.5.1.Case description
According to this 13years old male mother alleged that the symptoms started 4weeks ago with episodes
of generalized body swelling fever, abdominal pain and sore throat for a month he was taken to the nearest
health center, and was treated but nothing seemed to improve. The fever was associated with abdominal
pain, thereafter, he received traditional medicine. Mother said that the pain killers were been given him
during the course of his illness. He was observed to have generalized body swelling, he was also taken to
the district health center and they decided to transfer him to RMH due to the severity of his condition.
There was no known medical condition noted according the child’s mother.The child has not been
hospitalized for serious condition like this, but sometimes suffered from malaria. No history of surgery as
explained by the mother. Mother alleged him taken all childhood vaccines as scheduled. She also said that
she took her maternity vaccine as well. Her birth was a normal vaginal delivery at term without birth
complication. The child completed all vaccines as scheduled. Mother alleged that child’s father died from
an abrupt high grade fever two months ago. There have been no other disease(s) or communication
diseases that the family suffered from. From the history I gathered,the family has low social support, not
working, and husband died two months ago.

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1.6. Clinical case three
A definitive history of a hit to the head, a laceration of the scalp or head, or altered consciousness, no
matter how brief, is included in a practical operational definition used in surveys in Scotland (Carnall, D.,
2000).
According to the 7yrs old child mother, he was hit by motorcycle while crossing the road. He was seen
with wound on the on the left hand and forearm. He began unconscious, bleeding from the head and nose,
face swelling and entire head, fever x 24hrs.
However, the head was swelling and with fluid draining from there. She alleged that her child is living
with his father; she was informed about the incidence that her child is brought to the hospital. The child
both parents are not together. The child’s father was no where to find after the incidence. The incidence
occurred at 9: am November 23, 2020 and the child was brought at the hospital at 2:00pm November
242020. There was no any reason why the child was delayed in sending him at the hospital immediately
or the same day. No known history of trauma or accident or other known medical condition noted. As for
the growth and Development,he was growing according to his age and weight.Vital signs
revealed:temperature38C,
HR:135bpm,
RR: 32breath/min,
SPO2 : 90% and pain assessment: 7/10.
1.7. Clinical Case Four
Down Syndrome (DS) is a congenital disorder that affects around one out of every 700 newborns born
worldwide, both male and female (SDSA,2001).
Trisomy 21(DS)-this is the most prevalent type, accounting for almost 95% of all cases. It occurs when
one of the parents, through non-disjunction, gives the sperm or egg two copies of chromosome 21 instead
of one. Every cell in the infant now has an additional copy( SDSA,2001). An additional copy of
chromosome 21 inside each of the body's cells causes DS (SDSA,2001).
This eight months old male known with trisomy 21, hypotonia had difficulty in breathing, cough since
birth, four days prior on admission, developed diarrhea, fever, vomiting and vomitus was projectile as
well as passing watery stool. Mother alleged giving ORS at the onset of symptoms, but still nothing
seemed to improve. The child mother alleged that during pregnancy, she suffered from PID (Pelvis
inflammatory disease) but was taken treatment during the course of illness. There is no history of surgery

19
or difficulty birth. He is 7th
child in the family, 2 died from unknown illness, and no abortion. There is no
known history of congenital disease(s) or other hereditary conditions.
Nutritional Assessment revealed: mild malnutrition, the child not sucking well and Vital Signs: temp:
36.5, Resp;40b/min, pulse 140b/min, SPO2;95%, Pain scale :0/10,Weight: 6kg. Growth and Development
status of the child, mother said that her son is 8months; he cannot even sit or crawl. Objectively, the child
is not growing according to Erikson stage of human development.
1.8. SWOT Analysis RMH 2020
Table 1: SWOT anlysis
STRENGTHS WEAKNESSES OPPORTUNITIES THREATS
Many experienced
senior-
Staff(specialists)
Regular and Effective
coordination meeting
for patients outcomes
Patients medical
Diagnoses are based
on
literature(evidenced-
based practice)
Mentorship by
doctors (bedside
teaching)
Effective and Strong
working relationship
with clinical Students
Pediatric health
assessment(nurses)
Improper
documentation
Lack of Assessment
materials(vital Signs )
are not been available
at all times
Some Laboratory
investigations not
done in the hospital
Stock out of some
drugs from Pharmacy
Growth and
monitoring chart
usage
Obtaining Laboratory
results in time
(example CT Scan)
Training and
upgrading nurses to
specialize
Partnership with
nongovernmental
Organizations
(NGOs)
Partnership with
clinical volunteers
and other health care
professionals
Enable Clinical
research
Postgraduate
program
Shortage of nurses
staff
High Workload
Nurse –Client ratio
(Imbalance )
Adequate diagnostic
machines

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Good learning
environment
(teaching hospital)
Referral System
IPC(Infection
Prevention Control)
policy in place
Availability of Health
insurance
Effective nurse-client
relationship
Effective nurse-
student relationship
Lack of pediatric
treatment guidelines
Implementation of
pediatric triage
system
Use of emergency
trolley
Multidisciplinary
team(delayed
responding )
RECOMMANDATIONS:
 Ensure that growth and monitoring chart be used regularly
 Avail Pediatric treatment guideline
 Ensure proper comprehensive health assessment and documentation for every pediatric
client(checklist for assessment )
 That nurses status to be upgraded in pediatric nursing
 Development of nurses' competency through the cases simulation and discussion activities
Reference:
Gameiro, J., Agapito Fonseca, J., Jorge, S. and Lopes, J.A., 2018. Acute kidney injury definition and
diagnosis: a narrative review. Journal of clinical medicine, 7(10), p.307.

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Eldadah, Z.A., Hamosh, A., Biery, N.J., Montgomery, R.A., Duke, M., Elkins, R. and Dietz, H.C., 2001.
Familial Tetralogy of Fallot caused by mutation in the jagged1 gene. Human molecular genetics, 10(2),
pp.163-169.
Fiske, J. and Shafik, H.H., 2001. Down's syndrome and oral care. Dental Update, 28(3), pp.148-156.
Carnall, D., 2000. Head injury. Bmj, 320(7245), p.1348.
University of Rwanda/Pediatric Track Master clinical placement Students @ Kanombe Military Hospital
2020

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CHAPTER TWO:CLINICAL TWO CHUK TEACHING HOSPITAL
2.1. Introduction/Background
This portfolio documents my second clinical placement as a master of pediatric nursing student at the
University of Rwanda's College of Medicine and Health Sciences, Nursing and Midwifery.This clinical
portfolio includes the module of advanced neonatal care as per my clinical aims.From May to June 2021,
I started with a one-month advanced newborn care module clinical placement at Kigali University
Teaching Hospital/CHUK.
I had limits for various procedures in managing neonatal conditions when I started this second clinical
placement. I had no idea what to expect because it was my first time learning how to use a mechanical
ventilator and CPAP at this hospital. As I gradually learned how to critically discuss the pediatric patient's
health and manage their care and needs with parents during my second clinical placement, I began to
consider myself as an experienced and skilled pediatric nurse.As a result, I became more confident in the
role I was committed to play. Although I believe I have a long way to go in this endeavor and will
continuously be learning.I am confident that I have gained a lot of knowledge throughout my clinical
placement.To improve my practice, I will employ critical thinking, decision-making, and theory, as these
will enable me to solve problems or learn from actions by caring actively about an activity and allowing
me to grow and develop my nursing skills. I will ensure that my focus on evidence-based nursing
practice,research and education to enhance children's health and in collaboration with their parents will
be on nursing knowledge and skills as well as advocacy to be my full responsibilities.
The University teaching hospital of Kigali/CHUK is the largest hospital located in District of Nyarugenge
at KN 4 Ave, Kigali City. It is also the biggest referral hospital of the country with a capacity of 519 beds.
CHUK provides quality healthcare to the population, training, clinical research and technical support to
district hospitals.
Some important dates for CHUK:
 In 1918: it was built; In 1928, it worked as health center; In 1965, it worked as hospital.
 From April 1994 to 1996, the CHK has served as a health center, a district hospital and as a referral
hospital as well.

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 In 2000, with the enactment of law Nr. 41/2000 of 7/12/2000 on the establishment and organization
of the University Teaching Hospital "CHUK", the CHK became a public institution with legal
personality known as “University Teaching Hospital of Kigali”.
2.2. Mission, Vision & Values
2.2.1. CHUK Vision
The University Teaching Hospital of Kigali will be the leader in providing Quality Healthcare Services,
Education and conducting Research, striving for Excellence in Africa
2.2.2. CHUK Mission Statement
The University Teaching Hospital of Rwanda is committed to provide quality health care according to
international standards, train health professionals, contribute to the development of human resources,
conduct outstanding research and provide technical support to the health system.
2.2.3. CHUK Values
Accountability-Integrity-Professionalism-Excellence
CHUK is one of Kigali's main hospitals, located on KN 4 Ave in Nyarugenge District. With a capacity of
519 beds, it is also the country's largest referral hospital. CHUK serves the public with high-quality
healthcare, as well as training, clinical research, and technical assistance to district hospitals..
However, on May 4, 2021, the first week of clinical activities began with orientation. As a result, we were
educated on the hospital's general norms and regulations (CHUK).
I realized that the Rwanda's University Teaching Hospital is dedicated to providing international-standard
health care, training health professionals, and contributing to the development of human resources.
2.3. Pediatric department
General Pediatrics manages 86 bedded pediatric ward with approximately 1800 admissions per year.
There is also a weekly follow up clinic for patients requiring ongoing medical care especially for chronic
diseases in different subspecialties.
The pediatric department of CHUK is made out of :

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1. Neonatology unit has 22 beds which are 19 incubators, 9 crubs and 3 beds for Kangaroo mother care
units (KMC).
2. Emergency unit with 11 beds,
3. Ward 1 has 28 beds composed by Cardiology ward, General Ward, High dependent Unit, Pediatric
intensive Care Unit
4. Ward 2 has 28 beds composed by Oncology ward, chronic ward, and Neurosurgery ward
5. Centre d’excellence Mpore (OPD).
The services are provided for outpatients every day from 7: AM to 5: PM, and for inpatients and
emergencies 24/24.
2.4. Clinical Objectives
These objectives highlights the achievable and unachievable during my clinical placements
The main purpose of this clinical placement as per my clinical objectives are as follow for the module of
advanced newborn care:
 Using theory and research in clinical practice, integrate critical thinking, ethical reasoning, and
decision-making abilities to prioritize and organize care for patients and their families.
 Represent the needs of patients and families by collaborating and communicating effectively with
members of the interprofessional health care team.
 To increase pediatric patients' physiologic capacities, incorporate effective use of invasive and
noninvasive technology, as well as other diagnostic approaches..
 Refine your history-taking and physical-assessment skills, as well as a few advanced talents.
 Analyze and use key pharmacology information in terms of dosage calculation, complex
calculatios, and comparability to properly deliver medication.
 As specialized care nurse apply the nursing process more extensively in the treatment of critically
sick children and their families.
 Inteprete, manage and document relevant data related to nursing care
 Apply evidence-based research to practice modifications in pediatric patients to enhance
outcomes.

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 Assess and evaluate nursing care delivery and advocate properly for the pediatric patient using
ethical analysis, moral agency, and clinical reasoning.
In the case of neonatology perspectives,you can also consider the below objectives:
 Be able to receive and admit the newborn
 Perform neonatal examination (vital signs, anthropometry measurement, reflexes )
 Perform silverman score,ballard score
 Perform oxygen therapy (mask,NGT,Ambu bag)
 To carry out care for premature infants and any infant with disability
 Be able to feed the newborn(NGT,breastfeeding and nutrition,IV)
 Be able to maintain airway patancy(suction,position,and monitoring)
 To perform neonatal resuscitation, Helping baby breath concept (HBB)
 Offer nursing care to a neonate in incubators and undergoing phototherapy
 Be able to utilize the equipment used in neonatlology(CPAP,Ventilator ECG)
 Ensure documentation for all findings
 However, 90% of the above objectives were achieved during my clinical placement at this
hospital. The 10% that were not achieved were: Be able to receive and admit the newborn, To
carry out care for premature infants and any infant with disability and perform silverman score.
2.5. Week one activity Orientation and PICU (MAY 4th and 5th 2021)
During this time, the clinical placement orientation day was held on May 4, 2021. I realized that the
University of Rwanda,College of nursing and midwifery has three different tracks assigned at the second
clinical placement.The postgraduate clinical coordinator of CHUK gave us a powerpoint presentation on
the general laws and regulations governing the hospital (CHUK) on May 4, 2021.
Furthermore,our clinical supervisors were present for each of the three tracks. Following the general
orientation, our clinical supervisor in person of Mr. Karanga met with us and shared our clinical objectives
with everyone as well as the timetable of our allocated areas on the various pediatric wards.
On May 5, 2021(week one), I was assigned to the PICU with one of my colleagues. Around 7:00 a.m., I
began working on the unit. A total of nine(9) nurses are assigned to both day and night shifts. There is a
unit manager, a resident doctor, and a senior doctor. When it comes to resources, I saw that there are three

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beds, three ventilators, three suction machines, four monitors, and one emergency trolley with a procedure
cart. IPC has three bin systems in place, as well as one desktop computer.
My first clinical day, however, was for orientation on May 4,2021, and I started at PICU with two weeks
of experience. Despite this, I faced a language problem when I was sent to the pediatric emergency unit
without any of my colleagues who spoke the language. Later, in collaboration with the supervisor, I was
permitted to talk with my colleague who was in PICU about joining her.
Although we were just taught theoritically how to use the mechanical ventilator in the PICU, it was a
difficult time for me and I did not know how to use it. However, I received assistance from the staff nurse
with whom I was assigned in utilizing the ventilator.
When a child develops a respiratory or cardiac problem, I can now employ the ventilator machine. For the
past two weeks, I've noticed that the majority of the emergency cases I've seen have been abdominal wall
problems, such as deduodem atresia, gastrochisis, and so on. I also noticed that the majority of the admitted
children were born prematurely.
A case of bronchialitis and a case of meningoenphalitis, on the other hand, were reported. I also looked at
the Rwandan neonatal protocol and other management of broncholitis and a newborn with respiratory
distress, and everything was done precisely according to the literature and protocol that I studied.
I realized that the ward policy was supplied to me by the personnel while I was assigned to them. Before
initiating any patient care, I was instructed that hygiene (IPC) was the most important consideration. The
PICU ward has nine (9) registered nurses, one unit manager, one resident doctor, and two senior doctors.
I also found that standard operating procedures (SOPs) for IV fluid preparation, as well as guidelines
available.

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Figure 1:Critical Care Nurse Specialist Educating on the use of Mechanical Ventilator

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Figure 2: Guidiline of Sedation with Mecahaniacal Ventilator

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2.6. Week two activity PICU ( May 10,11 and 12,2021)
During this time, I was able to integrate critical thinking, clinical reasoning, and decision-making to
prioritize and synchronize care for pediatric patients admitted according to their developmental age, which
met my objectives. In doing so, I listed a family-centered treatment strategy, which I implemented through
the use of childhood development and research in my clinical practice.
In such a case, I discussed and used evidence-based knowledge with the interprofessional healthcare team
for improved child care outcomes through family education, and because I didn't speak the language, I
was supervised by the assigned staff for translation.
As a result of these interventions, I was able to interact and communicate effectively with the staff
representing the needs of the pediatric clients and their families during admission.
Notwithstanding, throughout the period under review, I was instructed on how to use the pediatric nursing
evaluation tools in accordance with the institution's guidelines. I utilized it inline with our aims for the
head to toe neonatal assessment instrument that we had.
The SOPs for IV fluid preparation, as well as the pediatric guideline for sedation with mechanical
breathing, were placed on the wall, which I discovered. When it comes to services, the first thing to do
before starting any job was to ensure that the emergency trolley is fully stocked with all necessary supplies,
and to assess all patients admitted to the ward. Patients were monitored every three hours, as per their
protocol, although it also depends on the patient's condition. I was able to assist the staff nurse in putting
all of those initiatives into action.
2.7. Case presentation/description(Jejunum atresia)
As part of my goals, I was able to choose a case of abdominal wall defect (Jejunum atresia) and the
management conducted by the multidisciplinary team.
2.7.1. Definition
Intestinal atresia is a congenital condition in which the bowel lumen is completely blocked. S(uryaningrat, A.A.A et
al 2020).

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2.7.2. Case Description
A 8-days-of-life (DOL) male delivered from the District health facility and brought to CHUK with
extensive bilious vomiting, lack of stool since birth, and inability to breastfeed presented with severe
bilious vomiting, lack of stool since birth, and inability to breastfeed.
He's been vomiting since he was four days old, brown at first, then greenish. He did not pass meconium
after the first day of life, however he did pass meconium once shortly after birth, a small amount with a
grey tint. During admission, the physical examination revealed a bloated abdomen and cry immediately
as a vigorous baby. Prenatal care was not provided to the woman in a timely manner.She went to the
doctor twice during her pregnancy according to her.There was no history of congenital disorders in the
family.
Vomiting and jaundice were the first symptoms, according to the mother's account on the third day of life.
The child had been stabilized and was now on NPO. The nasogastric tube remained in place, but it was
switched to NPO immediately after surgery and then to complete parenteral nutrition (TPN) as directed.
This newborn's abdominal distention and bilious vomiting were key clinical signs of intestinal obstruction,
necessitating an early operation and intervention.
The patient in this case was diagnosed with bilious vomiting and mild abdominal distention on the third
day of life. The patient had previously passed meconium within the first 24 hours. The patient .had his
first bowel movement a few days after surgery and began oral feeding.
The baby's vital signs were meticulously monitored after surgery. Temperature, respiratory condition, and
hydration status were all regularly monitored. In this case, infection was a major concern as well as one
of the top reasons of death. As a result, the ward places a high priority on infection control and prevention.
I also kept an eye out for indicators of sepsis, such as hypothermia, lethargy, respiratory difficulty, and a
pale skin color.The patient was diagnosed with sepsis due to a high septic marker value, which was closely
monitored in the PICU to avoid unnecessary danger.
Oral feeding began on the fifth day of life following surgery. His condition was improving and remaining
steady. Meropenem and vancomycin antibiotics, as well as IV hydration were given according to
procedure. Midazolam was also used to sedate the baby.

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2.8. Week Three General Pediatric Ward(May 17,18 and 19 )
At the pediatric general ward, I had a good experience. I saw that the bulk of the newborns admitted had
surgical problems. There were ten beds on the general ward, with ten children admitted with various
surgical conditions. I also looked over the files of the children who had been admitted, and one of the
surgical cases, a newborn with gastrochisis,
I noticed SOPs for IV fluid preparation taped on the wall, as well as SOPs for basic life support (BLS)
and 15 nurses allocated to the ward. Abdominal wall abnormalities (gastrochisis)were found in 80% of
newborns admitted during my clinical placement.
2.9. Week Four General Pediatric Ward(May 24 25,and 26 )
During the fourth week, I was primarily concerned with an impeccable newborn health assessments, drug
administration, ward rounds with physicians, opening an IV line on the neonatal, revising management
and procedures, and other duties in accordance with my clinical goals.During this period,we had onsight
ward presentation with one of the guest lecturers of the pediatric track on the various surgical conditions
admitted( gastrochisis and Omphalocele and Jejunal atresia).
2.10. Week five NICU( May 31, June 1 and 2,2021)
With only one week of experience on the NICU, this was my last week there. I noticed that there was one
neonatologist as well as 15 nurses, including the unit manager. The NICU unit was divided into three
divisions, which I noticed:
1. Preterm baby section:
At this section,there were 10 baby incubators, 5 CPAP,8 syringe pumps,2 mobile monitors,12
oxygen on the wall, neonatal management protocols and other SOPs displaced on the wall, 3 lamp
warmers,
2. Term baby- At this section,term baby with different medical conditions are admitted.I observed 9
cribs
3. KMC- This section is concerned with preterm baby less than 1kg but stable with 3 beds
I also realized that vital signs are taken twice day and weight measurements are taken twice weekly in the
NICU.During this time, our supervisors instructed me to choose one neonatal condition to examine the
management in relation to the theory and practical management of the case in the NICU.Although there
were various neonatal illnesses available, I chose a newborn with respiratory distress syndrome..

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My primary goal was to discover or critically evaluate the relationship between theories and the current
practice in the management of a newborn diagnosed with respiratory distress syndrome admitted to
CHUK's Neonatal Intensive Care Unit (NICU). My method of the case analysis was to examine and audit
the management processes followed by the multidisciplinary team when this newborn with RDS case was
admitted.
2.11. Case study on the management of the child diagnosed with Respiratory distress Syndrome
2.11.1. Case presentation
Definition
Respiratory distress syndrome is defined as respiratory distress that happens in a newborn infant after the
onset of breathing, within the first few hours of life, and is primarily due to an absence of the pulmonary
surfactant system (Verma RP,1995).
On May 28,2021, a five(5)male infant born at 31 weeks, 5 days gestational age for preterm premature
rupture of membranes (PPROM) was admitted for Respiratory distress syndrome with the manifestations
of sustained grunting, intermittent nasal flaring, severe chest indrawing, and an accidental sound of crackle
was transferred from the maternity ward to the NICU ward. He had a normal capillary refill time of 3
seconds, as well as a normal heart sound with S1,S2. His skin was warm and his body temperature was
normal. His limbs were shown to be active, but he had inadequate sucking, rooting, and swallowing
reflexes.
While on NICU hospitalization, he had jaundice with an elevated serous bilirubin level on the third day
of life. As a result, hygienics, antibiotics, oxygen, and phototherapy were administered along with
emotional and mental care provided to the mother.
2.11.2. Health History of newborn and Mother
Baby details
Day of life (DOL) five(5)male infant born at 31 weeks, 5 days gestational age for preterm premature
rupture of membranes (PPROM) admitted for Respiratory distress syndrome with manifestations of
sustained grunting, intermittent nasal flaring, severe chest indrawing, and the possibility of hearing a
crackle. The baby was given vitamin K and tetracycline eye drops, but vaccination was still waiting..The
baby weighed 1.5 kilograms at birth. Body temperature at birth

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was 36.8 degrees Celsius, heart rate was 128 beats per minute, respiratory rate was 52 breaths per minute,
and oxygen saturation was 92 percent, according to vital signs.
2.11.3. Vital Signs Framemwork of Days of Life(DOL)
Figure 3:Vital Signs Framework of DOL

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The daily vital signs taken by health personnel for the newborn's and close monitoring are shown in the
diagram above. I also assisted the nurse with the vital signs of the newborn.
Note: NICU ward , new born vital signs are taken twice daily as well as the weights are also taken twice
weekly as per protocol:
2.11.4. Neonatal Nursing Assessment and Physical examination
Table 2: Neonatal Nursing Assessment
Baby Data:
Hospital
number: 596494
Date of birth: 28
May
2021
Place Of
birth:MaternityC
enter,
CHUK
Time of
delivery: 7:30
am
Date of
Admission: 28
May,2021
Sex: Male
Growth and
developmental Assessment/G
rowth Chart
Use of growth
chart= available but not used
Weight :1.5kg,LBW
Height: 42cm
Gestational age: 31weeks,5
days
Head Circumference: 31.5cm
Chest circumference :27cm
Ballard score: 20
Reflexes: Poor
sucking,rooting and
swallowing
Pain Assessment
NIPS(Neonatal pain Scale)
0- 1 month
0 1 2 Tot
al
Face Relax
ed
contracted - 0
Cry absent smell vigoro
us
0
Breathi
ng
relaxe
d
Not
normal
- 0
Arms relaxe
d
flexed 0
legs relaxe
d
flexed 0
Alertne
ss
calm uncomfort
able
0
Adopted from NICU.CHUK 2021
Note: the Yellow indicates the findings for the
assessment of the newborn
Physical Examination
Focused neonatal Assessment
General appearance:

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 Growth –Small for gestational age
 Odor-normal
 Observed in respiratory distress
 Skin appeared jaundiced within 48hrs.
Respiratory System
Airway and breathing:
 Not patent
 Cry normal
 Grunting
 Nasal flaring
 Severe chest indrawing
 Breath sound –crackle
 Cyanosis –none
Note: The baby presented with all of the above signs on admission
Cardiovascular Assessment
Pulses:
 Strong
Weak,
Location = brachial
Skin temperature
 Normal/warm, CRT<3secs
Hot
Cold
Skin color
Within normal limits(WNL)
Flushed,Pale,Cyanotic: Nothing abnormal detected at the first and second days of life(DOL)

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Gastrointestinal
Abdomen:
Shape-normal
Palpation:soft and flat
Bowel sounds: normal
Nutrition/Route
Tube feeds as requested
NG/OG Tube- as ordered
Mother concern: child’s health and no risk of injury
Neurologic and disability
Movement= within normal limit
Muscle Tone =weak
Suck reflex =absent/unable
Fontanel=soft and flat
Head shape =Normal
Gastrointestinal
Abdomen:
Shape-normal
Palpation:soft and flat
Bowel sounds: normal
Nutrition/Route
Tube feeds as requested
NG/OG Tube- as ordered
Mother concern: child’s health and no risk of injury
Genitourinary
Urine color
 Clear

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Genital
 Nothing abnormal detected
Medical diagnosis on Admission
 Respiratory Distress Syndrome (RDS)
 Prematurity
2.11.5. Nursing care plan
Table 3:Nursing Plan
Date
and
Time
Nursing diagnosis Objectives Nursing
Interventions
Expected Outcome
9am
28/
/5/2021
Ineffective airway
clearance related to the
disease
Process as evidenced by
grunting.nasal
flaring,crackles
-To open patent
airway
-To administer
oxygen
-Patient airway is
patent
-Initiate supplemental
oxygen
Patient will gain
normal respiratory
rate,no grunting or
crackles since 24
hours
9am
29/
/5/2021
Imbalanced nutrition, less
than body requirements r/t
absent sucking reflex
secondary to preterm
birth,low birth
weight(1.5kg) and type of
feeding
-To insert
feeding tube for
nutrition
-To Open iv
line for total
parenteral
feeding and IV
fluid
-NG tube was
inserted right after
birth,
-IV opened
-Parenteral feeding
and IV fluid initiated
-Patient feeding
pattern regular and
-Parenteral IV
nutrition in progress

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-To increase
body weight
9am
30/
/5/2021
Risk of infection related to
prematurity secondary
to preterm premature
rupture of membrane
-To provide
antibiotic for
secondary
bacteria
infection
-Ampicillin
+gentamicin were
administered for the
prevention and
treatment of bacteria
infection
Patient will be free
from development
secondary bacteria
infection with 3 to 4
days of life
9am
31/
/5/2021
Risk for impaired parent,
infant attachment r/t
premature birth &
separation
To provide the
ability of
parents to meet
personal needs
Interview parents,
noting their
perception of the
situation, individual
concerns.
Parents will identify
and use resources to
meet needs of their
child

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2.11.6. Laboratory investigat ion framework Development
Figure 4:Framework of laboratory investigation conducted,NICCU,CHUK,2021

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2.11.7. Maternal Details , Family Centered Care and /Education
This 35-year-old woman with G1 P1 claimed to have experienced spotting and minor bleeding up to 28
weeks of pregnancy during her first and late second trimesters. As she indicated, a portion of amniotic
fluid was seen daily during that time. She went to the emergency room at her place of employment, where
she worked as a medical laboratory officer. The doctor encouraged her to stay in the hospital for up to 34
weeks of pregnancy while she was there. However, due to a decrease in amniotic fluid, she was given
dexamethasone to maintain the fetus' lung maturity as well as antibiotics to prevent secondary bacteria
infection.
The doctor recommended that she be transported from Muhma District Hospital to CHUK Teaching
Hospital for additional consultation after a week in the hospital. She did not reach 34 weeks gestation
during her two weeks at CHUK hospital,and gave birth at 31 weeks gestation, five days old, and the
delivery was spontaneous with cephalic presentation. She was diagnosed with premature labor.
I got this information straight from the newborn's mother, who was able to convey everything to me in
English. She gave her permission and signed the information she provided. The hospital's education and
communication form, which was linked to the baby's file, was filled out with all of the information
acquired from the newborn’s mother.
During this time,I was elated and used a family-centered-care approach to address child’s developmental
theory. The health, nutrition, and nursing of the neonate as well as treatment, patient rights, culture, and
patient safety were all respected. I discussed with the newborn's mother upon admission as shown in the
newborn file. From the first day of life to the fifth day of life, I noticed that the nutritional status of
expressed breast milk (EBM) ranged from 6ml/kg/day to 25ml/kg/day, and birth weight ranged from 1.5kg
to 1.9kg.
2.11.8. Past Medical/Pregnancy Details
According to the mother, she has not had any serious health problems until she became pregnant, and she
has been in good health since then. She completed four prenatal appointments and received two TT
vaccines on time, with the third due for July 2021. During the first and late second trimesters, the main
problem or issue she had was spotting, which caused her to bleed she was pregnant.

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2.11.9. Nutritional Details
NICU personnel, CHUK, provided proper nutritional food requirements, prenatal, antenatal care,
medications, and education during pregnancy, as well as postnatal nutritional food requirements and
education. Currently, postnatal care is adequate. Mother's health is fine, and she is using expressed
breast milk (EBM) to feed her baby in accordance with Rwanda neonatal protocol, as the infant is also
on tube feeding.
2.11.10. Surgical Details
There was no prior surgical experience. She indicated that this was her first pregnancy at the age of 35,
and that she had never had a surgical complication or even begun a pregnancy before.
2.11.11. Birth and Labor Details
With a cephalic presentation, the delivery was normal. At 31 weeks and 5 days into the pregnancy, the
baby was born. After more than 18 hours of pregnancy, the membrane ruptured. It took almost five hours
to complete the task. A labor complication was a preterm premature rupture of membrane (PPROM) that
lasted 18 days. The APGAR score of the newborn was 6, suggesting that he was moderately
depressed,after being stimulated.
2.11.12. Psychosocial Details
This was the first pregnancy for the newborn mother, who is married. Rwanda's health-care system is
classified as category III and she was classified in this same category . Any chemical, drug, or alcohol has
no history with her.She was in good health when she was admitted, and she was providing express breast
milk for her newborn. I was able to provide psychosocial counseling to her because she was able to
articulate her pregnancy history and health status to me. As I observed, she was attempting to build some
psychological issues. She indicated to me that in her 35 years, giving birth to a kid who did not reach term
due to this type of condition frightened her much. I was able to provide her with psychosocial and
emotional support, and she acquired hope for the future of her child's health.
2.12. Findings/observation of the Management of the Case

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Days of life five male premature infant born by normal vaginal delivery with cephalic presentation who
was diagnosed with respiratory distress syndrome.Due to the child’s condition,he was transferred from
the maternal ward to the NICU,CHUK for admission.With immediate effect, IV line,NG tube were
established. I realized that there multidisciplinary team approaches initiated during the time of admission.
Due to the prematurity and with the preterm premature rupture of membrane,he was noted to be an
increased risk of infection as well as prematurity of apnea, ,malnutrition,hypoglycemia and hypothermia
respectively.
Therefore;he was been managed with the administration of antibiotics, caffeine, Expressed breast
milk(EBM)and parenteral IV fluid and nutrition.In another instance, his serous bilirubin level was high,
as the result of neonatal jaundice and in that case,phototherapy was ordered and administered according
to his condition.Oxygen therapy and CPAP were been initiated immediately.
I realized that the neonate IV fluid and parenteral nutrition protocols and SOPs were displaced on the wall
and followed by the multidisciplanary team.The nurses used that as reference in managing the
child’s condition. As for the antibiotic,I did not see the SOPs for antibiotics during the child’s care,but
from the protocol I observed that it is inline and followed. I realized that the administration of surfactant
is not initiated in the national guideline for the management of RDS,but I noted that in the international
guideline and standard.
2.13. Framework of management
Table 4:Framework of management provided
Days of
life and Date
Management
DOL one
May 28,2021
1. At birth, initial management wereVit. K and eye prophylaxis applied.
2. The child was on a radiant warmer.
3. Oxygen was initiated and CPAP QD 3 hrs
4. NG Tube inserted
5. Body Heat and skin care were taken care of.
6. EBM 6ml Q 3hourlhy through tube feeding and on NPO
7. D10 1/4RL-80ml/kg/day(120ml/24hours,5ml/hour)
8. Caffeine 20 mg/kg/day
9. Ampicillin 150mg/kg bid +gentamicin 3mg/kg QD

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DOL two
May 29,2021
1. Continue EBM 6ml/
2. Continue ampicillin and gentamicin
3. Started CPAP and Oxygen
4. Continue feeding according to national protocol
DOL three
May 30,2021
1. Due to the increase serous bilirubin- phototherapy
Nursing management I noticed on the administration of the phototherapy,the
child face was covered to protect from the light and it was measured as the level
of 45 degree distance
2. Continue caffeine 20 mg/kg /day
3. Continue EBM according to the protocol
4. Continue Oxygen therapy
5. D101/4RL
DOL four
May 31,2021
1. Continue phototherapy
2. Continue EBM according to the protocol
3. Continue ampicillin and gentamicin
DOL five
Jine 1,2021
1. Stop ampicillin and gentamicin
2. Start meropenem and Vancomycin
3. EBM 25ml QD3hrs

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2.14. Gaps identified in managing the Case
In examining and evaluating theories, and current practice in the management of a newborn diagnosed
with respiratory distress syndrome in the NICU, I noticed that care providers are not effectively monitoring
and documenting the neonate's progress. I saw that the patient's growth and monitoring charts were
missing from the file. Despite the fact that patient weights are obtained twice weekly, some metrics are
not.
I also saw that nurses do not do holistic nursing assessments; nevertheless,documents are completed,
based on my observations during my clinical placement. I was able to inquire from one of the nurses with
whom I was placed, and she subsequently explained to me that the work overload made it impossible to
spend much time in assessing the infants from head to toe.
I also saw that the ballard scoring of the neonate was noted on the physician assessment form, but no
information was provided in the space provided, and the scoring was not cited on the nursing assessment
form either.
The information can assist the midwife, physician, or nurse in determining the gestational age of a
pregnant woman who does not know her last menstrual cycle. Finally, I noted that laboratory findings are
not accessible on time, although the attending physician makes requests to the laboratory. The gaps I saw
on the side of the family members were not this exact example, but others, such as a family member's
delay in paying laboratory expenses, as I documented in the patient file. I also noticed that the NICU's
vital signs monitoring were insufficient.
2.15. Effects of the Gaps on the baby
Preterm babies are clearly at a higher risk of a variety of negative outcomes, including respiratory distress
syndrome, necrotizing enterocolitis, neonatal sepsis, and malnutrition. As a result, they are more prone
than term babies to exhibit motor and sensory impairment, cognitive development delays, and behavioural
issues in the long run.
Effective growth mentoring and charting on the neonate file, in my opinion, will decide growth and
development as well as nutrition.
As a result, ensuring that preterm newborns' postnatal growth is as healthy as possible is crucial to their
survival and long-term results.In this case, it requires having vigorous standards to monitor their growth
and development on the growth chart when complications arise, if nurses do not completely assess all
neonates holistically, the child and family will bear the brunt of the consequences, which will be

45
excruciating for them. Because utilizing one or two monitors on each infant may have an effect, the limited
of vital signs monitors for all newborns may expose them to various infections.I noticed that one monitor
was used for all of the newborns admitted.
2.16. Strengths and weaknesses noticed in managing the case
One of the benefits I noted in the NICU ward was that the pediatric and neonatal procedures are actually
followed by care professionals, and family-centered care techniques are effective, i.e., families are
involved and educated in the care of their babies.
I also saw that infection prevention and control is one of the hospital's top goals for all patient care. I
realized that the idea mentioned in the reduction of neonatal mortality in Rwanda according to the RDHS
2019-2020 report is actually proven in practice, because during the period under consideration of my
clinical placement, I did not see any neonatal death.
Although this report is only done at one Rwandan hospital, it is one of Rwanda's teaching hospitals, where
the majority of the country's complicated cases are sent or moved. I found that neonatal resuscitation tools
are readily available and frequently used by caregivers. I saw that the nurses had the potential to teach the
students who are on clinical placement at the various hospitals.
The following, on the other hand, were some faults I noticed that was care providers inadvertently using
the growth and monitoring chart, inadequate staff assigned to the unit, resulting in work overload, and
ineffective communication between the prescribing physician and the laboratory unit, resulting in a delay
in providing patient results. Other issues linked with presenting laboratory findings or delays are yet
unknown, as is the NICU's absence of master level staffing. Furthermore, according to the unit manager,
just one neonatologist is currently assigned to the unit, whereas the unit had five neonatologists five years
ago.
2.17. SWOT Analysis of the pediatric Department.CHUK
Table 5:SWOT Analysis
STRENGTHS WEAKNESS OPPORTUNITIES THREATS
-Effective way of induction
and orientation for students
(education and research
officer; nurse in charge of
-Insufficient medical
equipements like
thermometers, vital
sign monitors,
weighting scale.
Strong social
services
-Life support
services (nutritional
-There is a shortage
of nurses in some
wards which
prevents them to

46
teaching and education in the
department)
-Good team work spirit
between nurses and
physicians
- Strong social services that
intervene in case of patient’s
inability to pay.
- Systematic screening of
retinopathy and cardiopathy
in neonates before discharge.
-Effective pain management
among neonates
-Good collaboration with
students, patients and
caregivers
-Effective teaching program
(under graduate and post
graduate).
-Patient’s families are
informed timely about the
disease conditions and
prognosis.
-some nurses
consider master’s
students as seniors in
the profession,
therefore not willing
to help them.
-some nursing
procedures like NG
tube feeding,
emptying urine bag
and measuring
output are done by --
-the patient’s next of
kin without a nurse
assistance except in
PICU.
-Ear examination is
not systematically
done in neonates.
support, financial
support,
psychological and
spiritual for all
clients and next of
kin)
-Medical students
available in each
ward and advocates
at time in case of
senior’s review.
provide all needed
care to patients.
-No staff meetings
and student
presentations in
order to adhere to
COVID-19
measures.
-Some patients
without insurances
become a burden
for the caring
nurse.
-some patients are
not hospitalized in
their specific ward
related to their
disease condition
putting at a risk of
not being followed
by a specific
specialist.
-No enough space
to accommodate all
neonates.

47
-Adequate infection control:
Daily bed cleaning with
chlorine, and daily bed sheets
change, and hand hygiene,
available hand sanitizers on
each bed, strict hand washing
before entering in the unit.
-Strong and regular health
education for
family(caregiver)
2.18. Recommendations
Based on my observation from the management of the newborn diagnosed with RDS,I would like to come
out with the following recommendations for a newborn with respiratory distress syndrome admitted at
NICU ward,CHUK:
 That growth and monitoring chart to be properly filled and documented in patient file
 That strong collaboration between the laboratory and the neonatal team for timely lab.results
 Nurses to be upgraded to master level in pediatric and neonatology nursing
 That nurses to ensure impeccable nursing assessment routinely
 To include ballard score and silverman’s score to be included in the nursing assessment form
 Nurse –newborn ratio to be 1:3 to reduce work overload
 Surfactant administration to be added in the Rwandan neonatal/pediatric national protocol in
accordance with international standard and guideline
 Make available vital signs monitors for each newborn
References
Verma RP. Respiratory distress syndrome of the newborn infant. Obstet Gynecol Surv. 1995;50(7):542–
55.
Suryaningrat, A.A.A. and Ariyanta, K.D.2020, A jejunal atresia type I in newborn: A case report.

48
CHAPTER THREE: CLINICAL TWO REMERA HEALTH CENTER
3.1.Introduction/Background
This document details a three-week clinical placement at the Remera Health Center from June 7 to June
23, 2021. The main purpose of this clinical placement at the Remera Health Center was to gain knowledge
and skills in health promotion activities available to children.
The Remera Health Center was established in 1994 and is located in Gasabo District,Remera sector,Rukiri
II Cell,Amahoro Village. This health center serves the population of 76,523 from 3 cells of Kimironko
sector 4Cells of Remera Sector and neighbour of those sectors.However,regarding the community health
services,the catchment area of the health center has 35 villages and each village 3ASC(2binomes and
ASM),so the Health center has 35ASC.
Those services offered at this health center are the following: PMTCT,TB,HIVCare and Treatment,
IMCI,Nutrition,Expanded program on immunization(EPI),Family planning,Community health
program,maternity services,mental health, Reception, curatcive consultation, Laboratory, primary care of
Optalmologie, small surgery included circumcision of Prepex, Prenatal Consultation,hospitalization,
accounting,Data base and Administration, Dentistry,Ultrasound, community health and hygiene.
Ideally, the clinical placement at the health center,intends to cover pediatric health promotion module with
the below clinical objectives that I achieved during this period.
 To perform anthropometric measurements, complete growth charts, determine Zscores,and
evaluate adequacy of physical growth at each pat ient visit .
 To Practice the principles of Early Childhood Development while assessing and counselling
families of children in PDC.
 To Assess the families’ understanding of their children’s specific condition and the appropriate
care, and counsel as needed.
 To Assess the child ’s development and relationship with the family through observation of play
and communication, and provide guidance about safe and developmentally appropriate play.

49
 To Assess the families’ social risk factors and support system, provide counselling to improve
coping skills, and communicat e co ncerns with the families’ community health workers to ensure
follow-up.
 To Assess and address any micronutrient deficiencies, vaccinat ion needs, and refer to supervising
physician or outside specialists if specific assessment concerns arise.
 To Assess and manage children with specific condit ions , e.g., Down Syndrome,hypoxic ischemic
encephalopathy, cerebral palsy, CNS infection, cleft lip/palate, prematurity/ low birth weight ,
hydrocephalus, other genet ic syndromes, or other
.
 To Identify systems factors that improve or worsen neonatal health outcomes, and ways that MSN-
prepared nurses can have a positive impact .
 To Hold community forums with parents to discuss determinants of neonatal health in their
context, i.e., physical environment , resources, family size, information, health system.
 To Provide context -appropriate informat ion and guidance about healthy nutrit ion at every age,
including women who are pregnant or are of childbear ing age.
 To Utilize proven successful methods in community education about breastfeeding practices, which may
include information about appropriate maternal health and birth-spacing
3.2.WEEK ONE June 7,8,9 2021
Expanded program on Immunization(EPI) unit
During this period,I was very interested in the Rwanda National immunization policy and guidelines inline
or comparing with WHO guideline and standard.It was nice week for me,the vaccinators and other health
care professionals were responsive and willing to teach me.
Due to the increased number of attendance for routine immunization services,I realized that all antigens
are scheduled according to the plan made the vaccinators so as to reduce workoverload. As for BCG,the
schedule is every Friday,DPTand other antigens for every Monday,Tuesday and Thursday. During this
period, the team was able to identify a case of congenital malformation and the team provided health
education to the child’s mother and she agreed to be transferred to the district hospital respectively
3.3. Routine immunization schedule as per Rwanda National Guideline
I also worked with the vaccinators to immunize children according to their age following the guideline.

50
Table 6: Immunization Schedules
Vaccines Schedule
BCG Birth to 11months
Or <12 months
OPV 0 Birth
OPV 1
DPT1.Pneumo1.Rota1
6weeks
OPV 2
DPT2.Pneumo
(PCV)2,Rota2
10weeks
OPV 3
DPT3.Pneumo 2, IPV
14Weeks
Mealses (MCV1)
MCV2
9months
15months
Vitamin A and Mebendazole
Type Color Administer to children
Vitamin A BLUE 6months
3gtt
100,000IU
Vitamin A RED 12-59 months/1-5years
200,000IU
With mebendazole
3.4.WEEK Two June 14,15 and 16 2021

51
With my previous knowledge,I was able to practice in the TB unit,IMCI,Nutrition unit,family planning
services.My objectives at these units were to look at national protocols and international standards and to
compare with current practice at the heath Center.I realized that the providers of these units were
knowledgeable and adhered to national guideline parallel with the current practice. I also realized that the
community health workers meetings are held at the health center every month. I had the opportunity to
have attended one of their meetings. I also found out that the Remera Center refers paitents that require
special or emergency care to the district hospital at Kibagabaga.
3.5.WEEK three June 21,22, and 23,2021
I was assigned at the nutrtion unit, where nutrition cares were provided to children and adult with
nutritional deficiencies.The nutritionist work closely with community health workers as well as the
various units within the health center.According to the nutritionist,if she suspects very severe acute
malnutrition without complications,the child is treated with Ready to use therapeutic food(RUTF) couple
with nutritional education following the guideline. On the other hand,if the child has or developed severe
acute malnutrition with complications in any case,the child is referred to the district hospital for further
management.I realized that there was no F-75,F-100 at the health center according to the nutrtitionist,but
they are provided at the district hospital for those complicated cases.
As for the moderate acute malnutrition, the unit provides CSB plus micronutrients,corn soyer blend and
milk and provide health education on the importance of consumption.I also noticed that the under weight
children were provided milk as well. I had some interactions with the nuttritionist on how she can meet
with the nutritonal needs of the children who lost to follow up. I was told that,they usually have monthly
meeting with community health workers to provide some demonstration on health promotion activities on
the importance of child nutrition with some contributions to keep the day during the activities.
I did not complete those weeks due to lackdown of COVID-19 situation, the clinical placememt was
suspended until August 2021. During this period, the team was divided into three goups to do a case study
on nutrition, immuniztion and PMTCT. The main aims of these case studies were to look at these services
at the health center and to compare with the national protocols and international guidelines if the we
observe any gaps in the management to recommend for improvement and also take the best practice of
these services to acknowledge their efforts in providing the services.
As I was found part of group three on PMTCT, we chose to look at a case study to determine the
effectiveness of the management strategy of the PMTCT Program at the Remera Health Center ,Kigali

52
City , Rwanda in June 2021. Our primary goal was to determine the effectiveness of the management
strategy of the PMTCT program at the Remera Health Center ,Kigali City,Rwanda.The group was
interested in evaluating the adeptness by providers of the PMTCT program management to national and
international standards during the clinical placement.This was intended to identify the gaps as well as
the strengths in the management of PMTCT services at the Remera health Center.Despite the global
pandemic of COVID-19, the health center continues to provide PMTCT services to the people of Kigali,
Rwanda.
Having found the group, we collaboratively prepared a questionnaire to be answered by PMTCT providers
for the services rendered. We also collected data from the monthly HMIS report for June 2021 for the
progress made so far.
3.6.Prevention of Mother-to-Child Transmission of HIV(PMTCT)
In countries where breastfeeding is a common practice like in Rwanda, the probability of transmission of
HIV from the mother to her child (MTCT) isvery high in the absence of prevention interventions with
ART. Probability of transmission varies between 20-45%, with 5-10% % chance of transmission during
pregnancy, 10-20% during delivery and 5-20% during breastfeeding.
In developed countries where PMTCT programs are well implemented and where the most efficacious
ART is provided to HIV-positive pregnant women with limited breastfeeding, the level of mother to child
transmission for HIV is below 2% at 18 months.
Since 2012, Rwanda has been implementing WHO Option B+ which means starting ART for all HIV
positive pregnant women regardless the level of CD4 count, exclusive breastfeeding protected by ART,
and mothers continuing ART as a lifelong treatment. The implementation of Option B+ has reduced the
MTCT rate at 18 months, recent data show an MTCT rate of 1.8% in a cohort of exposed infants. PMTCT
(prevention of mother-to-child transmission) is a key components in HIV prevention programs for mothers
and their children. During pregnancy, childbirth, and breastfeeding, HIV can be transmitted from an HIV-
positive woman to her child.
3.7.Packages of PMTCT
The PMTCT program is based on a comprehensive four-pronged approach
including:
(1) Primary prevention of HIV infection among women in childbearing age

53
(2) Preventing unintended pregnancies among women living with HIV
(3) Preventing HIV transmission from women living with HIV to their Infants
(4) Providing appropriate treatment, care and support to mothers living with HIV, their children and
families
As per these packages, I had the means going through all of these packages during my clinical placement.
3.8.Organogram of PMTCT Service at Remera Health Center
As I observed the PMTCT services during my clinical placement,I developed this oranogram
Figure 5:PMTCT Service at Remera Health Center organigram

54
3.9.PMTCT Empirical studies conducted in Rwanda( 2014 and 2020)
According to a research conducted in Rwanda for PMTCT, 92,366 pregnant women in Karongi District
received PMTCT services between 2010 and 2019,(Mutagoma M,et al 2020). A total of 83.5 percent of
the women who attended were accompanied by their husbands for PMTCT services. HIV prevalence
among pregnant women seeking ANC services fell from 2.7 percent in 2010 to 0.3 percent in 2019, with
rates varying amongst sub-districts from 0.011 percent in 2010 to 0.003 percent in 2019 ).
From 2010 to 2019, the Kibuye sub-district has the greatest number of HIV-positive women (460) in
Rwanda,(Mutagoma M,et al 2020).During the study period, 45,118 pregnant women in Karongi District
sought maternity services, with 113 (0.25%) of them tested positive for HIV,(Mutagoma M,et al 2020).
In 2019, one HIV transmission was recorded as a result of this research,(Mutagoma M,et al 2020). Since
2010, 22 exposed infants have been infected with HIV by MTCT at the ages of 8 weeks and 18
months,(Mutagoma M,et al 2020).For the time under consideration, the transmission rate in 2019 (a single
case) was 0.12%,(Mutagoma M,et al 2020).PMTCT was successful in Karongi District, according to the
findings of this study,(Mutagoma M,et al 2020).This achievement in preventing HIV transmission from
mother to child should be maintained in this setting, an HIV-free generation is possible,(Mutagoma M,et
al 2020).The socioeconomic features of mother-infant couples enrolled in the Muhima cohort research
were revealed in another study undertaken in Rwanda for PMTCT,(Bucagu M, et al 2014).With a median
age of 27 years (range: 17 – 45 years), nearly one-third of the mothers (29.7%) were young(Bucagu M, et
al 2014).The majority of mothers (75 percent) had only a primary or no education and were married (82.7
percent ). Over two out of every five participants (40.3% were considered as wealthy (Bucagu M,et al
2014). In the same study, the overall cumulative rate of HIV-1 mother-to-child transmission observed at
6 weeks of age after birth was 3.2 percent among the 679 live born babies followed up in this investigation
(Bucagu M,et al 2014). Twenty-one HIV-1 infected mothers and their newborns were lost to follow-up (3
percent) of the 700 included in the trial(Bucagu M,et al 2014). The study also found that 81.1 percent of
study participants knew and revealed their male partner's HIV status, which is a key indicator of PMTCT
service utilization (Bucagu M,et al 2014).Less than half of the moms (48.2%) said they used ART
throughout pregnancy, with the majority (51.8%) saying they used ARV prophylaxis.The duration of
ART/ARV prophylaxis before to childbirth was shorter than 6 weeks for more than one-third of the
individuals (22.5%) (Bucagu M,et al 2014).The study revealed that the vast majority of newborns (97.1%)
were born in a hospital, with 82.2 percent vaginal and/or instrument-assisted deliveries and 17.8%
caesarean sections (Bucagu M,et al 2014). At the time of enrollment, 38.7% of participants had a CD4
count of less than 350 cells/mm3, with a median CD4 count of 429.50 cells/mm3 (range: 11 - 1718

55
cells/mm3).The great majority of mothers (86.1%) stated that they exclusively breastfed their children
(Bucagu M,et al 2014).
According to the above two empirical studies conducted in Rwanda with a good success story of PMTCT,
I decided to look at PMTCT services at the Remera Health Center on the effectiveness of the management
strategy for the month of June 2021. A self prepared questionnaire for PMTCT providers and reviewed
of HMIS report for June 2021 were conducted.The below are questionnaires prepared for PMTCT
providers and HMIS report of mothers and exposed infants for the month of June 2021.

61
3.10. ANC PMTCT HMIS June /2021 Report
Table 7:ANC HMIS
< 25yrs >25yrs
1.Women presenting for first ANC consultation 80 181
2 Women with unknown HIV status presenting for first ANC
consultation.
80 168
3.Known HIV positive pregnant women presenting for first ANC 0 13
4.known HIV positive pregnant women on ART presenting for first
ANC consultation
0 13
5.Pregnant women with unknown HIV status tested for HIV 80 168
6. Pregnant women tested HIV positive 0 2
7.HIV positive pregnant women who initiated on ART 0 2
8. Pregnant women Partners tested for HIV 10 100
9.Partners tested HIV positive 0 0
10 Number of pregnant women who received self-test kit for their
partner testing
0 0
11. Discordant couples identified in ANC 0 6
12.HIV negative pregnant women whose partners are tested HIV
positive
0 6
13.HIV positive partners of HIV negative pregnant women started
on ART
0 6
3.11. PMTCT Labor and Delivery
Table 8:PMTCT Report
Maternity TOTAL
1. All women giving birth in the reporting period (HIV+ HIV_ 54

62
2. Known HIV positive women giving birth at the facility 2
3. Known HIV positive women giving birth at home 0
4. Women previously tested HIV negative during ANC 110
5. Women not previously tested for HIV during ANC 2
6. Women previously tested HIV negative during ANC and tested HIV positive
during labor
0
7. Women not previously tested during ANC and tested HIV positive during labor 0
8. HIV positive women identified at maternity who started ARVs 0
9. Total number of children born from HIV positive mothers 2
10. Children born from HIV mothers who received NVP and AZT at birth within
72hours of birth
2
3.12. HIV exposed Infant Follow up
Table 9:HIV exposed on Infant Follow up
1. Total number of HIV exposed infants follow up at the HF this month 316
2. Mother of HIV exposed infants who use modern family planning
methods by this month
62
3. HIV exposed infant who are 6weeks of age 27
4. HIV exposed infant starting CPT at 6weeks of age 27
5. HIV exposed infants tested at 6weeks with PCR 27
6. HIV exposed infants tested HIV positive at 6weeks with PCR 0
7. HIV exposed infants who are 9 months of age 11
8. HIV exposed infants who tested at 9 months 10
9. HIV exposed infants tested positive for HIV at 9 months 0
11. HIV exposed infants tested HIV at 18 months 11

63
12. HIV exposed infants tested HIV positive at 18 months 0
14. HIV exposed infants tested for HIV at 24 months 16
15. HIV exposed infant tested positive at 24months 0
16. Children who confirmed HIV positive and enrolled to care and
treatment
0
II HIV EXPOSED INFANT OUTCOME
17 . HIV exposed infant were followed at this health facility last month 302
18.HIV exposed infants newly erolled in PMTCT at birth(up to 6 months 27
19. HIV exposed infants newly enrolled in PMTCT after 6 weeks 2
20.HIV Exposed infants transferred in the facility this month 1
21. HIV exposed infant who were lost and retraced this month 1
22. HIV exposed infants who are confirmed HIV positive this month 0
23. . HIV exposed infants who exited negative PMTCT at 24 months 16
24. HIV exposed infants who are transferred out for followup in PMTCT 0
25. HIV exposed infants who are reported as lost to followup after 3 months
follow up
0
26. HIV exposed infants who are deceased this month 0

64
3.13. Analysis of Exposed Infants Outcomes(June 2021)
Having carried out the interview questionnaire,a monthly HMIS data for June 2021and findings showed
below:
Figure 6:HIV exposed infants outcomes at six weeks
As shown in figure one details that HIV exposed infants outcomes at six 6weeks as noted in June 2021
HMIS report. Exposed infants who were at 6weeks of age were at 100%,while those started CPT were
100% and those exposed infants tested at 6weeks of age were also 100% and those tested positive of HIV
were 0%.

65
Figure 7:HIV exposed infants outcomes at 9 months
As revealed in figure two , HIV Exposed infants at nine months of age were at 100%,those tested for HIV
were 90.9% while those tested positive were at 0% in June 2021 according to thr HMIS report
respectively.

66
Figure 8: HIV exposed infants outcomes at 18 Months
Figure 3 also shows that HIV Exposed infants who were at 18months in PMTCT were at 100%,those
tested at 18months were at 78.6% while those tested HIV positive were at 0%.

67
Figure 9:HIV exposed infants outcomes at 24 months
This figure shows that HIV exposed infants who were at 18 months of age during the period of June
2021 in PMTCT were at 100%,those who tested for HIV at 24 months were at 88.9% and those tested
positive were at 0%. This indicates that there is a success story of the PMTCT program at this health
center,

68
Figure 10:Exposed inffants follow up results
This figure also details that HIV infant were lost and retraced this month in this reporting month were
100%,while those who were reported as lost to follow up after three months were 0% and 0% death
during the reported period.

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