A. DESCRIPTIONS

-History of the Hospital

The Neuro-psychiatric hospital caraes Ndera, was founded by the congregation of the Brothers of charity in 1968 and this is when the first stone was put down for the construction of very hospital. This was on the demand and the catholic church of Rwanda too.

In 1972, this is when the construction of the hospital took place and it had a capacity of holding 120 patients. Since then, the hospital’s tremendous development came with:

- The creation of its branch in Butare in the year 1976, cater for the needs of patients coming from West and south-west of the country.

- The creation of a psychotherapeutic centre at kichukiro in kigali city in 2003. this

Branch or centre is for these patients who suffer from genocide trauma.

- Creation of kundwa centre for the adolescents.

- Creation of home St Jules for the chronic patients

· The very hospital is a real work of the congregation of the brothers of charity. it has a financial and human resources support from the Rwandan government

· This hospital is integrated in the national policy of mental health and activists in the decentralization of the mental health care.

· It is a referral hospital which maintains and supervises other mental health services in the country.

THE HOSPITAL’S GOALS

Its work is based on a Christian charity culture, build on the following points:

.* To treat mental illnesses and neurological suffering patients from the district hospitals

* To give a standard supervision to the district hospitals.

* To train mental health personnel.

The capacity of the hospital to admit new patients, depends on the beds in each ward the table bellow shows the number of bed in each ward

The ward	crises	improved	total
A and B for men	51	38	89
D and C for women	52	42	94
Children in kundwa center	12	-	12
chronic	-	22	22
Butare caraes	33	30	63
Icyzee center	00	8	8

-Ward “C” Presentation

The ward “C” is the ward of the women in improved situation, who has been transferred from the ward of crisis and are preparing to be discharged. It has the capacity of 38 beds but it can accommodate more than 50 patients, some can share beds. It has five dormitories, there are also some rooms like:

Ø 2 conversation rooms

Ø 2 stores rooms

Ø 1 dinning room

Ø 1 office of the chief department of the ward

Ø 1 recreation room

Ø 1 private room

The ward is composed of:

v 9 nurses

v 1 religious sister

v 1 watch man

All the nurses are trained in the psychiatric field. Each nurse has some of the patients whom he or she is call to follow personally and to whom he/she is as referral nurse. The ward activities are organized in a way that there are some orientations which help the patient to consider herself as someone whom the society is expecting to go and do something

B. The activities done

On the first day when the practicum started, the activities were not well explained and followed due to some preparations but we did the general observation and we visit some corners of the ward, the rooms, the toilets, the nurse’s room, the private room and the compound in general. The following day, I started with the activities of assisting and sharing during the patient’s group in the morning and also to assist and participate in the ergo-therapy activities during noon. Since the practicum started on Monday, it was a bit complicated to make a follow up of a patience due to the fact that the nurses were preparing the patients to be discharged on Thursday and to welcome those in crisis from ward D. we only had some practical explanation concerning files of the nurse, the doctor and other documents concerning the clinician and her patient.

Patient’s History

Name: M

Surname: E

Date of birth: she was born in 1959

Sex: Female

Marital status: She is married

Profession:

Religion: Protestant

Geographical origin:

Family status genogram

Mme M. E. born in 1959 in Rwanda in a family of five brothers and one sister. Traveled to Burundi then Tanzania in her early age where she started her standard one up to standard seven before moving to Kenya where she did catering for four years instead of normal education because of missing school fees. After completing her studies, she was obliged to apply for the working permit to the Kenyan Immigration office but her request was not taken into consideration and as the answer, many Kenyan as the ability to do that job instead of a foreigner person. After that she found an opportunity to get a job but the man who should grant her a job, asked first of all to have sex with her and to that she refused categorically as the result she missed the job. She was leaving with her uncle who later will be her father in law.

When still leaving in Kenya, she met her husband in their early age and whom they related as cousins. At first this relation was well respect but after the time when her husband went for further studies they separate for a while and when he was back, they start a relationship which leads them to live as concubine and finally she was pregnant by her cousin, as they were loving each other, they continue until they start being open and God bless them with five children, among those children, one is a medical doctor in Rwanda and another is a U.N peace keeper in Darfur-Sudan. At first also this brought problem in the family and for that, they were forgiven by the elders and they continue up to now. Officially they are not married.

History of the disease:

-The patient was strike down by a strong headache in her early adulthood which was followed by sinusitis diagnosed in Kenyatta hospital of Nairobi. This was cured and she recovered and return to her normal state of mind.

The really problem of our patient started when she got a car accident in Nairobi in 1997 due to the high speed of the bus and in which she loss her aunt and other family member, herself was not in a grieve situation but she only broke her finger and got some minor injuries whereby others died and some injured. After the accident, she did not present any sign of symptom of mental problem. She even assists to the burial of the people who died in that accident.

It’s after three months that she start showing sign of being depressed and for that she was brought and admitted at Nairobi Hospital in Kenya. From here she was diagnosed as presenting mood depression and she started at once medication and this really helps her and returns in her normal state. She also present as having blood pressure after the accident. Two years later she falls into a relapse situation and she undergoes medication which helps her again to recover. In 2001, she relapses again and was brought to a medical center in Kigali where they deal with people presenting some mental problems.

She claims saying that her really problem is when she starts thinking about those who died in the car accident, as from there, she start presenting some disorganized gestures, mood, even social interaction. She is always anxious about death. As from June last year till now, she is in a mood of depression since she was refusing medication and other therapies. In the hospital she always tried to follow well the medication because of the nurses’ surveillance.

- The other issue is the fact that the children are not aware that their parents are related as cousin. This came up with the question of her last born daughter who was told by her uncle that he; the uncle is a relative of both parents mother and father, so she doesn’t understand how and really when they talk always the stories raised are from the same family and same persons to both parents.

The mother is worried if one it happens again to one of her child to present to them a friend to marry who is also one of their family members of a cousin, “How will it be?”

-Medication of the patient

The patient medication has been done into two phases:

Crisis: Ward D

· Largactil 100mg it is a Neuroleptic sedative, she was in agitation when she present herself to the clinician for the first day.

· Haldol 10mg it is a neuroleptic incisive, just to play on her ideas and thinking.

· Pronothazine 50mg it is a kind of largactil, it was used when she was to much agitated.

Improved situation: Ward C

· Largactil 100mg 1morning and 1 evening

· Tegretol 200mg 2morning. This is a mood stabilizer

-Desired and non-desired effects

The medication prescribed shows really some improvement on the patient because on the side of agitation, she has improved and as for now on she is stable and quiet. Nevertheless, she also presents some non-desired effects like:

§ Weakness (physically)

§ Constipation

§ Doziness

§ Some inflammation of the muscles (legs)

-View of the patient regarding medication

The patient has fall twice into relapses for the medication negligence. She always starts in a good way but she ends in a medication refusal of taking. Her family members have tried to convinced her to take drugs but she refuse sometime. The husband always tried also but still she is aggressive at certain point. She knows well she has relapsed twice because of quitting the medication.

Some time also, she was leaving the drugs because of some side effects which she was encountering and since there were no one to help her.

She also admits that, she quits treatment once she starts feeling okay even before finishing her dosage of medication.

Positive things seen and some reason

Most of the positive things seen in the patient are that, when comparing the way she presented herself just when she was brought by her family and seeing the repot of ward D department where she was admitted, I can say that the patient is showing some positive and collaborative signs due to the taking of medication and other therapies. She also shows some positive impression in group meeting and always her ideas are coherent and clear. She had also showed some kind of relationship with the other patients. As in general, despite the language and other lack of means of communication, the patients were collaborative and they really helped us to know and discover what or which problem they were presenting mentally. To some extend it was not easy. The ward C as well known, as the ward of improved people and really the presence of a patient shows that she has improved due to her presence there. Most of the activities are done by the patients themselves like:

Ø Personal Hygiene

Ø Cleaning the dishes

Ø Cleaning the compound

Ø Cleaning their own clothes

Despite this small independency, there is always a follow up the medical cleanness personal.

For the patients who are really respecting their dosage and their appointment with the doctors, they always come back in the ward to greet the nurses and to greet also their follow patients who are present in the ward.

C. Suggestions to be done to improve the patient’s quality life

For our patient, she really needs a strong follow up since some time of the medical personnel. Apart from that, she needs:

v A psycho-clinician

v Addition of antidepressants

v Addition of ergo therapy

D. Personal gain during the practicum

During this practicum, I personally have gained many experiences which really I hope that they are going to help in my field of psychiatry. Really the way in which entered the practicum and the way I came out of it is different. The expectation I had, some were fulfilled and some were not due to the time we had which was very short. The time which we started felling deeply in the field, which also the collaboration with the nurses was quiet clear, it was also the time we were leaving the hospital for other program. To be brief, the practicum was live and encouraging.