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Casusanalyse 'Levenskracht in tweevoud, een dubbel verhaal' High Care Neonatologie Verpleegkundig redeneren aan de hand van een casusanalyse Versie 1
Naam student: Ilse de Winter [email protected]
Studentnummer: 586936
Opleiding:High Care Neonatologie verpleegkundige
Datum:08-01-2024
EPA: MK HC-IC-N-3
Stage-instelling & afdeling:Erasmus MC Sophia – ICN unit 1
Praktijkopleider: Nicole van Rijken [email protected]
Senior onderwijs: Marloes Schaap [email protected]
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Inhoudsopgave Inleiding.................................................................................................................................................5 Aanleiding opdracht...........................................................................................................................5 Persoonlijke leerdoelen.....................................................................................................................5 Mijn rol in de betreffende dienst.......................................................................................................5 Stap 1: Oriëntatie zorgsituatie...............................................................................................................7 Persoonlijke gegevens.......................................................................................................................7 (Voorlopige) medische diagnose en actuele problematiek................................................................7 Actueel beleid....................................................................................................................................7 Monitor instellingen......................................................................................................................7 Allergieën.......................................................................................................................................7 Medicatie.......................................................................................................................................7 Background........................................................................................................................................7 Event..................................................................................................................................................8 Sociale Situatie en Familieanamnese (SCEGS):..................................................................................8 Behandelwensen en -Grenzen...........................................................................................................9 Stap 2. Observeren Methodisch gegevens verzamelen.......................................................................10 ABCDE en Klinimetrie.......................................................................................................................10 Airway (luchtweg)........................................................................................................................10 Breathing.....................................................................................................................................10 Circulation....................................................................................................................................10 Disability......................................................................................................................................10 Exposure......................................................................................................................................10 Specifieke Monitoring/(Beademing)apparatuur..............................................................................10 Overige scoresystemen voor gegevensverzameling........................................................................11 Niet-pluis Signalen...........................................................................................................................11 Labwaardes......................................................................................................................................11 Stap 3. Analyseren...............................................................................................................................12 Zorgthema 1. Welbevinden.............................................................................................................12 Probleem 1: Algehele malaise, discomfort en ongemak..............................................................12 Probleem 2: Vermoeidheid..........................................................................................................12 Interventies Welbevinden............................................................................................................12 Zorgthema 2. Mentale functies........................................................................................................13 Probleem 3: Verstoorde slaap.....................................................................................................13 Zorgthema 3. Sensorische functies en pijn......................................................................................13
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Probleem 4: Verstoord zuigelingengedrag...................................................................................13 Probleem 5: Dreigende Pijn.........................................................................................................13 Zorgthema 4. Stem en spraak..........................................................................................................14 Zorgthema 5. Luchtwegen en Zorgthema 6. Ademhaling................................................................14 Probleem 6: Dreigende Hoge of lage luchtweginfectie................................................................14 Probleem 7: Sputumvorming, taai slijm.......................................................................................14 Probleem 8: Dreigende aspiratie door braken.............................................................................14 Probleem 9: Onrijpheid longen door prematuriteit.....................................................................14 Probleem 10: Dreigende Inefficiënte ademhaling........................................................................15 Probleem 11: Diafragmahoogstand.............................................................................................15 Probleem 12: Pulmonale hypertensie..........................................................................................15 Probleem 13: Dreigende Respiratoire uitputting.........................................................................15 Interventie Luchtwegen & ademhaling........................................................................................15 Zorgthema 7. Circulatie en 8. Zuurstofvoorziening van het hart.....................................................16 Probleem 15: Inspanning door infectie........................................................................................16 Probleem 16: Veneuze stuwing en overvulling............................................................................16 Probleem 17: Tachypneu.............................................................................................................16 Probleem 18: Bradycardie............................................................................................................16 Probleem 20: Anemie..................................................................................................................17 Probleem 21: Tachycardie...........................................................................................................17 Interventies Circulatie..................................................................................................................17 Zorgthema 9. Urogenitale functie met vocht-elektrolyten huishouding..........................................17 Probleem 22: Risico op vochttekort en elektrolytenstoornis.......................................................17 Probleem 23: Dreigende oedeemvorming door ontstekingsreactie............................................17 Zorgthema 10 Bloed........................................................................................................................18 Probleem 24: Dreigende problemen zuur-base-evenwicht.........................................................18 Zorgthema 11. Zenuwstelsels..........................................................................................................18 Probleem 26: Dreigende hersenbloeding....................................................................................18 Zorgthema 12. Bewegingsapparaat.................................................................................................18 Zorgthema 13. Hormonaal stelsel....................................................................................................18 Zorgthema 14. Thermoregulatie......................................................................................................18 Probleem 27: Infectie en risico op complicaties ten gevolge van SIRS/sepsis..............................18 Zorgthema 15. Huid en afweerfunctie.............................................................................................19 Probleem 28: Risico Verminderde huiddoorbloeding..................................................................19 Zorgthema 16. Spijsverteringsfunctie en voedingstoestand............................................................19
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Probleem 29: Reflux en misselijkheid/braken..............................................................................19 Probleem 30: Obstipatie..............................................................................................................19 Zorgthema 17. Voortplantingsfuncties............................................................................................19 Zorgthema 18. Functioneren en zelfredzaamheid...........................................................................19 Probleem 31: Angst, vrees en machteloosheid bij ouders...........................................................19 Interventies ouders......................................................................................................................20 Prioriteiten in de dienst...................................................................................................................20 Disciplines........................................................................................................................................21 SBAR Communicatie Verpleegkundige.............................................................................................21 SBAR Communicatie met de arts.....................................................................................................22 Stap 5. Reflecteren..............................................................................................................................22 Literatuurlijst.......................................................................................................................................24 Bijlage 1. Uitwerking ziektebeeld Twin-to-Twin Transfusion Syndrome..............................................27 Bijlage 2 Uitwerking ziektebeeld Prematuriteit...................................................................................31 Bijlage 3. Uitwerking ziektebeeld Open Ductus Botalli........................................................................38 Bijlage 4. Uitwerking ziektebeeld Bronchopulmonale Dysplasie.........................................................41 Bijlage 5. NEO-EWS..............................................................................................................................45 Bijlage 6. Comfortscore........................................................................................................................47 Bijlage 7. Groeicurve............................................................................................................................49
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