Case
Analyse zorg situatie
- Course
- Institution
Dit was mijn casus voor AZS waarin het verpleegkundig proces is uitgewerkt volgens alle stappen.
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81-jarige patiënt met eencholangiocarcinoom
Naam: Anouk Buijsman
Studentnummer: 0978107
Klas: 21-OVK-310
Cursusnaam en -code: Analyse zorgsituatie AZS, OVK31AZS01
Docent: Alwin van der Geer & Rochus Neeleman
Cursushouder: Bas Baris & Yolanda Vis
Onderwijsinstelling: Hogeschool Rotterdam
Opleiding: HBO-Verpleegkunde
Onderwijsperiode: 1 & 2
Datum: 9-9-2021 t/m 26-1-2022
,Voorwoord
Ik ben Anouk Buijsman, 20 jaar oud. Ik studeer HBO-verpleegkunde aan de Hogeschool
Rotterdam en zit in het 3e jaar. Ik loop stage op de afdeling Interne Oncologie van een
academisch ziekenhuis. Dit verslag is geschreven in het eerste semester van schooljaar
2021-2022.
Voor het vak analyse zorgsituatie kreeg ik de opdracht om een casus die aan bepaalde
voorwaarden voldoet uit te werken volgens de zes stappen van het verpleegkundig proces
en een ziektescript te schrijven over het ziektebeeld. Ik heb een casus gekozen van een
zorgvrager die ik zelf heb gecoordineerd met een complex genoeg ziektebeeld, die voldoet
aan de voorwaarden.
, Inhoudsopgave
Voorwoord..........................................................................................................................................................................2
Inleiding...............................................................................................................................................................................5
Stap 1: Gegevensverzameling.......................................................................................................................................6
Gordon patronen..................................................................................................................................................................................... 6
SCEGS........................................................................................................................................................................................................... 7
MEWS........................................................................................................................................................................................................... 8
Samenvatting ziektescript.................................................................................................................................................................. 8
Mechanismen............................................................................................................................................................................ 8
Epidemiologie............................................................................................................................................................................ 8
Klinische presentatie.............................................................................................................................................................. 9
Tijdsaspect.................................................................................................................................................................................. 9
Argumentatie van de verzamelde gegevens................................................................................................................................ 9
Patronen van Gordon.............................................................................................................................................................. 9
SCEGS............................................................................................................................................................................................ 9
MEWS............................................................................................................................................................................................ 9
Stap 2: Diagnose..............................................................................................................................................................10
Potentiële diagnoses:.......................................................................................................................................................................... 10
Uitgewerkte diagnoses....................................................................................................................................................................... 12
Stap 3 Doelen en zorgresultaten...............................................................................................................................13
Diagnose 1: Vochttekort.................................................................................................................................................................... 13
Diagnose 2: Machteloosheid............................................................................................................................................................ 13
Diagnose 3: Verstoorde slaap......................................................................................................................................................... 13
Stap 4: Interventies & planning.................................................................................................................................15
Diagnose vochttekort......................................................................................................................................................................... 15
Diagnose machteloosheid................................................................................................................................................................. 15
Diagnose verstoorde slaap............................................................................................................................................................... 16
Stap 5: Interventies toepassen..................................................................................................................................18
Diagnose: vochttekort........................................................................................................................................................................ 18
Diagnose: machteloosheid................................................................................................................................................................ 18
Diagnose: verstoorde slaap.............................................................................................................................................................. 18
Stap 6: Nabeschouwing en evaluatie.......................................................................................................................20
Evalutie: vochttekort.......................................................................................................................................................................... 20
Evaluatie: Machteloosheid............................................................................................................................................................... 20
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