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Klinisch redeneren van de oncologische/palliatieve patiënt --> 7,7

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  • Course
  • Klinisch Redeneren PL4 (GVE4.PL417)
  • Institution
  • Hogeschool Utrecht (HU)

Als verpleegkundige ben je verantwoordelijk voor het indiceren en verlenen van zorg. Dit betekent dat je kennis nodig hebt over pathologie, psychopathologie, farmacologie, meetinstrumenten/scorelijsten, redeneerhulpen etc. om op basis daarvan de behoefte aan zorg te kunnen vaststellen en een zorgpl...

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Document information

  • June 27, 2022
  • 49
  • 2021/2022
  • Case
  • Welmoed steenstra
  • 7-8

Subjects

  • klinisch redeneren
  • ascites
  • blaascarcinoom
  • metastasering
  • nierinsufficiëntie
  • peritonitis carcinomatosa
  • digestief systeem
  • orgaansystemen
  • hyponatriëmie
  • hyperkaliëmie
  • oedeem
  • vocht en elektrolytenbalans
  • ob

Written for

  • Hogeschool Utrecht (HU)
  • Verpleegkunde
  • Klinisch Redeneren PL4 (GVE4.PL417)
All documents for this subject (5)

1  review

review-writer-avatar

By: sarahhadj03 • 6 months ago

Translated by Google

Good report for pl 1,2 or maybe 3. But below level for pl4

reply-writer-avatar

By: MrKaaijman • 6 months ago

Translated by Google

Too bad that the report is not satisfactory! The assignments have been adjusted in the meantime, so maybe this has an influence. In any case, the lecturer found it more than enough;)

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MrKaaijman

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KLINISCH REDENEREN
Praktijkleren 4




Figuur 1: Meander logo (Meander Medisch Centrum, 2019)
Naam cursus: Praktijkleren 4 (GVE-4.PL4-17)
Aantal woorden: 4462

,Inhoudsopgave
Stap 1: Probleemoriëntatie/klinisch beeld.............................................................................................5
1.1 Introductie zorgvrager..................................................................................................................5
1.2 Verandering situatie.....................................................................................................................7
1.2.1 Lichamelijke klachten.............................................................................................................7
1.2.2 Psychische/sociale klachten...................................................................................................7
1.2.3 Ernst van situatie...................................................................................................................7
Stap 2: Probleemanalyse........................................................................................................................8
2.1 Disfunctionele orgaansystemen...................................................................................................8
2.1.1 Digestief systeem...................................................................................................................8
2.1.2 Vocht- en elektrolytenbalans.................................................................................................8
2.1.3 Zintuiglijk systeem.................................................................................................................8
2.2 Psychosociale, functionele, spirituele en functionele problematiek.............................................8
2.2.1 Zingeving................................................................................................................................8
2.2.2 Activiteiten en participatie.....................................................................................................9
2.2.3 Slaapproblemen.....................................................................................................................9
Stap 3: Aanvullend onderzoek en diagnose..........................................................................................10
3.1 Aanvullend onderzoek................................................................................................................10
3.1.1 Kwetsbare ouderen.............................................................................................................10
3.1.2 Numeric (Pain) Rating Scale (NRS).......................................................................................10
3.1.3 Echo-nieren en abdomen.....................................................................................................10
3.1.4 Positron Emissie Tomografie (PET)......................................................................................10
3.1.5 World Health Organisation (WHO) performance status......................................................10
3.1.6 Utrecht Symptomen Dagboek 4 Dimensioneel (USD-4D)....................................................11
3.1.7 Bristol Stool Form Scale (BSFS)............................................................................................11
3.1.8 Labonderzoek......................................................................................................................11
3.2 Verpleegkundige diagnoses........................................................................................................12
3.3.1 Pijn.......................................................................................................................................12
3.3.2 Angst....................................................................................................................................12
3.3.3 Vermoeidheid en slapeloosheid..........................................................................................12
3.3.4 Rouwende familie................................................................................................................12
3.3.5 Obstipatie............................................................................................................................12
3.3.6 Functieverlies.......................................................................................................................12
3.3.7 Elektrolytenstoornis.............................................................................................................13
Stap 4: Klinisch beeld............................................................................................................................14

2

, 4.1 Resultaat.....................................................................................................................................14
4.1.1 Pijn.......................................................................................................................................14
4.1.2 Angst....................................................................................................................................14
4.1.3 Vermoeidheid en slapeloosheid..........................................................................................14
4.1.4 Rouwende familie................................................................................................................14
4.1.5 Obstipatie............................................................................................................................14
4.1.6 Functieverlies.......................................................................................................................14
4.1.7 Elektrolytenstoornis.............................................................................................................14
4.2 Verpleegkundige interventies.....................................................................................................14
4.2.1 Pijn.......................................................................................................................................14
4.2.2 Angst....................................................................................................................................14
4.2.3 Vermoeidheid en slapeloosheid..........................................................................................15
4.2.4 Rouwende familie................................................................................................................15
4.2.5 Obstipatie............................................................................................................................15
4.2.6 Functieverlies.......................................................................................................................16
4.2.7 Elektrolytenstoornis.............................................................................................................16
Stap 5: Klinisch verloop........................................................................................................................17
5.1 Korte termijn..............................................................................................................................17
5.2 Lange termijn..............................................................................................................................17
5.3 Zelfmanagement.........................................................................................................................17
Stap 6: Evaluatie...................................................................................................................................18
6.1 Evaluatie zorgvrager en naasten.................................................................................................18
6.2 Reflectie zorgproces...................................................................................................................18
6.3 Reflectie op Elektronisch Patiëntendossier (EPD).......................................................................18
Literatuurlijst........................................................................................................................................19
Bijlage 1: Medicatielijst.........................................................................................................................27
Bijlage 2: Overige disfunctionele orgaansystemen...............................................................................30
2.1.4 Circulatie..................................................................................................................................30
2.1.5 Respiratoir systeem.................................................................................................................30
2.1.6 Thermoregulatiesysteem.........................................................................................................30
2.1.7 Endocrien systeem...................................................................................................................30
Bijlage 3: SCEGS....................................................................................................................................31
Somatisch; signalen en klachten (bio-fysiologische dimensie).........................................................31
Cognitief (psychologische dimensie)................................................................................................31
Emotioneel (psychologische dimensie).............................................................................................31
Gedragsmatig (psychologische dimensie).........................................................................................31

3

, Sociaal systeem (sociale dimensie)...................................................................................................32
Bijlage 4: Aanvullend onderzoek..........................................................................................................33
Kwetsbare ouderen..........................................................................................................................33
DOSS.............................................................................................................................................33
SNAQ............................................................................................................................................33
Valpreventie.................................................................................................................................33
Functieverlies................................................................................................................................33
Gastroscopie.....................................................................................................................................34
Bijlage 5: Utrecht Symptomen Dagboek 4 Dimensioneel (USD-4D)......................................................35
Bijlage 6: Labonderzoek........................................................................................................................37
Bloedonderzoek................................................................................................................................37
Urinesediment..................................................................................................................................38
Ascitesvocht......................................................................................................................................38
Tumormarkers..................................................................................................................................38
Constateringen op basis van labwaarden.........................................................................................39
Tumormarker................................................................................................................................39
Nierfunctie....................................................................................................................................39
Bloedwaarden...............................................................................................................................39
Urinesediment..............................................................................................................................39
Ascitesvocht..................................................................................................................................39
Bijlage 7: Hospital Anxiety and Depression Scale (HADS).....................................................................40
Bijlage 8: Multidimensionale Vermoeidheidsindex (MVI).....................................................................46
Bijlage 9: MDO......................................................................................................................................48
Bijlage 10: Feedbackformulier werkbegeleider....................................................................................49




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