Zeer uitgebreide Casus analyse voor de opleiding High care neonatologie verpleegkundige niveau 6 volgens de stappen van het klinisch redeneren van Marc Bakker over een meisje prematuur geboren op de NICU en diverse problematiek. Daarbij gebruik gemaakt van Cerpenito volgens de NIC NOC en Nanda voor...
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 i.dewinter@erasmusmc.nl
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 n.rijken@erasmusmc.nl
Senior onderwijs: Marloes Schaap m.schaap@erasmusmc.nl
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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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