Case

patiëntbespreking Inflammatoire Bowel Disease: exacerbatie colitis ulcerosa

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Course
Vervolgopleiding kinderverpleegkundige

Institution
Vervolgopleiding Kinderverpleegkundige

Book
ProActive Nursing: klinische problematiek inzichtelijk

Dit document bevat de volledig uitwerking van de patiëntenbespreking gericht op Inflammatoire Bowel Disease (IBD), exacerbatie colitis ulcerosa. Alle disfunctionele zorgsystemen zijn volledig uitgewerkt volgens het boek van M. Bakker. Ook is de powerpoint presentatie te koop, gericht op de offici�...

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Uploaded on March 26, 2024
Number of pages 18
Written in 2023/2024
Type Case
Professor(s) C. oene
Grade 9-10

ibd
colitis ulcerosa
exacerbatie
patiëntbespreking
patiëntenbespreking
casus bespreking
kinderverpleegkundige
vkv
inflammatoire bowel disease
cu
pb
amstel academie
opleiding tot kinderverpleegkunde

Book Title:ProActive Nursing: klinische problematiek inzichtelijk

Author(s):Marc Bakker

Edition:Unknown
ISBN:9789089538079
Edition:3

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Formatieve patiëntenbespreking
casus Sanjay
Opleiding tot Kinderverpleegkundige

Naam
Afdeling Emma Kinderziekenhuis AMC

,Inhoudsopgave
Formatieve patiëntenbespreking casus Sanjay.......................................................................................1
Opleiding tot Kinderverpleegkundige.................................................................................................1
Stap 1: Probleemoriëntatie/klinisch beeld/SBAR...................................................................................4
1.1 Situation:......................................................................................................................................4
1.2 Background:..................................................................................................................................4
1.3 Assessment:..................................................................................................................................5
Parametrie:.....................................................................................................................................5
Labwaarden:...................................................................................................................................6
PEWS:.............................................................................................................................................6
1.4 Recommendation:........................................................................................................................6
Stap 2: Klinische probleemstelling..........................................................................................................7
2.1 Huid en afweerfuncties.................................................................................................................7
2.2 Spijsverteringsfuncties..................................................................................................................8
Voedselinname...............................................................................................................................8
Afbraak en vertering.......................................................................................................................8
Absorptie........................................................................................................................................9
Defecatie........................................................................................................................................9
2.3 Circulatie.......................................................................................................................................9
Veneus aanbod...............................................................................................................................9
Hartritme......................................................................................................................................10
Pompfunctie.................................................................................................................................10
Arteriële vaatstelsel & microcirculatie..........................................................................................10
2.4 Urogenitale functies...................................................................................................................11
Vochtinname en totale watermassa.............................................................................................11
Osmolariteit..................................................................................................................................11
Nierfuncties..................................................................................................................................11
Mictie............................................................................................................................................12
2.5 Bloedwaarden.............................................................................................................................12
Zuur-base evenwicht....................................................................................................................12
Zuurstoftransport.........................................................................................................................13
Klinische chemie...........................................................................................................................13
2.6 Thermoregulatiesysteem............................................................................................................14
2.7 Sensorische functies en pijn.......................................................................................................14

2

, 2.8 Psychosociaal functioneren o.b.v. SCEGS...................................................................................14
Stap 3: Aanvullend onderzoek..............................................................................................................14
3.1 Anamnese...................................................................................................................................14
3.2 Lichamelijk onderzoek................................................................................................................15
3.3 Beeldvormend onderzoek...........................................................................................................15
3.4 Laboratoriumonderzoek.............................................................................................................15
Stap 4: Klinisch beleid...........................................................................................................................15
4.1 Medisch:.....................................................................................................................................15
4.2 Verpleegkundig:..........................................................................................................................16
Stap 5: Klinisch verloop........................................................................................................................16
5.1 Gewenst verloop.........................................................................................................................16
Korte termijn................................................................................................................................16
Lange termijn................................................................................................................................17
5.2 Ongewenst verloop....................................................................................................................17
Korte termijn................................................................................................................................17
Lange termijn................................................................................................................................17
Stap 6: Nabeschouwing........................................................................................................................17
6.1 Patiëntveiligheid.........................................................................................................................17
6.2 Kwaliteit van de beroepsuitoefening..........................................................................................17
6.3 Ethische dilemma’s.....................................................................................................................17
6.4 Leersituatie.................................................................................................................................18
Bibliografie...........................................................................................................................................18
Stap 1: Probleemoriëntatie/klinisch beeld/SBAR...................................................................................3
1.1 Situation:......................................................................................................................................3
1.2 Background:..................................................................................................................................4
1.3 Assessment:..................................................................................................................................4
1.4 Recommendation:........................................................................................................................6
Stap 2: Klinische probleemstelling..........................................................................................................6
2.1 Huid en afweerfuncties................................................................................................................6
2.2 Spijsverteringsfuncties..................................................................................................................7
2.3 Circulatie.......................................................................................................................................8
2.4 Urogenitale functies...................................................................................................................10
2.5 Bloedwaarden............................................................................................................................11
2.6 Thermoregulatiesysteem............................................................................................................13
2.7 Sensorische functies en pijn:......................................................................................................13
2.8 Psychosociaal functioneren o.b.v. SCEGS...................................................................................13

3

,Stap 3: Aanvullend onderzoek..............................................................................................................13
3.1 Anamnese...................................................................................................................................13
3.2 Lichamelijk onderzoek................................................................................................................14
3.3 Beeldvormend onderzoek..........................................................................................................14
3.4 Laboratoriumonderzoek.............................................................................................................14
Stap 4: Klinisch beleid...........................................................................................................................14
4.1 Medisch:...............................................................................................................................14
4.2 Verpleegkundig:.........................................................................................................................15
Stap 5: Klinisch verloop........................................................................................................................15
5.1 Gewenst verloop........................................................................................................................15
5.2 Ongewenst verloop....................................................................................................................16
Stap 6: Nabeschouwing........................................................................................................................16
6.1 Patiëntveiligheid.........................................................................................................................16
6.2 Kwaliteit van de beroepsuitoefening..........................................................................................16
6.3 Ethische dilemma’s.....................................................................................................................16
6.4 Leersituatie.................................................................................................................................17
Bibliografie...........................................................................................................................................17

Stap 1: Probleemoriëntatie/klinisch beeld/SBAR
1.1 Situation:

Naam Sanjay
Leeftijd 14 jaar
Geslacht Jongen
Nationaliteit Indiaas
Geloof Hindoeïsme
Event Sanjay is begin van de nacht met spoed opgenomen op
de spoedeisende hulp (SEH) in het Amsterdam UMC
locatie AMC. Hij presenteerde zich met bloederige
diarree, braken (7-10x per dag) en buikpijn (boven de
navel) bij Inflammatoiry Bowel Disease (IBD). In de loop
van de nacht wordt hij overgeplaatst naar het Emma
Kinderziekenhuis op de afdeling Emma Sport.
Sanjay voelt zich op de afdeling niet lekker, heeft ook
meer buikpijn en heeft in één uur vijf keer bloederige
diarree gehad en twee keer gespuugd.
Tabel 1: casus

1.2 Background:
AMPLE
Allergies Patiënt is bekend met een allergie voor Ferricarboxymaltose
Medication - Prednisolon 20 mg tablet, 40 mg, oraal, 1x per dag, 1 dd 40 mg voor 4 weken

4

, - Mesalazine 3 g granulaat mg, 3 g, oraal, 1x per dag
- Calciumcarbonaat/colecalciferol 500/800 kauwtablet, 1 tablet, oraal, 1x per dag
- Ferrofumaraat 100 mg tablet, 200 mg, oraal, 3x per week
Past illness Colitis Ulcerosa waarvan de laatste 60 cm dikke darm aangedaan. Is sinds een paar
maanden gediagnosticeerd.
Sinds een week is er sprake van toename diarree met helderroodbloed. Is hiervoor op de
poli geweest waarna gestart werd met prednison. Dit hielp niet. Sinds gisteren begonnen
met braken en daarbij ook pijn in de bovenbuik boven de navel.
Last meal Eet sinds 4 dagen geen vast voedsel meer wegens misselijkheid. Vanaf vandaag houdt hij
ook geen vocht/drinkvoeding meer binnen.
Tabel 2: AMPLE

1.3 Assessment:
Parametrie:
Parametrie Bij de patiënt Referentiewaarden
Adempatroon/arbeid Rustige ademhaling, geen Geen verhoogde ademarbeid
intrekkingen/neusvleugelen
Ademgeluid Symmetrisch goed doorkomend Goed doorkomend ademgeruis
ademgeruis, geen bijgeluiden
Ademfrequentie 14 keer per minuut 12 – 20 keer per minuut
Saturatie 99 % 92-100% bij Fio2 21%
Hartfrequentie 115 keer per minuut 60-100 keer per minuut
Pulsaties Krachtige perifere pulsaties Voelbare pulsaties
Slijmvliezen Vochtige slijmvliezen, droge lippen Normaal
Tensie 85/43 mmHg. 110/65 mmHg (ouder dan 12
jaar)
Kleur Bleek Roze
Capillaire refill 3 sec 2 - 3 sec
Temperatuur 38,6 graden Celcius 36,5-37,5 graden celcius

Lauwe acra Warme acra
Diurese Vandaag wel 2 keer geplast Minimaal 2-3 ml/kg/uur
(vochtbalans niet bijgehouden)

Gastro-intestinaal Heeft 15 minuten geleden nog Normaal
bloederige slijmerige diarree gehad.

Heeft 15 minuten geleden nog
gebraakt.

5

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