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
4
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
4
