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
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
Senior onderwijs: Marloes Schaap
1
, 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
2
, 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
3
, 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
4
High Care Neonatologie
Verpleegkundig redeneren aan de hand van een casusanalyse
Versie 1
Naam student: Ilse de Winter
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
Senior onderwijs: Marloes Schaap
1
, 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
2
, 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
3
, 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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