The Keller Index of Nausea (KIN) - FOD Volksgezondheid ...

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ÉCHELLE DE DÉPISTAGE DU DÉLIRIUM (Nu-DESC) 1. Noter l’absence ou la présence des cinq manifestations comportementales de délirium à la fin de chaque quart de travail, aux huit heures; N: Nuit / J: Jour / S: Soir. 2. Utiliser les définitions suivantes : a. Désorientation: Manifestations verbales ou comportementales indicatives d’une mauvaise orientation dans le temps et/ou l’espace ou d’un mauvais discernement des personnes dans l’environnement. b. Comportement inapproprié: Comportement inapproprié pour l’endroit et/ou pour la personne, par exemple, arracher ses sondes ou ses pansements, essayer de sortir du lit alors que c’est contre-indiqué, être constamment agité, réagir de façon exacerbée aux stimuli. c. Communication inappropriée: Communication inappropriée pour l’endroit et/ou pour la personne, par exemple, incohérence, état d’incommunicabilité, discours inintelligible ou insensé. d. Illusions/Hallucinations: Voir ou entendre des choses qui ne sont pas réellement présentes; distorsion dans la perception des objets. e. Ralentissement physique et/ou mental inhabituel, en tenant compte de la condition médicale: Temps de réaction allongé, peu ou pas d'actions/de paroles spontanées; par exemple, lors de l’interaction avec le patient, celui-ci réagit toujours après un laps de temps et/ou il est difficile à stimuler/à réveiller. 3. Coter chacune des cinq manifestations comportementales comme suit : 0 = comportement absent durant le quart de travail. 1 = comportement présent durant le quart de travail, mais peu prononcé, ni en durée ni en intensité. 2 = comportement présent durant le quart de travail et prononcé, soit en durée, soit en intensité (toute autre situation que 0 ou 1). N.E. = non-évaluable.* 4. Recueillir les observations des proches du patient si ceux-ci mentionnent avoir été témoins de manifestations comportementales anormales, potentiellement indicatives d’un délirium; dans le doute, il est toujours recommandé de s’enquérir auprès des proches afin d’établir si le patient a présenté ou non des symptômes de délirium au cours du quart de travail. 5. À partir du témoignage des proches du patient quant à la durée et à l’intensité du (des) comportement(s) anormal(aux) noté(s), déterminer le pointage des proches, selon les critères décrits aux points 2 et 3. Inscrire ce pointage, encerclé, à droite de celui de l’infirmière, dans la même case : ce sont les pointages individuels les plus élevés pour chaque case qui seront additionnés afin d’obtenir le pointage total. * Inscrire N.E. seulement s’il a été impossible d’évaluer le comportement du patient durant toute la durée du quart de travail; 1025
En préciser la raison: a = sommeil naturel b = sédation induite par la médication c = stupeur ou coma d = autre raison 1026
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OPZETTEN VAN EEN DATABANK MET GEVAL
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Wat is BEST? BEST staat voor BElgia
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Zoekstrategie symptoommanagement se
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NEUROLOGISCHE ZORG.................
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Lijst met tabellen Tabel 1: Zoekfil
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Projectinhoud Inleiding Objectieve
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Methodologie Het opstellen van de d
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Gebruik van de website Aan het opst
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Figuur 1: Overzicht validiteit en b
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voorspelling wordt gemaakt op grond
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Figuur 2: Overzicht sensitiviteit -
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NAUSEA - VOMITING 22
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Inleiding nausea/braken Deze rubrie
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The Index of Nausea, Vomiting, and
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Gebruiksvriendelijkheid De gebruiks
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Author (year) V. Rhodes, P. Watson,
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Author (year) M. Fu, V. Rhodes, & B
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Author (year) Q. Zhou, B. O’Brien
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The Index of Nausea, Vomiting, and
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Vertaling: The Index of Nausea, Vom
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The Keller Index of Nausea (KIN) V.
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Opmerkingen De bekomen correlaties
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Results reliability Results validit
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The Nausea Profile (NP) E. Muth, R.
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Referenties Muth, E. R., Stern, R.
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Reprinted with permission from Dr.
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Betrouwbaarheid Betrouwbaarheid wer
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• de aandacht te vestigen op miss
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Author (year) L.L. Dupuis, A. Taddi
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The Pediatric Nausea Assessment Too
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Have you ever thrown up (use family
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Betrouwbaarheid Niet gespecifieerd.
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Validiteit Validiteit van de VAS we
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Author (year) Boogaerts, J. G., Van
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DECUBITUSRISICO 75
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Inleiding evaluatie decubitusrisico
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De Bradenschaal Bergstrom, N., Brad
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Gebruiksvriendelijkheid De gebruiks
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Author (year) T. Defloor, & M. Gryp
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Author (year) Pancorbo-Hidalgo, P.
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Author (year) Gould, D., Goldstone,
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Braden Scale Bron: Bergstrom, N., B
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Vertaling Bradenschaal Bron: Defloo
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In latere publicaties stelt de aute
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Norton, D. (1996). Calculating the
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Vertaling Nortonschaal Bron: Defloo
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SEDATIE 106
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Inleiding symptoommanagement sedati
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Bewustzijnsscores zijn interessant
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Betrouwbaarheid De betrouwbaarheid
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Vertaling Motor Activity Assessment
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selecteren. De Ramsay Scale omvat
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Author (year) Mondello, E., Panasit
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Author (year) Ely, E. W., Truman, B
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Author (year) Sessler, C. N., Gosne
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Ramsey Scale Bron: Ramsay, M., Save
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The Richmond Agitation - Sedation S
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kunnen volgens 86,2% van de verplee
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Vertaling Richmond Agitation-Sedati
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Betrouwbaarheid De interrater relia
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Author (year) Rassin, M., Sruyah, R
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Author (year) Riker, R. R., Picard,
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Author (year) Sessler, C. N., Gosne
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Sedation-Agitation Scale (SAS) Bron
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Dit helpt om bij gesedeerde patiën
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PIJN 152
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Inleiding symptoommanagement pijn H
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OR assessment self assessment (ps
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Beschrijving De BPI is oorspronkeli
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verpleegkundige praktijk. De omvang
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Author (year) Tan, G., Jensen, M. P
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Brief Pain Inventory (Short Form) B
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gevalideerd bij ouderen met een cog
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Wong & Baker, 1988). Vergelijking v
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Wong, D. L. & Baker, C. M. (1988).
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Reprinted with permission from the
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Reprinted with permission from the
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• Een eerste deel omvat een teken
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Validatie Nederlandstalige versie D
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Author (year) Gagliese, L., Weizbli
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Author (year) Grafton, K. V., Foste
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Author (year) Melzack, R. (1975) Se
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Author (year) Wright, K. D., Asmund
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Author (year) Kaasalainen, S. & Cro
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McGill Pain Questionnaire Bron: Mel
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Short form McGill Pain Questionnair
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Numeric Rating Scale (NRS) Verschei
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Om de construct validity van de VAS
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Mawdsley, R. H., Moran, K. A., & Co
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Vertaling Numerieke beoordelingscha
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Laatstgenoemde combinatie is een on
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properties and usability of selecte
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Author (year) Jensen, M. P., Chen,
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Author (year) Wong, D. L. & Baker,
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Author (year) Ware, L. J., Epps, C.
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Author (year) Jensen, M. P., Engel,
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Author (year) Kaasalainen, S. & Cro
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Author (year) Pautex, S., Michon, A
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Author (year) Herr, K. A., Spratt,
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Author (year) Taylor, L. J. & Herr,
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Author (year) Benaim, C., Froger, J
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Author (year) Pautex, S., Herrmann,
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Verbal Rating Scale Bron: Herr, K.
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Visual Analogue Scale (VAS) Versche
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Om de construct validity van de VAS
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Gagliese, L. & Katz, J. (2003). Age
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Author (year) Pautex, S., Michon, A
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Author (year) Freeman, K., Smyth, C
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Author (year) Pautex, S., Herrmann,
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Author (year) Bijur, P. E., Silver,
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Author (year) Herr, K. A., Spratt,
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Author (year) Van Dijk, M., Koot, H
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Author (year) Triano, J. J., McGreg
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Author (year) Gagliese, L. & Katz,
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Author (year) Stinson, J. N., Kavan
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Author (year) Benaim, C., Froger, J
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Author (year) Kim, E. J. & Buschman
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Horizontal VAS Bron: Huskisson, E.
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Vertaling Horizontale VAS Instructi
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320
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Overzicht meetinstrumenten evaluati
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OR Zoekstrategie evaluatie mondstat
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Er werd gepreciseerd wat men met be
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Author (year) Kayser-Jones J., Bird
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Kayser-Jones Brief Oral Health Stat
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Graad Omschrijving Graad 0 Geen sym
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De tabel bevat dus 8 items: lippen,
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Author (year) CHALMERS JM., KING PL
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Oral Health Assessment Tool (OHAT)
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Voor elke soort aantasting in elk m
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Author (year) McGuire DB, Peterson
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The 20 items Oral Mucositis Index (
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Hoe hoger de totale score, hoe erge
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350
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Overzicht meetinstrumenten vermoeid
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Inleiding vermoeidheid Deze rubriek
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Brief Fatigue Inventory (BFI) Mendo
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Vindplaats van het instrument: http
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Beschrijving: Het gaat om een korte
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Author (year) Krupp LB., LaRocca NG
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Fatigue Severity Scale The Fatigue
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Deze schaal levert 2 scores op: een
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372
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Het gaat om een vragenlijst van 13
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Hagell P., Höglund A., Reimer J.,
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die is ondervonden op de dag voor d
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Author (year) Smets E.M.A., Garssen
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Multidimensional Fatigue Inventory
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Het is mogelijk om de meer objectie
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390
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Betrouwbaarheid: De Cronbach’s al
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Author (year) Piper B., Lindsey A.,
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Revised Piper Fatigue Scale (R-PFS)
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te hebben alsook het affectieve asp
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402
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404
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Betrouwbaarheid: De Cronbach’s al
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Author (year) Lee KA, Hicks G, Nino
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VISUAL ANALOGUE SCALE FOR FATIGUE (
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FUNCTIONEEL - MENTAAL - PSYCHOSOCIA
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to Predict Which Elderly Inpatients
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Inleiding bij het onderwerp “func
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Tabel 7: Zoekfilter voor het deel F
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Autonomie gérontologique et groupe
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Author (year) Neirynck I,, Closon M
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Berg Balance Scale Berg, K. el al (
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Variant Chou et al (Chou et al.2006
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Author (year) Berg, K. O., Wood-Dau
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Author (year) shigeru usuda, kazufu
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Author (year) Liston, R. A. and Bro
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Functional Independence Measure (FI
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Opmerkingen Voor het afnemen van de
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Result reliability (E) Interrater r
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Result reliability (S) Test retest
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Result reliability (IC) Internal co
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Author (year) Van Marwijk, H. W., W
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Author (year) Agrell, B. and Dehlin
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Identification of senior at risk (I
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McCusker, J., Bellavance, F., Cardi
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Result reliability (S) Stability Th
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afhankelijkheid. De totale score ko
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Author (year) Cromwell, D. A., Eaga
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Katz index of Independance in Activ
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Katz S, Vignos PJ, Moskowitz RW, et
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Result reliability (IC) Internal Co
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Beschrijving De PEDI meet de functi
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3,5 - 4,5 punten: laag risico 5-6 p
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Result reliability Result validity
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Vertaling: Ziekenhuisscore ter eval
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St. Thomas's Risk Assessment Tool I
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Milisen, K., Staelens, N., Schwendi
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Bij een herziening van de schaal we
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Author (year) Hebert et al. 1988 Ag
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Mini Motor Test (MMT) Camus, A., Mo
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Camus, A., Mourey, F., d'Athis, P.,
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Betrouwbaarheid De interne consiste
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Author (year) Mahoney & Barthel (19
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Bristol Activities of Daily Living
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Author (year) Bucks, R. S., Ashwort
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Bristol Activities of Daily Living
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11. MOBILITY 12. ORIENTATION - TIME
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Vertaling: Bristol Activities of Da
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10. OPSTAAN EN GAAN ZITTEN 11. MOBI
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Timed “Up & Go” (TUG) Podsiadlo
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Referenties Andersson, A. G., Kamwe
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Author (year) Podsiadlo D., Richard
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Author (year) Rockwood K., Awalt E.
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Test de tinetti (TT) ou Performance
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Validiteit De criteriumvaliditeit v
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TINETTI TEST (TT) OU PERFORMANCE-OR
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Tinetti, M. E. TINETTI TEST (TT) OF
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TINETTI TEST (TT) OF PERFORMANCE-OR
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Tinetti test (TT) of Performance-Or
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Performance-Oriented Mobility Asses
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GAIT Instructions: Participant stan
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Move a hard, armless chair against
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prefers (e.g. going down on knees,
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2. Path: (estimate in relation to t
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2. Evaluatie van het evenwicht tijd
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COGNITIEF FUNCTIONEREN 546
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Activities in Patients With Dementi
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Test for the Early Detection of Dem
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Zoekstrategie voor het item ‘cogn
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Validiteit De diagnostische sensiti
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De volledige beoordeling neemt onge
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Author (year) Heinik, J., & al. (20
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Rotterdam -Cambridge Cognitive Exam
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564
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Orientation /8 Memory (recall and r
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evattingsvermogen oplettendheid. D
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Author (year) Trzepacz PT & al. (20
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Author Setting Sample (year) (n) Ha
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Author (year) Hart RP, Best AM, Ses
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Functional Cognitive Assessment Sca
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Assessment Scale When Administered
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3. -Please call this number (writte
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we suppose that the patient has com
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SOCIOGRAFIC INFORMATION Patient nam
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Vertaling: Functional Cognitive Ass
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3. Op de tafel liggen zomer- en win
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c) Een patiënt zoekt niets (toilet
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Benodigd materiaal We hebben de vol
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2 Normaal tijdverloop stap voor sta
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- De GPCOG-informant: een informati
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GENERAL PRACTITIONER ASSESSMENT OF
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General Practitioner Assessment of
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Vertaling: General Practitioner Ass
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GPcog van Brodaty Psychiatrische fe
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Les cinq mots (5W) Dubois, B., Touc
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Dubois, B., Touchon, J., Portet, F.
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Museum Limonade Sprinkhaan Zeef Vra
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Betrouwbaarheid De interne consiste
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Author (year) Breitbart W. & al. (1
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Author (year) Lawlor PG & al. (2000
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Author (year) Smith, M. J., Breitba
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Mental Alternation Test (MAT) Jones
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Author (year) Salib, E. and McCarth
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Middlesex Elderly Assessment of Men
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Author (year) Cartoni A. & Lincoln
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Mini Mental State Exam - Mini Menta
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De MMSE is een ‘gold standard’
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Result reliability (E) Inter-rater
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Als de personen, ondanks een correc
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Author (year) Borson, S., Scanlan,
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Author (year) "The Mini-Cog As a Sc
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Mini-COG Borson S, Scanlan J, Brush
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Vertaling: Mini-COG Borson S, Scanl
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Modified Informant Questionnaire on
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In zijn ‘overzicht’ vermeldde J
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Author (year) MODIFIED INFORMANT QU
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Author (year) Jorm, A. F. (2004) MO
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Modified Informant Questionnaire on
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10. Remembering where to find thing
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Informant Questionnaire on Cognitiv
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Vertaling: Informant Questionnaire
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Hoe is mevrouw/meneer, vergeleken m
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Verkorte Informant Vragenlijst over
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Modified Mini Mental State Examinat
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Meetinstrument te vinden bij Teng E
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De totale maximumscore die voor de
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minute hand; hands must be centred
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can remember. Make a check mark ( )
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Vertaling: Montreal Cognitive Asses
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Seriële 7’s: Afname: De onderzoe
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gehad (gerekend vanaf leeftijd 6 ja
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Neurobehavioral Cognitive Status Ex
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Opmerkingen De cognistat is een com
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- affectief - competentieverlies -
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Author (year) "Validation of a New
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Patient-reported Outcomes in Cognit
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702
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704
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June 2005 PROCOG - Informant Versio
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708
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710
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712
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Repeatable Battery for the Assessme
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Hobart, M. P., Goldberg, R., Bartko
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Betrouwbaarheid De stabiliteit van
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Author (year) Katzman,R.; Brown,T.;
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Six-Item Cognitive Impairment test
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Vertaling: Six-Item Cognitive Impai
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Six-Item Screener Callahan, C. M.,
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Author (year) SIX-ITEM SCREENER CAL
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Six-Item Screener Callahan, C. M.,
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Test for the Early Detection of Dem
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Diagnosis of Dementia With Differen
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Result reliability (E) Inter rater
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Vertaling: Test for the Early Detec
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The Clock Drawing Test Sunderland,
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Seigerschmidt et al. bestudeerden d
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3. De patiënt krijgt een derde ins
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Agrell B. and Dehlin O. 1998. "The
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Result reliability (E) Inter rater
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andere vraag te stellen en vraagt h
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Author (year) Solomon, P. R., & al.
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Vertaling: Seven Minute Screen (7MS
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Test van de tijdoriëntatie Maand (
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Voorbeeldfiche: 764
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TEST OVER VLOEIEND TAALGEBRUIK Schr
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NEUROLOGISCHE ZORG 768
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Introductie neurologische zorg Deze
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OR questionnaires scales assessm
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De auteurs stellen voor om deze sco
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778
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780
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782
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- reageert niet = 0 punten - opent
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Voor elk criterium wordt er een beo
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o Het kind lokaliseert normaal de p
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Referenties : Born JD, Albert A, Ha
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hiërarchische items die de verschi
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Author (year) GIACINO JT, KALMAR K,
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National Institute Health Stroke Sc
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Referenties: Brott T, Adams HP, Oli
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DESORIENTATION 806
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Overzicht meetinstrumenten m.b.t. h
Page 813 and 814:
Mini Mental State Exam - Mini Menta
Page 815 and 816:
Introduction de l’item « désori
Page 817 and 818:
Abbreviated Mental Test (AMT) Hodki
Page 819 and 820:
Author (year) Ni, Chonchubhair A.,
Page 821 and 822:
Abbreviated Mental Test (AMT) Hodki
Page 823 and 824:
Clinical Assessment of Confusion A
Page 825 and 826:
Author (year) Hadley Vermeersch PE,
Page 827 and 828:
Cognitive test for delirium (CTD) H
Page 829 and 830:
Remarque Pour le domaine de l’ori
Page 831 and 832:
Page 833 and 834:
Page 835 and 836:
Page 837 and 838:
834
Page 839 and 840:
Directions for scoring Score for ea
Page 841 and 842:
5. « Maintenant je vais vous montr
Page 843 and 844:
840
Page 845 and 846:
Confusion Assessment Method (CAM) I
Page 847 and 848:
Convivialité Le temps nécessaire
Page 849 and 850:
Author (year) Lemiengre J. Nelis T.
Page 851 and 852:
CONFUSION ASSESSMENT METHOD (CAM) I
Page 853 and 854:
Title - Author (year) Schuurmans MJ
Page 855 and 856:
Confusion Assessment method (CAM) I
Page 857 and 858:
Directions of use Complete CAM take
Page 859 and 860:
□ Oui □ Non □ Incertain □ N
Page 861 and 862:
suivante : En général, comment é
Page 863 and 864:
Fiabilité Les différentes études
Page 865 and 866:
Page 867 and 868:
864
Page 869 and 870:
866
Page 871 and 872:
a) The attention Screening Examinat
Page 873 and 874:
Le score maximal total est de 8. Le
Page 875 and 876:
Page 877 and 878:
Traduction: The confusion Rating Sc
Page 879 and 880:
Tous les items sont définis dans l
Page 881 and 882:
Page 883 and 884:
Les scores attribués pour les item
Page 885 and 886:
Author (year) McCusker J, Cole MG,
Page 887 and 888:
Delirium Index (DI) McCusker J, Col
Page 889 and 890:
Traduction : Delirium Index (DI) Mc
Page 891 and 892:
Delirium-O-Meter (DOM) de Jonghe JF
Page 893 and 894:
Author (year) de Jonghe JF, Kalisva
Page 895 and 896:
Delirium-O-Meter (DOM) de Jonghe JF
Page 897 and 898:
Traduction : Delirium-O-Meter (DOM)
Page 899 and 900:
12. Inquiétude / crainte Se sent
Page 901 and 902:
Lorsque un item ne peut être éval
Page 903 and 904:
Author (year) Schuurmans MJ, Shortr
Page 905 and 906:
Delirium Observation Screening Scal
Page 907 and 908:
13 items DOS scale OBSERVATION The
Page 909 and 910:
Traduction: Delirium Observation Sc
Page 911 and 912:
DOS- Version à 13 items OBSERVATIO
Page 913 and 914:
Delirium Rating Scale (DRS) Trzepac
Page 915 and 916:
La valeur diagnostique du test est
Page 917 and 918:
Author (year) Rosen et al. (1994) R
Page 919 and 920:
Title - Author (year) Trzepacz PT.
Page 921 and 922:
Title - Author (year) Trzepacz P.T.
Page 923 and 924:
Delirium Rating Scale (DRS) Trzepac
Page 925 and 926:
Item 8: sleep wake cycle disturbanc
Page 927 and 928:
Traduction: Delirium Rating Scale (
Page 929 and 930:
Item 7 : trouble physique 0. aucun
Page 931 and 932:
Delirium Rating Scale-Revised-98 (D
Page 933 and 934:
Localisation de l’instrument de m
Page 935 and 936:
Results reliability Results valdidi
Page 937 and 938:
934
Page 939 and 940:
936
Page 941 and 942:
Traduction: Delirium Rating Scale-R
Page 943 and 944:
10. Attention Les patients présent
Page 945 and 946:
Feuille de score DRS-R-98 Nom du pa
Page 947 and 948:
Delirium Severity Scale (DSS) Betti
Page 949 and 950:
Author (year) Bettin, K. & al. (199
Page 951 and 952:
Delirium Severity Scale (DSS) Betti
Page 953 and 954:
Traduction: Delirium Severity Scale
Page 955 and 956:
Delirium Symptom Interview (DSI) Al
Page 957 and 958:
Casarett, D. J. and Inouye, S. K. 3
Page 959 and 960:
Page 961 and 962:
6a. At what time of day did this co
Page 963 and 964:
(0) Never (1) Rarely (2) Sometimes
Page 965 and 966:
14g. Things seemed as if they were
Page 967 and 968:
much of the time? (0) Never (1) Rar
Page 969 and 970:
(0) No (1) Mild (2) Moderate (3) Se
Page 971 and 972:
Traduction: Delirium Symptom Interv
Page 973 and 974:
(1) oui si OUI, allez à la questio
Page 975 and 976:
13a. Des gens font des choses qu'il
Page 977 and 978: 14o. Est ce quelque chose de nouvea
Page 979 and 980: (0) non (1) Légèrement (2) modér
Page 981 and 982: 29d. augmentation de la vitesse de
Page 983 and 984: The Memorial Delirium Assessment Sc
Page 985 and 986: Références Breitbart, W., Rosenfe
Page 987 and 988: Results reliability Results validit
Page 993 and 994: 990
Page 995 and 996: Traduction: The Memorial Delirium A
Page 997 and 998: □ 3 troubles sévères (déviatio
Page 999 and 1000: Le test exclut la mesure des troubl
Page 1001 and 1002: Author (year) Folstein M.F., Folste
Page 1003 and 1004: Mini Mental State Examination (MMSE
Page 1005 and 1006: Language Naming: Show the patient a
Page 1007 and 1008: Praxies constructives / 1 Directive
Page 1009 and 1010: Modified Mini Mental State Examinat
Page 1011 and 1012: Localisation de l’instrument de m
Page 1013 and 1014: Result reliability (E) Inter-rater
Page 1015 and 1016: The Modified Mini-Mental State (3MS
Page 1017 and 1018: Traduction: Modified Mini Mental St
Page 1019 and 1020: 1016
Page 1021 and 1022: A chaque item est attribué un scor
Page 1023 and 1024: Author (year) Gaudreau JD, Gagnon P
Page 1025 and 1026: The Nursing Delirium Screening Scal
Page 1027: Date (mois, jour) Désorientation C
Page 1031 and 1032: entre les différents évaluateurs
Page 1033 and 1034: Results reliability Results valdidi
Page 1035 and 1036: Traduction: Pediatric Anesthesia Em
Page 1037 and 1038: Fiabilité 3-4 : présence d’une
Page 1039 and 1040: Author (year) Pfeiffer E. (1975) Ma
Page 1041 and 1042: Short Portable Mental Status Questi
Page 1043 and 1044: The Short Test of Mental Status (ST
Page 1045 and 1046: Author (year) Kokmen E, Smith GE, P
Page 1047 and 1048: The Short Test of Mental Status (ST
Page 1049 and 1050: Traduction: The Short Test of Menta
Page 1051 and 1052: The Strain of care for Delirium Ind
Page 1053 and 1054: THE STRAIN OF CARE FOR DELIRIUM IND
Page 1055 and 1056: The Strain of care for Delirium Ind
Page 1057 and 1058: Traduction: The Strain of care for
Page 1059 and 1060: The Neelon/Champagne Confusion Scal
Page 1061 and 1062: Convivialité Facile d’utilisatio
Page 1063 and 1064: Result reliability (IC): Internal c
Page 1065 and 1066: Result reliability (IC): Internal c
Page 1067 and 1068: fluctuates. Uses visual cues to ori
Page 1069 and 1070: Easy to use and rapid (10 minutes),
Page 1071 and 1072: TRAITEMENT - ORIENTATION : (Orienta
Page 1073 and 1074: Directives pour l’utilisation Fac
Page 1075: 1072
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