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Casus klinisch redeneren
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  • Course
  • Klinisch Redeneren
  • Institution
  • ROC ID College

Casus klinisch redeneren

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Document information

  • March 23, 2021
  • 2
  • 2019/2020
  • Case
  • M van dijk
  • 7-8

Subjects

  • klinisch redeneren
  • casus

Written for

  • ROC ID College
  • Verpleegkunde Niveau 4 BOL
  • Klinisch Redeneren
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Lauradebruijne

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Dhr Klatert
Vitale functies
 RR: 101/62 mmHg
 Ademfrequentie: 12x per minuut
 Hartfrequentie: 81x per minuut
 Saturatie: 96%
 Temperatuur: 36,6C
 Bloedsuiker: 5,6 mmol/L
Dhr heeft een afwijkend bloedonderzoek. Dhr heeft waarschijnlijk een hyponatriëmie
(tekort aan natrium). Dit kan ontstaan door:
 Laag natriumgehalte (brandwonden, braken, diarree of door plasmedicatie of
nierziekten)
 Laag natriumgehalte en teveel vocht vasthouden (oedeem/hartproblemen)
 Hormonale afwijkingen.
Verschijnselen hyponatriëmie:
 Hoofdpijn
 Misselijkheid en braken
 Lusteloosheid
 Verwardheid en sufheid
 Spierkrampen
 Epileptische aanvallen.
Dhr slikt metoprolol 100 mg, dit is een hoge dosering. Je kan hierdoor erg duizelig
worden, dit kan dhr zijn duizeligheid veroorzaken.
Misschien heeft dhr last van orthostase. Dhr gebruikt namelijk medicatie om zijn
bloeddruk te verlagen. Orthostase meten.
Dhr is niet benauwd, er zou dus vocht in zijn benen kunnen zijn. Vocht zou kunnen
veroorzaken door dhr zijn hartproblemen.
Interventies
 Orthostase meten.
 DOS bijhouden (verdenking delier)
 ECG maken.
 Bloedonderzoek: prikken op CK-MB (creatinekinase- MB), natriumgehalte

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