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Casus klinisch redeneren

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Casus klinisch redeneren

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  • March 23, 2021
  • 1
  • 2019/2020
  • Case
  • M van dijk
  • 7-8

1  review

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By: marloesvdpeijl • 2 year ago

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SBAR Mw. Cesar
Situation
Mw. Cesar (36 jaar) heeft terminale nierinsufficiëntie op basis van hypertensie en
therapie ontrouw. Vandaag komt mw. met 4.7 kilo boven streefgewicht binnen en heeft
zij een opgezet hoofd en dikke enkels. Mw. geeft aan benauwd en verzwakt te zijn, zij
vertelde wel dat zij gisteren een zomer tuinfeestje te hebben gehad.

Background
Heden – vermoeidheidsklachten daardoor gestopt met werken.
Februari 2009 – start dialyse 3x per week, 3 uur per keer.
Mw. was therapie ontrouw en kwam poliafspraken niet na.

Assessment
Reactiepatroon – alert



Recommendation
 Anamnese  Nagaan wat heeft mw. allemaal gegeten en gedronken ivm
aangepast dieet en vochtbeperking, is mw. hier wel trouw aangebleven?
 Om de 3 uur controles (RR, pols, temp en sat, met name omdat mw bekend is met
hypertensie.
 Overleg met arts  Diureticamedicatie en eventueel aanpassing bètablokker(s).
Indien deze niet voldoende resultaat geven, overleg over eventuele
nefrostomiekatheter.
 Lab prikken op creatinine, ureum
 Urine onderzoeken op eiwitten, bloedcellen en op afvalstoffen (creatinine en
ureum).

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