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Klinisch redeneren KBS 8
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Volledig verslag KBS 8, klinisch redeneren binnen de intensieve zorg
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By: eline426 • 2 year ago
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MEVROUW VEENSTRA,Inhoudsopgave
Inleiding........................................................................................................................................................ 2
Hoofdstuk 1 Uitwerking SBAR........................................................................................................................ 3
Hoofdstuk 2 Klinische problematiek in kaart brengen.....................................................................................5
2.1 Zorgthema’s....................................................................................................................................................5
2.2 Samenhang zorgthema’s................................................................................................................................7
2.3 Prioriteren.......................................................................................................................................................8
2.4 De SCEGS-Psychosociale status......................................................................................................................9
2.5 Differentiaaldiagnosen.................................................................................................................................10
.................................................................................................................................................................... 10
Hoofdstuk 3 Aanvullend onderzoek.............................................................................................................. 10
3.2 Ontlastingspatroon.......................................................................................................................................11
3.4 Bloedonderzoek............................................................................................................................................11
3.7 Wondkweek heup.........................................................................................................................................13
3.8 Bladderen......................................................................................................................................................13
3.10 Aanvullende vragen....................................................................................................................................14
Hoofstuk 4 Klinisch beleid............................................................................................................................ 14
4.1 Verpleegplan.................................................................................................................................................15
4.2 Redeneerweb................................................................................................................................................16
Hoofdstuk 5 Samenwerking......................................................................................................................... 17
Bibliografie................................................................................................................................................. 17
Bijlage 1: casus mevrouw Veenstra.............................................................................................................. 19
Bijlage 2: ICDSC............................................................................................................................................ 21
Bijlage 3: vragenlijst GDS schaal................................................................................................................... 22
Bijlage 4: qSOFA- score sepsis...................................................................................................................... 25
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, Inleiding
Het onderwerp tijdens KBS 8 is klinisch redeneren binnen de intensieve zorg. De casus die bij
dit verslag wordt gebruikt, is mevrouw Veenstra. Zij heeft een CVA doorgemaakt en ligt nu
op de revalidatieafdeling in een verpleeghuis.
De methode die wordt toegepast in dit verslag, is ProActive Nursing. Dit is een methode om
klinisch te redeneren die bestaat uit zes stappen, vier daarvan worden beschreven in dit
verslag. In hoofdstuk één wordt georiënteerd op de situatie en wordt een klinisch beeld
geschetst. Vervolgens wordt bij hoofdstuk twee de klinische problematiek inzichtelijk
gemaakt. Dan volgt hoofdstuk drie. Hierin wordt aanvullend onderzoek gedaan. Tot slot
wordt in hoofdstuk vier een klinisch beleid gemaakt.
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