6,7 - Klinisch redeneren - PL3- Delier - MET beoordeling
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Course
Opdracht Klinisch Redeneren PL3 (GVE3.PL316)
Institution
Hogeschool Utrecht (HU)
Book
Klinisch redeneren in zes stappen
Document over klinisch redeneren bij een Delier in een ziekenhuissetting. Verslag behoort tot praktijkleren 3 (PL 3). Beoordeeld met een 6.7. Beoordeling is toegevoegd.
50 interview questions you can ask any nurse about their work
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Hogeschool Utrecht (HU)
Verpleegkunde
Opdracht Klinisch Redeneren PL3 (GVE3.PL316)
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HBO-V
4-6
Klinisch redeneren
Naam: Tom Immers
Opleiding: B Verpleegkunde
Studentnummer:
Groepscode: GVE-DUV-PLF
Cursuscode: GVE-3.PL3-16
Praktijkleren: 3
Afdeling:
Examinator:
Mentoren:
Aantal woorden: 4485/4500
,Inhoudsopgave
Onderdeel 1: Veranderende situatie......................................................................................................4
Stap 1: Probleemoriëntatie en klinisch beeld.....................................................................................4
Opname indicatie...........................................................................................................................4
Voorgeschiedenis...........................................................................................................................4
Delier..............................................................................................................................................4
Veranderende situatie....................................................................................................................4
Delirium Observatie Schaal (DOS)...................................................................................................5
Ernst van de situatie.......................................................................................................................5
Relevante context...........................................................................................................................6
Differentiaal diagnose.....................................................................................................................6
Stap 2: Probleemanalyse....................................................................................................................7
Disfunctionele orgaansystemen.....................................................................................................7
Psychische stoornis.........................................................................................................................7
Psychosociale problematiek...........................................................................................................8
Functionele problematiek...............................................................................................................8
Spirituele problematiek..................................................................................................................8
Analyse van de resultaten..............................................................................................................8
Stap 3: Aanvullend onderzoek en diagnose........................................................................................8
Familieparticipatie en heteroanamnese.........................................................................................9
DELIER-O-METER............................................................................................................................9
Glasgow Coma Schaal.....................................................................................................................9
Controle van de vitale functies.......................................................................................................9
Laboratorium onderzoek................................................................................................................9
Verpleegkundige diagnoses..........................................................................................................10
Stap 4: Klinisch beleid.......................................................................................................................11
Zorg op maat................................................................................................................................11
Multidisciplinaire interventies......................................................................................................12
Disciplines inschakelen.................................................................................................................12
Besluitvorming..............................................................................................................................12
Onderdeel 2: Het verpleegkundig proces.............................................................................................13
Stap 5: Klinisch verloop.....................................................................................................................13
Verloop korte termijn...................................................................................................................13
Langere termijn; complicaties en gevolgen..................................................................................13
Zelfmanagement..........................................................................................................................13
Inventarisatie professionele zorg en mantelzorg..........................................................................13
, Stap 6: Evaluatie...............................................................................................................................14
Zorgvrager....................................................................................................................................14
Reflectie zorgproces.....................................................................................................................14
Reflectie patiëntendossier............................................................................................................14
Literatuurlijst........................................................................................................................................15
Bijlage 3: Literatuur over het letsel......................................................................................................19
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