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Samenvatting - verpleegkunde theorie - 'verpleegkundige multidisciplinaire diagnosestelling'
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HC verpleegkundige multidisciplinaire diagnosestellingVpk diagnose is het klinisch oordeel over een menselijke reactie v iemand op veranderede
gezondheid/levensproces, basis v vpk interventie
VPk diagnostiek:
- Kennisbron
- Verantwoorden kwaliteitszorg
- Continiuïteit zorg
- Kwaliteitsvolle zorg op maat diagnose i systeem bv canmedsrollen
Vpk beschrijft specifieke diagnose, beoogde doelen en geplande interventies !!
Systematisch verpleegkundig handelen
- Verzekert kritische zorgverlening
- Bevorderd kwaliteitsvolle zorg
- Bevordert participatie pt
- Bevordert samenwerking
- Professionele rapportering
- Wettelijk verplicht
Gegevens verzamelen: auto-anamnese: pt zelf
Hetero- anamnese: omgeving
Klinisch redeneren
1. Situatie pt beschrijven
2. Gegevens verzamelen door observeren
o Airway: beoordeling ademweg
o Breathing: symptomen bedreigde ademhaling
o Circulation:
o Disability:
o Exposure / environment:
Na 1e observaties full set of signs:
o Reden opname
o Diagnose
o Voorgeschiedenis
o Behandeling
o Onderzoeken
o Dimensies v positieve gezondheid
Gegevens bekomen door anamneses (=gesprek), niet enkel over wat pt niet meer kan,
ook praten over kwaliteiten die herstel kunnen bevorderen
Algemene anamnes vragen
Gerichte anamnesevragen
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