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Klinisch redeneren niveau C
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Dit verslag is geschreven voor de opleiding HBO-V deeltijd voor KR op niveau C. Het product is beoordeeld met een 7 (incl assessment).
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By: lauraboskabouter • 1 year ago
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Voorblad werkstukNaam student Carlijn Hopman
Studentnummer 684060
Klas AMVPKDTS21E
Domein
Opleiding Verpleegkunde
Variant (VT / DT / DU) DT
Jaar 2021-2022
Locatie Amsterdam
Klinisch Redeneren
Titel werkstuk
Naam toets Klinisch Redeneren niveau C
Toetscode 2019DTKR3A
Naam docent: Sietske Bos
Studiejaar 2021-2022
Toetsperiode 4
Kans Regulier
Ik verklaar dat ik bij het onderzoek voor en het schrijven van dit werkstuk niet heb
Verklaring student geplagieerd, gefraudeerd of anderszins in strijd met de Onderwijs- en Examen
Regeling (OER) heb gehandeld.
Datum
Handtekening
In te vullen door student:
(* doorhalen wat niet van toepassing is)
1
, Klinisch redeneren
niveau C
Naam: Carlijn Hopman
Studentnummer: 684060
E-mail: 684060@student.inholland.nl
Instelling: OLVG, locatie West
Afdeling: Longgeneeskunde/Cardiologie
Leercoach: Mirjam van Meningen
Werkveldcoach: Adam Azis
Opleiding: HBO-V deeltijd
Opleidingsinstelling: Hogeschool InHolland Amsterdam
Inhoudsopgave
2
,Voorwoord.................................................................................................................................................... 5
PAN-methode................................................................................................................................................ 7
Stap 1: oriëntatie op de situatie..................................................................................................................... 8
Situatie.................................................................................................................................................................8
Background..........................................................................................................................................................8
Overige voorgeschiedenis................................................................................................................................8
Therapietrouw.................................................................................................................................................8
Sociaal..............................................................................................................................................................8
Huidige medicatie............................................................................................................................................9
Assessment...........................................................................................................................................................9
Huidige situatie................................................................................................................................................9
Bloedwaarden................................................................................................................................................10
Werkdiagnosen..............................................................................................................................................10
Recommendation...............................................................................................................................................10
Stap 2: klinische problematiek..................................................................................................................... 11
Zorgthema’s.......................................................................................................................................................11
Activiteiten en participatie............................................................................................................................11
Circulatie........................................................................................................................................................15
Ademhaling....................................................................................................................................................15
Urogenitale functies......................................................................................................................................16
Bloedwaarden................................................................................................................................................16
Mentale functies............................................................................................................................................17
.................................................................................................................................................................... 18
Stap 3: aanvullend klinisch onderzoek.......................................................................................................... 19
Stap 4: klinisch beleid.................................................................................................................................. 20
PES 1: verminderd ademhalingsvermogen........................................................................................................20
PES 2: overvulling...............................................................................................................................................22
PES 3: risico op obstipatie..................................................................................................................................23
PES 4: verminderde mobiliteit............................................................................................................................24
Onderzoek..........................................................................................................................................................26
Zelfmanagement.......................................................................................................................................... 28
Het 5A-model.....................................................................................................................................................28
Achterhalen...................................................................................................................................................28
Adviseren.......................................................................................................................................................29
Afspreken.......................................................................................................................................................29
Assisteren.......................................................................................................................................................30
Arrangeren.....................................................................................................................................................30
Stap 5: klinisch verloop................................................................................................................................ 31
Indiceren van zorg..............................................................................................................................................31
Stap 6: nabeschouwing................................................................................................................................ 32
Reflectie volgens STARR.....................................................................................................................................32
3
, E-health....................................................................................................................................................... 34
Wetgeving................................................................................................................................................... 35
Literatuurlijst............................................................................................................................................... 37
.................................................................................................................................................................... 38
Bijlage 1....................................................................................................................................................... 39
Complexiteitsscorelijst........................................................................................................................................39
Bijlage 2....................................................................................................................................................... 44
LSD-methode......................................................................................................................................................44
Terugvraagmethode...........................................................................................................................................44
Bijlage 3....................................................................................................................................................... 45
Uitleg meetinstrumenten...................................................................................................................................45
Bijlage 4....................................................................................................................................................... 46
Medicatie uitwerking.........................................................................................................................................46
4
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