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Klinisch redeneren pl4
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Klinisch redeneren PL4Naam: Rebecca Slagmolen
Studentnummer: 1676724
Naam cursus: GVE-4.PL4.17
Groepscode: GVE-2DUV-PLD
Aantal woorden: 4475
Stagedocent: Floortje Keuskamp
Organisatie: Beweging 3.0, Lisidunahof, Leusden.
Werkbegeleider: Jasper Meursing
Uiterlijke inleverdata: 16 januari 2023
,Inhoudsopgave
Inleiding........................................................................................................................................................ 3
Onderdeel 1: klinisch redeneren t.b.v. een veranderende situatie..................................................................4
Stap 1: Probleemoriëntatie/klinisch beeld...................................................................................................... 4
1.1 Voorgeschiedenis...........................................................................................................................................4
1.2 Veranderende situatie door middel van de SBAR..........................................................................................4
1.3 Screeningsinstrumenten.................................................................................................................................6
1.5 Differentiaaldiagnoses...................................................................................................................................7
Stap 2: Probleemanalyse................................................................................................................................ 8
2.1 Disfunctionele orgaansystemen.....................................................................................................................8
2.2 Psychische problematiek:...............................................................................................................................8
2.3 Functionele problematiek:..............................................................................................................................8
2.4 Psychosociale problematiek:..........................................................................................................................9
2.5 Spirituele problematiek:.................................................................................................................................9
3.1 Aanbevelingen vanuit het verpleegkundig oogpunt....................................................................................10
............................................................................................................................................................................10
3.2 Medisch aanvullend onderzoek....................................................................................................................10
............................................................................................................................................................................10
3.3 Medische diagnose.......................................................................................................................................10
............................................................................................................................................................................10
3.4 Verpleegkundige diagnoses.........................................................................................................................10
Stap 4: Klinisch beleid.................................................................................................................................. 12
4.2 De prioritering voor het verpleegkundig handelen......................................................................................13
4.3 Gezamenlijke besluitvorming.......................................................................................................................13
Onderdeel 2: Het klinisch redeneren t.b.v. het totale verpleegkundig proces................................................14
Stap 5: Klinisch verloop................................................................................................................................ 14
5.1 Ziekteverloop korte/lange termijn...............................................................................................................14
5.6 Inventarisatie professionele zorg en mantelzorg aan zorgvrager...............................................................15
Stap 6: Evaluatie.......................................................................................................................................... 16
6.1 Reflectie zorgproces.....................................................................................................................................16
6.2 Reflectie gebruik elektronisch patiëntendossier..........................................................................................16
Bronnenlijst................................................................................................................................................. 17
Bijlagedocumenten...................................................................................................................................... 20
Bijlagedocument 1 – Katz-schaal.......................................................................................................................20
Bijlagedocument 2 – PACSLAC-D........................................................................................................................21
, Bijlagedocument 3 - FAS....................................................................................................................................22
Bijlagedocument 4 – DOS schaal........................................................................................................................23
Bijlage document 5 – Eenzaamheidsschaal.......................................................................................................24
Bijlagedocument 6 – NPI....................................................................................................................................25
Inleiding
Deze opdracht is geschreven in het kader van de Verpleegkundige opleiding aan de
Hogeschool Utrecht.
Tijdens het signaleren van een veranderende situatie is het noodzakelijk meetinstrumenten
te gebruiken om te onderzoeken en de situatie duidelijk in kaart te brengen.
Door middel van de zes stappen van Bakker kun je klinisch redeneren en kan de
zorgverlener observaties onderbouwen. De zes stappen van Bakker geven vorm aan het
klinisch redeneren (Bakker, 2017, p.11).
Omdat er rekening gehouden moet worden met de privacy van de zorgvragers en de
betrokkenen zijn alle gegevens geanonimiseerd.
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