"Treat first what kills first". In dit stuk worden de ABCDE-methode, Early Warning Score en Glasgow Coma Scale behandeld en toegelicht volgens het Proactive Nursing model.
Na primary survey AMPLE (Allergiën, Medicatie, Pas illnesses, Last meal, Events)
EMV-score
1
, Lyndsey Bommer
645220
MEWS
Referentiewaarden parameters
Observatie, parameter Referentiewaarde volwassene
Reactiepatroon Alert
Oriëntatie in trias In tijd, plaats en persoon
Ademfrequentie 12-15 /minuut
Alveolair ademgeruis Vesiculair ademgeruis (VAG)
SpO2 > 95%
NIBP (mean) 120/80 mmHg (70-95)
Pulsaties 60-100 /minuut, regulair, equaal, krachtig
Hartritme Sinusritme
Vulling halsvenen Zittend= vlak, liggend= gestuwd
Kleur Roze
Capillaire refilltijd 2-3 sec.
Diurese 1 ml/kg/uur, helder lichtgeel
Gewichtsverandering <2% variatie
Huidturgor Snel en elastisch verstrijken
Slijmvliezen conditie Vochtig, glanzend
Kerntemperatuur 36,5-37,5 C
PAN-model
Ademhaling (aanvoer 02 en afvoer CO2)
Mindmap met 5 aandachtspunten:
2
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