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Klinisch redeneren PL4 Traumatologie en Orthopedie UMC
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Klinisch redeneren opdracht PL4 Traumatologie en Orthopedie UMC
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Klinisch redeneren PL4Traumatologie en orthopedie
,Inhoudsopgave
Onderdeel 1: klinisch redeneren.................................................................................................................... 2
Stap 1: Probleemoriëntatie/klinisch beeld..........................................................................................................3
Situation..........................................................................................................................................................3
Background.....................................................................................................................................................3
Assessment (Pre-OK lab & EWS).....................................................................................................................6
Psychosociaal..................................................................................................................................................7
Recommendation............................................................................................................................................8
De veranderde situatie...................................................................................................................................8
Ernst van de situatie.......................................................................................................................................9
Screeningsinstrumenten & resultaten............................................................................................................9
Diagnoses, differentiaaldiagnoses en hypothetische diagnoses.......................................................................11
Stap 2: Probleemanalyse.................................................................................................................................11
Disfunctionele orgaansystemen...................................................................................................................11
Respiratoir systeem (breathing)...................................................................................................................11
Afweersysteem (circulation & exposure).....................................................................................................11
Neurologisch systeem (Disability)................................................................................................................12
Digestief systeem..........................................................................................................................................12
Psycho-sociale problematiek........................................................................................................................12
Functionele problematiek.............................................................................................................................12
Spirituele problematiek................................................................................................................................12
Resultaten screeningsinstrumenten.............................................................................................................12
Stap 3: Aanvullend onderzoek en diagnose......................................................................................................13
Laboratoriumonderzoek...............................................................................................................................13
Lichamelijk onderzoek..................................................................................................................................13
Aanvullende anamnese................................................................................................................................13
Verpleegkundige diagnoses..........................................................................................................................14
Stap 4: Klinisch beleid.......................................................................................................................................15
Onderdeel 2: klinisch redeneren.................................................................................................................. 18
Stap 5: Klinisch verloop.....................................................................................................................................18
Korte termijn.................................................................................................................................................18
Lange termijn................................................................................................................................................18
Zelfmanagement...........................................................................................................................................19
Nodige zorg...................................................................................................................................................19
Stap 6: Evaluatie...............................................................................................................................................20
Literatuurlijst klinisch redeneren................................................................................................................. 24
Onderdeel 1: klinisch redeneren
, Stap 1: Probleemoriëntatie/klinisch beeld
De probleemoriëntatie en het klinische beeld worden aan de hand van de SBAR-methode (situation,
background, assessment, recommendation) uitgewerkt vormgegeven (Bakker, 2017).
Situation
Deze casus betreft een 41-jarige Oekraïense militair (man). Eén september is dhr. overgenomen uit
Oekraïne, heeft daar 11-07-2022 onder andere (o.a) een mijnletsel opgelopen. De reden van
overnamen is een open crurisfractuur links met vaatletsel waarvoor externe fixatie waarschijnlijk
gecompliceerd met compartimentsyndroom waarvoor fasciotomie. Bij opnamen verdenking fractuur
gerelateerde infectie. Naast zijn crursisfractuur heeft dhr. ook:
- Multipele aangezichtfracturen met granaatscherf in zygoma;
- Laceratie linkerwang (gehecht);
- Trommelvliesperforatie rechts, conservatief beleid;
- Pneumothorax rechts, thoraxdrain (voor overnamen verwijderd);
- Laceraties rechterbovenbeen (gehecht).
Background
De background wordt uitgewerkt door het gebruik van de AMPLE-methode (allergieën, medicijnen,
past, laatste maaltijd, e: context) (Bakker, 2017).
Allergieën
Geen allergie bekend.
Medicijnen
De gehele opnamen zijn er veel verschillende soorten medicatie voorgeschreven. Hieronder in Tabel
1 en 2 een overzicht van alle voorgeschreven medicatie de gehele opnamen en bij ontslag.
Tabel 1
Overzicht van gehele medicatie voorschriften
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