,KLINISCH REDENEREN
CASUÏSTIEK OVER MEVROUW DE BOER
LINDA VAN HARN
HOGESCHOOL UTRECHT
Stagedocent: Judith Timmerman
1
, INHOUDSOPGAVE
Inleiding.....................................................................................................................................................................3
Stap 1 Oriëntate op de situate/klinisch beeld........................................................................................................4
Introducte............................................................................................................................................................4
SBAR......................................................................................................................................................................6
S (SITUATION)....................................................................................................................................................6
B (BACKGROUND)..............................................................................................................................................6
A (Assessment)..................................................................................................................................................6
R (Recommendaton).........................................................................................................................................6
R (Repeat)..........................................................................................................................................................6
Ernst van de situate.............................................................................................................................................6
Stap 2 Klinische probleemstelling.............................................................................................................................7
Wat zijn de orgaansystemen die betrokken zijn?.................................................................................................7
Problematek op psychisch spiritueel en sociaal gebied......................................................................................8
stap 3: Aanvullend onderzoek en diagnose..............................................................................................................8
Overige meetnstrumenten...................................................................................................................................8
Diferentaal diagnoses..........................................................................................................................................8
(1) Hypercapnie.................................................................................................................................................9
(2) Decompensato Cordis.................................................................................................................................9
(3) Long carcinoom..........................................................................................................................................10
Stap 4: Klinisch beleid.............................................................................................................................................10
Interventes.........................................................................................................................................................11
Angst................................................................................................................................................................11
Respiratoire insufciënte...............................................................................................................................12
Mobiliteit.........................................................................................................................................................12
Stap 5: Klinisch verloop...........................................................................................................................................13
Te verwachten klinische verloop van de ziekte op korte- en langetermijn........................................................13
(eventuele) complicates.....................................................................................................................................14
Bewaken van de zorgresultaten..........................................................................................................................14
Gevolgen van de ziekte voor het psychische psychosociale en spirituele functoneren...................................15
Interventes ter bevordering van het zelfmanagement......................................................................................15
Stap 6: Evaluate......................................................................................................................................................16
Bibliografe..............................................................................................................................................................17
Bijlage 1...................................................................................................................................................................18
Bijlage 2 ABCDE Methodiek.....................................................................................................................................19
ABCDE Methodiek...............................................................................................................................................19
2
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