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Praktijkleren 4: Klinisch redeneren (eindcijfer 8,3)
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KLINISCH REDENERENNaam: Bousra
Naam cursus: GVE-4.PL4.23
Aantal woorden: 4499
Inleverdatum: 10 juni 2024
,Inhoudsopgave
1. Probleemoriëntatie.............................................................................................................................2
1.1. Casusbeschrijving.........................................................................................................................2
1.2. Situation-Background-Assesment-Recommendation (SBAR).......................................................3
1.2.1. Situation...............................................................................................................................3
1.2.2. Background..........................................................................................................................3
1.2.3. Assessment...........................................................................................................................4
1.2.4. Recommendation..................................................................................................................4
1.3. Differentiaal en hypothetische diagnoses....................................................................................5
2. Probleemanalyse................................................................................................................................5
2.1. Disfunctionele orgaansystemen...................................................................................................5
2.2. Functionele problematiek............................................................................................................6
2.3. (Psycho)sociale problemen..........................................................................................................7
2.4. Psychische stoornis(sen)..............................................................................................................7
2.5. Spirituele problematiek...............................................................................................................7
3. Aanvullende onderzoeken..................................................................................................................7
3.1. Verpleegkundige diagnoses.........................................................................................................8
4.Het klinisch beleid...............................................................................................................................9
4.1. Interventies................................................................................................................................10
4.2. Shared Desicion-Making............................................................................................................11
5. Het klinische verloop........................................................................................................................11
5.1. Zelfmanagement........................................................................................................................12
5.2. Betrokkenen..............................................................................................................................12
6. Evaluatie...........................................................................................................................................12
6.1. Doelen.......................................................................................................................................13
6.2. Reflectie zorgproces...................................................................................................................14
6.3. Reflectie Elektronische Patiëntendossier...................................................................................14
Literatuurlijst........................................................................................................................................15
Bijlagen.................................................................................................................................................18
Bijlage 1: De gezondheidspatronen volgens Gordon........................................................................18
Bijlage 2: Medicatielijst.....................................................................................................................20
Bijlage 3: Early Warning Score..........................................................................................................21
Bijlage 4: Glasgow Coma Scale..........................................................................................................22
Bijlage 5: De verkorte checklist veilige zorg risico op vallen..............................................................23
Bijlage 6: Barthel-index.....................................................................................................................24
, Bijlage 7: Laboratoriumuitslag..........................................................................................................25
Bijlage 8: SCEGS-methode................................................................................................................26
Bijlage 9: Hospital Anxiety and Depression Scale..............................................................................27
Bijlage 10: De Mini-Mental State Examination..................................................................................28
Bijlage 11: Delirium Observatie Screening........................................................................................29
1. Probleemoriëntatie
1.1. Casusbeschrijving
Meneer C. is 75 jaar oud en woont met zijn echtgenote in een tussenwoning in Utrecht. Ze hebben
twee zoons en zijn betrokken en zorgzaam als ouders en grootouders van vijf kleinkinderen. De
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