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Klinisch redeneren in de thuiszorg PL3
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Klinisch redeneren in de thuiszorg PL3
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KLINISCHREDENEREN
CAREYN ZORG THUIS
Hogeschool Utrecht
,Voorwoord
Voor de bachelor verpleegkunde worden er meerdere stages gelopen. Mijn 3ejaars stage
wordt in de thuiszorg gevolgd. Het verslag klinisch redeneren gaat over een veranderde
situatie. De opdracht schetst deze situatie als mogelijk acuut. Omdat de thuiszorg niet te
vergelijken is met een ziekenhuis komen hier minder acute situaties voor. Hierom is er
voornamelijk gefocust op de maatschappelijke problemen van de gekozen cliënt.
Het verslag bestaat uit zes verschillende stappen die verder uitgelegd worden in het boek
van Bakker & Van Heycop ten ham (2014).
1
, Inhoud
Voorwoord.............................................................................................................................................1
Onderdeel 1 – klinisch redeneren t.b.v. een veranderende situatie.......................................................3
Stap1: Probleemoriëntatie/ klinisch beleid........................................................................................3
Casus...............................................................................................................................................3
Het klinisch beeld...........................................................................................................................4
Aanvullende screeningsinstrumenten............................................................................................5
Hypothetische diagnose(s).............................................................................................................6
Stap 2: Probleemanalyse....................................................................................................................7
Verpleegkundige problemen..........................................................................................................7
Medische problemen......................................................................................................................7
Analyse...........................................................................................................................................9
Stap 3: Aanvullend onderzoek..........................................................................................................11
Aanvullend onderzoek..................................................................................................................11
Differentiële diagnose...................................................................................................................12
Stap 4: Klinisch beleid.......................................................................................................................13
Onderdeel 2 – het klinisch redeneren t.b.v. het totale verpleegkundig proces....................................14
Stap 5: Klinisch verloop.....................................................................................................................14
Stap 6: Evaluatie...............................................................................................................................16
Literatuurlijst........................................................................................................................................17
Bijlage 1 Medicatie overzicht................................................................................................................19
Bijlage 2 Risicoanalyse..........................................................................................................................20
Bijlage 3 Feedbackformulier ingevuld door de werkbegeleider...........................................................22
2
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