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Module 3 Klinisch redeneren BoN
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Integrale beroepsprestatiemodule 3 klinisch redeneren
Casus Mw. S
Naam: Whitley Flecken
Mail: whitley.flecken@lzr.nl
School: Avans+ Hogeschool
Opleiding: HBO-V / Bachelor of
Nursing (2,5 jaar)
Klas: BNVEN2122P2
Werkzaam bij: Laurentius
Ziekenhuis Roermond (LZR)
Verpleegafdeling:
Orthopedie/KNO/Kaakchirurgie
en Geriatrische Trauma Unit
IBP Module 3: Klinisch redeneren
Docent module KR: Ray
Vondenhoff
Werkbegeleider: Floor van Hagen
Praktijkbegeleider: Anouk
Cuijpers
Professioneel leiderschap
docent: Janine Doornbos
Deadline: 15 juli 2022 17:00 uur
Aantal woorden: 7882
Exclusief bijlagen, inclusief tabellen en grafieken.
1
,Voorwoord
Mijn naam is Whitley Flecken en ik ben 22 jaar oud. De afdeling waar ik werkzaam ben is de
verpleegafdeling Orthopedie/KNO/Kaakchirurgie en Geriatrische Trauma Unit binnen het
Laurentius Ziekenhuis in Roermond.
Na het afronden van mijn opleiding tot MBO-verpleegkundige heb ik eerst een jaar fulltime
gewerkt. Ik miste de uitdaging, verdere diepgang en een nieuw doel. Hierom heb ik besloten
om te starten met de hbo-opleiding: Bachelor of Nursing. Hiermee hoop ik mezelf verder te
ontwikkelen tot een volwaardige regieverpleegkundige en in de toekomst verder tot
spoedeisende hulp verpleegkundige of, - cosmetisch verpleegkundige.
Ter afsluiting van module 3 Klinisch Redeneren ligt voor u mijn integrale beroepsprestatie. In
het kader van de opleiding Bachelor of Nursing via Avans+ ben ik op 13 mei 2022 gestart met
dit verslag.
Veel leesplezier gewenst!
Whitley Flecken
Roermond, 15 juli 2022
2
,Inhoudsopgave
Voorwoord .............................................................................................................................................. 2
Inleiding ................................................................................................................................................... 5
Introductie casus ................................................................................................................................. 5
Stap 1: Oriëntatie op de situatie ............................................................................................................. 7
Oriënteren op de situatie door middel van de SBAR-methode .......................................................... 7
EWS...................................................................................................................................................... 8
Lichamelijk onderzoek volgens de ABCDEFG-methode ...................................................................... 9
Interpretatie van de parameters: ...................................................................................................... 10
Bloedonderzoek: ............................................................................................................................... 10
Interpretatie van de bloedwaarden: ................................................................................................. 11
SIRS- criteria: ..................................................................................................................................... 11
Urgentie inschatting: ......................................................................................................................... 12
DOS .................................................................................................................................................... 12
SCEGS ................................................................................................................................................. 12
Werkdiagnosen in volgorde van waarschijnlijkheid (DD) differentiaaldiagnose: ........................ 12
Stap 2: Klinische problematiek inzichtelijk ............................................................................................ 14
Mentale functies ............................................................................................................................... 14
Sensorische functies en pijn .............................................................................................................. 14
Ademhaling ....................................................................................................................................... 14
Circulatie............................................................................................................................................ 15
Urogenitale functies .......................................................................................................................... 15
Spijsverteringsfuncties ...................................................................................................................... 16
Huid en afweerfuncties ..................................................................................................................... 16
Bloedwaarden ................................................................................................................................... 16
Thermoregulatiesysteem .................................................................................................................. 17
Activiteiten en participatie ................................................................................................................ 17
Stap 3: Aanvullend onderzoek............................................................................................................... 18
Anamnese .......................................................................................................................................... 18
Telefonische aanvullende hetero anamnese .................................................................................... 18
Lichamelijk onderzoek ....................................................................................................................... 18
Laboratoriumonderzoek .................................................................................................................... 19
Beeldvormend onderzoek ................................................................................................................. 19
Functieonderzoek .............................................................................................................................. 19
Stap 4: Klinisch beleid ............................................................................................................................ 20
Medisch beleid .................................................................................................................................. 20
3
, Verpleegkundig beleid ....................................................................................................................... 22
Positieve gezondheid ......................................................................................................................... 27
Stap 5: Klinisch verloop ......................................................................................................................... 28
Gewenste situatie .............................................................................................................................. 28
Ongewenste situatie.......................................................................................................................... 28
Stap 6: ‘Nabeschouwing’ ....................................................................................................................... 30
CanMEDS rollen ................................................................................................................................. 31
Bijlage 1 Auto- anamnese ...................................................................................................................... 33
Bijlage 2 Indicator complexiteit patiënt ................................................................................................ 37
Bijlage 3 EWS ......................................................................................................................................... 38
Bijlage 4 DOS ......................................................................................................................................... 40
APA-literatuurlijst .................................................................................................................................. 41
4
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