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Samenvatting ABCDE voor verpleegkundigen - Minor Critical Care
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Uitgebreide samenvatting van hoofdstuk 1 t/m 8 van het boek 'ABCDE voor verpleegkundigen'.
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By: amberhoving • 2 year ago
By: hjcdjong • 3 year ago
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ABCDE voor verpleegkundigen – samenvattingInhoudsopgave
Hoofdstuk 1............................................................................................................................................8
Hoofdstuk 2 Primary survey en de A (Airway)........................................................................................9
Head-tilt/chin-lift manoeuvre.............................................................................................................9
Jaw-thrust manoeuvre........................................................................................................................9
Orofaryngeale luchtweg.....................................................................................................................9
Nasofaryngeale luchtweg.................................................................................................................10
Larynxmasker als luchtweg...............................................................................................................10
Multilumen-oesofagusluchtweg.......................................................................................................10
Larynxtube........................................................................................................................................10
Intubatie en definitieve luchtweg.....................................................................................................10
Gum Elastic Bougie (GEB).................................................................................................................11
Nasotracheale intubatie...................................................................................................................11
Luchtwegobstructie..........................................................................................................................11
Afwijkende ademgeluiden bij een gedeeltelijke luchtwegobstructie...........................................12
Hoofdstuk 3 B (Breating)......................................................................................................................13
Opname van zuurstof in lichaam......................................................................................................13
Ventilatie..........................................................................................................................................13
Diffusieproblemen............................................................................................................................13
Perfusie.............................................................................................................................................14
Zuurstofdissociatiecurve...................................................................................................................14
Zuur-base-evenwicht........................................................................................................................14
Ventilatie-perfusieverhouding..........................................................................................................15
Ademcentrum...................................................................................................................................15
Dyspneu............................................................................................................................................15
Ademhalingsgeluiden.......................................................................................................................16
Vesiculair/normaal ademgeruis....................................................................................................16
Verminderd tot geen ademgeruis.................................................................................................16
Stridor...........................................................................................................................................17
Rhonchi.........................................................................................................................................17
Crepitaties....................................................................................................................................17
Geluiden bij subcutaan emfyseem................................................................................................17
Pleurawrijfgeruis...........................................................................................................................17
1
,Auscultatie van de longen................................................................................................................17
Afwijkingen van inspirium en expirium.............................................................................................18
Verlengd expirium........................................................................................................................18
Verlengd inspirium.......................................................................................................................18
Aanvullende diagnostiek bij dyspnoïsche patiënten.........................................................................18
Oorzaken van dyspnoe.....................................................................................................................18
Pleuravocht.......................................................................................................................................18
Behandeling pleuravocht..............................................................................................................19
Pneumonie.......................................................................................................................................19
Symptomen pneumonie...............................................................................................................19
Onderzoek bij pneumonie............................................................................................................19
Behandeling van pneumonie........................................................................................................19
Bronchospasme................................................................................................................................19
Thoraxletsel......................................................................................................................................20
Hematothorax..............................................................................................................................20
Rib-, sternum- en scapulafracturen..............................................................................................20
Fladderthorax...............................................................................................................................20
Longcontusie................................................................................................................................21
Pneumothorax..............................................................................................................................21
Open pneumothorax (zuigende thoraxwond)..............................................................................22
Astma...............................................................................................................................................22
Astma-exacerbatie en status astmaticus......................................................................................23
Oorzaken van astma.....................................................................................................................23
Aanvullend onderzoek bij astma...................................................................................................23
Ernstige en levensbedreigende astma..........................................................................................23
Intubatiecriteria bij acute astma...................................................................................................24
COPD................................................................................................................................................24
Stadia van COPD...........................................................................................................................24
Exacerbatie COPD.........................................................................................................................24
Symptomen COPD........................................................................................................................25
Hypoxic drive bij COPD.................................................................................................................25
Medicamenteuze behandeling van een exacerbatie COPD..........................................................25
Longemfyseem.................................................................................................................................25
Longembolie.....................................................................................................................................25
ECG-bevindingen bij longembolie.................................................................................................26
D-dimeerbepaling bij longembolie...............................................................................................26
2
, Acuut longoedeem...........................................................................................................................26
Asthma cardiale................................................................................................................................27
Rechtsdecompensatie bij asthma cardiale...................................................................................27
Hyperventilatie.................................................................................................................................27
Guillain-Barré-syndroom en dyspnoe...............................................................................................28
Amyotrofische Laterale Sclerose (ALS) en dyspnoe..........................................................................28
Technieken voor ventilatie (beademing)..........................................................................................28
Beademing met een mondmasker................................................................................................28
Maskerballonbeademing..............................................................................................................28
Non-invasieve beademing............................................................................................................28
Mechanische ventilatie.................................................................................................................29
Problemen in de zuurstofvoorziening...............................................................................................29
Zuurstofvoorziening in het bloed......................................................................................................29
Klinische tekenen van zuurstoftekort...............................................................................................29
Observatie van de ademhaling.........................................................................................................29
Frequentie van de ademhaling.....................................................................................................29
Diepte van de ademhaling............................................................................................................30
Verwondingen of huidafwijkingen op de borstkas.......................................................................30
Asymmetrische ademhaling.........................................................................................................30
Kussmaul-ademhaling...................................................................................................................30
Centrale cyanose..........................................................................................................................30
Perifere cyanose...........................................................................................................................30
Cheyne-Stokes-ademhaling..........................................................................................................30
Afwezig, verminderd of verscherpt ademgeruis...........................................................................31
Aanwezigheid van bijgeluiden......................................................................................................31
Gedempte of hypersonore percussie...........................................................................................31
Afwijkende stand van de trachea.................................................................................................31
Pijn bij het uitoefenen van druk op de borstkas...........................................................................31
Subcutaan emfyseem...................................................................................................................31
Hoofdstuk 4 C (Circulation)...................................................................................................................32
Basale concepten van de circulatie...................................................................................................32
Hartcyclus.....................................................................................................................................32
Bloedvolumes in de verschillende onderdelen van de circulatie..................................................32
Druk in verschillende onderdelen van de circulatie......................................................................32
MAP (Mean Arterial Pressure)......................................................................................................33
Druk in de aorta en in de longvaten.............................................................................................33
3
, Cardiale reserve............................................................................................................................33
Hartfrequentie (HF)......................................................................................................................33
Slagvolume...................................................................................................................................33
Hartminuutvolume (cardiac output).............................................................................................34
Totale perifere vaatweerstand en totale pulmonale vaatweerstand...........................................34
Preload.........................................................................................................................................34
Afterload.......................................................................................................................................34
Sympathicusactivatie als compensatie bij shock...........................................................................34
Compensatie door frequentieverhoging.......................................................................................35
Wet van Frank-Starling.................................................................................................................35
Circulatoire shock.............................................................................................................................35
Toxinen en cellulaire schade bij shock..........................................................................................35
Leverfalen bij shock......................................................................................................................35
Nierfalen en tubulusnecrose bij shock..........................................................................................35
Verhoogde doorlaatbaarheid van de capillairen...........................................................................36
Verminderde pompfunctie van het hart door hypotensie............................................................36
Energiedepletie en acidose bij shock............................................................................................36
Kussmaul-ademhaling bij metabole acidose.................................................................................36
Decompensatie van het hart............................................................................................................36
Links decompensatio cordis (decompensatie van de linkerharthelft)...........................................36
Rechts decompensatio cordis (decompensatie van de rechterharthelft).....................................36
Forward failure.............................................................................................................................37
Backward failure...........................................................................................................................37
Cardiogene shock.........................................................................................................................38
Hypovolemische en hemorragische shock....................................................................................38
Positionering van patiënten met een hypovolemische shock.......................................................38
Hematothorax..................................................................................................................................38
Oorzaken hematothorax...............................................................................................................38
Symptomen hematothorax...........................................................................................................38
Behandeling van een hematothorax.............................................................................................39
Massale hematothorax.................................................................................................................39
Shock bij abdominaal letsel..............................................................................................................39
Inspectie van het abdomen..........................................................................................................39
Auscultatie van het abdomen.......................................................................................................39
Percussie en palpatie van het abdomen.......................................................................................39
Shock bij bekkenfractuur en geassocieerde letsels.......................................................................40
4
, Neurogene shock..........................................................................................................................40
Distributieve shock.......................................................................................................................40
Septische shock............................................................................................................................40
Anafylactische shock.........................................................................................................................40
Obstructieve shock...........................................................................................................................41
Obstructieve shock bij harttamponade.........................................................................................41
Behandeling van een harttamponade...........................................................................................41
Obstructieve shock bij een spanningspneumothorax...................................................................41
Obstructieve shock bij een longembolie.......................................................................................42
Behandeling van shock met sympathicomimetica........................................................................42
Valkuilen bij de C..............................................................................................................................42
Ouderen........................................................................................................................................42
Kinderen.......................................................................................................................................42
Atleten..........................................................................................................................................42
Stappenplan bij de C.........................................................................................................................43
Interpretatie van de pulsaties.......................................................................................................43
Capillary refill................................................................................................................................43
Kleur.............................................................................................................................................44
Stoppen van inwendig bloedverlies (‘four places more’)..............................................................44
Vochtbeleid..................................................................................................................................44
Hoofdstuk 5 D (Disability).....................................................................................................................45
ABCDE-gerelateerde oorzaken van een verminderd bewustzijn......................................................45
Hypoglykemie en hyperglykemie......................................................................................................46
Alcoholintoxicatie.............................................................................................................................47
Koolmonoxidevergiftiging.................................................................................................................47
Verhoging van de intracraniële druk (hersendruk)...........................................................................47
Insulten en epilepsie.........................................................................................................................47
Cerebrovasculair accident (CVA)......................................................................................................48
Herkennen ven een CVA met de FAST-test...................................................................................48
Locatie van het CVA......................................................................................................................48
Behandeling van een ischemische CVA.........................................................................................49
Behandeling van een bloedig CVA................................................................................................49
Subarachnoïdale bloeding............................................................................................................49
Encefalitis en meningitis...............................................................................................................49
Doorbloeding van de hersenen....................................................................................................50
Hersenletsel..................................................................................................................................50
5
, Schedelfracturen..........................................................................................................................50
Contusie en intracerebrale hematomen...........................................................................................51
Epiduraal hematoom....................................................................................................................51
Subduraal hematoom...................................................................................................................51
Licht traumatisch hersenletsel (LTH, GCS 13-15)..............................................................................51
Indicatie voor CT schedel/hersenen bij volwassen LTH-patiënten................................................51
Indicaties voor CT schedel/hersenen bij kinderen met LTH..........................................................52
Stappenplan bij de D.........................................................................................................................53
Hoofdstuk 6 E (Exposure en Environment)...........................................................................................54
Valkuilen bij de E..............................................................................................................................54
Hypothermie (onderkoeling)............................................................................................................54
Hyperthermie...................................................................................................................................54
Huidafwijkingen................................................................................................................................55
Pijn bij de vitaal bedreigede patiënt.................................................................................................55
Instrumenten voor het meten van de pijn....................................................................................55
Frequentie van pijnmeting............................................................................................................55
Factoren die invloed hebben op de pijnbeleving..........................................................................56
Overzicht farmacologische middelen............................................................................................56
Belemmerende factoren in de spoedketenzorg...............................................................................57
Herevaluatie van de ABCDE’s na afronding van de E (Exposure)......................................................57
Stappenplan bij de E.........................................................................................................................58
Hoofdstuk 7 Aanvulling op de primary survey......................................................................................59
Pulsoximetrie....................................................................................................................................59
Voorwaarden voor een adequate saturatiemeting:.....................................................................59
Toedienen van zuurstof....................................................................................................................60
Indicaties voor toedienen zuurstof...............................................................................................60
Toedieningswijzen zuurstof..........................................................................................................60
Ritmemonitoring..............................................................................................................................62
Urinekatheter...................................................................................................................................62
Bloedgasanalyse...............................................................................................................................62
Capnografie......................................................................................................................................62
Beeldvormend onderzoek................................................................................................................62
X-thorax........................................................................................................................................63
X-bekken.......................................................................................................................................63
X-BOZ (buikoverzicht)...................................................................................................................63
Echografie.....................................................................................................................................63
6
, CT-scan.........................................................................................................................................63
MRI-scan.......................................................................................................................................63
Hoofdstuk 8 Secondary survey.............................................................................................................64
AMPLE-anamnese.............................................................................................................................64
Lichamelijk onderzoek bij de secondary survey................................................................................64
Onderzoek van het hoofd.................................................................................................................64
Onderzoek van de hals.....................................................................................................................64
Onderzoek van de thorax.................................................................................................................65
Auscultatie van de longen.............................................................................................................65
Auscultatie van het hart...............................................................................................................65
Onderzoek van de buik.....................................................................................................................65
Onderzoek van perineum, rectum en vagina....................................................................................66
Onderzoek van bewegingsapparaat.................................................................................................66
Wervelkolomtrauma.........................................................................................................................66
Diagnostiek...................................................................................................................................66
Nexus-criteria...............................................................................................................................66
Logroll...........................................................................................................................................67
Neurologisch onderzoek...................................................................................................................67
7
, Hoofdstuk 1
Vitale parameters
- Ademhaling
o Ademhalingsfrequentie (AF)
(12-20 p/m) (vitaal bedreigd bij ≤ 8/ >30 p/m)
o Zuurstofsaturatie (tel laag = hypoxie)
(< 90% vitaal bedreigd)
- Circulatie
o Hartfrequentie (HF) (pols)
(vitaal bedreigd <40/ >130 p/m)
o Bloeddruk
(vitaal bedreigd systolische bloeddruk <90/>200 mmHg)
- Bewustzijn
o Bewustzijnsverandering
EMV & Glasgow Coma Scale, ≤ 8 ernstig hersenletsel/comateuze toestand
intubatie
Score 9 – 12 matig hersenletsel
Score 13 – 15 lichte hersenletsel
Zelden geïntubeerd bij patiënten met lage EMV-score bij een GHB-intoxicatie
stabiele zijligging + afwachten
AVPU-score
A = alert
V = reactie op aanspreken
P = reactie op pijn
U = geen reactie
EWS-score
8
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