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Klinisch redeneren

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Opdracht klinisch redeneren, onderdeel van de opdracht PL2 In het verslag is gebruik gemaakt van de stappen klinisch redeneren volgens Marc Bakker Leerjaar 1

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  • February 12, 2019
  • 20
  • 2017/2018
  • Other
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KLINISCH REDENEREN
Themakaart



Naam:
Studentnummer:
Studiegroep:
Docent:
HBO-V Duaal
Mentor:
Afdeling: UMC Utrecht, Verpleegafdeling
KNO/MKA/Plastische chirurgie D5West
Inleverdatum: 22-6-2018

,Inhoudsopgave:

Voorwoord……………………………………………………………………………………………3
Stap 1: Probleem oriëntatie/klinisch beeld………………………………………………………….
Casus…………………………………………………………………………………………4.
SBAR…………………………………………………………………………………………5.
EWS&NRS…………………………………………………………………………………5/6
Stap 2: Probleemanalyse…………………………………………………………………………….
….....7/8.
Betrokken orgaansystemen …………………………………………………..…………7/8
Prioriteiten……………………………………………………………………………...…..7/8
Stap 3: Aanvullend onderzoek en diagnose…………………………………………………………
Anamnese……………………………………………………………………………………9
Lichamelijk onderzoek………………………………………………………………...……9
Bloedonderzoek………………………………………………………………………….…9
Microbiologisch onderzoek…………………………………………………………..…….9
Beeldvormend onderzoek………………………………………………………………9/10
Differentiële diagnoses……………………………………………………………………10
Stap 4: Klinisch beleid……………………………………………………………………………….
Interventies………………………………………………………………………...……11/12
Stap 5: Klinisch verloop……………………………………………………………………………….
Klinisch verloop op de korte termijn ………………………………………………….…13
Klinisch verloop op de lange termijn …………………………………………………....14
Zelfmanagement…………………………………………………………………….…….13
Stap 6: Evaluatie……………………………………………………………………………………….
Evalueren op de gegeven zorg………………………………………………….……….14
Zorg bij ontslag………………………………………………………………………….…14
Reflectie…………………………………………………………………….………………15
Literatuurlijst……………………………………………………………………………………...…16
Bijlage 1: Uitgebreide anamnese…………………………………………………………………….
Bijlage 2: Tabeloverzicht vitale functies bij bloedtransfusie........................................................
Bijlage 3: Beoordelingsformulier mentor afdeling…………………………………………………...




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, Voorwoord:
Klinisch redeneren is een belangrijke vaardigheid voor verpleegkundigen om eigen
observaties en interpretaties te koppelen aan medische kennis. Op deze manier kunnen
verpleegkundigen interventies inzetten bij bepaalde ziektebeelden of verpleegproblemen en
hieruit vervolgstappen ondernemen. Door medische kennis te hebben van de fysiologie,
anatomie, pathologie en farmacologie kunnen verpleegkundigen de genomen interventies
tevens onderbouwen. De onderstaande opdracht is gebaseerd op de zesstappen- methodiek
van Marc Bakker (2016) om het klinisch redeneren gestructureerd toe te passen.




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