PATIËNTBESPREKING
KLINISCH REDENEREN
, Inhoud
Stap 1: SBAR..........................................................................................................................................................................................2
Stap 2 Klinische probleemstelling.........................................................................................................................................................6
Systemen...........................................................................................................................................................................................6
1.Ademhaling................................................................................................................................................................................6
2.Circulatie....................................................................................................................................................................................6
3.Zuurstofbalans myocard............................................................................................................................................................7
4.Bloedwaardes.............................................................................................................................................................................7
5.Hormonaal stelsel......................................................................................................................................................................8
6.Urogentitale functies..................................................................................................................................................................8
7.Huid en afweer...........................................................................................................................................................................9
8.Neurologische functies...............................................................................................................................................................9
9.Spijsveteringsfuncties.................................................................................................................................................................9
10.Themoregulatie........................................................................................................................................................................9
11.Mentale functies......................................................................................................................................................................9
12.Activiteiten en participatie.......................................................................................................................................................9
13.Bewegingsapparaat................................................................................................................................................................10
14.Stem en spraak.......................................................................................................................................................................10
15.Sensorische functies en pijn...................................................................................................................................................10
SCEGS..............................................................................................................................................................................................10
Stap 3 Aanvullend onderzoek.............................................................................................................................................................10
Onderzoeken door arts afgesproken:.............................................................................................................................................10
Onderzoeken verpleegkundige:......................................................................................................................................................11
Stap 4 Klinisch beleid...........................................................................................................................................................................11
Stap 5 Klinisch verloop........................................................................................................................................................................11
Stap 6 Nabeschouwing........................................................................................................................................................................12
1
KLINISCH REDENEREN
, Inhoud
Stap 1: SBAR..........................................................................................................................................................................................2
Stap 2 Klinische probleemstelling.........................................................................................................................................................6
Systemen...........................................................................................................................................................................................6
1.Ademhaling................................................................................................................................................................................6
2.Circulatie....................................................................................................................................................................................6
3.Zuurstofbalans myocard............................................................................................................................................................7
4.Bloedwaardes.............................................................................................................................................................................7
5.Hormonaal stelsel......................................................................................................................................................................8
6.Urogentitale functies..................................................................................................................................................................8
7.Huid en afweer...........................................................................................................................................................................9
8.Neurologische functies...............................................................................................................................................................9
9.Spijsveteringsfuncties.................................................................................................................................................................9
10.Themoregulatie........................................................................................................................................................................9
11.Mentale functies......................................................................................................................................................................9
12.Activiteiten en participatie.......................................................................................................................................................9
13.Bewegingsapparaat................................................................................................................................................................10
14.Stem en spraak.......................................................................................................................................................................10
15.Sensorische functies en pijn...................................................................................................................................................10
SCEGS..............................................................................................................................................................................................10
Stap 3 Aanvullend onderzoek.............................................................................................................................................................10
Onderzoeken door arts afgesproken:.............................................................................................................................................10
Onderzoeken verpleegkundige:......................................................................................................................................................11
Stap 4 Klinisch beleid...........................................................................................................................................................................11
Stap 5 Klinisch verloop........................................................................................................................................................................11
Stap 6 Nabeschouwing........................................................................................................................................................................12
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