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stageportfolio leerjaar 2
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dit document bevat de opdrachten klinisch redeneren en onderzoekend vermogen van leerjaar 2 van de opleiding verpleegkunde.
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STAGE VERSLAG..... ..... .....
,Inleiding ........................................................................................................................................................... 1
Klinisch redeneren en onderzoekend vermogen .............................................................................................. 2
Casusbeschrijving ............................................................................................................................................... 2
Anamnese ........................................................................................................................................................... 2
Zorgtraject ..................................................................................................................................................... 5
Aanvullende meetinstrumenten.................................................................................................................... 5
CMAI: ........................................................................................................................................................ 5
Barthel-index: ........................................................................................................................................... 5
Katz-schaal: ............................................................................................................................................... 5
Diagnostiek ...................................................................................................................................................... 6
Anatomie en functies .......................................................................................................................................... 6
Zenuwstelsel .................................................................................................................................................. 6
F. psychische stoornissen en gedragsstoornissen .................................................................................... 6
Spijsverteringsstelsel ..................................................................................................................................... 6
K. ziekten van spijsverteringsstelsel ......................................................................................................... 6
Externe en persoonlijke factoren ........................................................................................................................ 6
Externe factoren: ........................................................................................................................................... 6
Persoonlijke factoren:.................................................................................................................................... 7
Coping stijl ..................................................................................................................................................... 7
Activiteiten en participatie ................................................................................................................................. 7
Meetinstrumenten ........................................................................................................................................ 8
EQ-5D ........................................................................................................................................................ 8
Nottingham health profile ........................................................................................................................ 8
Beperkingen in activiteitenpatroon en participatie ............................................................................................ 8
Kwaliteit van leven ............................................................................................................................................. 8
Sf-12 ............................................................................................................................................................... 8
Verpleegkundige diagnose ............................................................................................................................... 9
Verstoord slaappatroon ..................................................................................................................................... 9
Stoornis in gedachtegang ................................................................................................................................... 9
Gebrek in ziekte-inzicht ...................................................................................................................................... 9
Resultaten ........................................................................................................................................................ 10
Interventies .................................................................................................................................................... 10
Verstoord slaappatroon: .................................................................................................................................. 10
Stoornis in gedachtegang: ................................................................................................................................ 11
Gebrek in ziekte-inzicht: ................................................................................................................................... 11
Evaluatie ........................................................................................................................................................ 12
Verpleegkundig overdracht ......................................................................................................................... 13
Advies ............................................................................................................................................................... 14
Bronnenlijst.................................................................................................................................................... 15
Bijlagen .......................................................................................................................................................... 17
Bijlage 1: CMAI ................................................................................................................................................. 17
0
,Bijlage 2: Barthel-index .................................................................................................................................... 19
Bijlage 3: Katz-schaal ....................................................................................................................................... 20
Bijlage 4: EQ-5D-5L ........................................................................................................................................... 21
Bijlage 5: Nottingham health profile ................................................................................................................ 24
Bijlage 6: SF-12 ................................................................................................................................................. 26
Bijlage 7: Lange versie voedingsmiddelen advies ............................................................................................. 29
Bijlage 8: korte versie voedingsmiddelen advies .............................................................................................. 30
Bijlage 9: zelfzorgschema en dagschema ......................................................................................................... 31
Bijlage 10: feedbackformulier stagebegeleider ................................................................................................ 32
Bijlage 11: evaluatieformulier CanMEDS-rollen PL2............................................. Error! Bookmark not defined.
1
, Inleiding
Deze opdracht is geschreven door een verpleegkundige student die haar opleiding op de hogeschool
Utrecht volgt. In het tweede jaar van de opleiding moet er een stage gelopen worden van twintig
weken. Deze stage is gelopen op ...... ..... is het centrum voor ouderenpsychiatrie op het landgoed .....
in ...... Ouderen vanaf 60 jaar kunnen terecht voor behandeling van psychische klachten. De casussen
zijn gebaseerd op bestaande patiënten die zijn opgenomen in een gesloten afdeling op ...... De
afdeling waar deze patiënten zijn opgenomen is een opname afdeling waar patiënten kortdurend
verblijven.
Dit document bevat een uitwerking van de opdracht klinisch redeneren en onderzoekend vermogen
met betrekking tot praktijkleren 2. Dit is een opdracht die ontworpen is door een stappenplan te
volgen van de opleiding verpleegkunde op de hogeschool Utrecht. U vindt onderaan de opdracht een
feedbackformulier die is ingevuld door mijn stagebegeleider.
1
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