Exam (elaborations)

Stage portfolio leerjaar 3 (beoordeling 8,2)

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Course
Praktijkleren 3 Stageportfolio

Institution
Hogeschool Utrecht (HU)

Stageportfolio leerjaar 3. In dit document staat klinisch redeneren en onderzoekend vermogen (CAT). Ik heb mijn stage volbracht in het Antonius ziekenhuis.

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Uploaded on September 20, 2021
Number of pages 96
Written in 2020/2021
Type Exam (elaborations)
Contains Questions & answers

praktijkleren
praktijkleren 3
stage
pl3
klinisch redeneren
onderzoekend vermogen
cat
hbo
verpleegkunde
hu

Institution
Hogeschool Utrecht (HU)
Education
Verpleegkunde
Course
Praktijkleren 3 Stageportfolio

annevisser01

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Stageportfolio
Klinisch redeneren
Critical Appraisal of a Topic

Anne …..

docent: …………………
HBO-Verpleegkunde Hogeschool Utrecht
code: GVE-3PL3-16

1

,Inhoudsopgave Stageportfolio
CanMEDS rollen.......................................................................................................................5
Opdracht klinisch redeneren....................................................................................................9
Voorwoord..............................................................................................................................9
Stap 1 probleem oriëntatie, klinisch beeld.............................................................................13
Geanonimiseerde introductie...........................................................................................................13
Medische voorgeschiedenis...............................................................................................................15
Anamnese.........................................................................................................................................16
Relevante observaties, metingen screeningsinstrumenten...............................................................16
Differentiaal diagnoses.....................................................................................................................19
Ernst van de situatie.........................................................................................................................20
Stap 2 Probleemanalyse.........................................................................................................21
Betrokken orgaansystemen..............................................................................................................21
Verpleegkundige problemen en prioritering.....................................................................................22
Psychische stoornissen.....................................................................................................................22
Functionele problematiek.................................................................................................................22
Sociale problematiek........................................................................................................................22
Spirituele problematiek....................................................................................................................22
Stap 3 aanvullend onderzoek en diagnosen...........................................................................22
Aanvullende informatie om de werkhypothese te bevestigen of te verwerpen................................23
Overig onderzoek.............................................................................................................................23
Vastgestelde differentiaaldiagnoses.................................................................................................23
Stap 4 klinisch beleid.............................................................................................................24
Diagnoses, doelstellingen en interventies.........................................................................................25
Medische behandelingen..................................................................................................................26
Stap 5: klinisch verloop..........................................................................................................27
Te verwachten klinisch verloop........................................................................................................27
Korte termijn.....................................................................................................................................27
Lange termijn.....................................................................................................................................27
Somatisch problematiek...................................................................................................................27
Psychisch problematiek....................................................................................................................27
Functionele problematiek.................................................................................................................27
Spirituele problematiek....................................................................................................................28
Interventies zelfmanagement...........................................................................................................28
Mantelzorg en professionele zorg.....................................................................................................28
Stap 6 evaluatie.....................................................................................................................28
Aspecten geleverde zorg...................................................................................................................29
Behandeling.......................................................................................................................................29
Interventies........................................................................................................................................29
Kwaliteit van zorg..............................................................................................................................29

2

, Patiëntveiligheid................................................................................................................................29
Ontslag.............................................................................................................................................29
Elektronisch patiëntendossier..........................................................................................................29
Nawoord...............................................................................................................................30
Bibliografie klinisch redeneren...............................................................................................30
Feedbackformulier werkbegeleiders......................................................................................33
Bijlagen klinisch redeneren....................................................................................................33
Bijlage 1: anamnese aan de hand van de elf gezondheidspatronen van Gordon...............................34
Bijlage 2 medicijn gebruik.................................................................................................................37
medicijn gebruik voor opname..........................................................................................................37
Bijlage 3 anamnese formulier G-3.....................................................................................................38
Bijlage 4 uitslag CAG.........................................................................................................................40
Bijlage 5 stappenmodel na CABG......................................................................................................42
Bijlage 6 screeningsinstrumenten.....................................................................................................48
6a. Malnutrion Universal screening Tool (MUST) (Elia,2003)............................................................48
6b. Delerium Observatie screening schaal (DOS) (Schuurmans,2001)...............................................49
6c. Caregiver Strain Index (CSI)..........................................................................................................49
6d. EWS..............................................................................................................................................50
6e. Visual anlog scale (VAS)...............................................................................................................51
Bijlage 7 externe overdracht thuiszorg..............................................................................................52
Opdracht onderzoekend vermogen........................................................................................57
Voorwoord............................................................................................................................57
Samenvatting.........................................................................................................................61
Inleiding................................................................................................................................64
Doelstelling.......................................................................................................................................65
Pico systeem.....................................................................................................................................65
Onderzoeksvraag..............................................................................................................................65
Deelvragen.......................................................................................................................................66
Methode zoekplan.................................................................................................................66
Keuze voor databanken....................................................................................................................66
In- en exclusiecriteria........................................................................................................................66
Correcte zoektermen........................................................................................................................66
Resultaten van de zoekactie.............................................................................................................67
Verantwoording van de gekozen artikelen.......................................................................................68
Resultaten.............................................................................................................................70
Overzicht van de resultaten..............................................................................................................70
Discussie................................................................................................................................72
Sterke en zwakke aspecten...............................................................................................................72
Implicaties voor de praktijk..............................................................................................................72

3

, Conclusie...............................................................................................................................73
Advies....................................................................................................................................73
Het concluderende advies................................................................................................................74
Nawoord...............................................................................................................................75
Bibliografie............................................................................................................................76
Bijlage 1: beoordelingsformulieren wetenschappelijke artikelen...........................................77
Bijlage 2 resultaten wetenschappelijke artikelen.....................................................................2
Bijlage 3 feedbackformulieren.................................................................................................4

4

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