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PL2 Portfolio | Cijfer: 8
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Portfolio die bij PL2 hoort, St. Antonius afd urologie/gynaecologie. Beoordeeld met een 8.
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PORTFOLIO PRAKTIJKLEREN 2:KLINISCH REDENEREN EN
ONDERZOEKEND VERMOGEN
-
GVE-2.PL2-17
1766429
Stagedocent: Laura Verbeij
Eerste gelegenheid
Inleverdatum: 08-06-2020
,Inhoud
Inleiding.....................................................................................................................................................................4
Verslag CanMEDS rollen............................................................................................................................................5
Klinisch redeneren en onderzoekend vermogen......................................................................................................6
1. Casusbeschrijving..............................................................................................................................................6
1.1. Aanvullende gegevens................................................................................................................................6
2. Anamnese..........................................................................................................................................................7
2.1 Gezondheidspatroon van Gordon...............................................................................................................7
2.2 Screeningsinstrumenten.............................................................................................................................9
2.3 Prioritering van de problemen....................................................................................................................9
2.4 Zorgtraject.................................................................................................................................................10
3. Diagnostiek......................................................................................................................................................10
3.1 Anatomie en functies................................................................................................................................10
3.2 Externe- en persoonlijke factoren.............................................................................................................12
4. Activiteiten en participatie..............................................................................................................................13
4.1 Beperkingen in participatie & activiteitenpatroon...................................................................................13
4.2 Kwaliteit van leven & SF-12.......................................................................................................................14
4.3 Verpleegkundige diagnoses & resultaten.................................................................................................15
5. Interventies.....................................................................................................................................................16
5.1 Verpleegkundige interventies...................................................................................................................16
5.2 Zelfmanagement.......................................................................................................................................18
5.3 Mening zorgvrager....................................................................................................................................18
6. Evaluatie..........................................................................................................................................................18
6.1 Verleende zorg..........................................................................................................................................18
6.2 Advies dossier............................................................................................................................................18
6.3 Overdracht.................................................................................................................................................19
Literatuur.................................................................................................................................................................21
Bijlagen....................................................................................................................................................................23
1. Medicatiegebruik............................................................................................................................................23
2. Screeningsinstrumenten.................................................................................................................................23
1.1 MUST-score & BMI....................................................................................................................................23
1.2 VAS.............................................................................................................................................................24
1.3 BDI.............................................................................................................................................................25
1.4 SIP..............................................................................................................................................................28
3. Barthel index...................................................................................................................................................33
4. EQ-5D...............................................................................................................................................................34
,5. Eenzaamheidsschaal........................................................................................................................................36
6. SF-12................................................................................................................................................................36
7. Feedbackformulier..........................................................................................................................................39
, INLEIDING
Voor u ligt het verslag ‘Klinisch redeneren en onderzoekend vermogen’. Dit verslag is gerelateerd aan mijn
tweedejaars stage voor de opleiding Verpleegkunde. Vanaf 4 februari 2020 tot en met 25 maart 2020 heb ik
stage gelopen op de afdeling F2 van het St. Antonius ziekenhuis te Nieuwegein. Op de afdeling F2 liggen
urologische en gynaecologische patiënten. Helaas is mijn stage vroegtijdig gestaakt vanwege de uitbraak van
het coronavirus. De casus die ik voor dit verslag heb gekozen betreft een patiënt van urologie.
Voorafgaand aan het verslag is het eindverslag van de CanMEDS-rollen te vinden. Dit is het verslag dat gebruikt
is voor de tussenevaluatie. Dit wordt echter gezien als mijn eindevaluatie in verband met de vroegtijdige
staking van mijn stage.
In dit document wordt rekening gehouden met de privacy van alle betrokken personen. Namen, leeftijden en
andere persoonsgebonden gegevens worden niet geopenbaard.
Aantal woorden: 6336
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