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Stageportfolio PL3 (Klinisch redeneren & Onderzoekend vermogen)
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In dit document is het klinisch redeneren uitgewerkt. De CAT is geschreven over het onderwerp PreOp drankjes, toegepast op de afdeling chirurgie.
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By: melikerahat • 1 year ago
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STAGEPORTFOLIOKlinisch redeneren en onderzoekend vermogen
Aantal woorden: Klinisch redeneren 4497 & onderzoekend vermogen 3369
,Inhoud
Stap 1: Probleemoriëntatie/klinisch beeld......................................................................................5
Introductie...................................................................................................................................5
Veranderende situatie (SBARR)...................................................................................................5
Situatie.....................................................................................................................................6
Background..............................................................................................................................6
Assessment..............................................................................................................................6
Hypothetische diagnoses.............................................................................................................8
Recommendation.....................................................................................................................9
Stap 2: Probleemanalyse...............................................................................................................10
Betrokken orgaansystemen.......................................................................................................10
Respiratoir systeem (A+B).....................................................................................................10
Cardiovasculair systeem (C)...................................................................................................10
Neurologisch systeem/ brein (D)...........................................................................................10
Afweersysteem (E).................................................................................................................10
Thermoregulatiesysteem (E)..................................................................................................10
Psychische, psychosociale, functionele en spirituele problematiek.........................................11
Psychische en psychosociale problemen...............................................................................11
Functionele problematiek......................................................................................................11
Spirituele problematiek.........................................................................................................11
Stap 3: Aanvullend onderzoek en diagnose...................................................................................12
Laboratoriumonderzoek............................................................................................................12
Controle van vitale functies.......................................................................................................12
Aanvullende anamnese..............................................................................................................13
Bladderscan................................................................................................................................13
Urine op kweek..........................................................................................................................13
Verpleegkundige diagnose (PES)...............................................................................................13
Stap 4: Klinisch beleid....................................................................................................................15
Medische interventies...............................................................................................................15
Verpleegkundige interventies en prioritering...........................................................................15
Stap 5: Klinisch verloop..................................................................................................................17
Ziekteverloop.............................................................................................................................17
Gevolgen op de korte termijn................................................................................................17
2
, Gevolgen op de lange termijn................................................................................................17
Gevolgen van de ziekte/aandoening op het somatische, psychosociale en spirituele
functioneren..............................................................................................................................17
Zelfmanagement........................................................................................................................18
Benodigde zorg..........................................................................................................................18
Stap 6: Evaluatie.............................................................................................................................19
Evaluatie met de zorgvrager......................................................................................................19
Reflectie op het zorgproces.......................................................................................................19
Reflectie op het gebruik van de EPD..........................................................................................20
Bijlage 1 Medicatieoverzicht..........................................................................................................20
Bijlage 2 feedbackformulier van de werkbegeleider.....................................................................21
Bronnenlijst....................................................................................................................................22
Onderzoekend vermogen..............................................................................................................25
Samenvatting.............................................................................................................................25
1. Probleemanalyse (Inleiding)......................................................................................................27
Oriënterende literatuurstudie...............................................................................................28
Probleemstelling....................................................................................................................28
Doelstelling............................................................................................................................28
De onderzoeksvraag..............................................................................................................28
Variabelen..............................................................................................................................29
Deelvragen.............................................................................................................................29
2. Onderzoeksmethode (Methode)...............................................................................................30
3. Dataverzameling (Uitvoering)................................................................................................32
Wijze van analyseren (voorbeeld).............................................................................................32
4. Data-analyse en Rapportage (Resultaten, Discussie, Conclusie en Advies)..............................34
Deelvraag 1: Zijn koolhydraatdranken effectiever dan preoperatief vasten?..........................34
Deelvraag 2: Heeft het gebruik van PreOp drankjes effect op de lichaamshydratie?..............35
Deelvraag 3: Heeft het gebruik van PreOp drankjes effect bij spinale anesthesie?..................35
Deelvraag 4: kan een patiënt daadwerkelijk sneller ontslagen worden als er gebruik wordt
gemaakt van PreOp drankjes?...................................................................................................36
Discussie.....................................................................................................................................36
Conclusie....................................................................................................................................36
Advies.........................................................................................................................................37
Bronnenlijst................................................................................................................................37
3
, Beoordelingslijst wetenschappelijke onderzoekspublicaties 1.....................................................38
Beoordelingslijst wetenschappelijke onderzoekspublicaties 2.....................................................41
Beoordelingslijst wetenschappelijke onderzoekspublicaties 3.....................................................44
Beoordelingslijst wetenschappelijke onderzoekspublicaties 4.....................................................47
Bijlage 5: twee feedbackformulieren van de CAT-presentatie......................................................51
Bijlage 6: feedbackformulier van de werkbegeleider....................................................................51
Bijlage 7: Evaluatie aan de hand van de CanMEDS-rollen.............................................................52
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