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Portfolio Klinisch redeneren & CAT Pratkijkleren 3 in WKZ $8.05
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Portfolio Klinisch redeneren & CAT Pratkijkleren 3 in WKZ

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Voor mijn derde jaar van verpleegkunde, heb ik een CAT geschreven en klinisch redeneren verslag gemaakt. Dit heb ik gedaan tijdens mijn stage in het Wilhelmina KinderZiekenhuis.

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  • September 2, 2022
  • 64
  • 2021/2022
  • Other
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Stageportfolio
PRAKTIJKLEREN 3




Naam:
Stageplek: Wilhelmina KinderZiekenhuis, Afdeling Papagaai
Mentor:
Stagedocent:
Inleverdatum: 24 januari 2022
Versie: 1.0

,Inhoudsopgave
Inleiding.............................................................................................................................................................. 4

Klinisch redeneren.............................................................................................................................................. 5

Stap 1. Probleem oriëntatie................................................................................................................................. 5
1.1. Casusbeschrijving................................................................................................................................................5
1.2. De veranderde situatie........................................................................................................................................5
1.3. SBAR-methode....................................................................................................................................................6
1.4. Differentiële diagnoses.......................................................................................................................................8

Stap 2. Probleemanalyse..................................................................................................................................... 9
2.2. Problematiek.....................................................................................................................................................10
2.3. Analyse gebruikte screening instrumenten......................................................................................................11

Stap 3. Aanvullend onderzoek en diagnosen...................................................................................................... 12
3.1. Aanvullend onderzoek.......................................................................................................................................12
3.2. Verpleegproblemen...........................................................................................................................................13

Stap 4. Klinisch beleid........................................................................................................................................ 14

Stap 5. Klinisch verloop..................................................................................................................................... 20
5.1. Kort termijn.......................................................................................................................................................20
5.2. Lang termijn......................................................................................................................................................20
5.3. Interventies stimuleren zelfmanagement.........................................................................................................21
5.4. Mantelzorg........................................................................................................................................................21

Stap 6. Evaluatie................................................................................................................................................ 22
6.1. Evaluatie gestelde doelen.................................................................................................................................22
6.2. Reflectie zorgproces..........................................................................................................................................23
6.3. Reflectie elektronisch patiëntendossier (EPD)..................................................................................................23

Bibliografie....................................................................................................................................................... 24

Bijlagen............................................................................................................................................................. 26
Bijlage I. Oesophagusatresie type C.........................................................................................................................26
Bijlage II. Anamnese Wilhelmina kinderziekenhuis.................................................................................................28
Bijlage III. Medicatie................................................................................................................................................30
Bijlage IV. Resultaat screeningsinstrumenten.........................................................................................................31
Bijlage V. Feedbackformulier...................................................................................................................................33

Onderzoekend vermogen: Critical appraisal of a Topic.......................................................................................34

2

,Data verzameling.............................................................................................................................................. 40

Data-analyse..................................................................................................................................................... 41

Conclusie.......................................................................................................................................................... 47

Advies............................................................................................................................................................... 48

Bibliografie....................................................................................................................................................... 49

Hoofdstuk 6. Bijlagen........................................................................................................................................ 50
Bijlage I. Zoekstrategie.............................................................................................................................................50
Bijlage II. Beoordelingsformulier artikel 1...............................................................................................................51
Bijlage III. Beoordelingsformulier artikel 2..............................................................................................................55
Bijlage IV. Beoordelingsformulier artikel 3..............................................................................................................58
Bijlage V. Beoordelingsformulier artikel 4...............................................................................................................61
Bijlage VI. Feedbackformulieren presentatie...........................................................................................................64




3

, Inleiding
Voor u ligt het portfolio: klinisch redeneren en onderzoekend vermogen. Dit portfolio is geschreven in
het kader van praktijkleren 3 voor de opleiding HBO-V aan de Hogeschool Utrecht.

In de periode van 6 september 2021 tot 4 februari 2022, liep ik stage op de afdeling Papagaai in het
Wilhelmina KinderZiekenhuis (WKZ) in Utrecht. Mijn verwachting was dat ik tijdens de stage veel kon
leren en groeien op zowel beroeps- als persoonlijk gebied.

Belangrijk is om bij stil te staan bij de vraag: ‘’Wat is nu dat klinisch redeneren, ofwel datgeen wat we als
verpleegkundigen de hele dag doen’’? Op die vraag geef ik antwoord in dit verslag, door u als lezer mee
te nemen in alle stappen die daarbij aan bod komen.

Als verpleegkundige is één van de taken, het indiceren en verlenen van zorg. Hierbij is het klinisch
redeneren iets wat dagelijks wordt toegepast. Daarbij is het ook belangrijk dat je als verpleegkundige
een onderzoekende rol hebt. In deel twee van dit portfolio zal dit nader worden toegelicht.

Wegens privacy redenen is de naam van de zorgvrager gefingeerd.

Ik wens u veel leesplezier!




4

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