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Klinisch redeneren PL3 (GVE-3.PL3-16)
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GVE-3.PL3-16 Stageportfolio PL3 onderdeel klinisch redeneren behaald met een 7,0 aan Hogeschool Utrecht in 2023.
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STAGEPORTFOLIOPraktijkleren 3
Naam docent
Groepsnummer
inleverdatum
Naam student
studentnummer
studentmail
,Inhoudsopgave
Onderdeel 1 Evaluatieformulier CanMEDS-rollen..................................................................................3
Onderdeel 2 Klinisch redeneren.............................................................................................................4
Hoofdstuk 1 Klinisch beeld.....................................................................................................................6
1.1 Situation.......................................................................................................................................6
1.2 Background...................................................................................................................................6
Anamnese.......................................................................................................................................7
1.3 Assessment...................................................................................................................................7
Early Warning Signs-score (EWS)....................................................................................................7
Sedatiescore...................................................................................................................................8
Numeric Pain Rating Scale (NPRS)..................................................................................................8
Rotterdam Elderly Pain Observation Scale (REPOS)........................................................................8
Bristol Stoelgangsschaal (BSS)........................................................................................................9
Glasgow Coma Scale (GCS).............................................................................................................9
Laboratoriumonderzoek.................................................................................................................9
Urgentie..........................................................................................................................................9
1.4 Recommendation.......................................................................................................................10
Hoofdstuk 2 Probleemanalyse..............................................................................................................13
2.1 Orgaansystemen.........................................................................................................................13
Respiratoir systeem......................................................................................................................13
Cardiovasculair systeem...............................................................................................................13
Neurologisch systeem / brein.......................................................................................................13
Thermoregulatie systeem.............................................................................................................13
2.2 Problematiek..............................................................................................................................13
Psychosociale problematiek.........................................................................................................13
Functionele problematiek.............................................................................................................13
Hoofdstuk 3 Aanvullend onderzoek en diagnose.................................................................................15
Hoofdstuk 4 Klinisch beleid..................................................................................................................16
4.1 Verpleegkundige diagnoses, doelen en interventies..................................................................16
4.2 Shared decision making..............................................................................................................17
Hoofdstuk 5 Klinisch verloop................................................................................................................18
5.1 Ziekteverloop..............................................................................................................................18
5.2 Zelfmanagement.........................................................................................................................19
5.3 Inventarisatie zorg......................................................................................................................19
1
,Hoofdstuk 6 Evaluatie...........................................................................................................................20
6.1 Doelen........................................................................................................................................20
6.2 Reflectie......................................................................................................................................20
Bibliografie...........................................................................................................................................21
Bijlagen.................................................................................................................................................25
Bijlage 1 SBAR-methode...................................................................................................................25
Bijlage 2 AMPLE methode.................................................................................................................26
Bijlage 3 Medicatielijst......................................................................................................................27
Bijlage 4 Voorgeschiedenis...............................................................................................................28
Bijlage 5 Early Warning Signs-score..................................................................................................29
Bijlage 6 Sedatiescore.......................................................................................................................30
Bijlage 7 Numeric Pain Rating Scale..................................................................................................31
Bijlage 8 Rotterdam Elderly Pain Observation Scale.........................................................................32
Bijlage 9 Bristol Stoelgangschaal.......................................................................................................33
Bijlage 10 Glasgow Coma Scale.........................................................................................................34
Bijlage 11 Laboratoriumonderzoek...................................................................................................35
Bijlage 12 ABCDE-methodiek............................................................................................................36
Bijlage 13 Anamnese volgens UMC Utrecht.....................................................................................37
Bijlage 14 Screening ondervoeding bij patiënten van 18 jaar en ouder (kliniek)..............................41
Bijlage 15 Valrisicoscreening bij patiënten van 18 jaar en ouder (kliniek)........................................42
Bijlage 16 Feedbackformulier mentoren..........................................................................................43
Onderdeel 3 Onderzoekend vermogen................................................................................................44
2
, Onderdeel 1 Evaluatieformulier CanMEDS-rollen
Toevoegen evaluatieformuliler CanMEDS
3
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