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Praktijkleren 3 - Klinisch redeneren en Onderzoekend vermogen (eindcijfer 8,2!)

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Dit verslag heb ik geschreven tijdens mijn stage PL3 in het UMC Utrecht (HBO Verpleegkunde, studiejaar 2022/2023, leerjaar 3). Het is een Critical Appraisal of a Topic (CAT) verslag dat gaat over het toedienen van warmte vóór een venapunctie. Met Klinisch Redeneren over een patiënt met sepsis. D...

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  • June 10, 2023
  • 52
  • 2022/2023
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STAGEPORTFOLIO
Klinisch Redeneren, Onderzoekend Vermogen en
Evaluatieformulier CanMEDS-rollen




Naam:
Studentnummer:
Mailadres:
Studiegroepscode: GVE-3.PL3-16
Naam cursus: Praktijkleren 3
Docent:
Aantal woorden Klinisch Redeneren: 5950 woorden
Aantal woorden Onderzoekend Vermogen: 3052 woorden
Aantal woorden Samenvatting: 288 woorden
Inleverdatum:

,Inhoudsopgave
Onderdeel A: Klinisch redeneren ........................................................................................................... 3
1. Probleemoriëntatie/klinisch beeld .................................................................................................. 4
1.1 SBAR .......................................................................................................................................... 4
1.2 Urgentie ..................................................................................................................................... 5
1.3 Hypothetische diagnose ............................................................................................................ 5
1.4 Differentiaaldiagnoses ............................................................................................................... 6
2. Probleemanalyse ............................................................................................................................. 6
2.1 Disfunctionele orgaansystemen ................................................................................................ 6
2.2 Psychische, (psycho)sociale, functionele en spirituele problemen........................................... 7
3. Aanvullend onderzoek en diagnose ................................................................................................ 8
3.1 Aanvullend onderzoek ............................................................................................................... 8
4. Verpleegkundige diagnoses............................................................................................................. 9
4.1 Verpleegkundige diagnoses bij de acute situatie ...................................................................... 9
4.2 Verpleegkundige diagnoses bij de algehele situatie ................................................................. 9
5. Klinisch beleid ................................................................................................................................ 12
5.1 Verpleegkundige interventies bij de acute situatie................................................................. 12
5.2 Verpleegkundige interventies bij de algehele situatie ............................................................ 13
6. Klinisch verloop ............................................................................................................................. 17
6.1 Prognose, complicaties en risico’s........................................................................................... 17
6.2 Somatisch, psychisch, (psycho)sociaal, functioneel en spiritueel verloop.............................. 17
6.3 Zelfmanagement ..................................................................................................................... 18
6.4 Inventarisatie van de benodigde zorg ..................................................................................... 18
7. Evaluatie ........................................................................................................................................ 19
7.1 Doelen bij de acute situatie ..................................................................................................... 19
7.2 Angstreductie .......................................................................................................................... 19
7.3 Voorkomen van decubitus, voorkomen van trombose en de patiënt zich zelfstandig te laten
verplaatsen .................................................................................................................................... 19
7.4 Dagelijks voldoende voedingsstoffen ...................................................................................... 19
7.5 Een evenwicht tussen rust en activiteiten bereiken ............................................................... 20
7.6 Reflectie zorgproces ................................................................................................................ 20
7.7 Reflectie elektronisch patiëntendossier .................................................................................. 20
Bronvermelding ................................................................................................................................. 21
Bijlage 1: AMPLE ................................................................................................................................ 25
Bijlage 2: Anamnese en must ............................................................................................................ 26
Bijlage 3: EWS UMC Utrecht .............................................................................................................. 29

1

, Bijlage 4: Uitslagen labonderzoek ..................................................................................................... 30
Bijlage 5: Feedback mentoren ........................................................................................................... 31
Onderdeel B: Onderzoekend vermogen .............................................................................................. 32
Samenvatting..................................................................................................................................... 33
1. Probleemanalyse ........................................................................................................................... 35
1.1 Doelstelling .............................................................................................................................. 35
1.2 Vraagstelling ............................................................................................................................ 36
1.3 PICO ......................................................................................................................................... 36
2. Onderzoeksmethode ..................................................................................................................... 37
3. Data-analyse .................................................................................................................................. 40
3.1 Resultaten................................................................................................................................ 40
4. Discussie ........................................................................................................................................ 42
4.1 De sterke en zwakke aspecten van dit onderzoek .................................................................. 42
5. Conclusie ....................................................................................................................................... 43
6. Advies ............................................................................................................................................ 43
Bronvermelding ................................................................................................................................. 44
Bijlage 1: Feedback mentoren op de presentatie ............................................................................. 47
Onderdeel C: Evaluatieformulier CanMEDS-rollen.............................................................................. 48
1. Evaluatieformulier UMC Utrecht ................................................................................................... 49
Bijlage 1: Ondertekening beoordelingsformulier .............................................................................. 51




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, Onderdeel A: Klinisch
redeneren




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