Exam (elaborations)
PL3 Stageportfolio HBO Verpleegkunde Stage Jaar 3 (Behaald)
Institution
Hogeschool Utrecht (HU)
Stageportfolio jaar 3
Stage gelopen in het Diakonessenziekenhuis Utrecht op de afdeling chirurgie. Dit verslag bevat klinisch redeneren, onderzoekend vermogen (CAT) en CANMEDS-verslag.
Stage(opdrachten) in één keer gehaald.
GVE-3.PL3-16
Hogeschool Utrecht
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July 14, 2023
Number of pages
60
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2022/2023
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Exam (elaborations)
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pl3
praktijkleren 3
stage
jaar 3
klinisch redeneren
onderzoekend vermogen
portfolio
hbo verpleegkundige
hbo v
cat
hu
hogeschool utrecht
Institution
Hogeschool Utrecht (HU)
Education
Verpleegkunde
Course
Praktijleren 3 (GVE3.PL316)
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Stageportfolio en Reflectie & Ethiek Praktijkleren 3 HBO Verpleegkunde
Alle stage verslagen Praktijkleren 3 HBO Verpleegkunde
1. Summary - Stage actieplan praktijkleren 3 hbo v
2. Exam (elaborations) - Pl3 stageportfolio hbo verpleegkunde stage jaar 3 (behaald)
3. Exam (elaborations) - Pl3 reflectie & ethiek hbo verpleegkunde stage jaar 3 (8)
4. Other - Voorbereidingsopdracht praktijkleren 3 hbo-v
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Naam: Yuhan
Studentennummer: -
Mail: -.-@student.hu.nl
Studiegroep: -
Cursuscode: GVE-3.PL3-16
Docent: -
Aantal woorden: 14710
Klinisch Redeneren: 4458
Onderzoekend Vermogen: 3835
Inleverdatum: 19-06-23
0
,Inhoudsopgave
Klinisch redeneren........................................................................................................................................3
1 Klinisch beeld............................................................................................................................................3
Casusbeschrijving.....................................................................................................................................3
De veranderde situatie............................................................................................................................4
Situation..............................................................................................................................................4
Background..........................................................................................................................................4
Assessment..........................................................................................................................................6
Recommendation................................................................................................................................6
Hypothetische diagnose..........................................................................................................................7
Perifeer arterieel vaatlijden Fontaine stadium 4.................................................................................7
Diabetische voet..................................................................................................................................7
Stap 2 Probleemanalyse..............................................................................................................................8
Orgaansystemen......................................................................................................................................8
Cardiovasculair systeem......................................................................................................................8
Neurologische systeem zintuiglijk........................................................................................................8
Endocrien.............................................................................................................................................9
Afweersysteem....................................................................................................................................9
Problematiek.........................................................................................................................................10
Meet- en screeninginstrumenten..........................................................................................................10
3 Aanvullend onderzoek en diagnose........................................................................................................11
Lichamelijk onderzoek.......................................................................................................................11
Lab onderzoek...................................................................................................................................11
Verpleegkundig onderzoek................................................................................................................11
Diagnoses...............................................................................................................................................11
Diagnose 1 Huiddefect.......................................................................................................................11
Diagnose 2 Fantoom pijn...................................................................................................................11
Diagnose 3 Mobiliteitstekort.............................................................................................................12
Diagnose 4 Bereidheid tot verbetering van het geestelijk welzijn.....................................................12
Stap 4 Klinisch beleid.................................................................................................................................12
Diagnose 1 Huiddefect...........................................................................................................................12
Diagnose 2 Fantoom pijn.......................................................................................................................12
Diagnose 3 Mobiliteitstekort.................................................................................................................13
1
, Diagnose 4 Bereidheid tot verbetering van het geestelijk welzijn.........................................................13
Shared decision making.........................................................................................................................13
5 Klinisch verloop.......................................................................................................................................14
Verloop aandoening..............................................................................................................................14
Zelfmanagement....................................................................................................................................15
Benodigde zorg......................................................................................................................................15
6 Evaluatie.................................................................................................................................................15
Evaluatie doelen en zorgproces.............................................................................................................15
Elektronisch patiëntendossier...............................................................................................................16
Literatuurlijst.............................................................................................................................................17
Bijlage 1 Medicatielijst van patiënt............................................................................................................21
Bijlage 2 ingevulde screeningsinstrumenten.............................................................................................22
DOS........................................................................................................................................................22
SNAQ.....................................................................................................................................................23
Prepurse................................................................................................................................................23
Bijlage 3 Feedbackformulier stage-opdracht Klinisch Redeneren..............................................................24
Onderzoekend vermogen..........................................................................................................................25
Samenvatting.............................................................................................................................................25
1. Probleemanalyse...................................................................................................................................27
Inleiding.................................................................................................................................................27
Literatuur onderzoek.............................................................................................................................27
De voor-en nadelen van het inzetten van deze interventie...............................................................27
Doelstelling............................................................................................................................................27
PICO.......................................................................................................................................................28
Essentiële variabelen.............................................................................................................................28
2. Onderzoeksmethodes............................................................................................................................29
Zoeksleutel............................................................................................................................................29
In- en exclusiecriteria.............................................................................................................................29
Zoekstrategie.........................................................................................................................................30
3. Dataverzameling....................................................................................................................................31
4. Data-analyse en rapportage..................................................................................................................32
Resultaten..............................................................................................................................................32
Discussie................................................................................................................................................34
Resultaten in relatie tot probleemstelling.........................................................................................34
2
, Sterke aspecten.................................................................................................................................34
Zwakke aspecten...............................................................................................................................35
Implicaties in de praktijk....................................................................................................................35
Conclusie...............................................................................................................................................35
Advies....................................................................................................................................................36
Literatuurlijst.............................................................................................................................................37
Bijlage 1 Beoordelingslijst artikel 1............................................................................................................39
Bijlage 2 Beoordelingslijst artikel 2............................................................................................................42
Bijlage 3 Beoordelingslijst artikel 3............................................................................................................45
Bijlage 4 Beoordelingslijst artikel 4............................................................................................................48
Bijlage 5 Feedbackformulier Onderzoekend Vermogen..............................................................................3
Bijlage 6 Feedbackformulier Onderzoekend Vermogen 2...........................................................................4
Klinisch redeneren
1 Klinisch beeld
Casusbeschrijving
De zorgvrager is geïntroduceerd met behulp van het ICF model. Het ICF model wordt gebruikt
om het menselijk functioneren te beschrijven vanuit drie verschillende perspectieven: het
menselijk organisme, het menselijk handelen en als participant in de maatschappij (ICF Nictiz,
2022).
Persoonlijke- en externe factoren
3