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Module: Beargumenteren van zorg (Behaald met een 7,5)

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Course
Module: Beargumenteren van zorg (HVVB18MBVZ)

Institution
Hanzehogeschool Groningen (Hanze)

Het document betreft de module: Beargumenteren van zorg. Gedurende mijn PLP3 heb ik genoemde module uitgevoerd tijdens een stage in het Ommelander Ziekenhuis. In de module worden de stappen van Marc Bakker gehanteerd. De module is begin 2024 beoordeeld en voldoet aan de recentste leeruitkomsten. In...

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Uploaded on January 9, 2024
Number of pages 75
Written in 2023/2024
Type Other
Person Unknown

klinische problematiek
aanvullend onderzoek
klinisch beleid
klinisch verloop
nabeschouwing
casusbespreking
sbar
ample
cijfer 7 8
oriëntatie op de situatie

Institution
Hanzehogeschool Groningen (Hanze)
Education
Academie Voor Verpleegkunde
Course
Module: Beargumenteren van zorg (HVVB18MBVZ)

DYCT

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MODULE: BEARGUMENTEREN
VAN ZORG

Naam:
Studentnummer:
Cursuscode:
Praktijkleerplaats: Ommelander Ziekenhuis Groningen, locatie Scheemda
Stageperiode: PLP3 (4 september 2023/2 februari 2024)
Docentbegeleider:
Tweede beoordelaar:
Praktijkopleiders:

,Inhoudsopgave

Leeruitkomsten............................................................................................................................................... 5

Inleiding.......................................................................................................................................................... 6

Hoofdstuk 1 | Stap 1: Oriëntatie op de situatie ............................................................................................... 7
1.1 SBAR ............................................................................................................................................................. 7
1.1.1 Situation................................................................................................................................................ 7
1.1.2 Background ........................................................................................................................................... 7
1.1.3 Assessment ........................................................................................................................................... 9
1.1.4 Recommendation ............................................................................................................................... 11
1.2 Verpleegkundige anamnese ....................................................................................................................... 12
1.2.1 Heteroanamnese ................................................................................................................................ 12
1.2.2 Gezondheidspatronen van Gordon .................................................................................................... 12
1.3 Opnamecontroles ....................................................................................................................................... 14
1.3.1 Opnamecontroles bij verpleegkundige anamnese ............................................................................. 14
1.3.2 BRMO-screening ................................................................................................................................. 16
1.4 Ecogram...................................................................................................................................................... 17

Hoofdstuk 2 | Stap 2: Klinische problematiek ............................................................................................... 18
2.1 Prioritering van zorgthema’s ...................................................................................................................... 18
2.2 Zorgthema’s................................................................................................................................................ 18
2.2.1 Luchtwegen en ademhaling ................................................................................................................ 18
2.2.2 Circulatie ............................................................................................................................................. 20
2.2.3 Zuurstofvoorziening van het hart ....................................................................................................... 21
2.2.4 Urogenitale functies ........................................................................................................................... 21
2.2.5 Bloed ................................................................................................................................................... 23
2.2.6 Functioneren en zelfredzaamheid ...................................................................................................... 24

Hoofdstuk 3 | Stap 3: Aanvullend onderzoek ................................................................................................ 25
3.1 Lichamelijk onderzoek ................................................................................................................................ 25
3.2 Beeldvormend onderzoek ........................................................................................................................... 25
3.3 Bloedonderzoek .......................................................................................................................................... 25

Hoofdstuk 4 | Stap 4: Klinisch beleid ............................................................................................................. 26
4.1 Clusteren van gegevens en het stellen van verpleegkundige diagnoses..................................................... 26
4.2 Prioriteren van diagnosen .......................................................................................................................... 28
4.2.1 Redeneerweb...................................................................................................................................... 28
4.2.2 Onderbouwing keuze prioritering ...................................................................................................... 29
4.3 Verpleegkundige zorgresultaten................................................................................................................. 30
4.3.1 Ineffectief adempatroon..................................................................................................................... 30
4.3.2 Activiteitsvermogen, verminderd ....................................................................................................... 31
4.3.3 Voedingstekort ................................................................................................................................... 32
4.3.4 Verstoorde verbale communicatie ..................................................................................................... 33
4.3.5 Zelfstandigheidstekort in wassen en kleden....................................................................................... 33
4.4 Verpleegkundige interventies ..................................................................................................................... 34
4.4.1 Ineffectief adempatroon..................................................................................................................... 34
4.4.2 Activiteitsvermogen, verminderd ....................................................................................................... 35
4.4.3 Voedingstekort ................................................................................................................................... 36

2

, 4.4.4 Verstoorde verbale communicatie ..................................................................................................... 37
4.4.5 Zelfstandigheidstekort in wassen en kleden....................................................................................... 38
4.5 Betrokken disciplines .................................................................................................................................. 38
4.5.1 Palliatiefadvies team (PAT) ................................................................................................................. 38
4.5.2 Diëtist.................................................................................................................................................. 39
4.5.3 Fysiotherapeut .................................................................................................................................... 39
4.5.4 Voedingsassistent ............................................................................................................................... 39

Hoofdstuk 5 | Culturele aspecten en communicatie ...................................................................................... 40
5.1 Culturele aspecten ...................................................................................................................................... 40
5.1.1 Taalbarrière ........................................................................................................................................ 40
5.1.2 Non-verbale communicatie ................................................................................................................ 40
5.1.3 Waarden en normen........................................................................................................................... 40
5.1.4 Religie ................................................................................................................................................. 40
5.2 Communicatieve vaardigheden .................................................................................................................. 40
5.2.1 ORBS-vaardigheden ............................................................................................................................ 40
5.2.2 Open- en gesloten vragen................................................................................................................... 41
5.2.3 Ezelbruggetjes in communicatie ......................................................................................................... 41
5.2.4 Non-verbale vaardigheden ................................................................................................................. 41
5.3 ICT- en communicatiemogelijkheden.......................................................................................................... 42
5.3.1 Elektronisch Verpleegkundig Dossier (EVD)........................................................................................ 42
5.3.2 Kwaliteitsportaal Zenya ...................................................................................................................... 42
5.3.3 Mijn Ommelander............................................................................................................................... 42
5.3.4 Google Vertalen .................................................................................................................................. 43
5.3.5 Pictogrammenboek............................................................................................................................. 43
5.3.6 Tolk ..................................................................................................................................................... 43
5.3.7 Verpleegoproepsysteem..................................................................................................................... 44

Hoofdstuk 6 | Stap 5: Klinisch verloop .......................................................................................................... 45
6.1 Gewenste situatie ....................................................................................................................................... 45
6.2 Ongewenste situatie ................................................................................................................................... 45

Hoofdstuk 7 | Evalueren van het verpleegkundig proces ............................................................................... 47
7.1 Evalueren van het verpleegkundig proces in de praktijk ............................................................................ 47
7.1.1 Rapporteren........................................................................................................................................ 47
7.1.2 Artsenvisite ......................................................................................................................................... 47
7.1.3 Multidisciplinair overleg (MDO).......................................................................................................... 48
7.2 Proces- en productevaluatie ....................................................................................................................... 48
7.2.1 Ineffectief adempatroon..................................................................................................................... 48
7.2.2 Activiteitsvermogen, verminderd ....................................................................................................... 49
7.2.3 Voedingstekort ................................................................................................................................... 49
7.2.4 Verstoorde verbale communicatie ..................................................................................................... 50
7.2.5 Zelfstandigheidstekort in wassen en kleden....................................................................................... 51

Hoofdstuk 8 | Stap 6: Nabeschouwing .......................................................................................................... 53
8.1 Patiëntveiligheid ......................................................................................................................................... 53
8.2 Kwaliteit van de beroepsuitoefening .......................................................................................................... 54
8.2.1 Methodisch-technisch handelen ........................................................................................................ 54
8.2.2 Attitude ............................................................................................................................................... 54
8.2.3 Organiseren van zorg .......................................................................................................................... 55
8.3 Ethisch dilemma ......................................................................................................................................... 55
8.3.1 Familiegesprek .................................................................................................................................... 55

3

, 8.3.2 Evaluatie ............................................................................................................................................. 56
8.4 Wat heb ik geleerd? .................................................................................................................................... 57

Hoofdstuk 9 | Casusbespreking ..................................................................................................................... 58
9.1 SBAR ........................................................................................................................................................... 58
9.1.1 Situation.............................................................................................................................................. 58
9.1.2 Background ......................................................................................................................................... 58
9.1.3 Assessment ......................................................................................................................................... 58
9.1.4 Recommendation ............................................................................................................................... 58
9.2 Klinisch redeneren en verpleegkundig proces ............................................................................................. 59
9.3 Hoe is rekening gehouden met de wensen van de patiënt? ....................................................................... 59
9.4 Wat heb ik geleerd? .................................................................................................................................... 60
9.5 Verkregen feedback .................................................................................................................................... 60

Literatuurlijst ................................................................................................................................................ 61

Bijlage A | Methodische reflecties ................................................................................................................ 66

Bijlage B | Waarderingsformulieren .............................................................................................................. 67

Bijlage C | Verslag hoe gehandeld in de praktijk? .......................................................................................... 68

Bijlage D | Medicatieoverzicht ...................................................................................................................... 70

Bijlage E | Early Warning Score ..................................................................................................................... 71

Bijlage F | Uitkomsten algeheel bloedonderzoek .......................................................................................... 72

Bijlage G | Verpleegkundige anamnese ......................................................................................................... 73

Bijlage H | Antiplagiaatverklaring ................................................................................................................. 75

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