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Module Beargumenteren van zorg

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De uitwerking van de module Beargumenteren van zorg. Ik heb deze module geschreven in PLP3 op de afdeling maag-darm chirurgie in het Martini Ziekenhuis. Ik heb hiervoor een 8.2 gekregen.

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  • February 16, 2024
  • 79
  • 2023/2024
  • Other
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BEARGUMENTEREN VAN
ZORG
Martini Ziekenhuis Verpleegafdeling 4C GE-Chirurgie




0

,Voorwoord
Dit verslag is geschreven door een student van de Hanzehogeschool te Groningen die de
opleiding HBO-Verpleegkunde volgt. Het onderwerp van dit verslag betreft de module
“beargumenteren van zorg”, welke deel uitmaakt van de derde praktijkleerperiode PLP3.

De module is uitgevoerd op verpleegafdeling 4C, maag-darmchirurgie, in het Martini
Ziekenhuis, verpleegafdeling maag-darmchirurgie. Op deze afdeling worden patiënten
behandeld die een chirurgische ingreep (hebben) ondergaan voor aandoeningen aan de
maag, darmen, lever, schildklier, galwegen of borst.

Gedurende het samenstellen van deze module ben ik begeleid door … en stagebegeleiders
… . Ik wil hen graag bedanken voor hun toegewijde begeleiding gedurende mijn stage.

Ik wens u veel leesplezier toe.

Met vriendelijke groet,


Groningen 30-11-2023




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,Inhoudsopgave
Voorwoord .............................................................................................................................................. 1

Inleiding .................................................................................................................................................. 4
De zes stappen van het klinisch redeneren ........................................................................................ 5

Hoofdstuk 1. Casuïstiek ........................................................................................................................ 6
1.1 De casus ................................................................................................................................ 6
1.2 Complexiteit van de casus ..................................................................................................... 7
1.3 Informatieverzameling ............................................................................................................ 7

Hoofdstuk 2. Oriëntatie op de situatie ................................................................................................. 8
2.1 Situation ........................................................................................................................................ 8
2.2 Background ................................................................................................................................... 9
2.3 Assessment ................................................................................................................................. 10
MEWS ........................................................................................................................................... 10
Urgentie van de situatie ................................................................................................................ 13
Disfunctionele aspecten in de observatie ..................................................................................... 13
Differentiaaldiagnosen .................................................................................................................. 13
Interpretatie verkregen gegevens ................................................................................................. 14
2.4 Recommendation ........................................................................................................................ 14

Hoofdstuk 3. Klinische problematiek ................................................................................................ 16
3.1 SCEGS ........................................................................................................................................ 16
3.2 Zorgthema’s ................................................................................................................................ 17
3.2.1 Prioritering zorgthema’s ....................................................................................................... 18
3.2.2 Aandachtspunten disfunctionele zorgthema’s ..................................................................... 20

Hoofdstuk 4. Aanvullend onderzoek ................................................................................................. 28
4.1 Dagelijkse aandachtspunten ....................................................................................................... 28
4.2 Screeningslijsten ......................................................................................................................... 31
4.3 Klinisch aanvullend onderzoek.................................................................................................... 33
4.4 Conclusie aanvullend onderzoek ................................................................................................ 33

Hoofdstuk 5. Klinisch beleid .............................................................................................................. 36
5.1 Betrokken disciplines ................................................................................................................. 36
5.2 Verpleegkundige diagnoses volgens PES .................................................................................. 37
5.3 Verpleegkundige behandeldoelen volgens de NOC ................................................................... 38
5.4 Verpleegkundige interventies volgens de NIC ............................................................................ 42

Hoofdstuk 6. Klinisch verloop ............................................................................................................ 45
6.1 Gewenst klinisch beloop ............................................................................................................. 45
6.2 Ongewenst klinisch beloop ......................................................................................................... 45
6.3 Klinisch beloop in de praktijk ....................................................................................................... 46

Hoofdstuk 7. Nabeschouwing ............................................................................................................ 48
7.1 Evaluatie zorgplan ....................................................................................................................... 48



2

, 7.2 Wet- en regelgeving .................................................................................................................... 53
7.3 Patiëntveiligheid .......................................................................................................................... 54
7.4 Evaluatie kwaliteit beroepsuitoefening ........................................................................................ 55
7.5 Ethisch dilemma .......................................................................................................................... 55
7.6 Leerpunten casus ........................................................................................................................ 56

Hoofdstuk 8. Informatie- en communicatietechnologie .................................................................. 57
8.1 Elektronisch Patiënten Dossier ................................................................................................... 57
8.2 Persoonsalarmering .................................................................................................................... 57
8.3 Mijn Martini .................................................................................................................................. 58
8.4 Persoonlijke Gezondheidsomgeving ........................................................................................... 58
8.5 Applicaties ................................................................................................................................... 58

Hoofdstuk 9. Casusbespreking .......................................................................................................... 59

Bibliografie ........................................................................................................................................... 63

Bijlage 1. Complexiteit van zorg ........................................................................................................ 71

Bijlage 2. Medicatieoverzicht.............................................................................................................. 74

Bijlage 3. Anamnese ............................................................................................................................ 76

Bijlage 4. Waarderingsformulieren PLP2 en PLP3 ........................................................................... 78
Waarderingsformulieren eindevaluatie PLP2 .................................................................................... 78
Waarderingsformulieren tussenevaluatie PLP3 .................................. Error! Bookmark not defined.
Waarderingsformulieren eindevaluatie PLP3 ...................................... Error! Bookmark not defined.

Bijlage 5. Reflectieverslagen PLP2 en PLP3........................................... Error! Bookmark not defined.
Reflectieverslag eindevaluatie PLP2................................................... Error! Bookmark not defined.
Reflectieverslag tussentijdse evaluatie PLP3 ..................................... Error! Bookmark not defined.
Reflectieverslag eindevaluatie PLP3................................................... Error! Bookmark not defined.

Bijlage 6. Verslag van handelen in de praktijk ....................................... Error! Bookmark not defined.

Bijlage 7. Antiplagiaatverklaring .............................................................. Error! Bookmark not defined.
............................................................................................................. Error! Bookmark not defined.




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