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Stageportfolio PL1. Behaald cijfer 8,3!
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Dit is mijn stageportfolio van PL1. Dit is de opdracht klinisch redeneren en onderzoekend vermogen. Ik heb hiervoor een 8,3 gehaald.
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StageportfolioPrakti jkleren 1
,Inhoudsopgave
Klinisch redeneren
Anamnese.............................................................................................................. 4
De eerste indruk.................................................................................................. 4
Uiterlijke kenmerken........................................................................................ 4
Gedrag............................................................................................................. 5
Woonomgeving................................................................................................ 5
Het ziektebeeld................................................................................................... 5
De ziekte van Alzheimer.................................................................................. 5
COPD en longemfyseem................................................................................... 6
Vitamine D deficiëntie...................................................................................... 6
Nierfunctiestoornis/nierinsufficiëntie................................................................6
Essentiële hypertensie zonder orgaanbeschadiging........................................7
De belevingswereld............................................................................................. 7
Inschatting van de gezondheid........................................................................... 7
Lichaamsfuncties............................................................................................. 7
Mentale functies en beleving........................................................................... 7
Spirituele en existentiële dimensie..................................................................8
Kwaliteit van leven........................................................................................... 8
Sociaal-maatschappelijke participatie..............................................................8
Dagelijks functioneren...................................................................................... 8
Gezondheidssituatie............................................................................................ 8
Wat is een wenselijke gezondheidssituatie voor mevrouw en/of haar naasten?
......................................................................................................................... 8
Wat vind ik wenselijke/haalbare gezondheidssituatie voor mevrouw?.............9
Diagnose................................................................................................................ 9
Aanknopingspunten voor de zorg........................................................................9
Diagnose 1..................................................................................................... 10
Diagnose 2..................................................................................................... 10
Diagnose 3..................................................................................................... 10
Diagnose 4..................................................................................................... 11
Diagnose 5..................................................................................................... 11
Evaluatie van de diagnoses............................................................................... 11
Resultaat.............................................................................................................. 12
Resultaten......................................................................................................... 12
Diagnose 1..................................................................................................... 13
Diagnose 2..................................................................................................... 13
, Diagnose 3..................................................................................................... 13
Diagnose 4..................................................................................................... 13
Diagnose 5..................................................................................................... 13
Evaluatie resultaten.......................................................................................... 13
Interventie............................................................................................................ 13
Interventie opstellen......................................................................................... 14
Diagnose 1..................................................................................................... 14
Diagnose 2..................................................................................................... 14
Diagnose 3..................................................................................................... 14
Diagnose 4..................................................................................................... 14
Diagnose 5..................................................................................................... 15
Terugkoppeling werkbegeleider.........................................................................15
Evaluatie verpleegplan...................................................................................... 15
Uitvoering en evaluatie........................................................................................ 15
Diagnose 1........................................................................................................ 15
Diagnose 2........................................................................................................ 16
Diagnose 3........................................................................................................ 16
Diagnose 4........................................................................................................ 16
Diagnose 5........................................................................................................ 16
Stap 1. Probleemanalyse...................................................................................... 18
Casusbeschrijving.............................................................................................. 18
Probleem vanuit de literatuur ...........................................................................18
Probleem-, doel- en vraagstelling......................................................................18
Stap 2. Onderzoeksmethode................................................................................ 18
De hoofdvraag................................................................................................... 18
Het zoekplan..................................................................................................... 19
De zoekstrategie en uitvoering.........................................................................19
Tijdsplanning..................................................................................................... 20
Stap 3. Dataverzameling...................................................................................... 20
Artikel 1:......................................................................................................... 21
Artikel 2:......................................................................................................... 21
Stap 4. Data-analyse............................................................................................ 21
Artikel 1:......................................................................................................... 21
Artikel 2:......................................................................................................... 22
Stap 5. Rapportage............................................................................................... 23
Conclusie........................................................................................................... 23
Advies................................................................................................................ 24
, Gesprek met zorgmedewerkers.........................................................................24
Visie van de coördinator................................................................................. 24
Visie van de werkbegeleider en derdejaars hbo-verpleegkundige in opleiding
....................................................................................................................... 24
Bronnenlijst.......................................................................................................... 24
Bijlage 1: Beoordelingslijst wetenschappelijke onderzoekspublicaties artikel 1 26
Bijlage 2: Beoordelingslijst wetenschappelijke onderzoekspublicaties artikel 2 30
Klinisch redeneren
Anamnese
De eerste indruk
Uiterlijke kenmerken
Mw. B. is een mevrouw van 89 jarige leeftijd. Mevrouw heeft een gemiddelde lengte, heeft kort grijs
haar en draagt een bril. Mevrouw haar lichaamsbouw is erg fragiel, ze is erg dun. Mevrouw is van
Nederlandse afkomst.
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