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Beargumenteren van zorg PLP3 behaald met een 8,8!

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Deze module is gebaseerd op een casus vanuit een PLP3 stage in het Martini ziekenhuis. Het verslag is uitgewerkt middels de zes stappen van Marc Bakker en opgesteld volgens APA-richtlijnen versie 7. Het verslag is erg gedetailleerd beschreven en beoordeeld met een 8,8! Dus, grijp je kans om deze st...

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  • June 5, 2024
  • 70
  • 2023/2024
  • Essay
  • Unknown
  • 8-9
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Module
Beargumenteren van
zorg
Naam:
Studentnummer:
Stagecoördinators:
Werkbegeleiders:
Docentbegeleider:
Academie voor Verpleegkunde, Groningen
Martini Ziekenhuis afdeling 4D Algemene chirurgie
Februari 2024 – Juli 2024


Cursuscode module beargumenteren van zorg: HVVB21MBVZ

1

,INHOUDSOPGAVE
Introductie...................................................................................................................................5
1. Oriëntatie op de situatie en het klinisch beeld......................................................................7
1.1. Introductie casus.............................................................................................................7
1.2 SBAR..................................................................................................................................9

1.2.3. Assessment.............................................................................................................10
1.2.4. Aanbeveling.............................................................................................................16

2. Klinische probleemstellingen...............................................................................................18
2.1. Zorgthema’s ProActive Nursing model..........................................................................18
2.2. Prioritering Zorgthema’s................................................................................................19
2.3. Uitwerking Zorgthema’s.................................................................................................19

2.3.1. Luchtwegen en Ademhaling....................................................................................19
2.3.2. Circulatie.................................................................................................................21
2.3.3. Zuurstofvoorziening hart........................................................................................22
2.3.4. Bloed.......................................................................................................................23
2.3.5. Thermoregulatiesysteem en huid & afweerfuncties..............................................24

3.1. Aanvullende anamnese..................................................................................................26
3.2. Lichamelijk onderzoek...................................................................................................26
3.3. Beeldvormend onderzoek..............................................................................................26
3.4. Bloedonderzoek.............................................................................................................26
3.5. Conclusie........................................................................................................................27

Echo cor.............................................................................................................................27
Trans Oesophagale Echo (TEE)..........................................................................................28

4. Klinisch beleid.......................................................................................................................29
4.1. Medisch beleid...............................................................................................................29
4.2. Verpleegkundige diagnose.............................................................................................29

Actuele verpleegkundige diagnoses.................................................................................29
Verpleegkundige risicodiagnoses......................................................................................30

4.3. Verpleegkundige resultaten...........................................................................................30

2

, 4.4. Verpleegkundige interventies........................................................................................33
4.5 Casusbespreking interventie EBP....................................................................................35

4.5.2. Onderzochte interventie EBP: Pulserend flushen van een PICC-lijn.......................36

5. Klinisch verloop.....................................................................................................................39
5.1. Gewenste situatie..........................................................................................................39
5.2. Ongewenste situatie......................................................................................................40

6. Nabeschouwing.....................................................................................................................42
6.1. Patiëntveiligheid............................................................................................................42
6.2. Kwaliteit van beroepsuitoefening..................................................................................44
6.3. Ethisch dilemma.............................................................................................................45

7. Communicatie.......................................................................................................................46
7.1. Persoonsgerichte en professionele communicatie........................................................46
7.2. Informatie en communicatietechnologieën (ICT)..........................................................46

8. Handelen in de praktijk.........................................................................................................49
8.1. Uitvoering van de zorg...................................................................................................49
8.2. Leerproces student........................................................................................................50

Literatuur...................................................................................................................................52
Bijlage A Gegevens verzameling spoedeisende hulp................................................................56
Bijlage B Anamnese...................................................................................................................57
Bijlage C Definities.....................................................................................................................60
1. Atriumfibrilleren............................................................................................................60
2. ECV: Elektrische Cardioversie........................................................................................61
3. TFNA: Proximal Femoral Nailing System.......................................................................61
4. Spica-broekje.................................................................................................................61
5. PICC-Lijn........................................................................................................................62

Bijlage D Overdracht OK............................................................................................................63
Bijlage E Genogram en Ecogram...............................................................................................64
Dhr. Blank..................................................................................................................................64
Bijlage F Reflectie tussenevaluatie............................................................................................66
Bijlage G Reflectie eindevaluatie...............................................................................................67
Bijlage H Waarderingsformulier tussenevaluatie......................................................................68
Bijlage I Waarderingsformulier eindevaluatie...........................................................................69

3

, Bijlage J Antiplagiaatverklaring.................................................................................................70




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