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Praktijkleren 4: Klinisch redeneren- Cijfer 8,1!

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  • Course
  • GVE-4.PL4-17
  • Institution
  • Hogeschool Utrecht (HU)
  • Book
  • Klinisch redeneren in zes stappen

Dit verslag over klinisch redeneren, onderdeel van mijn portfolio tijdens praktijkleren 4, is beoordeeld met een 8,1 op 25 juni 2024! De opdracht omvat een gedetailleerde casus uit het ziekenhuis, uitgewerkt volgens de zes stappen van klinisch redeneren: Probleemoriëntatie/klinisch beeld, probleem...

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Last document update: 7 months ago

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Document information

  • July 3, 2024
  • July 3, 2024
  • 28
  • 2023/2024
  • Case
  • -
  • 8-9

Subjects

  • klinisch redeneren
  • ziekenhuis
  • praktijkleren 4
  • pl4
  • gve 4pl4 17
  • tergooi mc
  • hbo v
  • cardiologie
  • longgeneeskunde
  • interne geneeskunde
  • nefrologie
  • marc bakker
  • hogeschool utrecht
  • zes stappen klinisch redeneren

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  • Verpleegkunde
  • GVE-4.PL4-17
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Klinisch redeneren
Praktijkleren 4




Naam:
Studentnummer:
Mailadres:
Groepscode: GVE-4R2-TGZ-A
Toets code: GVE-4.PL4-17
1e Examinator:
2e Examinator:
Inleverdatum: 10-06-2024
Aantal woorden:
Versie: Eerste poging

,Inhoudsopgave
1 Probleemoriëntatie/klinisch beeld ................................................................................................. 4
1.1 Introductie patiënt ................................................................................................................. 4
1.2 De veranderde situatie ........................................................................................................... 4
1.3 Ernst van de situatie ............................................................................................................... 5
1.4 Relevante context................................................................................................................... 6
1.5 Hypothetische en differentiaal diagnose ............................................................................... 6
2 Probleemanalyse ............................................................................................................................ 7
2.1 Afweersysteem....................................................................................................................... 7
2.2. Thermoregulatiesysteem ....................................................................................................... 7
2.3 Cardiovasculair systeem ......................................................................................................... 7
2.4 Endocrien systeem ................................................................................................................. 7
2.5 Psychische stoornis ................................................................................................................ 8
2.6 Psychosociale problematiek ................................................................................................... 8
2.7 Functionele problematiek ...................................................................................................... 9
2.8 Spirituele problematiek.......................................................................................................... 9
2.9 Prioritering problematiek....................................................................................................... 9
3 Aanvullend onderzoek en diagnose .............................................................................................. 10
3.1 Anamnese en lichamelijk onderzoek ................................................................................... 10
3.2 Bloedkweken en/of wondkweken ........................................................................................ 10
3.3 Laboratoriumuitslagen ......................................................................................................... 10
3.4 Verpleegkundige diagnoses ................................................................................................. 10
4 Klinisch beleid ............................................................................................................................... 12
4.1 Prioritering verpleegkundig handelen ................................................................................. 13
4.2 Gezamenlijke besluitvorming ............................................................................................... 13
5 Klinisch verloop............................................................................................................................. 15
5.1 Gevolgen op somatisch, psychisch en (psycho)sociaal functioneren .................................. 15
5.2 Zelfmanagement .................................................................................................................. 15
5.3 Nazorg .................................................................................................................................. 16
6 Evaluatie........................................................................................................................................ 17
6.1 Verloop van het zorgproces ................................................................................................. 17
6.2 Gebruik van het elektronisch patiëntendossier ................................................................... 17
Literatuurlijst ......................................................................................................................................... 18
Bijlagen .................................................................................................................................................. 21

, Bijlage A Verpleegkundige anamnese ........................................................................................ 21
Bijlage B Medicatieoverzicht ...................................................................................................... 24
Bijlage C Ingevulde DOS ............................................................................................................. 25
Bijlage D Katz-ADL schaal ........................................................................................................... 26
Bijlage E Toelichting labuitslagen ............................................................................................... 27

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