Deze bewijslasten zijn op hoog niveau geschreven en ook staat in dit bestand de gekregen feedback op de bewijsmaterialen. De stage is ruimvoldoende behaald en met de bewijslasten heb ik alle canmedsrollen ruim aangetoond. Daarnaast is er veel variatie in de bewijsmaterialen: klinisch redeneren, ref...
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Stageplaats: Maxima Medisch Centrum Veldhoven Cardiologie
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Datum:
Bewijsstukken bij pleidooien
Inhoudsopgave:
Bewijsstuk 1: Klinisch Redeneren volgens Marc Bakker........................................................................7
Inleiding:..............................................................................................................................................17
1. Oriëntatie op de situatie:.................................................................................................................18
Introductie:......................................................................................................................................18
Sbar:.................................................................................................................................................18
Situation:......................................................................................................................................18
Background:.................................................................................................................................18
Assesment:...................................................................................................................................19
Recommandation:........................................................................................................................21
2. Klinische probleemstelling:..............................................................................................................22
Decompensatie cordis/hart en vatenstelsel:...................................................................................22
Aortaklepstenose/hart- en vastenstelsel:....................................................................................23
Pulmonale hypertensie/ademhalingsstelsel:...............................................................................23
Atriumfibrilleren/hart- en vatenstelsel:.......................................................................................23
Diabetes/hormoonstelsel:...........................................................................................................24
VVI Pacemaker/hart- en vatenstelsel:..........................................................................................24
Psychische stoornissen:...............................................................................................................24
Sociale problematiek:..................................................................................................................24
Functionele problematiek:...........................................................................................................25
Wonden/de huid:.........................................................................................................................25
3. Aanvullend onderzoek:....................................................................................................................26
Anamnese:...................................................................................................................................26
X-thorax:......................................................................................................................................26
ECG:.............................................................................................................................................26
, Labratorium:...............................................................................................................................26
Verpleegkundige diagnoses:............................................................................................................27
Verpleegkundige diagnose 1:.......................................................................................................27
Verpleegkundige diagnose 2:.......................................................................................................27
Verpleegkundige diagnose 3:.......................................................................................................28
Verpleegkundige diagnose 4:.......................................................................................................28
Samenhang:.....................................................................................................................................28
4. Klinisch beleid:.................................................................................................................................30
Verpleegkundige diagnose 1: beperkte inspanningstolerantie........................................................30
Doel:............................................................................................................................................30
Interventies:.................................................................................................................................30
Wat doe ik zelf hieraan op de werkvloer?...................................................................................30
Verpleegkundige diagnose 2: overvulling........................................................................................31
Doel:............................................................................................................................................31
Interventies:.................................................................................................................................31
Wat doe ik zelf hieraan op de werkvloer?...................................................................................32
Interdisciplinaire samenwerking:.....................................................................................................32
5. Klinisch verloop:...............................................................................................................................33
Korte termijn:..................................................................................................................................33
Lange termijn:..................................................................................................................................33
Stimuleren zelfmanagment:.............................................................................................................33
6. Evalueren:........................................................................................................................................34
Zorgvrager:......................................................................................................................................34
Zorgproces:......................................................................................................................................34
Mijn eigen leerproces:.....................................................................................................................34
Bronnenlijst:........................................................................................................................................35
Bewijsstuk 2: reflectie verslag volgens het 5G model op het persoonlijke leerdoel............................39
Kernkwadrant:.................................................................................................................................41
Het persoonlijk leerdoel:.....................................................................................................................47
Leeractiviteiten voor mijn persoonlijke leerdoel:................................................................................49
Het bespreekbaar maken van mijn persoonlijke leerdoel:..............................................................49
Protocol grondig doorlezen:............................................................................................................49
.........................................................................................................................................................50
Meekijken met de handeling:..........................................................................................................50
Het uitwerken van mijn persoonlijke leerdoel:................................................................................50
Reflectie verslag:..................................................................................................................................51
, 5.2 klinische bottomline...................................................................................................................89
Reflectie:..............................................................................................................................................90
Literatuurlijst:......................................................................................................................................91
Bewijsstuk 5: verpleegkundig proces + ethisch dilemma.....................................................................92
Inleiding:............................................................................................................................................100
Anamnese/vraagverheldering:..........................................................................................................101
De zorgvrager:...............................................................................................................................101
Het anamnesegesprek:..................................................................................................................102
Diagnose:...........................................................................................................................................104
Verpleegkundige diagnose 1:.........................................................................................................104
Verpleegkundige diagnose 2:.........................................................................................................104
Verpleegkundige diagnose 3:.........................................................................................................105
Verpleegkundige diagnose 4:.........................................................................................................105
Planning van resultaten:....................................................................................................................106
Planning van interventies..................................................................................................................107
Verpleegkundige diagnose 1: risico op infecties............................................................................107
Interventies arts:........................................................................................................................107
Interventies verpleegkundige:...................................................................................................107
Verpleegkundige diagnose 2:.........................................................................................................108
Interventies arts:........................................................................................................................108
Interventies verpleegkundige:...................................................................................................108
...........................................................................................................................................................109
Uitvoering van geplande werkzaamheden........................................................................................110
Reflectie coördinatie 04/06:..........................................................................................................110
Feedback desbetreffende verpleegkundige:..................................................................................111
Evaluatie:...........................................................................................................................................112
Bijlage 1: ethisch dilemma:................................................................................................................113
Verkennen:....................................................................................................................................113
Formuleren:...................................................................................................................................113
De situatie:.................................................................................................................................113
Ethische dilemma’s:...................................................................................................................114
Morele vraagstelling:.................................................................................................................114
Analyseren:....................................................................................................................................114
Afwegen:........................................................................................................................................115
Argumenten voor nazorg:..........................................................................................................115
Argumenten tegen nazorg:........................................................................................................115
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