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portfolio PL4 (Klinisch redeneren Verpleegkundig leiderschap)
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Portfolio: Klinisch Redeneren Verpleegkundig leiderschap. Stageopdrachten PL4 vanuit Hogeschool Utrecht. Behaald cijfer: 7.2
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VERLOSKUNDE/KRAAM- ,
ZWANGEREN
AFDELING
PORTOFOLIO
Hbo-v opleiding 4de leerjaar
, 1
Inhoudsopgave
Klinisch redeneren..................................................................................................................................4
1. Probleemoriëntatie/ Klinisch beeld....................................................................................................5
1.1 Situatie..........................................................................................................................................5
1.2 Background...................................................................................................................................5
1.2.1 Allergieën...............................................................................................................................5
1.2.2 Medicatie overzicht...............................................................................................................6
1.2.3 Medische diagnoses...............................................................................................................6
1.2.4 Actieve medische diagnoses..................................................................................................6
1.2.5 Last meal................................................................................................................................6
1.2.6 Psychosociale problemen (SCEGS).........................................................................................6
1.3 Assessment...................................................................................................................................7
1.3.1 controles bij opname.............................................................................................................7
1.3.2 controles in de ochtend.........................................................................................................7
1.3.2 controles op het moment......................................................................................................7
1.4 Hypothetische diagnoses..............................................................................................................7
1.5 Differentiële diagnose...................................................................................................................8
1.6 Urgentieniveau.............................................................................................................................8
2. Probleemanalyse................................................................................................................................9
2.1 Verpleegproblemen......................................................................................................................9
2.1.1 Functionele problemen..........................................................................................................9
2.1.2 Psychische stoornis..............................................................................................................10
2.1.3 Psychosociale stoornis.........................................................................................................10
2.2 Verstoorde orgaansystemen.......................................................................................................10
2.2.1 Thermoregulatiesysteem.....................................................................................................11
2.2.2 Bloed....................................................................................................................................11
2.2.3 Zuurstofbalans myocard......................................................................................................12
3. Aanvullend onderzoek......................................................................................................................13
3.1 Aanbeveling................................................................................................................................13
3.1.1 Lichamelijk onderzoek/ beleid gynaecoloog........................................................................13
3.1.2 Diagnostische onderzoek vanuit gynaecoloog.....................................................................13
3.2 Observatie..................................................................................................................................13
3.3 Bloedonderzoek..........................................................................................................................13
3.4 CTG onderzoek...........................................................................................................................14
3.5 Terugblik/ samenvatting.............................................................................................................14
Marinde Bakker Afdeling 4de jaars HBO-V, HU
, 2
3.6 Verpleegkundig beleid...............................................................................................................14
4. Klinisch Beleid...................................................................................................................................16
4.1 Medisch beleid/arts:...................................................................................................................16
5. Klinisch Verloop................................................................................................................................17
5.1 Ziekteverloop op korte termijn...................................................................................................17
5.1.1 Patiëntgericht......................................................................................................................17
5.1.2 Literatuur.............................................................................................................................17
5.2 Ziekteverloop op lange termijn...................................................................................................17
5.2.1 Patiëntgericht......................................................................................................................17
5.2.2 Literatuur.............................................................................................................................17
5.3 Gevolgen aandoening psychisch.................................................................................................18
5.4 Zelfmanagement.........................................................................................................................18
5.5 Verschillende disciplines.............................................................................................................19
6. Evaluatie...........................................................................................................................................20
6.1 De behandeling...........................................................................................................................20
6.2 De interventies...........................................................................................................................20
6.3 Kwaliteit van zorg + Patiëntveiligheid.........................................................................................20
6.4 Ethische aspecten.......................................................................................................................20
6.5 Opname/opnameduur/ regelen van zorg na ontslag..................................................................21
6.6 Rapportage.................................................................................................................................21
Literatuurlijst........................................................................................................................................22
Bijlage 1; Woordenlijst.........................................................................................................................24
Verpleegkundig Leiderschap................................................................................................................25
1.2 Wat is verpleegkundig leiderschap.............................................................................................26
1.1.1 Management vs. leiderschap...............................................................................................26
1.1.2 Ohio state & Michigan studies.............................................................................................26
1.1.3 Eigen definitie van verpleegkundig leiderschap...................................................................27
1.2 Voorbeelden van verpleegkundig leiderschap............................................................................27
1.2.1 Coördineren van zorg met meerdere disciplines..................................................................27
1.2.2 Handelen volgens de richtlijnen en protocollen...................................................................27
1.3 Verpleegkundig leiderschap speelt een rol bij verbeteren van kwaliteit van zorg......................28
1.3.1.............................................................................................................................................28
1.3.2.............................................................................................................................................28
1.4 Verpleegkundig leiderschap speelt een rol bij het verbeteren van de kwaliteit van zorg op
organisatie-, regionaal of landelijk niveau........................................................................................28
1.4.1 Vakinhoudelijk leiderschap..................................................................................................28
Marinde Bakker Afdeling 4de jaars HBO-V, HU
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1.4.2 Verpleegkundig adviesraad..................................................................................................28
1.4.3 Wet kwaliteit en geschillen zorg..........................................................................................29
1.4.4 Beroepscode........................................................................................................................29
1.5 Verpleegkundig leiderschap tijdens mijn stage..........................................................................29
1.5.1 Kritisch kijken naar beleid van de arts.................................................................................29
1.5.2 Werken met meerdere disciplines........................................................................................29
2.Onderzoeken van leiderschap...........................................................................................................30
2.1 Thema + relevantie + 2.2 Passende informatie vanuit 3 gezaghebbende bronnen....................30
2.3 Betrokken stakeholders..............................................................................................................31
2.4 Schaduwen.................................................................................................................................32
2.4.1 Vragen voor het schaduwen................................................................................................32
2.4.2 Antwoorden op de vragen...................................................................................................32
2.5 Ervaringen en observaties tijdens het schaduwen......................................................................33
2.5.1 Verbinding tussen eigen ervaring, opgedane kennis over het thema en de kwaliteit van de
patiëntenzorg...............................................................................................................................34
2.6 Reflectie......................................................................................................................................34
2.6.1Reflectie op eigen rol/gedrag tijdens het schaduwen. Verwerkt de gekregen feedback......34
2.6.2 Ontwikkelpunten ten aanzien van verpleegkundig leiderschap..........................................35
Literatuur..............................................................................................................................................36
Bijlage 2; Presentatie verpleegkundig leiderschap...............................................................................39
Marinde Bakker Afdeling 4de jaars HBO-V, HU
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