Opdracht "Klinisch redeneren" is met een 8,5 afgerond en opdracht "Verpleegkundig leiderschap" met een 8,3. Ook Eindverslag CanMEDS-rollen PL4 zit erbij.
pl4 klinisch redeneren en verpleegkundig leiderschap
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Hogeschool Utrecht (HU)
Verpleegkunde
Praktijkleren 4 (PL4)
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Klinisch redeneren
en verpleegkundig
leiderschap
Stageportfolio Praktijkleren 4
Naam: Larysa Vuijst
Opleiding: HBO-Verpleegkunde
Studentnummer: 1751303
Studiegroep: GVE-2DUV-PLH-19
Naam cursus: GVE-4.PL4-17
Naam docent: Suzanne van de Peppel
Datum: 20-01-2019
,Inhoud
Klinisch redeneren ................................................................................................................................... 4
1. Klinisch redeneren t.b.v. een veranderende situatie .......................................................................... 5
Stap 1: Probleemoriëntatie/klinisch beeld.............................................................................................. 5
Introductie zorgvrager......................................................................................................................... 5
Voorgeschiedenis: ........................................................................................................................... 5
Medicatie gebruik bij opname: ....................................................................................................... 5
Klinisch beeld....................................................................................................................................... 6
Differentiaal diagnose ......................................................................................................................... 8
Stap 2: Probleemanalyse ....................................................................................................................... 10
Verpleegproblemen........................................................................................................................... 10
Verpleegkundige diagnoses............................................................................................................... 10
Betrokken orgaansystemen............................................................................................................... 12
Respiratoir systeem ....................................................................................................................... 12
Neurologisch systeem ................................................................................................................... 13
Neurologisch systeem/zintuigelijk ................................................................................................ 13
Analyse meetinstrumenten en/of scoringssystemen ....................................................................... 13
Stap 3: Aanvullend onderzoek en diagnose .......................................................................................... 14
Stap 4: Klinisch beleid ............................................................................................................................ 15
Verpleegkundige en multidisciplinaire interventies.......................................................................... 15
Prioritering voor het verpleegkundig handelen ................................................................................ 17
Andere betrokken disciplines ............................................................................................................ 17
Informeren zorgvrager en naasten ................................................................................................... 17
2. Het klinisch redeneren t.b.v. het totale verpleegkundig proces ....................................................... 18
Stap 5: Klinisch verloop ......................................................................................................................... 18
Het verloop van de ziekte op de korte en lange termijn................................................................... 18
Gevolgen op functioneel, psychisch, psychosociaal en spiritueel gebied ......................................... 18
Zelfmanagement van de zorgvrager ................................................................................................. 18
Nazorg ............................................................................................................................................... 19
Stap 6: Evaluatie .................................................................................................................................... 19
Evaluatie ............................................................................................................................................ 19
Het zorgproces aan de hand de gestelde doelen .............................................................................. 19
Reflectie op het verloop van het zorgproces ........................................................................................ 20
Reflectie op het gebruik van het zorgdossier ........................................................................................ 20
1
,Literatuurlijst ......................................................................................................................................... 21
Bijlage .................................................................................................................................................... 31
Bilage 1. Utrecht Symptoom Dagboek (USD) ........................................................................................ 31
Bijlage 2. De Numeric Rating Scale (NRS) .............................................................................................. 32
Bijlage 3. De Bradenschaal .................................................................................................................... 33
Bijlage 4. HADS (Hospital Anxiety and Depression Scalegebruikt) ........................................................ 35
Bijlage 5. Barthel- Index (BI) .................................................................................................................. 38
Bijlage 6. De Multidimensionele Vermoeidheidsindex (MVI) ............................................................... 41
Bijlage 7. EDIZ (Ervaren Druk door Informele Zorg) ............................................................................. 44
Bijlage 8. Lastmeter ............................................................................................................................... 46
Bijlage 9. Verpleegkundige diagnoses .................................................................................................. 47
Bijlage 10. Verpleegkundige en multidisciplinaire interventies ............................................................ 49
Bijlage 11. Ars Moriendi model (diamantmodel) .................................................................................. 53
Bijlage 12. Feedbackformulier stage-opdracht voor werkbegeleiders ................................................. 54
Verpleegkundig leiderschap .................................................................................................................. 56
1. Voorbereiding op leiderschap ........................................................................................................... 57
1.1 Verpleegkundig leiderschap ........................................................................................................ 57
1.2. Verpleegkundig leiderschap in het dagelijks werk van verpleegkundigen ................................ 57
Onderzoekend houding ................................................................................................................. 58
Samenwerken ................................................................................................................................ 58
Nemen van beslissing .................................................................................................................... 58
Ontwikkeling.................................................................................................................................. 58
1.3. Verpleegkundig leiderschap en kwaliteit van zorg op de werkvloer ......................................... 59
1.4. De rol van verpleegkundig leiderschap bij het verbeteren van de kwaliteit van zorg op
organisatie-, en regionaal of landelijke niveau ................................................................................. 59
Mesoniveau ................................................................................................................................... 59
Macroniveau.................................................................................................................................. 60
1.5. Persoonlijke voorbeelden van verpleegkundig leiderschap....................................................... 61
2. Onderzoeken van leiderschap ........................................................................................................... 61
2.1 Thema het belang van MIC melden ............................................................................................ 61
Situatie in verpleeghuiszorg en thuiszorg ..................................................................................... 62
De relevantie van gekozen thema ................................................................................................. 62
Oorzaken van incidenten............................................................................................................... 62
Waarom worden incidenten niet altijd gemeld? .......................................................................... 62
2
, Wat is MIC? ................................................................................................................................... 63
Doel van MIC? ............................................................................................................................... 63
Wat wordt gemeld?....................................................................................................................... 63
Verschil tussen incidenten en calamiteiten .................................................................................. 63
Wie meldt? .................................................................................................................................... 63
Procesbeschrijving ......................................................................................................................... 63
Hoe kan de meldingsbereidheid worden beïnvloed? ................................................................... 63
Wat zegt de wet?........................................................................................................................... 63
Wat zegt de IGJ? ............................................................................................................................ 64
Wat zegt beroepscode? ................................................................................................................. 64
Wat zegt Inovum? ......................................................................................................................... 64
Conclusie ....................................................................................................................................... 64
2.2 Betrokken stakeholders............................................................................................................... 64
2.3 Het schaduwen ............................................................................................................................ 65
Vraagstelling en beantwoording ................................................................................................... 65
Vragen ........................................................................................................................................... 65
Antwoorden op vragen.................................................................................................................. 66
2.4 Ervaringen/Observaties tijdens het schaduwen ......................................................................... 67
2.5 Verbinding leggen........................................................................................................................ 68
2.6 Reflectie ....................................................................................................................................... 68
2.7 Sterke en ontwikkelpunten ten aanzien van verpleegkundig leiderschap ................................. 68
Sterke punten ................................................................................................................................ 68
Ontwikkelpunten ........................................................................................................................... 68
Literatuur ............................................................................................................................................... 69
Bijlage .................................................................................................................................................... 73
Bijlage 1. Presentatie ............................................................................................................................. 73
1. PowerPoint .................................................................................................................................... 73
2. Verhaal .......................................................................................................................................... 78
Bijlage 2. Feedback van praktijkbegeleider ........................................................................................... 86
Bijlage 3. Feedback van schaduwen ...................................................................................................... 87
Senior verpleegkundige ..................................................................................................................... 87
Hoofdverpleegkundige ...................................................................................................................... 88
Bijlage 4. Feedback van presentatie ...................................................................................................... 89
Bijlage 5. Eindverslag CanMEDS-rollen PL4 ........................................................................................... 90
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