Exam (elaborations)
Portfolio PL3
- Course
- Institution
Compleet portfolio van PL3. Dit bevat: klinisch redeneren, onderzoekend vermogen (CAT), tussen- en eindevaluatie (CANMEDS-rollen). Portfolio is met een 8,7 beoordeeld.
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Student: Isa HeikampStudentnummer:1721002.
Stageklas: GVE-3R1-MMC-B-19
Datum: 27-01-2020
Docent: Gerlien Roke.
Instelling: Meander Medisch
Centrum
PORTFOLIO Isa Heikamp
Praktijkleren 3
GVE-3R1-MMC-B-19
Klinisch redeneren & onderzoekend vermogen
1
,Inhoudsopgave
Voorwoord ............................................................................................................................. 4
Stap 1: Probleemoriëntatie/klinisch beeld .............................................................................. 5
Casusbeschrijving ....................................................................................................................... 5
Situation ........................................................................................................................................ 5
Background .................................................................................................................................. 6
Assessment .................................................................................................................................. 7
Recommendation......................................................................................................................... 8
Stap 2: Probleemanalyse. ....................................................................................................... 9
Sociale problematiek................................................................................................................... 9
Psychische problematiek ........................................................................................................... 9
Functionele problematiek ........................................................................................................... 9
Spirituele problematiek ............................................................................................................... 9
Disfunctionele orgaansystemen: ............................................................................................ 10
Analyse meetinstrumenten ...................................................................................................... 11
Stap 3: Aanvullend onderzoek en diagnose ........................................................................... 12
Aanvullend onderzoek .............................................................................................................. 12
Verpleegkundige diagnoses .................................................................................................... 12
Stap 4: Klinisch beleid ........................................................................................................... 14
Stap 5: Klinisch verloop ......................................................................................................... 16
Klinisch verloop op korte termijn: .......................................................................................... 16
Klinisch verloop op lange termijn: .......................................................................................... 16
Mogelijke complicaties: ............................................................................................................ 16
Gevolgen van de ziekte op psychisch-, psychosociaal- en spiritueel functioneren: ..... 16
Interventies om zelfmanagement te stimuleren: .................................................................. 16
Stap 6: Evaluatie................................................................................................................... 17
Reflectie op het zorgproces: .................................................................................................... 17
Reflectie op het EPD: ................................................................................................................ 17
Bijlagen ................................................................................................................................ 18
Bijlage 1: Multiple sclerosis ..................................................................................................... 18
Bijlage 2: Anamnese van Gordon ........................................................................................... 19
Bijlage 3: Uitwerking medicijnen............................................................................................. 26
Bijlage 4: Meetinstrumenten .................................................................................................... 29
2
, ...................................................................................................................................................... 34
Bibliografie ........................................................................................................................... 35
Samenvatting ....................................................................................................................... 37
Inleiding ............................................................................................................................... 39
Probleemanalyse .................................................................................................................. 40
Doelstelling:................................................................................................................................... 40
PICO: ............................................................................................................................................. 40
Essentiële variabele: ...................................................................................................................... 41
Onderzoeksmethode............................................................................................................. 42
Resultaten zoekacties: ................................................................................................................... 43
Data-analyse: ....................................................................................................................... 45
Artikel 1: ........................................................................................................................................ 45
Artikel 2: ........................................................................................................................................ 46
Artikel 3: ........................................................................................................................................ 47
Artikel 4: ........................................................................................................................................ 48
Discussie ............................................................................................................................... 49
Conclusie .............................................................................................................................. 50
Advies .................................................................................................................................. 50
Concluderend advies ...................................................................................................................... 50
Bijlagen ................................................................................................................................ 51
3
, Voorwoord
Voor mijn derde stage, van de opleiding verpleegkunde aan de Hogeschool Utrecht, ben ik
geplaatst op de afdeling urologie in het Meander Medisch Centrum.
De afdeling waar ik stageloop betreft veel interessante ziektebeelden. Na lang te hebben
nagedacht heb ik een casus gekozen voor de opdracht klinisch redeneren en een onderwerp
voor de opdracht onderzoekend vermogen.
Voor de opdracht klinisch redeneren heb ik verschillende interventies op moeten stellen om de
kwaliteit van leven van de patiënt te verbeteren.
Voor de opdracht onderzoekend vermogen heb ik een CAT moeten maken, wat dit inhoudt
wordt in de opdracht haarfijn uitgelegd.
Alle namen die zijn gebruikt in deze opdracht zijn fictief.
Veel leesplezier!
4
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