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Portfolio PL4 Klinisch redeneren (7.9) en verpleegkundig leiderschap(8.7)
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Portfolio PL4Klinisch
redeneren en
verpleegkundi
g leiderschap
,Inhoud
Klinisch redeneren..................................................................................................................................3
Stap 1: Probleemoriëntatie/klinisch beeld.............................................................................................3
Huidige situatie:..................................................................................................................................3
Symptomen........................................................................................................................................4
Psychiatrisch:..................................................................................................................................4
Somatisch:......................................................................................................................................4
Huidige medicatie:..............................................................................................................................4
Gebruikte meetinstrumenten:............................................................................................................4
Hypothetische diagnosen...................................................................................................................5
Differentiële diagnoses:......................................................................................................................5
Stap 2 Probleemanalyse:........................................................................................................................5
Functies en anatomische eigenschappen:..........................................................................................6
Activiteiten en participatie:................................................................................................................6
Externe factoren:................................................................................................................................7
Persoonlijke factoren:.........................................................................................................................7
Uitwerking meetinstrumenten:..........................................................................................................7
Health of Nation Outcome Scales:..................................................................................................7
Broset Violence Checklist:..............................................................................................................7
Montgomery–Åsberg Depression Rating Scale:..............................................................................7
Global Assesment of Functioning (GAF):........................................................................................8
Montreal Cognitive Assesment:......................................................................................................8
Ziektebeeld:........................................................................................................................................8
Stap 3 Aanvullend onderzoek en diagnose:............................................................................................8
Verschil dementie en depressie:.....................................................................................................8
Labafname:.....................................................................................................................................9
Controles:.......................................................................................................................................9
Risico op suïcide:............................................................................................................................9
Obstipatie:....................................................................................................................................10
Stap 4 Klinisch beleid:..........................................................................................................................10
Verpleegkundige diagnosen:............................................................................................................10
Verpleegkundige diagnose één:....................................................................................................10
Verpleegkundige diagnose twee:..................................................................................................11
Verpleegkundige diagnose drie:...................................................................................................11
Verpleegkundige diagnose vier:....................................................................................................12
, Verpleegkundige diagnose vijf:.....................................................................................................12
Medische diagnose, hoge prioriteit:.............................................................................................12
Informatieoverdracht zorgvrager en naasten:..................................................................................12
Stap 5. Klinisch verloop:.......................................................................................................................13
Korte termijn:...................................................................................................................................13
Gevolgen voor somatisch, psychosociaal en spiritueel functioneren:..............................................13
Interventies op het gebied van ondersteunen en versterken van het zelfmanagement:.................14
Inventarisatie professionele zorg en mantelzorg:.............................................................................14
Stap 6. Evaluatie:..................................................................................................................................14
Het zorgproces:................................................................................................................................14
Zorgdossier:......................................................................................................................................15
Literatuurlijst:.......................................................................................................................................15
Verpleegkundig leiderschap:................................................................................................................17
Voorbereiding op leiderschap:.........................................................................................................17
Rol van verpleegkundig leiderschap in het dagelijks werk:...............................................................18
Verpleegkundig leiderschap en kwaliteit van zorg op de stageplek:................................................19
Teamontwikkeling:.......................................................................................................................19
Werkgroepen:...............................................................................................................................19
Leerlingenbegeleiding:.................................................................................................................20
Verpleegkundig leiderschap op organisatie, regionaal en landelijk niveau:.....................................20
Verpleegkundige adviesraad (VAR):..............................................................................................20
Werkgroepen:...............................................................................................................................20
Persoonlijk verpleegkundig leiderschap:..........................................................................................21
Het onderzoeken van verpleegkundig leiderschap:..............................................................................21
Schaduwen en stakeholders:............................................................................................................22
..........................................................................................................................................................23
Vragen en antwoorden:....................................................................................................................23
Microniveau:.................................................................................................................................23
Mesoniveau:.................................................................................................................................23
Macroniveau:................................................................................................................................24
Relevante ervaringen en observaties schaduwen:...........................................................................24
Verbindingen tussen ervaringen, verworven kennis over het betreffende thema en de kwaliteit van
de patiëntenzorg op de stageplek:...................................................................................................24
Reflectie:...........................................................................................................................................25
Sterke en ontwikkelpunten verpleegkundig leiderschap:.............................................................25
Literatuur:.............................................................................................................................................25
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