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Portfolio praktijkleren 3 (PL3)
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Portfolio van praktijkleren 3. Behaald met een 8.
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Portfolio praktijkleren 3Het portfolio bestaat uit de volgende onderdelen:
1. Onderzoekend vermogen;
2. Klinisch redeneren;
3. Eindverslag CanMEDS rollen.
Geschreven door
Timothy van der Steen
,Inhoudsopgave
Onderzoekend vermogen – PL3...................................................................................................................... 5
Samenvatting................................................................................................................................................. 7
Probleemanalyse......................................................................................................................................... 10
1.1 Interventie.....................................................................................................................................................10
1.2 Voor- en nadelen..........................................................................................................................................10
1.3 Oriënterende literatuurstudie......................................................................................................................10
1.4 Doelstelling...................................................................................................................................................11
1.4.1 Onderzoeksvraag..................................................................................................................................11
1.4.2 Essentiele variabelen uit de onderzoeksvraag.....................................................................................11
Onderzoeksmethode.................................................................................................................................... 13
2.1 Zoekstrategie................................................................................................................................................13
2.2 Analyse..........................................................................................................................................................15
2.3 Beoordeling...................................................................................................................................................15
Resultaten................................................................................................................................................... 16
3.1 Artikel 1.........................................................................................................................................................16
3.2 Artikel 2.........................................................................................................................................................17
3.3 Artikel 3.........................................................................................................................................................17
3.4 Artikel 4.........................................................................................................................................................18
Discussie en conclusie.................................................................................................................................. 20
4.1 Discussie........................................................................................................................................................20
4.2 Conclusie.......................................................................................................................................................20
Advies.......................................................................................................................................................... 22
Literatuurlijst............................................................................................................................................... 24
Bijlagen....................................................................................................................................................... 26
Bijlage I...............................................................................................................................................................26
Bijlage II..............................................................................................................................................................28
Bijlage III.............................................................................................................................................................30
Bijlage IV.............................................................................................................................................................32
Bijlage VI.............................................................................................................................................................35
Klinisch redeneren – PL3.............................................................................................................................. 36
Inleiding...................................................................................................................................................... 38
Probleemoriëntatie...................................................................................................................................... 39
1.1 Casus beschrijving.........................................................................................................................................39
2
, 1.1.1 Situation................................................................................................................................................39
1.1.2 Background...........................................................................................................................................40
1.1.3 Assessment...........................................................................................................................................41
1.1.4 Recommendation.................................................................................................................................41
1.2 Extra informatie............................................................................................................................................42
1.3 Hypothetische-, en/of differentiaaldiagnoses..............................................................................................42
1.3.1 Bloeding................................................................................................................................................42
1.3.2 Gastroparese........................................................................................................................................42
1.3.3 Dehydratie............................................................................................................................................42
Probleemanalyse......................................................................................................................................... 43
2.1 Somatische-problematiek.............................................................................................................................43
2.1.1 Respiratoir systeem..............................................................................................................................43
2.1.2 Cardiovasculair systeem.......................................................................................................................43
2.1.3 Zuurstofbalans myocard.......................................................................................................................43
2.1.4 Vocht & elektrolytenbalans..................................................................................................................43
2.1.5 Afweersysteem.....................................................................................................................................43
2.1.6 Thermoregulatie systeem.....................................................................................................................43
2.1.7 Bloed.....................................................................................................................................................43
2.1.8 Digestief systeem..................................................................................................................................43
2.1.9 Neurologisch systeem/ zintuigelijk.......................................................................................................43
2.1.10 Neurologisch systeem/ brein..............................................................................................................43
2.1.11 Neurologisch systeem/ motoriek.......................................................................................................44
2.1.12 Endocrien systeem..............................................................................................................................44
2.2 Prioriteit somatische-problematiek..............................................................................................................44
2.3 Functionele-, sociale-, psychische-, spirituele-problematiek........................................................................44
2.3.1 Functionele-problematiek....................................................................................................................44
2.3.2 Sociale-problematiek............................................................................................................................44
2.3.3 Psychische-problematiek......................................................................................................................44
2.3.4 Spirituele-problematiek........................................................................................................................44
2.4 Prioriteit functioneel-, sociale-, psychische-, spirituele-problematiek..........................................................45
Aanvullend onderzoek en diagnose.............................................................................................................. 46
3.1 Aanvullend onderzoek..................................................................................................................................46
3.1.1 Vitale functies.......................................................................................................................................46
3.1.2 Aanvullende anamnese........................................................................................................................46
3.1.3 Laboratoriumonderzoek.......................................................................................................................46
3.1.4 Beeldvormend onderzoek....................................................................................................................47
3.2 Verpleegkundige diagnoses..........................................................................................................................47
Klinisch beleid.............................................................................................................................................. 49
4.1 Verpleegkundige interventies somatische problematiek.............................................................................49
4.2 Verpleegkundige interventies functioneel-, sociale-, psychische-, spirituele-problematiek.........................49
4.3 Multidisciplinair............................................................................................................................................49
4.4 Shared-decision making (SDM).....................................................................................................................49
Klinisch verloop........................................................................................................................................... 50
5.1 Klinisch verloop somatisch-gebied................................................................................................................50
5.2 Klinisch verloop functioneel-, sociale-, psychische-, spirituele-gebied.........................................................50
5.3 Zelfmanagement..........................................................................................................................................50
3
, 5.4 Zorg inventarisatie........................................................................................................................................51
Evaluatie...................................................................................................................................................... 52
6.1 Reflectie zorgproces......................................................................................................................................52
6.2 Zorgdossier...................................................................................................................................................52
Begrippenlijst.............................................................................................................................................. 53
Nawoord..................................................................................................................................................... 54
Literatuurlijst............................................................................................................................................... 55
Bijlagen....................................................................................................................................................... 59
Bijlage I...............................................................................................................................................................59
Bijlage II..............................................................................................................................................................60
Bijlage III.............................................................................................................................................................61
Bijlage IV.............................................................................................................................................................62
Bijlage V..............................................................................................................................................................63
Bijlage VI.............................................................................................................................................................64
............................................................................................................................................................................64
Bijlage VII............................................................................................................................................................66
Evaluatieformulier CanMEDS-rollen – PL3.................................................................................................... 67
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