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Stageportfolio PL3 klinisch redeneren en CAT
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Dit document bevat de opdrachten Klinisch redeneren en onderzoekend vermogen. Hier wordt een CAT (Critical Appraisal of a Topic) uitgewerkt.
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StageportfolioKlinisch redeneren, CAT en CanMEDS-formulier
Naam:
Studentnummer:
Stage docent:
Werkbegeleider:
Inleverdatum:
Aantal woorden klinisch redeneren: 4071
Aantal woorden onderzoekend vermogen: 3501
1
,Inhoudsopgave
Inhoudsopgave........................................................................................................................................................ 2
Inleiding.................................................................................................................................................................... 5
Klinisch redeneren................................................................................................................................................... 6
Stap 1: Probleem oriëntatie................................................................................................................ 6
Introductie...................................................................................................................................... 6
Veranderende situatie via SBAR-methode.....................................................................................7
Ernst van de situatie....................................................................................................................... 9
Hypothetische/ differentiaal diagnose................................................................................................ 9
Stap 2: Probleemanalyse...................................................................................................................................... 11
Orgaansystemen.............................................................................................................................. 11
Respiratoir systeem..................................................................................................................... 11
Digestief systeem......................................................................................................................... 11
Vocht- en elektrolyten balans....................................................................................................... 11
Afweer systeem............................................................................................................................ 12
Psychische problematiek............................................................................................................. 12
Psychosociale problematiek......................................................................................................... 12
Functionele problematiek:............................................................................................................ 12
Spirituele problematiek:................................................................................................................ 12
Stap 3: Aanvullend onderzoek en diagnose........................................................................................................13
Onderzoeken................................................................................................................................... 13
De onderzoeken in het ziekenhuis............................................................................................... 13
Screeningsinstrumenten.............................................................................................................. 14
Verpleegkundige diagnoses............................................................................................................. 14
Verpleegkundige diagnose 1:....................................................................................................... 14
Verpleegkundige diagnose 2:....................................................................................................... 15
Verpleegkundige diagnose 3:....................................................................................................... 15
Verpleegkundige diagnose 4:....................................................................................................... 15
Stap 4: Klinisch beleid........................................................................................................................................... 16
Interventies...................................................................................................................................... 16
Verpleegkundige diagnose 1: Ineffectieve ademhaling (dyspneu)...............................................16
Verpleegkundige diagnose 2: Hevige vermoeidheid....................................................................17
Verpleegkundige diagnose 3: Misselijkheid.................................................................................18
..................................................................................................................................................... 20
Verpleegkundige diagnose 4: Posttraumatische reactie..............................................................21
Informatieoverdracht en gezamenlijke besluitvorming.................................................................22
Stap 5: Klinisch verloop........................................................................................................................................ 23
Ziekteverloop................................................................................................................................... 23
Gevolgen somatisch/functioneel functioneren..............................................................................23
Gevolgen psychisch functioneren................................................................................................ 23
Gevolgen psychosociale functioneren.......................................................................................... 23
Zelfmanagement versterken/ondersteunen..................................................................................23
Professionele zorg....................................................................................................................... 23
Stap 6: Evaluatie.................................................................................................................................................... 25
Reflectie........................................................................................................................................... 25
Zorgproces................................................................................................................................... 25
2
, Reflectie EPD............................................................................................................................... 25
Literatuurlijst.......................................................................................................................................................... 26
Bijlage 1: Ashtma Control Questionnaire............................................................................................................29
Bijlage 2: Instrumentele ADL................................................................................................................................ 30
Bijlage 3 : Malnutrition Universal Screening Tool..............................................................................................31
Bijlage 4: Major Depression Inventory.................................................................................................................32
Bijlage 5 : Screeningsinstrument VVV.................................................................................................................33
Bijlage 6: Feedbackformulier werkbegeleider....................................................................................................34
CANMEDS-verslag................................................................................................................................................. 35
Balans tussenevaluatie:........................................................................................................................................ 46
Onderzoekend vermogen: Critical appraisal of a Topic....................................................................................48
Probleemanalyse............................................................................................................................. 48
Inleiding........................................................................................................................................ 48
Doelstelling:.................................................................................................................................. 48
Onderzoeksvraag:........................................................................................................................ 48
PICO............................................................................................................................................ 48
Essentiele variabelen:.................................................................................................................. 48
Onderzoeksmethode........................................................................................................................ 49
Inclusiecriteria.............................................................................................................................. 49
Exclusiecriteria............................................................................................................................. 49
Zoek strategieën.......................................................................................................................... 49
Dataverzameling.............................................................................................................................. 50
Data-analyse.................................................................................................................................... 51
Resultaten.................................................................................................................................... 51
Discussie...................................................................................................................................... 53
Implicaties voor de praktijk........................................................................................................... 53
Conclusie......................................................................................................................................... 55
Advies.............................................................................................................................................. 56
Past de (nieuwe) interventie binnen de visie van de instelling, het team en de zorgprofessionals?
..................................................................................................................................................... 56
Beschikken de zorgprofessionals over voldoende vaardigheden?...............................................56
Welke middelen zijn nodig om deze interventie toe te passen in het dagelijks handelen?...........56
Belemmerende en bevorderende factoren...................................................................................56
Wat zou je willen doen om het te laten slagen?...........................................................................56
Wat zou je willen doen om het te laten slagen?...........................................................................56
Samenvatting................................................................................................................................... 57
Literatuurlijst.......................................................................................................................................................... 60
Bijlage 1: Beoordelingslijst artikel 1.................................................................................................................... 62
Bijlage 2: Beoordelingslijst artikel 2.................................................................................................................... 65
Bijlage 3: Beoordelingslijst artikel 3.................................................................................................................... 68
Bijlage 4: Beoordelingslijst artikel 4.................................................................................................................... 71
Bijlage 5: Feedbackformulier................................................................................................................................ 74
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