Het genoemde document bevat het stageportfolio van PL4. De opdrachten zijn geschreven op de afdeling cardiologie. Het betreft de opdracht; klinisch redeneren en Verpleegkundig leiderschap.
Mike van Roden
1712279
GVE-4R1-DIA-D-20
Bert Warmelink
11/01/2021
,Inhoud
Evaluatie canMEDS-rollen......................................................................................................................3
Klinisch redeneren................................................................................................................................10
Onderdeel 1: klinisch redeneren ten behoeve van een veranderende situatie....................................13
Stap 1: Probleemoriëntatie/klinisch beeld..........................................................................13
1.1 Situatie..................................................................................................................... 13
1.2 Background.............................................................................................................13
1.3 Assessment.............................................................................................................. 14
1.4 Recommendation.....................................................................................................14
De ernst van de situatie..................................................................................................14
Differentiaaldiagnoses passend bij het klinisch beeld.....................................................14
Stap 2: Probleemanalyse...................................................................................................15
Disfunctionele orgaansystemen.....................................................................................15
Psychische stoornissen..................................................................................................16
(Psycho)Sociale problematiek........................................................................................16
Functionele problematiek...............................................................................................16
Spirituele problematiek...................................................................................................16
Analyse gebruikte meetinstrumenten.............................................................................16
Stap 3: Aanvullend onderzoek en diagnose.......................................................................17
Medische diagnose........................................................................................................17
Verpleegkundige diagnoses...........................................................................................17
Stap 4: Klinisch beleid.......................................................................................................18
Shared decision making.................................................................................................21
Onderdeel 2: Het klinisch redeneren ten behoeve van het totale verpleegkundig proces...................22
Stap 5: Klinisch verloop.....................................................................................................22
Korte termijn................................................................................................................... 22
Lange termijn................................................................................................................. 22
Gevolgen van de ziekte..................................................................................................23
Zelfmanagement............................................................................................................ 23
Mantel- of professionele zorg.........................................................................................23
Stap 6: Evaluatie................................................................................................................ 24
Behandeling en opnameduur.........................................................................................24
Kwaliteit van zorg...........................................................................................................24
Zorgdossier.................................................................................................................... 24
Ontslag........................................................................................................................... 24
Ethische aspecten..........................................................................................................24
1
,Literatuurlijst........................................................................................................................................25
Bijlage...................................................................................................................................................27
Bijlage 1. Anamnese volgens Gordon................................................................................27
Bijlage 2. Eerste lab uitslagen, vitale parameters en medicatielijst 03/09/2020.................29
Medicatielijst.................................................................................................................. 30
Bijlage 3. relevante meetinstrumenten...............................................................................32
Bijlage 4. Overdracht bestemd voor verpleegkundige van de thuiszorg.............................35
Feedbackformulier klinisch redeneren.................................................................................................37
Voorbereiding op leiderschap..............................................................................................................41
Wat is verpleegkundig leiderschap?..................................................................................41
Voorbeelden in de praktijk.................................................................................................41
Verbetering van kwaliteit van zorg op de stageplek...........................................................42
De rol van verpleegkundig leiderschap op organisatie-, en regionaal of landelijk niveau...42
Organisatie..................................................................................................................... 42
Landelijk......................................................................................................................... 43
Stagevoorbeelden..............................................................................................................43
Onderzoeken van leiderschap..............................................................................................................45
Het thema.......................................................................................................................... 45
Stakeholders...................................................................................................................... 45
Vragen en beantwoording..................................................................................................46
Relevante ervaringen.........................................................................................................48
Conclusie........................................................................................................................... 48
Reflectie............................................................................................................................. 48
Ontwikkelpunten met betrekking tot leiderschap............................................................49
Bronnenlijst..........................................................................................................................................50
Bijlage 1. De interviewvragen...............................................................................................................52
Bijlage 2. Presentatie............................................................................................................................53
Bijlage 3. Stakeholder, member check..................................................................................................56
Feedbackformulier verpleegkundig leiderschap...................................................................................58
Bewijs deelname interprofessioneel klinisch redeneren......................................................................59
2
, Evaluatie canMEDS-rollen
3
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