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PL4 Stageportfolio- Klinisch redenen en Verpleegkundig Leiderschap

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In dit document vind je Klinisch Redeneren en Verpleegkundig Leiderschap van jaar 4 van de opleiding Verpleegkunde. Opdrachten zijn gemaakt in het Diakonessenhuis Utrecht op afdeling Verloskunde.

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  • September 28, 2023
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  • 2021/2022
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Stageportfolio




Klinisch redeneren & verpleegkundig leiderschap
Renske van ’t Wout
Studentnummer: 1734405
Docent PL4:
Begeleider:
Cursuscode: GVE-4.PL4-17
Datum: 16 januari 2022
Aantal woorden klinisch redeneren: 4499
Aantal woorden verpleegkundig leiderschap:
3001

,Inhoudsopgave
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 diagnoses................................................................................................................9

Stap 2: Probleemanalyse.............................................................................................................................. 10

Orgaansystemen.................................................................................................................................................10
Voortplantingssysteem...................................................................................................................................10
Afweersysteem...............................................................................................................................................10
Neurologisch systeem/ zintuiglijk..................................................................................................................10
Bloed...............................................................................................................................................................10
Vocht- en elektrolytenbalans.........................................................................................................................10
Digestief systeem...........................................................................................................................................10
Respiratoir systeem........................................................................................................................................10
Psychische problematiek................................................................................................................................11
Psychosociale problematiek...........................................................................................................................11
Functionele problematiek..............................................................................................................................11
Spirituele problematiek..................................................................................................................................11

Stap 3: Aanvullend onderzoek en diagnose..................................................................................................12

Onderzoeken.......................................................................................................................................................12
Screeningsinstrumenten................................................................................................................................12
Verpleegkundige diagnoses................................................................................................................................12
Verpleegkundige diagnose 1:.........................................................................................................................12
Verpleegkundige diagnose 2:.........................................................................................................................12
Verpleegkundige diagnose 3:.........................................................................................................................12
Verpleegkundige diagnose 4:.........................................................................................................................13

Stap 4: Klinisch beleid.................................................................................................................................. 14

Interventies.........................................................................................................................................................14
Verpleegkundige diagnose 1: Acute pijn........................................................................................................14
Verpleegkundige diagnose 2: Ineffectieve borstvoeding...............................................................................15
Verpleegkundige diagnose 3: Risico op infectie.............................................................................................15
Verpleegkundige diagnose 4: Risico op postpartum depressie.....................................................................16
Informatieoverdracht en gezamenlijke besluitvorming.................................................................................17

Stap 5: Klinisch verloop................................................................................................................................ 18

Ziekteverloop......................................................................................................................................................18
Opname..........................................................................................................................................................18
Op de korte termijn........................................................................................................................................18


2

, Lange termijn..................................................................................................................................................18
Gevolgen op psychisch en psychosociaal functioneren.................................................................................19
Zelfmanagement versterken/ondersteunen..................................................................................................19
Professionele zorg..........................................................................................................................................19
Mantelzorg.....................................................................................................................................................19

Stap 6: Evaluatie.......................................................................................................................................... 20

Reflectie..............................................................................................................................................................20
Zorgproces......................................................................................................................................................20
Reflectie EPD...................................................................................................................................................20

Literatuurlijst............................................................................................................................................... 21

Bijlage 1: Meetinstrument GARS.................................................................................................................. 24

Bijlage 2: Meetinstrument: ACQ................................................................................................................... 26

Bijlage 3: Early warning score (obstretic)...................................................................................................... 27

Bijlage 4: Edinburgh Postnatal Depression Scale...........................................................................................28

Bijlage 5: Sociale Steun Lijst......................................................................................................................... 30

Bijlage 6: Feedbackformulier werkbegeleider............................................................................................... 32

Verpleegkundig leiderschap......................................................................................................................... 33

Kennismaken met leiderschap............................................................................................................................33
Karaktereigenschappen en stijl van leiders en leiderschap...........................................................................33
Verpleegkundig leiderschap in praktijk..........................................................................................................34
Verpleegkundig leiderschap voor verbeteren van kwaliteit van zorg...........................................................34

Rol van verpleegkundig leiderschap bij het verbeteren van de kwaliteit van zorg op organisatie- en regionaal
of landelijk niveau...............................................................................................................................................35
Landelijk niveau..............................................................................................................................................35
Individueel leiderschap...................................................................................................................................36

Onderzoeken van leiderschap...................................................................................................................... 37

Onderwerp..........................................................................................................................................................37
Stakeholders...................................................................................................................................................37

Schaduwen..........................................................................................................................................................39
Relevante ervaringen en observaties.............................................................................................................39
Reflectie op het schaduwen...........................................................................................................................40
Sterke- en ontwikkelpunten ten aanzien van verpleegkundig leiderschap...................................................41

Bronnenlijst................................................................................................................................................. 42

Bijlage 1: Organogram.................................................................................................................................. 44

Bijlage 2: Vragen aan stakeholder................................................................................................................ 45

Bijlage 3: Feedbackformulier stakeholder..................................................................................................... 47

3

, Bijlage 4: Feedbackformulier werkbegeleider............................................................................................... 48

Bijlage 5: Presentatie.................................................................................................................................. 50

Bijlage 6: Bewijs deelname workshop Interprofessioneel klinisch redeneren................................................52

Bijlage 7: interprofessioneel feedbackdialoog.............................................................................................. 53

CANMEDS- formulier.................................................................................................................................... 56




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