Praktijkleren 3 - Complete stageportfolio (Klinisch Redeneren en Onderzoekend Vermogen)
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Course
Praktijkleren 3 (GVE3.PL316)
Institution
Hogeschool Utrecht (HU)
In dit document zijn twee stageopdrachten toegevoegd, namelijk: klinisch redeneren en onderzoekend vermogen. Inclusief de bronnenlijst en beoordelingslijsten voor wetenschappelijke onderzoek.
, 1.3 Differentiaal en hypothetische diagnoses.................................................................................5
2 Probleemanalyse.............................................................................................................................6
2.1 (Disfunctionele) orgaansystemen.............................................................................................6
2.2 (Psycho)sociale problematiek...................................................................................................7
2.3 Psychische stoornis(sen)...........................................................................................................7
2.4 Functionele problematiek.........................................................................................................7
2.5 Spirituele problematiek............................................................................................................8
3 Aanvullend onderzoek en diagnose.................................................................................................8
3.1 Aanvullende onderzoeken........................................................................................................8
3.2 Verpleegkundige diagnoses......................................................................................................8
4 Klinisch beleid..................................................................................................................................9
4.1 Interventies...............................................................................................................................9
4.2 Shared Decision-Making (SDM)..............................................................................................10
5 Klinisch verloop..............................................................................................................................10
5.1 Klinische verloop op korte termijn..........................................................................................10
5.2 Klinisch verloop op lange termijn............................................................................................11
5.3 Zelfmanagement.....................................................................................................................11
5.4 Betrokken disciplines en mantelzorg......................................................................................11
6 Evaluatie........................................................................................................................................12
6.2 Reflectie zorgproces...............................................................................................................13
6.3 Reflectie elektronische cliëntendossier..................................................................................13
7 Literatuurlijst.................................................................................................................................13
8 Bijlagen..........................................................................................................................................16
Bijlage 1: Medicatielijst.................................................................................................................16
Bijlage 2: De Early Warning Score.................................................................................................17
Bijlage 3: De elf functionele gezondheidspatronen van Gordon...................................................17
Bijlage 4: SCEGS............................................................................................................................19
Bijlage 5: Visual Analogue Scale (VAS)..........................................................................................20
Bijlage 6: De Mini-Mental State Examination instrument.............................................................21
Bijlage 7: De verkorte checklist veilige zorg ‘risico op vallen’.......................................................22
Bijlage 8: Barthel-index.................................................................................................................23
Bijlage 9: Feedbackformulier werkbegeleider..............................................................................24
Samenvatting....................................................................................................................................27
1. Probleemanalyse (Inleiding).............................................................................................................28
2.1 Probleemstelling.........................................................................................................................29
2.2 Doelstelling.................................................................................................................................30
2
, 2.3 Vraagstelling...............................................................................................................................30
2.4 Essentiële variabelen..................................................................................................................30
2. Onderzoeksmethode........................................................................................................................31
2.1 Onderzoekscriteria.....................................................................................................................32
2.2 Zoektermen................................................................................................................................32
2.3 Onderzoeksstrategie...................................................................................................................33
2.4 Verantwoording gekozen artikelen.............................................................................................34
3. Resultaten.........................................................................................................................................35
3.1 Beoordeling gekozen artikel.......................................................................................................35
3.2 Resultaten gekozen artikel..........................................................................................................35
Artikel 1........................................................................................................................................36
Artikel 2........................................................................................................................................36
Artikel 3........................................................................................................................................36
Artikel 4........................................................................................................................................37
4. Discussie...........................................................................................................................................37
Artikel 1............................................................................................................................................37
Artikel 2............................................................................................................................................38
Artikel 3............................................................................................................................................38
Artikel 4............................................................................................................................................38
5. Conclusie..........................................................................................................................................39
6. Advies...............................................................................................................................................40
7. Literatuurlijst....................................................................................................................................41
8. Bijlagen.............................................................................................................................................44
Bijlage 1: Beoordelingslijsten wetenschappelijke onderzoek publicaties.........................................44
Bijlage 2: Feedbackformulieren werkbegeleidsters..........................................................................55
1. Probleemoriëntatie/ klinisch beeld
In de eerste stap, wordt de actuele gezondheidssituatie van de gekozen zorgvrager in kaart
gebracht met behulp van redeneerhulpen. Het klinisch beeld wordt ondersteund door
observaties en metingen (Bakker, 2014, p. 20).
1.1 Casusbeschrijving
Mevrouw A. is rond de 80 jaar en woont samen met haar echtgenoot in een appartement in
Utrecht. Sinds februari is mevrouw in zorg bij Careyn Thuiszorg Leidsche Rijn. Mevrouw was
niet tevreden over de vorige zorgaanbieder. De kinderen willen dat hun moeder nu de juiste
zorg ontvangt en ondersteund wordt in haar algemene dagelijkse levensverrichtingen (ADL).
Mevrouw is niet meer zelfredzaam en heeft één keer per week op de donderdag hulp nodig
bij het douchen en aankleden. Op de andere dagen wordt mevrouw geholpen door haar
kinderen, die ook haar mantelzorgers zijn. De afgelopen tijd is het de kinderen opgevallen
dat er bij mevrouw cognitieve achteruitgang is toegenomen. Mevrouw heeft vier dochters en
twee zoons. Mevrouw is Afghaans, begrijpt de Nederlandse taal niet goed en spreekt
3
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