Dit is het verslag klinisch redeneren en onderzoekend vermogen, onderdeel van je PL2.
Ik had voor dit verslag een 8,0.
Enkele links zijn verwijderd in verband met privacy en gebruik vanuit een database.
,Voorwoord
Het portofolio heb ik gemaakt voor het behalen van mijn Praktijk leren 2 (PL2). Het bestaat uit twee
onderdelen. Het eerste onderdeel is het eindverslag van de CanMEDS-rollen. Het tweede onderdeel
is een uitwerking van de opdracht klinisch redeneren en onderzoekend vermogen.
In het eerste onderdeel beschrijf ik hoe aan de CanMEDS-rollen heb gewerkt gedurende mijn sta
Voor het tweede onderdeel heb ik een patiënt gekozen die verbleef in het [organisatie]. Hij lag op de
long- en vaatchirurgie verpleegafdeling. Zijn gegevens zijn veranderd naar fictieve gegevens.
Klinisch redeneren is de vaardigheid om eigen observaties en interpretaties te koppelen aan
medische kennis. Zo kunnen verpleegkundigen goed onderbouwen welke verpleegkundige
interventies zij moeten inzetten bij een ziektebeeld of verpleegprobleem en welke vervolgstappen ze
moeten nemen. (Berends, 2017)
2
,Inhoudsopgave
Voorwoord.............................................................................................................................................2
Casusomschrijving..................................................................................................................................6
Stap 1: Anamnese...................................................................................................................................8
1.1 Gegevens uit het EPD....................................................................................................................8
1.1.1 Algemene informatie.............................................................................................................8
1.1.2 Vitale functies........................................................................................................................8
1.1.3 Lichaamsbouw.......................................................................................................................8
1.1.4 Medicatie tijdens de opname................................................................................................9
1.1.5 Lab-waarden........................................................................................................................10
1.2 Classificatiemodel van Gordon...................................................................................................11
1.2.1 Patroon van gezondheidsbeleving en –instandhouding......................................................11
1.2.2 Voedings- en stofwisselingspatroon....................................................................................11
1.2.3 Uitscheidingspatroon...........................................................................................................11
1.2.4 Activiteitenpatroon..............................................................................................................11
1.2.5 Slaap- en rustpatroon..........................................................................................................12
1.2.6 Cognitie- en waarnemingspatroon......................................................................................12
1.2.7 Zelfbelevingspatroon...........................................................................................................12
1.2.8 Rollen- en relatiepatroon.....................................................................................................12
1.2.9 Seksualiteit- en voortplantingspatroon................................................................................12
1.2.10 Stressverwerkingspatroon.................................................................................................12
1.2.11 Aarden en levensovertuigingspatroon...............................................................................12
1.3 Meet- en Screeningsinstrumenten.............................................................................................13
1.3.1 Early Warning Score (EWS)..................................................................................................13
1.3.2 Numeric (pain) Rating Scale (NRS).......................................................................................13
1.3.3 Delirium Observatie Screening (DOS)..................................................................................13
1.3.4 Bristol Stoelgangschaal (BSS)...............................................................................................13
1.3.5 Decubitus.............................................................................................................................14
1.3.6 Wondformulier....................................................................................................................14
1.4 Shared decision making..............................................................................................................15
1.5 Zorgtraject..................................................................................................................................15
Stap 2: Diagnostiek...............................................................................................................................16
2.1 Anatomie en functies..................................................................................................................16
2.1.1 Afweersysteem....................................................................................................................16
2.1.2 Bloed....................................................................................................................................16
3
, 2.1.3 Zintuiglijk systeem...............................................................................................................17
2.1.4 Overige disfunctionele orgaansystemen..............................................................................17
2.2 Externe en persoonlijke factoren................................................................................................17
2.2.1 Beperkende factoren voor het herstel.................................................................................17
2.2.2 Versterkende factoren voor het herstel..............................................................................18
2.2.3 Copingstijl............................................................................................................................18
2.3 Activiteiten en participatie.........................................................................................................19
2.3.1 Beperkingen.........................................................................................................................19
2.3.2 (Aanvullende) Meet- en Screeningsinstrumenten...............................................................19
2.3.3 Kwaliteit van leven...............................................................................................................21
2.4 Verpleegkundige diagnoses........................................................................................................21
Stap 3: Resultaat...................................................................................................................................22
3.1 Verminderde mobiliteit..............................................................................................................22
3.2 Eenzaamheid..............................................................................................................................22
3.3 Risico op terugval (roken)...........................................................................................................22
Stap 4: Interventies (zorgbehandelplan)..............................................................................................23
4.1 Verminderde mobiliteit..............................................................................................................23
4.1.1 Pijnbestrijding......................................................................................................................23
4.1.2 Coban-zwachtel...................................................................................................................23
4.1.3 Mobiliseren stimuleren........................................................................................................23
4.2 Eenzaamheid..............................................................................................................................23
4.2.1 Interventies voor sociale facilitering....................................................................................23
4.2.2 Betrekken bij activiteiten.....................................................................................................23
4.2.3 Emotionele ondersteuning..................................................................................................23
4.3 Risico op terugval (roken)...........................................................................................................24
4.3.1 De 5Rs..................................................................................................................................24
4.3.2 Advies en ondersteuning.....................................................................................................24
4.3.3 Ondersteuning van zorginstellingen....................................................................................24
4.3.4 Nicotine-vervangende therapie...........................................................................................24
Stap 5: Evaluatie...................................................................................................................................25
5.1 Evaluatie interventies.................................................................................................................25
5.1.1 Verminderde mobiliteit.......................................................................................................25
5.1.2 Eenzaamheid.......................................................................................................................25
5.1.3 Risico op terugval (roken)....................................................................................................25
5.2 Aanpassingen zorgdossier...........................................................................................................25
5.3 Overdracht..................................................................................................................................26
4
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