Portfolio PL3
1. Klinisch redeneren
2. Onderzoekend vermogen
3. Reflectie & Ethiek
Naam:
Studentnummer:
Mailadres:
Studiegroepscode:
Naam docent:
Cursuscode: GVE-2.PL3-23
Inleverdatum: 17 – 06 – 2024
,KLINISCH REDENEREN
Naam:
Studentnummer:
Mailadres:
Studiegroepscode:
Naam docent:
Cursuscode: GVE-2.PL3-23
Aantal woorden: 4471
Inleverdatum: 17 – 06 – 2024
,Inhoudsopgave
Probleemoriëntatie/klinisch beeld ........................................................................................................................ 3
Casus .................................................................................................................................................................. 3
Medische voorgeschiedenis ............................................................................................................................... 3
Medicatie-overzicht ........................................................................................................................................... 4
Veranderende situatie ....................................................................................................................................... 4
Lichamelijke klachten .................................................................................................................................... 4
Psychische klachten ....................................................................................................................................... 5
Sociale klachten ............................................................................................................................................. 5
Ernst van de situatie ...................................................................................................................................... 5
Differentiaal diagnoses ..................................................................................................................................... 5
Femurfractuur ............................................................................................................................................... 6
Heupluxatie ................................................................................................................................................... 6
Probleemanalyse .................................................................................................................................................... 6
Disfunctionele orgaansystemen ........................................................................................................................ 6
Neurologisch systeem/motoriek ................................................................................................................... 6
Neurologisch systeem/brein ......................................................................................................................... 6
Bloed .............................................................................................................................................................. 7
Neurologisch systeem/zintuigelijk ................................................................................................................. 7
Endocrien systeem ........................................................................................................................................ 7
Cardiovasculaire systeem .............................................................................................................................. 7
Stoornissen en/of problematiek ........................................................................................................................ 8
Psychische stoornissen .................................................................................................................................. 8
(psycho)Sociale problematiek ....................................................................................................................... 8
Functionele problematiek ............................................................................................................................. 8
Spirituele problematiek ................................................................................................................................. 8
Aanvullend onderzoek en diagnose ....................................................................................................................... 8
Aanvullend onderzoek ....................................................................................................................................... 8
Femurfractuur ............................................................................................................................................... 8
Heupluxatie ................................................................................................................................................... 9
Verpleegkundige diagnoses .............................................................................................................................. 9
Klinisch beleid ....................................................................................................................................................... 10
Interventies ...................................................................................................................................................... 10
Gezamenlijke besluitvorming .......................................................................................................................... 11
Klinisch verloop .................................................................................................................................................... 12
Korte termijn .................................................................................................................................................... 12
Lange termijn ................................................................................................................................................... 12
Gevolgen van aandoening ............................................................................................................................... 12
Zelfmanagement ............................................................................................................................................. 12
Professionele zorg en mantelzorg ................................................................................................................... 13
1
, Evaluatie met cliënt .............................................................................................................................................. 13
Reflectie zorgproces ......................................................................................................................................... 14
Reflectie elektronisch patiëntendossier .......................................................................................................... 14
Literatuurlijst ........................................................................................................................................................ 15
Bijlages .................................................................................................................................................................. 18
Bijlage 1: Valrisico test voor veranderende situatie ......................................................................................... 18
Bijlage 2: Barthel-index na veranderende situatie ........................................................................................... 19
Bijlage 3: Barthel-index vóór veranderende situatie ........................................................................................ 21
Bijlage 4: Falls Efficacy Scale ............................................................................................................................ 23
Bijlage 5: Caregiver Scale Index ........................................................................................................................ 24
Bijlage 6: Feedback werkbegeleider ................................................................................................................. 25
Bijlage 7: Evaluatieformulier CanMEDS-rollen PL3............................................................................................. 0
Bijlage 8: Volledige anamnese meneer ‘X’ ......................................................................................................... 1
2
1. Klinisch redeneren
2. Onderzoekend vermogen
3. Reflectie & Ethiek
Naam:
Studentnummer:
Mailadres:
Studiegroepscode:
Naam docent:
Cursuscode: GVE-2.PL3-23
Inleverdatum: 17 – 06 – 2024
,KLINISCH REDENEREN
Naam:
Studentnummer:
Mailadres:
Studiegroepscode:
Naam docent:
Cursuscode: GVE-2.PL3-23
Aantal woorden: 4471
Inleverdatum: 17 – 06 – 2024
,Inhoudsopgave
Probleemoriëntatie/klinisch beeld ........................................................................................................................ 3
Casus .................................................................................................................................................................. 3
Medische voorgeschiedenis ............................................................................................................................... 3
Medicatie-overzicht ........................................................................................................................................... 4
Veranderende situatie ....................................................................................................................................... 4
Lichamelijke klachten .................................................................................................................................... 4
Psychische klachten ....................................................................................................................................... 5
Sociale klachten ............................................................................................................................................. 5
Ernst van de situatie ...................................................................................................................................... 5
Differentiaal diagnoses ..................................................................................................................................... 5
Femurfractuur ............................................................................................................................................... 6
Heupluxatie ................................................................................................................................................... 6
Probleemanalyse .................................................................................................................................................... 6
Disfunctionele orgaansystemen ........................................................................................................................ 6
Neurologisch systeem/motoriek ................................................................................................................... 6
Neurologisch systeem/brein ......................................................................................................................... 6
Bloed .............................................................................................................................................................. 7
Neurologisch systeem/zintuigelijk ................................................................................................................. 7
Endocrien systeem ........................................................................................................................................ 7
Cardiovasculaire systeem .............................................................................................................................. 7
Stoornissen en/of problematiek ........................................................................................................................ 8
Psychische stoornissen .................................................................................................................................. 8
(psycho)Sociale problematiek ....................................................................................................................... 8
Functionele problematiek ............................................................................................................................. 8
Spirituele problematiek ................................................................................................................................. 8
Aanvullend onderzoek en diagnose ....................................................................................................................... 8
Aanvullend onderzoek ....................................................................................................................................... 8
Femurfractuur ............................................................................................................................................... 8
Heupluxatie ................................................................................................................................................... 9
Verpleegkundige diagnoses .............................................................................................................................. 9
Klinisch beleid ....................................................................................................................................................... 10
Interventies ...................................................................................................................................................... 10
Gezamenlijke besluitvorming .......................................................................................................................... 11
Klinisch verloop .................................................................................................................................................... 12
Korte termijn .................................................................................................................................................... 12
Lange termijn ................................................................................................................................................... 12
Gevolgen van aandoening ............................................................................................................................... 12
Zelfmanagement ............................................................................................................................................. 12
Professionele zorg en mantelzorg ................................................................................................................... 13
1
, Evaluatie met cliënt .............................................................................................................................................. 13
Reflectie zorgproces ......................................................................................................................................... 14
Reflectie elektronisch patiëntendossier .......................................................................................................... 14
Literatuurlijst ........................................................................................................................................................ 15
Bijlages .................................................................................................................................................................. 18
Bijlage 1: Valrisico test voor veranderende situatie ......................................................................................... 18
Bijlage 2: Barthel-index na veranderende situatie ........................................................................................... 19
Bijlage 3: Barthel-index vóór veranderende situatie ........................................................................................ 21
Bijlage 4: Falls Efficacy Scale ............................................................................................................................ 23
Bijlage 5: Caregiver Scale Index ........................................................................................................................ 24
Bijlage 6: Feedback werkbegeleider ................................................................................................................. 25
Bijlage 7: Evaluatieformulier CanMEDS-rollen PL3............................................................................................. 0
Bijlage 8: Volledige anamnese meneer ‘X’ ......................................................................................................... 1
2
