Hogeschool Utrecht
BVK Praktijkleren 2, Pl-2 2018-2019
Stage portfolio
Opdracht klinisch redeneren
Naam
Studentnummer
Studiegroep:
Cursuscode:
Beoordelaar
Datum
,Inhoudsopgave
INLEIDING .......................................................................................................................................... 4
OPDRACHT KLINISCH REDENEREN EN ONDERZOEKEND VERMOGEN ................................................... 5
CASUSBESCHRIJVING.......................................................................................................................... 5
ANAMNESE ........................................................................................................................................ 5
SCREENINGSINSTRUMENTEN ..................................................................................................................... 6
MUST: ‘MALNUTRITION UNIVERSAL SCREENING TOOL’ .........................................................................................6
USD: ‘UTRECHT SYMPTOOM DAGBOEK’ ...............................................................................................................7
DOS: ‘DELIRIUM OBSERVATIE SCREENING SCHAAL’ ................................................................................................7
CSI: ‘CAREGIVER STRAIN INDEX’...........................................................................................................................7
KARNOFSKY/ECOG PERFORMANCE STATUS: ‘EASTERN COOPERATIVE ONCOLOGY GROUP’ ........................................7
EWS: ‘EARLY WARNING SCORE’ ..........................................................................................................................8
PRIORITEITEN ........................................................................................................................................ 8
SHARED DECISION MAKING ....................................................................................................................... 9
BETROKKEN DISCIPLINES .......................................................................................................................... 9
DIAGNOSTIEK ................................................................................................................................... 10
ANATOMIE EN FUNCTIES ........................................................................................................................ 10
DISFUNCTIONELE ORGAANSYSTEMEN ................................................................................................................. 10
EXTERNE EN PERSOONLIJKE FACTOREN ...................................................................................................... 11
COPINGSTIJL ................................................................................................................................................... 13
ACTIVITEITEN EN PARTICIPATIES ............................................................................................................... 13
BEPERKINGEN IN ACTIVITEITEN EN PARTICIPATIE IN DE MAATSCHAPPIJ .................................................................... 13
SCREENINGSINSTRUMENTEN ............................................................................................................................. 13
DE BARTHEL-INDEX.......................................................................................................................................... 14
CFS-APQ....................................................................................................................................................... 14
IPA................................................................................................................................................................ 14
MSP.............................................................................................................................................................. 14
KWALITEIT VAN LEVEN...................................................................................................................................... 14
SF-12 SCORINGSLIJST ...................................................................................................................................... 14
VERSCHILLENDE OPVATTINGEN.......................................................................................................................... 15
VERPLEEGKUNDIGE DIAGNOSES ............................................................................................................... 15
RESULTAAT ...................................................................................................................................... 17
RESULTAAT OPSTELLEN .......................................................................................................................... 17
EVALUATIE MET DE ZORGVRAGER EN FAMILIE .............................................................................................. 17
INTERVENTIES .................................................................................................................................. 18
EVALUATIE ....................................................................................................................................... 20
OVERDRACHT ...................................................................................................................................... 20
EPD.................................................................................................................................................. 20
NAWOORD ...................................................................................................................................... 21
2
, BIJLAGEN ......................................................................................................................................... 22
BIJLAGE 1: ANAMNESE GESPREK AAN DE HAND VAN DE ELF GEZONDHEIDSPATRONEN VAN GORDON ........................ 22
BIJLAGE 2: SCREENINGSLIJSTEN ............................................................................................................... 27
A: MUST (ELIA, 2003). .................................................................................................................................. 27
B: USD .......................................................................................................................................................... 28
C: DOS .......................................................................................................................................................... 29
D: CSI............................................................................................................................................................ 30
E: KARNOFSKY/ECOG PERFORMANCE STATUS ................................................................................................... 31
F: EWS.......................................................................................................................................................... 32
BIJLAGE 3: OVERZICHT VOORGESCHIEDENIS................................................................................................ 33
BIJLAGE 4: ICF MODEL .......................................................................................................................... 34
BIJLAGE 5: LABUITSLAGEN ...................................................................................................................... 35
BIJLAGE 6 ........................................................................................................................................... 36
A. BARTHEL-INDEX ............................................................................................................................... 36
B: CFS-APQ .................................................................................................................................................. 38
C: IPA............................................................................................................................................................ 43
D: MSP ......................................................................................................................................................... 51
BIJLAGE 7: SF-12 VRAGENLIJST ............................................................................................................... 54
BIJLAGE 8: OVERDRACHT NAAR VERVOLGPLEK PATIËNT X............................................................................... 57
BIBLIOGRAFIE................................................................................................................................... 59
3
BVK Praktijkleren 2, Pl-2 2018-2019
Stage portfolio
Opdracht klinisch redeneren
Naam
Studentnummer
Studiegroep:
Cursuscode:
Beoordelaar
Datum
,Inhoudsopgave
INLEIDING .......................................................................................................................................... 4
OPDRACHT KLINISCH REDENEREN EN ONDERZOEKEND VERMOGEN ................................................... 5
CASUSBESCHRIJVING.......................................................................................................................... 5
ANAMNESE ........................................................................................................................................ 5
SCREENINGSINSTRUMENTEN ..................................................................................................................... 6
MUST: ‘MALNUTRITION UNIVERSAL SCREENING TOOL’ .........................................................................................6
USD: ‘UTRECHT SYMPTOOM DAGBOEK’ ...............................................................................................................7
DOS: ‘DELIRIUM OBSERVATIE SCREENING SCHAAL’ ................................................................................................7
CSI: ‘CAREGIVER STRAIN INDEX’...........................................................................................................................7
KARNOFSKY/ECOG PERFORMANCE STATUS: ‘EASTERN COOPERATIVE ONCOLOGY GROUP’ ........................................7
EWS: ‘EARLY WARNING SCORE’ ..........................................................................................................................8
PRIORITEITEN ........................................................................................................................................ 8
SHARED DECISION MAKING ....................................................................................................................... 9
BETROKKEN DISCIPLINES .......................................................................................................................... 9
DIAGNOSTIEK ................................................................................................................................... 10
ANATOMIE EN FUNCTIES ........................................................................................................................ 10
DISFUNCTIONELE ORGAANSYSTEMEN ................................................................................................................. 10
EXTERNE EN PERSOONLIJKE FACTOREN ...................................................................................................... 11
COPINGSTIJL ................................................................................................................................................... 13
ACTIVITEITEN EN PARTICIPATIES ............................................................................................................... 13
BEPERKINGEN IN ACTIVITEITEN EN PARTICIPATIE IN DE MAATSCHAPPIJ .................................................................... 13
SCREENINGSINSTRUMENTEN ............................................................................................................................. 13
DE BARTHEL-INDEX.......................................................................................................................................... 14
CFS-APQ....................................................................................................................................................... 14
IPA................................................................................................................................................................ 14
MSP.............................................................................................................................................................. 14
KWALITEIT VAN LEVEN...................................................................................................................................... 14
SF-12 SCORINGSLIJST ...................................................................................................................................... 14
VERSCHILLENDE OPVATTINGEN.......................................................................................................................... 15
VERPLEEGKUNDIGE DIAGNOSES ............................................................................................................... 15
RESULTAAT ...................................................................................................................................... 17
RESULTAAT OPSTELLEN .......................................................................................................................... 17
EVALUATIE MET DE ZORGVRAGER EN FAMILIE .............................................................................................. 17
INTERVENTIES .................................................................................................................................. 18
EVALUATIE ....................................................................................................................................... 20
OVERDRACHT ...................................................................................................................................... 20
EPD.................................................................................................................................................. 20
NAWOORD ...................................................................................................................................... 21
2
, BIJLAGEN ......................................................................................................................................... 22
BIJLAGE 1: ANAMNESE GESPREK AAN DE HAND VAN DE ELF GEZONDHEIDSPATRONEN VAN GORDON ........................ 22
BIJLAGE 2: SCREENINGSLIJSTEN ............................................................................................................... 27
A: MUST (ELIA, 2003). .................................................................................................................................. 27
B: USD .......................................................................................................................................................... 28
C: DOS .......................................................................................................................................................... 29
D: CSI............................................................................................................................................................ 30
E: KARNOFSKY/ECOG PERFORMANCE STATUS ................................................................................................... 31
F: EWS.......................................................................................................................................................... 32
BIJLAGE 3: OVERZICHT VOORGESCHIEDENIS................................................................................................ 33
BIJLAGE 4: ICF MODEL .......................................................................................................................... 34
BIJLAGE 5: LABUITSLAGEN ...................................................................................................................... 35
BIJLAGE 6 ........................................................................................................................................... 36
A. BARTHEL-INDEX ............................................................................................................................... 36
B: CFS-APQ .................................................................................................................................................. 38
C: IPA............................................................................................................................................................ 43
D: MSP ......................................................................................................................................................... 51
BIJLAGE 7: SF-12 VRAGENLIJST ............................................................................................................... 54
BIJLAGE 8: OVERDRACHT NAAR VERVOLGPLEK PATIËNT X............................................................................... 57
BIBLIOGRAFIE................................................................................................................................... 59
3
