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pl2 opdracht HBO-V duale variant, cijfer 7.5!
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mijn pl2- opdracht, cijfer 7,5
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,InhoudsopgaveInleiding..................................................................................................................................................2
Casus......................................................................................................................................................3
Anamnese...............................................................................................................................................3
Toelichting anamnese.........................................................................................................................3
Aandachtspunten vanuit de anamnese..............................................................................................5
Screeningsinstrumenten.....................................................................................................................5
Must...............................................................................................................................................5
Multiple Sclerose Impact Scale (MSIS-29).......................................................................................5
Fatique Severity Scale (FSS)............................................................................................................6
Pain Disability Index (PDI)...............................................................................................................6
Shared decision making......................................................................................................................7
Zorgtraject..........................................................................................................................................7
Diagnostiek.............................................................................................................................................8
Anatomie en functies..........................................................................................................................8
Externe en persoonlijke factoren.....................................................................................................10
Externe factoren...........................................................................................................................10
Persoonlijke factoren....................................................................................................................10
Coping-stijl zorgvrager..................................................................................................................11
Activiteiten en participatie...............................................................................................................12
Beperkingen in het activiteitenpatroon en participatie in het maatschappelijk leven.....................12
Kwaliteit van leven...........................................................................................................................12
Verpleegkundige diagnoses..............................................................................................................12
Verpleegkundige resultaten.................................................................................................................13
Interventies..........................................................................................................................................13
Evaluatie...............................................................................................................................................16
Overdracht...........................................................................................................................................16
Advies over bijstellen zorgdossier........................................................................................................16
Bronnenlijst..........................................................................................................................................17
Bijlage 1 anamneseformulier op basis van Gordon..............................................................................19
Bijlage 2: MUST checklist......................................................................................................................24
Bijlage 3: MSIS-29 vragenlijst................................................................................................................25
Bijlage 4: Fatique Severity Scale (FSS)...................................................................................................26
Bijlage 5: Pain Disability Index..............................................................................................................27
Bijlage 6: Orgaansystemen...................................................................................................................29
1
, Bijlage 7: SF-12 vragenlijst (ingevuld)...................................................................................................30
Inleiding
Ik werk met veel plezier in de thuiszorg, het is zelfstandig werken en je hebt veel
verantwoordelijkheid voor de cliënten die in de wijk wonen. In onze wijk zien we veel verschillende
cliënten. Jong en oud, met veel of weinig zorg. Soms cliënten die tijdelijk in zorg komen na een
operatie, maar ook cliënten die langdurig hulp nodig hebben bij de dagelijkse zorg. Ook zijn er
cliënten die in de laatste levensfase zitten en daar bieden wij palliatieve en terminale zorg. Soms is
het nodig om 24-uurs zorg in te schakelen en ook daarbij kunnen wij cliënten en hun naasten helpen.
Voor mijn opdracht “klinisch redeneren en onderzoekend vermogen” heb ik een nieuwe cliënt
gevraagd of zij het goed vond dat ik haar casus gebruikte voor deze opdracht. Zij gaf aan graag mee
te werken en zo een bijdrage te leveren aan mijn studie.
Om privacy redenen zijn haar gegevens geanonimiseerd.
2
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