Dit document bevat een volledige uitwerking van de casusopdracht van beroepssituatie 2. De casus is gefocust op meneer en mevrouw Kowalski.
Meneer Kowalski heeft een CVA gehad en is hierdoor rechts halfzijdig verlamd, heeft last van afasie en is rolstoelafhankelijk.
Mevrouw Kowalski heeft al ...
Casusopdracht BS 4
Grote zorgen bij dhr. en mw. Kowalski
Afbeelding 1: dhr. en mw. Kowalski
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,Inhoudsopgave
Inleiding................................................................................................................................... 3
Hoofdstuk A: Voorbereiding op het indiceren..........................................................................4
Norm 1: Professionele autonomie........................................................................................4
Norm 2: Bachelor of master opgeleide verpleegkundige......................................................4
Norm 3: Eigen regie en zelfredzaamheid versterken...........................................................4
Norm 4: Verpleegkundig proces..........................................................................................4
Anamnese........................................................................................................................ 5
Diagnose.......................................................................................................................... 5
Planning van resultaten....................................................................................................5
Planning van interventies.................................................................................................5
Uitvoering......................................................................................................................... 5
Evaluatie van zorg............................................................................................................ 5
Norm 5: Volgens V&VN-richtlijn verslagleggen....................................................................5
Norm 6: Volgens V&VN standaard de verpleegkundige overdracht van zorg......................5
Hoofdstuk B: Indicatiestelling..................................................................................................6
Anamnese........................................................................................................................... 6
2 hypothetische diagnosen onder het NANDA-domein ‘Activiteiten/rust’ (3)....................6
2 hypothetische diagnosen onder het NANDA-domein ‘Rollen/relaties’ (3)......................6
Oorzaken en gevolgen.........................................................................................................6
Zelfstandigheidstekort in wassen (00108)........................................................................6
Zelfstandigheidstekort in kleden (00109)..........................................................................6
Risico op ineffectieve partnerrelatie (00229)....................................................................6
Risico op overbelasting van de mantelzorger (00062)......................................................7
Mogelijke diagnosen............................................................................................................ 7
Zelfredzaamheid en het inzetten van mantelzorgers/vrijwilligers.........................................7
ZelfredzaamheidsRadar...................................................................................................7
Mantelzorg voor de Kowalski’s.........................................................................................8
Mantelzorgers ondersteunen............................................................................................8
Belasting van de mantelzorger.........................................................................................9
Vrijwilligershulp................................................................................................................ 9
Diagnose vaststellen............................................................................................................ 9
Doel bepalen..................................................................................................................... 10
Interventies bepalen (indiceren).........................................................................................10
Toewijzen en/of doorverwijzen...........................................................................................10
Hoofdstuk C: Multidisciplinair samenwerken.........................................................................11
1
, Sociaal domein..................................................................................................................11
Zorgdomein....................................................................................................................... 11
Kwaliteit van zorg en veiligheid.............................................................................................12
Kwaliteit van veiligheid.......................................................................................................12
Kwaliteit van zorg...............................................................................................................12
Hoofdstuk E: Verantwoording literatuur.................................................................................13
Hoofdstuk F: Reflectie...........................................................................................................14
Fase 1: Handelen.............................................................................................................. 14
Fase 2: Terugblikken op het handelen...............................................................................14
Fase 3: Bewust worden van essentiële aspecten..............................................................14
Fase 4: Formuleren van handelingsalternatieven..............................................................14
Bronvermelding..................................................................................................................... 15
Bronvermelding afbeeldingen............................................................................................15
Bijlagen................................................................................................................................. 16
Bijlage I: Functionele Gezondheidspatronen van Gordon (FGP’s).....................................16
Patroon 1: Gezondheidsbevordering en -instandhouding...............................................16
Patroon 2: Voedings- en stofwisselingspatroon..............................................................16
Patroon 3: Uitscheidingspatroon....................................................................................16
Patroon 4: Activiteitenpatroon........................................................................................16
Patroon 5: Slaap- en rustpatroon...................................................................................16
Patroon 6: Cognitie- en waarnemingspatroon................................................................16
Patroon 7: Zelfbelevingspatroon....................................................................................16
Patroon 8: Rollen- en relatiepatroon...............................................................................16
Patroon 9: Seksualiteits- en voortplantingspatroon........................................................16
Patroon 10: Stressverwerkingspatroon..........................................................................16
Patroon 11: Waarden- en levensovertuigingenpatroon..................................................16
Bijlage II: De ZelfredzaamheidsRadar...............................................................................17
ZelfredzaamheidsRadar meneer Kowalski.....................................................................17
ZelfredzaamheidsRadar mevrouw Kowalski...................................................................17
Bijlage III: Ervaren Druk Informele Zorg (EDIZ).................................................................18
EDIZ van mevrouw Kowalski..........................................................................................18
EDIZ van Zofia............................................................................................................... 18
EDIZ van Janek.............................................................................................................. 18
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