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Opdracht klinisch redeneren en onderzoekend vermogen
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Opdracht klinisch redeneren en onderzoekend vermogen pl2 + Innovatie opdracht eenzaamheidsschaal
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2021Klinisch redeneren en
onderzoekend vermogen
14-JUNI-2021
,Voorwoord
Dit verslag gaat over een zorgvrager met multimorbiditeit. Hierbij zijn verschillende
diagnoses en interventies opgesteld om de algehele gezondheid te verbeteren.
Om de privacy van in bescherming te houden, worden de gegevens van de cliënt in de casus
geanonimiseerd. De cliënt wordt aangeduid met mevrouw.
1
,Inhoudsopgave
Voorwoord.............................................................................................................................................1
1.1 Casusbeschrijving.............................................................................................................................3
2.1 Anamnese.........................................................................................................................................4
2.1.1 Omgevings-domein................................................................................................................4
2.1.3 Psychosociaal Domein...........................................................................................................4
2.1.4 Fysiologisch Domein..............................................................................................................4
2.1.5 Gezondheidsgerelateerd Gedrags-Domein............................................................................4
2.2 Aanvullende informatie uit screeningsinstrumenten.......................................................................4
2.3 Zorgtraject........................................................................................................................................6
3 Diagnostiek..........................................................................................................................................7
3.1 Disfunctionele orgaansystemen...................................................................................................8
3.2 Externe en persoonlijke factoren..................................................................................................9
3.2.1 Beperkende factoren en versterkende factoren....................................................................9
3.3.2 Coping....................................................................................................................................9
3.3 Activiteiten en participatie.........................................................................................................10
3.5 Verpleegkundige diagnoses........................................................................................................11
4. Resultaat...........................................................................................................................................12
5. Interventies......................................................................................................................................13
5.1 Verpleegkundige diagnose: Risico op eenzaamheid...................................................................14
5.2 Verpleegkundige diagnose: valpreventie....................................................................................14
5.3 Verpleegkundige diagnose: Pijn..................................................................................................15
6. Evaluatie...........................................................................................................................................15
6.1 Advies voor veranderingen in dossier.........................................................................................16
6.2 Overdracht..................................................................................................................................17
Bronvermelding....................................................................................................................................18
Bijlage 1: Dynamic Gait Index...............................................................................................................21
Bijlage 2 Barthel index..........................................................................................................................22
Bijlage 3 SARC-F vragenlijst...................................................................................................................22
Bijlage 4: Algofunctionele Index voor artrose van heup.......................................................................24
Bijlage 5 Algofunctionele Index voor artrose van knie..........................................................................24
Bijlage 6 eenzaamheidsschaal..............................................................................................................25
Bijlage 7: SF-12.....................................................................................................................................27
Bijlage 8 Eenzaamheidsschaal 2...........................................................................................................28
Bijlage 9 Innovatie opdracht.................................................................................................................28
2
, Deelopdracht 1.............................................................................................................................29
Deelopdracht 2.............................................................................................................................30
......................................................................................................................................................30
Deelopdracht 3.............................................................................................................................32
Deelopdracht 4.............................................................................................................................32
1.1 Casusbeschrijving
De gekozen zorgvrager is een mevrouw van 89. Mevrouw is woonachtig in De Meern.
Mevrouw was getrouwd, maar haar man is jaren gelden overleden. Mevrouw woont nu
3
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