Klinisch redeneren en verpleegkundige classificaties
In het 2e semester van jaar 2, heb ik voor mijn stage een verpleegkundig proces gemaakt, op basis van één van de bewoners van mijn afdeling. Door mevrouw te leren kennen en het voeren van gesprekken ben ik veel te weten gekomen over mevrouw. Na het verzamelen van vele informatie, ben ik begonnen ...
Casus mevrouw ‘X’......................................................................................................................................... 6
Fase 1: Gegevens verzamelen......................................................................................................................... 7
1.1 Rode loper......................................................................................................................................................7
1.2 Mindmap mevrouw X...................................................................................................................................12
1.3 Anamnese gesprek volgens Gordon.............................................................................................................13
1.3 ......................................................................................................................................................................13
1.4 Model van Lalonde.......................................................................................................................................17
Fase 2: Diagnose.......................................................................................................................................... 18
2.1 Piramide van Maslow...................................................................................................................................18
2.2 Aandachtsgebieden vaststellen met Omaha System...................................................................................19
2.3 PES-methode................................................................................................................................................20
2.3.1 Actuele problemen: PES-methode.......................................................................................................21
2.3.2 Potentiële problemen: PES-methode...................................................................................................24
2.4 Prioriteit patiëntprobleem............................................................................................................................25
Fase 3: Resultaten........................................................................................................................................ 26
3.1 Vaststellen van scores..................................................................................................................................26
3.2 SMART-doelstelling.....................................................................................................................................27
3.2.1 SMART-doel PES: Verminderde eetlust................................................................................................27
3.2.2 Formulering SMART-doel......................................................................................................................27
Fase 5: Uitvoeren van zorg........................................................................................................................... 31
5.1 Wie worden er ingeschakeld?......................................................................................................................31
5.2 Contact onderhouden...................................................................................................................................32
Fase 6: Evaluatie van zorg............................................................................................................................ 32
6.1 Evaluatie.......................................................................................................................................................33
6.1.1 Productevaluatie...................................................................................................................................33
6.1.2 Procesevaluatie.....................................................................................................................................33
6.1.3 Structuurevaluatie................................................................................................................................33
6.2 Na het proces...............................................................................................................................................33
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