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PL2 Stageportfolio- Klinisch redeneren (cijfer 8,6)

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In het portfolio wordt het verpleegkundig proces laten zien waarin gekeken wordt naar de belangrijkste problemen van de cliënt, welke verpleegkundige diagnoses er gesteld zijn en tenslotte welke interventies er bedacht zijn de cliënt te ondersteunen en te helpen waar nodig. Voor deze opdracht is ...

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  • September 18, 2022
  • 34
  • 2019/2020
  • Essay
  • Unknown
  • 8-9

3  reviews

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By: RIM2000 • 1 year ago

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By: nicolevanginkel • 1 year ago

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By: marit94plat • 1 year ago

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Klinisch redeneren
PL2 Stageportfolio
2019 – 2020

,Inleiding


In het portfolio wordt het verpleegkundig proces laten zien waarin gekeken wordt naar de
belangrijkste problemen van de cliënt, welke verpleegkundige diagnoses er gesteld zijn en tenslotte
welke interventies er bedacht zijn de cliënt te ondersteunen en te helpen waar nodig. Voor deze
opdracht is een cliënt uitgekozen met Chronic Obstructive Pulmonary Disease(COPD) en
Decompensatio cordis. De cliënt staat beschreven als mevrouw Oosterhuis, dit is een fictieve naam in
verband met de privacy. Helaas beschikt de auteur niet over alle gegevens van mevrouw, omdat zij
niet meer voor haar zorgt en hier ook geen toegang meer tot het dossier heeft. Om deze reden is een
deel van dit verslag fictief, om toch een zo compleet mogelijk beeld van de cliënt te vormen.




2

,Inhoud
Inleiding..................................................................................................................................................2
Anamnese...............................................................................................................................................5
Casusbeschrijving...............................................................................................................................5
Medische voorgeschiedenis...............................................................................................................6
Medicatieoverzicht.............................................................................................................................6
Anamnese volgens Gordon.................................................................................................................6
Screenings/ meet instrumenten.........................................................................................................9
Barthel- index.................................................................................................................................9
Bradenschaal..................................................................................................................................9
Short Nutritional Assessment Questionnaire (SNAQ).....................................................................9
Eenzaamheidschaal........................................................................................................................9
Probleemgebieden.......................................................................................................................10
Tabel 1: Zorgtraject.......................................................................................................................10
Diagnostiek...........................................................................................................................................12
Anatomie en Fysiologie....................................................................................................................12
Externe en persoonlijke factoren.....................................................................................................13
Copingstijlen.....................................................................................................................................14
Activiteiten en participatie...............................................................................................................14
Tabel 2: Screeningsinstrumenten.....................................................................................................14
Kwaliteit van leven...........................................................................................................................15
Verpleegkundige diagnoses..............................................................................................................15
Tabel 3: Zorgplan..............................................................................................................................16
Evaluatie...............................................................................................................................................17
Advies...............................................................................................................................................18
Literatuurlijst........................................................................................................................................20
Bijlagen.................................................................................................................................................23
Bijlage 1 Screeningsinstrument: Barthel- index....................................................................................23
Bijlage 2 Screeningsinstrument: Bradenschaal.....................................................................................25
Bijlage 3 Screeningsinstrument: MRC...................................................................................................28
Bijlage 4 Screeningsinstrument:SNAQ 65+...........................................................................................29
Bijlage 5 Screeningsinstrument: Eenzaamheidschaal...........................................................................30
Bijlage 6 SF-12......................................................................................................................................31




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