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Praktijkleren 2 - Portfolio 7/8
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Praktijkleren 2 - Klinisch redeneren
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By: huizedas • 1 year ago
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Figuur 1 De Vierstroom, bron: Persoonlijke Gezondheidscheck (2021).PORTFOLIO,
DEELTOETS 2
Cursusnaam: GVE-2.PL2-17
,Inhoudsopgave
CASUSBESCHRIJVING ...................................................................................................................................... 3
ANAMNESE..................................................................................................................................................... 3
NANDA-ANAMNESE ............................................................................................................................................... 3
Domein 1 Gezondheidsbevordering ............................................................................................................... 3
Domein 2 Voeding .......................................................................................................................................... 3
Domein 3 Uitscheiding/uitwisseling............................................................................................................... 4
Domein 4 Activiteit/rust ................................................................................................................................. 4
Domein 5 Waarneming/cognitie.................................................................................................................... 4
Domein 6 Zelfperceptie .................................................................................................................................. 4
Domein 7 Rollen/relaties................................................................................................................................ 4
Domein 8 Seksualiteit .................................................................................................................................... 4
Domein 9 Coping/stresstolerantie ................................................................................................................. 4
Domein 10 Levensprincipes ............................................................................................................................ 4
Domein 11 Veiligheid/bescherming ............................................................................................................... 4
Domein 12 Welbevinden ................................................................................................................................ 5
Domein 13 Groei/ontwikkeling ...................................................................................................................... 5
SCREENINGS INSTRUMENTEN ..................................................................................................................................... 5
De Nortonschaal ............................................................................................................................................ 5
De Katz algemeen dagelijkse levensverrichtingen schaal .............................................................................. 5
De Elderly Mobility Scale ................................................................................................................................ 5
SHARED DECISION MAKING ........................................................................................................................................ 6
PROBLEEMGEBIEDEN VAN MEVROUW X ....................................................................................................................... 6
SCHEMATISCH OVERZICHT VAN HET AFGELEGDE ZORGTRAJECT .......................................................................................... 7
DIAGNOSE ...................................................................................................................................................... 8
ANATOMIE EN FUNCTIES ........................................................................................................................................... 8
Cardiovasculair systeem ................................................................................................................................ 8
Afweersysteem............................................................................................................................................... 8
EXTERNE EN PERSOONLIJKE FACTOREN ......................................................................................................................... 8
Beperkende factoren ...................................................................................................................................... 8
Versterkende factoren ................................................................................................................................... 9
Copingstijl ...................................................................................................................................................... 9
ACTIVITEITEN EN PARTICIPATIE ................................................................................................................................... 9
KWALITEIT VAN LEVEN .............................................................................................................................................. 9
VERPLEEGKUNDIGE DIAGNOSE .................................................................................................................................. 10
Risico op vallen ............................................................................................................................................ 10
Huiddefect.................................................................................................................................................... 10
Zelfstandigheidstekort in wassen................................................................................................................. 11
RESULTAAT ................................................................................................................................................... 12
RISICO OP VALLEN .................................................................................................................................................. 12
HUIDDEFECT ......................................................................................................................................................... 12
ZELFSTANDIGHEIDSTEKORT IN WASSEN ....................................................................................................................... 12
INTERVENTIES............................................................................................................................................... 13
RISICO OP VALLEN .................................................................................................................................................. 13
HUIDDEFECT ......................................................................................................................................................... 13
ZELFSTANDIGHEIDSTEKORT IN WASSEN ....................................................................................................................... 14
EVALUATIE ................................................................................................................................................... 15
OVERDRACHT ....................................................................................................................................................... 15
Situation ....................................................................................................................................................... 15
Background .................................................................................................................................................. 15
Assessment .................................................................................................................................................. 15
1
, Recommendation ......................................................................................................................................... 16
LITRATUURLIJST............................................................................................................................................ 17
BIJLAGES....................................................................................................................................................... 19
BIJLAGE 1: DE NORTONSCHAAL ................................................................................................................................ 19
BIJLAGE 2: DE KATZ ALGEMEEN DAGELIJKSE LEVENSVERRICHTINGEN SCHAAL ..................................................................... 20
BIJLAGE 3: ELDERLY MOBILITY SCALE ........................................................................................................................ 21
BIJLAGE 4: AFGENOMEN SF-12 LIJST ........................................................................................................................ 22
BIJLAGE 5: FEEDBACKFORMULIER .......................................................................... FOUT! BLADWIJZER NIET GEDEFINIEERD.
BIJLAGE 6: EINDVERSLAG CANMEDS ROLLEN ............................................................................................................. 25
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