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dhr Kuilen

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Hierin kun je een uitwerking van de toetscasus van dhr Kuilen vinden. dit document betreft een volledige uitwerking hiervan

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  • November 23, 2022
  • 79
  • 2021/2022
  • Case
  • Sara
  • 7-8
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Zorgplan dhr. Kuilen




Inleverdatum: 13 Juni 2021
Studenten: Klas:
Vak: LUK 2.2
Opleiding: HBO Verpleegkunde
Hogeschool: NHL Stenden Leeuwarden
Aantal pagina’s: 13 (excl. Voorblad, inleiding en index)
Studiecoach:
Docent:
Index Kans; 1e kans

Inleiding.................................................................................................................................................... 3
Problemen vaststellen en uitwerken........................................................................................................ 4
Actueel aandachtsgebied...................................................................................................................... 4
Prioritering aandachtsgebieden............................................................................................................ 4

, Aandachtsgebied psychosociaal........................................................................................................... 4
Uitwerking............................................................................................................................................ 5
PES........................................................................................................................................................ 5
Verantwoording van de fase aandachtsgebied vaststellen...................................................................6
Vaststellen wat je wilt bereiken................................................................................................................ 7
Aandachtsgebied.................................................................................................................................. 7
Doel (rumba geformuleerd).................................................................................................................. 7
Hoe verhoudt dit doel zich tot de RUMBA-criteria?..............................................................................7
Waarom mijn uitkomst goed aansluit bij de verpleegkundige diagnose...............................................8
Waarom ik heb gekozen voor een uitkomst op lange of korte termijn of beide...................................8
Waarom mijn uitkomst valide en betrouwbaar is.................................................................................8
Waarom mijn uitkomst wel of niet een bijdrage levert aan gezondheidsbevordering..........................8
Waarom dit zorgresultaat past bij deze cliënt....................................................................................... 8
Verantwoording.................................................................................................................................... 9
Interventies vaststellen........................................................................................................................... 10
Casus .................................................................................................................................................. 10
Klinische onzekerheid......................................................................................................................... 10
Beantwoording klinische vraag; zie bijlage 15*................................................................................... 10
Interventies............................................................................................................................................. 11
Argumentatie...................................................................................................................................... 11
Verantwoording/reflectie interventies............................................................................................... 13
Uitvoeren van zorg.................................................................................................................................. 15
Betrokken disciplines.......................................................................................................................... 15
Communicatie met cliënt en diens familie/naasten............................................................................15
Gebruik ICT in combinatie met verpleegkundig proces.......................................................................15
Evaluatie van zorg................................................................................................................................... 16
Procesevaluatie – effectiviteit en efficiëntie interventies....................................................................16
Wanneer en met wie?........................................................................................................................ 16
LableCare................................................................................................................................................ 16
Conclusie lablecare............................................................................................................................. 16
Bijlagen................................................................................................................................................... 19
Bijlage 1; Ontvangen feedback anamnesefase en 1e deel diagnosefase.................................................20
Bijlage 2; Verzamelen en onderzoeken van gegevens............................................................................23
Bijlage 3; Aandachtsgebied vaststellen.................................................................................................32
42 aandachtsgebieden: ...................................................................................................................... 33
............................................................................................................................................................... 33
Bijlage 4; Dhr. Kuilen ............................................................................................................................37

,Bijlage 5; Rode Loper.............................................................................................................................38
Bijlage 6; Ecogram.................................................................................................................................44
Bijlage 7; Barthel Index..........................................................................................................................45
Bijlage 8; Anamnesegesprek..................................................................................................................47
Bijlage 9; Feedbackformulieren hetero-anamnese.................................................................................50
Bijlage 10; Reflectie anamnesegesprek:.................................................................................................53
Bijlage 11; Risico-inventarisatie:............................................................................................................55
Meetinstrumenten bij de risico's:..........................................................................................................55
Bijlage 12; SNAQ score...........................................................................................................................57
Bijlage 13; Gecompliceerde rouw..........................................................................................................58
Bijlage 14; EBP.......................................................................................................................................59
PICO........................................................................................................................................................ 59
BIJLAGE 1 Template uitwerking opdracht............................................................................................... 60
BIJLAGE 2 Template PICO........................................................................................................................ 61
BIJLAGE 5 -Beoordelingsformulier RCT.................................................................................................... 62
Identification.......................................................................................................................................... 69
Screening................................................................................................................................................ 69
Eligibility................................................................................................................................................. 69
Included.................................................................................................................................................. 69
Bijlage 15; Evaluatie rapport EPD; LableCare.........................................................................................70
Inleiding.................................................................................................................................................. 71
Voordelen lablecare ten opzichte papieren dossier................................................................................74
Totstandkoming...................................................................................................................................... 74
Methodiek vilans “zinvol uitproberen”................................................................................................... 74
Literatuurlijst.......................................................................................................................................... 78

, Inleiding
Luk 2.2 is opgedeeld in twee delen, in dit verslag ben ik begonnen met de 2e helft van de diagnosefase en
de anamnesefase + 1e helft diagnosefase in de bijlagen verwerkt. Ik heb als casus dhr Kuilen toegewezen
gekregen met de focus op het uitwerken van het aandachtsgebied psychosociaal met als aandachtsgebied
“rouw” / “gecompliceerde rouw”. Ik heb op basis van de anamnesefase en diagnose een aantal
interventies opgesteld met behulp van EBP en een richtlijn die ik heb geraadpleegd. Het verslag is
ingedeeld op basis van het OMAHA systeem.

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