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VPLP2 opdr 18 casusuitwerking
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VPLP2 opdr 18 casusuitwerking
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Zorgplan Mevrouw W.CBP 2.1 Zorgverlener
Naam: Maxime Geers
Studentnummers: 1101187
Emailadres student: 1101187@student.hsleiden.nl
Naam docent: Claudia Hoogenboom
Code toets: VPLP2-OPDR-18
Toetsdatum: 4 juni 2019
Aantal woorden: 4477
,Voorwoord
Dit verpleegplan is geschreven op het niveau van een beginnend verpleegkundige in opleiding.
De aanleiding van dit verslag is een zorgplan voor mevrouw W., om de veiligheid en kwaliteit
van leven zo hoog mogelijk houden.
Dit zorgplan is erg leerzaam voor mij geweest. Door dit zorgplan heb ik inzicht gekregen in het
leven van een cliënt met dementie en de gevolgen van dementie op het dagelijks leven en
functioneren. Ook vond ik het leuk dat dit een echte casus was en dit zorgplan toegepast wordt
in de praktijk.
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,Inhoudsopgave
Inleiding ................................................................................................................................... 6
H1 Anamnese .......................................................................................................................... 7
1.1 Casusbeschrijving ........................................................................................................... 7
1.2 De functionele gezondheidspatronen van Gordon ........................................................... 7
1.2.1 Patroon van gezondheidsbeleving en –instandhouding .............................................. 7
1.2.2 Voedings- en stofwisselingspatroon .......................................................................... 7
1.2.3 Uitscheidingspatroon ................................................................................................ 7
1.2.4 Activiteitenpatroon .................................................................................................... 8
1.2.5 Cognitie- en waarnemingspatroon ............................................................................ 8
1.2.6 Slaap- en rustpatroon ............................................................................................... 8
1.2.7 Zelfbelevingspatroon ................................................................................................ 8
1.2.8 Rollen- en relatiepatroon ........................................................................................... 8
1.2.9 Seksualiteits- en voortplantingspatroon .................................................................... 8
1.2.10 Stressverwerkingspatroon ...................................................................................... 8
1.2.11 Waarden- en levensovertuigingspatroon ................................................................ 8
1.3 Scoresystemen................................................................................................................ 9
1.3.1 Depressie ................................................................................................................. 9
1.3.2 Voeding .................................................................................................................... 9
1.3.3 Incontinentie ............................................................................................................. 9
1.3.4 Dementie .................................................................................................................. 9
1.3.5 Algemene dagelijkse levensverrichtingen ................................................................. 9
H2 Clusteren .......................................................................................................................... 10
2.1 Cluster 1 ........................................................................................................................ 10
2.2 Cluster 2 ........................................................................................................................ 10
2.3 Cluster 3 ........................................................................................................................ 10
H3 OMAHA-systeem.............................................................................................................. 11
3.1 Woning .......................................................................................................................... 11
3.2 Sociaal contact .............................................................................................................. 11
3.3 Cognitie ......................................................................................................................... 12
3.4 Gehoor .......................................................................................................................... 12
3.5 Neuro/musculaire/skelet functie ..................................................................................... 13
3.6 Urineweg functie ............................................................................................................ 13
3.7 Medicatie ....................................................................................................................... 14
3.8 Persoonlijke zorg ........................................................................................................... 14
3.9 Voeding ......................................................................................................................... 15
H4 Risicodiagnosen .............................................................................................................. 16
4.1 Cluster 1 ........................................................................................................................ 16
4.1.1 Hypothetische diagnosen........................................................................................ 16
4.1.2 Verifiëren ................................................................................................................ 16
4.2 Cluster 2 ........................................................................................................................ 17
4.2.1 Hypothetische diagnosen........................................................................................ 17
4.2.2 Verifiëren ................................................................................................................ 17
4.3 Cluster 3 ........................................................................................................................ 18
4.3.1 Hypothetische diagnosen........................................................................................ 18
4.3.2 Verifiëren ................................................................................................................ 18
H5 Vaststelling diagnosen .................................................................................................... 19
H6 Doelen en interventies..................................................................................................... 20
6.1 Geheugenstoornis ......................................................................................................... 20
6.1.1 SMART-doel ........................................................................................................... 20
6.1.2 Interventies ................................................................................................................. 20
3
, 6.2 Zelfzorgtekort syndroom ................................................................................................ 20
6.2.1 SMART-doel ........................................................................................................... 20
6.2.2 Interventies ............................................................................................................. 20
6.3 Reflexincontinentie ........................................................................................................ 21
6.3.1 SMART-doel ........................................................................................................... 21
6.3.2 Interventies ................................................................................................................. 21
6.4 Uitvoering en monitoring ................................................................................................ 21
H7 Evaluatie ........................................................................................................................... 22
7.1 Geheugenstoornis ......................................................................................................... 22
7.1.1 Productevaluatie ..................................................................................................... 22
7.1.2 Procesevaluatie ...................................................................................................... 22
7.2 Zelfzorgtekortsyndroom ................................................................................................. 22
7.2.1 Productevaluatie ..................................................................................................... 22
7.2.2 Procesevaluatie ...................................................................................................... 22
7.3 Reflexincontinentie ........................................................................................................ 23
7.3.1 Productevaluatie ..................................................................................................... 23
7.3.2 Procesevaluatie ...................................................................................................... 23
7.4 Patiënt tevredenheid en patiënt veiligheid ..................................................................... 23
Literatuurlijst ......................................................................................................................... 24
Bijlagen .................................................................................................................................. 25
Bijlage 1: CES-D ................................................................................................................. 25
Bijlage 2: SNAQ65+ ............................................................................................................ 27
Bijlage 3: Incontinence Severity Index ................................................................................. 28
Bijlage 4: IQCODE .............................................................................................................. 29
Bijlage 5: Life Habits ............................................................................................................ 29
Bijlage 6: Self-Care Status - (I)ADL-toestand 0313 .............................................................. 37
Bijlage 7: Complexiteitsscorelijst ......................................................................................... 38
Bijlage 8: Verklaring waarheid gegevens ............................................................................. 41
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