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Verpleegplan / HBO-V / Verpleegkundig proces / Casus /Beoordeling goed!

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Een voorbeeld van een overzichtelijk verpleegplan uit het boek van Wilkinson, 6e editie, Kritisch denken binnen het verpleegkundig proces. In het verpleegplan zit de casus, wordt aan de hand van het ICF-model gewerkt. De anamnese aan de hand van de 11 gezondheidspatronen van Gorden, piramide va...

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  • January 10, 2023
  • 46
  • 2021/2022
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2  reviews

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By: sa160880nika • 9 months ago

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By: madeliefdejong1 • 1 year ago

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Verpleegkundig proces
Casus Eline




Groep:
Klas:
Inleverdatum:
Studiecoach:
Kans:
Aantal woorden:
Opleiding: HBO-Verpleegkunde




1

,Inleiding
Voor onze casusopdracht verdiepen wij ons in het verpleegkundig proces van de casus Eline. In onze
casus betreft het probleemgebied het dagelijks fysiek functioneren en de mentale verwerking van de
Reumatoïde Artritis. In dit verslag willen wij het verpleegkundig proces duidelijk uitwerken en
weergeven. We nemen de lezer mee in onze stap 1: gegevens verzamelen en stap 2: diagnose daarna
gaan we verder meer stap 3: resultaten en stap 4: interventies. We eindigen met de stap 5 en 6. Ook
staan in het verslag de benodigde bijlagen.




2

,Inhoudsopgave
Inleiding........................................................................................................................................................ 2

ICF-Model...................................................................................................................................................... 5

Numeric Rating Scale (NRS)............................................................................................................................ 5

11 gezondheidspatronen van Gordon............................................................................................................. 6
1. Patroon van gezondheidsbeleving en-instandhouding....................................................................................6
2. Voedings- en stofwisselingspatroon................................................................................................................6
3. Uitscheidingspatroon.......................................................................................................................................7
4. Activiteitenpatroon..........................................................................................................................................7
5. Slaap- en rustpatroon.......................................................................................................................................8
6. Cognitie- en waarnemingspatroon..................................................................................................................8
7. Zelfbelevingspatroon........................................................................................................................................8
8. Rollen-en relatiepatroon..................................................................................................................................9
9. Seksualiteits-en voortplantingspatroon.........................................................................................................10
10. Stress verwerkingspatroon...........................................................................................................................10
11. Waarde-en levensovertuigingspatroon.......................................................................................................10
Waarom de 11 gezondheidspatronen van Gordon............................................................................................11

Gebruikte gesprekstechnieken..................................................................................................................... 11

Subjectieve en objectieve gegevens............................................................................................................. 13

Primaire en secundaire gegevens................................................................................................................. 13

Piramide van Maslow................................................................................................................................... 13
Uitleg en voorbeelden eerste basisbehoefte Maslow piramide.........................................................................14
Uitleg en voorbeelden tweede fase Maslow piramide......................................................................................14
Uitleg en voorbeelden derde fase Maslow piramide.........................................................................................14
Uitleg en voorbeelden vierde basisbehoefte Maslow piramide.........................................................................14
Uitleg en voorbeelden vijfde basisbehoefte Maslow piramide..........................................................................14
Uitleg nut Piramide van Maslow........................................................................................................................15
De piramide van Maslow van casus Eline..........................................................................................................15

Fase 2: Diagnose.......................................................................................................................................... 16

Kernset patiëntproblemen........................................................................................................................... 17

Verpleegkundige diagnose (PES).................................................................................................................. 18
Actuele diagnoses..............................................................................................................................................19
Potentiële diagnose .........................................................................................................................................21

Fase 3: Resultaten........................................................................................................................................ 22


3

, Fase 4: Interventies...................................................................................................................................... 24

Feitelijke verpleegkundige diagnose............................................................................................................. 24

Verpleegkundige interventie........................................................................................................................ 24

Feitelijke verpleegkundige diagnose............................................................................................................. 25

Potentiële verpleegkundige diagnose........................................................................................................... 25

Verpleegkundige interventie........................................................................................................................ 25

Samenspraak met cliënt en familie............................................................................................................... 25

EPB.............................................................................................................................................................. 26
Stap 1 ...............................................................................................................................................................27
Stap 2.................................................................................................................................................................27
Stap 3.................................................................................................................................................................28
Stap 4.................................................................................................................................................................28

Fase 5: Uitvoering ....................................................................................................................................... 29
Zorgtoewijzing ..................................................................................................................................................30
Interventies per zorgniveau ............................................................................................................................30
Continuïteit en coördinatie van zorg .................................................................................................................31
Wet – en regelgeving ........................................................................................................................................33

Fase 6: Evaluatie van de zorg ..................................................................................................................... 33

Bijlage......................................................................................................................................................... 34
Casus Eline ........................................................................................................................................................35
De rode loper Reumatoïde artritis......................................................................................................................36
STRAK zelfassessment; fase 1 en 2.....................................................................................................................39
STRAK zelfassessment; fase 3 en 4.....................................................................................................................40

Beoordeling SR............................................................................................................................................ 41

AGREE-beoordeling...................................................................................................................................... 42

AGREE GLOBAL RATING SCALE..................................................................................................................... 42
OVERALL ASSESSMENT.......................................................................................................................................44

Individuele STARR........................................................................................................................................ 45

Bronnen....................................................................................................................................................... 46




Fase 1: Anamnesefase; gegevens verzamelen

4

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