In het verslag wordt een casus van een mevrouw op de revalidatie afdeling beschreven. mw. is komen te vallen en heeft meerdere fracturen opgelopen. Het verpleegproces wordt doorlopen en er wordt gebruik gemaakt van meetinstrumenten.
Klinisch redeneren
OO-C-1 Casus 2 - PL2-opdracht Klinisch Redeneren en Onderzoekend Vermogen
Naam: Dione Kopp
Studentnummer: 1820178
Studiegroepscode: GVE-1DUVF-C
Naam cursus: OO-C-1 Casus 2 - PL2-opdracht Klinisch Redeneren en Onderzoekend
Vermogen
Docent: Lotte Verweij
Aantal woorden: 5742
Inleverdatum: 06-04-2022
,Inhoud
1. Voorwoord..........................................................................................................................................3
2. Casus beschrijving...............................................................................................................................4
3. Anamnese...........................................................................................................................................5
3.1 Uitleg anamnese...........................................................................................................................5
3.2 Uitwerking anamnese...................................................................................................................5
3.3 SAMPC..........................................................................................................................................6
3.4 Meetinstrumenten.......................................................................................................................8
3.4.1 Barthel index..........................................................................................................................8
3.4.2 Bradenschaal.........................................................................................................................9
3.4.3 NORD.....................................................................................................................................9
3.5. Shared decision making...............................................................................................................9
3.6. Zorgtraject....................................................................................................................................10
4. Diagnose...........................................................................................................................................11
4.1 Anatomie en functies..................................................................................................................11
4.1.1 Afweersysteem....................................................................................................................11
4.1.2 Motorisch systeem..............................................................................................................11
4.2 Externe en persoonlijke factoren................................................................................................11
4.1.1 Coping stijl...........................................................................................................................12
4.2 Activiteiten en participatie.........................................................................................................12
4.2.1 Beperkingen in activiteiten..................................................................................................12
4.3 De kwaliteit van leven.................................................................................................................13
4.3.1 Mijn eigen inschatting..........................................................................................................13
4.3.2 SF-12 vragenlijst...................................................................................................................13
4.3.3 Overeenkomsten en verschillen..........................................................................................13
4.4 Verpleegkundige diagnoses........................................................................................................14
4.4.1 Verpleegprobleem 1: Pijnklachten.......................................................................................14
4.4.2 Verpleegprobleem 2: Vermoeidheid....................................................................................14
4.4.3 Verpleegprobleem 3: Obstipatie..........................................................................................15
4.5 Resultaat.....................................................................................................................................15
4.6 Verpleegdoelen..........................................................................................................................15
5. Interventies......................................................................................................................................17
5.1 Interventies bij pijnklachten...................................................................................................17
5.2 Interventies bij obstipatie.......................................................................................................17
5.3 Interventies bij vermoeidheid.................................................................................................17
Pagina | 1
, 5.4 Bevorderen zelfmanagement en de mening van mevrouw Kok.............................................18
6. Evaluatie...........................................................................................................................................19
6.1 Overdracht casus naar collega’s.............................................................................................19
6.2 Elektronisch cliënten dossier (ECD).........................................................................................19
7. Nawoord.......................................................................................................................................21
8. Literatuurlijst....................................................................................................................................22
9. Bijlagen.............................................................................................................................................25
9.1 Bijlage 1 opname formulier Silverein, Revalidatie en Herstel.....................................................25
9.2 Bijlage anamnese formulier........................................................................................................27
9.3 Bijlage Barthel index...................................................................................................................33
9.4 Bijlage Bradenschaal...................................................................................................................34
9.5 Bijlage NORD...............................................................................................................................35
9.6 Bijlage Vermoeidheidsindex.......................................................................................................36
9.7 Bijlage SF-12...............................................................................................................................38
Pagina | 2
, 1. Voorwoord
Beste lezer,
Afgelopen jaar heb ik mijn opleiding MBO verpleegkunde succesvol afgerond. Momenteel
volg ik de opleiding tot HBO verpleegkundige. In dit verslag wordt het verpleegkundig proces
doorlopen bij een zorgvrager met multi morbiditeit. Voor dit verslag is een zorgvrager op de
geriatrische revalidatie afdeling waar ik werkzaam ben gebruikt. Het doel van dit verslag is
om adviezen aan de zorgvrager en haar naasten te kunnen geven. Dit wordt gedaan door
middel van klinisch redeneren.
Ik wens u veel plezier bij het lezen van dit verslag.
Dione Kopp
Amersfoort, maart 2022.
Pagina | 3
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