Case
Casusopdracht BS4
- Course
- Institution
In deze casusopdracht wordt het hele proces van klinisch redeneren doorlopen aan de hand van een casus (meneer en mevrouw Kowalski)
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Meneer en mevrouw KowalskiVakraad Mitt
Naam: Lotte Wisselo
Studentnummer: S1106215
Mail: S1106215@student.hsleiden.nl
Toetscode: VBS4-CA-16
Datum toets: 04-06-18
Docent: Ilona de Rooij
Aantal woorden: 3980
,Inhoudsopgave
Inleiding..................................................................................................................................................2
1. Het normenkader V&VN.....................................................................................................................3
2. Indicatiestelling...................................................................................................................................5
2.1. Anamnesegesprek.......................................................................................................................5
2.2. Diagnosen volgens PES-structuur................................................................................................5
2.3. Diagnosen voorleggen.................................................................................................................7
2.4. Zelfredzaamheid..........................................................................................................................7
2.5. Mantelzorg..................................................................................................................................7
2.5.1. Mantelzorger ondersteunen.................................................................................................8
2.5.2. Vrijwilliger mantelzorg..........................................................................................................9
2.6. CSI................................................................................................................................................9
2.7. Diagnosen vaststellen..................................................................................................................9
2.8. Doel bepalen................................................................................................................................9
2.9. Interventies................................................................................................................................10
3. Multidisciplinair samenwerken.........................................................................................................11
4. Kwaliteit van zorg en veiligheid........................................................................................................12
5. Verantwoording literatuur................................................................................................................13
6. Reflectie............................................................................................................................................14
7. Literatuurlijst....................................................................................................................................15
8. Bijlagen.............................................................................................................................................16
8.1. Anamnese..................................................................................................................................16
8.2. Zelfredzaamheidsradar..............................................................................................................18
8.3. CSI..............................................................................................................................................20
8.4. Literatuurlijst bijlage..................................................................................................................21
1
, Inleiding
In dit document staat de casusopdracht van BS4 uitgewerkt. Het doel van deze opdracht is
om een indicatie voor meneer Kowalski te schrijven. Meneer Kowalski heeft een CVA
doorgemaakt, waarbij hij rechts halfzijdig verlamd is geraakt en last heeft gekregen van
afasie. Hij is sinds kort weer thuis en ik kom bij hem langs als wijkverpleegkundige.
2
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