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Verpleegkundig proces casus Step
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In dit verslag is de casus van Peter Step behandeld. Hierin wordt zijn zorgproces volledig uitgewerkt.
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Peter StepLEERUITKOMST 1.2 ORIËNTATIE OP VERPLEEGKUNDIG PROCES
KANS 3
INLEVERDATUM – 28 AUGUSTUS 2023
NINA SPOOR - 5167124
MARTINE SCHONENBURG - 5171660
FLORE ELIZARRARAS VEENSTRA - 5205980
AYAAN FARAH – 5175755
BACHELOR VERPLEEGKUNDE, NHL STENDEN HOGESCHOOL LEEUWARDEN.
AANTAL WOORDEN – 8720
DHR. SYBREN MULDER EN DHR. PEPIJN ROELOFS
,Voorwoord
In het kader van onze hbo-opleiding Verpleegkunde aan de NHL Stenden Hogeschool hebben
we dit verslag geschreven. We hebben veel geleerd tijdens het maken van dit verslag. Tijdens
het maken van dit verslag hebben we taken verdeeld, zodat iedereen een goede bijdrage
leverde.
We willen Sybren Mulder en Pepijn Roelofs bedanken voor alle hulp die we hebben gekregen bij
de beantwoording van onze vragen en de lessen die we hebben gekregen.
Te Leeuwarden, 21-12-2021
PAGINA 1
,Verklaring eigen werk
Hierbij verklaren wij, Nina spoor, Martine Schonenburg, Ayaan Farah en Flore Elizarraras
Veenstra, dat wij dit verslag zelf hebben geschreven en dat wij de volledige
verantwoordelijkheid op ons nemen voor de inhoud ervan. Wij bevestigen dat de tekst en het
werk dat in dit verslag gepresenteerd wordt origineel is.
NHL Stenden Hogeschool Leeuwarden is alleen verantwoordelijk voor de begeleiding tot
inleveren van dit verslag.
PAGINA 2
, Inhoudsopgave
Voorwoord.....................................................................................................................................1
Verklaring eigen werk.....................................................................................................................2
Inleiding..........................................................................................................................................4
Ziektebeeld.....................................................................................................................................5
Fase 1: de gegevens verzamelen....................................................................................................6
Anamnese lijst Gordon.............................................................................. 6
Anamnesegesprek..................................................................................... 8
Samenvatting anamnesegesprek...............................................................9
Mindmap................................................................................................... 9
Rode loper............................................................................................... 11
Kernset.................................................................................................... 13
Fase 2: Diagnose...........................................................................................................................14
PES & PE................................................................................................. 14
Informed Consent.................................................................................... 15
Piramide van Maslow.............................................................................. 15
Fase 3: Resultaten........................................................................................................................16
Zorgresultaat........................................................................................... 16
Informed Consent.................................................................................... 17
Fase 4: Interventies......................................................................................................................18
Interventie............................................................................................... 18
Evidence based practice (EBP)......................................................................................................20
Nawoord.......................................................................................................................................22
Bibliografie...................................................................................................................................23
Bijlagen.........................................................................................................................................24
Bijlage 1: Casus meneer Step..................................................................24
Bijlage 2: Anamneselijst..........................................................................25
Bijlage 3: Kernset.................................................................................... 27
Bijlage 4: Gegevens uit systematic review..............................................28
Bijlage 5: AGREE instrument resultaten.................................................28
Bijlage 6: STARR-verslagen.....................................................................30
PAGINA 3
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