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Opdracht Klinisch redeneren en onderzoekend vermogen stage jaar 2
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De opdracht klinisch redeneren en onderzoekend vermogen voor stage jaar 2 uitgewerkt! Er handig om een voorbeeld erbij te hebben.
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By: adegooijer1970 • 4 year ago
Gives at least a good guideline of what is expected of the contract
By: verwerprins • 4 year ago
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Klinisch redeneren en11-6-2018 onderzoekend
vermogen
Stageopdracht
Merel Baaij, 1694743
HOGESCHOOL UTRECHT, GVE-2.PL2-17
DOCENT: CAROLINE JOCHEMS
,Inhoudsopgave
Casusbeschrijving...................................................................................................................................3
Anamnese...............................................................................................................................................3
Anamnese volgens Gordon:................................................................................................................3
Patroon van gezondheidsbeleving en -instandhouding..................................................................3
Voedings- en stofwisselingspatroon...............................................................................................4
Uitscheidingspatroon......................................................................................................................4
Actviteitenpatroon.........................................................................................................................4
Slaap- en rustpatroon.....................................................................................................................4
Cognite- en waarnemingspatroon.................................................................................................5
Zelfelevingspatroon......................................................................................................................5
Rollen- en relatepatroon................................................................................................................5
Seksualiteit- en voortplantngspatroon..........................................................................................5
Stressverwerkingspatroon..............................................................................................................5
Waarden en levensovertuigingspatroon........................................................................................5
Prioritering van de problemen...........................................................................................................6
Shared decision making......................................................................................................................6
Zorgtraject..........................................................................................................................................7
Diagnostek.............................................................................................................................................8
Anatomie en functes .........................................................................................................................8
Cardiovasculair systeem.................................................................................................................8
Vocht en elektrolytenbalans...........................................................................................................8
Afweersysteem...............................................................................................................................8
Bloed...............................................................................................................................................8
Digestef systeem............................................................................................................................9
Neurologisch systeem / zintuigelijk................................................................................................9
Neurologisch systeem / brein.........................................................................................................9
Neurologisch systeem / motoriek...................................................................................................9
Endocrien systeem.......................................................................................................................10
Externe en persoonlijke factoren.....................................................................................................10
Versterkende externe factoren.....................................................................................................10
Beperkende externe factoren.......................................................................................................10
Versterkende persoonlijke factoren.............................................................................................10
Beperkende persoonlijke factoren...............................................................................................12
Copingstjl.....................................................................................................................................12
1
, Actviteiten en partcipate ..............................................................................................................12
Beperkingen in actviteitenpatroon en partcipate......................................................................12
Screeningsinstrumenten...............................................................................................................13
Gevolgen van de beperkingen voor de kwaliteit van leven..........................................................13
Ervaring zorgvrager van de huidige kwaliteit van leven................................................................13
Overeenkomsten en verschillen tussen zorgverlener en zorgvrager............................................13
Verpleegkundige diagnoses..........................................................................................................14
Resultaat...............................................................................................................................................15
Risico op eenzaamheid.....................................................................................................................15
Risico op decubitus...........................................................................................................................15
Risico op verminderde mobiliteit......................................................................................................15
Interventes..........................................................................................................................................15
Risico op eenzaamheid.....................................................................................................................16
Risico op decubitus...........................................................................................................................16
Risico op verminderde mobiliteit......................................................................................................16
Interventes op het gebied van het versterken van het zelfmanagement........................................16
Mening van de zorgvrager en diens naasten....................................................................................17
Onderbouwing van de 3 interventes met wetenschappelijke literatuur.........................................17
Risico op eenzaamheid.................................................................................................................17
Risico op decubitus.......................................................................................................................17
Risico op verminderde mobiliteit..................................................................................................17
Evaluate...............................................................................................................................................18
Advies voor het ECD.........................................................................................................................18
Overdracht voor het vervolgtraject..................................................................................................18
Verpleegkundige diagnosen.........................................................................................................18
Resultaten.....................................................................................................................................18
Interventes..................................................................................................................................19
Bibliografie...........................................................................................................................................20
Bijlage 1, Risicosignalering a.d.h.v. ECD................................................................................................22
Bijlage 2, GDS........................................................................................................................................23
Bijlage 3, BRADENschaal.......................................................................................................................24
Bijlage 4, MMSE....................................................................................................................................25
Bijlage 5, Eenzaamheidsschaal.............................................................................................................26
Bijlage 6, Barthelindex..........................................................................................................................27
Bijlage 7, Scoringslijst SF-12..................................................................................................................29
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