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Stageportfolio PL2 Klinisch redeneren en onderzoekend vermogen (8,6) $8.04
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Stageportfolio PL2 Klinisch redeneren en onderzoekend vermogen (8,6)

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Stageportfolio, klinisch redeneren en onderzoekend vermogen. Jaar 2, stage 2. Opdracht over ouderenzorg. Beoordeeld met een 8,6.

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  • November 26, 2020
  • 33
  • 2019/2020
  • Essay
  • Unknown
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STAGEPORTFOLIO
Klinisch redeneren en onderzoekend vermogen




Naam:
Studentnummer:
Studiegroepscode:
Naam cursus: GVE-2.PL2-17
Docent:
Inleverdatum:
u

,Voorwoord
In dit stageportfolio is de opdracht Klinisch Redeneren en Onderzoeken vermogen
uitgewerkt. In deze opdracht is een casus van een cliënt uitgewerkt, waarbij een anamnese
is afgenomen, verpleegkundige diagnoses zijn opgesteld, resultaten zijn uitgewerkt en
interventies zijn beschreven.




2

,Inhoud
Voorwoord ............................................................................................................................. 2
Klinisch redeneren................................................................................................................. 5
Casusbeschrijving............................................................................................................................. 5
Anamnese .......................................................................................................................................... 6
Anamnese ...................................................................................................................................... 6
Screeningsinstrumenten .............................................................................................................. 7
Shared decision making .............................................................................................................. 8
Zorgtraject ...................................................................................................................................... 8
Diagnose ............................................................................................................................................ 9
Anatomie en functies .................................................................................................................... 9
Externe en persoonlijke factoren .............................................................................................. 10
Copingstijl..................................................................................................................................... 10
Activiteiten en participatie .......................................................................................................... 11
Kwaliteit van leven ...................................................................................................................... 11
Verpleegkundige diagnoses ...................................................................................................... 11
Resultaat .......................................................................................................................................... 13
Resultaat risico op vallen........................................................................................................... 13
Resultaat probleem met korte termijn geheugen ................................................................... 13
Resultaat obesitas ...................................................................................................................... 13
Interventies ...................................................................................................................................... 14
Mening zorgvrager en naasten ................................................................................................. 15
Evaluatie .......................................................................................................................................... 16
Evaluatie verleende zorg ........................................................................................................... 16
Overdracht ................................................................................................................................... 16
Advies zorgdossier ..................................................................................................................... 17
Bronnenlijst ...................................................................................................................................... 18
Bijlagen ............................................................................................................................................. 21
Bijlage 1. Gordon anamnese ........................................................................................................ 21
Bijlage 2. Timed Get-Up-and-Go-Test (TGUGT) ....................................................................... 25
Bijlage 3. Intake valrisico ............................................................................................................... 26
Bijlage 4. The Short Portable Mental Status Questionnaire (SPMSQ) .................................. 27
Bijlage 5. SNAQRC .......................................................................................................................... 28
Bijlage 6. Hearing Handicap Inventory for the Elderly (HHIE-S) ............................................. 29
Bijlage 7. Barthel Index .................................................................................................................. 30
Bijlage 8. SF-12 vragenlijst ........................................................................................................... 31

3

,4

, Klinisch redeneren
Casusbeschrijving
Mevrouw X is 86 jaar oud en is bekend met Diabetes type 2, hartfalen, COPD en
hypertensie. Ze is ongehuwd en heeft zes dochters. Haar visus is verminderd, evenals haar
gehoor. Hiervoor gebruikt mevrouw een loep voor tijdens het lezen en een gehoorapparaat
voor haar verminderd gehoor. Ze loopt met van een rollator en krijgt hulp bij het douchen en
aankleden. Ze heeft oedeemvorming in de onderbenen en daarvoor worden steunkousen bij
haar aangetrokken. Bij mevrouw wordt insuline geïnjecteerd in verband met de Diabetes type
2.




5

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