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stage leerjaar 3 casestudy 3 incomplete dwarslaesie
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- Institution
een verslag over het traject van een patiënt met een incomplete dwarslaesie
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Rijndam Revalidatie Dwarslaesie/ HeelkundeCasestudy
mevrouw
Casestudy 2
,Inhoudsopgave
Algemene gegevens ...............................................................................................................................2
Persoonsgegevens..............................................................................................................................2
Korte beschrijving van de patiënt:......................................................................................................3
1. Enter/initiate......................................................................................................................................3
2. Set the stage.......................................................................................................................................3
3. Assess / evaluate................................................................................................................................3
3.1. COPM-formulier .........................................................................................................................3
3.2. Jamar test 21-09-2020.................................................................................................................5
3.3. Observatie aan- en uitkleden 22-09-2020...................................................................................5
3.4 Propriocepsis handen...................................................................................................................6
Probleemdefinitie Rijndam.....................................................................................................................6
4. Agree on objectives and plan .............................................................................................................7
4.1. Doelen.........................................................................................................................................7
4.2. Behandelplannen.........................................................................................................................8
5. Implement the plan..........................................................................................................................11
6. Evaluate............................................................................................................................................11
Bijlagen.................................................................................................................................................13
Bijlage 1: Formulier aanvraagprocedures...........................................................................................0
Bijlage 2: Professioneel redeneren.....................................................................................................0
Bijlage 3: Reflectie..............................................................................................................................2
Bijlage 4: bronvermelding...................................................................................................................3
1
, Algemene gegevens
Persoonsgegevens
Achternaam T.
Voornaam K.
Geboortedatum 03/04/1954
Geslacht Vrouw
Burgerlijke staat Gehuwd. 3 kinderen. 2 kleinkinderen.
Adres Herenlaan 56
PC/ Woonplaats Den Haag
Tel. nummer 0181-439483
Zorgverzekeraar De Friesland Zorgverzekeraar
BSN 123456
Gegevens ergotherapeut
Naam Nienke Moll
Werkzaam bij Rijndam revalidatie
E-mailadres NMoll@rijndam.nl
Tel. nummer 0637436650
Werktijden Ma,di,wo,do, 08.00-16.30 u.
Medische gegevens
Medische diagnose Progressieve cervicale myelopathie bij stenose op meerdere niveaus
waarvoor corpectomie C4, anterieure cervicale discectomie en fusie (ACDF)
en medi-expand met plaat C3-C7 dd 02-09-2020.
Hulpvraag op het ☒ Wonen/ zorgen (mobiliteit, zelfzorg, huishouden, ..)
gebied van ☒ Vrije tijd/ spel (sociale contacten, hobby’s, vrije tijdsbesteding, …)
Toelichting Ik wil graag zelfstandig lopen, zonder loophulpmiddel met zelfstandige ADL,
hulpvraag/ zelfstandig eten en drinken en huishoudelijke activiteiten.
reden verwijzing
Andere betrokken - Fysiotherapeut
hulpverleners - Revalidatiearts
- Psycholoog
- Maatschappelijk medewerker
- Therapie assistent
- Verpleegkundige
- Ervaringsdeskundige
- Diëtist
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