Essay
stage leerjaar 3 casestudy 3 revalidatie dwarslaesie
- Course
- Institution
een verslag over het traject van een patiënt met een incomplete dwarslaesie
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1 review
By: madelief57 • 3 year ago
It's a good case study! Everything was well processed, I only missed the underpinnings for certain assessments and a plan of action for the treatments. In addition, all of the client's data is on the first page, which doesn't seem to me.
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Rijndam RevalidatieCasestudy meneer
Casestudy 3
Inhoud
Algemene gegevens ....................................................................................................................................2
Persoonsgegevens...................................................................................................................................2
Korte beschrijving van de patiënt:...........................................................................................................4
,1. Enter/initiate...........................................................................................................................................4
2. Set the stage............................................................................................................................................4
3. Assess / evaluate.....................................................................................................................................4
3.1. COPM-formulier .............................................................................................................................4
3.2. Jamar................................................................................................................................................6
CMOP-E inhoudsmodel................................................................................................................................7
Probleemdefinitie Rijndam..........................................................................................................................9
4. Agree on objectives and plan ................................................................................................................10
Doelen vanuit patiënt........................................................................................................................10
Doelen vanuit revalidatie...................................................................................................................10
4.2. Behandelplannen............................................................................................................................12
Behandelplan 1: inventarisatie vork rechts........................................................................................12
Behandeling 2: WMO melding bespreken.........................................................................................13
Behandeling 3: handen doorbewegen en oefening voor de hand....................................................14
5. Implement the plan...............................................................................................................................15
6. Monitor and Modify..............................................................................................................................15
8. Conclude / exit.......................................................................................................................................17
Bijlagen......................................................................................................................................................18
Bijlage 1: Professioneel redeneren........................................................................................................19
Casus..................................................................................................................................................19
Dilemma............................................................................................................................................19
Client..................................................................................................................................................19
Therapeut..........................................................................................................................................19
Bewijs.................................................................................................................................................20
Conditioneel......................................................................................................................................20
Bijlage 2: Reflectie.................................................................................................................................21
Bijlage 3: Bibliografie.................................................................................................................................22
Algemene gegevens
Persoonsgegevens
Achternaam H.
, Voornaam A.M.
Geboortedatum 21-09-1953
Geslacht Man
Burgerlijke staat Gehuwd. 2 kinderen. 4 kleinkinderen.
Adres Herenlaan 56
PC/ Woonplaats Papendrecht
Tel. nummer 0181-439483
Zorgverzekeraar Unive
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 Traumatisch incompleet dwarslaesie C5 AIS-C 24-10-2020
Hulpvraag op het ☒ Wonen/ zorgen (mobiliteit, zelfzorg, huishouden, ..)
gebied van ☒ Vrije tijd/ spel (sociale contacten, hobby’s, vrije tijdsbesteding, …)
☒ Werken/ leren (arbeid, school, …)
Toelichting Ik wil meer zelfstandig functioneren waarbij ik verwacht in rolstoel te blijven
hulpvraag/ functioneren.
reden verwijzing Ik wil zelfstandig kunnen aan/uitkleden.
Ik wil zelfstandig in mijn rolstoel kunnen stappen en daarmee bewegen. Als
het zou kunnen, dan zou ik weer willen lopen, maar dat verwacht ik niet.
Andere betrokken - Fysiotherapeut
hulpverleners - Revalidatiearts
- Psycholoog
- Maatschappelijk medewerker
- Therapie assistent
- Verpleegkundige
- Ervaringsdeskundige
- Diëtist
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