Tijdens het klinisch redeneren en het schrijven van dit verpleegplan is gebruik gemaakt van Carpenito. 3 verpleegkundige diagnoses zijn uitgewerkt middels de PES, doelen en interventies en uiteindelijk evalueren.
Er is gebruik gemaakt van Evidence Based Practice.
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Verpleegplan
Eenheid van leeruitkomst
2.1 klinisch redeneren
Student naam
Student nummer
Groep
Vak code VPK21D20
Datum van inleveren 21-04-2021
Naam leerwerkbegeleider
Organisatie
,Inhoudsopgave
................................................................................................................................................................1
Verpleegplan Eenheid van leeruitkomst 2.1 klinisch redeneren............................................................1
Inleiding..................................................................................................................................................3
Casus......................................................................................................................................................4
Keuze voor het gebruikte verpleegkundig classificatiesysteem..............................................................5
Verpleegkundige diagnosen...................................................................................................................6
Uitwerking Diagnosen........................................................................................................................6
Diagnose 1: zelfzorgtekortsyndroom......................................................................................................6
Evaluatie diagnose 1...........................................................................................................................9
Diagnose 2: Ondervoeding...................................................................................................................11
Motivatie voor diagnose 2................................................................................................................11
Doel met onderbouwing...................................................................................................................11
Evaluatie diagnose 2.........................................................................................................................13
Diagnose 3: Risico op eenzaamheid......................................................................................................14
Motivatie voor diagnose 3................................................................................................................14
Doel met onderbouwing...................................................................................................................15
Evaluatie diagnose 3.........................................................................................................................16
Privacy AVG en WGBO..........................................................................................................................17
Literatuurlijst........................................................................................................................................18
Nawoord...............................................................................................................................................19
Bijlage 1: Verpleegkundige Anamnese.................................................................................................20
Bijlage 2: Intramurale Veilige Zorg Risicosignalering........................................................................21
Bijlage 3: ULCA Eenzaamheidsschaal................................................................................................21
Bijlage 4: STARRT-methode..............................................................................................................22
Bijlage 5: Feedback leerwerkbegeleider...........................................................................................23
Bijlage 6: Beoordelingsformulier......................................................................................................23
Inleiding.................................................................................................................................................3
Casus.....................................................................................................................................................4
Keuze voor het gebruikte verpleegkundig classificatiesysteem.............................................................5
Verpleegkundige diagnosen..................................................................................................................5
Uitwerking Diagnosen.......................................................................................................................5
Diagnose 1: zelfzorgtekortsyndroom.....................................................................................................6
2
, Motivatie voor diagnose 1.................................................................................................................6
Doel met onderbouwing....................................................................................................................6
Passende interventies.......................................................................................................................7
Interventie Evidence Based Practice onderbouwen..........................................................................7
Evaluatie diagnose 1..........................................................................................................................8
Diagnose 2: Ondervoeding..................................................................................................................10
Motivatie voor diagnose 2...............................................................................................................10
Doel met onderbouwing..................................................................................................................10
Passende interventies.....................................................................................................................11
Interventie Evidence Based Practice onderbouwen........................................................................11
Evaluatie diagnose 2........................................................................................................................12
Diagnose 3: Risico op eenzaamheid....................................................................................................13
Motivatie voor diagnose 3...............................................................................................................13
Doel met onderbouwing..................................................................................................................13
Passende interventies.....................................................................................................................14
Interventie Evidence Based Practice onderbouwen........................................................................14
Evaluatie diagnose 3........................................................................................................................14
Privacy AVG en WGBO.........................................................................................................................16
Literatuurlijst.......................................................................................................................................17
Nawoord..............................................................................................................................................18
Bijlage 1: Verpleegkundige Anamnese................................................................................................19
Bijlage 2: Intramurale Veilige Zorg Risicosignalering.......................................................................22
Bijlage 3: ULCA Eenzaamheidsschaal...............................................................................................27
Bijlage 4: STARRT-methode.............................................................................................................28
Bijlage 5: Feedback leerwerkbegeleider..........................................................................................29
Bijlage 6: Beoordelingsformulier.....................................................................................................31
Inleiding
Voor u ligt het verpleegplan van Mevrouw …. die woont in … In …wonen mensen met een somatische
en/of cognitieve beperking. Er is sprake van 24-uurszorg welke wordt geboden door huishoudelijk
medewerkers, gastvrouwen, verzorgenden vanuit de individuele gezondheidszorg, verpleegkundigen,
kwaliteitsverpleegkundige en wijkverpleegkundige. Er is nauw contact met de huisartsenpraktijk en
de fysiotherapeuten omtrent de gezondheidssituatie van de bewoners. Wanneer dit nodig is kunnen
andere disciplines ter consult worden gevraagd, zoals de specialist ouderengeneeskundige, diëtist,
3
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