Een succesvolle uitwerking van PLP2 van de volgende modules:
- Werken aan gezondheid afgerond met het cijfer 9.
- Bevorderen van zelfmanagement afgerond met het cijfer 8.5.
- Regisseren van zorg afgerond met het cijfer 9.
De modules zijn uitgevoerd binnen een acute opname afdeling binnen de ...
,Inhoudsopgave
Inleiding.....................................................................................................................................................................6
Hoofdstuk 1 Vertrouwen opbouwen........................................................................................................................8
Hoofdstuk 2 Anamnese.............................................................................................................................................9
2.1. Patiëntcasus...................................................................................................................................................9
2.2. Anamnese.....................................................................................................................................................10
2.3. Complexiteit van de situatie.........................................................................................................................15
2.4. Ecogram........................................................................................................................................................18
2.5. Draagkracht en draaglast.............................................................................................................................19
2.5.1. Conclusie...............................................................................................................................................20
2.6. Zelfrezaamheidsmeter.................................................................................................................................20
2.6.1. Conclusie...............................................................................................................................................22
2.7. Fase van zelfmanagement............................................................................................................................22
Hoodstuk 3 Oorzaak en gevolg................................................................................................................................24
3.1. ASE-model....................................................................................................................................................24
3.1.1. Conclusie...............................................................................................................................................25
3.2. Transtheoretische model.............................................................................................................................25
3.2.1. Tot betrekking van de casus..................................................................................................................26
Hoofstuk 4 Mogelijke risico diagnose vaststellen en voorleggen aan de patiënt..................................................27
4.1. Mogelijke risicodiagnoses............................................................................................................................27
4.2. Redeneerweb...............................................................................................................................................28
4.3. Prioriteren....................................................................................................................................................28
4.3.1. Argumentatie........................................................................................................................................28
Hoofdstuk 5 Resultaat bepalen...............................................................................................................................30
5.1. Zorgresultaten.............................................................................................................................................30
Hoofdstuk 6 Interventie bepalen............................................................................................................................34
6.1. Signaleringsplan...........................................................................................................................................34
Hoofdstuk 7 Toewijzen en/ of verwijzen................................................................................................................38
Hoofdstuk 8 Evalueren en monitoren.....................................................................................................................39
Tussenevaluatie......................................................................................................................................................40
Waarderingsformulier.........................................................................................................................................40
reflectie...............................................................................................................................................................41
Eindevaluatie...........................................................................................................................................................41
Waarderingformulier..........................................................................................................................................41
Reflectie...............................................................................................................................................................42
Hoofdstuk 1 casuïstiek............................................................................................................................................44
1.1. Casus.............................................................................................................................................................44
1.2. Vastgestelde DSM-diagnose.........................................................................................................................45
hoodstuk 2 Zelf- en samenredzaamheid.................................................................................................................48
2
, 2.1. Samenhang zelf- en samenredzaamheid.....................................................................................................48
2.2. Zelf- en samenredzaamheid in de praktijk...................................................................................................48
2.3. Eigen visie.....................................................................................................................................................49
Hoofdstuk 3 Systeemgericht assesment.................................................................................................................50
3.1. Indicatie voor familiegesprek.......................................................................................................................50
3.2. Assesment....................................................................................................................................................51
3.3. Ecogram........................................................................................................................................................52
3.4. Draagkracht- draaglast analyse....................................................................................................................53
3.5. Zelfredaamheidsradar..................................................................................................................................54
3.6. Mantelscan (EDIZ)........................................................................................................................................57
Hoofdstuk 4 Systeemgesprek..................................................................................................................................58
4.1. Systeemgesprek met patiënt en ouders......................................................................................................58
4.1.1. De sociale fase.......................................................................................................................................58
4.1.2. Probleemstadium..................................................................................................................................58
4.1.3. Interactie stadium.................................................................................................................................59
4.1.4. Doelstadium..........................................................................................................................................59
4.1.5. Afspraakstadium...................................................................................................................................59
4.2. Communicatie vaardigheden.......................................................................................................................60
hoofdstuk 5 Zorgsituatie.........................................................................................................................................61
5.1. Analyse zorgsitautie.....................................................................................................................................61
5.1.1. Gespreksanalyse ouders en patiënt......................................................................................................61
5.1.2. Zorgsituatie............................................................................................................................................62
5.2. Informatie- en communicatietechnologieën...............................................................................................62
5.2.1. E-care Roqua (routine outcome monitoring)........................................................................................62
5.2.2. E-Health psycho-educatie.....................................................................................................................63
hoofdstuk 6 Advies..................................................................................................................................................64
6.1. Preventief adviesbrief..................................................................................................................................65
tussenevaluatie.......................................................................................................................................................68
Waarderingsformuier..........................................................................................................................................68
Reflectie...............................................................................................................................................................69
eindevaluatie...........................................................................................................................................................70
Waarderingsformulier.........................................................................................................................................70
Reflectie...............................................................................................................................................................71
Hoofdstuk 1 Casus...................................................................................................................................................73
1.1. Casuïstiek......................................................................................................................................................73
1.2. DSM-IV classificatie......................................................................................................................................73
1.3. Huidige medicatie overzicht.........................................................................................................................74
1.4. Complexiteit van de situatie.........................................................................................................................75
Hoofdstuk 2 multidisciplinaire zorgproces..............................................................................................................77
2.1. Multidisciplinaire zorg..................................................................................................................................77
2.2. Betrokken disciplines...................................................................................................................................78
3
, Hoofstuk 3 HBO- verpleegkundige..........................................................................................................................80
3.1. De zorgverlener............................................................................................................................................80
3.2. De communicator.........................................................................................................................................80
3.3. Samenwerker...............................................................................................................................................81
3.4. De reflectieve professional...........................................................................................................................81
3.5. De gezondheidsbevorderaar........................................................................................................................81
3.6. De organisator..............................................................................................................................................82
3.7. De professional en kwaliteitsbevorderaar...................................................................................................82
Hoofdstuk 3 Shared discion making........................................................................................................................83
3.1. Cultuur sensitieve zorg.................................................................................................................................83
3.2. Gezamelijke besluitvorming.........................................................................................................................84
Hoofdstuk 4 Overdracht..........................................................................................................................................85
4.1. Rapportage EPD............................................................................................................................................85
4.1.1. Mijn rapportage....................................................................................................................................86
4.2. Mondelinge overdracht................................................................................................................................87
4.3. Overdrachtsinstrumenten............................................................................................................................88
Hoofdstuk 5 Verbeterplan.......................................................................................................................................90
5.1. Oordeel geboden zorg..................................................................................................................................90
5.1.1. Conclusie...............................................................................................................................................91
5.2. Probleemvaststelling....................................................................................................................................91
5.3. Voorstel........................................................................................................................................................92
Hoofdstuk 6 Implementatie....................................................................................................................................93
6.1. Ochtendoverdracht......................................................................................................................................93
6.2. Verpleegkundige rapportage.......................................................................................................................94
6.3. Vaste bezoeksmoment.................................................................................................................................95
Hoofdstuk 7 Uitvoering in de praktijk.....................................................................................................................96
Hoofdstuk 8 Wet- en regelgeving...........................................................................................................................98
Tussenevaluatie.....................................................................................................................................................100
Waarderingsformulier.......................................................................................................................................100
Reflectie.............................................................................................................................................................101
Eindevaluatie.........................................................................................................................................................102
Waarderingsformulier.......................................................................................................................................102
Reflectie.............................................................................................................................................................103
Tussenevaluatie.....................................................................................................................................................105
Waarderingsformulier.......................................................................................................................................105
Eindevaluatie.........................................................................................................................................................106
waarderingsformulier........................................................................................................................................106
reflectie.............................................................................................................................................................107
Tussenevaluatie.....................................................................................................................................................109
Waarderingsformulier.......................................................................................................................................109
Eindevaluatie.........................................................................................................................................................110
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