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HVVB21MBVZ
Opleiding tot HBO-Verpleegkundige
Hanzehogeschool Groningen
Naam: Laura Wouda
Studentnummer: 385027
Stagebegeleider: Christien de Jong
Gegevens instelling:
Ziekenhuis Nij Smellinghe
A1 Chirurgie / MDL / Urologie / Gynaecologie
Werkbegeleider: Karina Punter, Vanessa Wijnstra en Hester Looijenga
Periode: PLP3
Leerjaar: 2022/2023
,Datum van inleveren: 23 december 2022
1
,Inhoud
Datum van inleveren: 23 december 2022...............................................................................1
Inhoud.................................................................................................................................... 2
Inleiding.................................................................................................................................. 4
Waarderingsformulieren en reflectie PLP3.............................................................................5
Hoofdstuk 1: Casuïstiek..........................................................................................................5
Hoofdstuk 2: Vertrouwen opbouwen.......................................................................................6
Hoofdstuk 3: Anamnese......................................................................................................... 7
3.1: Gezondheidspatronen van Gordon.............................................................................7
Tabel 1: Patronen van Gordon..................................................................................7
3.2: Aanvullende informatie..............................................................................................11
3.2.1: Medicatie........................................................................................................... 11
Tabel 2: Medicatieoverzicht....................................................................................11
.................................................................................................................................... 14
3.2.2: Ondergewicht en ondervoeding.........................................................................14
3.2.3: Decubitus.......................................................................................................... 14
Tabel 3: Decubitusscore.........................................................................................15
3.3: Ecogram................................................................................................................... 16
Afbeelding 1: Ecogram Indy....................................................................................16
3.4: Balansmodel............................................................................................................. 17
Tabel 4: Balansmodel.............................................................................................17
3.5: Zelfredzaamheid.......................................................................................................18
Tabel 5: Zelfredzaamheidsradar Indy.....................................................................18
Afbeelding 2: Mijn Positieve Gezondheid van M. Huber.........................................22
3.6: Stoplichtmethode......................................................................................................23
Tabel 6: Stoplichtmethode volgens M. Bakker........................................................23
3.7: Clusteren.................................................................................................................. 27
Tabel 7: Clusters.....................................................................................................27
3.8: Potentiële diagnoses.................................................................................................31
Hoofdstuk 4: Shared Decision Making, prioriteren en vastleggen.........................................34
4.1: Shared decision making............................................................................................34
4.2: Diagnoses prioriteren................................................................................................36
Tabel 8: Diagnoses voorleggen..............................................................................37
4.3: Prioriteren en vastleggen.........................................................................................38
Tabel 9: Model van Maslow...................................................................................39
Afbeelding 3: Redeneerweb....................................................................................40
Hoofdstuk 6: Resultaten bepalen..........................................................................................41
Tabel 10: Resultaten...............................................................................................41
Hoofdstuk 7: Interventies bepalen........................................................................................43
Tabel 11: Interventies.............................................................................................43
7.1: Toelichting ICT.......................................................................................................... 47
7.1.1: Daymate............................................................................................................ 47
7.1.2: Daglichtlamp......................................................................................................48
2
, Hoofdstuk 8: Monitoren en evalueren...................................................................................48
8.1: Monitoren.................................................................................................................. 49
8.2: Evalueren.................................................................................................................. 49
8.3: Rol van de verpleegkundige......................................................................................49
Literatuurlijst......................................................................................................................... 50
Anti-plagiaatscan.................................................................................................................. 54
......................................................................................................................................... 54
......................................................................................................................................... 54
......................................................................................................................................... 54
Bijlage 1: Geneeskundige methodiek...................................................................................55
Bijlage 2: Voorgeschiedenis.................................................................................................57
Bijlage 3: Wie is Indy............................................................................................................ 58
Bijlage 4: Bradenschaal........................................................................................................60
Bijlage 5: Casusbespreking..................................................................................................61
3
HVVB21MBVZ
Opleiding tot HBO-Verpleegkundige
Hanzehogeschool Groningen
Naam: Laura Wouda
Studentnummer: 385027
Stagebegeleider: Christien de Jong
Gegevens instelling:
Ziekenhuis Nij Smellinghe
A1 Chirurgie / MDL / Urologie / Gynaecologie
Werkbegeleider: Karina Punter, Vanessa Wijnstra en Hester Looijenga
Periode: PLP3
Leerjaar: 2022/2023
,Datum van inleveren: 23 december 2022
1
,Inhoud
Datum van inleveren: 23 december 2022...............................................................................1
Inhoud.................................................................................................................................... 2
Inleiding.................................................................................................................................. 4
Waarderingsformulieren en reflectie PLP3.............................................................................5
Hoofdstuk 1: Casuïstiek..........................................................................................................5
Hoofdstuk 2: Vertrouwen opbouwen.......................................................................................6
Hoofdstuk 3: Anamnese......................................................................................................... 7
3.1: Gezondheidspatronen van Gordon.............................................................................7
Tabel 1: Patronen van Gordon..................................................................................7
3.2: Aanvullende informatie..............................................................................................11
3.2.1: Medicatie........................................................................................................... 11
Tabel 2: Medicatieoverzicht....................................................................................11
.................................................................................................................................... 14
3.2.2: Ondergewicht en ondervoeding.........................................................................14
3.2.3: Decubitus.......................................................................................................... 14
Tabel 3: Decubitusscore.........................................................................................15
3.3: Ecogram................................................................................................................... 16
Afbeelding 1: Ecogram Indy....................................................................................16
3.4: Balansmodel............................................................................................................. 17
Tabel 4: Balansmodel.............................................................................................17
3.5: Zelfredzaamheid.......................................................................................................18
Tabel 5: Zelfredzaamheidsradar Indy.....................................................................18
Afbeelding 2: Mijn Positieve Gezondheid van M. Huber.........................................22
3.6: Stoplichtmethode......................................................................................................23
Tabel 6: Stoplichtmethode volgens M. Bakker........................................................23
3.7: Clusteren.................................................................................................................. 27
Tabel 7: Clusters.....................................................................................................27
3.8: Potentiële diagnoses.................................................................................................31
Hoofdstuk 4: Shared Decision Making, prioriteren en vastleggen.........................................34
4.1: Shared decision making............................................................................................34
4.2: Diagnoses prioriteren................................................................................................36
Tabel 8: Diagnoses voorleggen..............................................................................37
4.3: Prioriteren en vastleggen.........................................................................................38
Tabel 9: Model van Maslow...................................................................................39
Afbeelding 3: Redeneerweb....................................................................................40
Hoofdstuk 6: Resultaten bepalen..........................................................................................41
Tabel 10: Resultaten...............................................................................................41
Hoofdstuk 7: Interventies bepalen........................................................................................43
Tabel 11: Interventies.............................................................................................43
7.1: Toelichting ICT.......................................................................................................... 47
7.1.1: Daymate............................................................................................................ 47
7.1.2: Daglichtlamp......................................................................................................48
2
, Hoofdstuk 8: Monitoren en evalueren...................................................................................48
8.1: Monitoren.................................................................................................................. 49
8.2: Evalueren.................................................................................................................. 49
8.3: Rol van de verpleegkundige......................................................................................49
Literatuurlijst......................................................................................................................... 50
Anti-plagiaatscan.................................................................................................................. 54
......................................................................................................................................... 54
......................................................................................................................................... 54
......................................................................................................................................... 54
Bijlage 1: Geneeskundige methodiek...................................................................................55
Bijlage 2: Voorgeschiedenis.................................................................................................57
Bijlage 3: Wie is Indy............................................................................................................ 58
Bijlage 4: Bradenschaal........................................................................................................60
Bijlage 5: Casusbespreking..................................................................................................61
3
