Hent manual til KOL-forløb her. - Sundhed.dk

Indholdsfortegnelse
1. Indledning ......................................................................................................................................................... 4
2. Baggrund ........................................................................................................................................................... 4
3. Målgruppe for manualen .............................................................................................................................. 5
4. Vision, formål, mål og forventede langsigtede effekter .................................................................. 5
5. Definitioner ....................................................................................................................................................... 6
6. Henvisning og visitation............................................................................................................................... 6
7. Illustration over forløb og tilbud ............................................................................................................... 8
8. Indledende samtale og kontaktperson ............................................................................................................. 9
8.1 Indledende samtale ................................................................................................................................ 9
8.2 Kontaktperson ........................................................................................................................................... 9
9. KOL-Forløb ...................................................................................................................................................... 10
10. Tilbud til særligt sårbare borgere ........................................................................................................ 19
10.1 Vedligeholdende KOL- HOLD .......................................................................................................... 20
10.2 Hensynstagende KOL- hold ............................................................................................................. 21
10.3 Kostvejledning individuelle forløb ................................................................................................. 22
10.4 Hjælp til rygestop ................................................................................................................................ 22
10.5 Individuel træning hos ergoterapeut ........................................................................................... 23
10.6 Individuelle forløb i hjemmesygeplejen...................................................................................... 23
11. Forløbskoordination .................................................................................................................................. 24
12. Pædagogisk tilgang ................................................................................................................................... 25
13. Videndeling og samarbejde ................................................................................................................... 26
14. Personalets kompetencer ....................................................................................................................... 27
15. Evaluering /kvalitetssikring /opdatering af manual ..................................................................... 27
Bilag 1. Funktionsbeskrivelse for medicinsk KOL specialistfunktion i Guldborgsund
kommune .............................................................................................................................................................. 29
Bilag 2 Sundhedspædagogiske begreber ................................................................................................. 30
3