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Opdracht Klinisch Redeneren PL2 HU - Cijfer 9,8

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Opdracht Klinisch Redeneren PL2 HU - Cijfer 9,8

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  • August 29, 2024
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Stageportfolio PL2: UMC Utrecht - C2West: Interne geneeskunde en geriatrie
Tom Buster
1841374




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, Inhoud
Casusbeschrijving..................................................................................................................................4
Casusbeschrijving..................................................................................................................................4
Anamnese..............................................................................................................................................5
Anamnese..............................................................................................................................................5
Anamnese en screeningsinstrumenten..............................................................................................5
Anamnese en screeningsinstrumenten..............................................................................................5
Prioriteren van problematiek............................................................................................................6
Prioriteren van problematiek............................................................................................................6
Zorgtraject van de zorgvrager...........................................................................................................7
Zorgtraject van de zorgvrager...........................................................................................................7
Diagnose................................................................................................................................................7
Diagnose................................................................................................................................................7
Anatomie en functies........................................................................................................................7
Anatomie en functies........................................................................................................................7
Externe en persoonlijke factoren en coping......................................................................................8
Externe en persoonlijke factoren en coping......................................................................................8
Beperkingen in activiteiten en participatie........................................................................................9
Beperkingen in activiteiten en participatie........................................................................................9
Kwaliteit van leven.........................................................................................................................10
Kwaliteit van leven.........................................................................................................................10
Verpleegkundige diagnoses............................................................................................................11
Verpleegkundige diagnoses............................................................................................................11
Probleem: Acute pijn.................................................................................................................12
Probleem: Acute pijn.................................................................................................................12
Probleem: Risico op obstipatie.................................................................................................12
Probleem: Risico op obstipatie.................................................................................................12
Probleem: Risico op voedingstekort..........................................................................................12
Probleem: Risico op voedingstekort..........................................................................................12
Resultaat..............................................................................................................................................13
Resultaat..............................................................................................................................................13
Diagnose: Acute pijn.................................................................................................................13
Diagnose: Acute pijn.................................................................................................................13
Diagnose: Risico op obstipatie...................................................................................................13
Diagnose: Risico op obstipatie...................................................................................................13
Diagnose: Risico op voedingstekort..........................................................................................13
Diagnose: Risico op voedingstekort..........................................................................................13
Interventies..........................................................................................................................................14
Interventies..........................................................................................................................................14
Diagnose: Acute pijn......................................................................................................................14
Diagnose: Acute pijn......................................................................................................................14
Patiënt-controlled analgetica: ondersteuning (2400) (expert)....................................................14
Patiënt-controlled analgetica: ondersteuning (2400) (expert)....................................................14
Voorschrijven medicatie (2390) (expert)...................................................................................14
Voorschrijven medicatie (2390) (expert)...................................................................................14
Warmte-/koudetoepassing (1380) (literatuur)............................................................................14
Warmte-/koudetoepassing (1380) (literatuur)............................................................................14



2

, Diagnose: Risico op obstipatie........................................................................................................14
Diagnose: Risico op obstipatie........................................................................................................14
Lichaamsbeweging, bevordering (0200) (literatuur)..................................................................14
Lichaamsbeweging, bevordering (0200) (literatuur)..................................................................14
Voorschrijven medicatie (2390) (expert)...................................................................................15
Voorschrijven medicatie (2390) (expert)...................................................................................15
Vochtbeleid (4120) (literatuur)..................................................................................................15
Vochtbeleid (4120) (literatuur)..................................................................................................15
Diagnose: Risico op voedingstekort................................................................................................15
Diagnose: Risico op voedingstekort................................................................................................15
Voorlichting: voorgeschreven dieet (5614) (literatuur)..............................................................15
Voorlichting: voorgeschreven dieet (5614) (literatuur)..............................................................15
Gedragsmodificatie (4360) (literatuur)......................................................................................15
Gedragsmodificatie (4360) (literatuur)......................................................................................15
Voedingstherapie (1120) (literatuur).........................................................................................16
Voedingstherapie (1120) (literatuur).........................................................................................16
Evaluatie..............................................................................................................................................16
Evaluatie..............................................................................................................................................16
Evaluatie met de patiënt..................................................................................................................16
Evaluatie met de patiënt..................................................................................................................16
Overdracht......................................................................................................................................16
Overdracht......................................................................................................................................16
Advies EPD....................................................................................................................................18
Advies EPD....................................................................................................................................18
Literatuur.............................................................................................................................................18
Literatuur.............................................................................................................................................18




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