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Klinisch redeneren
Course
Klinisch redeneren
Institution
Hogeschool Leiden (HSL)
Deze opdracht is gemaakt in opdracht van hogeschool Leiden in het eerste jaar van het schakeltraject. Deze opdracht is behaald met een 8,5.
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July 1, 2020
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klinisch redeneren
hbo v
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verpleegkunde
Institution
Hogeschool Leiden (HSL)
Education
Verpleegkunde / HBO-V
Course
Klinisch redeneren
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KLINISCH REDENEREN
Module 2
,Inhoudsopgave
Inleiding........................................................................................................................................................ 3
Onderbouwing Gordon patronen:.................................................................................................................. 4
Keuze Nanda, NIC, NOC.................................................................................................................................. 4
1. Situatie:..................................................................................................................................................... 4
Voorgeschiedenis:.................................................................................................................................................4
Huidige medicatie:................................................................................................................................................4
Actuele situatie.....................................................................................................................................................4
2. Gegevensverzameling................................................................................................................................ 5
Redeneermodel SCEGS (4)....................................................................................................................................6
Hetero anamnese.................................................................................................................................................6
3. Gegevens clusteren.................................................................................................................................... 7
4. Aanvullend onderzoek............................................................................................................................... 8
5. Prioriteren piramide van Maslow............................................................................................................. 13
Feitelijke diagnose: verstoord lichaamsbeeld (00118).......................................................................................14
Risico diagnose: risico op vochttekort (00028)...................................................................................................14
Multidisciplinair probleem: Slikstoornis (00103)................................................................................................15
Onderbouwing multidisciplinair probleem:........................................................................................................15
Onderbouwing keuze diagnoses:........................................................................................................................15
6. RUMBA-doelen en resultaten................................................................................................................... 16
Diagnose: verstoord lichaamsbeeld (00118)......................................................................................................16
Onderbouwing....................................................................................................................................................16
6. RUMBA-doelen en resultaten................................................................................................................... 17
Diagnose: Risico op vochttekort (00028)............................................................................................................17
Onderbouwing....................................................................................................................................................17
6. RUMBA-doelen en resultaten................................................................................................................... 18
Diagnose: Slikstoornis (00103)...........................................................................................................................18
Onderbouwing....................................................................................................................................................18
7. Interventies............................................................................................................................................. 19
Interventies verstoord lichaamsbeeld (00118)...................................................................................................19
Onderbouwing....................................................................................................................................................19
Interventies risico op vochttekort (00028)..........................................................................................................19
Onderbouwing....................................................................................................................................................20
1
, Interventies: slikstoornis (00103).......................................................................................................................20
Onderbouwing....................................................................................................................................................20
8. Uitvoering en evaluatie............................................................................................................................ 21
Diagnose: Verstoord lichaamsbeeld (00118).....................................................................................................21
Diagnose: Risico op vochttekort (00028)............................................................................................................21
Diagnose: Slikstoornis (00103)...........................................................................................................................21
9. Reflectie volgens Korthagen..................................................................................................................... 23
10. Literatuurlijst......................................................................................................................................... 24
2
, Inleiding
In opdracht van Hogeschool Leiden ligt voor u de schriftelijke opdracht klinisch redeneren
(1). Deze opdracht is onderdeel van het schakeltraject periode 4
‘Niets uit dit document mag zonder toestemming worden overgenomen door derden’
3