Klinisch redeneren

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