KLINISCH REDENEREN
Casus Natasja Slootes
Hanzehogeschool Groningen
HBO Verpleegkunde
Klinisch Redeneren
‘’Naam van de docent’’
12 november 2018
‘’Naam van de student + studentnummer’’
‘’Klas’’
,Inhoudsopgave
Inleiding........................................................................................................................................................ 3
Hoofdstuk 1: De anamnese............................................................................................................................ 4
1.1 Inleiding..........................................................................................................................................................4
1.2 Anamnese.......................................................................................................................................................4
1.3 Gezondheidspatronen van Gordon................................................................................................................5
1.4 Objectevee en subjecteve gegevens.............................................................................................................5
1.5 Functonele of disfunctonele gezondheidspatronen....................................................................................5
1.6 Uitwerking 11 Gezondheidspatronen van Gordon........................................................................................5
1.6.1 Patroon van gezondheidsbeleving en instandhouding..........................................................................5
1.6.2 Voedingse en stofwisselingspatroon......................................................................................................6
1.6.3 Uitscheidingspatroon.............................................................................................................................6
1.6.4 Actviteitenpatroon................................................................................................................................6
1.6.5 Cognitee en waarnemingspatroon.........................................................................................................7
1.6.6 Slaape/rustpatroon.................................................................................................................................7
1.6.7 Zelfelevingspatroon..............................................................................................................................7
1.6.8 Rollene en relatepatroon.......................................................................................................................7
1.6.9 Seksualiteite en voortplantngspatroon.................................................................................................7
1.6.10 Stressverwerkingspatroon...................................................................................................................7
1.6.11 Waardene en geloofsovertuigingspatroon...........................................................................................7
Hoofdstuk 2: Clusteren van gegevens en formuleren van vermoedelijke diagnosen........................................7
2.1 Inleiding..........................................................................................................................................................7
2.2 Clustertabel....................................................................................................................................................8
2.2 Vermoedelijke (hypothetschee diagnosen....................................................................................................9
Hoofdstuk 3: Diagnosen analyseren en prioriteren.......................................................................................10
3.1 Inleiding........................................................................................................................................................10
3.2 Het redeneerweb.........................................................................................................................................10
Hoofdstuk 4: Feitelijke verpleegkundige diagnosen......................................................................................12
4.1 Inleiding........................................................................................................................................................12
4.2 Voedingstekort.............................................................................................................................................12
4.3 Vochtekort..................................................................................................................................................12
4.4 Therapieontrouw.........................................................................................................................................12
4.5 Verstoord lichaamsbeeld.............................................................................................................................13
Hoofstuk 5: De PES-structuur....................................................................................................................... 13
5.1 Inleiding........................................................................................................................................................13
5.3 PES Voedingstekort......................................................................................................................................14
5.4 PES Vochtekort............................................................................................................................................14
5.5 PES Therapieontrouw...................................................................................................................................14
5.6 PES Verstoord lichaamsbeeld......................................................................................................................14
Hoofdstuk 6: Beoogd resultaat.................................................................................................................... 14
6.1 Inleiding........................................................................................................................................................14
6.2 Zorgresultaat voedingstekort.......................................................................................................................14
6.3 Zorgresultaat vochtekort............................................................................................................................15
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, 6.4 Zorgresultaat therapieontrouw...................................................................................................................15
6.5 Zorgresultaat verstoord lichaamsbeeld.......................................................................................................16
Hoofdstuk 7: Interventes............................................................................................................................ 16
7.1 Inleiding........................................................................................................................................................16
7.2 Interventetabel...........................................................................................................................................16
Hoofdstuk 8: Evaluate................................................................................................................................. 19
8.1 Inleiding........................................................................................................................................................19
8.2 Procese en productevaluate........................................................................................................................19
Conclusie..................................................................................................................................................... 20
Literatuurlijst.............................................................................................................................................. 21
Bijlagen....................................................................................................................................................... 22
Bijlage 1: Geneeskundige methodiek anorexia nervosa....................................................................................22
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Casus Natasja Slootes
Hanzehogeschool Groningen
HBO Verpleegkunde
Klinisch Redeneren
‘’Naam van de docent’’
12 november 2018
‘’Naam van de student + studentnummer’’
‘’Klas’’
,Inhoudsopgave
Inleiding........................................................................................................................................................ 3
Hoofdstuk 1: De anamnese............................................................................................................................ 4
1.1 Inleiding..........................................................................................................................................................4
1.2 Anamnese.......................................................................................................................................................4
1.3 Gezondheidspatronen van Gordon................................................................................................................5
1.4 Objectevee en subjecteve gegevens.............................................................................................................5
1.5 Functonele of disfunctonele gezondheidspatronen....................................................................................5
1.6 Uitwerking 11 Gezondheidspatronen van Gordon........................................................................................5
1.6.1 Patroon van gezondheidsbeleving en instandhouding..........................................................................5
1.6.2 Voedingse en stofwisselingspatroon......................................................................................................6
1.6.3 Uitscheidingspatroon.............................................................................................................................6
1.6.4 Actviteitenpatroon................................................................................................................................6
1.6.5 Cognitee en waarnemingspatroon.........................................................................................................7
1.6.6 Slaape/rustpatroon.................................................................................................................................7
1.6.7 Zelfelevingspatroon..............................................................................................................................7
1.6.8 Rollene en relatepatroon.......................................................................................................................7
1.6.9 Seksualiteite en voortplantngspatroon.................................................................................................7
1.6.10 Stressverwerkingspatroon...................................................................................................................7
1.6.11 Waardene en geloofsovertuigingspatroon...........................................................................................7
Hoofdstuk 2: Clusteren van gegevens en formuleren van vermoedelijke diagnosen........................................7
2.1 Inleiding..........................................................................................................................................................7
2.2 Clustertabel....................................................................................................................................................8
2.2 Vermoedelijke (hypothetschee diagnosen....................................................................................................9
Hoofdstuk 3: Diagnosen analyseren en prioriteren.......................................................................................10
3.1 Inleiding........................................................................................................................................................10
3.2 Het redeneerweb.........................................................................................................................................10
Hoofdstuk 4: Feitelijke verpleegkundige diagnosen......................................................................................12
4.1 Inleiding........................................................................................................................................................12
4.2 Voedingstekort.............................................................................................................................................12
4.3 Vochtekort..................................................................................................................................................12
4.4 Therapieontrouw.........................................................................................................................................12
4.5 Verstoord lichaamsbeeld.............................................................................................................................13
Hoofstuk 5: De PES-structuur....................................................................................................................... 13
5.1 Inleiding........................................................................................................................................................13
5.3 PES Voedingstekort......................................................................................................................................14
5.4 PES Vochtekort............................................................................................................................................14
5.5 PES Therapieontrouw...................................................................................................................................14
5.6 PES Verstoord lichaamsbeeld......................................................................................................................14
Hoofdstuk 6: Beoogd resultaat.................................................................................................................... 14
6.1 Inleiding........................................................................................................................................................14
6.2 Zorgresultaat voedingstekort.......................................................................................................................14
6.3 Zorgresultaat vochtekort............................................................................................................................15
1
, 6.4 Zorgresultaat therapieontrouw...................................................................................................................15
6.5 Zorgresultaat verstoord lichaamsbeeld.......................................................................................................16
Hoofdstuk 7: Interventes............................................................................................................................ 16
7.1 Inleiding........................................................................................................................................................16
7.2 Interventetabel...........................................................................................................................................16
Hoofdstuk 8: Evaluate................................................................................................................................. 19
8.1 Inleiding........................................................................................................................................................19
8.2 Procese en productevaluate........................................................................................................................19
Conclusie..................................................................................................................................................... 20
Literatuurlijst.............................................................................................................................................. 21
Bijlagen....................................................................................................................................................... 22
Bijlage 1: Geneeskundige methodiek anorexia nervosa....................................................................................22
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