UNIVERSIDAD DEL TURABO

ESCUELA DE CIENCIAS DE ENFERMERA

GRADO ASOCIADO

HISTORIAL DE ENFERMERA
Nombre:
Curso : NURS 109-Cuidado de Enfermera
Materno Infantil
Fecha:

Nmero de estudiante :
Seccin:
Profesora: Sonia E. Cedeo Aponte RN, MSN.

ESTIMADO INICIAL
Fecha de Ingreso: ______________________ Hora de Ingreso: ________________
Queja Principal: _______________________ Estimado de Dolor: ______________
Contracciones Uterinas: ______ Frecuencia: _______ Regular ______cada / min.
Sangrado: Bloody Show_____ Mnimo_____ Moderado _____Profuso________
HISTORIAL MDICO:
Alergias :________________________________________________________
Operaciones: ( fecha, sitio, diagnstico)_______________________________
Hbitos:_________________________________________________________
Fumar: Cantidad al da ____ Alcohol ____ Drogas ____
HISTORIAL FAMILIAR:

Hipertensin_____________________________________________________
Enfermedad. del corazn____________________________________________
Diabetes_________________________________________________________
Cncer__________________________________________________________
Tuberculosis_____________________________________________________
Epilepsia________________________________________________________
Anemia Falciforme________________________________________________
Hepatitis________________________________________________________
Anomalas Congnitas_____________________________________________
Partos mltiples__________________________________________________
Otras___________________________________________________________

ENFERMEDADES PASADAS:
Problemas ginecolgicos___________________________________________
Enfermedades sexualmente transmisibles_______________________________
Problemas del rin________________________________________________

Infeccin urinaria__________________________________________________
Hematuria________________________________________________________
Problemas de tiroides_______________________________________________
Ictericia_________________________________________________________
lceras estomacales________________________________________________
Asma ___________________________________________________________
Tuberculosis______________________________________________________
Sarampin_______________________________________________________
Anemia__________________________________________________________
Problemas de sangra_______________________________________________
Iso inmunizacin RH, ABO__________________________________________
Fiebre reumtica___________________________________________________
Transfusiones_____________________________________________________
Enfermedad del corazn____________________________________________
Hipertensin______________________________________________________
Venas Varicosas___________________________________________________
Flebitis__________________________________________________________
Embolias________________________________________________________
Epilepsia_______________________________________________________
Problemas Emocional______________________________________________

PROBLEMAS DESPUS DE LA LTIMA MENSTRUACIN:

Naseas_________________________________________________________
Vmitos_________________________________________________________
Indigestin_______________________________________________________
Estreimiento_____________________________________________________
Sangrado Vaginal_________________________________________________
Picor rea vaginal_________________________________________________
Dolor de Cabeza__________________________________________________
Dolor Abdominal_________________________________________________
Problemas de orina________________________________________________
Sarampin Alemn________________________________________________
Problemas de visin_______________________________________________
Mareos_________________________________________________________
Accidentes______________________________________________________
Otras enfermedades_______________________________________________
Medicinas_______________________________________________________
Edemas_________________________________________________________
Exposicin a radiacin_____________________________________________

HISTORIAL OBSTTRICO GINECOLGICO

Menstruacin: Duracin _____

LMP ________
EDC ________
G ___________
P ___________
A ___________
Semana de Gestacin ___________

SNTOMAS:

Dolor de cabeza________________
Mareos_______________________
Edemas: Cara __ Manos __ Pies __
Peso ____
Presin ____
Altura del Fondo Uterino _____
Posicin _______
Presentacin _______
FHS___________________________
Orina: Albmina _____ Azcar ____
Desea planificacin familiar post parto _________
Permiso para la esterilizacin__________________

EXAMN FSICO

Pulso _____
Presin sangunea _____
Estatura _____
Peso ideal ____ Peso antes del embarazo ____ Peso actual _____
Apariencia y nutricin _________________________________________
Piel ________________________________________________________
Ojos, visin __________________________________________________
Odos, nariz y garganta _________________________________________
Boca, dientes y encas __________________________________________
Cuello, tiroides y ndulos _______________________________________
Pecho y mamas ______________________________________________
Corazn ____________________________________________________
Pulmones ___________________________________________________
Abdomen ___________________________________________________
Feto: Presentacin _______________ Posicin ________ FHS ____
Extremidades: Venas ______ Edema _______ Reflejos _______

Vulva y perineo _______________________________________________

Vagina ______________________________________________________
Cervix ______________________________________________________
Fondo Uterino _______________________________________________
Recto ______________________________________________________

EXAMEN DE LABORATORIO:

Hemoglobina__________________________________________________
Hematocrito___________________________________________________
Cerologa_____________________________________________________
2 hrs. pp______________________________________________________
Tipo y Rh ( Madre)_____________________________________________
Tipo y Rh ( Padre)______________________________________________
Coombs indirecto_______________________________________________
Orinalisis_____________________________________________________
Citologa Paps_________________________________________________
GC__________________________________________________________
Vacunacin___________________________________________________
PPD_________________________________________________________
GTT_________________________________________________________
Rubella_______________________________________________________
Cultivo de orina________________________________________________
Hepatitis B____________________________________________________
HIV_________________________________________________________