PROCESSO DE ENFERMAGEM

ANO LETIVO: ________/________

LOCAL DE ESTGIO:

____________________________________________________________________

NOME DO(A) ALUNO(A): ___________________________________________

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COLHEITA DE DADOS
1. IDENTIFICAO DO DOENTE:

Nome: __________________________________________

Cama: _____

2. INFORMAES PRVIAS
____________________________________________________________________
Diagnstico Mdico:
Nome preferido: _________________________________________________________________________
Data de Nascimento: _____ / _____ / ______
Idade: _____ anos
Pessoa significativa a contactar:
_______________________________ Contacto: _________________
Prestador de cuidados:
_____________________________________ Contacto: _________________
Centro de sade de referncia:
_______________________________
N ____
Data ltimo: _____/_____/______
Internamentos anteriores:
Sim
No
Motivo: ________________________________________________________
________________________________________________________
Local:
Intervenes Cirrgicas:
Sim
No
_______________________________________________________________
Antecedentes pessoais:
Patologias: _____________________________________________________
Teraputica domiciliria:
_______________________________________
_______________________________________________________________
Alergias:
Quais: ________________________
Sim
No
Prteses:
Quais: ________________________
Sim
No
Ortteses:
Quais: ________________________
Sim
No
Antecedentes familiares:
Patologias: _____________________________________________________
Informaes gerais:
Provenincia:
Urgncia
Consulta
Transferncia
Fonte de Informao:
Familiar
Doente
Outros
Hbitos alcolicos: Sim
Quantidade
diria:
_________
No
Hbitos tabgicos: Sim
Quantidade diria: _________
No
Droga:
Sinais Vitais:
Temperatura:
Pulso:
T. A.:
Respirao:
Peso:
Altura:
Permetro abdominal:
Membros inferiores: ____________
OBS.:
________________________________________________________
TA: ___/___ mmHg
Pulso: ___ bp/mm
Caractersticas:
Dor:
Ausente
No avalivel
Presente
Escala da Dor
Intensidade: ______

Incio: ______________ _____

Localizao:__________________

9 10

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Tipo:

Picada

Periodicidade:
Breve

Moedeira

Aperto

_______________________

Constante

Peridica

_______________________

____________________________________________________________________

Medidas de alvio:

_________________________________________________________

______________________________________________________________________________
______________________________________________________________________________
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SD

DL

NA
SD
DL
DM
DI
MX

DM

DI

MX

No Avalivel
Sem Dor
Dor Ligeira
Dor Moderada
Dor Intensa
Dor Mxima
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3. RESPIRAR
Frequncia respiratria: _____ c/mn
Sem alteraes
Com alteraes

____________________________________

Caractersticas:
-

Ventimask

FiO2 _____ %

Cnula nasal

- 1/mn ______

Ventilao no invasiva
Dispneia

Sim

No

Espectorao

Sim

No

Consistncia___________

4. BEBER E COMER
Oral
Entrica
Parentrica
Gastronomia
Jejunostomia

Tipo:______________________

Contedo___________

Quantidade____________

______________________________________________
SNG

(Tipo Sonda _________ N ______ Data colocao _____/_____/____)

Motivo: ____________________________________________________

Independente
Sem alteraes
Estado Nutricional:

5. ELIMINAR
Vesical:

Dependente
Total
___________________________
Parcial
Nuseas
Vmitos
Anorexia
Disgagia
Dific. Mastig.
Com alteraes
Normal
Obesidade
Malnutrio
Caquexia
Desidratao
____________________________
N de refeies:
____
____________________________________________
Alimentos que no gosta:
__________________________________
Alimentos que provocam alteraes:
____________________________________________________________________

Independente
Sem alteraes

Dependente
Com alteraes

Total

Incontinncia
Hematria

Algaliao
Intestinal: Independente
Sem alteraes

Tipo de alglia: _______________ N __

Dependente
Com alteraes

Data colocao: ___/___/____

Motivo: __________________________
Parcial
__________________

Total

Incontinncia

Hbitos intestinais _________________

Uso de laxantes ___________________
6. MOVIMENTAR-SE E MANTER A POSTURA CORRETA
Independente
Dependente
Total
Acamado
Sem alteraes
Com alteraes
Plegias

Insnias

Ansiedade

Outro

Reteno
Urgncia urinria

Obstipao

7. DORMIR E REPOUSAR
Sono
Sem alteraes

__________________

Parcial

Com alteraes

Diarreia

Outro

Melenas

Rectorragias

Data da ltima dejeco:

Caractersticas das fezes:

_____/_____/______
___________________

___________________________
Equipamento daptativo
________________

Parcial

OBS.: ___________________________________________

Dificuldade em adormecer

Medicao no domiclio: _________________________________

Sono Intermitente
Horas Dirias de sono: ______

Hbitos de sono: __________________________________________________________________________

Repouso
Exausto

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Sem alteraes
Ansiedade

Dificuldade
Incapacidade
Fadiga
Com alteraes
_________________________________________________________________

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8. VESTIR-SE E DESPIR-SE
Independente
Dependente

Total

Parcial

_______________________________

9. MANTER A TEMPERATURA DO CORPO NOS LIMITES NORMAIS

Temperatura (Axilar/Rectal/Oral/Timpnica) ________ C
10. ESTAR LIMPO, CUIDADO E PROTEGER OS TEGUMENTOS
Independente
Total
Dependente
Bom

Deficiente

Sem alterao

Seca

Hmida

Escoriaes

Feridas

Outras

Hemorragias

Edemas

Varizes

Apreciao geral do estado de higiene:

Estado da pele:

Parcial

________________________
Mau
Ictrica

____________________________

Sem alteraes
Com alteraes
Quais? _____
Colorao da pele/Mucosas/Extremidades:
_______________________________________________________________________________________
11. EVITA OS PERIGOS PARA O PRPRIO E PARA OUTREM
Escala de Glasgow: _____________pontos
Olhos abertos:
Resposta verbal
Resposta motora
4 - Espontaneamente
5 - Orientada
6 - Obedece a ordens
3 - Por ordem
4 - Confusa
5 - Localiza a dor
2 - dor
3 - Inapropriada
4 - Foge dor
1 - Nula
2 - Incompreensvel
3 - Em flexo dor
1 - Nula
2 - Em extenso dor
1 - Nula
Dfices sensoriais:
Auditivos:
Sem alteraes
Com alteraes
Quais? __________________________
Visuais:
Sem alteraes
Com alteraes
Quais? __________________________
12. COMUNICAR COM OS SEMELHANTES
Sem alteraes
Com alteraes
Quais?
Lngua estrangeira: __________________________
Outro: _____________________________________

_________________________________________
Necessidade intrprete:
Sim
No
Sabe ler?
Sim
No

13. PRATICAR A RELIGIO OU AGIR SEGUNDO AS SUAS CRENAS

No identificado
Deseja assistncia espiritual?
Em caso afirmativo,
Sim
No
____________________________________________
quem deve ser contactado para essa assistncia?
Telefone: _____________________
_____________________________________________________

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14. OCUPAR-SE DE MODO A SENTIR-SE TIL

Profisso: ______________________________________________________________________________
Situao no emprego:
Activo
Baixa
Reforma
Desempregado
_________
Foi identificada necessidade de ensino em alguma rea?
No
Sim
Quais:
________________________________________________________________________________
15. RECREAR
_______________________________________________________________________________________
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_______________________________________________________________________________________
16. APRENDER
Foi identificada necessidade em alguma rea?
Sim
No
Quais:
________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

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APRECIAO DE ENFERMAGEM
DIAGNSTICOS DE ENFERMAGEM
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DATA DE INCIO DIAGNSTICO DE ENFERMAGEM

INTERVENES DE ENFERMAGEM

PLANO DE CUIDADOS
RESULTADO ESPERADO

DATA DE FIM

NOTAS DE EVOLUO
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