ELABORACIÓN SITUACIÓN CLÍNICA DE ENFERMERÍA

Justificación: ________________________________________________________________________________________________
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Datos personales
NOMBRE: _________________________________________________________________________________________________
EDAD/SEXO:_________________________________________________________________________________________________
ESTADO CIVIL: _____________________________________________________________________________________________
SERVICIO/UNIDAD:___________________________________________________________________________________________
DIAGNÓSTICO MÉDICO DE INGRESO: ___________________________________________________________________________
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Motivo de ingreso y diagnóstico médico:
MOTIVO DE INGRESO, INICIO DE SIGNOS Y SÍNTOMAS, EVOLUCIÓN DE ESTOS:__________________________________________
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FISIOPATOLOGÍA DEL CUADRO CLÍNICO: (Manifestaciones clínicas, diagnósticos y tto).___________________________________
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EXÁMENES REALIZADOS: (identificar alterados y posibles efectos sobre el estado del pcte)._______________________________
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TRATAMIENTO EFECTUADO: (justificar el uso y consideraciones de enfermería)
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Historia de salud:
ANTECEDENTES MÓRBIDOS: ____________________________________________________________________________________
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ANTECEDENTES QUIRÚRGICOS: _________________________________________________________________________________
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HÁBITOS: ___________________________________________________________________________________________________
TRATAMIENTO FARMACOLÓGICO DE USO PREVIO: _________________________________________________________________
ANTECEDENTES DE ALERGIA(relevancia con la hospitalización actual):__________________________________________________
Valoración de la familia:
CUIDADOR PRINCIPAL, RELACIONES SIGNIFICATIVAS, CARACTERÍSTICAS DE LA VIVIENDA:__________________________________
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GENOGRAMA: _______________________________________________________________________________________________
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Examen físico general:
ESTADO DE CONCIENCIA: ______________________________________________________________________________________
POSICIÓN: __________________________________________________________________________________________________
MARCHA: ___________________________________________________________________________________________________
FACIE: ______________________________________________________________________________________________________
ESTADO NUTRICIONAL (IMC): ___________________________________________________________________________________
COLOR E HIDRATACIÓN DE LA PIEL: ______________________________________________________________________________
SIGNOS VITALES: (EVA = )
FC = SAT O2 = PA =
FR = T° = PAM =

OBS:________________________________________________________________________________________________________
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Examen físico segmentario (aspectos clínicos alterados):

 Piel y mucosas:___________________________________  Zonas de apoyo:_____________________________
 Cabeza:_________________________________________  Zona sacra:_________________________________
 Pupilas:_________________________________________  Alimentación:_______________________________
 Cuello:__________________________________________  Diuresis:___________________________________
 Tórax:__________________________________________  Deposiciones:_______________________________
 Abdomen:_______________________________________ ___________________________________________________
 Ext. Sup. Der.:____________________________________ __________________________________________________
 Ext. Sup. Izq.:_____________________________________ __________________________________________________
 Ext. Inf. Der.:_____________________________________ __________________________________________________
 Ext. Inf. Izq.:______________________________________ __________________________________________________
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Genitales:_______________________________________
Identificación  Problemas de Salud Reales:  Problemas de Salud Potenciales:
de problemas _____________________________________________ _______________________________________________
y priorización _____________________________________________ _______________________________________________
(los 3 _____________________________________________ _______________________________________________
principales) _____________________________________________ _______________________________________________
Luego viene el _____________________________________________ _______________________________________________
DIAG. _____________________________________________ _______________________________________________

EJECUCIÓN (describe y evidencia la ejecución de las actividades planificadas para el día)._______________________________

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REGISTRO (registro de las actividades según norma institucional).__________________________________________________
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EVALUACIÓN: _____________________________________________________________________________________________
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DIAGNÓSTICO 1: _______________________________________________________________________________________________________________________________
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TEORÍA DE ENFERMERÍA: ______________________________________________________________________________________________________________________

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OBJETIVO: _____________________________________________________________________________________________________________________________________
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ACTIVIDADES (10 de valoración y/o de satisfacción) HORARIO/FRECUENCIA RESPONSABLE EJECUTOR

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