ALFA FACULDADE DE ALMENARA Rua Vereador Virglio Mendes Lima, 847 Bairro So Pedro. Almenara/MG CEP: 39900-000 Fone/Fax: (33) 3721-1098 E-mail: alfa.caldeira@yahoo.com.br

GUIA PRTICO DE COLETA DE DADOS DE ENFERMAGEM Data: ___/___/___ RG: __________ Leito: ________ Clnica: ____________ Nome: _________________________________________________________ Sexo: ______________ Idade: _________________ Cor: ________________ Estado civil: __________________________ Filhos: ____________________ Grau de instruo: ____________________ Ocupao: __________________ Proveniente: _____________________ Naturalidade: ___________________ Chegou em: _______________________ Na companhia de: ______________ Histria da doena atual (motivo da admisso, queixas) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ AMP (doenas, tratamento, transfuso sangnea) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ AMF (doenas, tratamento) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ PADR'ES FUNCIONAIS DE SADE _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Percepo da sade - controle da sade (comprometimento com a sade, vcios, alergias) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Condies de moradia (urbana/rural, prpria/alugada, nmero de cmodos por pessoa, construo, ventilao, animais, gua, esgoto, sanitrio, lixo, eletricidade) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

- Cuidado corporal (banho - imerso/abluo, higiene oral - prteses, cabelos/barba/plos, higiene ntima, higiene mos/ps/unhas/olhos/nariz) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Nutricional - metablico (alimentao, hidratao, problemas tegumentares) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Eliminao (vesical, intestinal, menstruao, outras vias - presente/ausente, caractersticas, problemas) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Atividade - exerccio (atividades de auto-cuidado, fsica, restrio motora) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Sono e repouso (hbitos, dificuldade) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Cognitivo - percepo (sentidos, dores) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Estado psicolgico _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Participao - relacionamento (estado social, barreira de linguagem) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

- Sexualidade - reproduo (preventivos, auto-exame, atividade, GPA) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Enfrentamento - tolerncia ao estresse (comportamento) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Valor - crena (nvel, significado, importncia) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Manuteno da sade (exames mdicos, dentrios peridicos, imunizao) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

EXAME FSICO 1. Temperatura ( ( ( ( ( ( ( ) ) ) ) ) ) ) Hipotermia Normotermia Febrcula Estado Febril Febre Pirexia Hiperpirexia 36 C 36 C - 37,4 C 37,5 C - 37,7 C 37,8 C - 38 C 38 C - 39 C 39 C - 40 C > 40 C

Obs.: Assistncia na hipertermia: banho morno, ambiente frio, compressas frias / gua e lcool, ingesta de lquidos. Assistncia na hipotermia: aquecimento / alimentos quentes. 2. Respirao ( ( ( ) Eupnico ) Bradipnico ) Taquipnico Recm-nascido 30-40 / Adulto 16 a 22 rpm < 16 rpm > 22 rpm

Obs.: Dispnia, ortopnia (respirao facilitada em posio vertical), apnia, respirao estertosa (com rudos). 3. Pulso - Normocardia 60-80 - Bradicardia - Taquicardia RN 120-140 / Lactente 100-120 / Adolescente 60-100 / Idoso Abaixo do normal Acima do normal

Obs.: Variando tambm para pulso cheio/fino (taquisfigmia/bradisfigmia) e pulso regular/irregular. 4. Presso Arterial ( ( ( 5. ( ( ( ( ) Normotenso ) Hipotenso ) Hipertenso Peso e Altura ) Abaixo do Peso ) Peso Ideal ) Acima do Peso ) Obeso 120x80 - 140x90 mmHg < 90x60 mmHg > 140x90 mmHg IMC < 18,5 IMC na faixa de 18,5 - 25 IMC na faixa 25 - 30 IMC > 30

6. Condies Gerais ( ( ( ( ) ) ) ) Bom estado geral Regular estado geral Mau estado geral Pssimo estado geral

7. Nvel de Conscincia ( ( ( ) Consciente ) Inconsciente ) Orientado

8. Observar simetria, sentado e em p: ( ( ) MMII simtricos ) MMII assimtricos

9. Locomoo ( ( ( ) Deambula - com ou sem auxlio ) Senta - com ou sem auxlio ) Levanta - com ou sem auxlio

10. Condies da pele e anexos: - Colorao (plida, ciantica, hiperemiada, corada) _________________________________________________________________ _________________________________________________________________ - Integridade (ntegra, lesionada, prurido, deformidade) _________________________________________________________________ _________________________________________________________________ - Turgor (normal, diminudo) _________________________________________________________________ _________________________________________________________________ - Hidratao (hidratada, ressecada, fissuras) _________________________________________________________________ _________________________________________________________________ - Manchas (equimose, hematomas) _________________________________________________________________ _________________________________________________________________ - Higiene _________________________________________________________________ _________________________________________________________________

11. Inicia-se a inspeo, palpao, percusso e ausculta cfalo-caudal CABEA - Cabelo e couro cabeludo (quebradios, ressecados, seborria, dermatite, sujidade, pediculoses, leses) _________________________________________________________________ _________________________________________________________________ - Orelhas e ouvidos (sujidade, acuidade, dor, leses, deformidades) _________________________________________________________________ _________________________________________________________________ - Olhos (secrees, edema de plpebras, avaliao pupilar, ptose palpebral, tersol ou flebite, conjuntivite, ictercia, anemia) _________________________________________________________________ _________________________________________________________________ - Nariz e fossas nasais (secreo, sujidade, deformidade, obstruo) _________________________________________________________________ _________________________________________________________________ - Boca (lbios - ressecados, normais, feridas; lngua e mucosas - lngua saborrosa, integridade, colorao, hidratao, aftas; sangramento gengival; condies da dentio; dificuldade de mastigao e deglutio; hlito e fonao; secrees; prteses) _________________________________________________________________ _________________________________________________________________ - Pescoo (ndulos e gnglios) _________________________________________________________________ _________________________________________________________________ TRAX (expansibilidade, dor, deformidade, funil - peito escavado, quilha - peito de pombo, cifoescoliose, abaulamento e retraes; mamas - flcidas, trgidas, deformidades, ndulos, dor, mamilos - planos, fissuras, secrees, rede venosa - visvel, palpvel, processo inflamatrio, esclerose) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Ausculta pulmonar (anterior: acima da linha axilar, ambos os lados e no incio da cada seio reto aos mamilos; paciente deve respirar pausada e profundamente com boca entreaberta. _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

Ausculta normal: murmrio vesicular. Rudos adventcios: Roncos, semelhante ao ronco do sono, ocorre na expira o, representa presena de secreo, pode indicar asma brnquica, bronquite, bronquiectasia e obstrues localizadas. Sibilos: semelhante ao chiado, representa obstruo de fluxo areo, ocorre em asma e DPOC. Estertor mido: ocorre no final da inspirao, so creptantes ou bolhosos) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Ausculta cardaca (ausculta dos focos: tricspide, parte baixa do esterno junto linha paraesternal esquerda; mitral, onde se identifica a ponta; artico, 2 espao intercostal direito junto ao esterno; pulmonar, 2 espao intercostal esquerdo junto ao esterno. Sons: bulha normal 2T, estalidos e sopros) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ TRAX DORSAL (regio sacra e gltea - hiperemia, ulceraes e musculatura) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ ABDOME (observar forma - globoso, flcido, tenso, distendido, escavado; abaulamento, retraes; localizao da cicatriz umbilical; ausculta a fim de detectar rudos peristlticos em toda a extenso; percusso a fim de detectar sons anormais; palpao a fim de detectar dores) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ MMSS e MMII (rede venosa, musculatura, movimentos, edemas) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ GENITLIA EXTERNA (secrees, alteraes epiteliais, colorao, algia) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ DECBITO NO LEITO (posio de preferncia, porque) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

AVALIAO DE PROBLEMAS COLABORATIVOS: ( ( ( ( ( ( ( ( ( ) ) ) ) ) ) ) ) ) Cardaca / vascular renal / urinria Metablica / imunolgica / hematopotica Muscular / esqueltica Multissistemas (efeitos adversos da terapia medicamentosa) Respiratria Gastrointestinal / heptica / biliar Neurolgica / sensorial Reprodutora

OBSERVAES _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ ________________________________________________________________

EVOLUO - Data e hora: ___________________ - Tempo de internao: ___________________________________________ -Motivo da internao: ____________________________________________ -Como paciente passou o perodo (dormindo agitado, calmo) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Nvel de conscincia (consciente, orientado, confuso, contactuando) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Locomoo (acamado, deambulando) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Estado geral (colorao da pele, hidratao) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Sinais vitais (temperatura, pulso, respirao, presso arterial) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Exame fsico _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Mantendo jejum (sim/no, porque) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Sono e repouso (sim/no, porque) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Inciso cirrgica (dreno, cateter) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

- Sonda vesical ou nasogstrica (aberta, fechada, drenando, caractersticas) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Venclise (regio, tipo - perifrica, intracath) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Eliminao urinria e fecal (ausente, presente) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Outros (higiene, aspirao, entubao, recebendo sangue, curativo, apoio psicolgico) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ - Queixas (nuseas, dor) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Exemplo: Paciente no 1 dia de internao por X, passou perodo calmo, consciente e orientado em tempo e espao, contactuando. Deambulando sob superviso. Corado, hidratado, nromocrdio, eupnico, hipertenso com PA X, acuidade auditiva e visual diminuda, ausculta pulmonar com presena de murmrios vesiculares sem rudos. mantendo jejum em 24 hs, mantendo repouso em 24 hs, mantendo venclise em MSE. Eliminaes fisiolgicas espontneas e presentes. Evolui sem queixas e sem mese. Refere melhora da X.