Estagio SupervisionadoSAE - SISTEMATIZAÇÃO DA ASSISTENCIA DE ENFERMAGEM

PROCESSO DE ENFERMAGEM1.0 HISTÓRICO DE ENFERMAGEMANAMNESE:IDENTIFICAÇÃO:NOME - SIGLA:_________________________________________________________________________RESID. ATUAL: _________________________________________________________________________DATA DE NASC.: ___/____/______ IDADE: ________ NATURAL DE : ____________________________SEXO: ____________ ESTADO CIVIL: ___________ RELIGIÃO: _______________________________ESCOLARIDADE: ______________________________ PROFISSÃO/OCUPAÇÃO: __________________DATA DE INTERNAÇÃO: ________________________ DATA DA ENTREVISTA: _______ Q/LEITO:_____INFORMANTE: ________________________________ENTREVISTADOR: _________________________

HISTÓRIA DA MOLÉSTIA ATUAL (Queixa principal e duração) : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________COMO FOI TRAZIDO ? SAMU O PROPRIO AMIGO

OUTROS : ________________________________________________________________________CIRURGIAS ANTERIORES ? NÃO SIM, QUAL(IS) ? ____________________MEDICAMENTOS DIÁRIOS ? NÃO SIM, QUAL(IS) ? __________________________________________________________________________________________________________POSSUI ALERGIAS ? NÃO SIM, QUAL(IS) ? __________________________________________________________________________________________________________MOLÉSTIAS CRÔNICAS ? NÃO SIM, QUAL(IS) ? __________________________________________________________________________________________________________

1.1 CONDIÇÕES DE MORADIA: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________1.2 HÁBITOS ALIMENTARES:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________1.3 ATIVIDADES FÍSICAS:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________1.4 USO ABUSIVO DE ÁLCOOL, TABAGISMO OU DROGAS: ______________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________2.0 EXAME FÍSICO 2.4.3 NARIZPESO: ________KG ALTURA: __________CM SECREÇÕES SEROSAS

DESVIO DE SEPTO2.1 SINAIS VITAIS: ÍNTEGRO OBSTRUÇÃOPULSO: _______BPM F.RESP.: __________RPM INFLAMAÇÃOTax: _________ºC P.A.: ______/______mmHg PRESENÇA DE DEFORMIDADES

2.4.4 ORELHAS2.2 NÍVEL DE CONSCIÊNCIA: SURDEZ ACÚMULO SERUME

ORIENTADO AGITADO INFLAMAÇÃO OBSTRUÇÃODEPRESSIVO DESORIENTADO ACUIDADE AUDITIVA NORMALHIPERATIVO HIPOATIVO ACUIDADE AUDITIVA ALTERADAINCONSCIENTE COMATOSO 2.4.5 BOCA

DENTIÇÃO NORMALCALMO CHOROSO PRÓTESE CÁRIECONFUSO ATIVO HALITOSESONOLENTO TORPOROSO 2.4.5.1 LÍNGUAPLEGIA PARESIA SABURROSA SECA

FISSURADA ROSADAANSIOSO LÍMPIDASEDADO 2.4.5.2 MUCOSACONSCIENTE ÍNTEGRA FERIMENTOSPARESTESIA HIPOCORADA HIPEREMIADA

2.3 ESTADO GERAL: (REFERE-SE AO ESTADO LESÕES AFTASHIGIÊNICO, NUTRICIONAL E HIDRATAÇÃO) 2.5 OROFARINGE

BOM (03 ITENS BONS) TONSILAS PALATINAS NORMAISREGULAR (01 ITEM ALTERADO) TONSILAS PALATINAS ALTERADASRUIM (02 ITENS ALTERADOS) PRESENÇA DE SECREÇÃO PURULENTAPÉSSIMO(TODOS OS ITENS ALTERADOS)

2.4 CABEÇA: 2.6 PESCOÇO2.4.1 COURO CABELUDO ÍNTEGRO E COM BOA MOVIMENTAÇÃO

ÍNTEGRO LESÕES DOLOROSO A PALPAÇÃOSEBORRÉIA PEDICULOSE GÂNGLIOS ENFARTADOSCALVÍCIE TIREÓIDE PALPÁVEL

2.4.2 OLHOS TIREÓIDE NÃO PALPÁVELACUIDADE VISUAL NORMAL TORCICOLOACUIDADE VISUAL ALTERADA

2.4.2.1 CONJUNTIVA 2.7 MMSSHIPERCORADA HIPOCORADA EUTRÓFICOS AUTRÓFICOSNORMOCORADA HIPERTRÓFICOS CONTIDOS

2.4.2.2 PUPILAS AUSÊNCIA DE MEMBROS D E E ISOCÓRICAS ANISOCÓRICAS FLEBITE CIANOSEREAGENTES NÃO REAGENTES EDEMA OXIGENADOSMIDRÍASE MIOSE AQUECIDOS

2.4.2.3 ESCLERÓTICAICTÉRICA ANICTÉRICAPTERÍGIO HIPEREMIADA

2.8 TÓRAX 2.11.1 AUSCULTA ABDOMINALPLANO CHATO TIMPÂNICO MACIÇOCIFÓLICO TONEL RUÍDOS HIDROÁEREOSESCOLIÓTICO CIFOESCOLIÓTICO SUBMACIÇO HIPERTIMPÂNICOTRAUMÁTICO PEITO DE POMBO

2.8.1 MAMASSIMÉTRICAS ASSIMÉTRICASDOLOROSA A PALPAÇÃOPRESENÇA DE NÓDULO(S)

2.9 SISTEMA CARDIOCIRCULATÓRIOPULSO

RITMICO ARRITMICOCHEIO FILIFORME

2.9.1 FREQUÊNCIA CARDÍACANORMOCARDICOBRADICARDICO 2.12 ELIMINAÇÕESTAQUICARDICO 2.12.1 URINÁRIAS/VOLUME

2.9.2 AUSCULTA CARDÍACA INCONTINENCIA URINARIANORMOFONÉTICA DIURESE ANÚRIAHIPOFONÉTICA POLIURIA DISURIAHIPERFONÉTICA POLIACIURIA NICTURIA

2.10 SISTEMA RESPIRATÓRIO OLIGURIA2.10.1 FREQUÊNCIA RESPIRATÓRIA 2.12.2 URINÁRIAS/COLORAÇÃO

EUPNEICO TAQUIPNEICO HEMATURIA AMARELO CLARODISPNEICO BRADIPNEICO TURVA PIURIA

2.10.2 AUSCULTA PULMONAR ODOR CARACTERÍSTICOMURMÚRIOS VESICULARES 2.13 ELIMINAÇÕESSIBILOS RONCOS FECAISESTERTORES CREPTOS PRESENTE/PASTOSA

2.10.3 TOSSE/SECREÇÃO AUSENTA HÁ _____ DIASPRODUTIVA SECA DIARREIA CONSTIPAÇÃOPURULENTA ESBRANQUIÇADA MELENA HEMATOQUESIA

ODOR CARACTERÍSTICOFÉTIDA

2.14 MMII2.11 ABDOME EUTROFICOS FLEBITE

PLANO DISTENDIDO EDEMA VARIZESFLÁCIDO TENSO CIANOSEHEPATOMEGALIA AUTROFICOS HIPERTROFICOSGLOBOSO DOLOROSO A PALP. AUSENCIA DE MEMBROS D E EESPLENOMEGALIA 2.15 SISTEMA MUSCULO ESQUELÉTICO

GRAVÍDICO INDOLOR A PALP. DEAMBULA NÃO DEAMBULAPRESENÇA DE OSTOMIA _________________ DEAMBULA COM AUXÍLIO

ACAMADO

2.16 PELEÍNTEGRA RESSECADAICTÉRICA NORMOCORADAHIPOCORADA HIPERCORADATURGOR DIMINUÍDOELASTICIDADE MANTIDAESCORIAÇÕES PRURIDOÚLCERAS

3.0 ANOTAÇÕES DE ENFERMAGEM:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4.0 DIAGNÓSTICOS DE ENFERMAGEM:#1 : _____________________________________________________________________________________________________________________________________________________________________________#2: _____________________________________________________________________________________________________________________________________________________________________________#3: _____________________________________________________________________________________________________________________________________________________________________________#4: _____________________________________________________________________________________________________________________________________________________________________________#5 : _____________________________________________________________________________________________________________________________________________________________________________#6: _____________________________________________________________________________________________________________________________________________________________________________#7: _____________________________________________________________________________________________________________________________________________________________________________#8: _____________________________________________________________________________________________________________________________________________________________________________

#9: _____________________________________________________________________________________________________________________________________________________________________________#10:____________________________________________________________________________________________________________________________________________________________________________#11: ____________________________________________________________________________________________________________________________________________________________________________5.0 PLANEJAMENTO ASSISTENCIAL: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6.0 PLANO DE CUIDADOS:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________7.0 EVOLUÇÃO DE ENFERMAGEM:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________8.0 PROGNÓSTICO DE ENFERMAGEM: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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