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Avaliao do Assistido

Informao Demogrfica e Avaliao Psicossocial


Identificao Pessoal:
Sexo: __________

Nome: _____________________________

Trato: __________

Data de Nascimento: _______ - ____ - ____

Morada: _______________________________________________
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Telefone: ______________

Idade(real e aparente): _____________

Mdico Assistente:_________________________________________
Habilitaes Literrias: _____________________________________
Profisso: ______________________________________________
Ocupao (reformado?): ________________________
Histria Militar: __________________________________________
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Estado Civil: ____________________________________________
Agregado Familiar: ________________________________________
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Pessoas Significativas: _____________________________________
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Linguagem Predominante: ___________________________________
Histria Scio-Cultural: _____________________________________
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Valores e Crenas Espirituais: _________________________________
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Actividade Cognitiva:
- Auto-conceito: ____________________________________
Auto-imagem (efeitos da doena): __________________
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Auto-estima:________________________________
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Desempenho de papis: _________________________
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Histria de Sade:
Razo de procura do Servio/ Motivo de Internamento: _______________
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Data: ___________________________________________
Transferncia:_____________________________________
Sintomas Predominantes:
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Histria de Doena Actual: ___________________________________
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Exames Auxiliares de Diagnstico:
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Diagnstico Clnico:
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Medicao Habitual vs. Actual:
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Preocupaes Presentes:
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Antecedentes Pessoais (doenas anteriores? traumatismos? cirurgias?):
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Antecedentes Familiares:
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Percepo do Indivduo:
Compreenso da doena:______________________________
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Adeso aos tratamentos (nvel de interveno e cooperao):______
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Avaliao Fsica
Altura: __________ cm

Peso: __________ Kg

Propores corporais: ______________________________________


Sinais Vitais:
Tenso Arterial: _______________________________
Pulso (local de avaliao): ________________________
Frequncia ____________________________
Amplitude _____________________________
Ritmo _______________________________
Caractersticas (cheio, forte / fraco, filiforme / no palpvel)
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Respirao:
Frequncia ________________________________
Amplitude _________________________________
Ritmo ____________________________________
Rudo ____________________________________
Tempos de I/E ______________________________
Expanso (simetria, regio) _____________________

Temperatura Timpnica: ______________________________


Dor: ____________________________________________
Localizao __________________________________
Qualidade (picada, punhalada, espasmos, clica...) _______
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Quantidade _________________________________
Progresso __________________________________
Irradiao __________________________________

Nvel de Conscincia:
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Comportamento:
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Pele e Mucosas:
Textura: _________________________________________
Integridade: ______________________________________
Descamao: ______________________________________
Hidratada? _______________________________________
Colorao: _______________________________________
Textura: _________________________________________
Solues de Continuidade: _____________________________
Turgor: __________________________________________
Rubor:___________________________________________
Abdmen:
Cicatrizes:________________________________________
Simetria: _________________________________________
Forma do umbigo: __________________________________
Permetro Abdominal:________________________________
Edema: __________________________________________
Cabea, Face e Pescoo:
Crnio (forma, tamanho, posio): _______________________
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Couro Cabeludo (cor, textura, leses):_____________________
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Nariz e Boca:
Permeabilidade das Vias: ______________________________
Alinhamento, insero e simetria do nariz: __________________
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Alinhamento do septo: _______________________________
Boca, mucosas e Lngua: ______________________________
Prteses: _____________________________
Dentes: ______________________________
Olhos e Ouvidos:
Cor dos olhos: _______________________________
Acuidade Visual: _____________________________
Campo Visual: _______________________________
Plpebras: _________________________________
Sobrancelhas: _______________________________
Conjuntiva: ________________________________
Ouvido Externo: _____________________________
Implantao: __________________________
Tamanho: ____________________________
Simetria: _____________________________
Cor: ________________________________
Exsudado: ____________________________
Leses/dor: ___________________________
Acuidade Auditiva: ___________________________
rgos Genitais e Recto:
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Funo Msculo-Esqueltica:
Forma de marcha:___________________________________
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Alinhamento Postural:________________________________
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Amplitude de Movimento e Simetria das Articulaes: __________
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Fora Muscular:____________________________________
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Necessidades Bsicas Afectadas


(segundo Virgnia Henderson):

Respirar

Comer e Beber

Eliminar

Movimentar-se e Manter Postura Correcta

Dormir e Repousar

Vestir-se e Despir-se

Manter a Temperatura Corporal dentro dos limites normais

Estar Limpo e Proteger os Tegumentos

Evitar os Perigos/ Segurana para si e terceiros

Comunicar com os Semelhantes

Praticar Religio ou agir segundo as suas crenas

Ocupar-se de modo a sentir-se til

Recrear-se

Aprender