Avaliao do

Razo de procura do Servio/ Motivo de Internamento: _______________

Assistido
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Informao Demogrfica e Avaliao Psicossocial
Histria de Sade:

Data: ___________________________________________
Identificao
Pessoal:
Transferncia:_____________________________________
Sexo:
__________ Nome: _____________________________
Trato: __________ Data de Nascimento: _______ - ____ - ____
Sintomas
Predominantes:
Morada: _______________________________________________
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Telefone: ______________ Idade(real e aparente): _____________
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Mdico Assistente:_________________________________________
Histria
de Doena
Actual:
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Habilitaes
Literrias:
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Profisso: ______________________________________________
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Ocupao (reformado?): ________________________
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Histria Militar: __________________________________________
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Estado Civil: ____________________________________________
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Agregado Familiar: ________________________________________
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Exames
de Diagnstico:
Pessoas Auxiliares
Significativas:
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Linguagem Predominante: ___________________________________
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Histria Scio-Cultural: _____________________________________
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Diagnstico
Clnico:
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Valores e Crenas Espirituais: _________________________________
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Medicao
Habitual vs. Actual:
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Actividade Cognitiva:
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- Auto-conceito: ____________________________________
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Auto-imagem (efeitos da doena): __________________
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Auto-estima:________________________________
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Desempenho de papis: _________________________
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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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