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HISTRICO DE ENFERMAGEM

Data: ___ /___ /___

Hora: ___:___hs

Quarto: _____

Leito: ____

Diagnstico Mdico: ______________________________________

CID: ________

Nome do Paciente: _____________________________________________________________


Idade: _____ anos

Sexo: ( )F ( )M

Etnia: ( )Branco

( )Negro

Estado Civil: _______________

( )Pardo

( )Amarelo

( )ndio

Profisso: _____________________________________________________________________
Proveniente: ( )Casa

( )Trabalho

( )Hospital

( )UBS

( )Rua

( )Outros ___________

Condies de Chegada: ( )Consciente/Orientado ( )Inconsciente ( )Confuso ( )Sonolento


( )Torporoso ( )Sncope ( )Crise Convulsiva ( )Perda de Memria ( ) Sedado
( )Intubado ( ) Traqueostomizado ( )Ventilao Mecnica ( )Mscara de O
Dico: ( )Normal

( )Lento

( )Balbuciada

( )Afasia

Queixa Inicial: _________________________________________________________________


Grau de Dependncia: ( )Sem Auxlio ( )Muletas ( )Cadeira de Rodas ( )Totalmente
Acamado ( )Paresia Total ( )Hemiparesia ( )Plegia Total ( )Hemiplegia
Detalhes: _____________________________________________________________________
Sinais Vitais: PA: ______ / ______mmHg
FR: _____ ipm
T: ___ C

FC: _____ bpm

Glicemia: ______ mg/dL


Peso: ______ Kg

Altura: _______

Possui lcera por presso? ( )No

( )Sim

Qual o estado da lcera? ( )Grau I

( )Grau II

Onde? _____________________________
( )Grau III

( )Grau IV

Aspecto da lcera: _____________________________________________________________


Doenas pr-existentes: _________________________________________________________
_____________________________________________________________________________
Antecedentes Familiares: ________________________________________________________
_____________________________________________________________________________
Pratica Atividades Fsicas? ( )No
Possui Algum Vcio? ( )No

( ) Sim

( )Sim Qual?__________________________________
Qual? ______________________________________

Quanto tempo est viciado? _______________________


Quanto tempo largou o vcio? ______________________
Utiliza algum medicamento? ( )No
( )Sim
Quais? ______________________________
_____________________________________________________________________________
Alrgico: ( )No
( )Sim
Medicamento: _________________________________________________________________
Contraste: ____________________________________________________________________
Alimento: _____________________________________________________________________
Outros: _______________________________________________________________________
Reaes: _____________________________________________________________________
J esteve internado antes? ( )No
( )Sim
Motivo: _____________________________
_____________________________________________________________________________
J foi operado? ( )No

( )Sim

Onde? ________________________________________

Perda de Peso: ( )No

( )Sim

Quanto: ____________

Dificuldade de Deglutir: ( )No

Tempo: ________________

( )Sim

Alimenta-se via: ( )Oral


( )SNE
( ) SNG
( )Gastrotomia
( )NPP
Outros: _______________________________________________________________________
Tipo de Dieta: ( )Geral
( )Restrita
Detalhes: _____________________________________________________________________
Mantm AVP? ( )No

( )Sim

Sinais Flogsticos: ( )No


Possui FAV? ( )No
Possui Frmito? ( )No

( )Sim

( )Sim

Onde? _______________________________________
Detalhes: _____________________________________
Onde? __________________________________________

( )Sim

Evacuao: ( )Normal ( )Constipao ( )Diarreia ( )Dor ( )Hemorridas ( ) Colostomia


Apoio: ( )Nenhum ( )Laxante ( )Enema ( )Supositrio
Diurese: ( )Normal
( )Nictria
( )Disria
( )Olguria
( )Anria
( )Hematria
( )Plria ( )Incontinncia
Aspecto e Cor da Urina: _________________________________________________________
Apoio: ( )Nenhum ( )Fraudas ( )Jontex
( )SVD
( )SVA ( )Citostomia
Tempo de SVD: _______________ Aspecto de SVD: __________________________________
Sono e Repouso:
Descanso Noturno: Acorda a Noite: ( )No
( )Sim
Descanso Diurno: ( )No
( )Sim
Apoio: ( )No
( )Sim
Quais? ______________________________________________
Detalhes: _____________________________________________________________________

Acuidade Visual: ( )Normal ( )Prejudicada ( )Cego ( )Nistagmo


Detalhes Visuais: _______________________________________________________________
Teste Giordano: ( )Positivo
( )Negativo
Detalhes: _____________________________________________________________________
Batimentos Cardacos: ( )Normocardaco ( )Bradicardaco ( )Taquicrdico
Bulhas: ( )Rtmicas ( )Arritmicas ( )Hipertonticas ( )Hipotonticas ( )Normofonticas
Sopro: ( )No
( )Sim
Onde?_______________________________________________
Detalhes Cardacos: _____________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Abdomen: ( )Flcido ( )Plano
( )Indolor a palpao

( )Globoso

( )Distendido

( )Doloroso a Palpao

Possui Alguma Cicatriz? ( )No ( )Sim Onde e Motivo: _____________________________


_____________________________________________________________________________
Rudos Hidroareos: ( )Presentes
( )Ausentes
( )Hipoativo ( )Hiperativo
Detalhes da Auscuta Abdominal: __________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Sistema Respiratrio: ( )Normal
( )Tosse
( )Falta de Ar
( )Hemoptise
( )Espectorao ( )Afogamento
Detalhes: _____________________________________________________________________
Rtmo: ( )Eupneico
( )Dispneico
( )Taquipneico
( )Bradipnico
( )Apnico
Mrmurios Vesiculares: ( )Claro Pulmonar
( )Roncos
( )Sibilos
( )Estertores
( )Creptao
Trax: ( )Normal/Simtrico
( )Assimtrico
( )Globoso/Tonel
( )Peito de Pombo
( )Escavado/Carinado
Detalhes Respiratrios: __________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Tegumento: ( )Pele Corada ( )Hipocorada
( )Ictrico
( )Ciantico
( )Esquimoses
( ) Petquias
( )Escoriaes
Umidade: ( )Normal
( )Sudortica ( )Seca
Detalhes Tegumentar: ___________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Temperatura: ( )Normal
( )Quente ( )Fria
Escala de Dor: ( )1 ( )2 ( )3 ( )4 ( )5 ( )6 ( )7
Sendo: 0 sem dor/ 5 Moderada/ 10 Insuportvel

( )8

( )9

( )10

Observaes Gerais: ___________________________________________________________


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Assinatura/Carimbo/COREN