Escolar Documentos
Profissional Documentos
Cultura Documentos
) formigamentos
) choques
) cimbras
) queima ou machuca sem perceber
( ) ppulas
( ) infiltraes
( ) tubrculos e ndulos
( ) diminuio ou queda de pelos
( ) diminuio ou perda da sensibilidade
( ) falta ou ausncia de sudorese no local - pele seca
Local
onde
cada
alterao
ucorre:_________________________________________________________________
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Outros sintomas e sinais:
( ) edema de mos ou ps
( ) artralgia
( ) hipertermia
(
(
(
(
(
(
(
(
(
Exame neurolgico
Face
Condio do septo nasal
Sensibilidade corneana
Fora muscular (logoftalmo)
Acuidade visual
Madarose
Triquase
Ectrpio
Logftalmo
Mos
Nervo ulnar (palpao)
Direita
Normal ( )
Alterado ( )
Normal ( )
Ausente ( )
Normal ( )
Diminudo ( )
Paralitico ( )
Normal ( )
Diminuda ( )
Presente ( )
Ausente ( )
Presente ( )
Ausente ( )
Presente ( )
Ausente ( )
Presente ( )
Ausente ( )
Esquerda
Normal ( )
Alterado ( )
Normal ( )
Ausente ( )
Normal ( )
Diminudo ( )
Paralitico ( )
Normal ( )
Diminuda ( )
Presente ( )
Ausente ( )
Presente ( )
Ausente ( )
Presente ( )
Ausente ( )
Presente ( )
Ausente ( )
Direita
Normal ( )
Espessado ( )
Fibroso ( )
Ndulo ( )
Dor ( )
Normal ( )
Esquerda
Normal ( )
Espessado ( )
Fibroso ( )
Ndulo ( )
Dor ( )
Normal ( )
Mobilidade articular
Garras
Ps
Nervo fibular (palpao)
Mobilidade articular
Diminuda ( )
Paraltico ( )
Normal ( )
Diminuda ( )
Paraltico ( )
Normal ( )
Diminuda ( )
Paraltico ( )
Normal ( )
Espessado ( )
Fibroso ( )
Ndulo ( )
Dor ( )
Normal ( )
Diminuda ( )
Paraltico ( )
Normal ( )
Espessado ( )
Fibroso ( )
Ndulo ( )
Dor ( )
Normal ( )
Diminuda ( )
Paraltico ( )
Normal ( )
Mvel ( )
Rgida ( )
Existente ( )
Inexistente ( )
Diminuda ( )
Paraltic0 ( )
Normal ( )
Diminuda ( )
Paraltico ( )
Normal ( )
Diminuda ( )
Paraltico ( )
Normal ( )
Espessado ( )
Fibroso ( )
Ndulo ( )
Dor ( )
Normal ( )
Diminuda ( )
Paraltico ( )
Normal ( )
Espessado ( )
Fibroso ( )
Ndulo ( )
Dor ( )
Normal ( )
Diminuda ( )
Paraltico ( )
Normal ( )
Mvel ( )
Rgida ( )
Existente ( )
Inexistente ( )
Direito
Normal ( )
Espessado ( )
Fibroso ( )
Ndulo ( )
Dor ( )
Normal ( )
Diminuda ( )
Paraltico ( )
Normal ( )
Diminuda ( )
Paraltico ( )
Normal ( )
Diminuda ( )
Paraltico ( )
Normal ( )
Diminuda ( )
Paraltico ( )
Normal ( )
Espessado ( )
Fibroso ( )
Ndulo ( )
Dor ( )
Normal ( )
Mvel ( )
Esquerdo
Normal ( )
Espessado ( )
Fibroso ( )
Ndulo ( )
Dor ( )
Normal ( )
Diminuda ( )
Paraltico ( )
Normal ( )
Diminuda ( )
Paraltico ( )
Normal ( )
Diminuda ( )
Paraltico ( )
Normal ( )
Diminuda ( )
Paraltico ( )
Normal ( )
Espessado ( )
Fibroso ( )
Ndulo ( )
Dor ( )
Normal ( )
Mvel ( )
Rgida ( )
Existente ( )
Inexistente ( )
P cado
Rgida ( )
Existente ( )
Inexistente ( )
Diagnsticos de enfermagem
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Achados do exame fsico geral, orientaes, encaminhamentos e
procedimentos realizados
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Assinatura e carimbo:_____________________________________________________