Caderno Registos

Notas de Enfermagem
Elaborado por: Ana Santos
Registos
- Estado de Conscincia
- Nvel de Vigilidade (Vgil; Letrgico; Obnubilado; Estuporoso; Comatoso)

- Contedo
- Orientao Temporal (Ano? Ms? Dia? Semana? Dia? Estao?)
- Orientao Espacial (onde vive? Onde est? Em que cidade? Distrito?)
- Orientao Pessoal (como se chama? Qtos anos tem? O que faz?)
- Sinais Vitais (passagem de turno: referir s achados anormais):

- Temperatura (apirtico ou no)
- Pulso
- Tenso Arterial
- Respirao (ciclos, tosse e caractersticas, SaPO2 com ou sem aporte de O2)
- Oxigenoterapia? Percentagem? Litros/Min?
- Dor (tipo de dor? Localizao? Irradia? Para onde? Intensidade segundo escala
de cor/numrica? durao? factores de alvio? Factores precipitantes?...)
- Cuidados de Higiene
- Autnomo ou Dependente na realizao das AVDs?
- Se dependente: colaborante? Avaliao da funo motora?
- Avaliao da pele e mucosas: hidratao, turgor, integridade?
- Pensos e pomadas presentes e realizadas (em que dia, at quando?)
Registos (cont.)
- Medicao (ocorrncia de urgncia e avaliao da respectiva eficcia associada ao SV
alterado; restantes: doente aderiu a teraputica? Efeitos teraputico/adversos observados?)
- Soroterapia (ritmo de perfuso? Qual? Que medicao? De que horas a que horas?)
- Bionctar/ Catter: localizao? Aspecto? Hematoma? Seroma?
- Alimentao
- Exames Auxiliares de Diagnstico
- Realizado... No servio tal... A doente saiu do servio as horas tal...
Aguarda-se resultado.
- Sangue quem colheu? Para que tipo de exame?
- Fezes e Urina quem colheu? Para que tipo de exame?
- Outras indicaes mdicas: alta? Discusso de observaes e propostas teraputicas?
Avisos em relao ao doente?
- Posicionamentos (Quais fizemos? Quais tolera? Quais prefere? Em qual foi posicionado?)
- Eliminao (evacuou dejeco mole/de cor tal....) (urinou caractersticas da urina)
- Drenagem Vesical (lavagem? Permevel? Dbito urinrio ao longo do turno
com urina de caractersticas?)
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____
Passagem de Turno: ______________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Respirao: N Ciclos: _____ Eupneico?_____________________
Temperatura Timpnica: _____C
Oxigenoterapia?_________________________________
BMTeste: 1.______ 2.______ Edema? ___ Sinal Godet ______ Peso: ______kg PA: ______cm
Higiene: Onde:______________ Colaborao: ______________________________________
Funo Motora: ________________________________________________________________
Pele: ntegra?____ Hidratada?________________________________________ Turgor? ____
Soluo de Continuidade: Tipo: 1.______________ 2._______________ 3._______________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Soro?: ___ Cateter/ Bionecteur Medicao?_________________________________________
Ritmo: ___________ Localizao:________________________________________________
Sinais Inflamatrios: _____________________________________________________________
Alimentao:___________________________________________________________________
EAD: _____________________ realizado por_______________ no servio _______________ s _______
Posicionamento: _______________________________________________________________
Eliminao? Evacuou? ___ Dejeco: ______________________________________________
Urinou? ___ Caractersticas: ______________________________________________________
Sonda Vesical: ____ Permevel? Dbito Urinrio:_______________ BH: ________________
Medicao de urgncia: ___________________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Dia:____________ Turno: ___________ Nome: ____________________

Sala:_____ Cama:_____

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Tenso Arterial: 1.______/______ 2.______/______ 3.______/______ 4.______/______ (...)
Dor:
10
Tipo/ Localizao:_______________________________________________________________
Pulso: ______b. p. m.
Oxigenoterapia?_________________________________
Funo Motora: ________________________________________________________________
Localizao: 1_____________________ 2_____________________ 3_____________________

Penso 1:_______________________________________________________________________
Penso 2:_______________________________________________________________________
Penso 3:_______________________________________________________________________
Ritmo: ___________ Localizao:________________________________________________
Alimentao:___________________________________________________________________
Posicionamento: _______________________________________________________________
Urina:
Quantidade:
Poliria: >2500 ml/dia;
Oligria: <400 ml/dia;
Anria: <100 ml/dia
Cor:
Normal: mbar
Hematria: Sangue Turva: Precipitao de Fosfato ou Bactrias
Ritmo: Nictria: predominantemente nocturna Opsiria: Atraso na eliminao da gua ingerida
Forma: Polaquiria: frequente
Disria: difcil
Tenesmo: mico dolorosa
Urina colrica: urina escura (vinho do porto) devido concentrao aumentada de urobilina
eliminada pelos rins na tentativa de remover o excesso de pigmentos biliares.
( Glicosria / Protenria costuma ser espumosa )
Fezes:
Obstipao: dificuldade constante ou eventual da evacuao das fezes
Diarreia: aumento do nmero de evacuaes (+ de 3x) e a presena de fezes amolecidas/lquidas
Consistncia e Cor: Melenas: pastosas de cor escura e cheiro ftido, sinal de hemorragia digestiva.
Aclicas: descoradas, branco-acizentadas, ausncia do bilirrubinognio
Esteatorreias: volumosas, acinzentadas ou claras, de odor caracterstico, flutuam
na gua e tm aparncia oleosa, ou so acompanhadas de gordura que flutua
Hemorragia Declarada

Caderno Registos

Enviado por

Dados do documento

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Caderno Registos

Enviado por

Direitos autorais:

Formatos disponíveis

Notas de Enfermagem

Elaborado por: Ana Santos

- Nvel de Vigilidade (Vgil; Letrgico; Obnubilado; Estuporoso; Comatoso)

- Sinais Vitais (passagem de turno: referir s achados anormais):

Dia:____________ Turno: ___________ Nome: ____________________

Passagem de Turno: ______________________________________________________________________

Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Respirao: N Ciclos: _____ Eupneico?_____________________

Temperatura Timpnica: _____C

Localizao: 1_____________________ 2_____________________ 3_____________________

Dia:____________ Turno: ___________ Nome: ____________________

Passagem de Turno: ______________________________________________________________________

Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Respirao: N Ciclos: _____ Eupneico?_____________________

Temperatura Timpnica: _____C

Localizao: 1_____________________ 2_____________________ 3_____________________

Dia:____________ Turno: ___________ Nome: ____________________

Passagem de Turno: ______________________________________________________________________

Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Respirao: N Ciclos: _____ Eupneico?_____________________

Temperatura Timpnica: _____C

Localizao: 1_____________________ 2_____________________ 3_____________________

Dia:____________ Turno: ___________ Nome: ____________________

Passagem de Turno: ______________________________________________________________________

Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Respirao: N Ciclos: _____ Eupneico?_____________________

Temperatura Timpnica: _____C

Localizao: 1_____________________ 2_____________________ 3_____________________

Dia:____________ Turno: ___________ Nome: ____________________

Passagem de Turno: ______________________________________________________________________

Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Respirao: N Ciclos: _____ Eupneico?_____________________

Temperatura Timpnica: _____C

Localizao: 1_____________________ 2_____________________ 3_____________________

Dia:____________ Turno: ___________ Nome: ____________________

Passagem de Turno: ______________________________________________________________________

Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Respirao: N Ciclos: _____ Eupneico?_____________________

Temperatura Timpnica: _____C

Localizao: 1_____________________ 2_____________________ 3_____________________

Dia:____________ Turno: ___________ Nome: ____________________

Passagem de Turno: ______________________________________________________________________

Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Respirao: N Ciclos: _____ Eupneico?_____________________

Temperatura Timpnica: _____C

Localizao: 1_____________________ 2_____________________ 3_____________________

Dia:____________ Turno: ___________ Nome: ____________________

Passagem de Turno: ______________________________________________________________________

Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Respirao: N Ciclos: _____ Eupneico?_____________________

Temperatura Timpnica: _____C

Localizao: 1_____________________ 2_____________________ 3_____________________

Dia:____________ Turno: ___________ Nome: ____________________

Passagem de Turno: ______________________________________________________________________

Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Respirao: N Ciclos: _____ Eupneico?_____________________

Temperatura Timpnica: _____C

Localizao: 1_____________________ 2_____________________ 3_____________________

Dia:____________ Turno: ___________ Nome: ____________________

Passagem de Turno: ______________________________________________________________________

Vgil?________________ Contedo? T:_____________ E:______________ P:______________

Respirao: N Ciclos: _____ Eupneico?_____________________

Temperatura Timpnica: _____C

Localizao: 1_____________________ 2_____________________ 3_____________________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________

Dia:______ Turno: _ Nome: ________________

Vgil?__________ Contedo? T:_ E: P:______

Respirao: N Ciclos: _ Eupneico?_________________

Localizao: 1___________ 2_ 3___________