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FOLHA DE ADMISSO

PACIENTE: _____________________________________________________________________________________

Idade: ______ anos Peso _________ Kg LEITO: _____________ DATA DO INTERNAMENTO: ___/___/___

DIAGNSTICOS:
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EXAME CLNICO na ADMISSO:


HMA:
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HMP:
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MEDICAMENTOS EM USO:
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EXAME FSICO NA ADMISSO:
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RESULTADO DOS EXAMES NA ADMISSO:


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Aps 24h horas:


APACHE IV: _____________ (http://intensivecarenetwork.com/Calculators/Files/Apache4.html)
SOFA: __________________ (http://clincalc.com/IcuMortality/SOFA.aspx?example)

**** IMPRESCINDVEL COMPARAR E COMPLEMENTAR COM EVOLUO ANTERIOR ***


EVOLUO DIRIA
DATA: ____/____/____ D ___ (UTI) Peso: _____________ Kg

S# HISTRICO DAS LTIMAS 24 HORAS

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DISPNEIA: (___) No / (___) Sim: ____________________________________________________________________

ANSIEDADE: (___) No / (___) Sim: __________________________________________________________________

DOR: (___) No / (___) Sim: ________________________________________________________________________

SONO: (___) No / (___) Sim: _______________________________________________________________________

SEDE: (___) No / (___) Sim: ________________________________________________________________________

MEDICAMENTOS EM USO:

ANTIBIOTICOTERAPIA:

a. ________________________________________________________________________________ (D ____ / ____)

(___) emprico (___) emprico, aguarda cultura (___) com cultura positiva (___) amplo espectro

Stio: _________________________________________________________________________ (coleta dia: _______)

Cultura: ____________________________________________________________________ (resultado dia: _______)

b. ________________________________________________________________________________ (D ____ / ____)

(___) emprico (___) emprico, aguarda cultura (___) com cultura positiva (___) amplo espectro

Stio: _________________________________________________________________________ (coleta dia: _______)

Cultura: ____________________________________________________________________ (resultado dia: _______)

c. ________________________________________________________________________________ (D ____ / ____)

(___) emprico (___) emprico, aguarda cultura (___) com cultura positiva (___) amplo espectro

Stio: _________________________________________________________________________ (coleta dia: _______)

Cultura: ____________________________________________________________________ (resultado dia: _______)


ANALGESIA: __________________________________________ dosagem: _____ml/h || __________ mcg/kg/h

SEDAO: ____________________________________________ dosagem: _____ml/h || __________ mg/kg/h

DVA: ________________________________________________ dosagem: _____ml/h || __________ mcg/kg/min

PROFILAXIA TVP: ______________________________________ dosagem:___________

PROTEO GSTRICA: _________________________________ dosagem:___________

PROTEO OCULAR: __________________________________ dosagem:___________

INALAO: __________________________________________ dosagem:___________

OUTROS MEDICAMENTOS: _________________________________________________________________________

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Se houver DRC: (__) AJUSTAR MEDICAO (__) MEDICAMENTOS J AJUSTADOS

O# EXAME FSICO

ESTADO GERAL ___________ RASS: ___________ SOFA: ___________ GCS: __________

Pupilas: (__) isocria / (__) Midrase / (__) Miose (__) Direita . (__) Esquerda. (__) Bilateral.

(__) fotorreagentes / (__) sem fotorreao (__) Direita . (__) Esquerda. (__) Bilateral.

Corado: (__) normo. (__) alterado: _____________________________________________________________

Hidratado: (__) normo. (__) alterado: _____________________________________________________________

Ictercia: (__) anictrico. (__) alterado: _____________________________________________________________

Cianose: (__) aciantico. (__) alterado: _____________________________________________________________

Febre: (__) afebril. (__) alterado: _____________________________________________________________

Pulsos: (__) palpveis. (__) difcil palpao / (__) simtricos. (__) assimtricos / (__) cheios. (__) filiforme

Perfuso (__) <2s. (__) alterado: _____________________________________________________________

Edema: (__) MMII (__) MMSS (__) ANASARCA (__) EDEMA GENERALIZADO

DIURESE MANH: _______ ml DIURESE TARDE: _______ ml DIURESE NOITE: _______ ml

DIURESE ATUAL (total): _______ ml DIURESE ANTERIOR: ______________ ml

BH ATUAL: ________ ml BH ANTERIOR: _______ ml BC __________________ ml

INFUSO DE VOLUME LTIMAS 24h: (__) SF 0,9% / (__) RL . Quantidade: ____________________________________ ml

EVACUAO: (__) presente. (__) Ausente h _____ dia(s). Observao: ______________________________________

DIETA: incio: ___/___/___ Caracterstica: ______________________________________________ (__) Jejum

POSIO NO LEITO: _________________________________ Cabeceira elevada? Sim (___) / No (___)

LESO POR PRESSO: (__) no / (__) sim: ________________________________________________________________


CATETERES:

ACESSO VENOSO CENTRAL: (__) no. (__) sim: _________________________________________. Data: ___/___/___

ACESSO VENOSO PERIFRICO: (__) no. (__) sim: _______________________________________. Data: ___/___/___

SONDA VESICAL DE DEMORA: (__) no. (__) sim: _______________________________________. Data: ___/___/___

SONDA NASO-ENTERAL: (__) no. (__) sim: ___________________________________________. Data: ___/___/___

DERIVAO VENTRICULAR: (__) no. (__) sim: _________________ Drenou: ______________ ml. Data ___/___/___

TRAQUEOSTOMIA: (__) no. (__) sim: _______________________________________________. Data: ___/___/___

VENTILAO: (__) ambiente. (__) O2 suplementar. (__) mscara de O2. (__) ventilao mecnica. Data: ___/___/___

PARMETROS DA VENTILAO MECNICA: FR:_______ PEEP:________ FiO2:__________ (__) no se aplica

RELAO pO2/Fio2: _________ ** Respirao em ar ambiente: FiO2 = 40 **

GASOMETRIA:

PH: ___________ pO2: __________ pCO2: _________ BIC: ___________ BE: ____________

IMPRESSO DIAGNSTICA: ________________________________________________________________________

EXAME FSICO PULMONAR: FR: ____ ipm (__) sinais de esforo respiratrio

MV __________________ / Rudos adventcios: __________________ em (__) HTD / (__) HTE / (__) ambos HT

EXAME FSICO CARDIOVASCULAR: FC: ______ PA: ____x_____ PAM: _________

Bulhas cardacas, ritmo __________________ / fonese __________________/ tempos: ___________

Sopro ___________________________________/ foco _______________________________________

Turgncia jugular: (__) presente (__) ausente

EXAME FSICO ABDOMINAL: RHA: (__) presente / (__) ausente Dor: __________________________
(__) flcido (__) globoso (__) em tbua/rgido (__) distendido (__) em avental

(__) com visceromegalias (__) massa palpvel (__) sinais de irritao peritoneal

(__) com globo vescical (__) Piparote positivo (__) som timpnico em quadrante ______________________

FGADO: (__) dimenses normais / (__) _______ cm abaixo do rebordo costal

MEMBROS INFERIORES: (__) edema ausente / (__) edema presente: _____/4+ / (__) com cacifo

Panturrilhas: (__) livres / (__) empastamento / (__) dolorosa palpao / (__) sinais flogsticos

Exame Vascular: (__) sem alteraes / (__) pulsos no palpveis / (__) leso vascular arterial / (__) CEAP _____
EXAME NEUROLGICO: (__) SEM ALTERAES (__) ALTERAES EM:

(__) ESTADO DE CONSCINCIA; ________________________________________________________________________

(__) fora: ____________________________________________________ OUTRAS ALTERAES _______________


(__) sensibilidade: ______________________________________________ _________________________________

(__) trofia: ____________________________________________________ _________________________________

(__) Babinski positivo em ________________________________________ _________________________________

(__) sinais menngeos ___________________________________________ _________________________________

(__) marcha ___________________________________________________ _________________________________

NNCC (__) sem alteraes (__) alterado:

1. Olfatrio________________________________________________ OUTRAS ALTERAES _______________


2. ptico _________________________________________________ _________________________________
3. Oculomotor _____________________________________________ _________________________________
4. Troclear ________________________________________________ _________________________________
5. Trigmeo _______________________________________________ _________________________________
6. Abducente _______________________________________________ _________________________________
7. Facial ___________________________________________________ _________________________________
8. Vestibulococlear __________________________________________ _________________________________
9. Glossofarngeo ___________________________________________ _________________________________
10. Vago ___________________________________________________ _________________________________
11. Acessrio _______________________________________________ _________________________________
12. Hipoglosso ______________________________________________ _________________________________

SINAIS VITAIS DAS LTIMAS 24 HORAS:

PA: mx:____x_____ PAM mx:_______ FC mx_______ TC mx _______

mn:____x_____ mn:________ mn________ mn________

FR mx__________ HGT mx_________

Mn__________ mn_________

OUTRAS ALTERAES NO EXAME FSICO: _______________________________________________________________

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(__) FERIDA OPERATRIA: ___________________________________________________________________________

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EXAMES LABORATORIAIS:

HEMOGRAMA: Hb____/ HT _____/ HCM: ____/ VCM: ____/ Leuccitos: __________________________

Blastonetes: __________________ / Plaquetas: __________/

(__) necessita de concentrado de hemcias

UREIA: anterior _________________________ atual ____________________ 15-36 mg/dL

CREATININA: anterior ___________________;_ atual ____________________ 0,60-1,10 mg/dL

CLEARANCE Cr: anterior __________________ atual ____________________ (__) DRC grau _____

SDIO: anterior _________________________ atual ____________________ 137-145 mmol/L

POTSSIO: anterior ______________________ atual ____________________ 3,5-5,1 mmol/L

BILIRRUBINAS TOTAIS: anterior ____________ atual ____________________ 0,20-1,30 mg/dL

BILIRRUBINA DIRETA: anterior _____________ atual _____________________ 0,00-0,30 mg/dL

PCR: anterior ___________________________ atual ____________________ < 1,0 mg/dL

OUTROS EXAMES LABORATORIAIS:


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RESULTADO DO EXAME DE IMAGEM / OUTROS EXAMES DIAGNSTICOS:


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A# AVALIAO

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P# PLANO

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CHECKLIST DOS EXAMES A SEREM SOLICITADOS:

(__) HEMOGRAMA / (__) UREIA / (__) CREATININA / (__) POTSSIO / (__) SDIO / (__) BILIRRUBINA

(__) GASOMETRIA / (__) PCR / (__) OUTROS: _______________________________________________

(__) EXAME DE IMAGEM: _______________________________________________________________

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(__) OUTROS EXAMES LABORATORIAIS:____________________________________________________

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(__) EXAME DIAGNSTICO:______________________________________________________________

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ENTRAR EM CONTATO COM ESPECIALIDADE / EQUIPE MULTIDISCIPLINAR:

1. (___) ________________________________________ 2. (___) _______________________________________


3. (___) ________________________________________ 4. (___) _______________________________________
5. (___) ________________________________________ 6. (___) _______________________________________
7. (___) ________________________________________ 8. (___) _______________________________________
9. (___) ________________________________________ 10(___) _______________________________________

RECOMENDAO DA ESPECIALIDADE OU EQUIPE MULTIDISCIPLINAR:

1. (___) _____________________________________________________________________________________
2. (___) _____________________________________________________________________________________
3. (___) _____________________________________________________________________________________
4. (___) _____________________________________________________________________________________
5. (___) _____________________________________________________________________________________
6. (___) _____________________________________________________________________________________
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