RESIDENCIAL LAR CAIÇARA

REGISTRO DE ENFERMAGEM
Data: ___/___/______ Hora inicial: ____:____
Dados do Cliente
Nome:______________________________________________________ Nascimento:___/___/______ Idade: _________
Hospedagem: ___________ Data da hospedagem: ___/___/______ Dias hospedados: __________
Nível de Consciência Estado Mental Estado Geral Respiração Tegumento
□ Hidratado □ Acianótico
□ Torporoso □ Lúcido □ Calmo
□ Ar ambiente □ Desidratado □ Cianótico
□ Sonolento □ Auto-orientado □ Agitado
□ Cateter nasal □ Corado □ Anictérico
□ Obnubilado □ Alo-orientado □ Irritado
□ Traqueostomia □ Hipocorado □ Ictérico (__+/4+)
□ Comatoso □ Crono-orientado □ Depressivo
□ Edema (__+) □ Anasarca
Extremidades Mucosas Locomoção Comunicação
□ Acamado
□ Hidratadas
□ Frias □ Repouso no leito □ Fasia □ Gestos
□ Desidratas (__+/4+)
□ Aquecidas □ Deambulando □ Afasia □ Dislalia
□ Coradas
□ Cianóticas □ Deambulando com auxílio □ Disartria □ Não se comunica
□ Hipocoradas (__+/4+)
□ Cadeira de rodas
Estado Térmico Estado pressórico Estado Cardíaco Estado Respiratório
□ Hipotérmico □ Febre □ Hipotenso □ Bradicárdico
□ Bradipneico □ Taquipneico
□ Normotérmico □ Pirexia □ Normotenso □ Normocárdico
□ Eupneico □ Dispneico
□ Febril □ Hiperpirexia □ Hipertenso □ Taquicádico
Dieta Eliminações Curativos
□ Líquida □ Livre □ Sim □ Descrito nas anotações
□ Sólida □ Pastosa □ Vesicais presentes □ Em fralda □ Não □ Descrito em protocolo anexo
□ Vesicais ausentes □ Colostomia
□ Enteral □ Nasogástrica □ Intestinais presentes □ Ileostomia Em: ______________________________
□ Paraenteral □ Nasoentérica □ Intestinais ausentes □ Coletor de urina __________________________________
□ Aceitando □ Recusando __________________________________
Queixas
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Orientações
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Assinatura e carimbo
Hora TAX PA FC FR HGT Assinatura e Carimbo

____:____ ______ ºC _____X_____ mmHg _____ bpm _______ irpm ______mg/dL

____:____ ______ ºC _____X_____ mmHg _____ bpm _______ irpm ______mg/dL

____:____ ______ ºC _____X_____ mmHg _____ bpm _______ irpm ______mg/dL

____:____ ______ ºC _____X_____ mmHg _____ bpm _______ irpm ______mg/dL

____:____ ______ ºC _____X_____ mmHg _____ bpm _______ irpm ______mg/dL

____:____ ______ ºC _____X_____ mmHg _____ bpm _______ irpm ______mg/dL

 Anotações de Enfermagem
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