RELATÓRIO DE FISIOTERAPIA

Paciente:____________________________________________________

Diagnóstico Principal:_________________________________________

Peso:_________________________ Altura:_______________________

Síntese do Quadro Clínico

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Estado Geral

Aspecto:____________________________________________________

Tª axilar: __________ºC Pressão Arterial: __________x__________

FC: ________bpm FR:________ipm SPO2: __________%

Karnofsky:___________________________________________________

Observações:_________________________________________________

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Sistema Neurológico
Grau de Orientação:__________________________________________

Grau de Consciência:_________________________________________

Estado Emocional:___________________________________________

Alterações da fala:____________________________________________

Acuidade Auditiva:____________________________________________

Acuidade Visual:______________________________________________

Contactuante:________________________________________________

Observações:________________________________________________

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Sistema Respiratório

Modo respiratório:____________________________________________

Tipo de Respiração:___________________________________________

Tosse:_______________________________________________________

Expansibilidade:______________________________________________

Auscuta:_____________________________________________________

Secreção:____________________________________________________

Aspirações:__________________________________________________

Dispositivos:_________________________________________________

Ventilação Mecânica:__________________________________________

Observações:________________________________________________
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Inspeção Torácica

Estática:

( ) Normal ( ) Tonel ( )Pectusescarvatum ( ) Pectuscarinatum

( ) Deformidades ( ) Cicatrizes ( ) Fraturas

Dinâmica:

Avaliação Motora

Arco de Movimento Passivo:____________________________________

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Força Muscular:_______________________________________________

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Dor ao Movimento:___________________ Local:____________________

Tônus:__________________________ Hipertonia:___________________

Trofismo Muscular:____________________________________________

Mobilidade no Leito:___________________________________________

Marcha:______________________________________________________

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Observações:________________________________________________

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Equilíbrio

Sentado:_____________________________________________________
Posição Ortostática:___________________________________________

Observações:_________________________________________________

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Conduta e Síntese da Evolução Clínica

Quadro Respiratório atual:______________________________________

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Quadro Motor Atual:____________________________________________

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Plano Terapêutico:_____________________________________________

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Objetivos:____________________________________________________

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Condutas

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DATA: ______/______/_____ _______________________________

ASSINATURA