Escolar Documentos
Profissional Documentos
Cultura Documentos
858-90 - HP155516527189142
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Anotações de Enfermagem
Evolução de Enfermagem
Data e hora;
Contato do acompanhante ou responsável pelo paciente;
Tempo de internação e transferência (quando houver);
Motivo da Internação;
Diagnostico do Paciente;
Descrição do estado geral (funções digestivas, nutricionais,
neurológicas, respiratórias, circulatórias, locomotoras e do trato
urinário).
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Principais recomendações
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Admissão
Pré-operatório
Tempo de jejum;
Orientações prestadas;
Esvaziamento de bexiga;
Administração de pré-anestésico;
Encaminhamento/transferência para o Centro Cirúrgico.
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Trans-operatório
Pós-operatório
Transferência de unidade/setor
Motivo da transferência;
Data e horário;
Setor de destino e forma de transporte;
Procedimentos/cuidados realizados (punção de acesso venoso,
instalação de oxigênio, sinais vitais, etc.);
Condições (maca, cadeira de rodas);
Queixas.
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Alta
Data e horário;
Condições de saída (deambulando, maca ou cadeira de rodas);
Procedimentos/cuidados realizados, conforme prescrição ou rotina
institucional (mensuração de sinais vitais, retirada de cateter
venoso, etc.);
Orientações prestadas.
Óbito
Dieta
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Diurese
Evacuação
Mudança de decúbito
Higienização
Higiene íntima
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Higiene oral
Curativo
Local da lesão;
Data e horário;
Sinais e sintomas observados (presença de secreção, coloração,
odor, quantidade, etc.);
Tipo de curativo (oclusivo, aberto, simples, compressivo, presença
de dreno, etc.);
Material prescrito e utilizado.
Dreno
Local e tipo;
Aspecto e quantidade de líquido drenado;
Sinais e sintomas observados.
Local da inserção;
Data e horário;
Dispositivo utilizado;
Motivos de troca ou retirada;
Sinais e sintomas observados e possíveis intercorrências
(transfixação, hematomas, extravasamento, hiperemia etc.).
Dor
Localização e características;
Intensidade (contínua ou intermitente);
Providências adotadas (comunicado à enfermeira, etc.)
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Intercorrências
Descrição do fato;
Sinais e sintomas observados;
Condutas tomadas (comunicado à enfermeira, etc.).
Administração de medicamentos
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Admissão
Anotações do pré-operatório
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Anotações no trans–operatório
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Anotações do pós-operatório
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Admissão
entrevista,
exame físico,
diagnósticos de enfermagem,
orientações ministradas.
Evolução diária
Evolução de Alta
Centro Obstétrico
Admissão
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idade gestacional,
exame obstétrico: foco, dinâmica uterina, toque (dilatação, colo,
apresentação, bolsa e líquido amniótico),
intercorrências gestacionais atuais (durante o pré-natal),
sinais vitais,
exames (USG, RX, exames laboratoriais, etc.).
Evolução de Alta
Alojamento Conjunto
Evolução da puérpera
Evolução do RN
dia de vida,
temperatura,
atividade,
aceitação da alimentação natural e/ou artificial,
eliminações,
análise da curva ponderal,
exame físico,
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relatos da mãe,
resultados de cuidados prescritos.
Evolução da gestante
dia de internação,
diagnóstico,
estado emocional,
exame físico,
sinais vitais,
batimentos cardíacos fetais,
dinâmica uterina,
perdas vaginais,
eliminações.
Berçário
Admissão
condições de nascimento,
Apgar e Capurro,
exame físico,
patologias maternas e grupos de risco para AIDS,
medicamentos ou outras substâncias utilizadas pela mãe que
interfiram nas condições do RN,
eliminações,
peso.
Evolução diária
idade do RN,
temperatura,
tratamentos,
encaminhamentos a outros serviços,
alimentação,
eliminações,
resultados de densidade urinária e glicoceto,
análise da curva ponderal.
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Admissão
entrevista,
exame físico,
procedimentos imediatos,
orientações ministradas,
condições de nascimento,
Apgar,
patologias maternas e grupos de risco para AIDS,
medicamentos ou outras substâncias utilizadas pela mãe que
interfiram nas condições do RN.
Evolução diária
Evolução de Alta
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Admissão
entrevista,
exame físico,
orientações ministradas.
Evolução diária
Evolução de Alta
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Emergência
Admissão
Evolução diária
Evolução de saída
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Pré-exame
Pós-exame
horário da alta,
avaliação das condições físicas e emocionais,
orientações ministradas. No cabeçalho do impresso de evolução
de enfermagem devem constar as seguintes informações:
dados do cliente ou paciente (nome e RG hospitalar), e
complementado com: data, número do leito e unidade de
internação.
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MODELOS DE EVOLUÇÃO
Patologias Prévias/Alergias:
Nega outras comorbidades.
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EVOLUÇÃO DE CURATIVOS
Localização
Categoria da lesão
Lesão por pressão ( I, II, III, IV, não estadiável), lesão traumática
(lacerante – bordas irregulares, incisas – bordas regulares), lesão em
cicatrização por 1ª intenção, lesão por queimadura, lesão por PAB, lesão
por PAF, escoriação.
Aspecto
Procedimento
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Condutas:
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EXAME FÍSICO
CONDUTAS:
DIAGNÓSTICOS DE ENFERMAGEM
INTERVENÇÕES
PENDÊNCIAS
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PROCEDIMENTOS
INTUBAÇÃO OROTRAQUEAL
SONDA NASOENTÉRICA
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SONDA NASOGASTRICA
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ÓBITO
RCP
Paciente (Luiz Inácio Lula) evolui com PCR, ritmo (assistolia, AESP,
TVSP, FV) às 22h, realizado 5 ciclos de reanimação, administração de 10
amp de adrenalina, 2 amp amiodarona, 1amp succinilcolina OU
administrado choque (____J). Paciente apresentou retorno da circulação
espontânea, sendo acoplado a VM modo PC, fiO² 80%, PEEP 6, FR 14
irpm, procedimento sem intercorrências. OU Paciente (Dilma) evoluiu a
óbito às 23h. Realizado cuidados pós-morte e invólucro, encaminhado ao
necrotério. Realizado contato com familiares.
Declaração de óbito preenchida / aguardando necropsia.
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Anotações
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Anotações
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ATENÇÃO!
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