AVALIAÇÃO DA DEGLUTIÇÃO – ANAMNESE UTENTE INTERNADO

SMFR – CHUC

Nome: _______________________________________________Idade: ___________

Morada: ______________________________________________________________

Contacto: _____________________________ Escolaridade: ____________________

Profissão_________________________________ Estado Civil: __________________

Serviço: _________________________________________Cama: _______________

P.U._________________Médico Responsável: _______________________________

Data de recolha dos dados: _______________________________________________

Terapeuta: __________________

HISTÓRIA CLINICA

Motivo de internamento. Em que data?

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Antecedentes pessoais:
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Exames complementares?
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Outros exames (Valor da PCR? Normal entre 0 -5. Se > 5 infecção?)

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Doente consciente e orientado?

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1
Comunicação:
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Alterações motoras? Posicionamento?

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Queixas actuais? Anteriores? Iguais? Acentuadas?

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Desde que está internado: Como está? Existência de secreções? Febre? Pneumonia?
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Perda de peso? Quantos quilos em quanto tempo?

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Via de alimentação actual?

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História de sonda? Quando retirou? Quem?

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Traqueotomia? Há quanto tempo? Tipo de cânula?

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2
Alimentação: Quem alimenta? Local? Posicionamento (do utente e do cuidador)?
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Consistências usadas? Utensílios usados? Quantidade?

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Como tem corrido? Engasgos? Outros sinais de aspiração?

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Higiene oral? Quantas vezes? Com que utensílios? Quem faz?

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Consciência do utente para a dificuldade de deglutição?

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