Académique Documents
Professionnel Documents
Culture Documents
Nome:________________________________________________________________________
Idade:________________________________________________________________________
Gnero: F___ M___
Raa: ________________________________________________________________________
Data de nascimento: ____/___/_____
Outras consideraes sobre o nascimento: _________________________________________
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Local de residncia: ____________________________________________________________
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Colheita de dados baseada no modelo das necessidades de Verginia Henderson. Efectuada atravs de
entrevista pessoal, avaliao fsica e avaliao neurolgica. Foram recolhidos dados objectivos e
subjectivos.
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Profisso:_____________________________________________________________________
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Condies scio-econmicas: ____________________________________________________
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Centro de sade (onde est inscrita): ______________________________________________
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Mdico(a) de famlia: ___________________________________________________________
Consulta efectuadas e regularidade: _______________________________________________
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Grupo sanguneo: ______________________________________________________________
Antecedentes pessoais (1.cirurgicos, 2.alrgicos, 3.patolgicos,4. internamentos
hospitalares): _________________________________________________________________
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Antecedentes familiares:
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Necessidades
Respirar
Amplitude
Profunda
respiratria
Superficial
Frequncia
_______ciclos/min
respiratria
Ritmo respiratrio
Regular
Irregular
Tosse
Reflexo de Tosse
Presente
Ausente
Tipo de respirao
Eupneica
Dispneica
Apneica
Sons respiratrios
Normal
Rudos adventcios
Crepitaes
Roncos
Sibilos
Secrees
Factores que
Exerccio
influenciam a
Dor aguda
respirao
Ansiedade
Tabagismo
Posio corporal
Medicamentos/ estupefacientes
Hemoglobina
Normal
Aumentada
Diminuda
Consideraes_____________________________________________
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Outros
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Beber e comer
Apetite
Estmulo para comer
Mastigao
Degluitio
Lquidos
Slidos
Dificuldade em comer
sozinho
Dificuldade em
hidratar-se sozinho
Dores gstricas
Caractersticas:
Frequncia:
Nuseas
Vmitos
Tipo de alimentao
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Glicemia
Estado da mucosa
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bucal
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Estado da lngua
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Estado de dentio
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Peso
_______Kg
Altura
_______m
Bebidas alclicas
Caf
Outros
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Eliminar
Eliminao intestinal
Frequncia: ____________________________________________
Caracteristicas
Fezes duras
Diarreia
Hemerrides
Fissuras
Dores
Anais
Abdominais
Sangue nas fezes
Prurido anal
Gazes
Tendncia para fecalomas
Incontinncia
Rudos intestinais
Outros _______________________________________________
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Eliminao urinria
Frequncia:____________________________________________
Disria
Hematria
Polaquiria
Nictria
Urina concentrada
Cheiro
Reteno
Necessria fora para urinar
Incotincia
Diurna
Noctura
Com esforo
Dificuldade em reter-se
Necessita de ajuda para ir ao WC
Sudorese
Com exerccio
Emocional
Cheiro
Secrees ligadas ao
Corrimento vaginal
aparelho vaginal
Quantidade
Cor
Cheiro
Regularidade
Menstruao
Data da ltima ____/____/_____
Dores menstruais
- antes
- durante
- aps
Tenso mamria
Corrimento de seios
Regularidade__________________________________
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Outros
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Mover-se e manter a
postura correcta
Modo de deslocar-se
Sozinho
Com ajuda
Amplitude de movimento
Colorao das
extremidades
Fadiga
Dores
Tremores
Edema
Varizes
Fora muscular
Tnus muscular
Normal
Diminuido
Aumentado
Exerccio fsico
Pratica
Regularidade
Sendentrio
Outros _______________________________________________
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T.A.
_____-_____mmHg
Pulso
Frequncia: _____bpm
Regularidade
Caracteristicas
Cheio
Fraco
Filiforme
Posturas
Correctas
Incorrectas
Conhecimento
Outros
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Dormir e repousar
Nmero de horas
habituais de sono
Dificuldade em
adormecer
Hora de deitar
Hora de acordar
Sono agitado
Pesadelos
Medos
Ansiedade
Nervosismo
Levanta-se a meio da
noite
Causas
Dores
Prurido
Desconforto
Preocupaes
Medos
Toma de medicamentos
Outras _________________________________________
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Hbitos
Outros
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Vestir-se e despir-se
Capacidade para se
vestir sozinho
Capacidade de escolher
as roupas
Capacidade de manter
as roupas limpas
Gostos
Roupa de vero
Roupa de inverno
Cores
Outros
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Oral ______
Axilar ______
Frequncia
Outros
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Auto-exame
Conhecimento
Frequncia
Estado dos rgos genitais
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Auto-exame
Conhecimento
Frequncia
Outros
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Evitar perigos
Alergias
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Estado de conscincia
Consciente
Inconsciente
Orientado
Desorientado
Tempo
Espao
Pessoas
Memria
Capacidade de escrita
Juzo crtico
Discurso
Linguagem
Reconhecimento de objectos
Capacidade de clculos aritmticos
Capacidade motora
Ateno
Funo sensitiva
Sensibilidade dolorosa
Sensibilidade trmica
Sensibilidade tctil
Funo reflexa
Ansiedade
Marcada
Pouco marcada
Hiperactividade
Agressividade verbal
Agitao
Risco de violncia
Calendrio de
Actualizado
vacinao
Desactualizado
Vacinas em falta:__________________________________
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Dores
Local:
Intensidade:
Tipo
Aguda
Crnica
Constante
Intermitente
Meio de alvio
Utilizao de medicamentos
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Outros
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Afasia
Disartria
Ritmo lento
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Capaz de compreender o
que dito
Viso
Olho direito
Olho esquerdo
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Audio
Ouvido direito
Ouvido esquerdo
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Capacidades intelectuais
Concentrao
Memria
Capacidade de leitura
Actividade sexual
Preocupaes
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religiosos
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Cultura e valores
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Divertir-se e ocupar-se
Gosta de rir e de se divertir
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Ocupao profissional
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Aprender
Capacidade de
Boa
aprender
Limitada
Motivao para
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aprender
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Necessidade de
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conhecimento
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Data ____/____/____
Assinatura:___________________