UNIVERSIDAD DE CARABOBO

FACULTAD DE CIENCIAS DE LA SALUD

ESCUELA DE ENFERMERIA
DPTO. CLINICO DE ENFERMERIA MEDICO QUIRURGICO
ASIGNATURA: CUIDADOS DEL ADULTO CON ALTERACIONES
DE LOS SISTEMAS ORGANICOS

HISTORIA DE SALUD

Fuente: NO, DO, VF

Actualizado: OM.
Julio 2005.

Valencia Junio 2008

I. DATOS DEMOGRAFICOS

Nombres y Apellidos __________________________N de Historia_________

Edad ___________________

Lugar de Nacimiento _____________________ Nacionalidad ______________

Grado de Instruccin _____________________ Ocupacin ________________

Estado Civil ____________________________ Religin __________________

Direccin ___________________________________ Telfono ____________

Unidad de Atencin _____________________ Sala ________ Cama ________

Fecha de Ingreso ______________________ Turno ________ Hora _________

II. MOTIVO DE CONSULTA: 1. ______________________________

2. ______________________________
3. ______________________________

III. HISTORIA DE ENFERMEDAD ACTUAL.

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IV. DIAGNOSTICO MEDICO: 1. _________________________________________

2. _________________________________________
3. _________________________________________

V. MEDICACION ACTUAL (Medicamento, dosis, va, frecuencia, hora)

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VI. ANTECEDENTES QUIRURGICOS. (INTERVENCIONES)

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VII. ANTECEDENTES FAMILIARES (SALUD/ ENFERMEDAD)

Padre ___________________________________________________________

Madre ___________________________________________________________

Hermanos ________________________________________________________

Tos ____________________________________________________________

Abuelos _________________________________________________________

VIII. DATOS SUBJETIVOS (Segn Gua de Valoracin Subjetiva)

PATRONES FUNCIONALES
1- Percepcin y Mantenimiento de la Salud.
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2- Nutricional- Metablico.
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3- Eliminacin.
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4- Actividad y Ejercicio.
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5- Descanso y Sueo.
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6- Cognitivo / Perceptual.
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7- Autopercepcin / autoconcepto.
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8- Sexualidad / Reproduccin.
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9- Adaptacin al Stress.
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10- Valoracin y creencia.

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IX. INTERROGATORIO FUNCIONAL POR SISTEMAS.

1- NEUROLOGICO: (Infecciones, Convulsiones, Prdida de Conciencia, Problemas

de Marcha, Medicacin).
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2- CARDIOVASCULAR: (Dolor torxico, Arritmias, Intolerancia a la de

ambulacin, Cianosis, Medicacin.)
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3- RESPIRATORIO: (Disnea, Taquipnea, Asma, Bronquitis, Infecciones,

Medicacin).
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4- DIGESTIVO Y ENDOCRINO: (Melenas, Hemorroides, Diabetes, Hepatitis,

Medicacin).
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5- GENITOURINARIO: (Infecciones, Dolor, Edema, Clculos, Medicacin).

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6- MUSCULOESQUELETICO: (Lesiones, Fracturas, Dolor, Artritis, Edema,

Medicacin).
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7- INMUNOHEMATOLOGICO: (Hematomas, Alergias, Anemias, Leucemia,

Infecciones, SIDA, Medicacin).
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8- OBSTETRICOS: (Menarquia, Embarazos, Partos, Abortos, Sangramiento,

Medicacin).
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X. DATOS OBJETIVOS. (Valorar cada aspecto segn tcnicas semiolgicas).

EXAMEN FISICO

1. GENERAL (Apariencia, facie, piel, panculo adiposo, estado nutricional,

ganglios linfticos, peso, talla, signos vitales, biotipo, actitud).
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2.- NEUROLOGICO
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3.- CARDIOVASCULAR
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4.- RESPIRATORIO
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5.- DIGESTIVO
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6.- RENAL
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7.- GENITALES
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8.- MIEMBROS SUPERIORES E INFERIORES.

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9.- HEMODINAMIA
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XI. PERFIL DE LABORATORIO Y PRUEBAS ESPECIALES.

FECHA

FECHA

FECHA

FECHA

FECHA

FECHA

FECHA

FECHA

FECHA

FECHA

PRUEBAS
PRUEBAS
PRUEBAS
PRUEBAS
PRUEBAS
PRUEBAS
PRUEBAS
PRUEBAS
PRUEBAS
PRUEBAS
PRUEBAS
PRUEBAS
PRUEBAS
PRUEBAS
PRUEBAS

INTERPRETACION Y ANALISIS.
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XII. PERFIL DE TRATAMIENTO

PACIENTE_____________________ SALA __________________ CAMA _______
FECHA

FECHA

FECHA

FECHA

FECHA

FECHA

FECHA

FECHA

FECHA

MEDICAMENTO

INTERPRETACION Y ANALISIS.
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FECHA

XIII. PERFIL DE LABORATORIO.

PACIENTE_____________________ SALA __________________ CAMA _______
PERFIL DE LOS PARACLINICOS
FECHA

FECHA

FECHA

FECHA

FECHA

FECHA

FECHA

FECHA

FECHA

FECHA

EXAMEN

INTERPRETACION Y ANALISIS.
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XIV. FARMACOTERAPEA

MEDICAMENTO

GENERICO

INDICACION

CATETER

EFECTOS
ADVERSOS

INTERACCION

CUIDADOS
DE
ENFERMERIA

XV. CUADRO ANALITICO.

DATOS

DATOS

PATRON

CATEGORIA

DIAGNOSTICO

SUBJETIVOS

OBJETIVOS

ALTERADO

DIGNOSTICA

DE
ENFERMERIA

XVI. PLAN DE CUIDADO

TEORIA DIAGNOSTICO DE CRITERIO DE
ENFERMERIA

EVALUACION

ANEXO.
1- SOAPIE
2- TARJETAS DE MEDICAMENTO.

ACCIONES DE
ENFERMERIA

EVALUACION