SISTEMATIZAO DA ASSISTNCIA DE ENFERMAGEM

ADULTO / IDOSO

1. IDENTIFICAO

DATA:___/___/_____
Nome:______________________________________________________________________
_
Data

de

Nasci.

___/___/______

SUS:_________________________________
Telefone:______________________________
Email:________________________________
Ocupao:_________________________________________________________________
_
Moradia:___________________________________________________________________
_____________________________________________________________________________
__

2. HISTRICO
Estado de sade atual: (HAS / DM / CARDIOPATIA / PNEUMOPATIA /
HEPATOPATIA, ETC).
_____________________________________________________________________________
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Estado de sade pregressa:
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Tratamentos anteriores e atuais: (cirurgia)
_____________________________________________________________________________
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Antecedentes familiares:
_____________________________________________________________________________
_____________________________________________________________________________
Alergia:

SIM

)NO

DESCREVA:____________________________________________
Tabagismo:

SIM

)NO

DESCREVA:___________________________________________
Etilismo:

SIM

DESCREVA:____________________________________________
Hidratao:
__________________________________________________________________

)NO

Alimentao: ( )Espontnea ( )Boa ( )Regular ( )Ruim ( )No Aceita

Uso de: ( )SNG ( )Gastrostomia ( )Outros
____________________________________________________________________________
Antecedentes

ginecolgicos:

Menarca:___________________Menopausa:________________
Imunizao:_______________________________________________________________
___
Medicaes:
ltima prescrio

Em uso

Sabe
p/
serve?

que Prescrito Por:

Cuidado
Corporal:______________________________________________________________
Sono

Repouso:_______________________________________________________________
Eliminaes:_______________________________________________________________
____
Incontinncia:

( ) Urinria

) Fecal

Lazer

recreao:______________________________________________________________
Locomoo/

Atividade

Fsica:_____________________________________________________
____________________________________________________________________________
Expresso

da

Sexualidade:_______________________________________________________
____________________________________________________________________________
Aspectos
psicosocioespirituais:__________________________________________________
____________________________________________________________________________

3. EXAME FSICO
Sinais Vitais:
Horrio

Presso

Tempera

Frequn

Frequn

Glicemia

Arterial

tura

cia

cia

Capilar

(mmHg)

Axilar

Cardaca

Respirat

(MG/dl)

(r.p.m)

ria
(r.p.m)

Medidas Antropomtricas:

Peso: _________

Altura:__________

IMC:________________
Cabea

Pescoo:______________________________________________________________
_____________________________________________________________________________
Audio:________________________________
Viso:________________________________
Nvel de Conscincia: (

)Consciente (

)Orientado (

)Confuso (

Inconsciente ( )Torporoso
Aparelho Respiratrio: Murmrios Vesiculares / Rudos Adventcios
+

( )

( )-

Aparelho

Cardiovascular:

BRNF

2T

S/

SOPRO

____________________________________
Abdmen: ( )Distendido ( )Globoso ( )Indolor ( )Doloroso

RHA

( ) + ( )Pele / Mucosa: (

)Integra (

)Hidratada (

)Corada (

)Descorada (

Desidratada______________
(

)Ictrico

)Cianose

)Leses

__________________________________________________
MMSS: ( )Sensibilidade e fora motora preservada

( ) Edema

( )Calor

( )Hiperemia
(

)Hematomas

)Escoriaes

)Feridas

Local:______________________________________
(

)Dor (

)Fora Motora (

)Sem anormalidades Perfuso Perifrica

______________________
MMII: ( )Sensibilidade e fora motora preservada

( ) Edema

( )Calor

( )Hiperemia
(

)Hematomas

)Escoriaes

)Feridas

Local:______________________________________
(

)Dor (

)Fora Motora (

)Sem anormalidades Perfuso Perifrica

______________________
4. LEVANTAMENTO DE PROBLEMAS:
_____________________________________________________________________________
_____________________________________________________________________________

_____________________________________________________________________________
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5. DIAGNSTICOS

DE

ENFERMAGEM:

(Car.

Definidora

Fator

Relacionado / Fator de Risco).

Dficit

de

Conhecimento

_____________________________________________________
(

Risco

para

queda

e/ou

da

pele

trauma________________________________________________
(

Integridade

prejudicada_______________________________________________
(

Risco

para

Infeco_________________________________________________________
(

Rico

para

alterao

no

padro

do

sono_________________________________________
(

Risco

para

constipao

intestinal______________________________________________
(

Risco

para

alterao

emocional_________________________________________________
(

Mobilidade

fsica

prejudicada_________________________________________________
(

Dficit

no

autocuidado_______________________________________________________
(

Dbito

cardaco

diminudo____________________________________________________
(

Risco

para

constipao______________________________________________________
(

Eliminao

urinaria

prejudicada_______________________________________________
(

Ansiedade__________________________________________________________________
(

Risco

para

nutrio

desequilibrada_____________________________________________
(

mental___________________________________________________________

Confuso

Estilo

de

vida

sedentrio_____________________________________________________
(

Intolerncia

atividade______________________________________________________
(

Dor

crnica_________________________________________________________________
(

Sofrimento

moral___________________________________________________________
(

Risco

de

glicemia

instvel_____________________________________________________
(

Controle

)eficaz

)ineficaz

do

regime

teraputico

_______________________________
(

Comunicao

verbal

prejudicada______________________________________________
(

Pesar

Desesperana_________________________________________________________
(

Risco

de

violncia

direcionada

si

mesmo_______________________________________
(

Isolamento

social____________________________________________________________
(

Processos

familiares

disfuncionais_____________________________________________
OUTROS:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
6. PRESCRIO DE ENFERMAGEM: (PREVENO / PROMOO /
RECUPERAO)
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_____________________________________________________________________________
_____________________________________________________________________________
7. EVOLUO DE ENFERMAGEM:

_____________________________________________________________________________
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Assinatura / COREN