Feridas e coberturas

Semiologia e semiotcnica
Atividade em classe
Profa Adriene kviatkovski

Feridas e coberturas
As funes da pele vo muito alm da proteo
estrutural contra agentes fsicos, mecnicos e
biolgicos ela responsvel por promover
barreira qumica; pela manuteno da
homeostase; pela sntese da vitamina D; um
orgo sensorial para percepo de presso, dor
e temperatura.

Reviso:
1. Identifique as camadas da pele na figura abaixo:

2. Cite as fases da cicatrizao.

3. Cite todos os aspectos que devem ser avaliados em
uma ferida.
4. Quais as possveis complicaes de uma ferida.
5. Cite e explique a classificao das UPP.
6. Cite as intervenes de enfermagem para a preveno
de UPP.
7. Cite as intervenes de enfermagem no tratamento
de feridas.

Preencha o quadro abaixo

Curativo

hidrocolide
hidrogel

AGE
Carvo ativado

Alginato de clcio
papana-10%

papana 04 a 06%
papana- 02%o
SF 0,9%

Indicaes

Contra indicaes

Avalie as imagens apresentadas:

Identifique qual o curativo e tcnica devem ser
utilizados.
1. Estabelea um diagnstico de enfemagem;
2. Realize uma prescrio de enfermagem,
3. Realize a anotao de enfermagem aps a
realizao do curativo.
Informaes que devem ser registradas (no necessariamente nesta ordem):
Nmero de leses, caractersticas das leses (localizao anatmica, tamanho,
profundidade, etiologia aguda
ou
crnica, agente causador, grau de
contaminao,comprometimento tecidual, mecanismos de cicatrizao da ferida
1,2,3 inteno, presena de exudato, presena de complicaes), mtodo de
curativo, cobertura indicada, nome do executante.

1 PO correo de fratura de tbia esquerda

DIAGNSTICO DE ENFERMEGEM
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
PRESCRIO DE ENFERMAGEM

AVALIAO DA FERIDA:
Nmero de leses: ______________
Localizao anatmica: ___________
Tamanho: __________________ cm
Profundidade: ______________ cm
Etiologia: aguda ( ) ou crnica( )
Agente causador, tipo de ferida:
______________________________
grau de contaminao: ___________
comprometimento tecidual:
______________________________
Mecanismos de cicatrizao da ferida:
1 ( ) 2 ( ) ,3 ( ) inteno
Presena de exudato: _____________
Presena de outras complicaes:
________________________________

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
ANOTAO DE ENFERMAGEM
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

PO imediato dreno pleural direito

DIAGNSTICO DE ENFERMEGEM
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
PRESCRIO DE ENFERMAGEM

AVALIAO DA FERIDA:
Nmero de leses: ______________
Localizao anatmica: ___________
Tamanho: __________________ cm
Profundidade: ______________ cm
Etiologia: aguda ( ) ou crnica( )
Agente causador, tipo de ferida:
______________________________
grau de contaminao: ___________
comprometimento tecidual:
______________________________
Mecanismos de cicatrizao da ferida:
1 ( ) 2 ( ) ,3 ( ) inteno
Presena de exudato: _____________
Presena de outras complicaes:
________________________________

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
ANOTAO DE ENFERMAGEM
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Malolo lateral MIE

DIAGNSTICO DE ENFERMEGEM
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
PRESCRIO DE ENFERMAGEM

AVALIAO DA FERIDA:
Nmero de leses: ______________
Localizao anatmica: ___________
Tamanho: __________________ cm
Profundidade: ______________ cm
Etiologia: aguda ( ) ou crnica( )
Agente causador, tipo de ferida:
______________________________
grau de contaminao: ___________
comprometimento tecidual:
______________________________
Mecanismos de cicatrizao da ferida:
1 ( ) 2 ( ) ,3 ( ) inteno
Presena de exudato: _____________
Presena de outras complicaes:
________________________________

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
ANOTAO DE ENFERMAGEM
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Regio distal da perna esquerda (face externa)

DIAGNSTICO DE ENFERMEGEM
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
PRESCRIO DE ENFERMAGEM

AVALIAO DA FERIDA:
Nmero de leses: ______________
Localizao anatmica: ___________
Tamanho: __________________ cm
Profundidade: ______________ cm
Etiologia: aguda ( ) ou crnica( )
Agente causador, tipo de ferida:
______________________________
grau de contaminao: ___________
comprometimento tecidual:
______________________________
Mecanismos de cicatrizao da ferida:
1 ( ) 2 ( ) ,3 ( ) inteno
Presena de exudato: _____________
Presena de outras complicaes:
________________________________

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
ANOTAO DE ENFERMAGEM
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

calcanhar esquerdo
DIAGNSTICO DE ENFERMEGEM
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
PRESCRIO DE ENFERMAGEM

AVALIAO DA FERIDA:
Nmero de leses: ______________
Localizao anatmica: ___________
Tamanho: __________________ cm
Profundidade: ______________ cm
Etiologia: aguda ( ) ou crnica( )
Agente causador, tipo de ferida:
______________________________
grau de contaminao: ___________
comprometimento tecidual:
______________________________
Mecanismos de cicatrizao da ferida:
1 ( ) 2 ( ) ,3 ( ) inteno
Presena de exudato: _____________
Presena de outras complicaes:
________________________________

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
ANOTAO DE ENFERMAGEM
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Malolo lateral MID

DIAGNSTICO DE ENFERMEGEM
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
PRESCRIO DE ENFERMAGEM

AVALIAO DA FERIDA:
Nmero de leses: ______________
Localizao anatmica: ___________
Tamanho: __________________ cm
Profundidade: ______________ cm
Etiologia: aguda ( ) ou crnica( )
Agente causador, tipo de ferida:
______________________________
grau de contaminao: ___________
comprometimento tecidual:
______________________________
Mecanismos de cicatrizao da ferida:
1 ( ) 2 ( ) ,3 ( ) inteno
Presena de exudato: _____________
Presena de outras complicaes:
________________________________

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
ANOTAO DE ENFERMAGEM
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Regio sacra
DIAGNSTICO DE ENFERMEGEM
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
PRESCRIO DE ENFERMAGEM

AVALIAO DA FERIDA:
Nmero de leses: ______________
Localizao anatmica: ___________
Tamanho: __________________ cm
Profundidade: ______________ cm
Etiologia: aguda ( ) ou crnica( )
Agente causador, tipo de ferida:
______________________________
grau de contaminao: ___________
comprometimento tecidual:
______________________________
Mecanismos de cicatrizao da ferida:
1 ( ) 2 ( ) ,3 ( ) inteno
Presena de exudato: _____________
Presena de outras complicaes:
________________________________

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
ANOTAO DE ENFERMAGEM
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Regio distal do MIE (face interna)

DIAGNSTICO DE ENFERMEGEM
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
PRESCRIO DE ENFERMAGEM

AVALIAO DA FERIDA:
Nmero de leses: ______________
Localizao anatmica: ___________
Tamanho: __________________ cm
Profundidade: ______________ cm
Etiologia: aguda ( ) ou crnica( )
Agente causador, tipo de ferida:
______________________________
grau de contaminao: ___________
comprometimento tecidual:
______________________________
Mecanismos de cicatrizao da ferida:
1 ( ) 2 ( ) ,3 ( ) inteno
Presena de exudato: _____________
Presena de outras complicaes:
________________________________

_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
ANOTAO DE ENFERMAGEM
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________