SAE

Sistematizao da
assistncia de Enfermagem I

Nome do paciente__________________________________________________________________
Nome do mdico___________________________________________________________________
Telefone do paciente_ ______________________________ Telefone da Liga_____________________

Liga de Hipertenso de _________________________________

Dept. de Hipertenso Arterial

da Sociedade Brasileira de Cardiologia

Seo Ligas de Hipertenso

9091 SAE-I.indd 1

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Dados

Pronturio________________________________ Ficha_ ______________ Data ____ / ____ / ____

Identificao
Nome___________________________________________________________________________
Endereo_________________________________________________________________________
Bairro_________________ Cidade_________________________ Estado______ CEP______________
Telefone_ ________________________________________________________________________
Data de nasc.: ____ / ____ / ____ Idade_______ Sexo_______ Estado civil______________________
RG:__________________________ Convnio___________________________________________

Escolaridade
Analfabeto

1o grau

Completo

Alfabetizao rudimentar

2o grau

Incompleto

Superior

Condies socioeconmica
Ativo

Inativo

Aposentado

Dependente

Desempregado

Profisso_________________________________________________________________________

PA __________________________ Peso __________ kg

Altura _____________ m

Circunferncia abdominal _______________________ Glicemia ______________________________

Colesterol total_ ______________________________ HDL__________________________________
LDL________________________________________ Triglicrides_ ___________________________

Dept. de Hipertenso Arterial

da Sociedade Brasileira de Cardiologia

Seo Ligas de Hipertenso

9091 SAE-I.indd 2

24/3/2009 15:32:49

SAE Sistematizao da assistncia de enfermagem I

Histrico da doena atual

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Antecedentes pessoais
Diabetes

Medicao em uso

Cardiopatias

______________________________________

Dislipidemias

______________________________________

Tabagismo

______________________________________

Etilismo

______________________________________

Drogas

______________________________________

Cirurgia anterior

______________________________________

Alergia

______________________________________

Vacina

Especificar ______________________________________

Terapia de reposio hormonal (TRH) Especificar ______________________________________

Contraceptivo oral

______________________________________

Outras doenas

______________________________________

Controle:

Mdico

Farmcia

______________________________________
Caseiro
Outros

Antecedentes familiares
Alguma pessoa da famlia com PA alta?

Sim

No

Ignorado

Grau de parentesco:_________________________________________________________________
Incio da doena: __________________________ Incio do tratamento:_________________________

Exame fsico Enfermagem

Realizado em: _____ / _____ / _____

Hora: _____h_____

Responsvel:______________________________________________________________________
Dept. de Hipertenso Arterial

da Sociedade Brasileira de Cardiologia

Seo Ligas de Hipertenso

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SAE Sistematizao da assistncia de enfermagem I (cont.)

Cardiovascular
Ritmo cardaco:

Regular

Pulso

Irregular

Pulso

Carotdeos

Femorais

Braquiais

Poplteos

Radiais

Pediosos

Pulsos: A: ausente; C: cheio; F: filiforme

Perfuso perifrica:

Boa

Diminuda

Obs.:____________________________________________________________________________
_______________________________________________________________________________
Presso arterial
Horrio: _____h_____
MSD (mmHg): _____________________________________________________________________
MSE (mmHg): _____________________________________________________________________
Obs.:____________________________________________________________________________
_______________________________________________________________________________
Postura

Sentado

Deitado

Em p

FC (bpm)_________________________________________________________________________
Avaliao do risco coronrio
_______________________________________________________________________________

Integridade cutnea/mucosa (edemas, leses, manchas, cicatrizes)

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Dor

Sim

No

Local: ___________________________________________________________________________
Tipo: ____________________________________________________________________________
Intensidade: ______________________________________________________________________
Dept. de Hipertenso Arterial

da Sociedade Brasileira de Cardiologia

Seo Ligas de Hipertenso

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24/3/2009 15:32:49

SAE Sistematizao da assistncia de enfermagem I (cont.)

Glicemia
Jejum:___________________________________________________________________________
Capilar:__________________________________________________________________________
Ps-prandial: _ _______________________________________________________________________
Peso:__________ kg

Altura:_ _________ m

IMC (ndice de massa corprea):__________________________ Peso ideal:___________ kg

Hospitalizao/cirurgia(s)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Prescrio Enfermagem (verificar, comunicar, encaminhar, controlar)

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Evoluo de Enfermagem
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Dept. de Hipertenso Arterial

da Sociedade Brasileira de Cardiologia

Seo Ligas de Hipertenso

9091 SAE-I.indd 5

24/3/2009 15:32:49

SAE Sistematizao da assistncia de enfermagem I (cont.)

Diagnstico de enfermagem (sinais e sintomas identificao das necessidades assistncia)

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Roteiro/Exames fsicos
1. Altura/peso
2. Aparncia geral
3. Cabea
4. Olhos e viso
5. Ouvido e audio
6. Nariz e seios nasais
7. Boca
8. Pescoo
9. Linfonodos
10. Mamas
11. Pulmes
12. Corao
13. Circulao perifrica
14. Abdmen
15. Genitlia masculina e hrnias
16. Genitlia feminina
17. Reto
18. Sistema musculoesqueltico
19. Sistema neurolgico

Ass._ ___________________________________________________ COREN_ _________________

Fonte: Conselho regional de enfermagem de So Paulo (SAE Sistematizao da assistncia de enfermagem)

Dept. de Hipertenso Arterial

da Sociedade Brasileira de Cardiologia

Seo Ligas de Hipertenso

9091 SAE-I.indd 6

24/3/2009 15:32:49