SAE Cardiologia
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Transcript of SAE Cardiologia
Sistematizao da assistncia de Enfermagem I
SAE
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
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DadosPronturio _______________________________ Ficha ______________ Data ____ / ____ / ____
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IdentificaoNome __________________________________________________________________________ Endereo ________________________________________________________________________ Bairro ________________ Cidade ________________________ Estado _____ CEP _____________ Telefone ________________________________________________________________________ Data de nasc.: ____ / ____ / ____ Idade ______ Sexo ______ Estado civil______________________ RG: _________________________ Convnio___________________________________________
EscolaridadeAnalfabeto Alfabetizao rudimentar 1o grau 2o grau Superior Completo Incompleto
Condies socioeconmicaAtivo 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
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SAE Sistematizao da assistncia de enfermagem IHistrico da doena atual_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
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Antecedentes pessoaisDiabetes Cardiopatias Dislipidemias Tabagismo Etilismo Drogas Cirurgia anterior Alergia Vacina
Medicao em uso______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ Especificar ______________________________________
Terapia de reposio hormonal (TRH) Especificar ______________________________________ Contraceptivo oral Outras doenas ______________________________________ ______________________________________ Mdico Farmcia ______________________________________ Caseiro Outros
Controle:
Antecedentes familiaresAlguma pessoa da famlia com PA alta? Sim No Ignorado Grau de parentesco: ________________________________________________________________ Incio da doena: _________________________ Incio do tratamento: ________________________
Exame fsico EnfermagemRealizado 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.)CardiovascularRitmo cardaco: Pulso Carotdeos Braquiais RadiaisPulsos: A: ausente; C: cheio; F: filiforme
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Regular D E
Irregular Pulso Femorais Poplteos Pediosos D E
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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SAE Sistematizao da assistncia de enfermagem I (cont.)GlicemiaJejum: __________________________________________________________________________ Capilar: _________________________________________________________________________ Ps-prandial: _______________________________________________________________________ Peso: _________ kg Altura: _________ m IMC (ndice de massa corprea): _________________________ Peso ideal:__________ kg
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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
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SAE Sistematizao da assistncia de enfermagem I (cont.)Diagnstico de enfermagem (sinais e sintomas identificao das necessidades assistncia) _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
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Roteiro/Exames fsicos 1. Altura/peso2. 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
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