1.

SISTEMA TEGUMENTAR
1.1 PELE:
( ) ntegra ( ) corada ( ) hidratada ( ) elstica e mvel ao teste de turgor
( ) perfuso dentro do padro de normalidade ao Sinal de Godet
Alteraes:_______________________________________________________________________
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1.2 PELOS E CABELOS:
( ) higiene preservada ( ) distribuio uniforme ( )consistncia mole, sedoso e no quebradio
Alteraes:_________________________________________________________________________
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1.3
UNHAS
( )higiene preservada ( ) rseas, lisas e curvelneas
Alteraes:_________________________________________________________________________
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2. CABEA E PESCOO
( ) face simtrica ( ) cabea ereta e equilibrada ( ) tireide no palpvel
Alteraes:_________________________________________________________________________
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2.1 OUVIDOS:
( ) acuidade auditiva preservada ( ) higiene preservada ( ) implantao simtrica
( )membrana timpnica translcida ( ) ausncia de algia a palpao do processo mastide
Alteraes:_________________________________________________________________________
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2.2 OLHOS:
( ) fotorreagentes + ( ) pupilas isocricas ( ) conjuntivas coradas ( ) esclerticas lmpidas
( ) acuidade visual preservada ( ) plpebras simtricas
Alteraes:_________________________________________________________________________
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2.3 NARIZ:
( ) higiene preservada ( ) presena de pelos e mucosa corada ( ) cavidade nasal e septo simtricos
Alteraes:_________________________________________________________________________
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2.4 BOCA:
( ) mucosas ntegras e midas ( ) higiene preservada sem caries ( ) ausncia de halitose
Alteraes:_________________________________________________________________________
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3. SISTEMA RESPIRATRIO
( ) trax simtrico ( ) respirao ritimica e superficial ( ) frmito palpvel ( ) sons timpnicos
( ) expanses torcicas simtricas ( ) presena de murmrios vesiculares
Alteraes:_________________________________________________________________________
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4. SISTEMA CARDIOVASCULAR
4.1 PULSOS
( ) carotdeos
( ) braquiais
( ) radiais
( ) femorais
( )poplteos
( ) tibiais
( ) pediosos

4.2 PA:_________x_________mmHg
( )D( )E
( )D( )E
( )D( )E
( )D( )E
( )D( )E
( )D( )E
( )D( )E

P: presente A: ausente
C: cheio F: filiforme
R: regular I: irregular

4.3 AUSCULTA
( ) sons B1 e B2 normofoneticos
Alteraes:______________________________
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5. SISTEMA GASTROINTESTINAL
( ) abdome plano ( ) fgado e bao no palpvel ( ) sons timpnicos ( ) eliminaes regulares
( ) presena de rudos hidroareos ( ) cicatriz umbilical mediana e simtrica
Alteraes:_________________________________________________________________________
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6. SISTEMA GENITURINARIO
( ) eliminaes regulares
( ) relato do paciente (genitais):
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Alteraes:_________________________________________________________________________
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7. SISTEMA MUSCULO-ESQUELETICO
( ) marcha regular ( ) coluna ereta
( ) fora preservada bilateral MMSS
( ) fora preservada bilateral MMII
Alteraes:_________________________________________________________________________
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8. SISTEMA NERVOSO:
( ) consciente e orientado ( ) sem sinal de desequilbrio na marcha (Sinal de Romberg)
( ) teste sensibilidade positivo
Alteraes:_________________________________________________________________________
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8.1 NERVOS:
Nervo olfatrio
( ) distingui odores
Nervo ptico
( ) dentro do padro de normalidade ao teste de Snellen
Nervo oculomotor, troclear e abducente ( ) movimentos oculares e plpebra regulares
Nervo trigemio
( ) sensibilidade facial
Nervo facial
( ) capacidade de sorrir, fechar os olhos e enrugar a testa
Nervo vestibulococlear
( ) escuta sussurros e apresenta equilbrio postural
Nervo glossofarngeo e vago
( ) paladar, palato e vula regulares
Nervo acessrio
( ) capacidade de movimentao dos ombros e pescoo
Nervo hipoglosso
( ) posio da lngua regular e capacidade de movimentos
P: presente A: ausente D: diminudo
Alteraes:_________________________________________________________________________
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9. DIAGNOSTICOS DE ENFERMAGEM (NANDA):
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10. INTERVENES DE ENFERMAGEM

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11. EVOLUO:
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