ALFA FACULDADE DE ALMENARA

Rua Vereador Virglio Mendes Lima, 847 Bairro So Pedro.

Almenara/MG
CEP: 39900-000
Fone/Fax: (33) 3721-1098
E-mail: alfa.caldeira@yahoo.com.br

GUIA PRTICO DE COLETA DE DADOS DE ENFERMAGEM

Data: ___/___/___ RG: __________ Leito: ________ Clnica: ____________
Nome:
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Sexo: ______________ Idade: _________________ Cor: ________________
Estado civil: __________________________ Filhos: ____________________
Grau de instruo: ____________________ Ocupao: __________________
Proveniente: _____________________ Naturalidade: ___________________
Chegou em: _______________________ Na companhia de: ______________
Histria da doena atual (motivo da admisso, queixas)
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AMP (doenas, tratamento, transfuso sangnea)
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AMF (doenas, tratamento)
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PADR'ES FUNCIONAIS DE SADE
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- Percepo da sade - controle da sade (comprometimento com a sade,
vcios, alergias)
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- Condies de moradia (urbana/rural, prpria/alugada, nmero de cmodos
por pessoa, construo, ventilao, animais, gua, esgoto, sanitrio, lixo,
eletricidade)
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- Cuidado corporal (banho - imerso/abluo, higiene oral - prteses,

cabelos/barba/plos, higiene ntima, higiene mos/ps/unhas/olhos/nariz)
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- Nutricional - metablico (alimentao, hidratao, problemas tegumentares)
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- Eliminao (vesical, intestinal, menstruao, outras vias - presente/ausente,
caractersticas, problemas)
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- Atividade - exerccio (atividades de auto-cuidado, fsica, restrio motora)
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- Sono e repouso (hbitos, dificuldade)
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- Cognitivo - percepo (sentidos, dores)
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- Estado psicolgico
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- Participao - relacionamento (estado social, barreira de linguagem)
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- Sexualidade - reproduo (preventivos, auto-exame, atividade, GPA)

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- Enfrentamento - tolerncia ao estresse (comportamento)
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- Valor - crena (nvel, significado, importncia)
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- Manuteno da sade (exames mdicos, dentrios peridicos, imunizao)
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EXAME FSICO
1. Temperatura
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Hipotermia
Normotermia
Febrcula
Estado Febril
Febre
Pirexia
Hiperpirexia

36 C
36 C - 37,4 C
37,5 C - 37,7 C
37,8 C - 38 C
38 C - 39 C
39 C - 40 C
> 40 C

Obs.:
Assistncia na hipertermia: banho morno, ambiente frio, compressas frias /
gua e lcool, ingesta de lquidos. Assistncia na hipotermia: aquecimento /
alimentos quentes.
2. Respirao
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) Eupnico
) Bradipnico
) Taquipnico

Recm-nascido 30-40 / Adulto 16 a 22 rpm

< 16 rpm
> 22 rpm

Obs.:
Dispnia, ortopnia (respirao facilitada em posio vertical), apnia, respirao
estertosa (com rudos).
3. Pulso
- Normocardia
60-80
- Bradicardia
- Taquicardia

RN 120-140 / Lactente 100-120 / Adolescente 60-100 / Idoso

Abaixo do normal
Acima do normal

Obs.:
Variando tambm para pulso cheio/fino (taquisfigmia/bradisfigmia) e pulso
regular/irregular.
4. Presso Arterial
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) Normotenso
) Hipotenso
) Hipertenso
Peso e Altura
) Abaixo do Peso
) Peso Ideal
) Acima do Peso
) Obeso

120x80 - 140x90 mmHg

< 90x60 mmHg
> 140x90 mmHg
IMC < 18,5
IMC na faixa de 18,5 - 25
IMC na faixa 25 - 30
IMC > 30

6. Condies Gerais
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Bom estado geral

Regular estado geral
Mau estado geral
Pssimo estado geral

7. Nvel de Conscincia
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) Consciente
) Inconsciente
) Orientado

8. Observar simetria, sentado e em p:

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) MMII simtricos
) MMII assimtricos

9. Locomoo
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) Deambula - com ou sem auxlio

) Senta - com ou sem auxlio
) Levanta - com ou sem auxlio

10. Condies da pele e anexos:

- Colorao (plida, ciantica, hiperemiada, corada)
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- Integridade (ntegra, lesionada, prurido, deformidade)
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- Turgor (normal, diminudo)
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- Hidratao (hidratada, ressecada, fissuras)
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- Manchas (equimose, hematomas)
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- Higiene
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11. Inicia-se a inspeo, palpao, percusso e ausculta cfalo-caudal

CABEA
- Cabelo e couro cabeludo (quebradios, ressecados, seborria, dermatite,
sujidade, pediculoses, leses)
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- Orelhas e ouvidos (sujidade, acuidade, dor, leses, deformidades)
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- Olhos (secrees, edema de plpebras, avaliao pupilar, ptose palpebral,
tersol ou flebite, conjuntivite, ictercia, anemia)
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- Nariz e fossas nasais (secreo, sujidade, deformidade, obstruo)
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- Boca (lbios - ressecados, normais, feridas; lngua e mucosas - lngua
saborrosa, integridade, colorao, hidratao, aftas; sangramento gengival;
condies da dentio; dificuldade de mastigao e deglutio; hlito e fonao;
secrees; prteses)
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- Pescoo (ndulos e gnglios)
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TRAX
(expansibilidade, dor, deformidade, funil - peito escavado, quilha - peito de
pombo, cifoescoliose, abaulamento e retraes; mamas - flcidas, trgidas,
deformidades, ndulos, dor, mamilos - planos, fissuras, secrees, rede venosa
- visvel, palpvel, processo inflamatrio, esclerose)
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- Ausculta pulmonar
(anterior: acima da linha axilar, ambos os lados e no incio da cada seio reto
aos mamilos; paciente deve respirar pausada e profundamente com boca
entreaberta.
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Ausculta normal: murmrio vesicular.

Rudos adventcios: Roncos, semelhante ao ronco do sono, ocorre na expira o,
representa presena de secreo, pode indicar asma brnquica, bronquite,
bronquiectasia e obstrues localizadas. Sibilos: semelhante ao chiado,
representa obstruo de fluxo areo, ocorre em asma e DPOC. Estertor mido:
ocorre no final da inspirao, so creptantes ou bolhosos)
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- Ausculta cardaca
(ausculta dos focos: tricspide, parte baixa do esterno junto linha paraesternal
esquerda; mitral, onde se identifica a ponta; artico, 2 espao intercostal direito
junto ao esterno; pulmonar, 2 espao intercostal esquerdo junto ao esterno.
Sons: bulha normal 2T, estalidos e sopros)
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TRAX DORSAL
(regio sacra e gltea - hiperemia, ulceraes e musculatura)
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ABDOME
(observar forma - globoso, flcido, tenso, distendido, escavado; abaulamento,
retraes; localizao da cicatriz umbilical; ausculta a fim de detectar rudos
peristlticos em toda a extenso; percusso a fim de detectar sons anormais;
palpao a fim de detectar dores)
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MMSS e MMII
(rede venosa, musculatura, movimentos, edemas)
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GENITLIA EXTERNA
(secrees, alteraes epiteliais, colorao, algia)
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DECBITO NO LEITO
(posio de preferncia, porque)
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 AVALIAO DE PROBLEMAS COLABORATIVOS:

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Cardaca / vascular
renal / urinria
Metablica / imunolgica / hematopotica
Muscular / esqueltica
Multissistemas (efeitos adversos da terapia medicamentosa)
Respiratria
Gastrointestinal / heptica / biliar
Neurolgica / sensorial
Reprodutora

OBSERVAES
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EVOLUO
- Data e hora: ___________________
- Tempo de internao: ___________________________________________
-Motivo da internao: ____________________________________________
-Como paciente passou o perodo (dormindo agitado, calmo)
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- Nvel de conscincia (consciente, orientado, confuso, contactuando)
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- Locomoo (acamado, deambulando)
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- Estado geral (colorao da pele, hidratao)
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- Sinais vitais (temperatura, pulso, respirao, presso arterial)
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- Exame fsico
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- Mantendo jejum (sim/no, porque)
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- Sono e repouso (sim/no, porque)
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- Inciso cirrgica (dreno, cateter)
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- Sonda vesical ou nasogstrica (aberta, fechada, drenando, caractersticas)

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- Venclise (regio, tipo - perifrica, intracath)
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- Eliminao urinria e fecal (ausente, presente)
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- Outros (higiene, aspirao, entubao, recebendo sangue, curativo, apoio
psicolgico)
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- Queixas (nuseas, dor)
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Exemplo: Paciente no 1 dia de internao por X, passou perodo calmo, consciente e orientado em tempo e espao, contactuando. Deambulando sob superviso. Corado, hidratado, nromocrdio, eupnico, hipertenso com PA X,
acuidade auditiva e visual diminuda, ausculta pulmonar com presena de
murmrios vesiculares sem rudos. mantendo jejum em 24 hs, mantendo repouso em 24 hs, mantendo venclise em MSE. Eliminaes fisiolgicas espontneas e presentes. Evolui sem queixas e sem mese. Refere melhora da X.