Santa Casa de Misericrdia de Barbacena

Unidade de Terapia Intensiva Neonatal

Ficha de Admisso Fisioteraputica
DADOS PESSOAIS
Leito: ___________

Data da Admisso: ______/______/______

Hora:______:_______

Nome da Me :__________________________________________________________________
Idade Materna: ______ anos N de Gestaes: ______ Aborto: _____ Filhos vivos :___________
Doena Previa: _________________________________________________________________
Contexto Infeccioso: (

) sim (

) no Prenatal: (

) sim, quantas consultas: _______ (

) no

Nome do Rn:_________________________________ Data de Nascomento: _____/_____/_____

IGE:__________IGC:_________ Sexo:___________ Peso:__________ Cor:________________
Apgar: 1 min.:________ 5 min.:_________ Reanimao na Sala de Parto: (

) sim (

Pediatra na Sala de Parto: (

) sim (

) sim (

) no

Pediatra no transporte: (

) no
) no

Procedncia :__________________________ Transportado :____________________________

Plantonista Fisioterapeuta:_____________________ Medico:____________________________
Diagnostico:____________________________________________________________________
Motivo da Admisso HDA: ______________________________________________________
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Observaes: __________________________________________________________________
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EXAME FISICO
Sinais Vitais : FC: ________ bpm FR:_______ inc/min SatPO2:____________ Tax: _______ C
Escore de Downes: _______ ndice de Silverman - Andersen: ________ Escore CRIB:________
Cianose : ____________________________ Edema: __________________________________
Fraturas: ___________________________ Luxaes: __________________________________
M formaes:__________________________________________________________________
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AVALIAO RESPIRATORIA
Dispineia: Sim ( ) No ( ) Tipo: _________________ Tipo de Trax: ________________________
Padro Ventilatorio: ____________________ Ritmo Respiratrio:____________________________
Expansibilidade: _________________________ Deformidades:______________________________
Simetria Torcica: _______________________ Percusso Torcica : _________________________
Sincronismo Trax Abdmen:__________________ Tiragem Intercostal:______________________
Retrao Xifide: ________________________ Batimento de Aleta Nasal:_____________________
Gemido Expiratrio: _____________________ Retrao Diafragmatica:_______________________
Tosse: ____________________________________________ Enfisema Subcutneo: Sim ( ) No ( )
Secreo:_________________________________________________________________________
Ausculta Respiratria : ______________________________________________________________
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Imagem Radiolgica: _______________________________________________________________
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DADOS GASOMTRICOS
pH _________ (7,35 a 7,45) - PaO2 ________ ( 80 a 100 mmHg) - PaC02 _______ ( 35 a 45 mmHg)
HCO3 ________ ( 22 a 26 molEq) - BE _____ ( +2 a -2) Resutado: ___________________________
SUPORTE VENTILATORIO
Oxigenioterapia: _________________________________________ Fluxo:_______ FiO2:_________
Vent. No Invasiva: CPAP N ( ) Pronga: _______ Fluxo:_______ Peep:________ FiO2:________
Ventilador Mecnico: Modelo: ________________________________________________________
Vent. Mecnica: Modo: ________ TOT ( ) TNT ( ) Numero: _______ Altura da Fixao :_______
Parmetros: PIP: _________ FR: _________ Fluxo: __________ Peep:_________FiO2 : __________
TI:_______ I:E:________ SatPO2 :_______ Umidificador: ________ Temp Umidificador:________

AVALIAO NEUROLGICA
Nvel de Conscincia: _______________________________________________________________
Pupilas: ______________________________ Face:_______________________________________
Mobilidade: Ativa ( ) Passiva ( ) Reflexos Adequados : sim ( ) no (

Tnus Muscular:___________________________________________________________________
ADM: _____________________________ Sensibilidade:__________________________________
Outras Informaes: ________________________________________________________________
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ATENDIMENTO INICIAL
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Barbacena, ______ de _____________________ de _____________ as _______:_______ horas.

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Fisioterapeuta