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Cardiovascularpulmonar
BEG ( )
REG ( )
Alerta ( )
*N Pronturio_______________
Anamnese
Queixa Principal: _______________________________________________________
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Histria da Doena Atual: ________________________________________________
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Histria da Doena Pregressa: ____________________________________________
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Doenas Associadas: ___________________________________________________
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Antecedentes Familiares: ________________________________________________
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Quais? ___________________
Avaliao Fsica
Peso: ________ Altura: _________ IMC: __________ Temperatura:_______________
FC: ______bpm FR: ______ipm PA*_______ mmHg Situao_________________
Presso sistlica
Presso diastlica
(mmHg)
(mmHg)
tima
120
80
Normal
130
85
Limtrofe*
130139
8589
Hipertenso estgio 1
140159
9099
Hipertenso estgio 2
160179
100109
Hipertenso estgio 3
= 180
= 110
Hipertenso sistlica
140
< 90
isolada
Avaliao Geral
Inspeo (ex: pele, mancha, cicatriz, expresso facial; relatar) _________________
_____________________________________________________________________
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Palpao (relatar): ____________________________________________________
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*Local ________________________Dor_____
AUSENTE
++
+++
++++
Tipo de Trax:
Normolneo
Tonel
Ciftico
Escavatum
Carinatum
Biotipo do trax
Normolneo ( )90
Amplitude respiratria:
Eupnico ( ) Bradipnico ( ) Taquipineico ( ) Taquidispinico ( ), Taquipnico ( )
Padro Ventilatrio:_____________________ Ritmo Respiratrio:________________
Expansibilidade (fita): Axilas ____________ Processo Xifide ____________
Abdomen______________
Deformidades:_________________________
Simetria Torcica: ( )Normal - >4cm ( )Reduzida 4 a 2 cm - Muito reduzida < 2cm
Percusso Torcica: ______________
Tiragens: Sim ( ) No ( ) ____________________Esforo:_____________________
Tosse: ______________________________ Enfisema Subcutneo: Sim ( ) No ( )
Secreo: ___________________ Ausculta Respiratria: _______________________
Utiliza Suporte Ventilatrio: ( ) Sim ( ) No
Dados Gasomtricos
Ph ______ (7,35 a 7,45) PaO2 ______ ( 80 a 100 mmHg) PaC02 ____ ( 35 a 45
mmHg)
HCO3 __________ 22 a 26 molEq)
Exames complementares
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Objetivos
Tratamento Fisioteraputico
Observao: _________________________________________________________
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