Serviço de Assistência Domiciliar e Cuidados Paliativos de Caucaia

ATENDIMENTO MULTIPROFISSIONAL: __________________________

DATA: ______/ ______/______ ( ) AD2 ( ) AD3

Nome: ______________________________________________________________Idade: ______

Acompanhantes: __________________________________________________________________
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Condição que indica SAD: __________________________________________________________

PPS atual: ____________ % Diagnósticos / data:

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Evolução:
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Exame Físico: ____________________________________________________________________

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ESAS: Medicamentos:
Sem dor: 0. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10
Sem fadiga: 0. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10
Sem náusea: 0. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10
Sem tristeza: 0. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10
Sem ansiedade: 0. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10
Sem sonolência: 0. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10
Sem dispnéia: 0. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10
Muito bom apetite: 0. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10
Melhor bem-estar: 0. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10

Impressão: _______________________________________________________________________
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Condutas:________________________________________________________________________
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Maciel, M.G. Avaliação de Pacientes em Cuidados Paliativos in Manual de Cuidados Paliativos ANCP. São Paulo, ANCP, 2012. p. 40 ADAPTADO