Ficha de Evolução de Fisioterapia Nova

 

FICHA DE AVALIAÇÃO FISIOTERAPÊUTICA  Pront: ___________ Data da Admissão: ______/______/______  Nome:___________________  Nome:________ ______________________ ______________________ ______________________ ______________________ _____________ Cuidador Responsável:___________________________________________________ Idade:_______Sexo:________ Idade:______ _Sexo:_________Cor:_________ _Cor:_________ Fisioterapeuta Resp:________ Resp:___________________ _____________ __ Carimbo:________ Carimbo:__________________ ________________ ______ Diagnostico:_______________ Diagnostico:___ _______________________ _______________________ _______________________ _____________________ __________ HDA:_________________________________________________________________ Doenças Anteriores:_____________________________________________________ Fumo ( ),Álcool ( ) , Bronquite ( ) , Asma ( ) , Diabetes ( ) , HAS ( ) , Emagrecimento ( ) Alergias ( ) a: _____________ ________________________ _______________________ _______________________ ______________________ ___________ Outras:________________________________________________________________ Cirurgias Anteriores:_________ Anteriores:____________________ ______________________ ______________________ ______________________ ___________ Observações:___________________________________________________________

EXAME FISICO  Sinais Vitais : FC: _____ bpm FR:_____irpm PA _____x____ mmHg Temp: ______º C Estado Nutricional:_______ Nutricional:__________________ ______________ ___ Abdome:_____ Abdome:________________ _____________________ __________ Curativos / Feridas: ( ) Sim ( ) Não Purulento: ( ) Sim ( ) Não Drenos :________________________________________________________ Cianose / :Sondas _____________________ Edema:__________________________________ Sudorese: ____________________ Úlceras de Decúbito:_______ Decúbito:__________________ _________________ ______ Fraturas: _____________ _____________________ ________ Luxaçõe Luxações: s: _____________ ________________________ ___________________ ________ Deformidades: __________ _____________________ ______________________ ______________________ ______________________ ______________ ___

AVALIAÇÃO RESPIRATÓRIA  Dispineia: Sim ( ) Não ( ) Tipo: _______________Tipo de Tórax:_________________ Tórax:_________________ Padrão Ventilatório: ____________ ____________________Exp ________Expansibilidade:______ ansibilidade:_________________ ______________ ___ Deformidades:_______________ Deformidades:___ ______________ __ Percussão Torácica :________________________ :________________________ Tiragens: Sim ( ) Não ( ) _____________________ _____________________ Esforço:_ Esforço:______________ _____________________ ________ Tosse: ________________________ __________________________________ __________ Enfisema Subcutâne Subcutâneo: o: Sim ( ) Não ( ) Secreção:________________ Secreção:___ ________________Ausculta ___Ausculta Respiratória: _____________________ _________________________ ____ Imagem Radiológica:______ Radiológica:_________________ _______________________ _______________________ ______________________ _____________ __

SUPORTE VENTILATORIO  Oxigenioterapia: ( ) Sim ( ) Nã Não. o. Ven Vent.t. Não Invasiva: _________, _______LO2/min _______LO2/min

AVALIAÇÃO NEUROLÓGICA E MOTORA   Nível de Consciência: Consciência: ________ ____________________ _______________________ ______________________ ____________________ _________ Face:_________________________Fala: ____________________________________ Mobilidade: Ativa ( ), Passiva ( ) Sensibilidade:___________ Sensibilidade:_______________________ _____________________ _________ Tônus Muscular:_______ Muscular:_________________ __________ Força Muscular:_______ Muscular:___________________ ___________________ _______ ADM:_________________________________________________________________ Outras Informações: ___________ ______________________ _______________________ _______________________ ___________________ ________

 

EVOLUÇÃO DE FISIOTERAPI FISIOTERAPIA: A:  ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ _______________________ _______________________ ______________________ ______________  ___   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ _______________________ _______________  ___   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ _______________________ _______________________ ______________________ ______________  ___   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ _____________________ ___________  ______________________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ _______________________ _______________________ ______________  ___   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ _______________________ _______________________ ______________  ___   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ ______________________ ______________________ _______________  ____   ______________________  ___________ ______________________ ______________________ _______________________ _______________________ ______________  ___    ___________  ______________________ ______________________ ______________________ ______________________ ______________________ _______________  ____