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Acadêmico (a): ​​​​​​__________________________________________________________________
Supervisor (a): __________________________________________________________________
FICHA DE AVALIAÇÃO – UTI
Dados Pessoais
Paciente: _______________________________________________________________________
Leito: ___________ Data da Admissão: ______/______/_______ Hora:______:_______
Data de inicio da fisioterapia:_____/_____/_______ 
Sexo: ______ Idade: __________ Data de Nascimento:_____/_____/______
Médico Responsável: _____________________________________________________________
Diagnóstico Clínico: _______________________________________________________________
ANAMNESE:
Q.P:_____________________________________________________________________________________________________________________________________________________________________
HMA:____________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________História Familiar:_________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
HMP:____________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________
Medicamentos Hospitalares: ___________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Hábitos de Vida:
Tabagista: ( ) Sim ( ) Não Quantidade: _________ Tempo: ________
Interrompeu: __________ Parou: ___________
Etilista: ( ) Sim ( ) Não Quantidade: __________ Tempo: _________
Interrompeu: __________ Parou: _________
Sedentário : ( ) Sim ( ) Não 
DADOS VITAIS:
PA: _____________ mmHg (145/95 - 90/60 mmHg)	 
FC:______________ bpm (100 - 60bpm)
FR:______________ rpm (12 a 16 rpm)
Temperatura:_______ º C (até 37,5 ºC)
Exames Complementares:
Gasometria ( PRESTO, 2013)
	Variáveis
	Valor
	Referencia
	pH
	
	7,35 a 7,45
	
PO2 
	
	80 a 100 mmHg
	
PCO2
	
	35 a 45 mmHg
	
BE
	
	-2 a +2
	HCO3
	
	22 a 28 mEq/l
	SatO2
	
	> 95%
Hemograma (Wintrobe, 1993)
Eritrograma adulto 
	variaveis
	valor
	Referencia
	Eritrocitos
	
	3.80 – 5,20 milhoes/ul
	Hemoglobina
	
	12.0 – 16,0 g/dl
	Hematocrito
	
	35,047.0%
	V.C.M
	
	80.0 – 100,0 fl
	H.C.M
	
	26,0 – 34,0 pg
	C.H.C.M
	
	31,0 – 36,0 %
	R.D.W
	
	10,0 – 15,0%
Leucograma
	Variáveis
	Valores
	Referencia
	Leucócitos
	
	3.800 – 10.600/ul
	Eosinófilos
	
	0 – 11% a 0 – 880/ul
	Basófilos
	
	0 – 1% a 0 – 100/ul
	
	
	
	Linfocitos Tipicos
	
	14 – 46% 850 – 4.000/ul
	Linfocitos Atipicos
	
	0-1% a 0 – 100/ul
	Monócitos
	
	0 – 10% a 0 – 850/ul
	Mielocitos
	
	0% a 0/ul
	Metamielócitos
	
	0% a 0/ul
	Bastonetes
	
	0 – 7% a 0 – 700/ul
	Segmentados
	
	42 – 77% a 2.00 – 7.00/ul
	Neutrófilos
	
	42 – 80% a 2.000 – 8.400/ul
	Plaquetas
	
	150.000 a 450.000/ul
Ventilação com Suporte Mecânico: 
( ) Ventilação não invasiva 
( ) Ventilação invasiva 
( ) Tubo traqueal ( ) Traqueostomia
 Parâmetros VM:
Modo Ventilatório:______________________________________________________________________
Peep:______________________________________________________________________________
SaO2:_____________________________________________________________________________
PaO2:______________________________________________________________________________
FR:______________________________________________________________________________
VC:________________________________________________________________________________
Sensibilidade:_______________________________________________________________________
FiO2:_____________________________________________________________________________
EXAME FÍSICO:
Inspeção: ____________________________________________________________________________
_________________________________________________________________________
Aspecto Físico: ( ) Obeso ( ) Emagrecido ( ) Normal ( ) Caquexia 
Condição da pele: Cicatrizes: ( ) sim ( ) não Local:__________________________________
 Escaras: ( ) sim ( ) não Local:__________________________________
 Edemas: ( ) sim ( ) não Local:__________________________________
 Deformidades: ( ) sim ( ) não Local:__________________________________
 Sudorese: ( ) sim ( ) não Local:__________________________________
 Cianose: ( ) sim ( ) não Local:__________________________________
 Hematomas: ( ) sim ( ) não Local:____________________________________ 
Presença:
( ) sondas nasogástrica 
( ) sonda vesical 
( ) drenos (tipo, local)_____________________________________________________________ 
( ) cateteres (tipo, local) ___________________________________________________________
( ) outros: ______________________________________________________________________
AVALIAÇÃO RESPIRATÓRIA:
Tipo de respiração: ( ) espontânea ( ) não espontânea
Padrão Respiratório: ( ) Diafragmático ( ) Apical ( ) Paradoxal ( ) Misto
Tipos de Tórax: ( ) Normal ( ) Tonel ( ) Pectus Carinatum ( ) Pectus Escavatum 
Batimento de asa de nariz: ( ) Sim ( ) Não
Uso de Musculatura Acessória: ( ) Sim ( ) Não ________________________________
Tiragem: ( ) Sim ( ) Não ___________________________________________________
Dispnéia: ( ) Presente ( ) Ausente ________________________________________
 ( )Presente aos grande esforços ( ) Presente aos médios esforços ( ) Presente nas atividades normais ( ) Repouso ( ) Trepopnéia ( ) Ortopnéia ( ) Dispnéia Paroxística Noturna 
Tosse: ( ) Presente ( )Ausente ( ) Produtiva ( ) Improdutiva ( ) Matinal ( ) Noturna 
( ) Ocasional ( ) Paroxística 
Secreção: ( ) Mucóide ( ) Mucopurulenta ( ) Purulenta ( )Hemoptise ( )Seróide
Uso de oxigenoterapia: ( ) sim ( ) não ________________________________________
( ) cateter nasal ( ) máscara facial ( )traqueostomia
Oxigênio em litros:_________________________ Fi O2:________________________________ 
Dor Torácica: ( )Presente ( )Ausente _________________________________
Angulação de Charpy: ( ) > 90 Brevelíneo ( ) < 90Longelíneo ( ) Normolíneo
Expansibilidade Torácica: ( )Simétrica ( )Assimétrica
Percussão torácica: ( ) normal ( ) maciça- submaciça ( ) timpânica- hipersonoridade
Força diafragmática: ( )Grau 0 ( )Grau 1 ( )Grau 2 ( )Grau 30- Ausência; 
1- Consistência muscular; 
2- Consistência muscular e expansão da caixa torácica; 
3- Consistência muscular e expansão da caixa torácica e vence resistência (CUELLO, 1980).
 	
Ausculta pulmonar: 
MV:_____________________________________________________________________
Ruídos Adventícios:______________________________________________________________
HTD ______________________ HTE ______________________
( ) Roncos ( ) Roncos
( ) Sibilos inspiratórios ( ) Sibilos inspiratórios
( ) Sibilos expiratórios ( ) Sibilos expiratórios
( ) Crepitantes ( ) Crepitantes
( ) Subcrepitantes ( ) Subcrepitantes
( ) Cornagem 				 ( ) Atrito pleural
AVALIAÇÃO NEUROLÓGICA:
Avaliação das Pupilas:
( ) Midríase ( ) Miose ( ) Isocóricas ( ) Anisocônicas
__________________________________________________________________________________________________________________________________________________________________________
Escala de Glasgow
	A) Abertura ocular
	B) Resposta Verbal
	C) Resposta dolorosa
	(4) Espontânea
	(5) Orientada
	(6) Obedece ao comando
	(3) Ordem verbal
	(4) Confuso
	(5) Localiza a dor
	(2) Dor
	(3) Palavras inapropriadas
	(4) Sem resposta a dor
	(1) Sem resposta
	(2) Incompreensível
	(3) Resposta em flexão (decorticação)
	
	(1) Sem resposta
	(2) Resposta em extensão (descerebração)
	
	
	(1) Sem resposta
	Grave: 3 a 8
	Moderado: 9 a 12
	Leve:   13 a 15
OBSERVAÇÕES GERAIS:
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OBJETIVOS DO TRATAMENTO:
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PLANO DE TRATAMENTO:
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