ANAMNESE ped

Prévia do material em texto

ANAMNESE:
Nome:_____________________________________ Data de Nascimento: ______________
Idade:______________ Gênero:________________. Tipo sanguíneo:____________________
Mãe:________________________________________________________________
Pai:_________________________________________________________________
Acampanhante:________________________________________________________
Endereço:____________________________________________________________ 
Queixa principal: __________________________________________________________________________________________________________________________________________________________
Historia Pregressa: __________________________________________________________________________________________________________________________________________________________
História Familiar: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
História Gestacional :
( ) Hepatite ; ( ) Sifilis; ( ) DST _______; ( ) outras ____________
Pré-Natal:______________________________________________________________
Parto: Tipo:_____________; Alterações: _____________________________________
Teste do pezinho:________ PC: __________PT: __________PA: __________
 Peso:______________
Teste da Orelhinha:__________________________________
Período Neonatal: alimentação:_____________________________________________
Alterações_______________________________________________________
História vacinal : _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
HistóriaNutricional: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________.
Necessidades da Criança:
Sono e Repouso: ________________________________________________________
____________________________________________________________________________________________________________________________________________
Higiene: _______________________________________________________________
______________________________________________________________________
Alimentação: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Eliminações:___________________________________________________________
______________________________________________________________________
Crescimento e Desenvolvimento: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Saúde Bucal: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
História Social :
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
EXAME FÍSICO:
Peso:__________________; Estatura:_______; FC:______; FR:_______; T:________
PC:________; PT:________; PA:_________;
Estado Geral:___________________________________________________________
______________________________________________________________________
Cabeça:_______________________________________________________________
____________________________________________________________________________________________________________________________________________
Pescoço: ______________________________________________________________
______________________________________________________________________
Tórax e Pulmões: ________________________________________________________
____________________________________________________________________________________________________________________________________________
Abdome:_______________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________
Genitália:______________________________________________________________
______________________________________________________________________
Dorso e extremidades:____________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________
Pele e anexos: __________________________________________________________
______________________________________________________________________
Linfonodos: ___________________________________________________________
_____________________________________________________________________
Sistema Nervoso (reflexos): ______________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________
AVALIAÇOES DE ENFERMAGEM:
Avaliação do crescimento ( peso ponderal, estatura e PC ): _______________________
______________________________________________________________________
Avaliação do desenvolvimento: _____________________________________________
______________________________________________________________________
DIAGNÓSTICOS DE ENFERMAGEM
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
.
PRESCRIÇÕES DE ENFERMAGEM
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
EVOLUÇÃO
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________