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Teoria fundamentada em Wanda Horta – Necessidades Humanas Básicas
FICHA DE EXAME FÍSICO
COLETA DE DADOS
Nome:__________________________________________, Enfermaria:__________
Identificação
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Queixa principal:_____________________________________________________________________________
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História da Doença Atual: (HDA)
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História da Doença Pregressa:
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História Familiar:
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Necessidades Psicossociais:
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Necessidades Psicoespirituais:
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Necessidades Psicobiológicas
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EXAME FÍSICO:
Sinais Vitais:
PAS:________________/ PAD:__________________
FR:_________________ Pulso:__________________
Temp.:_____________________________________
Peso:__________ Altura:_________ IMC:__________
RCQ:_______________________________________
Glicemia:____________________________________
Estado Geral:______________________________________________________________________________
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Sistema Neurológico:_______________________________________________________________________
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Cabeça e Pescoço:________________________________________________________________________________
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Sistema Respiratório:_____________________________________________________________________________
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Sistema Cardiovascular:___________________________________________________________________________
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Sistema Gastrientestinal:__________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Manobras realizadas:_____________________________________________________________________
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Sistema Urinário_________________________________________________________________________________
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Integridade Tegumentar:__________________________________________________________________
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Extremidades:___________________________________________________________________________
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Medicamentos:__________________________________________________________________________
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Exames Laboratoriais: 
	DATA
	EXAME
	RESULTADO
	REFERÊNCIA
	
	
	
	MULHER
	HOMEM
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
				
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