Ficha de Avaliação Lesão Medular UNESA

Prévia do material em texto

FICHA DE AVALIAÇÃO 
CURSO DE FISIOTERAPIA 
UNIVERSIDADE ESTÁCIO DE SÁ 
 
 
Data da Avaliação: _______________ Estagiário: ____________________ Pedido Médico: ( ) Sim ( ) Não 
Nome: _______________________________________________________________________________________ 
Endereço: ____________________________________________________________________________________ 
Telefone: _____________________________ Data de Nascimento: _______________________ Idade: __________ 
Cor: _______________________ Naturalidade: _________________ Escolaridade: _________________________ 
Estado Civil: ______________________ Renda - 2 salários mínimos: ( ) abaixo ( )acima Nº de Filhos: _______ 
Sexo: ( ) Fem. ( ) Masc. Religião: ________________________ Profissão: ___________________________ 
Plano de Saúde: ______________________ Tel. emergência: _____________________ Tipo Sanguíneo: _________ 
Nome do Responsável: __________________________________________________________________________ 
Médico: _____________________________ Peso: __________ Kg Altura: ___________ cm IMC: __________ 
Dispositivos Auxiliares: ( ) cadeira de rodas ( ) Muletas auxiliares ( ) Órtese ( ) Bengala ( ) Andador 
Dominância: ( ) Direita ( ) Esquerda 
Diagnóstico clínico (CID):_________________________________________________________________________ 
 _____________________________________________________________________________________________ 
Diagnóstico fisioterapêutico (CIF):_________________________________________________________________ 
 _____________________________________________________________________________________________ 
Queixa Principal: _______________________________________________________________________________ 
______________________________________________________________________________________________ 
______________________________________________________________________________________________ 
Sinais e Sintomas (termos técnicos): _______________________________________________________________ 
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_____________________________________________________________________________________________ 
Anamnese: ___________________________________________________________________________________ 
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
______________________________________________________________________________________________ 
Outras comorbidades: __________________________________________________________________________ 
_______________________________________________________________________________________________
___________________________________________________________________________________________ 
Medicamento utilizados e dosagens: _______________________________________________________________ 
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_____________________________________________________________________________________________ 
Antecedentes familiares: ________________________________________________________________________ 
_______________________________________________________________________________________________
_______________________________________________________________________________________________ 
Exames Complementares: _________________________________________________________________________ 
_______________________________________________________________________________________________
___________________________________________________________________________________________ 
 
 
 
 
FICHA DE AVALIAÇÃO 
CURSO DE FISIOTERAPIA 
UNIVERSIDADE ESTÁCIO DE SÁ 
 
 
 
EXAME FÍSICO 
 
 
 
An. nível de consciência___________________________________________________________________ 
_______________________________________________________________________________________ 
An. perfil emocional______________________________________________________________________ 
_______________________________________________________________________________________ 
_________________________________________________________________________ 
An. locomoção__________________________________________________________________________ 
_______________________________________________________________________________________
_______________________________________________________________________________________ 
An. tônus ______________________________________________________________________________ 
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________ 
 
 
 
 
FICHA DE AVALIAÇÃO 
CURSO DE FISIOTERAPIA 
UNIVERSIDADE ESTÁCIO DE SÁ 
 
 
Escala modificada de Ashworth 
Grau Descrição 
0 ( ) Sem aumento do tônus muscular 
1 ( ) Discreto aumento do tônus muscular, manifestado pelo apreender e liberar, ou por mínima 
resitência ao final da amplitude de movimento, quanto a(s) parte(s) é movimentada em flexão ou 
extensão. 
+ 1 ( ) Discreto aumento do tônus muscular, manifestado pelo apreender, seguido de minima resistência 
através do resto (menos da metade) da amplitude do movimento. 
2 ( ) Marcante aumento do tônus muscular através da maior parte de amplitude de movimento, porém 
as partes afetadas são facilmente movimentadas. 
3 ( ) Considerável aumento do tônus muscular, movimentos passivos dificultados 
4 ( ) A(s) parte(s) mostram-se rígida à flexão ou extensão 
 
An. trofismo____________________________________________________________________________ 
_______________________________________________________________________________________
_______________________________________________________________________________________
_____________________________________________________________________________________ 
An. espasmos __________________________________________________________________________ 
______________________________________________________________________________________ 
An. clonus_____________________________________________________________________________ 
______________________________________________________________________________________ 
An. deformidades _______________________________________________________________________ 
_______________________________________________________________________________________
______________________________________________________________________________________ 
An. mudança de decúbito_________________________________________________________________ 
______________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________ 
An. mudança de posição (DNE)____________________________________________________________ 
_______________________________________________________________________________________
_______________________________________________________________________________________ 
An. equilíbrio___________________________________________________________________________ 
_______________________________________________________________________________________
_______________________________________________________________________________________ 
An. coordenação_________________________________________________________________________ 
_______________________________________________________________________________________
_______________________________________________________________________________________ 
An. sensibilidade superficial_______________________________________________________________ 
_______________________________________________________________________________________
_______________________________________________________________________________________ 
______________________________________________________________________________________ 
An. reflexos profundos____________________________________________________________________ 
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________ 
An. reflexos patológicos___________________________________________________________________ 
 
 
 
FICHA DE AVALIAÇÃO 
CURSO DE FISIOTERAPIA 
UNIVERSIDADE ESTÁCIO DE SÁ 
 
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________ 
An. esfincteres___________________________________________________________________________ 
_______________________________________________________________________________________ 
An. face_______________________________________________________________________________ 
An. Fala _______________________________________________________________________________ 
_______________________________________________________________________________________ 
An. dor ________________________________________________________________________________ 
_______________________________________________________________________________________ 
An. edema______________________________________________________________________________ 
_______________________________________________________________________________________ 
An. postural ____________________________________________________________________________ 
_______________________________________________________________________________________
An. articular____________________________________________________________________________ 
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________ 
An. força muscular_______________________________________________________________________ 
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________ 
An. AVDs______________________________________________________________________________ 
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________ 
An. Gerais: altura______________ peso____________ biótipo:______________________________ 
pulsação___________ PA_____________ FR____________ temperatura_____________ 
 
Obs. Particulares_________________________________________________________________________ 
_______________________________________________________________________________________ 
_______________________________________________________________________________________ 
Demandas______________________________________________________________________________ 
______________________________________________________________________________________ 
______________________________________________________________________________________ 
Testes específicos (medida objetiva)_________________________________________________________ 
______________________________________________________________________________________ 
______________________________________________________________________________________ 
 
Objetivos Terapêuticos 
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________ 
_______________________________________________________________________________________ 
 
 
 
 
 
 
 
 
FICHA DE AVALIAÇÃO 
CURSO DE FISIOTERAPIA 
UNIVERSIDADE ESTÁCIO DE SÁ 
 
TRATAMENTO PROPOSTO: 
 
1.