Ficha de avaliação hospitalar adulto

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Faculdade Sudoeste Paulista 
(Instituição Chaddad de Ensino S/C Ltda) 
 
 Estágio Supervisionado em Fisioterapia no Hospital Geral e UTI 
 
FICHA DE AVALIAÇÃO FISIOTERAPÊUTICA 
 
 
1) Identificação 
 
Nome:________________________________________________________ Registro:____________ DI:_____________ 
Unidade:________________ Leito:_____ Idade:____ Sexo: ( ) M ( ) F Data de admissão: __/__/____ 
 
2) HD:___________________________________________________________________________________________ 
Cirurgia: ( ) Sim ( ) Não ( ) Eletiva ( ) Urgência Tipo:______________________________________ 
 
3) HMA: 
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4) HMP (antecedentes pessoais e familiares): 
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5) Avaliação geral do paciente: 
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SOFA:________________________ CPIS:___________________________ 
 
6) Avaliação Neurológica 
Nível de consciência:______________________________ Glasgow:_______ Pupilas:___________________ 
Sedação: ( ) Sim ( ) Não Dose:_______ Ramsay:________ PIC:_________ mmHg 
Funções motoras/sensitivas: __________________________________________________________________ 
 
7) Avaliação Hemodinâmica 
DVA: ( ) Sim ( ) Não Dose:_______ Medicação: ____________________________________________________ 
T:___ ºC FC:____ bpm PA:____x____ mmHg PAM:______ mmHg 
 
8) Avaliação Respiratória 
FR: ____ rpm ( ) eupneico ( ) bradipneico ( ) taquipneico 
Padrão respiratório: ( ) misto ( ) costal ( ) abdominal Tipo de tórax: _____________________________________ 
Ritmo respiratório: ( ) Normal ( ) Dispneico ( ) Cheyne-Stokes ( ) Kussmaul ( ) Biot ( ) Suspirosa 
Expansibilidade torácica:_____________________ Alterações dinâmicas: _____________________________________ 
Percussão:_________________________________________ FTV:__________________________________________ 
Tosse/ expectoração:________________________________________________________________________________ 
Ventilação: __________________________________________________________________________ SpO2:______ % 
AP:______________________________________________________________________________________________ 
AC:______________________________________________________________________________________________ 
9) VMI- Altura:______ Peso ideal:______ VC ideal:______ Modalidade:_______ Variável de controle: ________ 
Data IOT: __/__/____ Nº TOT:______ VC ou PC: ______ Fluxo:_____ Tins: ______ FR ___/___rpm 
PEEP: ____ cmH20 PS:___ cmH2O FiO2: ___ % RI:E___:____ Sb:_______ PaO2/FiO2:_____ 
P. Pico:______ P.Platô:_______ Complacência:______________Resistência:_________________DP:____________ 
 
10) Exame físico 
Inspeção:__________________________________________________________________________________________ 
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Força muscular: MRC- ___________ / __________________________________________________________________ 
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ADM:____________________________________________________________________________________________
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11) Exames Complementares (especificar data) 
RX:______________________________________________________________________________________________
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TC:______________________________________________________________________________________________ 
Bioquímicos:_______________________________________________________________________________________ 
Hemograma:_______________________________________________________________________________________ 
Gasometria arterial- pH_____ PaO2_____ PaCO2 _____ HCO3 _____ BE _____ SaO2 _____ 
Distúrbio:_________________________________________________________________________PaO2 ideal:_______ 
Eletrólitos:______________________________________________________________ BH24h:_____________ 
Outros:_____________________________________________________________________________________ 
 
12) Medicação Vigente:______________________________________________________________________________ 
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13) Diagnóstico Funcional:____________________________________________________________________________ 
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14) Objetivos da fisioterapia: 
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15) Plano de conduta: 
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OBS:_____________________________________________________________________________________________ 
Data da avaliação: __/__/____ 
Aluno:________________________________ 
Supervisor:___________________________________