ROTEIRO Avaliação MUITIDIMENSIONAL - SAUDE DO ADULTO - HAYANDS

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DISCIPLINA: SAÚDE DO ADULTO 
DATA: _____________________________ HORA: ___________________________ 
 
ROTEIRO PARA AVALIAÇÃO DA SAÚDE DO ADULTO 
 
I – IDENTIFICAÇÃO 
 
Nome: ________________________________________________________________ 
 
End.: _________________________________________________________________ 
 
Bairro: __________________________ Município: __________________________ 
 
Cep: ____________________________ Telefone: ____________________________ 
 
 
 
a) Qual foi a última vez que o Sr. procurou o serviço de saúde? Por quê? 
 
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b) Para o Sr. o que significa saúde? 
 
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c) Como o Sr. cuida da sua saúde? 
 
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II – INFORMAÇÕES GERAIS: 
 
a) Sexo: ______________________________________ 
b) Cor: _______________________________________ 
c) Idade: _____________________________________ 
d) Data de nascimento: __________________________ 
e) Naturalidade: ________________________________ 
f) Nacionalidade: _______________________________ 
g) Grau de instrução: ____________________________ 
h) Renda familiar: ______________________________ 
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III – INVESTIGAÇÃO DOS FATORES DE RISCO 
 
a) Atividades que desempenha na sua vida diária 
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b) Histórico de acidentes/violência 
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c) Fuma e/ou bebe? Se sim, descreva característica do vício. 
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d) Histórico de internações 
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e) Risco para Hipertensão Arterial 
 
→ História Familiar: ___________________________________________________________ 
 
→ Alimentação (descrever do que se alimenta nas três refeições do dia): 
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→ Histórico de atividade física (qual o tipo prática): 
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→ Verificação da pressão arterial: 
 
PRESSÃO ARTERIAL SISTÓLICA DIASTÓLICA UNIDADE 
Início da entrevista 
 
X 
 mmHg 
Milímetro de 
mercúrio 
Meio 
 
X 
 mmHg 
Milímetro de 
mercúrio 
Final 
 
X 
 mmHg 
Milímetro de 
mercúrio 
 
f) Risco para Diabetes Melitus Tipo 2 
 
- Peso __________________ 
 
- Altura _________________ 
 
- IMC __________________ 
 
- Cintura abdominal _________________________ 
 
- Antecedente familiar_____________________________________________________________________ 
 
- Colesterol e triglicerídeos ________________________________________________________________ 
 
- Doença cardiovascular, cerebrovascular ou vascular periférica definida 
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g) Se apresentar idade maior ou igual a 40 anos investigar acompanhamento urológico (se homem). Investigar 
manifestações que implicam acometimento da próstata. Em caso de atendimento à mulher perguntar sobre 
exames prevenção de colo de útero e de mama. 
 
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h) Histórico de IST’s 
 
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i) Faz uso do preservativo. Se não diga o Por quê? 
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j) Histórico de imunização (tipos de vacina que já tomou): 
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_ 
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l) Medicações em uso: 
 
MEDICAMENTOS DOSAGEM 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
m) Resultado de exames: 
 
TIPO DE EXAME DATA RESULTADO 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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IV – IDENTIFICAÇÃO DOS PROBLEMAS 
 
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V-DIAGNÓSTICO DE ENFERMAGEM (NANDA) 
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VI- INTERVENÇÕES DE ENFERMAGEM 
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VII- AVALIAÇÃO 
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 ASSINATURA 
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