Sistematizao da assistncia de Enfermagem I
SAE
Nome do paciente
_________________________________________________________________
Nome do mdico
__________________________________________________________________
Telefone do paciente ______________________________ Telefone da
Liga ____________________
Liga de Hipertenso de _________________________________Dept. de
Hipertenso Arterial
da Sociedade Brasileira de Cardiologia Seo Ligas de
Hipertenso
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DadosPronturio _______________________________ Ficha
______________ Data ____ / ____ / ____
2
IdentificaoNome
__________________________________________________________________________
Endereo
________________________________________________________________________
Bairro ________________ Cidade ________________________ Estado
_____ CEP _____________ Telefone
________________________________________________________________________
Data de nasc.: ____ / ____ / ____ Idade ______ Sexo ______ Estado
civil______________________ RG: _________________________
Convnio___________________________________________
EscolaridadeAnalfabeto Alfabetizao rudimentar 1o grau 2o grau
Superior Completo Incompleto
Condies socioeconmicaAtivo Inativo Aposentado Dependente
Desempregado
Profisso
________________________________________________________________________
PA _________________________ Peso _________ kg
Altura ____________ m
Circunferncia abdominal ______________________ Glicemia
_____________________________ Colesterol total
______________________________ HDL
_________________________________ LDL
_______________________________________ Triglicrides
___________________________
Dept. de Hipertenso Arterial
da Sociedade Brasileira de Cardiologia Seo Ligas de
Hipertenso
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SAE Sistematizao da assistncia de enfermagem IHistrico da doena
atual_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
3
Antecedentes pessoaisDiabetes Cardiopatias Dislipidemias
Tabagismo Etilismo Drogas Cirurgia anterior Alergia Vacina
Medicao em uso______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________ Especificar
______________________________________
Terapia de reposio hormonal (TRH) Especificar
______________________________________ Contraceptivo oral Outras
doenas ______________________________________
______________________________________ Mdico Farmcia
______________________________________ Caseiro Outros
Controle:
Antecedentes familiaresAlguma pessoa da famlia com PA alta? Sim
No Ignorado Grau de parentesco:
________________________________________________________________
Incio da doena: _________________________ Incio do tratamento:
________________________
Exame fsico EnfermagemRealizado em: _____ / _____ / _____ Hora:
_____h_____ Responsvel:
_____________________________________________________________________Dept.
de Hipertenso Arterial
da Sociedade Brasileira de Cardiologia Seo Ligas de
Hipertenso
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SAE Sistematizao da assistncia de enfermagem I
(cont.)CardiovascularRitmo cardaco: Pulso Carotdeos Braquiais
RadiaisPulsos: A: ausente; C: cheio; F: filiforme
4
Regular D E
Irregular Pulso Femorais Poplteos Pediosos D E
Perfuso perifrica:
Boa
Diminuda
Obs.:
___________________________________________________________________________
_______________________________________________________________________________
Presso arterial Horrio: _____h_____ MSD (mmHg):
____________________________________________________________________
MSE (mmHg):
____________________________________________________________________
Obs.:
___________________________________________________________________________
_______________________________________________________________________________
Postura Sentado Deitado Em p FC (bpm)
________________________________________________________________________
Avaliao do risco coronrio
_______________________________________________________________________________
Integridade cutnea/mucosa (edemas, leses, manchas,
cicatrizes)_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Dor
Sim
No
Local:
__________________________________________________________________________
Tipo:
___________________________________________________________________________
Intensidade:
_____________________________________________________________________Dept.
de Hipertenso Arterial
da Sociedade Brasileira de Cardiologia Seo Ligas de
Hipertenso
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SAE Sistematizao da assistncia de enfermagem I
(cont.)GlicemiaJejum:
__________________________________________________________________________
Capilar:
_________________________________________________________________________
Ps-prandial:
_______________________________________________________________________
Peso: _________ kg Altura: _________ m IMC (ndice de massa
corprea): _________________________ Peso ideal:__________ kg
5
Hospitalizao/cirurgia(s)_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Prescrio Enfermagem (verificar, comunicar, encaminhar,
controlar)_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Evoluo de
Enfermagem_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Dept. de Hipertenso Arterial
da Sociedade Brasileira de Cardiologia Seo Ligas de
Hipertenso
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SAE Sistematizao da assistncia de enfermagem I (cont.)Diagnstico
de enfermagem (sinais e sintomas identificao das necessidades
assistncia)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
6
Roteiro/Exames fsicos 1. Altura/peso2. Aparncia geral 3. Cabea
4. Olhos e viso 5. Ouvido e audio 6. Nariz e seios nasais 7. Boca
8. Pescoo 9. Linfonodos 10. Mamas 11. Pulmes 12. Corao 13. Circulao
perifrica 14. Abdmen 15. Genitlia masculina e hrnias 16. Genitlia
feminina 17. Reto 18. Sistema musculoesqueltico 19. Sistema
neurolgico
Ass. ___________________________________________________ COREN
_________________Fonte: Conselho regional de enfermagem de So Paulo
(SAE Sistematizao da assistncia de enfermagem)
Dept. de Hipertenso Arterial
da Sociedade Brasileira de Cardiologia Seo Ligas de
Hipertenso
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