VALORACION

Nombre: _______________________________________________________________________________________________________
Nmero de cama: ________________________________________________________________________________________________
Edad: _________________________________________________________________________________________________________
Etapa de la vida: _________________________________________________________________________________________________
Sexo: _________________________________________________________________________________________________________
Religin: _______________________________________________________________________________________________________
Estado Civil: ____________________________________________________________________________________________________
Ocupacin: _____________________________________________________________________________________________________
Lugar de Nacimiento: _____________________________________________________________________________________________
Grado de Instruccin: _____________________________________________________________________________________________
Fecha de Ingreso: _______________________________________________________________________________________________
Servicio: _______________________________________________________________________________________________________
Dx Mdico: _____________________________________________________________________________________________________
Estado en que se encontr
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PATRONES
- Patrn 1: Percepcin de la salud.
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- Patrn 2: Nutricional - Metablico.

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- Patrn 3: Eliminacin.
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- Patrn 4: Actividad - Ejercicio.
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- Patrn 5: Sueo - Descanso.
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- Patrn 6: Cognitivo - Perceptivo.
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- Patrn 7: Autopercepcin - Auto concepto.

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- Patrn 8: Rol - Relaciones.
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- Patrn 9: Sexualidad - Reproduccin.
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- Patrn 10: Tolerancia al estrs.
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- Patrn 11: Valores - Creencias.
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EXAMEN FSICO
CUERO CABELLUDO
Inspeccin: _________________________________________________________________________________________________
Palpacin: _________________________________________________________________________________________________
ODOS
Inspeccin: _________________________________________________________________________________________________
Palpacin: _________________________________________________________________________________________________
OJOS
Inspeccin: _________________________________________________________________________________________________
NARIZ
Inspeccin: _________________________________________________________________________________________________
Palpacin: _________________________________________________________________________________________________
CARA
Inspeccin: Piel, cara y labios (superior/inferior)
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CUELLO
Inspeccin: _________________________________________________________________________________________________
CABEZA
Inspeccin:_________________________________________________________________________________________________
Palpacin: _________________________________________________________________________________________________
CUELLO:
Inspeccin: _________________________________________________________________________________________________
Palpacin: _________________________________________________________________________________________________
COLUMNA VERTEBRAL
Inspeccin: _________________________________________________________________________________________________

TRAX
Inspeccin: _________________________________________________________________________________________________
Percusin: _________________________________________________________________________________________________
AXILA
Inspeccin: _________________________________________________________________________________________________
ABDOMEN
Inspeccin: _________________________________________________________________________________________________
MIEMBROS SUPERIORES
Inspeccin: _________________________________________________________________________________________________
MIEMBROS INFERIORES
Inspeccin: _________________________________________________________________________________________________
PIEL
Presencia de hongos: ________________________________________________________________________________________
PIES (UAS) __________________________________________________________________________________________________
MANOS (UAS) ________________________________________________________________________________________________
Presencia de Tatuajes___________________________________________________________________________________________
ANTECEDENTES
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TERAPEUTICA MEDICAMENTOSA
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