Valoracion14necesidadesv Henderson1 PDF

E.C.
SaludMlaga
DepartamentoEnfermera
Valoracin14necesidadesV.Henderson
1.RESPIRACINCIRCULACIN
RESPIRACIN:
VaArea:Permeable__.NoPermeable__.Intubacin:No.__S.___Traqueotoma:No.__S.___
Obstruccin:Parcial.__Total.__Nariz.__Boca.___Bronquial.__Pulmonar.__Causa:
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CnulaTipo:No.__S__.:Nasotraqueal.__Orotraqueal.__Traqueal.__.Tipo:_____________
N.__
Mascarilla:No.__S.__GafaNasal:No.__S.__%O2:_______
Frecuencia:Respiraciones:____pormto.SO2:___%.
Tipo:Eupnea.__Taquipnea.__Bradipnea.__Ortopnea.__Cheynestokes.__Apnea.__AleteoNasal.
__Tiraje:__Supraesternal.__Infraesternal.__Amplitud:Normal__Profunda.__Superficial__
Movimiento:Torcica.__Abdominal.__
Secreciones:Ausente.__Escasa.__Abundante.__Boca.__Nariz.__Color________
Olor:__________
Volumen:Normal.___Hiperventilacin.___Hipoventilacin.___Ruidos:Normal__Crepitaciones.__
Estertores.__Silbido.__Gorgoteo.__Estridor.__Otros:
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DificultadRespiratoria:No.__Si.___Tos:__Seca.__Hmeda.__Quintosa.__Ronquera.__
Afona.__Disfona.___Estornudo.___Ronquido.___Obesidad.___Ansiedad.___Estrs.___
Cianosis:No.__S.__Central:No.__S.__Perifrica:No.__S.__Localizacin:
__________________
Dolor:No.__Si.__:Garganta.__Trax.__Abdomen.__
Otros:______________________________
Deformaciones:No.__S__:.__Nariz.__Boca.__Trax.__Abdomen.___Otros:_______________
Fumador:No.__Si.__NCigarrillosda:_____Alergias:No___Si.__Tipo:__________________
Intoxicacin:No.__Si.__:Respiratoria.__Metablica.___Medicamentosa.__
Txico:____________
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1.RESPIRACINCIRCULACIN
CIRCULACIN:
F.C.:____X.Pulsos:Si_____No___Localizacin:____________________Tipo:
_______________
T/A.:Sistlica._______Diastlica._______P.V.C:____________cm/H2O
ECG:No____Si.____Alteraciones:____No____Si.Tipo:
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Dolor:No._____S.____Torcico:____No.____S.
Localizacin:___________________________
Edemas.:No.____Si.____Localizacin:
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Heridas:No____Si.___Tipo:____________________Localizacin:
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Hemorragia.:No._____S.____Localizacin:
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Colorpielytegumentos:Normal.__Cianosis___Equimosis__
Localizacin:____________________
CambiosTemperatura:No____Si.____Localizacin:
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2.BEBERYCOMER,ALIMENTARSE
Vmitos:No.__S.__Nveces_________Cantidad:________Contenido:______________________
Estadodelaboca:Normal.____Deficiente.____Causas:___________________________________
DenticinSuficiente:S._____No.____Prtesis.____No.____S.Ajustada:_____Si.____No.
Mucosaoralrosada:Si.___No.___Color:_________Encasrosadas:__S.__No.Color:________
Lenguarosada:S.____No.____Color________________Hmeda:S.____No._____
Heridas:No.___S.___Tipo:________________Localizacin:
_______________________________
Masticacin:lenta.____rpida.___Reflejodeglucin:S.___No.___Causa:___________________
Apetito:Si.____No.____Saciedad:S.____No.____Causas:_______________________________
HorarioComidas:Maana._______Tarde.________Noche.______
Tomaentrecomidas:No._____S.____TipoyCantidad:_____________________Hora:________
Cantidaddeslidosda:Mucho,_______Normal,________Escaso._____grms./da._________
Cantidaddeliquidosda:Mucho,_______Normal,________Escaso._____cm3./da_________
Digestin:Ligera,____Lenta,____Pesada.____Alimentosindigestos:
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AlimentosPreferidos:Verduras.___Carnes.___Pescados.___Frutas.__Otros:________________
AlimentosNoDeseados:
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1.
3.ELIMINACIN
ELIMNACINURINARIA:
Cantidad:___________cm3/da.________cm3/hora.Satisfactoria:Si:____No:____
Frecuencia:_____vecesda.Cantidadpormiccin:________cm3
Dolor:No._____S._____Coloracin:Trigo___mbar.___Transparente.____
Olor:No.____Si._____Dbil.______Fuerte.______Semejanzaa:
___________________________
Contenido:No:____S:___Tipoycaractersticas:_________________________________________
2.
PH:_____Densidad:___________Urea:_____________Creatinna:______________
VaUretral:Permeable____.NoPermeable____.
Obstruccin:Total.__Parcial:__
Causa:_________________________________________________
SondaVesical:No.___S.___Permanente:S.___No.___Tipo:___________________N______
Caractersticasy/odificultaddelSondje:________________________________________________
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3.ELIMINACIN
ELIMNACINFECAL:
Frecuencia:_____vecesda.Satisfactoria:Si.____No.____
Estreimiento:No.___Si.___Diarrea:No.___S.___Habitual:No.___S.___
ColoracinMarrn:S.__No.__Otro
color:_____________________________________________
Cantidad:Normal.___Escasa.___Abundante.___Peso:_______gms/deposicin.________gms/da.
Olor:Dbil.______Fuerte.______Semejanza:
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Consistencia:Dura.___Blanda.____Liquida.____OtrosContenidos:________________________
Obstruccin:Total.__Parcial:__
Causa:_________________________________________________
TomaLaxantes:No.___S.___Tipo:
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SondaRectal:No.___S.___Permanente:S.___No.___Tipo:___________________N______
Caractersticasy/odificultaddelSondje:________________________________________________
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3.ELIMINACIN
ELIMNACINSUDOR:
S:__No:___
Cantidad:Normal.___Escasa.___Abundante.___Valoracin._______________________cm3/da.
Olor:No.___Si.___Dbil.______Fuerte.______Semejanzaa:
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OtrasFuentesdeEliminacinyCaractersticas:
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4.MOVIMIENTO:MANTENERPOSTURAADECUADA
Dambulacin:S.___No.____Silln.S.___No.____Cama.S.___No.____
Mantieneposicinadecuada:S.___No.___Dificultad:_____________________________________
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Lesin:No.____S.____Cabeza:____Cuello:___Tronco:____Extremidades:___
Tipo:
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Deformacin:No.__S__Tipo:
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Dolor:No__S__LocalizacinyTipo:
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Realizaejercicio:Activo:S.___No.___Pasivo:S.___No.___Tipo:
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Fuerzamuscular:Normal.S.__No.__Disminuida:No.__S.__
dificultad:_______________________
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Posibilidaddemovimientos:
Levantarse:S.___No.____CaminarS.___No.___Inclinarse:S.___No.__Sentarse:S.___No.___
Acostarse:S.___No.___Correr:S.___No.___Agacharse:S.___No.___Arrodillarse:S.___
No.___
LevantarPeso:S.___No.___Estirarse:S.___No.___Cogerobjetos:S.___No.___
Alcanzarobjetos:S.___No.___Dificultad:
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Prtesis:S.___No.____
Tipo:___________________________________________________________
Utilizamediosmecnicos:S.___No.____
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5.NECESIDADDEDORMIRYDESCANSAR
SUEO:
Nocturno:S.___No.___Duracin:__________h.Diurno:S.___No.___Duracin:________h.
Normal:___Profundo:___Ligero:____Satisfactorio:S.___No.___
Caractersticas:
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Hbitosligadosalsueo:Bao:No.___S.___ducha:No.___S.___Infusin:No.___S.___
Leche:S.___No.___Lectura:S.___No.___Medicacin:No.__S.__Tipo:
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6.VESTIRSEYDESVESTIRSE
Capacidad:S.___No.___Dificultad:No.___S.___Tipo:___________________________________
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Utilizaropay/ocalzadoadecuadoal:Fro:S.___No.___Calor:S.___No.___Humedad:S.___
No.___Movimiento:S.___No.___Actividadfsica:S.___No.___Trabajo:S.___No.___Evitar
peligros:S.___No.___Creenciasy/ocultura:S.___No.___Estticay/ogustos:S.___No.___
Limpieza:S.___No.___ObjetosSignificativos:S.___No.___Gusto:S.___No.___
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7.MANTENERLATEMPERATURACORPORALDENTRODELIMITESNORMALES
Temperatura:_________g/c.Axilar:S.___No.___Oral:S.___No.___RectalS.___No.___
Homeotermia:S.___No.___Hipertermia:No.___S.___Hipotermia:No.___S.__Duracin:
______h.
Sensacinde:Fri:No.___S.___Calor:No.___S.___Escalofros:No.___S.__Sudor:S.__No.__
PielRosada:S.___No.___Cianosis:No.___S.___Perifrica:S.___No.___Central:S.___No.___
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8.HIGIENE
EstadodelaPiel:
3.
Limpia.S.__No.__Hidratada:S.__No.__Integra:S.__No.__ColorRosada:S.__No.__
Pigmentacin:No.__S.__Tipo:_____________________Turgencia:S.__No.__Lisa:S.__No.__
Suavidad:S.__No.__Flexibilidad:S.__No.__Transpiracin:No.__S.__Olor:No.__S.__
Frecuenciadelavado:_________________Productosusados:
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4.
5.
6.
Bao:S.___No.___Ducha:S.___No.___Frecuencia:_______________Duracin:
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ProductosUsados:
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LesinTipoylocalizacin:
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Nariz:LimpiaS.__No.__MucosaIntegra:S.__No.__HumedadmucosaS.__No.__
Ojos:Limpios:S.__No.__ntegros:S.__No.__HumedadmucosaS.__No.__PrtesisNo__S.__
Orejas:LimpiaS.__No.__Integra:S.__No.__Configuracin_____________________
Genitales:LimpiosS.__No.__MucosaIntegra:S.__No.__HumedadmucosaS.__No.__
Ano:LimpioS.__No.__MucosaIntegra:S.__No.__LesinNo.__S__Tipo:
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Cabello:Limpio:S.__No.__Integro:S.__No.__Longitud:______________Aspecto____________
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Vellos:Escaso:S.__No.__Medio:S.__No.__Abundante:S.__No.__
Uas:LimpiasS.__No.__Integras:S.__No.__Configuracin
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Boca:LimpiaS.__No.__MucosaIntegra:S.__No.__HumedadmucosaS.__No.__
Dientes:LimpiosS.__No__Prtesis:No.__S.__Faltas:S.__No.__
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9.SEGURIDAD
Mantieneseguridadfsica:S.__No.__Riesgo:
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Mantieneseguridadbiolgica:S.__No.__Riesgo:________________________________________
Mantieneseguridadpsicolgicaoemocional:S.__No.__Riesgo:____________________________
Mantieneentornosocial:S.__No.__Riesgo:
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Mantieneestrs:No.__S.__
Tipo:______________________________________________________
MantieneEntornofamiliarseguro:S.__No.__Riesgo:____________________________________
Mantienemedioambienteseguro:S.__No.__Riesgo:_____________________________________
Mantieneinmunidadsegura.S.__No.__Riesgo:
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Vacunas:S.__No.__Necesidadde:
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MantieneTrabajoseguro:S.__No.__Riesgo:___________________________________________
Mantienemedidaspreventivas:S.__No.__Necesidadde:__________________________________
Mantienefactoreshereditariosderiesgo:S.__No.__Riesgo:_______________________________
Conocelospeligros:S.__No.__Tipo:
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Mantienemedidasdeproteccin:S.__No.__Tipo:________________________________________
MantieneEntornosano:Temp.ambiental18.3a25c.S.__No.__Riesgo:____________________
7.
8.
9.
Humedad30y60%:S.__No.__Riesgo:
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Iluminacinoscuraobrillante:S.__No.__Riesgo:
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Ruido120decibelios:S.__No.__Riesgo:
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Aireconhumos,polvo,microorganismosproductosqumicos:S.__No.__Riesgo:______________
Aparatosy/oartefactosposiblesaccidentes:S.__No.__Riesgo:_____________________________
Conoceysabelosmecanismosdeproteccin:S.__No.__Riesgo:____________________________
Conocenormativaslegales:S.__No.__Riesgo:
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FactoresCulturales/religioso/sociales.S.__No.__Tipo:
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Mantienergimenteraputico:S.__No.__Riesgo:________________________________________
Riegodeaccidente:S.__No.__Riesgo:
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Riesgodeinfeccin:S.__No.__Riesgo:
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Riesgodeagresin:S.__No.__Riesgo:
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10.COMUNICACIN
Comunicacinverbal:S.__No.__Fcil:S.__No.__Moderado:S.__No.___Claro:S.__No.__
PrecisoS.__No.__AsertivoS.__No.__Agresivo:No.__S.__Voluntaddecomunicar:S.__No.__
10.
Limitaciones:No.__S.__Tipo:
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MantieneLenguajeNoverbal:S.__No.__SmbolosNo.__S.__Otros:_____________________
Expresamovimientossignificativos:No.__S.__Tipo:____________________________________
ExpresaGestossignificativos:No.__S.__Tipo:
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Miradasignificativa:No.__S.__Tipo:
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Manifiestanecesidades:S.__No.__Tipo:
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Manifiestaopiniones/ideas:S.__No.__Tipo:
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ManifiestaSentimientos/experiencias:S.__No.__Tipo:
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Solicitainformacin:S.__No.__Tipo:
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Presentaalteracin,intelectual,psicolgica,sociolgica:No.__S.__Tipo:_______________
MantieneTodoslossentidos:S.__No.__
Odo:Agudeza:S.__No.__LimitacinNo.__S.__Tipo:
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Vista:Agudeza:S.__No.__LimitacinNo.__S.__Tipo:
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Olfato:Fineza:S.__No.__LimitacinNo.__S.__Tipo:
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Gusto:Fineza:S.__No.__LimitacinNo.__S.__Tipo:
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Tacto:sensibilidad:S.___No.___LimitacinNo.__S.__Tipo:
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UtilizaPrtesis:No.___S.___Tipo:
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Mantiene:Silencio:S.___No.___lloros:S.___No.___Risas.___S.__No.__Otros:
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ManifiestaPerfeccinobjetivademensajerecibido:S.___No.___
Mantienecapacidaddeverificarsuspercepciones:S.___No.___
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Buscaatencindeafectodelosdems:S.___No.___
ManifiestaReaccionesParticulares:No.___S.___Tipo:
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3.
Manifiestaactitudreceptivay/oconfianza:S.___No.___
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11.CREENCIASYVALORES
Solicitaayudareligiosa:No.___S.___Tipo:
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Mantienelimitacionesreligiosas:No.___S.___Tipo:
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Mantienelimitacionesmoralesy/oculturales:No.___S.___Tipo:
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Utilizaobjetosreligiososy/oculturales:No.___S.___Tipo:
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12.REALIZACIN:OcuparsedeAlgotil13.OCIORECREARSE
Solicitamediosoactividadderealizacinorecreativa:No.___S.___Tipo:_____________________
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Mantienelimitacionesparasuactividadrecreativaoderealizacin:No.___S.___Tipo:_________
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Utilizaobjetosparticularesdeactividadrecreativaoderealizacin:No.___S.___Tipo:_________
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Lectura:No.__S.__Msica:No.___S.__Bricolaje:No.__S.__Arte:No.__S.__Deporte:No.__S._
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DatosaConsiderar:
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_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
____________
Otros:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
________________
14.APRENDER
Conocesuestadodesalud:S.__No.__ConocesusdiagnsticosS.__No.__Tipo:_____________
ConocelosmediosteraputicosS.__No.__Tipo:_________________________________________
Conocelosfrmacos,horariosyvasdeadministracin:S.__No.__Tipo:_____________________
ManifiestanecesidaddeaprenderS.__No.__Tipo:_______________________________________
ManifiestacapacidadreceptivaomemoriaS.__No.__Limitacin:___________________________
Existenfactoresquelimitansuaprendizaje:No.__S.__Tipo:_______________________________
Necesitamediosdeapoyoparaelaprendizaje:No.__S.__Tipo______________________________
Otrasconsideraciones:
_________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
________
_________________________________________________________________________________
_________________________________________________________________________________
________
_________________________________________________________________________________
_________________________________________________________________________________
________
_________________________________________________________________________________
_________________________________________________________________________________
________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_______________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
________________________
DatosaConsiderar:
__________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
________________
Otros:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
____________________________

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