CONVENIO DE ASISTENCIA AL ADULTO MAYOR RAPA NUI

Plan Familiar de Cuidados

I. ANTECEDENTES PERSONALES

Nombre: ________________________________________________________________________
Edad : __________ Fecha de Nacimiento: __________________________________
Cedula de identidad: ___________________ N de ficha: _______________________________
Direccin: ______________________________ _________________________________________
Telfono de contacto: ____________________________Previsin de Salud: __________________
RND: SI ___ NO ___ En Trmite___
Nombre de la persona responsable:___________________________________________________
Telfono: ________________________ Email: _________________________________________
Nombre del cuidador asignado: ______________________________________________________

II. ANTECEDENTES DE SALUD

Unidad que deriva: ________________________________________________________________

Fecha de Ingreso: _________________________________________________________________
Fecha de Egreso y Motivo: __________________________________________________________
Diagnstico/s Mdico:
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Peso: ____ Talla: ____ IMC: ____
Antecedentes Mrbidos: HTA ___ diabetes ___ epilepsia ___ otros: __________________

Factores de riesgo: consumo de alcohol___ _ tabaquismo ____ consumo de drogas ____

obesidad___ otros: ____________________________________________
CONVENIO DE ASISTENCIA AL ADULTO MAYOR RAPA NUI

Tratamiento Farmacolgico: __________HACER TABLA CON HORARIOS Y

DAS______________________________________________

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Controles en otras Unidades del HHR (especificar):

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Impresin general al ingreso:
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Asistencias tecnolgicas:
Anteojos ___ audfonos ___ bastones ___ andador ___ rtesis ___ prtesis ___
Silla de ruedas ___ (tipo) _______________ otros ____________________________________

III. ANTECEDENTES DE VIVIENDA

Vivienda:
Casa propia: SI / NO Allegado: SI / NO N de pisos (niveles): ___ Sector: URBANO / RURAL
Adaptaciones ambientales: SI / NO (especificar cules):
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Servicios bsicos:
Agua potable: SI / NO Luz: SI / NO Alcantarillado: SI / NO Calefn: SI / NO
Cocina: Si/No Gas/Lea
Otros servicios:
Internet ___ telefona fija/mvil ___ Asesora de hogar ___ Movilizacin particular ___
CONVENIO DE ASISTENCIA AL ADULTO MAYOR RAPA NUI

IV. ANTECEDENTES BIOGRFICOS Y OCUPACIONALES

Antecedentes educacionales:
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Experiencia laboral: (trabajos, capacitaciones, voluntariados, aos de experiencia, etc.)
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Tiempo de ocio y esparcimiento: (Actividades e intereses):
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Rutina
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CONVENIO DE ASISTENCIA AL ADULTO MAYOR RAPA NUI

V. ANTECEDENTES DE LA FAMILIA/ CUIDADOR

Genograma

Hitos:___________________________________________________________________________
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CONVENIO DE ASISTENCIA AL ADULTO MAYOR RAPA NUI

Mapa de redes:

Observaciones:
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- SITUACIN SOCIOECONMICA (OCUPACIONES, RENTA LIQUIDA

APROX, INGRESOS, NIVEL EDUCACIONAL, PREVISIN DEL GRUPO
FAMILIAR, SITUACIONES DE SALUD, EXISTENCIA DE PERSONAS CON
DISCAPACIDAD, TTO FARMACOLOGICOS,
- RECEPCIN DE BENEFICIOS SOCIALES (SUBSIDIO, APOYO DEL
MUNICIPIO, ETC)
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I. AREAS DEL DESEMPEO
rea Pauta Inicio Medio Final
AVDB Barthel
Cognitivo MOCA
CONVENIO DE ASISTENCIA AL ADULTO MAYOR RAPA NUI

Pauta de
domicilio
Depresin Yessavage
Cuidador Zarit
Observaciones:____________________________________________________________________
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II. HABILIDADES Y DESTREZAS DE EJECUCIN (Kinesilogo o profesional a fin)

a. rea Motora Gruesa:

Control postural Prueba especfica

Control de cabeza Existe Regular Asistido Nulo

Control de tronco Existe regular Asistido Nulo

Alineacin postural Existe Regular Asistida Nulo

Equilibrio esttico Existe Regular Asistida Nulo (Test unipodal)D: /I:

Equilibrio dinmico Existe Regular Asistido Nulo (Up and go)tiempo:

Observaciones:____________________________________________________________________
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Tolerancia sedente
Buena Regular Deficiente Tiempo

Tolerancia bpedo
Buena Regular Deficiente Tiempo

Tono muscular (especificar segmento/s valorado)

sin alteracin __ Hipotona __ Escala de ashworth (mod): 0__ 1__ 2 __ 3 __ 4 __ 5__

Observaciones:
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Fuerza muscular (especificar segmento/s valorado) (valoracin segn PFM de Daniels)
 CONVENIO DE ASISTENCIA AL ADULTO MAYOR RAPA NUI

Observaciones:____________________________________________________________________
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Movimientos de rangos articulares:
Observaciones:____________________________________________________________________
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b. rea Motora Fina:

Prehensin gruesa Lograda No lograda Con dificultad Observaciones

Esfrica I / D I / D I / D
Cilndrica I / D I / D I / D
Pinzas Lograda No lograda Con dificultad Observaciones
Ter-terminal I / D I / D I / D
Sub-terminal I / D I / D I / D
Lateral I / D I / D I / D
Trpode I / D I / D I / D

III. EVALUACIN SENSITIVA

Alteraciones sensitivas:
Hipoestesia __ Hiperestesia __ Hiperalgesia __ Alodinia __ Parestesias __
Otros ___________________ Localizacin ____________________________
Alteraciones vasomotoras:
Coloracin: ______________________________________________________________________
Edema: Si/NO Medicin permetro (cm): ______________________________________
Valoracin de dolor
Localizacin :
Irradiacin :
Tipo : Quemante Elctrico Punzante Otro _______________
Frecuencia : Ocasional Frecuente Constante No precisa
EVA
En reposo 0 1 2 3 4 5 6 7 8 9 10
En actividad 0 1 2 3 4 5 6 7 8 9 10
Nocturno 0 1 2 3 4 5 6 7 8 9 10
 CONVENIO DE ASISTENCIA AL ADULTO MAYOR RAPA NUI

Sensibilidad Conservada Alterada No Aplicable

Superficial

Profunda

Temperatura

Estereognosia

Propiocepcin

IV. OBJETIVOS DE LA INTERVENCIN

A.- QU ESPERA LA FAMILIA/ RED DE APOYO/ CUIDADOR(ES)?

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B.- OBJETIVOS A TRABAJAR EN LA INTERVENCIN

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C.- ACCIONES SEGN PRESTADOR

PONER CUADRO CON ACTIVIDADES Y RESPONSABLES

Kinesiologa:
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CONVENIO DE ASISTENCIA AL ADULTO MAYOR RAPA NUI

Cuidador del programa

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Familia
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Diciembre

Lu. Ma. Mi. Ju. Vi. S. Do.

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