Valoracin 14 Necesidades Virginia Henderson

E.C. Salud Mlaga

Departamento Enfermera Valoracin 14 necesidades V. Henderson

1.- RESPIRACIN - CIRCULACIN

RESPIRACIN:

Va Area: Permeable __. No Permeable __. Intubacin: No.__ S.___ Traqueotoma: No.__ S.___

Obstruccin: Parcial.__ Total.__ Nariz. __ Boca. ___ Bronquial. __ Pulmonar. __ Causa: __________
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Cnula Tipo: No. __ S__.: Naso traqueal. __ Oro traqueal. __ Traqueal. __.Tipo: _____________ N.__

Mascarilla: No. __ S. __ Gafa Nasal: No. __ S. __ % O2: _______

Frecuencia: Respiraciones: ____ por mto. SO2: ___ %.

Tipo: Eupnea. __ Taquipnea. __ Bradipnea. __ Ortopnea. __ Cheyne-stokes. __ Apnea. __Aleteo Nasal.

__ Tiraje: __ Supra esternal. __ Infra esternal. __Amplitud: Normal __ Profunda. __ Superficial __

Movimiento: Torcica. __ Abdominal. __

Secreciones: Ausente. __Escasa. __Abundante. __Boca. __ Nariz. __ Color________ Olor:__________

Volumen: Normal.___ Hiperventilacin.___ Hipo ventilacin.___ Ruidos: Normal __ Crepitaciones.__

Estertores. __ Silbido. __ Gorgoteo. __ Estridor. __ Otros: _____________________________________

Dificultad Respiratoria: No. __ Si. ___ Tos: __ Seca. __ Hmeda. __ Quintosa. __Ronquera.__

Afona. __Disfona. ___Estornudo. ___ Ronquido. ___Obesidad. ___ Ansiedad. ___Estrs.___

Cianosis: No. __ S.__ Central: No.__ S.__ Perifrica: No.__ S.__ Localizacin:
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Dolor: No. __ Si. __: Garganta. __ Trax. __ Abdomen. __ Otros:______________________________

Deformaciones: No. __ S__:. __ Nariz. __ Boca. __ Trax. __ Abdomen. ___ Otros:_______________

Fumador: No. __ Si. __ N Cigarrillos da: _____ Alergias: No ___ Si. __ Tipo:__________________

Intoxicacin: No. __Si. __: Respiratoria. __ Metablica. ___ Medicamentosa. __

Txico:____________

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Otras manifestaciones de Independencia: _________________________________________________

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Otras manifestaciones de Dependencia: __________________________________________________

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Datos a Considerar: __________________________________________________________________

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Otros: ______________________________________________________________________________
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1.- RESPIRACIN - CIRCULACIN

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: _________________________________

Dolor: No. _____ S. ____ Torcico: ____ No. ____ S. Localizacin:___________________________

Edemas.: No. ____ Si. ____ Localizacin: ________________________________________________

Heridas: No ____ Si. ___ Tipo:____________________ Localizacin: __________________________

Hemorragia.: No. _____ S. ____ Localizacin: ____________________________________________

Color piel y tegumentos: Normal. __ Cianosis ___ Equimosis __

Localizacin:____________________

Cambios Temperatura: No ____ Si. ____ Localizacin: ______________________________________

Otras manifestaciones de Independencia: _________________________________________________

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Otras manifestaciones de Dependencia:

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Datos a Considerar:
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Otros:
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2.- BEBER Y COMER, ALIMENTARSE

Vmitos: No.__ S.__ N veces _________ Cantidad:________ Contenido:______________________

Estado de la boca: Normal. ____ Deficiente. ____ Causas: ___________________________________

Denticin Suficiente: S. _____ No. ____ Prtesis. ____ No. ____ S. Ajustada: _____ Si. ____ No.

Mucosa oral rosada: Si.___ No. ___ Color: _________ Encas rosadas: __ S. __ No. Color: ________

Lengua rosada: S. ____ No. ____ Color________________ Hmeda: S. ____ No. _____

Heridas: No.___ S. ___ Tipo:________________ Localizacin: _______________________________

Masticacin: lenta. ____ rpida.___ Reflejo deglucin: S. ___ No. ___ Causa:___________________

Apetito: Si. ____ No. ____ Saciedad: S.____ No.____ Causas:_______________________________

Horario Comidas: Maana. _______ Tarde. ________ Noche. ______

Toma entre comidas: No. _____ S. ____ Tipo y Cantidad: _____________________ Hora:________

Cantidad de slidos da: Mucho, _______Normal, ________ Escaso. _____ grms./da. _________

Cantidad de liquidos da: Mucho, _______Normal, ________ Escaso. _____ cm3./da _________

Digestin: Ligera, ____ Lenta, ____ Pesada. ____ Alimentos indigestos: ________________________

Alimentos Preferidos: Verduras. ___ Carnes. ___ Pescados. ___ Frutas. __ Otros: ________________

Alimentos No Deseados: _______________________________________________________________

Restricciones: ________________________________________________________________________

Otras manifestaciones de Independencia: _________________________________________________

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Otras manifestaciones de Dependencia: __________________________________________________

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Datos a Considerar: __________________________________________________________________

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Otros: ______________________________________________________________________________
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3.- ELIMINACIN

ELIMNACIN URINARIA:

Cantidad: ___________ cm3/da. ________ cm3/hora. Satisfactoria: Si: ____ No: ____

Frecuencia: _____ veces da. Cantidad por miccin: ________ cm3

Dolor: No. _____ S. _____ Coloracin: Trigo ___ mbar. ___ Transparente. ____

Olor: No.____ Si. _____ Dbil. ______ Fuerte. ______ Semejanza a: ___________________________

Contenido: No: ____ S: ___ Tipo y caractersticas:_________________________________________

PH: _____ Densidad: ___________ Urea: _____________ Creatinna: ______________

Va Uretral: Permeable ____. No Permeable ____.

Obstruccin: Total.__ Parcial: __ Causa:_________________________________________________

Sonda Vesical: No. ___ S. ___ Permanente : S. ___ No. ___ Tipo: ___________________ N ______

Caractersticas y/o dificultad del Sondje: ________________________________________________

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Otras manifestaciones de Independencia: _________________________________________________

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Otras manifestaciones de Dependencia: __________________________________________________

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Datos a Considerar: __________________________________________________________________

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Otros: ______________________________________________________________________________

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3.- ELIMINACIN

ELIMNACIN FECAL:

Frecuencia: _____ veces da. Satisfactoria: Si. ____ No. ____

Estreimiento: No.___ Si.___ Diarrea: No. ___ S. ___ Habitual: No.___ S.___

Coloracin Marrn: S. __ No. __ Otro

color:_____________________________________________

Cantidad: Normal. ___ Escasa.___ Abundante. ___ Peso: _______ gms/deposicin. ________ gms/da.

Olor: Dbil. ______ Fuerte. ______ Semejanza: ____________________________________________

Consistencia: Dura. ___ Blanda. ____ Liquida. ____ Otros Contenidos: ________________________

Obstruccin: Total.__ Parcial: __ Causa:_________________________________________________

Toma Laxantes: No. ___ S. ___ Tipo: ____________________________________________________

Sonda Rectal: No. ___ S. ___ Permanente: S. ___ No. ___ Tipo: ___________________ N ______

Caractersticas y/o dificultad del Sondje: ________________________________________________

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Otras manifestaciones de Independencia: _________________________________________________

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Otras manifestaciones de Dependencia: __________________________________________________

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Datos a Considerar: __________________________________________________________________

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Otros: ______________________________________________________________________________
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3.- ELIMINACIN

ELIMNACIN SUDOR:

S: __ No: ___

Cantidad: Normal. ___ Escasa.___ Abundante. ___ Valoracin. _______________________cm3/da.

Olor: No.___ Si. ___ Dbil. ______ Fuerte. ______ Semejanza a: ______________________________

Otras Fuentes de Eliminacin y Caractersticas:

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Otras manifestaciones de Independencia: _________________________________________________

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Otras manifestaciones de Dependencia: __________________________________________________

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Datos a Considerar: __________________________________________________________________

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Otros: ______________________________________________________________________________
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4.- MOVIMIENTO: MANTENER POSTURA ADECUADA

D ambulacin: S.___ No.____ Silln. S.___ No.____ Cama. S.___ No.____

Mantiene posicin adecuada: S.___ No.___ Dificultad: _____________________________________

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Lesin: No.____ S.____ Cabeza: ____ Cuello: ___ Tronco:____ Extremidades: ___

Tipo: _______________________________________________________________________________
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Deformacin: No. __ S__ Tipo: _________________________________________________________

Dolor: No __ S __ Localizacin y Tipo:

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Realiza ejercicio: Activo: S.___ No.___ Pasivo: S.___ No.___ Tipo: ____________________________
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Fuerza muscular: Normal. S.__ No.__ Disminuida: No.__ S.__ dificultad:_______________________

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Posibilidad de movimientos:

Levantarse: S.___ No.____ Caminar S.___ No.___ Inclinarse: S.___ No.__ Sentarse: S.___ No.___

Acostarse: S.___ No.___ Correr: S.___ No.___ Agacharse: S.___ No.___ Arrodillarse: S.___ No.___

Levantar Peso: S.___ No.___ Estirarse: S.___ No.___ Coger objetos: S.___ No.___

Alcanzar objetos: S.___ No.___ Dificultad: ________________________________________________

Prtesis: S.___ No.____ Tipo:___________________________________________________________

Utiliza medios mecnicos: S.___ No.____ Tipo:____________________________________________

Otras manifestaciones de Independencia: _________________________________________________

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Otras manifestaciones de Dependencia: __________________________________________________

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Datos a Considerar: __________________________________________________________________

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Otros: ______________________________________________________________________________
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5.- NECESIDAD DE DORMIR Y DESCANSAR

SUEO:

Nocturno: S.___ No.___ Duracin: __________h. Diurno: S.___ No.___ Duracin: ________h.

Normal: ___ Profundo: ___ Ligero: ____ Satisfactorio: S.___ No.___

Caractersticas: ______________________________________________________________________
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Hbitos ligados al sueo: Bao: No.___ S.___ ducha: No.___ S.___ Infusin: No.___ S.___

Leche: S.___ No.___ Lectura: S.___ No.___ Medicacin: No.__ S.__ Tipo: ______________________

Otros hbitos de reposo/sueo:

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Otras manifestaciones de Independencia: _________________________________________________

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Otras manifestaciones de Dependencia: __________________________________________________

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Datos a Considerar: __________________________________________________________________

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Otros: ______________________________________________________________________________
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6.- VESTIRSE Y DESVESTIRSE

Capacidad: S.___ No.___ Dificultad: No.___ S.___ Tipo: ___________________________________

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Utiliza ropa y/o calzado adecuado al: Fro: S.___ No.___Calor: S.___ No.___ Humedad: S.___

No.___ Movimiento: S.___ No.___ Actividad fsica: S.___ No.___ Trabajo: S.___ No.___ Evitar

peligros: S.___ No.___ Creencias y/o cultura: S.___ No.___ Esttica y/o gustos: S.___ No.___

Limpieza: S.___ No.___ Objetos Significativos: S.___ No.___ Gusto: S.___ No.___

Otras manifestaciones de Independencia:

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Otras manifestaciones de Dependencia: __________________________________________________

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Datos a Considerar: __________________________________________________________________

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Otros: ______________________________________________________________________________
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7.- MANTENER LA TEMPERATURA CORPORAL DENTRO DE LIMITES NORMALES

Temperatura: _________ g/c. Axilar: S.___ No.___ Oral: S.___ No.___ Rectal S.___ No.___

Homeotermia: S.___ No.___ Hipertermia: No.___ S.___ Hipotermia: No.___ S.__ Duracin: ______h.

Sensacin de: Fri: No.___ S.___Calor: No.___ S.___ Escalofros: No.___ S.__ Sudor: S.__ No.__

Piel Rosada: S.___ No.___ Cianosis: No.___ S.___ Perifrica: S.___ No.___ Central: S.___ No.___

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Otras manifestaciones de Independencia: _________________________________________________

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Otras manifestaciones de Dependencia: __________________________________________________

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Datos a Considerar: __________________________________________________________________

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Otros: ______________________________________________________________________________
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8.- HIGIENE

Estado de la Piel:

Limpia. S. __ No. __ Hidratada: S. __ No. __ Integra: S. __ No. __ Color Rosada: S. __ No. __

Pigmentacin: No.__ S. __Tipo: _____________________Turgencia: S. __ No. __ Lisa: S. __ No.__

Suavidad: S. __ No. __ Flexibilidad: S. __ No. __ Transpiracin: No. __ S. __ Olor: No. __ S. __

Frecuencia de lavado: _________________ Productos usados: _________________________________

Bao: S. ___ No. ___ Ducha: S. ___ No. ___ Frecuencia: _______________ Duracin: ___________

Productos Usados: ____________________________________________________________________

Lesin Tipo y localizacin: ______________________________________________________________

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Nariz: Limpia S. __ No. __ Mucosa Integra: S. __ No. __ Humedad mucosa S. __ No. __

Ojos: Limpios: S. __ No. __ ntegros: S. __ No. __ Humedad mucosa S. __ No. __ Prtesis No __ S.__

Orejas: Limpia S. __ No. __ Integra: S. __ No. __ Configuracin _____________________

Genitales: Limpios S. __ No. __ Mucosa Integra: S. __ No. __ Humedad mucosa S. __ No. __

Ano: Limpio S. __ No. __ Mucosa Integra: S. __ No. __ Lesin No.__ S__ Tipo: _________________

Cabello: Limpio: S. __ No. __ Integro: S. __ No. __Longitud: ______________ Aspecto____________

Frecuencia de lavado: _________________ Productos usados: _________________________________

Vellos: Escaso: S. __ No. __ Medio: S. __ No. __ Abundante: S. __ No. __

Uas: Limpias S. __ No. __ Integras: S. __ No. __ Configuracin _____________________________

Boca: Limpia S. __ No. __ Mucosa Integra: S. __ No. __ Humedad mucosa S. __ No. __

Dientes: Limpios S.__ No __ Prtesis: No.__ S.__ Faltas: S. __ No. __ Tipo:_____________________

Frecuencia de lavado: _________________ Productos usados: _________________________________

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Otras manifestaciones de Independencia: _________________________________________________

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Otras manifestaciones de Dependencia: __________________________________________________

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Datos a Considerar: __________________________________________________________________

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Otros: ______________________________________________________________________________
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9.- SEGURIDAD

Mantiene seguridad fsica: S. __ No. __ Riesgo: ____________________________________________

Mantiene seguridad biolgica: S. __ No. __ Riesgo: ________________________________________

Mantiene seguridad psicolgica o emocional: S. __ No. __ Riesgo: ____________________________

Mantiene entorno social: S. __ No. __ Riesgo: _____________________________________________

Mantiene estrs: No. __ S. __ Tipo:______________________________________________________

Mantiene Entorno familiar seguro: S. __ No. __ Riesgo: ____________________________________

Mantiene medio ambiente seguro: S. __ No. __ Riesgo: _____________________________________

Mantiene inmunidad segura. S. __ No. __ Riesgo: __________________________________________

Vacunas: S. __ No. __ Necesidad de: ____________________________________________________

Mantiene Trabajo seguro: S. __ No. __ Riesgo: ___________________________________________

Mantiene medidas preventivas: S. __ No. __ Necesidad de: __________________________________

Mantiene factores hereditarios de riesgo: S. __ No. __ Riesgo: _______________________________

Conoce los peligros: S. __ No. __ Tipo: ___________________________________________________

Mantiene medidas de proteccin: S. __ No. __ Tipo: ________________________________________

Mantiene Entorno sano: Temp. ambiental 18.3 a 25 c. S. __ No. __ Riesgo: ____________________

Humedad 30 y 60 %: S. __ No. __ Riesgo:

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Iluminacin oscura o brillante: S. __ No. __ Riesgo:

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Ruido 120 decibelios: S. __ No. __ Riesgo: ________________________________________________

Aire con humos, polvo, microorganismos productos qumicos: S. __ No. __ Riesgo: ______________

Aparatos y/o artefactos posibles accidentes: S. __ No. __ Riesgo: _____________________________

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Conoce y sabe los mecanismos de proteccin: S. __ No. __ Riesgo: ____________________________

Conoce normativas legales: S. __ No. __ Riesgo: ___________________________________________

Factores Culturales /religioso /sociales. S. __ No. __ Tipo: ___________________________________

Mantiene rgimen teraputico: S. __ No. __ Riesgo: ________________________________________

Riego de accidente: S. __ No. __ Riesgo: __________________________________________________

Riesgo de infeccin: S. __ No. __ Riesgo: __________________________________________________

Riesgo de agresin: S. __ No. __ Riesgo: __________________________________________________

Otras manifestaciones de Independencia: _________________________________________________

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Otras manifestaciones de Dependencia: __________________________________________________

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Datos a Considerar: __________________________________________________________________

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Otros:
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10.- COMUNICACIN

Comunicacin verbal: S. __ No. __ Fcil: S. __ No. __ Moderado: S. __ No. ___ Claro: S. __ No. __

Preciso S.__ No. __ Asertivo S. __ No.__ Agresivo: No. __ S. __ Voluntad de comunicar: S. __ No. __

Limitaciones: No. __ S. __ Tipo: _________________________________________________________

Mantiene Lenguaje No verbal: S. __ No. __ Smbolos No. __ S. __

Otros:_____________________

Expresa movimientos significativos: No. __ S. __ Tipo: ____________________________________

Expresa Gestos significativos: No. __ S. __ Tipo: ___________________________________________

Mirada significativa: No. __ S. __ Tipo: __________________________________________________

Manifiesta necesidades: S. __ No. __ Tipo: ________________________________________________

Manifiesta opiniones / ideas: S. __ No. __ Tipo: ____________________________________________

Manifiesta Sentimientos / experiencias: S. __ No. __ Tipo: ___________________________________

Solicita informacin: S. __ No. __ Tipo: __________________________________________________

Presenta alteracin, intelectual, psicolgica, sociolgica: No. __ S. __ Tipo: _______________

Mantiene Todos los sentidos: S. __ No. __

Odo: Agudeza: S. __ No. __ Limitacin No. __ S. __ Tipo: ___________________________________

Vista: Agudeza: S. __ No. __ Limitacin No. __ S. __ Tipo: ___________________________________

Olfato: Fineza: S. __ No. __ Limitacin No. __ S. __ Tipo: ___________________________________

Gusto: Fineza: S. __ No. __ Limitacin No. __ S. __ Tipo: ___________________________________

Tacto: sensibilidad: S.___ No.___ Limitacin No. __ S. __ Tipo: ______________________________

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Utiliza Prtesis: No.___ S.___ Tipo: ______________________________________________________

Mantiene: Silencio: S.___ No.___ lloros: S.___ No.___ Risas.___ S.__ No.__ Otros: _____________

Manifiesta Perfeccin objetiva de mensaje recibido: S.___ No.___

Mantiene capacidad de verificar sus percepciones: S.___ No.___

Busca atencin de afecto de los dems: S. ___ No. ___

Manifiesta Reacciones Particulares : No.___ S.___ Tipo: ____________________________________

Manifiesta actitud receptiva y/o confianza: S. ___ No. ___ Tipo:______________________________

Otras manifestaciones de Independencia: _________________________________________________

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Otras manifestaciones de Independencia: _________________________________________________

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Otras manifestaciones de Dependencia: __________________________________________________

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Datos a Considerar: __________________________________________________________________

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Antonio Bentez Leiva. Enfermero Prof. Asociado Medico Quirrgica II. Enfermera U.M.A Mlaga febrero 2.002 14
 Valoracin 14 Necesidades Virginia Henderson

Otros:
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11.- CREENCIAS Y VALORES

Solicita ayuda religiosa: No.___ S.___ Tipo: ______________________________________________

Mantiene limitaciones religiosas: No.___ S.___ Tipo: _______________________________________

Mantiene limitaciones morales y/o culturales: No.___ S.___ Tipo:

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Utiliza objetos religiosos y/o culturales: No.___ S.___ Tipo: __________________________________

Otras manifestaciones de Independencia: _________________________________________________

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Otras manifestaciones de Dependencia: __________________________________________________

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Datos a Considerar: __________________________________________________________________

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Otros:
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Antonio Bentez Leiva. Enfermero Prof. Asociado Medico Quirrgica II. Enfermera U.M.A Mlaga febrero 2.002 15
 Valoracin 14 Necesidades Virginia Henderson

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12.- REALIZACIN: Ocuparse de Algo til 13.- OCIO RECREARSE

Solicita medios o actividad de realizacin o recreativa: No.___ S.___ Tipo: _____________________

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Mantiene limitaciones para su actividad recreativa o de realizacin : No.___ S.___ Tipo: _________
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Utiliza objetos particulares de actividad recreativa o de realizacin : No.___ S.___ Tipo: _________
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Lectura: No.__ S.__ Msica: No.___ S.__ Bricolaje: No.__ S.__ Arte: No.__ S.__Deporte: No.__ S._

Tipo:________________________________________________________________________________
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Otras consideraciones: _________________________________________________________________

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Antonio Bentez Leiva. Enfermero Prof. Asociado Medico Quirrgica II. Enfermera U.M.A Mlaga febrero 2.002 16
 Valoracin 14 Necesidades Virginia Henderson

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Otras manifestaciones de Independencia: _________________________________________________

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Otras manifestaciones de Dependencia: __________________________________________________

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Datos a Considerar: __________________________________________________________________

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Otros:
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14.- APRENDER

Conoce su estado de salud: S. __ No. __ Conoce sus diagnsticos S. __ No. __ Tipo: _____________

Conoce los medios teraputicos S. __ No. __ Tipo: _________________________________________

Conoce los frmacos, horarios y vas de administracin: S. __ No. __ Tipo: _____________________

Manifiesta necesidad de aprender S. __ No. __ Tipo: _______________________________________

Manifiesta capacidad receptiva o memoria S. __ No. __ Limitacin :___________________________

Existen factores que limitan su aprendizaje: No. __ S. __ Tipo: _______________________________

Necesita medios de apoyo para el aprendizaje: No. __ S. __ Tipo

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Otras consideraciones: _________________________________________________________________

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Otras manifestaciones de Independencia: _________________________________________________

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Antonio Bentez Leiva. Enfermero Prof. Asociado Medico Quirrgica II. Enfermera U.M.A Mlaga febrero 2.002 17
 Valoracin 14 Necesidades Virginia Henderson

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Otras manifestaciones de Dependencia: __________________________________________________

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Datos a Considerar: __________________________________________________________________

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Otros:
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Antonio Bentez Leiva. Enfermero Prof. Asociado Medico Quirrgica II. Enfermera U.M.A Mlaga febrero 2.002 18