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REPÚBLICA BOLIVARIANA DE VENEZUELA MINISTERIO DEL PODER POPULAR

PARA LA DEFENSA UNIVERSIDAD NACIONAL EXPERIMENTAL POLITÉCNICA DE LA FUERZA


ARMADA NÚCLEO VALENCIA – EXTENCION LA ISABELICA

Materno I sección D01

HISTORIA DE SALUD MATERNA

Datos demográficos:

Nombres ____________________________________

Apellidos ____________________________________

Edad _____ CI_________________ Sexo _________ Fecha de nacimiento ______________

Estado civil: S___ C___ D___ V___ Años de unión: _______________

Lugar de Nacimiento: ___________________________________________________________

Grado de instrucción: __________________________________________________________

Profesión _____________________________________________________________________

Religión: __________________________________________________________________

Dirección actual:
_____________________________________________________________________________
_____________________________________________________________________________

Parroquia ____________________________ Municipio __________________ Ciudad


_________________ Estado ________________ N° de historia_______________

Fecha de ingreso _______________________

Motivo de consulta :
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Evaluación actual de salud de la Gestante / Puerpera

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Dx medico

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Antecedentes Familiares

Hipertensión arterial (describir)


_________________________________________________________________________

Diabetes_____________________________________________________________________

Cardiovasculares ______________________________________________________________

Alergias ______________________________________________________________________

Respiratorias__________________________________________________________________

Tuberculosis __________________________________________________________________

Renales ______________________________________________________________________

ITS___________________________________________________________________________

Urinarias______________________________________________________________________

Neurológicas __________________________________________________________________

Drogas_______________________________________________________________________

Alcohol_______________________________________________________________________

Cigarrillo _____________________________________________________________________

Examen físico general

Facies
_____________________________________________________________________________
_____________________________________________________________________________

Vestimenta
_____________________________________________________________________________
_____________________________________________________________________________

Actitud o posición
_____________________________________________________________________________
_____________________________________________________________________________
Conciencia
_____________________________________________________________________________
_____________________________________________________________________________
Memoria
_____________________________________________________________________________
_____________________________________________________________________________

Lenguaje
_____________________________________________________________________________
_____________________________________________________________________________

Marcha
_____________________________________________________________________________
_____________________________________________________________________________

Movimientos Corporales
_____________________________________________________________________________
_____________________________________________________________________________

Peso ____________________ Talla ______________

Estado Nutricional
____________________________________________________________________________

Signos Vitales Fecha __________________________________________

Pulso _______________________________________________________________________

FR_________________________________________________________________________

Temperatura__________________________________________________________________

T/A__________________________________________________________________________

Examen Físico Segmentario

Cabeza
_____________________________________________________________________________
_____________________________________________________________________________

Cara_________________________________________________________________________
_____________________________________________________________________________

Ojos_________________________________________________________________________
_____________________________________________________________________________

Nariz_________________________________________________________________________
_____________________________________________________________________________

Boca_________________________________________________________________________
_____________________________________________________________________________
Oído
_____________________________________________________________________________
_____________________________________________________________________________

Tórax
anterior_______________________________________________________________________
_____________________________________________________________________________

Mamas
_____________________________________________________________________________
_____________________________________________________________________________

Tórax posterior
_____________________________________________________________________________
_____________________________________________________________________________

Abdomen
_____________________________________________________________________________
_____________________________________________________________________________

Genitales

Labios mayores________________________________________________________________

Labios menores________________________________________________________________

Periné ________________________________ Loquios ________________________________

Secreciones ____________________________ Sangramiento ___________________________

Prurito ________________________________ Lesiones _______________________________

Miembros superiores ___________________________________________________________

Miembros inferiores ____________________________________________________________

Antecedentes obstétricos y perinatales

Menarquia ____________________________________________________________________

Ciclo menstrual ________________________________________________________________

sexarquia____________________________________________________________________

Anticonceptivos ________________________________________________________________

N° gesta _____________________________________________________________________

N° de partos __________________________________________________________________

Nacidos vivos _________________________________________________________________


Nacidos Muerto
_____________________________________________________________________________

Abortos ______________________________________________________________________

Cesareas______________________________________________________________________

FUR _________________________________________________________________________

FPP__________________________________________________________________________

Edad Gestacional _______________________________________________________________

Patología durante el embarazo


_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Grupo Sanguíneo ____________________ control Prenatal ____________________________

Consultas obstétricas ___________________________________________________________

Toxoide _____________________________ N° de dosis ______________________________

Duración de trabajo de Parto _____________________________________________________

Complicaciones
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Fecha de parto __________________________ Tipo de parto ________ G___ C___F_____

Episiotomía ________________ Legrado _________________ Puerperio inmediato _________

Complicaciones
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Fecha de engreso ______________________________________________________________

Condiciones de egreso __________________________________________________________


Recién Nacido

Nombres y apellidos __________________________________ Sexo______________

Apgar 1 _________________ Apgar 2______________ Grupo Sanguíneo__________

Inmunización
_______________________________________________________________________
_______________________________________________________________________

Alimentación
______________________________________________________________________

Eliminación Urinaria _____________________________________________________

Eliminación intestinal ____________________________________________________

Cordón Umbilical ________________________________________________________

Cabeza ________________________________________________________________

Tórax __________________________________________________________________

Abdomen ______________________________________________________________

Genitales_______________________________________________________________

Miembros superiores ____________________________________________________

Miembros Inferiores _____________________________________________________

Patrones funcionales de Salud

1- Manejo y percepción del estado de salud


_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

2- Nutricional metabólica
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
3- Eliminación
Urinaria __________________________________________________________
Intestinal _________________________________________________________
4- Actividad – ejercicio
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
5- Sueño y reposo
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
6- Cognoscitivo Perceptual
_________________________________________________________________
_________________________________________________________________
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7- Autopercepción -Autoconcepto
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
8- Rol
interrelación______________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
9- Adaptación y tolerancia al estrés
_________________________________________________________________
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_________________________________________________________________
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10- Sexualidad – reproducción
_________________________________________________________________
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_________________________________________________________________
_________________________________________________________________
11- Valores y creencias
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Observaciones
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Tratamiento Recibido
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Examen de laboratorio
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Dx de enfermería
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Bachiller:

C.I:

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