Valoracion 14 Necesidades v. Henderson PDF

E.C.
SaludMlaga
Valoracin14necesidadesV.Henderson
DepartamentoEnfermera
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.
__Aleteo
Nasal.
__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:
_____________________________________
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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OtrasmanifestacionesdeIndependencia:
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1.RESPIRACINCIRCULACIN
CIRCULACIN:
F.C.:
_
___X.Pulsos:Si_____No___Localizacin:____________________Tipo:
_______________
T/A.:
Sistlica._______Diastlica.
_____
__
P.V.C:
____________cm/H
2
O
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:
____________________________________________
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:
________________________
AlimentosPreferidos
:
Verduras.___Carnes.___Pescados.___Frutas.__Otros:
________________
AlimentosNoDeseados:
_______________________________________________________________
Restricciones:
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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:___
Tipoy
caractersticas:_________________________________________
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:
____________________________________________
Consistencia:
Dura.___Blanda.____Liquida.____
OtrosContenidos:
________________________
Obstruccin:
Total.__Parcial:__
Causa:_________________________________________________
TomaLaxantes:No.___S.___Tipo:
____________________________________________________
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:
______________________________
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:
_________________________________________________________
Dolor:
No__S__LocalizacinyTipo:
____________________________________________________
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:
________________________________________________
Prtesis:
S.___No.____
Tipo:___________________________________________________________
Utilizamediosmecnicos:
S.___No.____
Tipo:
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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:
______________________
Otroshbitosdereposo/sueo:
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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:
_________________________________
4. Bao:S.___No.___Ducha:S.___No.___Frecuencia:_______________Duracin:
___________
5.
6. ProductosUsados:
____________________________________________________________________
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:
_________________
Cabello:
Limpio:S.__No.__Integro:S.__No.__Longitud:______________
Aspecto____________

Productosusados:
_________________________________
Vellos:
Escaso:S.__No.__Medio:S.__No.__Abundante:S.__No.__
Uas:
LimpiasS.__No.__Integras:S.__No.__Configuracin
_____________________________
Boca:
LimpiaS.__No.__MucosaIntegra:S.__No.__HumedadmucosaS.__No.__
Dientes:
LimpiosS.__No__Prtesis:No.__S.__Faltas:S.__No.__
Tipo:_____________________
Productosusados:
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9.SEGURIDAD
Mantieneseguridadfsica:
S.__No.__Riesgo:
____________________________________________
Mantieneseguridadbiolgica:
S
.__No.__Riesgo:
________________________________________
Mantieneseguridadpsicolgicaoemocional:
S.__No.__Riesgo:
____________________________
Mantieneentornosocial:
S.__No.__Riesgo:
_____________________________________________

Mantieneestrs
:
No.__S.__
Tipo:______________________________________________________
MantieneEntornofamiliarseguro:
S.__No.__Riesgo:
____________________________________
Mantienemedioambienteseguro:
S.__No.__Riesgo:
_____________________________________
Mantieneinmunidadsegura.
S.__No.__Riesgo:
__________________________________________
Vacunas:
S.__No.__Necesidadde:
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MantieneTrabajoseguro:
S.__No.__Riesgo:
___________________________________________
Mantienemedidaspreventivas:
S.__No.__Necesidadde:
__________________________________
Mantienefactoreshereditariosderiesgo
:
S.__No.__Riesgo:
_______________________________
Conocelospeligros:
S.__No.__Tipo:
___________________________________________________
Mantienemedidasdeproteccin:
S.__No.__Tipo:
________________________________________
MantieneEntornosano:
Temp.
ambiental18.3a25c.S.__No.__Riesgo:
____________________
7. Humedad30y60%:S.__No.__Riesgo:
__________________________________________________
8.
9. Iluminacinoscuraobrillante:
S.__No.__Riesgo:
_________________________________________
Ruido120decibelios:
S.__No.__Riesgo:
________________________________________________
Aireconhumos,polvo,microorganismosproductosqumicos:
S.__No.__Riesgo:
______________
Aparatosy/oartefactosposiblesaccidentes:
S.__No.__Riesgo:
_____________________________
Conoceysabelosmecanismosdeproteccin:
S.__No.__Riesgo:
____________________________
Conocenormativaslegales:
S.__No.__Riesgo:
___________________________________________
FactoresCulturales/religioso/sociales
.
S.__No.__Tipo:
___________________________________
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:
_________________________________________________________
MantieneLenguajeNoverbal:
S.__No.__
Smbolos
No.__S.__
Otros:_____________________
Expresamovimientossignificativos:
No.__S.__
Tipo:
____________________________________
ExpresaGestossignificativos:
No.__S.__Tipo:
___________________________________________
Miradasignificativa:
No.__S.__Tipo:
__________________________________________________
Manifiestanecesidades:
S.__No.__
Tipo:
________________________________________________
Manifiestaopiniones/ideas:
S.__No.__
Tipo:
____________________________________________
ManifiestaSentimientos/experiencias:
S.__No.__
Tipo:
___________________________________

Solicitainformacin:
S.__No.__
Tipo:
__________________________________________________
Presentaalteracin,intelectual,psicolgica,sociolgica:
No.__S.__
Tipo:_______________
MantieneTodoslossentidos:
S.__No.__
Odo:
Agudeza:S.__No.__LimitacinNo.__S.__Tipo:
___________________________________
Vista:
Agudeza:S.__No.__LimitacinNo.__S.__Tipo:
___________________________________
Olfato:
Fineza:S.__No.__LimitacinNo.__S.__Tipo:
___________________________________
Gusto:
Fineza:S.__No.__LimitacinNo.__S.__Tipo:
___________________________________
Tacto:
sensibilidad:S.___No.___LimitacinNo.__S.__Tipo:
______________________________
1.
UtilizaPrtesis:
No.___S.___Tipo:
______________________________________________________
2.
3.
Mantiene:
Silencio:S.___No.___lloros:S.___No.___Risas.___S.__No.__Otros:
_____________
ManifiestaPerfeccinobjetivademensajerecibido:
S.___No.___
Mantienecapacidaddeverificarsuspercepciones:
S.___No.___
1.
Buscaatencindeafectodelosdems:S.___No.___
ManifiestaReaccionesParticulares:
No.___S.___Tipo:
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2.
3.
Manifiestaactitudreceptivay/oconfianza:
S.___No.___
Tipo:______________________________
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11.CREENCIASYVALORES
Solicitaayudareligiosa:
No.___S.___Tipo:
______________________________________________
Mantienelimitacionesreligiosas:
No.___S.___Tipo:
_______________________________________
Mantienelimitacionesmoralesy/oculturales:
No.___S.___Tipo:
_____________________________
Utilizaobjetosreligiososy/oculturales:
No.___S.___Tipo:
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___________________________________
12.REALIZACIN:OcuparsedeAlgotil13.OCIORECREARSE
Solicitamediosoactividadderealizacinorecreativa:
No.___S.___Tipo:
_____________________
________________________________________________________________________________
________________________________________________________________________________
__________
________________________________________________________________________________
________________________________________________________________________________
__________
Mantienelimitacionesparasuactividadrecreativaoderealizacin:
No.___S.___Tipo:
_________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________
________________________________________________________________________________
_____
Utilizaobjetosparticularesdeactividadrecreativaoderealizacin:
No.___S.___Tipo:
_________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________
________________________________________________________________________________
_____
Lectura:No.__S.__Msica:No.___S.__Bricolaje:No.__S.__Arte:No.__S.__Deporte:No.__
S._
Tipo:____________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
______________
Otrasconsideraciones:
_________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________
_________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_________________________
__________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________
DatosaConsiderar:
__________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________
Otros:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________
14.APRENDER
Conocesuestadodesalud:
S.__No.__
Conocesusdiagnsticos
S.__No.__
Tipo:_____________
Conocelosmediosteraputicos
S.__No.__
Tipo:
_________________________________________
Conocelosfrmacos,horariosyvasdeadministracin:
S.__No.__
Tipo:
_____________________
Manifiestanecesidaddeaprender
S.__No.__
Tipo:
_______________________________________
Manifiestacapacidadreceptivaomemoria
S.__No.__
Limitacin
:___________________________
Existenfactoresquelimitansuaprendizaje:
No.__S.__
Tipo:
_______________________________

Necesitamediosdeapoyoparaelaprendizaje
:No.__S.__
Tipo
______________________________
Otrasconsideraciones:
_________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
__________
________________________________________________________________________________
________________________________________________________________________________
__________
________________________________________________________________________________
________________________________________________________________________________
__________
________________________________________________________________________________
________________________________________________________________________________
__________
_________________________________________________
_________________________________________
_______________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
______________________________________________________________________
__________
________________________________________________________________________________
_______________________________________
__________________________________________________
______________________________________________
__________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________________________________________________
____________________
________________________________________________________________________________
______________________________
DatosaConsiderar:
__________________________________________________________________
_____________________________________
___________________________________________
________________________________________________________________________________
_______________________________________________
_________________________________
________________________________________________________________________________
____________________
Otros:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
______________________________________________
__________________________________
________________________________________________________________________________
________________________________________________________
________________________
___________________________________

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