Valoracion 14 Necesidades v. Henderson

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

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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: ______________________________________
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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: ________________________________________________________________________
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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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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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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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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: ____________________________________________________
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:____________________________________________
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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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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.___
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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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8.- HIGIENE
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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____________
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:_____________________
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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: __________________________________________________
Iluminacin oscura o brillante: S. __ No. __ Riesgo: _________________________________________
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: _____________________________
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: __________________________________________________
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Riesgo de agresin: S. __ No. __ Riesgo: __________________________________________________

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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: ______________________________
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.___
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Busca atencin de afecto de los dems: S. ___ No. ___
Manifiesta Reacciones Particulares : No.___ S.___ Tipo: ____________________________________
Manifiesta actitud receptiva y/o confianza: S. ___ No. ___ Tipo:______________________________
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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: _____________________________
Utiliza objetos religiosos y/o culturales: No.___ S.___ Tipo: __________________________________
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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._
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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 ______________________________
Otras consideraciones: _________________________________________________________________
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Otros:
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Valoracion 14 Necesidades v. Henderson

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Valoracin 14 Necesidades Virginia Henderson

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Valoracin 14 necesidades V. Henderson

1.- RESPIRACIN - CIRCULACIN

Valoracin 14 Necesidades Virginia Henderson

Valoracin 14 Necesidades Virginia Henderson

2.- BEBER Y COMER, ALIMENTARSE

Ajustada: _____ Si. ____ No.

Valoracin 14 Necesidades Virginia Henderson

Valoracin 14 Necesidades Virginia Henderson

Satisfactoria: Si. ____ No. ____

Estreimiento: No.___ Si.___

Diarrea: No. ___ S. ___ Habitual: No.___ S.___

Coloracin Marrn: S. __ No. __ Otro color:_____________________________________________

Valoracin 14 Necesidades Virginia Henderson

Valoracin 14 Necesidades Virginia Henderson

Valoracin 14 Necesidades Virginia Henderson

Valoracin 14 Necesidades Virginia Henderson

Otros hbitos de reposo/sueo:

Valoracin 14 Necesidades Virginia Henderson

Valoracin 14 Necesidades Virginia Henderson

Valoracin 14 Necesidades Virginia Henderson

Valoracin 14 Necesidades Virginia Henderson

Otras manifestaciones de Independencia: _________________________________________________

Valoracin 14 Necesidades Virginia Henderson

Valoracin 14 Necesidades Virginia Henderson

Valoracin 14 Necesidades Virginia Henderson

11.- CREENCIAS Y VALORES

Valoracin 14 Necesidades Virginia Henderson

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

Valoracin 14 Necesidades Virginia Henderson

Valoracin 14 Necesidades Virginia Henderson

S-ar putea să vă placă și

Ajustada: _ Si. No.

Satisfactoria: Si. No.

Estreimiento: No._ Si._

Diarrea: No. _ S. _ Habitual: No._ S._

Coloracin Marrn: S. No. Otro color:_____________________________________________