Sistema de classificação de pacientes -Metodologia Fugullin
Autor: Enfermagem Atual | Publicado: 2011-03-21T11:40:00-07:00

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Exemplo de ficha de avaliação inicial :Classificação do paciente aos cuidados
      

Área de cuidado       
Graduação da complexidade assistêncial  
      1      2      3      4  
      Estado mental       (&nbsp;&nbsp; ) consciente(&nbsp;&nbsp;&nbsp; )ansioso (&nbsp;&nbsp;&nbsp; ) calmo       (&nbsp;&nbsp;&nbsp;&nbsp; ) confuso (&nbsp;&nbsp;&nbsp;&nbsp; )desorientado (&nbsp;&nbsp;&nbsp;&nbsp; ) agitado       (&nbsp;&nbsp;&nbsp;&nbsp; ) sonolento (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )torporoso 
      (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )inconsciente (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )comatoso (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )sedado   
      Oxigenação       (&nbsp;&nbsp;&nbsp;&nbsp; ) ar ambiente       (&nbsp;&nbsp;&nbsp;&nbsp; )uso intermitente de CN ou MF      (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ) uso contínuo de CN ou MF       (&nbsp;&nbsp;&nbsp;&nbsp; ) entubado (&nbsp;&nbsp;&nbsp;&nbsp; ) traqueostomizado (&nbsp;&nbsp;&nbsp;&nbsp; )ambú (&nbsp;&nbsp;&nbsp;&nbsp; )ventilação mecânica   
      Sinais vitais       (&nbsp;&nbsp;&nbsp; ) controle de 8/8 horas       (&nbsp;&nbsp;&nbsp; ) controle de 6/6 horas       Controle   de 4/4 horas       (&nbsp;&nbsp;&nbsp;&nbsp; )controle em intervalos menores de 2   horas   
      Motilidade       (&nbsp;&nbsp;&nbsp;&nbsp; )movimentação independente       (&nbsp;&nbsp;&nbsp;&nbsp; ) movimentação com limitação (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )dependência mínima       (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )hemiparesia (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )parestesia (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ) dependência parcial       (&nbsp;&nbsp;&nbsp; ) hemiplegia (&nbsp;&nbsp;&nbsp;&nbsp; ) dependência total   
      Deambulação       (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )ambulante       (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ) deambulação com auxílio de pessoa (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ) deambulação com auxílio de   dispositivo(&nbsp;&nbsp;&nbsp;&nbsp; ) colo       (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ) cadeiras de rodas      (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ) acamado (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )contido (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )repouso absoluto   
      Alimentação       (&nbsp;&nbsp;&nbsp;&nbsp; ) auto- suficiente       (&nbsp;&nbsp;&nbsp;&nbsp; ) VO com auxílio       (&nbsp;&nbsp;&nbsp;&nbsp; )SNG(&nbsp;&nbsp;&nbsp;&nbsp; )SNE(&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ) gastrostomia (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )jejunostomia       (&nbsp;&nbsp;&nbsp; ) NPT(&nbsp;&nbsp;&nbsp; ) NPP
  
      Cuidado corporal       (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ) auto-suficiente       (&nbsp;&nbsp;&nbsp;&nbsp; ) banho de aspersão com auxílio (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ) higiene oral com auxílio&nbsp;       (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )banho de aspersão higiene oral pela   enfermagem(&nbsp;&nbsp;&nbsp;&nbsp; ) banho de imersão       (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ) de aspersão e higiene oral pela   enfermagem   
      Eliminações       (&nbsp;&nbsp;&nbsp;&nbsp; ) auto-suficiente       (&nbsp;&nbsp;&nbsp;&nbsp; ) uso de vaso sanitário com auxílio      (&nbsp;&nbsp;&nbsp;&nbsp; ) uso de comadre / papagaio       (&nbsp;&nbsp;&nbsp;&nbsp; )uso de fraldas (&nbsp;&nbsp;&nbsp;&nbsp; ) Uso de SVD  
      Terapêutica       (&nbsp;&nbsp;&nbsp; ) VO(&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )IM      (&nbsp;&nbsp;&nbsp;&nbsp; )acesso salinizado       (&nbsp;&nbsp;&nbsp; ) EV contínuo (&nbsp;&nbsp;&nbsp;&nbsp; )SNG/SNE      (&nbsp;&nbsp;&nbsp;&nbsp; )uso de drogas vasoativas   
      Integridade   cutânea-mucosa       (&nbsp;&nbsp;&nbsp;&nbsp; ) pele íntegra       (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )hiperemia (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )equimose (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )UPP/lesão grau I(&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )UPP/lesão grau II
      (&nbsp;&nbsp;&nbsp; ) UPP/lesão grau III(&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )cicatriz cirúrgica (&nbsp;&nbsp;&nbsp;&nbsp; ) drenos (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )ostomias       (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ) UPP/lesão grau IV(&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )evisceração   
      curativo      (&nbsp;&nbsp;&nbsp;&nbsp; ) sem curativo(&nbsp;&nbsp;&nbsp;&nbsp; ) limpeza da lesão/cicatriz cirúrgica   durante o banho       (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )1 vez ao dia       (&nbsp;&nbsp;&nbsp; ) 2 vezes ao dia       (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )3 vezes ou mais ao dia   
      Tempo de realização   do curativo       (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ) sem curativo (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ) (&nbsp;&nbsp;&nbsp;&nbsp;   ) limpeza da lesão/cicatriz cirúrgica durante o banho      (&nbsp;&nbsp;&nbsp; ) 5 a 15 minutos       (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ) 15 a30 minutos       (&nbsp;&nbsp;&nbsp;&nbsp; ) superior a 30 minutos   
      Fonte :Categoria de   cuidado segundo Fugulin et al:&nbsp;&nbsp;&nbsp;   Escore:----------------------  
(&nbsp;&nbsp;&nbsp;&nbsp; ) cuidado mínimo&nbsp; (12 a 17)&nbsp; (&nbsp;&nbsp;&nbsp;&nbsp; ) cuidado intermediário (18 a 22)&nbsp; (&nbsp;&nbsp;&nbsp; ) cuidado alta dependência (23 a 28)&nbsp; (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ) cuidado semi- intensivo (&nbsp; 29 a 34 )&nbsp; (&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; )cuidado intensivo&nbsp; (acima de 34)