Avaliação Fisioterapêutica Respiratória

Data:___/___/___

Nome:______________________________________ Idade:___________DN:___/____/____Sexo:______
Profissão:_____________________________________________________________________________
Altura:______cm Peso Atual:_______IMC:______cm²/kg
Procedência:_____________________________
Diag. Médico:__________________________________________________________________________
QP:__________________________________________________________________________________
HMA:___________________________________________________________________________________________
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HMP:___________________________________________________________________________________________
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HO:__________________________________________________________________________________
Doença de base:_______________________________________________________________________
Doenças associadas:____________________________________________________________________
Medicamentos:_________________________________________________________________________
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Sinais vitais: FR:_____ rpm FC:_______bpm SatO2: _____% PA:_________mmHg Temp__________

Inspeção Clinica Estática

Cianose central ( )
Cianose periférica ( ) extremidades ( ) lóbulos/orelha
Baqueteamento digital ( ) sim ( ) nao
Musculatura respiratória: ( ) atrofia ( ) encurtamento ( ) hipertrofia
Padrão Respiratório: ( ) misto ( ) torácico ( ) abdominal ( ) paradoxal
Tipo torácico:

( ) normal ( ) barril ( ) cifótico ( ) escavatum ( ) carinatum

Parede abdominal ( ) ascite
 Inspeção Clinica Dinâmica
Excursão diafragmática: Direita ( ) boa ( ) regular ( ) ruim
Esquerda ( ) boa ( ) regular ( ) ruim
Expansibilidade Torácica: ( ) diminuída ( ) anterior ( ) assimétrica _________________
Esforço respiratório: ( ) fúrcula ( ) supraclavicular ( ) intercostal ( ) batimento de asa de nariz
Uso de musculatura acessória, qual?____________________________________________________
Ritmo respiratório ( ) Cheyne – Stokes ( ) Biot ( ) Kussmaul ( ) suspirosa
Expansibilidade torácica ( ) simétrica ( ) assimétrica
Tosse: ( ) espontânea ( ) assistida ( ) estimulada ( ) produtiva ( ) improdutiva
( ) ineficaz ( ) eficaz
Secreção: ( ) mucóide ( ) purulenta ( ) hemática ( ) fétida ( ) hemoptise
Enfisema subcutâneo ( ) sim ( ) não
Localização: __________________________________________________________________________
Ausculta Pulmonar:_____________________________________________________________________
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Assistência ventilatória ( ) sim ( ) não

( ) Traqueostomia ( ) tubo orotraqueal

( ) ventilação não invasiva, associada a oxigenioterapia ( ) sim ( ) não

Modo ventilatório ( ) CPAP ( ) BIPAP
Parâmetros: __________________________________________________________________________
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Oxinenioterapia ( ) sim ( ) não
( ) cateter nasal /litros ____________________________
( ) mascara de Venturi/ dosador e litros:___________________________________
( ) macronebulização /_________________________

Gasometria arterial
pH
PaO2
PaCO2
HCO3
BE

Interpretação: _________________________________________________________________________

Interpretação Radiografia de tórax: __________________________________________________________

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 AVALIACAO FUNCIONAL BASICA

Avaliação de 1 Repetição máxima:

1 RM=_________________________________________________________________________
Carga a ser trabalhada:____________________________________________________________
Peak Flow:

Força muscular respiratória:

PImáx prevista:
PEmáx prevista:

PImáx do paciente:
PEmáx do paciente:

Carga de treinamento:
 PImáx
- Mulheres: y= -0,49 (idade) + 110,4;
- Homens: y= -0,80 (idade) + 155,3;

PEmáx
- Mulheres: y= -0,61 (idade) + 115,6;
- Homens: y= -0,81 (idade) + 165,3; (NEDER 1999)

NEDER;1999

CLASSIFICACAO DE COMPROMETIMENTO DO NIVEL DE CONSCIENCIA - GLASGOW

Pontuação Grau de comprometimento
3 pontos Menor responsividade
4-8 pontos Coma profundo
9-12 pontos Coma moderado
13-15 pontos Coma leve

Diagnostico
Fisioterapêutico:__________________________________________________________________________________
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Objetivos:
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Conduta
Inicial___________________________________________________________________________________________
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Conduta a longo prazo:
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