Sistematização da Assistência de Enfermagem - Período Pré-Operatório

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Sistematização da Assistência de Enfermagem - SAE
Nome:____________________________________________________________
Data de nascimento: _____/_____/_____ Idade:____________________
Sexo: ( ) F M ( ) Profissão:_________________________________
Endereço:________________________________________________________
Naturalidade: ____________________________________________________ 
Estado civil: ( ) Casado ( ) Solteiro ( ) União estável ( ) Viúvo ( ) Outros
Histórico pessoal:
Tabagismo: ( ) Sim ( ) Não Etilismo ( ) Sim ( ) Não 
Drogas ilícitas:__________________________________ 
História pregressa
Internações anteriores: __________________________________________________
______________________________________________________________________
Cirurgias anteriores/tempo: ______________________________________________
_______________________________________________________________
História atual:
( ) ITU ( ) Cardiopatia ( ) Doença Mental ( ) Alergias
( ) Colesterol alto ( ) Diabetes Mellitus ( ) Hipertensão 
( ) Anemia ( ) Doença Renal ( ) Labirintite
Outros:____________________________________________________________________________________________________________________________________________________________________
Histórico familiar: 
Hipertenso ( ) sim ( ) não
Diabético ( ) sim ( ) não
Cardiopatia ( ) sim ( ) não
Outros Quais_____________________________________________________________________________________________________________________________________________________________________
Nível de consciência 
( ) Calmo ( ) Consciente ( ) Orientado ( ) Agitado ( ) Desorientado ( ) Não comunicativo ( )Choroso ( ) Inconsciente
AO EXAME FÍSICO
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Sinais Vitais (SSVV)
PA: ________mmHg T: ________°C FC: ________bpm 
Pulso: _________ bpm Fr: _________ rpm
SPO2________ 
Portando sondas: ( ) sim ( ) não, especificar_________________________________________________
Punção venosa viável: ( ) sim ( ) não, especificar______________________________________________
PERÍODO PRÉ-OPERATÓRIO IMEDIATO
Exames pré-cirúrgico
Hemograma completo__________________________________________________________________
Uréia________________________________________________________________________________
Creatinina ___________________________________________________________________________
Sódio________________________________________________________________________________
Coagulograma_________________________________________________________________________
Exames de imagens, Quais?______________________________________________________________
Encaminhado a S.O nº_______Hora_____h_____min.______
PERÍODO INTRA OPERATÓRIO
Cirurgia proposta:______________________________________________________________________
Sitio demarcado: ( ) sim ( ) não ( ) não se aplica
Verificação de segurança anestésica concluída: ( ) sim ( ) não 
Oximetro no paciente e em funcionamento: ( ) sim ( ) não
Via aérea difícil/risco de aspiração? ( ) sim ( ) não 
Risco de perda sanguínea >500ml (7ml/kg em crianças) ? ( ) sim ( ) não
Inicio da anestesia:____h____min 
A profilaxia antimicrobiana foi realizada nos utimos 60 min? ( )sim ( ) não 
As imagens essenciais estão disponíveis? ( )sim ( )não, não se aplica 
Posição do paciente para cirurgia : ( )Decúbito dorsal-( )decúbito lateral- ( ) decúbito ventral-( ) semifowler-( ) Fowler-( ) trendelenburg -( ) trendelenburg invertido- ( ) litotomica- ( ) posição de canivete- ( ) posição genupeitoral- ( )posição renal 
Utilização do bisturi elétrico/laser ( )sim ( )não
Local da placa:_________________________________________________________________________
Solução utilizada para degermação e antissepsia do campo operatório:____________________________ 2.3 DURANTE O PROCEDIMNTO CIRÚRGICO
Inicio da incisão:_______:______ temperatura da SO:_______°C
Grau de contamição do procedimento cirúrgico: ( ) Limpo ( ) Potencialmente contaminado ( ) Contaminado ( ) Infectado
Aparelho raio X utilizado na sala: ( ) sim ( ) não, Local:_________________________________________
Solução infundida___________________________________volume em ml________________________
Sondas ( ) sim, ( ) não, especificar:_________________________________________________________
Drenos ( ) sim, ( ) não, especificar:_________________________________________________________
Irrigação Vesical: ( ) sim, ( ) não, especificar____________volume:_______________________________
Características:________________________________________________________________________
Laboratorio: ( ) hiatopatologico ( ) cultura ( ) citologia ( ) não se aplica
Intercorrências:________________________________________________________________________
As contagens de instrumentais cirúrgicos, compressas e agulhas estão corretas? ( ) sim, ( ) não, ( ) não se aplica
Termino da cirurgia: ________h______min Termino da anestesia: _____h____ min
Cirurgia realizada:______________________________________________________________________
Nome do cirurgião:_____________________________________________________________________
Instrumentador: _______________________________________________________________________
Auxiliar de cirurgia:_____________________________________________________________________
Circulante:____________________________________________________________________________
Hora da saída da S.O n°__________Hora______h______min.
 
3.SALA DE RECUPERAÇÃO PÓS ANESTÉSICA-SRPA
Admissão do paciente:____h____ min Acompanhado por:_____________________________________
Nível de consciência:( )Lúcido ( )Sonolento ( )Consciente ( )Torporoso 
 ( ) Desorientado ( )Comatoso ( ) Agitado outros,especificar__________________________________Queixas: ( ) Dor ( ) Emese ( ) Náuseas ( )Frio ( ) Dispneia ( )Tontura ( ) Outras, especificar:___________________________________________( )sem queixas.
Hidratatação venosa/local:________________________Condições:______________________________
Solução infudida:______________________________volume total infundido: _________ml
Curativo cirúrgico/local: ( ) Não ( )Sim, especificar
Sinais de hemorragia:( )Não ( )Sim,especificar
Extremidade: ( )Aquecidas ( )Frias ( )Cianóticas ( )Perfundidas
Drenos: ( ) Não ( ) Sim,especificar:_________________________________________________________
Diurese: ( ) Espontanea ( ) Ausente ( ) Por sonda vesical
Intercorrências:________________________________________________________________________
ESCALA DE ALDRETE E KROULIK
	
	Parâmetro resposta pontos
	15
	30
	45
	60
	1h30
	 Movimenta os quatro membros 2
	
	
	
	
	
	Atividade Movimenta dois membros 1
	
	
	
	
	
	Muscular Incapaz de mover os membros 0
	
	
	
	
	
	 Voluntariamente ou sob comando 
	
	
	
	
	
	 Capaz de respirar profundamente 2
	
	
	
	
	
	Respiração Dispneia ou limitação da respiração 1
	
	
	
	
	
	 Apneia 0
	
	
	
	
	
	 PA com variação de até 20 %do nível pré-anestésico 2
	
	
	
	
	
	Circulação PA com variação de 20 a 49 % do nível pré-anestésico 1
	
	
	
	
	
	 PA com variação acima de 50 % do nível pré-anestésico 0
	
	
	
	
	
	 Lucido e orientado no tempo e no espaço 2
	
	
	
	
	
	Consciência Desperta, se solicitando 1
	
	
	
	
	
	 Não responde 0
	
	
	
	
	
	 Capaz de manter saturação de O2> 92%, em ar 2
	
	
	
	
	
	 Ambiente
	
	
	
	
	
	Saturação Necessita de O2 para manter a saturação >90% 1
	
	
	
	
	
	 Saturação de O2 <90%, com suplementação de oxigênio 0
	
	
	
	
	
	Total de pontos Obs.: de 8 a 10 pontos , paciente apto, para alta -
	
4. DIAGNOSTICO DE ENFERMAGEM
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___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________5. PRESCRIÇAO DE ENFERMAGEM
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