Dispensação de material para curativo domiciliar

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Assinatura da enfermeira responsável

Cadastro de paciente em curativo

Nome:______________________________________________________________________________________

Endereço: ____________________________________________________________________________________

Data de nascimento:______/______/_________ idade:_________ Telefone:___________________________

Doenças/ Hábitos

Hipertenso: ( ) sim ( )Não Cardíaco: ( ) sim ( )Não outros: ______________________

Diabético: ( ) sim ( )Não Vascular: ( ) sim ( )Não Fuma: ( ) sim ( )Não

Historia da ferida:______________________________________________________________

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Característica da ferida

Medicações em uso/pomadas Alergias medicamentosa/pomadas

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Localização Extensão

Tecido Exsudato Odor

Epitelização Sim Fétido

Granulação Pouco Característico

Macerada Médio Sem odor

Esfacelo Muito

Necrose Debridamento

Fibrina Não Cirúrgico

UBS Regional Sul