Rev. agosto 2013 1

UNIVERSITÀ DEGLI STUDI DI BRESCIA Dipartimento di Scienze Cliniche e Sperimentali

CORSO DI STUDIO IN FISIOTERAPIA

CARTELLA DIDATTICO-RIABILITATIVA ambito: riabilitazione respiratoria

III anno - Anno Accademico ____________

STUDENTE______________________________________________________________

SEZIONE DI CORSO

BRESCIA CREMONA MANTOVA

SEDE DI TIROCINIO: ____________________________________________________

VALUTAZIONE FINALE ELABORATO: ..………/ 30

NOTE:______________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

TUTORE________________________________________________________________

ASSISTENTE_____________________________________________________

STUDENTE______________________________________________________

Rev. agosto 2013 2

DATI GENERALI E ANAMNESI (Dalla cartella clinica, dalla comunicazione interdisciplinare,

dal colloquio con il paziente e i familiari)

Cognome e nome (iniziali)___________ età_______ sesso □ F □ M

nazionalità____________________________ scolarità _____________________________

professione________________________________________________________________

□ paziente ambulatoriale □ paziente ricoverato in___________________________

dal (data)_______________________

Diagnosi di accoglimento: ___________________________________________________

__________________________________________________________________________

Data evento indice_______________________

Specificare se d’esordio o riacutizzazione_________________________________________

Informazioni utili per la valutazione ed il trattamento riabilitativo

Comorbilità associate________________________________________________________

_________________________________________________________________________

Terapia farmacologica:_______________________________________________________

_________________________________________________________________________

Presidi: □ sondino n/g □ peg □ catetere vescicale □ CVC □ altro

Ausili ed ortesi:_____________________________________________________________

Situazione abitativa: □ vive solo □ con famigliari □ con caregiver

Barriere architettoniche: □ no □ sì - quali:_______________________________________

Abitudini di vita e aspetti relazionali:____________________________________________

_________________________________________________________________________

_________________________________________________________________________

Autonomia nelle ADL (igiene personale, vestizione, alimentazione, ecc.)

_________________________________________________________________________

Anamnesi riabilitativa (trattamenti riabilitativi precedenti):___________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Indagini strumentali (data, tipologia d’esame e sintesi del referto):____________________

_________________________________________________________________________

_________________________________________________________________________

Rev. agosto 2013 3

VALUTAZIONE FUNZIONALE Attraverso l’osservazione diretta, le tecniche di valutazione manuale e le scale di misura.

Aspetti psicocomportamentali e neuropsicologici

Stato di coscienza Comportamento Orientamento Comunicazione Aspetto cognitivo

□ Vigile □ Attento □ Obnubilato □ Soporoso □ Comatoso

□ Adeguato □ Agitazione □ Aggressività □ Rallentamento □ Altro

Spazio □ sì □ no

□ Normale □ Altro_________

□ Normale □ Altro_________

Tempo □ sì □ no Persona □ sì □ no

□ Non valutabile

Note _________________________________________________________________________

ESAME OBIETTIVO DEL PAZIENTE

OSSERVAZIONE DELLA MECCANICA RESPIRATORIA (rilevare alterazioni

morfologiche, alterazioni nella dinamica inspiratoria ed espiratoria, mobilità diaframmatica…)

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

________________________________________________________________________

POSTURA SUPINA:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

POSTURA SEDUTA:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Rev. agosto 2013 4

POSTURA ERETTA:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

________________________________________________________________________

DEAMBULAZIONE:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

STATO DELLA CUTE: □ normale □ arrossata □ decubiti: ___________________

FERITE: _________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Dolore Caratteristiche Insorgenza ____________________________________________________ ______________________________________________________________

□ Continuo □ Intermittente □ Superficiale □ Profondo □ Acuto □ Diffuso □ Sordo □ A fitte

Localizzazione __________________________________________________ ______________________________________________________________ Risposta nelle attività funzionali____________________________________ ______________________________________________________________

Fattori allevianti/aggravanti________________________________________ ______________________________________________________________

VAS ☺ � NESSUN DOLORE DOLORE INSOPPORTABILE

SCALA ANALOGICO – VISIVA DEL DOLORE (VAS): rappresentazione visiva del dolore che il paziente crede di avvertire

Rev. agosto 2013 5

TEST e SCALE SOMMINISTRATE (le scale utilizzate vanno allegate):

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Limitazione nelle attività di vita quotidiana e restrizione della partecipazione:

_________________________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

VALUTAZIONE FUNZIONALE (sintesi): ________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

DIAGNOSI FUNZIONALE/FISIOTERAPICA: __________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

PROBLEMI RIABILITATIVI __________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

PROGNOSI RIABILITATIVA

Rev. agosto 2013 6

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Rev. agosto 2013 7

OBIETTIVI RIABILITATIVI OBIETTIVI A BREVE TERMINE ________________________________________________________________________________________

________________________________________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

OBIETTIVI A MEDIO/LUNGO TERMINE ________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Altro:____________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

PROGRAMMI RIABILITATIVI SPECIFICI

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Note:_____________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Rev. agosto 2013 8

PROGRAMMA RIABILITATIVO/EDUCATIVO DOMICILIARE __________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

SEDUTA FISIOTERAPICA (tempi, setting, sequenze di intervento):

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

SEDUTA FISIOTERAPICA di GRUPPO:

__________________________________________________________________________

__________________________________________________________________________

_________________________________________________________________________

Rev. agosto 2013 9

VERIFICA DEI RISULTATI OBIETTIVI RAGGIUNTI (completamente o parzialmente: quali e come): __________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

OBIETTIVI NON RAGGIUNTI (quali e perché):

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

GRADO DI COMPLIANCE DEL PAZIENTE:

al trattamento: �________________☺

all’educazione terapeutica: �________________☺ GRADIMENTO DEL PAZIENTE RISPETTO AL TRATTAMENTO:

�___________________________☺

Rev. agosto 2013 10

DIARIO FISIOTERAPICO

DATA