| 1. General instructions |
Presents information on the use and objective of the application; physical examination concept; NANDA-1 taxonomy; Wanda Horta and categorization of Basic Human Needs (BHN); materials; equipment and techniques used in the nursing interview and physical examination; and Nursing Technologies Laboratory - CuidarTech. |
| 2. Patient identification |
For filling in the following information: health institution; patient's name; time; date; sector; bed; address; contact; email; reason for hospitalization; current complaint; medical diagnosis; interviewee; examiner; marital status; and general observations. |
| 3. Communication, body care, self-image, self-esteem and locomotion |
For assessing facial expression, communication and locomotion of the patient, completion of the Morse fall scale and description of how the patient feels. |
| 4. Therapeutics, immunology, acceptance, learning, religious or theological, ethics or philosophy of life |
For filling out the following information: medications used; vaccinations taken; allergy to drugs and other substances; surgical and clinical history; previous hospitalizations; current and past chemical dependency; acceptance of the diagnosis and therapy; history of family disease; level of instruction; ability to learn new words and challenges; religiosity and beliefs; and observations of the assessor. |
| 5. Safety, dwelling, environment, space, self-realization, love, sociability, freedom, leisure, recreation, physical activity/exercise; sleep and rest |
For filling in the following information: housing; profession/occupation; family life; social ties; leisure activities; and quality of sleep/rest. |
| 6. Neurological regulation, orientation in space and time, attention |
For assessing level of consciousness (Glasgow coma scale); content of consciousness; orientation; recent and distant memory; anxiety; sadness; thoughts; and coordination, balance and sensitivity, through tests. |
| 7. Thermoregulation; vascular; oxygenation and pain perception |
For assessing body temperature; pulse; respiration; oxygen saturation; blood pressure; and pain (pain scale). |
| 8. Nutrition, hydration, hydrosaline and electrolytic regulation |
For assessing weight; height; body mass index; waist, abdominal and hip circumference; waist-to-hip ratio; eating habits; and water balance. |
| 9. Skin and mucous membrane integrity; cell growth and hormonal regulation |
For assessing tegument; presence of drains and catheters; injury risk (Braden scale); head; face; neck; trachea; thyroid and lymph nodes. |
| 10. Auditory and visual perception |
For assessment of the ear (symmetry, secretion, edema, pain, signs of inflammation and infection and tympanic membrane - otoscopy); eyes (eyebrows, eyelids, eyeballs, eyelashes, conjunctiva, cornea, lens, retina, sclera, iris, pupils and lacrimal apparatus); application of Rinne and Weber tests, optic nerve, examination of cardinal points, corneal-eyelid reflex, Bobinskh test. |
| 11. Smell and taste perception |
For assessment of the nose (symmetry, skin, foreign bodies, nasal conchae, septum, vibrissae, secretion, texture, bone structure, maxillary and frontal sinus, transnomination); mouth (integrity, color, hydration, teeth and gums, oral mucosa, salivary ducts, palate, uvula, breath, tonsils); application of nerve tests: olfactory, glossopharyngeal, trigeminal, hypoglossal, facial and glossopharyngeal. |
| 12. Vascular and oxygenation |
For assessment of the precordium (collateral circulation, ictus cordis, tremor, pulse rate and rhythm, cardiac auscultation - sounds and murmurs); neck (jugular vein distention, hepatojugular reflux, carotid arteries); peripheral vascularity (signs of arterial insufficiency - pain, skin, reflex hyperemia of the lower limbs, pulse, Allen's test - and of venous insufficiency - lower mobility in clogged calf compared to the other calf, Homans sign, Godet's sign); chest (shape, collateral circulation, type of breathing, chest expansion, tactile fremitus, percussion, diaphragmatic excursion, respiratory sounds, adventitious sounds). |
| 13. Motility, elimination and sexuality |
For assessment of the abdomen (shape, symmetry, collateral circulation, skin, pulse, peristalsis, liver, splenic dullness, superficial and deep palpation, Blumberg's sign, flick test, Giordano's sign, spleen, aorta); breasts; external female genitalia; male genitals. |
| 14. Locomotion and body mechanics |
For assessing the upper and lower limbs (symmetry, circumference, length, skin color, edema, temperature, injuries or deformities, bone and muscle structure, pain, range of motion - shoulder, elbow, wrist and hand, hip, knee, ankle joints). |
| 15. Cranial nerves |
Quick access by users to the examinations related to the 12 pairs of cranial nerves. |
| 16. Scales |
Quick access by users to the Braden, Morse and Glasgow scales and the visual analog scale for pain. |
| 17. Additional tests |
Designed for filling in test results: X-ray, MRI, electrocardiogram, ultrasound, serum tests, urinalysis, parasitology, pet scan, computed tomography, mammography, vascular doppler, scintigraphy, bone densitometry, culture (microbiology) and others. |
Construction and validation of a mobile application for development of nursing history and diagnosis
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