ISTANBUL MEDIPOL UNIVERSITY / SCHOOL OF HEALTH SCIENCES
DEPARTMENT OF NURSING / PATIENT DATA COLLECTION FORM
Student’s Name Surname: Elanur Ebru Turul
Student ID Number:4G220004
Hospital Name: Dr.Lütfi Kirdar Eĝitim ve Araştirma Hastanesi
Clinical Practice Area: Chemotherapy
1. PATIENT IDENTIFYING
Patient’s Name & Surname (Initials only):Ayşe KOLONKAYA
Sex: Female
Age:50
Allergy O No/Undefined O Yes .....smart drug allergy related to
chemoterapy………………….(Please, specify)
Infectious Disease O No/Undefined O Yes...........................................................(Please, specify)
Blood Type: ……………………………….
Medical Diagnosis (Reason for hospitalization): …………………………………………
Date of Diagnosis:
…02…./…01…/.2023
Date of hospitalization: …
19…. /…02……/…2023
Disease Process (Detailed explanation of the complaints that led to hospitalization):
……………………………………………………………………………for
surgery………………………………………
……………………………………………………………………………………………………………………
Date of surgery*:26 /02../2023.............(To be filled for individuals who have undergone surgery.)
Performed/Planned Surgical Procedure:…………………………bowel cancer
surgery……………………………………… Postoperative……7……day
Preoperative ....7.....day.
2. MEDICAL HISTORY
Previous Dieases
Chronic Diseases hypertension
Family History unknown
Experience and Reason for
Hospitalization
3. CONTINUOUSLY USED MEDICINES O No O Yes
Name of the medicine Dosage/Frequency Route of Drug Administration. Duration (months/year)
Reason for Use
…smart drug related to chemotherapy……………… once a week ………….…bowel cancer…………
…....……………… …………………
……………………………. ..…………… …....……………… …………………
Unhealthy Habits Tobacco O No O Yes O Amount: ……./day
Duration………… Quitting Date …
Alcohol O No O Yes O Amount: ……/day
Duration………… Quitting date ……
4. ENSURING AND MAINTAINING A SAFE ENVIRONMENT ACTIVITY
Conscious Level :normal Sense organs: no problem
Pain Assessment :3_4 Falling Risk: no
Infection risk :no Need for Restraint :no
Isolation need :no Environmental Safety Precautions
5. COMMUNICATION ACTIVITY
Sensory/neurological defects that will prevent communication (Hearing prosthesis, voice ptosis,
etc.): ...........................no..................
6. RESPIRATORY AND CIRCULATION ACTIVITIES
Respiratory Cardiovascular
System System
Respiration Pattern nosal Blood Pressure.........................mm/Hg
Respiration Rate/Depth/Rhythm...................../min Pulse Rate/Volume/Rhythm..................../min
Respiration Type: normal Respiratory System Problems :no
Cardiovascular System Problems :no
7. NUTRITIONAL ACTIVITY
Feeding type O Oral O Enteral O Parenteral
Height:155 ……cm Weight:…73… BMI:………kg/m2
kg
ProblemsFactors Affecting Dietary Activity :no
Problems Related to Dietary Activity :no
Intake and Outtake (Fill out the form of I&O and attach it to your report)
8. EXCRETION ACTIVITY
The frequency of bowel movements: Urinary frequency:........times/day
…/min
Date of last defecation …../…../…..
with Fecal Excretion: none Problems with Urinary Excretion: can not urinate on
her own
Practices for Fecal Excretion :none Practices for Urinary Excretion : inserting urinary
catheter
9. PERSONAL HYGIENE AND CLOTHING ACTIVITY
Problems Observed Regarding Hygiene Observed Problems Related to Dressing Habits:
Habits:< none
none
Skin Assessment
General view of the skin: Turgor:. Color Pressure Ulcer: Edema:
THERE IS NO PROBLEMS ABOUT SKIN :
10. BODY TEMPERATURE CONTROL ACTIVITY
Room/Environment temperature: 25 Body temperature....................36.3°C
11. MOBILIZATION ACTIVITIY
Difficulty in moving.: diffuculty walking
Does he/she have any physical/mental disability that prevents him/her from moving?: Difficulty walking due to
urinary catheder
12. WORK AND LEISURE ACTIVITY
Employment status: no working status
Have normal daily activities been disrupted due to the health problem in the last month (Housework, Work Life)?
: no
Have his/her physical health and mental health problems prevented social activities/hobbies in the last month?:
no
13. SEXUAL EXPRESSION
Effects of Treatment/medication and Illness on Sexuality:
O No
O Yes…………………….…………………………
Annual/Monthly check-up (breast/vaginal examination/Prostate/Testis examination):
Problems during menstruation:
Has she gone through menopause? O No O If yes, when:…….
14. SLEEP AND REST ACTIVITY
General Sleep Habits : She has very irregular sleep Night…….h/day
Day……h/day
General Sleep Habits Problems Related to Sleep Activity : Sleep disorders
15. DEATH (IF EVALUATION IS NECESSARY)
Need for palliative care:
O No
O Yes (Please, specify) ……………………………………………………………………..
Observed conditions related to death
16. DEFINING NURSING PROBLEMS
Type of the Activities of Daily Living (ADL): Identified Nursing Problem Related to ADL: Planned Nursing Interventions related to ADL:
Difficulty walking
Helping the patient when she needs to walk
Mobilization
Reasons for Nursing Problem:
urinary problem( urinary catheter insertion)
Type of the Activities of Daily Living (ADL) Identified Nursing Problem Related to ADL: Planned Nursing Interventions related to ADL:
Reasons for Nursing Problem:
Type of the Activities of Daily Living (ADL) Identified Nursing Problem Related to ADL: Planned Nursing Interventions related to ADL:
Reasons for Nursing Problem:
