ISTANBUL MEDIPOL UNIVERSITY / SCHOOL OF HEALTH SCIENCES
DEPARTMENT OF NURSING / PATIENT DATA COLLECTION FORM
Student’s Name Surname: Student ID Number:
Hospital Name: Clinical Practice Area:
1. PATIENT IDENTIFYING
Patient’s Name & Surname (Initials only):
Sex:
Age:
Allergy O No/Undefined O Yes……………………………………….(Please, specify)
Infectious Disease O No/Undefined O Yes...........................................................(Please, specify)
Blood Type: ……………………………….
Medical Diagnosis (Reason for hospitalization): …………………………………………
Date of Diagnosis:
……./………/……….
Date of hospitalization:
……. /………/……….
Disease Process (Detailed explanation of the complaints that led to hospitalization):
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
Date of surgery*:……/……../..............(To be filled for individuals who have undergone surgery.)
Performed/Planned Surgical Procedure:…………………………………………………………………
Postoperative…………day Preoperative.................day
2. MEDICAL HISTORY
Previous Dieases
Chronic Diseases
Family History
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
……………………………. ..…………… …....……………… …………………
……………………………. ..…………… …....……………… …………………
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 Sense organs
Pain Assessment Falling Risk
Infection risk Need for Restraint
Isolation need Environmental Safety Precautions
5. COMMUNICATION ACTIVITY
Sensory/neurological defects that will prevent communication (Hearing prosthesis, voice ptosis,
etc.): .............................................
6. RESPIRATORY AND CIRCULATION ACTIVITIES
Respiratory Cardiovascular
System System
Respiration Pattern Blood Pressure.........................mm/Hg
Respiration Rate/Depth/Rhythm...................../min Pulse Rate/Volume/Rhythm..................../min
Respiration Type: Respiratory System Problems
Cardiovascular System Problems
7. NUTRITIONAL ACTIVITY
Feeding type O Oral O Enteral O Parenteral
Height: ……cm Weight:…… kg BMI:………kg/m2
Factors Affecting Dietary Activity
Problems Related to Dietary Activity
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 …../…../…..
Problems with Fecal Excretion Problems with Urinary Excretion
Practices for Fecal Excretion Practices for Urinary Excretion
9. PERSONAL HYGIENE AND CLOTHING ACTIVITY
Problems Observed Regarding Hygiene Habits Observed Problems Related to Dressing Habits
Skin Assessment
General view of the skin: Turgor: Color Pressure Ulcer: Edema:
:
10. BODY TEMPERATURE CONTROL ACTIVITY
Room/Environment temperature: Body temperature....................°C
11. MOBILIZATION ACTIVITIY
Difficulty in moving.
Does he/she have any physical/mental disability that prevents him/her from moving?
12. WORK AND LEISURE ACTIVITY
Employment status:
Have normal daily activities been disrupted due to the health problem in the last month (Housework, Work Life)?
Have his/her physical health and mental health problems prevented social activities/hobbies in the last month?
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 Night…….h/day Day……h/day
General Sleep Habits Problems Related to Sleep Activity
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:
Immobility Use lifting accessories
Mobilization Inability to walk Help to patient with walker
Reasons for Nursing Problem:
Neurological Problem (Paraplegia)
Cardiac problem (Heart Failure)
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:
