Professional Documents
Culture Documents
3 - Patient Data Collection Form
3 - Patient Data Collection Form
Sex:
Age:
Date of hospitalization:
……. /………/……….
5. COMMUNICATION ACTIVITY
Sensory/neurological defects that will prevent communication (Hearing prosthesis, voice ptosis,
etc.): .............................................
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
Skin Assessment
General view of the skin: Turgor: Color Pressure Ulcer: Edema:
:
Does he/she have any physical/mental disability that prevents him/her from moving?
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?
O No
O Yes…………………….…………………………
Type of the Activities of Daily Living (ADL) Identified Nursing Problem Related to ADL: Planned Nursing Interventions related to ADL:
Type of the Activities of Daily Living (ADL) Identified Nursing Problem Related to ADL: Planned Nursing Interventions related to ADL: