T.R.

İSTANBUL GELİŞİM UNIVERSITY

FACULTY OF HEALTH SCIENCES
DEPARTMENT OF NURSING
COURSE OF PUBLIC HEALTH NURSING
PRACTICE FORM
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İSTANBUL GELİŞİM UNIVERSITY
FACULTY OF HEALTH SCIENCES DEPARTMENT OF NURSING
COURSE OF PUBLIC HEALTH NURSING INDIVIDUAL/PATIENT ASSESSMENT FORM

Student's name and surname: Sami Bouchabti Student ID Number: 190512109

Practical Placement Area: 44 NOLU ASM

Individual / Patient Name- Number of

Surname children
Gender Social Security

Date of Birth-Age / Place of Birth

Phone Number
Education Gsm / e-mail

Profession Address:
Marital Status

Family members Date of Birth-Age Education Job / Profession Social Security

1
2
3
4
5
6
 Medical History
Past medical and surgical history

Family history
Habits (Smoking, Alcohol, Drug, etc.) / Time of Use / Amount of
use / History of quiting habits

Current Medical Diseases and Treatments

Current drug therapy / indications

Prosthesis (Dental, Contact lens, Hearing Device, Walker, etc.)

Surgically Implanted Prosthesis (Orthopedic, Heart valve,
Pacemaker etc.)

Current Status / Complaints / Medical history:

 T.R.
İSTANBUL GELİŞİM UNIVERSITY
FACULTY OF HEALTH SCIENCES DEPARTMENT OF NURSING
COURSE OF PUBLIC HEALTH NURSING - NURSING CARE PLAN

Individual/Patient Name-Surname: Planning Date:

Student Nurse’s Name Surname:
Nursing Diagnosis Outcome Identification Nursing Interventions Date of interventions Evaluation
(Problem) (If any, notes on
Observation)
1.

2.

3.

4.

5.

VISITING REPORT:
1. Visit (../../ 2017):
2. Visit (../../ 2017):
Note: Please write nursing diagnoses according to ‘the list of NANDA-International approved nursing diagnosis’, and place applicable appropriate interventions according to their priority for each individual/patient.
 T.R.
İSTANBUL GELİŞİM UNIVERSITY
FACULTY OF HEALTH SCIENCES DEPARTMENT OF NURSING
COURSE OF PUBLIC HEALTH NURSING - PRACTICE EVALUATION FORM
Date:
Student
Student’sName and Practical Placement Area-
Surname:
Name of the Institution:
Student ID Number: Practice Area:

No PROFESSIONAL BEHAVIORS AND COMMUNICATION Point Point

1 He/She is aware of his/her duties and responsibilities. 5
Adheres to the rules of the Clinical Practicum Policy of the Institution
2 It takes care of his/her personal appearance. 5
Dresses in appropriate attire as per relevant to School policies
3 Uses his/her practice-time effectively. 5
Pays attention to working hours.
4 Motivates himsel/herself well 5
Attends 80% of his/her placement experience
5 He realizes his mistakes and makes an effort to correct it. 5
6 Makes himself/herself open to any criticisms. Makes self-criticism 5
7 Establishes positive, effective and restpectful communications with his clients- 5
individuals, family and others.
8 Communicates appropriately with the members of the health staff 5
9 Cooperates well and communicates restpectfully with other students . 5
10 Establishes appropriate communication with his/her educators. 5
Total Point 50

PREPARATION AND PRESENTATION OF HOMEWORK

1 Able to choose an appropriate case/subject for his/her homework. 2
2 Uses his/her time effectively 2
3 Collects and organises appropriate information for his/her case/subject. 2
4 Uses literature and other resources effectively 2
5 He/She consult his/her educator 2
6 Prepares a plan for his/her subject presentation. 2
7 Prepares an appropriate plan for his/her presentation-subject 2
8 Able to prepare required equipment 2
9 Able to summarise well his/her presentation 2
10 Uses the presentation time effectively 2
11 Evaluation of the assessment form 15
12 Evaluation of the nursing care plan 15
Total Point 50
GRAND TOTAL 100