University Graduates Union ‫محافظة الخليل‬/ ‫رابطة الجامعين‬

Palestine Polytechnic University ‫جامعة بوليتكنك فلسطين‬

College of Nursing ‫كلية التمريض‬

Collection Sheet 100%

Select a case study from your clinical training based on a medical or surgical

disease covered in your Medical-Surgical 1 theory topics. Carefully gather and

:document the necessary data according to the following guidelines

________________________________________________:STUDENT NAME ●

___________________________________________________CLINICALSITE ●

________________________________________________________:DATE ●

:The reason for choosing this case

_____________________________________________________________________
_____________________________________________________________________
__________

:Biographic Data and history (10pt) ***

________________________ :Name of patient (initial)

:Age: Hospital: Department: Room/bed
. :Admission Date
. :Type of Admission
Allergies: Food Drug Medication Unknown
.
_________________________ :Diet patient on
_____________________________ :Informant

Medical Diagnosis: (1 pt) ***

_____________________________________________________________________
_____________________________________________________________________
__________
: Chief complaint: Reason for seeking health care (1 pt)**
_____________________________________________________________________
 University Graduates Union ‫محافظة الخليل‬/ ‫رابطة الجامعين‬

Palestine Polytechnic University ‫جامعة بوليتكنك فلسطين‬

College of Nursing ‫كلية التمريض‬

_____________________________________________________________________
_______________________________________________

History of present illness: (OPQRST)(2pt)**

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Other Current health problems : (1pt)**

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Past medical Health History: (1pt)**
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Past surgical history: (1pt)**
_____________________________________________________________________
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Family History : (1pt)
_____________________________________________________________________
_____________________________________________________________________
_________________________________________________

: Psychosocial History (1pt)**

_____________________________________________________________________
_____________________________________________________________________
_________________________________________________
:Environment/culture (1pt)**
_____________________________________________________________________
_____________________________________________________________________
 University Graduates Union ‫محافظة الخليل‬/ ‫رابطة الجامعين‬

Palestine Polytechnic University ‫جامعة بوليتكنك فلسطين‬

College of Nursing ‫كلية التمريض‬

_____________________________________________________________________
_____________________________________________________________________

:Review of system: Physical assessment(normal and abnormal) (27 pt) ***

: General Appearance (1)**

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_____________________________________________________________________
_________________________________________________
:Skin & Nails (1)**
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_________________________________________________
:Head (1)**
_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
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: Neck (1) **
_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________

: Hair (1)**
_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________
:Eyes (1)**
_____________________________________________________________________
____________________________________________________________________
 University Graduates Union ‫محافظة الخليل‬/ ‫رابطة الجامعين‬

Palestine Polytechnic University ‫جامعة بوليتكنك فلسطين‬

College of Nursing ‫كلية التمريض‬

_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________
:Ears (1)**
_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
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___________________________________________________________________
:Nose and sinus (1)**
_____________________________________________________________________
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:Mouth and pharynx (1)**

_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
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___________________________________________________________________
: Neck and nodes (1)**
_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________
:Respiratory system (2)**
_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________
 University Graduates Union ‫محافظة الخليل‬/ ‫رابطة الجامعين‬

Palestine Polytechnic University ‫جامعة بوليتكنك فلسطين‬

College of Nursing ‫كلية التمريض‬

:Cardiovascular system (2)**

_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________
:Breast and axillary (1)**
_____________________________________________________________________
___________________________________________________________________

_____________________________________________________________________
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___________________________________________________________________
:Abdomen (2)**
_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
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: General & Reproductive System***
:Male (1)**
_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________

:Female & Obstetric history (1)**

_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________

:Rectum& Anus (1)**

 University Graduates Union ‫محافظة الخليل‬/ ‫رابطة الجامعين‬

Palestine Polytechnic University ‫جامعة بوليتكنك فلسطين‬

College of Nursing ‫كلية التمريض‬

_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________
:Eliminations**
:Bowel (1) **
_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________
:Urinary (1)**
_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________
:Diet and Nutrient (1)**
_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________

: Musculoskeletal (2)**
_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________

:Neurological (2)**
 University Graduates Union ‫محافظة الخليل‬/ ‫رابطة الجامعين‬

Palestine Polytechnic University ‫جامعة بوليتكنك فلسطين‬

College of Nursing ‫كلية التمريض‬

_____________________________________________________________________
____________________________________________________________________

_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________

Intravenous therapy given to the patient : (2pt )

.Note : if currently off IV , mention the previous IV

Type of IVF Amount Frequency Reason for IVF

Radiology (X-RAYS/CT SCAN/MRI / Ultrasound/ECG/ECHO)

:(5pt)
Name of Date/Time Indication for Result Treatment
diagnostic test diagnostic test
 University Graduates Union ‫محافظة الخليل‬/ ‫رابطة الجامعين‬

Palestine Polytechnic University ‫جامعة بوليتكنك فلسطين‬

College of Nursing ‫كلية التمريض‬

:Laboratory Data(10pts)
.Note: from each type lab include the latest
Test Date/Time Indication Patient Normal Rational Treatment
name Value Value if for this
Abnormal abnormality

: Pathophysiology of the disease (In your own words)(4 pts.)**

.)No more than one page(
 University Graduates Union ‫محافظة الخليل‬/ ‫رابطة الجامعين‬

Palestine Polytechnic University ‫جامعة بوليتكنك فلسطين‬

College of Nursing ‫كلية التمريض‬

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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____________________________________________________________

Medication pharmacology (10pts)

Nursing Side effect Rational for Medication Dose \ Generic \
priorities of administration action )Therapeuti frequency trade name
and medication (c class Classification
interventions route\
Major 4

:Nursing Care Plan( 20pts) (5% for each one)

:Main pt. problem according to the NANDA
..………………………………………………………………………………………1
 University Graduates Union ‫محافظة الخليل‬/ ‫رابطة الجامعين‬

Palestine Polytechnic University ‫جامعة بوليتكنك فلسطين‬

College of Nursing ‫كلية التمريض‬

..………………………………………………………………………………………2
..………………………………………………………………………………………3
…………………………………………………………………………………………4

:Pt Problem-1

:Patient Assessment

:Nursing Dx

:Short and Long Goal

Nursing Interventions Rationale

: Evaluation of STG & LTG

 University Graduates Union ‫محافظة الخليل‬/ ‫رابطة الجامعين‬

Palestine Polytechnic University ‫جامعة بوليتكنك فلسطين‬

College of Nursing ‫كلية التمريض‬

:Pt Problem-2

:Patient Assessment

:Nursing Dx

:Short and Long Goal

Nursing Interventions Rationale

: Evaluation of STG & LTG

 University Graduates Union ‫محافظة الخليل‬/ ‫رابطة الجامعين‬

Palestine Polytechnic University ‫جامعة بوليتكنك فلسطين‬

College of Nursing ‫كلية التمريض‬

Pt. Problem– 3

:Patient Assessment

:Nursing Dx

:Short and Long Goal

Nursing Interventions Rationale

: Evaluation of STG & LTG

 University Graduates Union ‫محافظة الخليل‬/ ‫رابطة الجامعين‬

Palestine Polytechnic University ‫جامعة بوليتكنك فلسطين‬

College of Nursing ‫كلية التمريض‬

:Pt. Problem– 4

:Patient Assessment

:Nursing Dx

:Short and Long Goal

Nursing Interventions Rationale

 University Graduates Union ‫محافظة الخليل‬/ ‫رابطة الجامعين‬

Palestine Polytechnic University ‫جامعة بوليتكنك فلسطين‬

College of Nursing ‫كلية التمريض‬

: Evaluation of STG & LTG

Teaching and Instructions given to patient during hospitalization

related to his disease about diet, exercises, life style, managing stress,
medications, comfort and rest…etc. (METHODS) (4pts)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________

: Reflection(5pts)
Write the positive and negative points in dealing with the case , points of your
strengths and weakness , what could have been done better , what did you learn
.most
_____________________________________________________________________
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_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_________________________________

:References (book , journal, website) (2pt)

___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
_________________

Organization , tidiness ,neatness , font size 12 , times new roman type

:(1pt)
 University Graduates Union ‫محافظة الخليل‬/ ‫رابطة الجامعين‬

Palestine Polytechnic University ‫جامعة بوليتكنك فلسطين‬

College of Nursing ‫كلية التمريض‬

_____________________________________________________________________
_____________________________________________________________________
_________