NR 305 Week 2 iHuman Nurse Notes Template

Name

Chamberlain University

NR-305: RN Health Assessment

Prof. Name

Date

NR 305 Week 2 iHuman Nurse Notes Template

Complete each item below:

1. SBAR Note (Situation, Background, Assessment, Recommendations)

Situation (S):

Luciana Gonzalez presented today for a comprehensive health assessment as part of the requirements for applying for life insurance through her job.

Background (B):

The patient complains of urinary frequency, pain, and discomfort, which began a few days ago. She mentions having experienced similar symptoms in the past. The patient denies any known allergies and is not currently taking any medications. She also denies the use of alcohol, smoking, or drugs.

Assessment (A):
The patient has a nevus on the right side of her face, and her vital signs are stable. She is alert and oriented to person, place, time, and situation (A&O x4). Her height is 5’4″, and she weighs 185 lbs. Blood pressure is 124/82, respiratory rate is 22 breaths per minute (non-labored), oxygen saturation is 98% on room air, and body temperature is 98.8°F. Luciana rates her pain during urination as 2/10. Her urine is normal in color, without any signs of blood, pus, or kidney stones. However, urinalysis results indicate bacteriuria.

Recommendations (R):
I recommend that the patient increase her fluid intake to help dilute the urine and flush out bacteria. Additionally, she should be advised to wipe from front to back to reduce the risk of bacterial transmission. I also suggest that the patient consult a physician for a urine culture to determine the underlying cause and appropriate treatment for a urinary tract infection (UTI).

2. Additional Assessment Questions for Ms. Gonzalez

Do you wear tight underwear made from non-breathable fabrics like nylon, polyester, or acrylic?
Can you describe your bathroom habits, specifically whether you wipe from front to back or back to front?
Do you often hold in your urine before using the restroom?

3. Explanation for Selected Questions

These questions were selected because patients with recurrent UTIs are often unaware of behaviors that increase the risk of infection. Women are anatomically more prone to UTIs due to the short distance between the urethra, vagina, and anus, which makes it easier for bacteria to spread. Wearing tight, non-breathable fabrics can trap moisture, creating an environment conducive to bacterial growth. Additionally, holding in urine can lead to bacterial buildup, further increasing the risk of infection (Schuiling & Likis, 2017).

4. Priority Opportunities for Health Promotion and Disease Prevention for Ms. Gonzalez

Educate the patient on the importance of completing the entire course of antibiotics.
Encourage the patient to increase her fluid intake.

5. Rationale for Selected Opportunities

The comprehensive iHuman assessment of Luciana Gonzalez indicated a lack of knowledge regarding the UTI disease process and her personal health care needs. For instance, during the assessment, she appeared confused about questions related to sexual practices, which may be related to the spread of bacteria leading to UTIs. Additionally, many patients discontinue their antibiotics prematurely once symptoms subside, which increases the risk of recurrent infections (Schuiling & Likis, 2017). Increasing her fluid intake could help flush out bacteria and aid in her recovery (Porth & Matfin, 2014).

References

Porth, C. M., & Matfin, G. (2014). Pathophysiology: Concepts of altered health states. Lippincott Williams & Wilkins.

NR 305 Week 2 iHuman Nurse Notes Template

Schuiling, K. D., & Likis, F. E. (2017). Women’s gynecologic health (3rd ed.). Jones & Bartlett Learning.