NR 305 Week 2 iHuman Nurse Notes Template
Student Name
Chamberlain University
NR-305: RN Health Assessment
Prof. Name:
Date
NR 305 Week 2 iHuman Nurse Notes Template
SBAR Note (Situation, Background, Assessment, Recommendations)
Situation (S)
Luciana Gonzalez presented for a comprehensive health assessment as part of her life insurance application process.
Background (B)
The patient reports experiencing urinary frequency, pain, and discomfort, which began a few days ago. She states that she has experienced similar symptoms in the past. Luciana denies any known allergies, is not currently on any medications, and does not consume alcohol, smoke, or use recreational drugs.
Assessment (A)
Luciana has a nevus on the right side of her face. Her vital signs are stable: blood pressure 124/82 mmHg, respiratory rate 22 breaths per minute (non-labored), oxygen saturation 98% on room air, and body temperature 98.8°F. She is alert and oriented to person, place, time, and situation (A&O x4). Luciana is 5’4″ tall and weighs 185 lbs. She reports pain during urination rated at 2/10. Her urine appears normal in color without signs of blood, pus, or kidney stones, but urinalysis reveals bacteriuria.
Recommendations (R)
The patient should increase fluid intake to help dilute the urine and flush out bacteria. She should also be advised to practice proper hygiene by wiping from front to back to minimize bacterial transmission. It is recommended that Luciana consult a physician for a urine culture to identify the cause and receive appropriate treatment for a suspected urinary tract infection (UTI).
Additional Assessment Questions for Ms. Gonzalez
| Question | Rationale |
|---|---|
| Do you wear tight underwear made from non-breathable fabrics such as nylon, polyester, or acrylic? | Tight, non-breathable fabrics can trap moisture, fostering bacterial growth and increasing the risk of UTIs. |
| Can you describe your bathroom habits, specifically whether you wipe from front to back or back to front? | Improper wiping techniques can facilitate bacterial transmission from the anal area to the urethra, a common cause of UTIs in women. |
| Do you often hold in your urine before using the restroom? | Holding in urine can encourage bacterial buildup in the bladder, increasing the likelihood of UTIs. |
Priority Opportunities for Health Promotion and Disease Prevention
| Opportunity | Rationale |
|---|---|
| Educate the patient on completing the full course of antibiotics. | Incomplete antibiotic courses can lead to recurring infections, as symptoms may subside before the infection is completely eradicated (Schuiling & Likis, 2017). |
| Encourage the patient to increase her fluid intake. | Adequate hydration can help flush out bacteria, promoting faster recovery and reducing the risk of recurring infections (Porth & Matfin, 2014). |
Explanation for Selected Questions
The additional questions were chosen to address potential behaviors contributing to recurrent UTIs. Anatomically, women are more susceptible to UTIs because the short distance between the urethra, vagina, and anus facilitates bacterial transfer. Wearing tight, non-breathable fabrics can trap moisture, creating a favorable environment for bacterial growth. Holding urine for extended periods may encourage bacterial accumulation, increasing infection risk. Educating Luciana about these factors can help her modify behaviors to prevent future UTIs (Schuiling & Likis, 2017).
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.
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