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

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

Situation (S):
Luciana Gonzalez presented today for a comprehensive health assessment, required for her life insurance application through her workplace.

Background (B):
Ms. Gonzalez reports experiencing urinary frequency, discomfort, and mild pain for the past several days. She mentions similar symptoms in the past. She denies any known allergies and reports no current use of medications, alcohol, tobacco, or recreational drugs.

Assessment (A):

Assessment Component	Findings
General Appearance	Alert and oriented to person, place, time, and situation (A&O x4); nevus on right side of face
Height	5’4″
Weight	185 lbs
Blood Pressure	124/82 mmHg
Respiratory Rate	22 breaths/min, non-labored
Oxygen Saturation	98% on room air
Temperature	98.8°F
Pain Assessment	Urinary pain 2/10
Urine Characteristics	Normal color, no blood, pus, or kidney stones; urinalysis shows bacteriuria

Recommendations (R):

Increase fluid intake to help dilute urine and flush bacteria.
Advise proper perineal hygiene—wipe front to back to minimize bacterial transmission.
Recommend consultation with a physician for urine culture to identify the cause and receive 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 such as nylon, polyester, or acrylic?
Can you describe your bathroom habits, specifically whether you wipe from front to back or back to front?
Do you frequently hold your urine before using the restroom?

3. Rationale for Selected Questions

These questions aim to identify behaviors that may contribute to recurrent UTIs. Women are anatomically more susceptible to UTIs due to the proximity of the urethra, vagina, and anus, which facilitates bacterial spread. Wearing tight, non-breathable clothing can trap moisture and promote bacterial growth. Additionally, delaying urination can allow bacteria to accumulate, increasing infection risk. These questions help uncover habits that may require modification for effective prevention (Schuiling & Likis, 2017).

4. Priority Opportunities for Health Promotion and Disease Prevention

Opportunity	Description
Complete full course of antibiotics	Ensures effective eradication of infection and prevents recurrence
Increase fluid intake	Helps flush bacteria from the urinary tract and promotes recovery

5. Rationale for Selected Opportunities

The assessment revealed gaps in Ms. Gonzalez’s understanding of UTI pathophysiology and personal health practices. She appeared uncertain about questions related to sexual activity, which may relate to bacterial transmission. Many patients stop taking antibiotics once symptoms resolve, increasing the risk of recurrent infections (Schuiling & Likis, 2017). Encouraging fluid intake helps flush bacteria, supporting recovery and preventing further complications (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.