NR305 Week 2 iHuman Nurse Notes Template
Complete each item below:
1. Write an SBAR note (Situation, Background, Assessment, Recommendations) to
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summarize this assessment. Hint: Since this is a wellness assessment your summary
should include a comprehensive, but brief, review of all of your findings, not only
abnormal results. To develop your note, type the appropriate information after each
letter below.
S – Luciana Gonzalez is a 32-year-old woman who has been admitted for a full health
examination. She stands 5'4 (163 cm) tall and weighs 185.0 pounds (84.1 kg). The BMI
for this person is 31.8.
B – BP is normal at 124/82. The pulse is 56 beats per minute. RR: 22 breaths per minute,
A&Ox4, On room air, SpO2 was 98 percent. The temperature is 98.8 F. The patient
mentioned that she has pain and discomfort when urinating. She rates her pain as a 2
out of 10 on a scale of 1 to 10. She feels the sense of needing to urinate more frequently
than normal, but she sometimes expels less urine. She has a weak stream and pee of a
normal hue with no foam. The patient does not require assistance in going to the
restroom or urinating. There is no blood, pus, or kidney stones in the urine. These
symptoms have been present for a few days in the patient. The patient has a history of
urinary frequency and dysuria. She does not currently take any prescription or over-thecounter medications, nor does she take any herbal supplements. She says she doesn't
11.30.21KC
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drink or do drugs. She isn't a sexually active person. The patient's immunizations are
current.
A – Patient appeared with nevus flammeus on the right side of the face after completing
the full assessment. The patient also has bacteriuria, according to the findings of the
tests.
R - I would start the patient on UTI interventions, such as drinking plenty of water and
keeping the perineal area as clean and dry as possible. I also advise the patient to
contact a doctor to assess if any pharmaceutical interventions are required due to the
presence of bacteria in her urine and to manage her pain.
2. State at least three additional assessment questions you would like to ask Ms. Gonzalez.
1) What are your eating habits at the moment?
2) Do you work out, and if so, how often?
3) Do you have access to a variety of healthy dietary options? [Show Less]