NR305 Week 2 iHuman Nurse Notes Template
Complete each item below:
1. Write an SBAR note (Situation, Background, Assessment, Recommendations)
... [Show More] to
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 – Patient is 32-year-old female name Luciana Gonzalez. She came for a comprehensive
assessment and she expressed concerns about discomfort while urinating. Her Urinalysis
showed cloudy yellow urine with bacteria 5+ present. Patient complains of pain upon
urination (dysuria), frequent urination and urinalysis might be indicative of a present
lower urinary tract infection (UTI).
B – Patient came to the clinic for a comprehensive health assessment in order to apply
for a life insurance for her job. Patient defines herself of Hispanic/Latino origin. She is
currently not assigned to a doctor.
A – A and O x 4
Height: 5’ 4’’ (163cm)
Weight: 185lbs BMI(31.8)
Temp: 98.8 F (37.1 C)
Pulse: 64 bmp, all pulses palpable +2 on all sites
ihuman
11.30.21KC
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RR: 22 bpm, regular, unlabored
SpO2: 98% (room air)
BP: 124/84 mmHg, lying down, Left arm
Cap refill <3 sec
HEENTHead: Normocephalic. Nevus flammeus noted on the right side of face.
Face symmetric.
Eyelids: no ptosis, erythema, or swelling.
Eyes: conjunctive is pink,sclerae is white. PERRLA intact. Orbital area no edema,
redness, tenderness, or lesions noted.
Ears: no deformities, discharge or edema noted.
Nose: No discharge or polyps.
Mouth/Pharynx: No hoarseness, clear mucosa, tonsils w/o exudate.
Tongue: pink,symmetrical, no swelling, no ulcerations.
Neck: No lesions noted, deformities, or visible scars. Trachea is midline. Lymph nodes
non palpable.
Lung Auscultation: R and Left lungs normal breath sounds.
Chest wall inspection: Symmetrical, diameter normal,
Lungs visual: excursion w/respiration symmetrical no retractions or use of accessory
muscles.
No distention, no swelling, no scars, rashes, masses.
Heart auscultation: normal heartbeat consists of an S1 and S2 and is heard throughout
the pericardium w/o any rubs, gallops or murmurs.
Abdomen Auscultation: Normal bowel sounds, present in all 4 quadrants
Abdomen Inspect/palpate/percuss: flat,symmetric, no scars, deformities,striae or
lesions noted. No pain, masses, or pulsations. No guarding or rebound tenderness. No
tympany or shifting dullness.
Extremities: no tenderness, muscularresistance, rigidity, deformity. No cyanosis,
swelling, or edema.
R – Patient requires urine culture and sensitivity for antibiotic treatment if a UTI is
confirmed. Kidney scans, ultrasound and CT scan to rule out kidney calculi, kidney
obstruction, tumors or cysts. Encourage increasing fluid intake 2 to 3 L of water per day
to dilute urine, increase renal blood flow and flush out bacteria.
2. State at least three additional assessment questions you would like to ask Ms. Gonzalez.
1) Ask patient to describe her elimination pattern. Assess whether the client
holds urine, or ignores the urge to void. [Show Less]