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 Summary of Wellness Assessment
Situation (S)
Luciana Gonzalez attended the clinic today for a comprehensive wellness evaluation as part of her life insurance application process through her employer.
Background (B)
The patient reported experiencing urinary frequency, pain, and discomfort over the past several days. She noted a history of similar episodes in the past but denied any known allergies. Ms. Gonzalez is not currently taking any medications. She reported no history of alcohol consumption, tobacco smoking, or recreational drug use.
Assessment (A)
Physical examination revealed a nevus on the right side of her face, with no concerning changes in size, shape, or color. Vital signs were stable: height 5’4” (162.5 cm), weight 185 lbs (83.9 kg), blood pressure 124/82 mmHg, respiratory rate 22 breaths per minute (non-labored), oxygen saturation 98% on room air, and temperature 98.8°F (37.1°C). She was alert and oriented to person, place, time, and situation (A&O ×4). Ms. Gonzalez reported mild pain (2/10) and discomfort during urination. Urinalysis results showed bacteriuria, although the urine was clear, without hematuria, pus, or evidence of kidney stones.
Recommendations (R)
It is recommended that the patient increase fluid intake to help dilute urine and facilitate bacterial clearance. She should be counseled on proper perineal hygiene, specifically wiping from front to back, to reduce the risk of bacterial transmission. A follow-up with a primary care provider for a urine culture is advised to confirm the diagnosis and determine the most effective treatment plan for urinary tract infection (UTI) management.
Additional Assessment Questions for Ms. Gonzalez
| No. | Question | Purpose |
|---|---|---|
| 1 | Do you typically wear tight-fitting underwear made from synthetic materials such as nylon, polyester, or acrylic? | To assess for clothing-related risk factors that promote bacterial growth. |
| 2 | Could you describe your bathroom hygiene habits, particularly whether you wipe from front to back or back to front? | To evaluate hygiene practices that may influence UTI recurrence. |
| 3 | Do you often delay urination for extended periods? | To determine if urinary retention habits contribute to bacterial buildup. |
Rationale for Selected Questions
The chosen questions aim to identify potential lifestyle and hygiene-related contributors to recurrent UTIs. Women are anatomically predisposed to UTIs due to a shorter urethra located near the vaginal and anal openings, facilitating bacterial transfer (Foxman, 2014). Holding urine for prolonged periods can allow bacteria to multiply within the bladder, while tight-fitting, non-breathable fabrics can create a warm, moist environment conducive to bacterial overgrowth (Hooton & Gupta, 2019). Identifying these factors supports tailored patient education to reduce recurrence.
Priority Opportunities for Health Promotion and Disease Prevention
- Educate the patient on the importance of completing the full course of prescribed antibiotics, even after symptom resolution.
- Encourage the patient to increase daily water intake to promote urinary tract health.
Rationale for Selected Opportunities
The assessment revealed that Ms. Gonzalez demonstrated limited awareness of UTI prevention strategies and appropriate antibiotic usage. Patient education is crucial because incomplete antibiotic regimens can lead to bacterial persistence or resistance, increasing the risk of recurrent infections (Centers for Disease Control and Prevention [CDC], 2022). Furthermore, maintaining adequate hydration helps dilute urine, reduces bacterial concentration, and supports urinary tract flushing, thereby decreasing the risk of infection progression (Mayo Clinic, 2023). Addressing these priorities can improve patient outcomes and reduce recurrence risk.
References
Centers for Disease Control and Prevention. (2022). Antibiotic use: Preventing antibiotic resistance. https://www.cdc.gov/antibiotic-use
Foxman, B. (2014). Urinary tract infection syndromes: Occurrence, recurrence, bacteriology, risk factors, and disease burden. Infectious Disease Clinics of North America, 28(1), 1–13. https://doi.org/10.1016/j.idc.2013.09.003
NR 305 Week 2 iHuman Nurse Notes Template
Hooton, T. M., & Gupta, K. (2019). Recurrent urinary tract infection in women. UpToDate. https://www.uptodate.com/contents/recurrent-urinary-tract-infection-in-women
Mayo Clinic. (2023). Urinary tract infection (UTI). https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection