NR305 Week 2 iHuman Nurse Notes Template

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NR305 Week 2 iHuman Nurse Notes Template Complete each item below: 1. Write an SBAR note (Situation, Background, Assessment, Recommendations) to summarize this assessment. Hint: Since this is a wel ... lness 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 This study source was downloaded by 100000852290574 from CourseHero.com on 01-21-2023 02:59:15 GMT -06:00 https://www.coursehero.com/collection/132553868/Week-2-Nurse-Notesdocx/ 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 More]

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