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 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 – The patient came to the clinic for a comprehensive assessment to apply for life
insurance, and she is positive for bacteria in her urine. She is also overweight.
B – the patient is a 32-year-old Hispanic female.
Note: the patient’s age and ethnicity are not relevant to the present situation.
A – Patient’s BMI is high, and she has tested positive for bacteria in her urine; she has a
risk of obesity and heart complications as well as UTI.
Not: the assessment was made by a professional healthcare officer.
R – refer to her primary care physician for follow-up on possible UTI. Consider intense
routine physical activities such as morning/evening runs to reduce her weight to avoid
cardiovascular complications. Since she is overweight, a full head-to-toe and nutritional
assessment are also crucial.
2. State at least three additional assessment questions you would like to ask Ms. Gonzalez.
1) Have you lately engaged in sexual activities without protection from a new
person?
2) Would it be alright and feasible to incorporate a running/another regular
exercise routine in your schedule?
3) Do you usually feel very thirsty or have numb or tingling hands or feet?
3. In a one-paragraph response, what made you select these questions?
I chose the above questions because, firstly, the patient tests positive for bacteria in her
urine; thus, assessment for a possible UTI or other STIs. Secondly, engaging in physical exercises,
possibly cardio, is important since she is overweight. Also, she has to be okay with creating time
for the exercisesin her daily schedule. Lastly, an assessment for diabetes was necessary because
of her weight. One of the defining symptoms of diabetes is thirst and ‘numb and tingling in feet
or hands.
4. State two priority opportunitiesfor health promotion and/or disease prevention for Ms.
Gonzalez.
1) Communication; learning about UTIsthrough health education strategies.
2) Gym/regular exercises memberships.
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