NR305-10247: Health Assessment for the Practicing RN #1

Week 2: Assignment: Wellness Assessment: Luciana Gonzalez (iHuman) (Graded)

 

Sample Solution

NR305 Week 2 iHuman Nurse Notes Template

1. Question 1: SBAR note
S – Luciana Gonzalez is a 32 year old Hispanic female. She came to the clinic for a comprehensive assessment. The primary goal was for her to apply for insurance.

B – The patient is alert and answers questions asked deligently, besides she confirms having good health. This is confirmed by the lack of relevant health history in her record or regular visits to the clinic.

A – Luciana’s vitals look good, however, she has a high BMI. She has urinary frequency issues and further assessment reveals signs of dysuria and bacteriuria. The patient has flammeus on her face.

R – I recommend her to visit a regular dietitian. The choice should help in developing a plan to manage her nutrition and besides develop good dietary habits. This should help her decrease her BMI. She also starts taking antibiotics to treat UTI.

2. Question 2: additional assessment questions for Ms. Gonzalez.

1) How long have you been experiencing urinary frequency and dysuria?
2) Have you had any other symptoms, such as fever, chills, or flank pain?
3) Do you have any known allergies to medications?

3. Question 3: the reason for selecting these questions.

I selected these assessment questions since they are important in understanding the severity of Ms. Gonzalez’s UTI. For example, the urinary frequency and dysuria questions will help me determine how long the patient has been experiencing symptoms. If Gonzalez had symptoms for more than a few days, this is an indication that she may be diagnosed with a more complicated UTI. The second question is on symptoms experienced by the patient. These are associated with pyelonephritis, a more serious type of UTI. If Ms. Gonzalez has none of the symptoms, I would recommend the patient to a specialist for advanced treatment. The third question is important and focuses on determining whether the patient has allergies to any medications. I would need to prescribe a different medication if she has any known allergies.

4. State two priority opportunities for health promotion and/or disease prevention for Ms. Gonzalez.
1) Urinary tract infection prevention: Ms. Gonzalez is diagnosed with UTI, which is one of the diseases caused by sexual activities, dehydration, and poor hygiene. There are a number of things that Ms. Gonzalez can do to prevent future incidences of UTI. The patient should drink lot of fluids and also, she should practice wiping front to back after using the toilet. Urinating after sexual activity is also encouraged.

2) Weight loss. The patient has a higher BMI, a condition that increases her risk for contracting chronic diseases including heart disease, type 2 diabetes, stroke, type 2 diabetes, and cancer. If the patient loses weight, she has a good chance of reducing these diseases.

5. Question 5: assessment findings in iHuman led you to select the two opportunities you have identified?

UTIs are considered one of the most common type of infection affecting women across the globe. More research suggests that one in five women will have a UTI at some later time in their lives (Czajkowski et al., 2021). In ihuman I documented the following assessment findings. High BMI, where the patient had a BMI of 30, which is classified as obese. From objective and subjective data from ihuman, Ms. Gonzalez is also experiencing urinary frequency dysuria, which is a symptom of UTI. This means that weight loss and urinary tract infection prevention are the area of focus to ensure the patient attain an optimum health.

References
Czajkowski, K., Broś-Konopielko, M., & Teliga-Czajkowska, J. (2021). Urinary tract infection in women. Menopause Review/Przegląd Menopauzalny, 20(1), 40-47.

Week 2: Discussion: Reflection on the Nurse’s Role in Health Assessment (Graded)

Purpose

The purpose of this reflection is for learners to reflect on the nurse’s role in health assessment in various care settings.

Course Outcomes

This assignment enables the student to meet the following course outcomes:

CO 1: Demonstrate a head to toe physical assessment. (PO 1)

CO 3: Describe physical, psychosocial, cultural, and spiritual influences on an individual’s health status. (PO 1)

Due Date

During the assigned week (Sunday the start of the assigned week through Sunday the end of the assigned week):

  • Posts in the discussion at least two times, and
  • Posts in the discussion on two different days

Total Points Possible

50 points

Directions

  • Reflection is an activity that involves your deep thought into your own experiences related to the concepts of the week. Answers should be detailed. In reflections students:
    • Demonstrate understanding of concepts for the week
    • Engage in meaningful dialogue with classmates and/or instructor
    • Express opinions clearly and logically, in a professional manner
  • Use the rubric on this page as you compose your answers.
  • Scholarly sources are NOT required for this reflection
  • Best Practices include:
    • Participation early in the week is encouraged to stimulate meaningful discussion among classmates and instructor.
    • Enter the reflection often during the week to read and learn from posts.
    • Select different classmates for your reply each week.

 Reflection Questions

Reflect on your current or prior practice setting.

  • Paragraph One: Briefly describe the type(s) of nursing health assessments you commonly perform.
    • Explain how your nursing health assessments are focused or comprehensive.
    • Provide examples of key subjective and objective data collected by nurses in this setting.
  • Paragraph Two: Describe the typical patient population in your practice setting.
    • What are some special considerations that you have used for obtaining an accurate health history and physical assessment in this patient population?
    • Examples may include age, lifestyle, financial status, health status, culture, religion, or spiritual practices.

Grading

To view the grading criteria/rubric, please click on the 3 dots in the box at the end of the solid gray bar above the discussion board title and then Show Rubric. See Syllabus for Grading Rubric Definitions.

Sample Solution

Working in the Emergency Department requires a broad knowledge of patient health assessments. Throughout my experience working in emergency medical services and critical care, I have learned many techniques and methods of completing patient assessments. Depending on the patient and their complaint, ER nurses may complete a very brief assessment that is focused on only the patient’s symptoms or we may complete a head-to-toe assessment that includes each body system. The level of acuity of the patient is completed by an emergency department nurse who uses different strategies to score the patient on a 1-5 scale. The number one level of triage means the highest level of acuity and these patient assessments often follow the ABCCS assessment (airway, breathing, circulation, consciousness, safety). Nurses follow this assessment to provide the highest level of care to the patient. During a patient assessment, subjective and objective data are collected. Subjective relates to the patient’s perspective, so the patient may tell the nurse they are feeling nauseous. Objective data is factual and not influenced by the patient’s beliefs or biases. An example of objective data is the patient’s vital signs or intake and output. 

The typical patient population in my practicing area includes middle-lower class white or Native American people. This population includes many unhealthy elderly people who come to my workplace for treatment. In this patient population, it is essential to obtain an accurate health history and physical assessment. In some scenarios contacting the patient’s family is essential to obtain an accurate health history. Many of my patients also do not speak the same language as me or my coworkers. When that is the situation we have a virtual interpreter that we can use to communicate with our patients. I enjoy working in emergency medicine because I get the privilege to work with multiple age groups and patients from all different walks of life!