Sample Answer for NR 305 Week 2: Assignment: Wellness Assessment: Luciana Gonzalez (iHuman) (Graded) Included After Question
NR305 Week 2 iHuman Nurse Notes Template
Name: Date: 16/9/2023
Complete each item below:
Situation
Luciana Gonzalez, a 32-year old female who presented for a comprehensive health assessment. She reports concerns with pain (4/10) and discomfort on urination. Urinalysis (UA) shows cloudy urine and bacteriuria (8+).
Background
Luciana Gonzalez is a Hispanic female, today she visits the clinic for a comprehensive health assessment. Luciana changed her jobs recently. She needs life insurance and lacks a regular HCP (healthcare provider).
Assessment
BP: 120/80mmHg
SPO2: 98%
Pulse: 59
RR: 24
Temp: 98.80F
Height/Weight: 64” 185lb
BMI: 31.8
HEENT: Head: normocephalic, without bruising or lesions. Eyes: vision 30/30 (RE & LE), PERRLA,no enophthalmos, or exophthalmos, nevus flammeus on the right eye. Ears: hearing is intact, tympanic membrane is intact. Nose & Throat: mucus membranes are pink and moist without bruises or bleeds. Tongue is soft and without exudates. No pain with neck movement. No masses or lumps on neck palpation.
Respiratory: chest has no scars, lumps, or swellings, its movement is symmetrical with breathing, lungs are bilaterally clear (without crackles, rhonchi, wheezing, or rales). No nipple discharge or skin dimpling with raising of arms.
Cardiovascular: S1 and S2 heard, no rubs, murmurs, or gallop. No facial, upper, or lower extremity edema. 2+ pulses in brachial, pedal, radial, and femoral pulse.
Gastrointestinal: no abdominal scars, abdomen is soft with normoactive bowel sounds, no guarding, tenderness or rebound tenderness
Genitourinary: external genitalia is withoutsores, edema, or erythema. The urethra is moist and pink. Bladder is non-distended. There are no tears, odor, or abnormal discharge from the vagina.
Musculoskeletal: lower and upper symmetrical muscle development, all joints have a FROM, Muscle strength is 5/5 in all groups, no deficits in coordination, gait, and balance.
CNS: the patient is AOX4, deep tendon reflexes are intact, cranial nerves II-XII are grossly intact,long-term and short-term memories are intact.
Integumentary: normal skin turgor, no lesions, sores, or wounds. Skin is warm and dry without evidence of bleeding or bruising.
Recommendation
Laboratory findings are significant for bacteriuria (8+) and cloudy urine suggestive of a UTI. Luciana will be referred to a PCP (primary care physician) for pharmacological management. She will also be educated on measures such as taking cranberry juice, proper wiping technique, and hygiene to prevent recurrent UTIs in future. Considering her BMI (31.8-obese), Luciana will be referred to a registered dietician for dietary recommendations to lower her BMI and subsequent obesity-related healthcare risks.
State at least three additional assessment questions you would like to ask Ms. Gonzalez.
Have you experienced other associated symptoms of nausea, vomiting, fevers, or rigors?
Has any of your 1st degree relatives been diagnosed with bladder, kidney, or prostate problems?
What does your diet look like on a average day including the fluid intake?
In a one paragraph response, what made you select these questions?
Patients with urological pathology can present with a wide range of symptoms and potential symptoms of worsening pathology (pyelonephritis) include rigors, fevers, nausea & vomiting (Storme et al., 2019). The family history will help to identify an underlying urological diseases while the patient’s diet history will inform on her dietary patterns since persistently dehydrated patients are at a higher risk of renal impairment and UTIs.
Two priority opportunities for health promotion and/or disease prevention for Ms. Gonzalez.
Educating Luciana Gonzalez on hydration and good personal hygiene to prevent UTIs in the future.
Patient education on behavior change modification (physical activity and diet) to decrease her BMI and lower the risk of type 2 diabetes mellitus.
What assessment findings led to selecting the two opportunities identified?
In ihuman, the patient Luciana Gonzalez’s BMI is 31.8. This BMI falls under the obese range. Obesity is a known risk factor for cardovascular disease development, hypertension, dyslipidemia, and type 2 Diabetes Mellitus (Cercato & Fonseca, 2019). Other than the impact on health, obesity has social, economic, and psychological consequences that can negatively the patiet and close family members, hence the need to be addressed. Another assessmemnt finding was bacteriuria 8+ on urinalysis and cloudy urine. These are characteristic findings of a urinary tract infection (UTIs). The known UTI risk factors include; poor hygiene, pregnancy, sexual activity, history of recurrent UTIs, and age (Storme et al., 2019). Considering the patient’s history, from the listed risk factors, the most likely risk factor for this patient is poor wiping technique and hygiene. With a gap in knowledge, this finding presents the opportunity to educate the patient on measures to implement to prevent UTIsv in future.
References
Cercato, C., & Fonseca, F. A. (2019). Cardiovascular risk and obesity. Diabetol Metab Syndr, 11, 74-88. doi: 10.1186/s13098-019-0468-0.
Storme, O., Tirán Saucedo, J., Garcia-Mora, A., Dehesa-Dávila, M., & Naber, K. G. (2019). Risk factors and predisposing conditions for urinary tract infection. Therapeutic advances in urology, 11, 1756287218814382. doi: 10.1177/1756287218814382.
iHuman Moodle Rubric
CriteriaExemplary
Exceeds ExpectationsAdvanced
Meets ExpectationsIntermediate
Needs ImprovementNovice
InadequateTotal PointsSubjective – 40%Determined by iHuman 40 pointsDetermined by iHuman 36 pointsDetermined by iHuman 32 pointsDetermined by iHuman 0 points40Objective – 25%Determined by iHuman 25 pointsDetermined by iHuman 22 pointsDetermined by iHuman 20 pointsDetermined by iHuman 0 points25Objective – 5% (Testing)Determined by iHuman 5 pointsDetermined by iHuman 4 pointsDetermined by iHuman 3 pointsDetermined by iHuman 0 points5Assessment–5%Three differential diagnoses are supported by findings and include worst-case scenario.
Rationale for differential diagnoses provided by scholarly resources.
5 pointsThree differential diagnoses include worst-case scenario, but one diagnosis might not be fully supported by findings.
Rationale for differential diagnoses provided by scholarly resources.
3 pointsDifferential diagnoses may or may not include worst-case scenario, and two differential diagnoses are not supported by findings.
Rationale for all differential diagnoses not provided by scholarly resources.
1 pointsFewer than three differential diagnoses identified, or differential diagnoses not supported by findings and do not include worst-case scenario.
Scholarly resources not provided or do not support differential diagnoses.
0 points5Plan–25%Comprehensive plan includes all components: Diagnostic testing Pharmacologic intervention Non-pharmacologic intervention Referrals Patient education Follow-up Appropriate and current guidelines cited.
25 pointsPlan missing one of the identified components: Diagnostic testing Pharmacologic intervention Non-pharmacologic intervention Referrals Patient education Follow-up Appropriate and current guidelines cited.
17 pointsPlan missing two of the identified components: Diagnostic testing Pharmacologic intervention Non-pharmacologic intervention Referrals Patient education Follow-up Guidelines are not current or appropriate for identified problem.
9 pointsPlan missing more than three of the identified components: Diagnostic testing Pharmacologic intervention Non-pharmacologic intervention Referrals Patient education Follow-up Guidelines for plan not cited.
0 points25Total Points100