Your text here
IHUMAN
LUCIAN
1. Write an SBAR note (Situation, Background, Assessment, Recommendations) to summarize
this assessment.
2. Based on your knowledge of Ms. Gonzalez, what are some specific opportunities for health
promotion and/or disease prevention that might apply? What additional questions would you
like to ask Ms. Gonzalez to be sure you have completed a holistic assessment and considered
opportunities to improve her current health status?
Respond in 1-2 paragraphs and include the following in your response:
State at least three additional assessment questions you would ask Ms. Gonzalez to identify
potential opportunities to improve her current health status and prevent future disease.
Based on what you know, identify two priority opportunities for health promotion and/or
disease prevention for Ms. Gonzalez. Explain why you selected these two items.
Please utilize the course textbook, weekly course lessons, or an outside scholarly source to
support your thoughts and ideas. Cite your sources and provide a reference list after your
response.
S: Patient came in for physical examination to obtain insurance through her employer. During
the assessment she complained of dysuria and frequent urination. Labs positive for bacteriuria.
Labs also show high side of normal A1C, LDL and triglycerides.
B: Patient has been experiencing dysuria and frequent urination for a few days leading up to this
visit.
A: Patient rated pain 2/10 on the numeric pain scale. Denies anything exacerbating or easing
pain and symptoms. Patient describes pain as more of a “discomfort” than pain. Does not seem
to be in distress. A&Ox4, BP: 124/82, Pulse: 56BPM, O2: 98% ORA, RR: 22BPM, T: 98.8F. Skin
clean dry and intact. PERRLA, moist mucosa, normal ROM, Capillary refill <3 seconds, HR:
regular no murmurs gallops or rubs, Lungs clear bilaterally to the bases, normoactive bowel
sounds. No pain or guarding.
R: I recommend antibiotics for UTI and referral to a dietician to prevent issues r/t high side of
normal A1C, LDL and triglycerides.
I would assess her normal eating and drinking habits for a typical day as well as any food
preferences. I would ask who shops for groceries and prepares meals? I want to know her
specific eating habits such as canned or fresh foods, does she eat out often? Lastly I would want
to know her activity level.
I would like to discuss diabetes and hyperlipidemia prevention. I would educate on ways to
circumvent possible health issues such as heart attack, stroke and peripheral arterial disease
(PAD). In PAD the arteries narrow due to plaque (cholesterol) forming in the artery walls which
causes decreased blood flow to the organs and tissues (Weber, 2017). Dietary modifications,
exercise, weight loss and careful monitoring are important strategies for managing
cardiovascular risk factors (Dixon, 2021). I chose these because both hyperlipidemia and
diabetes are major cardiovascular risk factors (Hinkle, 2018).
This study source was downloaded by 100000844708667 from CourseHero.com on 09-10-2022 20:11:27 GMT -05:00
https://www.coursehero.com/file/110987396/NR305-Luciana-Gonzalez-SBARdocx/
IHUMAN
LUCIAN
1. Write an SBAR note (Situation, Background, Assessment, Recommendations) to summarize
this assessment.
2. Based on your knowledge of Ms. Gonzalez, what are some specific opportunities for health
promotion and/or disease prevention that might apply? What additional questions would you
like to ask Ms. Gonzalez to be sure you have completed a holistic assessment and considered
opportunities to improve her current health status?
Respond in 1-2 paragraphs and include the following in your response:
State at least three additional assessment questions you would ask Ms. Gonzalez to identify
potential opportunities to improve her current health status and prevent future disease.
Based on what you know, identify two priority opportunities for health promotion and/or
disease prevention for Ms. Gonzalez. Explain why you selected these two items.
Please utilize the course textbook, weekly course lessons, or an outside scholarly source to
support your thoughts and ideas. Cite your sources and provide a reference list after your
response.
S: Patient came in for physical examination to obtain insurance through her employer. During
the assessment she complained of dysuria and frequent urination. Labs positive for bacteriuria.
Labs also show high side of normal A1C, LDL and triglycerides.
B: Patient has been experiencing dysuria and frequent urination for a few days leading up to this
visit.
A: Patient rated pain 2/10 on the numeric pain scale. Denies anything exacerbating or easing
pain and symptoms. Patient describes pain as more of a “discomfort” than pain. Does not seem
to be in distress. A&Ox4, BP: 124/82, Pulse: 56BPM, O2: 98% ORA, RR: 22BPM, T: 98.8F. Skin
clean dry and intact. PERRLA, moist mucosa, normal ROM, Capillary refill <3 seconds, HR:
regular no murmurs gallops or rubs, Lungs clear bilaterally to the bases, normoactive bowel
sounds. No pain or guarding.
R: I recommend antibiotics for UTI and referral to a dietician to prevent issues r/t high side of
normal A1C, LDL and triglycerides.
I would assess her normal eating and drinking habits for a typical day as well as any food
preferences. I would ask who shops for groceries and prepares meals? I want to know her
specific eating habits such as canned or fresh foods, does she eat out often? Lastly I would want
to know her activity level.
I would like to discuss diabetes and hyperlipidemia prevention. I would educate on ways to
circumvent possible health issues such as heart attack, stroke and peripheral arterial disease
(PAD). In PAD the arteries narrow due to plaque (cholesterol) forming in the artery walls which
causes decreased blood flow to the organs and tissues (Weber, 2017). Dietary modifications,
exercise, weight loss and careful monitoring are important strategies for managing
cardiovascular risk factors (Dixon, 2021). I chose these because both hyperlipidemia and
diabetes are major cardiovascular risk factors (Hinkle, 2018).
This study source was downloaded by 100000844708667 from CourseHero.com on 09-10-2022 20:11:27 GMT -05:00
https://www.coursehero.com/file/110987396/NR305-Luciana-Gonzalez-SBARdocx/
