module 5

NURS 3315 Holistic Health Assessment

©2014 UTA School of Nursing Page 1 of 4

Submit assignments and quizzes by 2359 Saturday of the week it is due.

Overview: Assessment Data Collection Use the interview guides and assessment forms for the topics we are covering. See the module 1 assignment instructions to refresh your memory if you are not sure about saving or submitting the work. You don’t have to use the same person for the entire class—try to find assessment “models” among people who actually have health problems so that you get experience assessing and documenting abnormal findings if possible.

For Assignment 5A, you will fill out the forms on the two systems:

 Abdomen

 Musculoskeletal

 SBAR

For Assignment 5B, you will complete the remaining forms:

• Nervous system • Mental Status, substance abuse, cognitive and developmental level

Important:

Instructions and requirements are the same as last week. Again, no “normal” or “WNL” or “good” as descriptions on the forms.

Submit your assignment as you did last week, uploading the completed form/s to the assignment portal.

Module 5 Assignment: Assignment A (abdomen and musculoskeletal) with SBAR, and Assignment B (Nervous system and mental status)

NURS 3315 Holistic Health Assessment

©2014 UTA School of Nursing Page 2 of 4

Rubric for Assignment 5 A (the rubric for 5 B is below)

Use this rubric to guide your work.

Excellent Good Needs Work Needs extensive work

Clearly incomplete

Use of specifically prohibited

terminology

20 Points Uses no vague

terms such as

good, normal,

N/A or not

applicable

15 Points 1 - 3 incorrect

terms are

used.

10 Points 4 - 5 incorrect

terms are used.

5 Points 6 - 8

incorrect

terms are

used.

0 Points 9 or more

incorrect

terms used.

Assessment descriptions

30 points All descriptions are appropriate & complete, describing findings as unilateral/bilateral, symmetrical or asymmetrical when appropriate. Uses correct units of measurement and documentation— such as mmHG, breaths/minute, etc.

25 points 1 - 5 descriptions that are not complete, or an area is missing/blank.

15 points 6 to 10 or more descriptions are incomplete or two areas are missing/blank.

10 points Several areas are incomplete, or more than 2-4 areas are missing information/bl ank.

0 points Most descriptions are incomplete or more than 4 areas of the assessment are blank.

Grammar

10 Points Short sentences

or phrases are

used, no

grammatical

errors.

8 Points One to two

grammatical

errors

5 Points three to five

grammatical

errors

2 Points Six to eight

grammatical

errors

0 Points Entire

document is

ungrammati

cal, greater

than 8

grammatical

errors.

SBAR Situation

10 Points Situation or

current problem

–the reason why

this problem is

important, how

7.5 Points Situation is

too wordy or

too brief, not

as clearly

identified as it

5 Points Vague, not

correctly done.

0 Points Missing

NURS 3315 Holistic Health Assessment

©2014 UTA School of Nursing Page 3 of 4

severe, when it

started.

should be.

SBAR Background

20 Points Health history

relating to this

problem, what is

being done, and

what assessment

findings are

most important

now.

15 Points Background

too wordy or

too brief, but

captures

pertinent data.

10 Points Information

given is vague

or some

pertinent data

is missing,

some relevant

data present.

5 Points Few relevant

data are

given or

format not

followed.

0 Points Missing

altogether or

poorly

executed so

that

background

cannot be

understood.

SBAR Assessment

5 Points Assessment

names the

trouble in a

word or phrase

that briefly

captures the

problem and

rates the

urgency.

3 Points This entry is

too wordy and

cites things

that belong in

situation or

background, in

addition to

capturing the

problem.

2 Points The problem is

stated too

briefly to be

clear.

1 Points Problem is

not

synthesized

correctly.

0 Points Missing or

incorrect.

SBAR Recommendation

5 Points What needs to

happen next?

Recommendatio

n is appropriate

for the situation.

3 Points Recommendat

ion has merit

but is not the

best choice for

this situation

or is not stated

well.

2 Points Recommendati

on has minimal

merit and is not

appropriately

stated.

1 Points Recommend

ation is

present but

is patently

incorrect.

0 Points Missing

NURS 3315 Holistic Health Assessment

©2014 UTA School of Nursing Page 4 of 4

Rubric for Assignment 5 B

Excellent Good Needs Work Needs extensive work

Clearly incomplete

Use of specifically prohibited

terminology

10 Points Uses no vague

terms such as

good, normal,

N/A or not

applicable

7.5 Points 1 - 3 incorrect

terms are

used.

5 Points 4 - 5 incorrect

terms are used.

2.5 Points 6 - 8

incorrect

terms are

used.

0 Points 9 or more

incorrect

terms used.

Assessment descriptions

80 points All descriptions are appropriate & complete, describing findings as unilateral/bilateral, symmetrical or asymmetrical when appropriate. Uses correct units of measurement and documentation— such as mmHG, breaths/minute, etc.

70 points 1 - 10 descriptions that are not complete, or an area is missing/blank.

60 points 11 to 15 or more descriptions are incomplete or two areas are missing/blank.

40 points More than 15 areas are incomplete, or more than 2-4 areas are missing information/bl ank.

0 points Most descriptions are incomplete or more than 4 areas of the assessment are blank.

Grammar

10 Points Short sentences

or phrases are

used, no

grammatical

errors.

8 Points One to two

grammatical

errors

5 Points Three to five

grammatical

errors

2 Points Six to eight

grammatical

errors

0 Points Entire

document is

ungrammatic

al, greater

than 8

grammatical

errors.

Performance Objectives:

Collect subjective data to include present health concerns, past health history, family history and lifestyle/health practices related to:

• Abdomen • Musculoskeletal • Nervous system • Mental Status, substance abuse