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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

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