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
