NURS 3315 Holistic Health Assessment

NURS 3315 Holistic Health Assessment

©2014 UTA School of Nursing Page 1 of 4

1

Submit quiz and assignments by 2359 Saturday night of the week this content is covered. Discussion board posting begins this week–see the instructions and rubric under the “Group” heading for Week 3

Overview: 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. Remember that you don’t have to use the same person as an assessment partner 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 3 A, you will fill out the guides below:

• Thorax • Lungs

For Assignment 3 B, you will do the following:

• Heart • Neck Vessels • Peripheral Vascular system

Important:

Note: N/A and Normal/WNL and “good” are not acceptable as assessment findings. For this class, you must state what the finding is—that applies to the work for each week.

Submitting your assignment

 Save this document to your desktop as a Word document.

 Open the document from your desktop and type your information directly into the assignment areas provided on the template.

 Save the completed document template as a Word document.

 Return to Blackboard and upload to assignment portal.

Module 3 Assignment: Assignment A (Thorax and lungs) with SBAR, and Assignment B (Heart, neck vessels, and peripheral vascular system.)

NURS 3315 Holistic Health Assessment

©2014 UTA School of Nursing Page 2 of 4

Rubric for Assignment 3 A (the rubric for 3 B is below)

Use this rubric to guide your work.

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 Points 1 – 3 incorrect

terms are

used.

5 Points 4 – 5 incorrect

terms are used.

2 Points 6 – 8

incorrect

terms are

used.

0 Points 9 or more

incorrect

terms used.

Assessment descriptions

45 points All descriptions are appropriate & complete, describing findings as unilateral/bilateral, symmetrical or asymmetrical when appropriate. Uses correct units of measurement

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

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

20 points More than 10 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

5 Points Short sentences

or phrases are

used, no

grammatical

errors.

4 Points One to two

grammatical

errors

3 Points three to five

grammatical

errors

2 Points Six to eight

grammatical

errors

0 Points Greater than

8 grammar

errors.

SBAR Situation

10 Points Situation or

current problem

–the reason why

this problem is

important, how

severe, when it

started.

7.5 Points Situation is

too wordy or

too brief, not

as clearly

identified as it

should be.

5 Points Vague, not

correctly done.

0 Points Missing

SBAR Background

20 Points Health history

relating to this

problem, what is

being done, and

15 Points Background

too wordy or

too brief, but

captures

10 Points Information

given is vague

or some

pertinent data

5 Points Few

relevant

data are

given or

0 Points Missing

altogether or

poorly

executed so

NURS 3315 Holistic Health Assessment

©2014 UTA School of Nursing Page 3 of 4

what assessment

findings are

most important

now.

pertinent data. is missing,

some relevant

data present.

format not

followed.

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 Recommen

dation is

present but

is patently

incorrect.

0 Points Missing

Rubric for Assignment 3 B

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

70 points All descriptions are appropriate & complete, describing findings as unilateral/bilateral, symmetrical or asymmetrical

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

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

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

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

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when appropriate. Uses correct units of measurement and documentation— such as mmHG, breaths/minute, etc.

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.

Performance Objectives:

 Collect subjective and objective data to include present health concerns, past health history, family history and lifestyle/health practices related to: • Thorax • Lungs • Heart • Neck Vessels • Peripheral Vascular