Module 2

(Submit quiz by 2359 Saturday night.)

Submit BOTH Assignment A and Assignment B by 2359 Saturday of the week in which Module 2 is covered.

Overview: Subjective and Objective Data Collection

Use the interview guides and assessment forms for the topics we are covering and fill in the forms. 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 partners among people who actually have health problems so that you get experience assessing and documenting abnormal findings if possible. Because you are covering more assessment topics this week, they will be turned in as two assignments.

The Module 2 A assignment will cover these topics, as well as the SBAR for this week:

• Skin • Hair • Nails

• Head • Neck

 

On the Module 2 B assignment form, you will find the following items: • Eyes • Ears • Mouth

• Nose • Throat • Sinuses

 

Remember not to use terms like “good”, “normal” and “NA”. From this week forward, you may not use terms in describing skin such as “spot”, “bump” or “pimple”—you need to use professional language. We expect you to use “macule”, “papule” and “pustule” appropriately. Read the section in your book thoroughly which describes skin lesions—these will be on the quiz!

SBAR Overview

As a part of this module’s assignment, you will write an SBAR: A short concise statement of:

Situation

Background

Module 2 Assignments: Assignment A (skin, hair, nails, head and neck) with SBAR, and Assignment B (eyes, ears, mouth, throat and sinuses)

 

 

1

 

 

Assessment

Recommendation

If you need a review on how to write an SBAR, see the Module 1 Assignment Instructions and Kaiser examples.

Submitting your assignment

 Save this document to your computer 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 (not odt.).

 Return to Blackboard and upload to the assignment portal.

Rubric for Assignment 2 A (the rubric for 2 B is below)

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 and documentation— such as mmHG, breaths/minute, etc.

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 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 5 Points Short sentences

or phrases are

4 Points One to two

grammatical

3 Points three to five

grammatical

2 Points Six to eight

grammatical

0 Points Entire

document is

 

 

2

 

 

used, no

grammatical

errors.

errors errors errors ungrammatic

al, greater

than 8

grammatical

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

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 Recommen

dation is

present but

is patently

incorrect.

0 Points Missing

 

 

Rubric for Assignment 2 B

 

 

3

 

 

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.