For Cathrine Ownes please I have uploaded Istuctions, some errors to avoid and the assigment sheet is in two parts 

Model A and B



(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:



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




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


Use of specifically


10 Points
Uses no vague

terms such as

good, normal,

N/A or not


7 Points
1 – 3 incorrect

terms are


5 Points
4 – 5 incorrect

terms are used.

N3315 Holistic Health Assessment

Rubric grading of assessment forms

One point is subtracted for each occurrence of the following, up to 10 points or more total for

the form. (Meaning students can’t get an A on the assessment if they use one of the

following 10 or more times.) See rubric for application in each form.

1. NA or Not applicable.

For this class, N/A or not applicable is appropriate only concerning the reproductive

system, if the item refers to a finding or process which does not apply to the sex of

the patient. For instance, date of last menstrual period (LMP): If the patient is male,

putting N/A for that item is allowed.

2. Good. For instance, referring to skin turgor as “good” is not sufficiently specific for

this class. Students need to describe the good finding: Elastic, for instance.

3. Normal. In this assessment class, students need to be more specific. Describing

bowel sounds as “normal in all 4 quadrants” is fine in a clinical setting, but for

purposes of this class, more specificity is required. The term “active” describes what

normal is, and is what is needed here.

4. Within normal limits. Describe what was found, even if that is normal. This makes

you use the terminology—say it. There are examples in the textbook for most


Here are a couple of things to keep in mind, and they are in table form, below:

When interviewing the assessment partner for the subjective finding, if the partner denies

having a problem, using the word “denies” is not sufficient documentation for that entry.

State what is denied.

Give a full description of findings for each entry, not leaving any blanks.

When describing a finding, state whether it is unilateral (on the left or the right) or bilateral.

Use units of measure: mmHg, millimeters. Your book no longer requires the use of

denominators for reporting strength (___out of 6) or reflexes (__out of 4) so you won’t get

points off for not using them, but they are still a good idea, and we encourage their use in

your assessments and in your employment. Do you remember “off the top of your head”

what a reflex is scored out of: 4, 5, or 6? It is 4, actually, but we can’t all remember for

every assessment! Assume the person reading the form doesn’t know the normal unit, and

you must supply it.

N3315 Holistic Health Assessment

Section of the

(See Grading Rubric)


Format Not


Spelling Incorrect

Font An easily readable font such as Times
New Roman, Ariel,


Assignment 2 A

Hair, skin, nails (See below for head, neck and SBAR)

Subjective data Name_______________

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.



Current Status

1. Skin problems as described by the assessment partner (ask them to describe all rashes, lesions, dry areas, any oiliness, drainage, bruising, swelling, or pigmentation issues)

2. Reported changes in lesion appearance

3. Reported changes in sensation (pain, pressure, itch, tingling)

4. Reported hair loss or changes

5. Reported nail changes

Past History

1. Previous problems with skin, hair, or nails (treatment and surgery)

Family History

1. Family history of skin problems or skin cancer

Lifestyle and Health Practices

1. Exposure to sun or chemicals

2. Daily care of skin, hair, and nails (use of sunscreen, etc.)

Head and neck

Subjective data

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.



Current Symptoms as reported by assessment partner

1. Reported nodules or lesions on head or neck.

2. Difficulty moving head or neck.

3. Facial or neck pain or frequent headaches.

4. Dizziness, lightheadedness, spinning sensation, or loss of consciousness.

Past History

5. Previous head or neck problems/trauma/injury (surgery, medication, physical or radiation therapy) results.

Family History

6. Family history of head and/or neck cancer.



Current Symptoms: Eyes

1. Recent changes in vision?

2. Spots or floaters in front of eyes?

3. Blind spots, halos, or rings around lights?

4. Trouble seeing at night?

5. Double vision?

6. Eye pain?

7. Redness or swelling in eyes with regular daily activity?

8. Excessive watering or tearing or other discharge from eyes?

Past History

9. Previous eye or vision problems (medication, surgery, laser treatment, corrective lenses)?

Family History

10. Family history of eye problems or vision loss?

Lifestyle and Health Practices

11. Exposure to chemicals, fumes, smoke, dust, flying sparks, etc.?

12. Use of safety glasses?

13. Use of sunglasses?

14. Medications (corticosteroids, lovastatin, pyridostigmine, quinidine, risperdal, and rifampin) may have ocular side effects?

15. Has vision loss affected ability to work or care for self or others?

16. Date of last eye examination?

17. Are corrective glasses or