NU140CL Unit 3 Assessment Write-Up Example

Course	NU140CL Nursing Fundamentals Clinical
Unit	Unit 3
Paper type	Assessment write-up
Length	About 680 words, 5 pages double-spaced
Format	APA 7 student paper
School	Purdue University Global
Program	BSN (prelicensure)
Updated	October 2026

Free sample paper for NU140CL Unit 3

Measured, Not Described: An Assessment Write-Up of Vital Signs and Head-to-Toe Findings for a Composite 52-Year-Old Woman Two Days Out From a Laparoscopic Colon Resection, System by System

[Student Name]

Purdue University Global

NU140CL: Nursing Fundamentals Clinical

Unit 3 Assessment Write-Up

[Instructor Name]

[Date]

The patient is composite; findings are illustrative and bracketed where they are values, and normal ranges follow the fundamentals text.

What this part is doingEach finding is stated as something measured or observed, so another nurse could compare it directly with the next assessment.

Patient and Context

Patient B, a composite 52-year-old woman, had a laparoscopic resection of part of her colon for a benign polyp two days ago. She has a history of well-controlled hypothyroidism. The assessment was performed at [0815] with her permission, after hand hygiene, in a private room.

Vital Signs

Temperature [37.6] C oral; heart rate [88], regular, radial; respirations [18], unlabored; blood pressure [128/78] right arm, sitting, adult cuff; oxygen saturation [95] percent on room air; pain [4] out of 10 at the incisions, described as sore, worse with coughing.

Neurological

Answers questions about who and where she is, the day and her surgery correctly. Speech clear. Pupils equal, round, [3] mm, briskly reactive to light. Moves all four limbs on command with equal strength in hand grips and foot pushes.

Cardiovascular

Apical pulse [88], regular, S1 and S2 heard, no extra sounds. Radial and pedal pulses present and equal, [2+] bilaterally. Capillary refill brisk, under [2] seconds, at fingertips and great toes. No swelling of ankles or feet. Calves soft, nontender, no redness. Sequential compression devices on both legs and functioning.

Respiratory

Breathing even and unlabored at [18] per minute. Lung sounds clear in upper lobes; fine crackles at both bases that cleared after three deep breaths and a cough. Uses incentive spirometer to [1,250] mL, goal [1,500] mL.

Crackles that clear with deep breathing point to collapsed small airways after surgery rather than fluid, and the write-up records that they cleared.

What this part is doingThe respiratory section records the crackles and their response to deep breathing, which separates a likely cause from a worrying one.

Gastrointestinal

Abdomen slightly rounded and soft, appropriately tender around the incisions. Five small laparoscopic incisions closed with skin glue, edges together, no redness, swelling or drainage. Bowel sounds present in all four quadrants, hypoactive at about [3] per minute. Patient reports passing gas once this morning; no bowel movement since surgery. Tolerating clear liquids; no nausea. Abdominal girth not ordered.

Genitourinary

Urinary catheter removed yesterday at [1400]. Voided [350] mL at [0630], clear yellow urine. Denies burning or urgency.

Musculoskeletal

Walked [20] meters in the hallway yesterday evening with one assist; steady gait. Moves in bed independently, guarding the abdomen when turning.

Integumentary

Skin warm, dry, intact, color appropriate for her ethnicity. No redness over sacrum, heels or hips; skin blanches over pressure points. IV site in left forearm: no redness, swelling or tenderness, dressing dry and dated, fluids running at the ordered rate.

Psychosocial

Calm, asks appropriate questions about when she can eat solid food. Husband visiting this evening.

Abnormal Findings and Actions

1. Low-grade temperature of [37.6] C with basal crackles that cleared: reported to the assigned nurse; deep breathing and incentive spirometer every hour while awake reinforced; temperature to be rechecked in four hours.

2. Hypoactive bowel sounds with gas passed: expected after bowel surgery; reported for awareness; walking encouraged to aid return of bowel function.

3. Incentive spirometer below goal: practice supervised and goal written on her board. These findings support a working diagnosis of ineffective breathing pattern related to incision pain, to be confirmed with the assigned nurse (Herdman et al., 2024).

What this part is doingThe abnormal findings are separated from the rest and each is paired with an action and who was told.

Why Precision Matters

Writing "lungs clear" or "abdomen normal" would hide the crackles and the slow bowel sounds that the next nurse needs to compare. Recording measurements, such as the spirometer volume and the number of bowel sounds per minute, lets the team see a trend. The fundamentals text describes the assessment as a baseline against which every later change is judged, which only works if the baseline is specific (Potter et al., 2023). A low-grade temperature on the second day after surgery is commonly linked with lung expansion problems or the body's normal response to surgery, but it is reported and rechecked because infection must also be considered (Mangram et al., 1999).

References

Herdman, T. H., Kamitsuru, S., & Takáo Lopes, C. (Eds.). (2024). NANDA International nursing diagnoses: Definitions and classification, 2024-2026 (13th ed.). Thieme.

Mangram, A. J., Horan, T. C., Pearson, M. L., Silver, L. C., Jarvis, W. R., & The Hospital Infection Control Practices Advisory Committee. (1999). Guideline for prevention of surgical site infection, 1999. Infection Control & Hospital Epidemiology, 20(4), 247-280. https://doi.org/10.1086/501620

Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2023). Fundamentals of nursing (11th ed.). Elsevier.

Reading the NU 140CL Unit 3 instructions

Unit 3 usually asks for a complete written assessment of one assigned patient: vital signs and findings for every body system. Prompts typically want objective, measurable language, abnormal findings identified and reported, and an organized format, often two to four pages. Faculty reward precision over length. Findings should be stated as what was seen, heard, felt or measured, with numbers wherever possible, rather than conclusions like normal or within limits. Abnormal findings should be separated and paired with what was done and who was notified. Context, such as surgery and its expected effects, helps the reader judge which findings are expected and which need attention. State the time and conditions of the assessment, since findings change through the day. Use the patient's own words for symptoms such as pain.

Inside the NU140CL Unit 3 example

The write-up opens with the patient, her surgery and the time and conditions of the assessment. Vital signs are given with method and site. Each system follows under its own heading, from neurological and cardiovascular to integumentary and psychosocial, with measurements throughout. The respiratory section records crackles that cleared after deep breaths, with the highlighted line explaining what that suggests. Gastrointestinal findings count bowel sounds and describe each incision. A section separates three abnormal findings with actions and names a working problem. The closing section explains why vague words would hide trends and why a low-grade fever after surgery is still reported and rechecked. Every value is bracketed in the sample, so readers know the numbers are illustrative. The tone stays factual throughout, without judgment words.

Where the points sit in the NU140CL Unit 3 rubric

Assessment write-ups in NU 140CL are generally marked on completeness, objectivity, accuracy, and recognition of abnormal findings. Completeness earns credit when every body system and all vital signs are covered. Objectivity rewards measured, specific language instead of conclusions. Accuracy points go to findings that fit the patient's condition and are described with correct terms. Recognition of abnormal findings is weighted heavily and requires separating them, explaining their possible significance and stating what was done and reported. Organization by system makes the write-up usable, and sources in APA 7 support interpretation of expected and unexpected findings. Graders also look for consistency: a finding listed as abnormal should appear in the action list. A write-up that a second nurse could use without asking questions is the standard to aim for.

NU140CL Unit 3 help from the desk

Write-ups often fill sections with "normal," "WNL" or "clear," which tells the next nurse nothing to compare against. Another common gap is noting an abnormal finding without saying whether it was reported or what was done. Some write-ups list findings without context, so expected postoperative changes look like problems. Others leave out systems that seem unrelated to the diagnosis. Write each finding as a measurement or observation, cover every system, explain which findings are expected after the procedure, separate the abnormal ones with actions and who was told, and add a sentence on why each abnormal finding matters. Count, measure and time whatever you can. Then reread each section asking whether a nurse arriving tomorrow could tell if things had improved.

Get an NU140CL Unit 3 example written to your instructions

Which assessment form does your program issue? A blank copy and the Unit 3 rubric are enough; the model completes it with composite values, and its layout, terminology and interpretation section follow your template. The first one is free and generally ready in 24-48h. Readings from your own shift stay yours to enter. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.

More NU140CL papers and BSN samples

NU140CL Unit 3 questions, answered

Where can I find a free NU140CL Unit 3 sample paper?

This page presents the full NU140CL Unit 3 assessment write-up, with vital signs, every body system in measured terms, three abnormal findings with actions and a note on why precision matters, with three references. Ask us for a write-up based on your own patient's findings.

Why avoid the word normal in an NU140CL assessment?

Normal hides the details the next nurse needs to spot a change. Measured findings, such as bowel sounds counted per minute or a spirometer volume, can be compared directly with the next assessment.

What do crackles that clear with deep breathing suggest?

Small airways that collapsed after surgery and reopen with deep breaths, rather than fluid in the lungs. The write-up records that they cleared and reinforces incentive spirometer use.

Is a low-grade fever after surgery a concern?

It is often linked to lung expansion problems or the normal response to surgery, but infection must also be considered, so it is reported and rechecked rather than dismissed.

How should abnormal findings be documented?

Separately from expected findings, each with what was done, who was told and when it will be rechecked, so the record shows the finding led to action.