NSG 521 Unit 8 assessment skills portfolio example

Assessment Skills Portfolio: One Patient From Interview to Ordered Problems, With a Technique Audit and the Parts That Still Disagree

Student Name

Department of Nursing, Herzing University

NSG 521: Fundamental Concepts and Health Assessment

Instructor Name

March 12, 2026

Assessment Skills Portfolio: One Patient From Interview to Ordered Problems, With a Technique Audit and the Parts That Still Disagree

Contents and How the Parts Link

This portfolio follows Mr. Walker, a composite retired bus mechanic in his sixties admitted with right lower lobe community-acquired pneumonia, across four hospital days. Part A is the interview (Unit 1 log). Part B describes the examination findings in words. Part C is the review of systems (Unit 3). Part D holds the care activities and vital sign trend (Units 5 and 6). Part E is the ordered problem list (Unit 7). Part F audits my own technique, and Part G lists what does not line up. Each claim in Parts B to E is tagged with the part its evidence came from, for example [A] for the interview, so a reader can trace it back.

Unit 2's normal baseline was written on a different person, a healthy volunteer in the skills lab. It is not reused here, since the whole point of this file is one patient; it served only as the model for how Part B describes findings.

Part A: The Interview, Revised

The history was taken on the evening of admission with his wife present for part of it. The four findings that the interview produced and that the admission note had missed are carried forward: the illness began eight days before admission rather than three; he had been taking a store-bought ibuprofen product four times daily for a week along with his usual lisinopril; his penicillin "allergy" was a childhood rash never retested; and he had been getting short of breath on one flight of stairs for about three months before the cough began. That last finding came from the closing open question and nothing else.

One revision was made on rereading. The Unit 1 log recorded his alcohol intake as "10 to 12 beers a week" without converting it to standard drinks or asking about his last drink. On day two I went back and asked; his last beer was the night before admission, which matters because withdrawal would usually show within the first few days. It did not appear.

Part B: Examination Findings, Described

Findings from the day-two examination, in the same system order as Part C, written as observed rather than as checkmarks.

General: a heavy-set man sitting upright against three pillows, speaking in full sentences, pausing to cough roughly every two minutes. Skin: warm and slightly damp at the forehead; no rash; lips dry and cracked. Chest: the right side moves a little less than the left on deep breathing; the sound on tapping is dull over the lower right back and resonant elsewhere; crackles that do not clear with coughing are heard at the right base [supports E1]; breath sounds on the left are clear. Heart: regular rhythm at about 90 per minute, no added sounds heard. Abdomen: soft, not tender, bowel sounds present. Legs: no swelling at the ankles or shins, calves soft and not tender [consistent with C, cardiovascular and musculoskeletal denials]. Mental status: alert, knows the date, place, and why he is in the hospital, gives a history that matches his wife's account.

Part C: The Systems Review, Carried Forward

The Unit 3 review is carried forward unchanged except for one addition. Its pertinent positives were the productive cough, sharp right chest pain on deep breathing, fever, reduced intake and urine, and the three months of exertional breathlessness [A]. Its pertinent negatives were no night sweats or earlier weight loss, no waking breathless or ankle swelling, no black stools despite the ibuprofen, no calf pain, and no confusion. The addition is his sleep: he now reports waking two or three times a night to cough, which Unit 3 recorded but did not carry into its summary. It appears in Part E's leftover grid for that reason.

Part D: Care Activities and the Vital Sign Trend

Four care activities were argued from the day-three findings in Unit 5: sitting him upright [B, saturation fell when flat], fluids [C, low intake and output; laboratory values], short walks, and mouth care. The Unit 6 trend block recorded his day-three values at 0800, 1200, and 1600, with temperature, pulse, and breathing rate all rising and saturation falling slightly while each stayed within the site's normal range. That trend was reported to the primary nurse and moved his checks to hourly. On day four the temperature settled to 37.3 °C and his saturation returned to 95% on the same oxygen, so the ordering in Part E was reviewed again but not changed.

Part E: The Ordered Problems

The Unit 7 order stands: impaired gas exchange [B, D], possible early sepsis or worsening infection [D], fluid volume deficit [C, D], activity intolerance [A, D], and impaired oral mucous membranes [B]. The one change after day four is to the urgency column: row 2 moves from report today to monitor at routine intervals, since the day-three trend reversed. The reshuffling trigger named in Unit 7, fever reaching 38.3 °C together with a dropping pressure, has not appeared.

Part F: Technique Audit

Quicker now: moving from a closed question to an open one without losing the thread; recording denials in the patient's own words; measuring a blood pressure with the right cuff and arm position on the first attempt rather than the second.

Still takes two attempts: telling crackles from the sound of the oxygen tubing rubbing on the gown. On day two I reported bilateral crackles, then listened again with the tubing moved aside and heard crackles on the right only. Percussion is also slow; I still compare sides by going back and forth twice instead of once.

One finding I would now describe differently: the Unit 5 note called his sputum "thick, yellow" on day three, while Unit 3 had recorded rust-colored sputum on day two. The change is plausible as the infection evolves, but the note should have said it was a change and when it happened, instead of simply giving a new color. Standard examination texts treat a change in sputum character as a finding in its own right (Bickley et al., 2021).

Part G: What Still Does Not Line Up

Three things remain unresolved and are listed rather than smoothed over. First, the three months of breathlessness before the illness [A, C] is not explained by the pneumonia, and nothing in this file settles it; the denials make heart failure less likely but do not rule it out, and follow-up after recovery is recommended, as the pneumonia guideline suggests for persistent symptoms (Metlay et al., 2019). Second, his weekend cigar smoking appears in Part A but was never assessed for amount or readiness to stop. Third, the sputum color change noted in Part F was recorded in two units without either one noticing the other.

Judgment frameworks describe reflection on a completed case as the stage where a learner's reasoning improves the most (Tanner, 2006). The main lesson from assembling this file is that inconsistencies appeared only when the parts were read side by side, which is the reason for assembling it.

References

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.

Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., Cooley, L. A., Dean, N. C., Fine, M. J., Flanders, S. A., Griffin, M. R., Metersky, M. L., Musher, D. M., Restrepo, M. I., & Whitney, C. G. (2019). Diagnosis and treatment of adults with community-acquired pneumonia: An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. American Journal of Respiratory and Critical Care Medicine, 200(7), e45-e67. https://doi.org/10.1164/rccm.201908-1581ST

Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. https://doi.org/10.3928/01484834-20060601-04