Exam 3 Study Guide

ADPIE, its names and characteristics emphasized in class

The nursing process is a systematic method, carried out with the patient's participation. It is the way nurses think; the care plan is only the paper that makes the thinking visible.

The process has five steps, but the ANA lists six standards of practice, because it splits outcome identification from planning. An item asking how many standards wants six; one asking how many steps wants five. Items may also use three other vocabularies.

The CJMM (NCSBN Clinical Judgment Measurement Model; ATI says “Action Model”) is the structure behind the NCLEX and the program's care-plan form. Generate solutions includes the actions to avoid (“I must not lay her flat” is planning), and evaluate outcomes loops back to the hypotheses. Tanner's four aspects are cyclical: noticing is the first grasp, shaped by what you expected; interpreting uses analytic, intuitive and narrative reasoning; responding includes deciding not to act; reflecting happens in and on action.

The five characteristics

Taylor also writes the steps as AAPIE.

The heartburn case: label each sentence

Label each sentence before reading the key. (1) After a spicy late dinner you wake with burning in mid-chest; you are young, healthy, with no other symptoms. (2) You decide the spicy food is the cause. (3) You decide to ease it with an over-the-counter remedy before sleeping. (4) You take a liquid antacid. (5) Minutes later the burning is gone and you go back to bed.

Thinking words, in one comparison table

Seven terms items swap for one another. The first three differ by stage; the next three are Taylor's ways of solving a problem; the last is sorted by timing.

Five ways to show critical thinking while assessing:

1. assess systematically;
2. detect the credibility of information;
3. distinguish normal from abnormal;
4. judge the significance of data;
5. check accuracy and reliability.

Creative thinking (asking “why?” and “what if?”, brainstorming) complements critical thinking and earns its place when the usual solutions have failed. Decision making is choosing among options; its clinical form is the judgment.

Blended competencies and QSEN

There are four blended competencies, “blended” because most nursing actions, suctioning for one, need all four at once.

QSEN, a refresher (Exam 2). Its goal is the knowledge, skills and attitudes to continuously improve the quality and safety of the health care systems nurses work in. The six: person-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, informatics. Advocacy, caring and cultural competence sound right and are not among the six.

Assessing: purpose, activities, phases and types

Assessing is the systematic and continuous collection, validation and communication of patient data. It builds the database, and the first full assessment gives the baseline every later finding is compared with. The patient is the primary source. Read the record before you walk in, and re-ask only what needs validating. Taylor's four factors that shape what you prioritize: health orientation (wellness or illness), developmental stage, culture and the need for nursing; a detailed sexual history is not a priority for an overnight concussion admission.

The five phases, in the deck's order:

1. Collecting data;
2. Identifying cues and making inferences;
3. Validating data;
4. Clustering related data and identifying patterns;
5. Reporting and recording data (the admission database the same day).

Validation comes before clustering: you do not build a pattern out of data you have not checked.

Other lists differ (the course objective names three steps; your NUR 120 guide teaches four). Use these five for any ordering item.

The five types of assessment

Learn them by purpose: an item describes a nurse doing something and asks which type it is.

The older deck gives four types (no communities). Taylor gives six, including triage (screening severity to direct follow-up) and quick priority assessment, which are not among the deck's five. NUR 120's “ongoing” assessment is the nearest match to time-lapsed.

Subjective or objective, primary or secondary: two axes

Objective data can be seen, heard, felt or measured by someone other than the person experiencing them: a raised temperature, moist skin, vomiting. Subjective data are perceived only by the affected person: pain, dizziness, anxiety. The care-plan form uses Taylor's other names: subjective = symptoms, objective = signs.

Two edges. A behavior that expresses a feeling is objective: you see the grimace or the restlessness, even though the pain behind it is subjective. And the interview yields objective data only through what you observe during it (fidgeting, laboured speech), never through what the patient says.

Taylor's definition says subjective data “cannot be perceived or verified by another,” and a usual weight could be verified, which is where the opposite reading comes from. The course reads it as actually perceived by someone else; ATI and both decks agree.

Source and type are two different questions

Subjective or objective asks how the finding was produced. Primary or secondary asks who supplied it. The two vary independently, so all four combinations exist.

The patient stays the primary source even when confused or unreliable; you add secondary sources, you do not promote them, and you record that a support person supplied the data. For a language barrier, a professional interpreter, never family: a relative filters and omits, and is not bound by confidentiality (Exam 2).

Methods, in one line. Observation, interview and physical examination; the exam's purpose is to make direct observations and validate subjective data. Its techniques are IPPA (inspection, palpation for temperature, turgor, texture, moisture and vibration, percussion, auscultation), in that order except the abdomen, where you listen first. Technique is in your NUR 120 Exam 1 guide.

Validation, cues and clustering

You cannot validate everything, so validate five kinds of data:

1. a discrepancy between what the patient says and what you observe (“I'm fine,” with a clenched jaw and guarding);
2. data that lack objectivity;
3. a conflict between pieces of data;
4. an inference, before you act on it;
5. findings that are out of range or suspicious.

How. Recheck with the right equipment and technique, ask clarifying questions, get a second opinion, compare with norms, and look for congruence between the subjective and objective data. Taylor's example: a 140/90 in a patient whose baseline is 120/80 is rechecked by an experienced nurse at 128/80, and the inference “hypertensive” is rejected; a narrow cuff or recent exertion could have made the first number. Before you treat a number, ask whether the patient or the method produced it.

From a datum to a judgment

A cue is a piece of data; an inference is your judgment about it, and it stays tentative until checked: identify cues → infer → validate → confirm or reject. A cue is anything that departs from a standard, and the standard can be the patient's own usual: 150/90 is a red flag in a patient whose usual is 120/70, and may be normal for a patient with long-standing hypertension. Taylor's four kinds of significant cue: a change from the patient's usual pattern, a departure from a population norm, behavior that works against the person, and a developmental lag.

Clustering groups related cues with a framework (Maslow, functional health patterns, body systems) until a pattern appears. A problem is built from a cluster, never from a single cue: tears after surgery may be a healthy release; tears plus refused meals plus staying in bed plus increasing discomfort are a pattern. Before naming it, check with the patient: “It seems bathing has become hard since you became afraid of falling. How do you see it?”

What goes wrong in collecting data: six errors

The deck names six errors in collecting data. Each one leaves a database that cannot support a correct problem statement.

A mistake here usually causes a mistake in naming the problem; Taylor's four diagnostic errors are in Part 3, From cluster to conclusion.

What step 2 does, and what a patient problem is

Step 2 (Diagnosis; the Management of Care deck's Analyzing) begins once the data have been collected and reported, and it ends with a prioritized list of validated patient problems. The deck gives it five activities:

1. Interpret and analyze the patient data.
2. Identify the patient's strengths as well as the problems (the item students forget).
3. Formulate and validate the analysis.
4. Develop a prioritized list of patient problems.
5. Detect and refer signs of a problem beyond the nurse's experience: if you cannot treat it, you are responsible for getting help. Taylor's SODA check asks whether a problem could be drug-related: side effect, overdose, drug interaction, allergy.

NANDA International leads the development and classification of nursing diagnoses. Its definition has three load-bearing parts: a patient problem (the course's name for a nursing diagnosis) is a clinical judgment about the responses of an individual, family or community to actual or potential health problems. Why it matters: a priority problem is the basis for selecting interventions to achieve outcomes the nurse is accountable for.

NNN = NANDA + NIC + NOC: diagnoses, interventions and outcomes.

The older deck's timeline: 1953, Fry calls nursing diagnosis integral to the care plan · 1973, the first national conference on classifying nursing diagnoses · 1982, the North American Nursing Diagnosis Association · 2002, renamed NANDA International · 2004, the NNN alliance. NANDA has 13 domains: health promotion, nutrition, elimination, activity and rest, perception and cognition, self-perception, role relationship, sexuality, coping and stress tolerance, life principles, safety and protection, comfort, growth and development.

Nursing, medical or collaborative: treat, report, monitor

The medical model diagnoses and treats disease, illness or injury. The nursing model analyzes and treats the human response to health problems, which in practice means function. After a stroke, the medical question is which artery is blocked; the nursing question is whether the patient can speak, eat and reach the bathroom.

The deck sorts problems into three types by who directs the treatment. A mnemonic: the nurse treats the nursing diagnosis, reports the medical one, and monitors for the collaborative problem.

From cluster to conclusion: four steps, five conclusions, four naming errors

The deck gives four steps of data interpretation and analysis: (1) recognize significant data and (2) recognize patterns or clusters, both taught in Part 2, Validation, cues and clustering; (3) identify strengths and problems, and potential complications of the diagnosis, drugs and procedures; and (4) reach conclusions.

Taylor makes it five by giving potential complications their own step. Answer four.

Step 4 has five possible conclusions: no problem, possible problem, at risk, actual problem, and a clinical problem other than a nursing problem (report or refer).

Four errors in naming the problem

Taylor's four diagnostic errors:

Premature or erroneous? The pair most often swapped. Premature is a problem of quantity (not enough data); erroneous is a problem of interpretation (enough data, read wrong; the “Mild anxiety” row in Writing wrong diagnoses is the classic case). Nor is a cultural practice nonadherence unless it actually threatens the outcome.

Problem statements: types, parts, and what each part drives emphasized in class

The deck names three types: problem-focused, risk and health promotion. The part count follows the type.

One Management of Care slide's risk template reads “as evidenced by [risk factors]” (“Risk for falls as evidenced by improper use of crutches”), a newer NANDA-I phrasing. What was said in class overrules it.

Every kind of “problem,” side by side

Seven kinds of “problem”:

The older deck lists two (actual and risk). The course answer is three; don't add a fourth (syndrome) type.

Related factors contribute to a problem that exists (actual statements); risk factors make a person vulnerable to one that does not exist yet (risk statements). Risk problems exist because nursing aims to predict, prevent, manage and promote (Alfaro-LeFevre), not only diagnose and treat.

PED: each part drives a different piece of the plan

The deck calls the three-part statement PED: Problem + Etiology + Defining characteristics. Taylor's PES (signs and symptoms) is the same thing.

The red rule, and every wrong statement corrected emphasized in class

Prioritizing several problems: ABCDE first emphasized in class

When a patient has several problems, the instructor's framework is ABCDE.

As labels: airway clearance and aspiration risk (A), gas exchange and breathing pattern (B), cardiac output (C), acute confusion (D). ABCDE sorts Maslow's bottom layer; it does not compete with it.

The priority ladder: nine rules in order

The deck's three helpful guides are Maslow, patient preference and anticipation, with both physiologic and psychosocial needs counted. Nine rules, in the order you apply them; the last three are tie-breakers, used only when the rules above leave two problems level:

The deck's two priority drills

Planning: priorities first, then outcomes

Planning turns the ranked problems into a written strategy that prevents, reduces or resolves them, built in partnership with patient and family. A goal is an aim to an end; an expected outcome is the expected conclusion to a health problem, judged against specific, measurable criteria (the ANA splits this step into outcomes identification and planning; Part 1, ADPIE). The four planning activities, in order:

1. Establish priorities, ABCDE first (Part 3, Prioritizing).
2. Identify and write expected outcomes.
3. Select evidence-based nursing interventions.
4. Communicate (document) the care plan.

A written plan serves three purposes: quality care, staff communication and continuity; informal planning lacks a coordinated plan known to everyone caring for the patient. Three stages:

Goals: writing one that is SMART and patient-specific emphasized in class

Four kinds of care-plan sentence look alike. The grammatical subject separates them.

Taylor says not every outcome needs conditions. If “conditions” is offered as the missing piece, check first for a missing time frame or a nurse subject.

The verb must be something you can see or hear

Use define, list, explain, describe, identify, verbalize, demonstrate, prepare, select, choose, apply; never know, understand, learn, become aware.

SMART, and patient-specific

Taylor, the program's worksheet and its rubric expand S as specific. On the exam, S = subject.

The five components are the parts; SMART is the test. “Will walk 1 mile” on post-op day 1 has all five parts and fails the A and the R.

Two more writing errors, and three rules beyond the components

The deck lists four errors in writing outcomes: the two above (written as an intervention; a verb you cannot observe) and these two.

People miss the two-behavior error: one half takes a day, the other months, so it is never met. Three more rules: (1) at least one outcome per problem must, if met, show the problem resolved; (2) the patient must value the outcomes; (3) they must fit the treatment plan: “will drink 2,000 mL per 24 hours” is wrong on a 1,500 mL heart-failure restriction.

Goals: classifying and checking them, by deadline and by type emphasized in class

Short-term and long-term

Taylor draws the line by duration: long-term is usually more than a week. Answer with the instructor's rule.

Four types of outcome, sorted by what changes

Four types. One slide lists only cognitive, psychomotor and affective; a later slide adds physiologic. Answer four.

Interventions: typed by who authorizes them

The type is set by where the authority comes from, not by who performs it, how simple it is, or who chose the moment.

Taylor's Chapter 17 also calls treatments started by pharmacists, respiratory therapists or physician assistants “collaborative.” Answer with the deck's definition above.

A second axis is delivery. Direct care happens through interaction with the patient, teaching and counseling included. Indirect care is done away from the patient, on their behalf: phoning another discipline, a care conference, charting. The trick rows:

“Collaborative and direct” is the usual wrong pick for the dietitian call: “who authorized it?” and “was the patient present?” are separate questions. For any dependent intervention, prescriber and nurse are both liable; never carry out an order you believe is wrong (Exam 2).

Writing the intervention, and the rationale behind it

A written intervention has four parts: date, verb, subject (who is responsible) and a descriptive phrase (how, when, where, how often, how long, how much).

Taylor adds a fifth part, the nurse's signature. Answer with the deck's four.

Choosing among interventions, the deck asks five questions: is it realistic; can the nurse do it safely and accurately; are the resources there; does it fit the patient's values; and is it safe alongside other therapies?

Specific beats vague, even when every option is true (the shape recurs in delegation, below, and teaching, Part 6). “Force fluids” is jargon; “encourage fluids as tolerated” is vague, and most picked because it sounds kind; “provide 2,000 mL a day” is correct but leaves the schedule to every nurse. “Offer 60 mL of cranberry or orange juice between meals and keep fresh water at the bedside” wins. The best intervention is one a stranger could carry out without asking you anything.

Rationale. Every intervention needs an evidence-based scientific rationale, cited with textbook and page number, so care is safe and consistent with accepted standards.

The care plan is the written guide, the final product of planning (columns: Part 1, ADPIE). A standardized plan is a base you individualize; a preprinted order set is dependent.

Implementing and delegating: reassess first, record last

Implementing is carrying out the plan. Five purposes: achieve valued health outcomes, plus nursing's four aims (Exam 2): promote, prevent, restore, help the patient cope. Seven habits:

A care bundle is three to five evidence-based practices applied to every patient, every time (the central-line and ventilator bundles). Doing only some elements loses the benefit: a bundle done 80% of the time does not give 80% of the protection.

What do you do first? Every rule in one table

In a what-first item every option is correct; only the order is tested. Every order rule in this guide (the SpO₂ and suction rows are taught in Part 5, Diagnostics and Part 6, Airway procedures):

Delegation: the task moves, the accountability stays

Delegation transfers responsibility for performing a task; the nurse keeps accountability for the outcome. Exam 2's other rule: the nursing process is never delegated (assessment, analysis, planning, teaching, evaluation and any unstable patient stay with the RN).

In one line: UAP hygiene, feeding, ambulating, turning, I&O, routine vitals; LPN adds routine medications, dressings and reinforcing teaching; RN keeps the nursing process, first-time teaching and the unstable patient. Students asked to do something untrained, such as removing a chest tube, go to the clinical instructor.

Evaluating: a verdict, the data, then reassess emphasized in class

Evaluation judges how well the patient reached each outcome (met, partially met or not met) and uses that to direct care. It is ongoing, not a last step, it leads to changing the plan, and nurse and patient do it together (ANA Standard 6).

Taylor's statement adds a revision and the nurse's signature. “What does the statement consist of?” wants the deck's two parts.

Evaluation has five elements:

1. Identify the criteria: the outcomes from planning (standards are levels set by authority or custom).
2. Collect data.
3. Interpret and summarize.
4. Document the judgment.
5. Terminate, continue or modify.

Evaluate as early as each time frame allows, not on discharge day.

The nurse is accountable to six groups: patients, families and significant others; colleagues; employers; society; the profession; and themselves, the one people leave out.

After the verdict

Five possible revisions, chosen after reassessing: change or delete the problem statement; make the outcome more realistic; raise its complexity (only once met); adjust the time frame; change the interventions. A lifelong loner skipping social activities may have no problem (change the statement); a resident admitted five days ago may need more time (adjust the time frame). The stem's detail picks the revision.

Evaluating the quality of care looks across many patients: structure is the building, process is the actions, outcome is the change in health.

Concurrent evaluation is during care, retrospective after discharge: a post-discharge chart review for documented teaching is process, retrospective. What is measured and when are separate questions. A refresher from Exam 2 and NUR 120: quality assurance asks whether care met a set standard, as in a nursing audit; quality improvement keeps testing small system changes (Plan–Do–Study–Act); peer review is by nurses at the same level, not a manager.

Documentation and reporting: the essentials

NUR 120 Exam 2 has already tested this chapter. The NUR 110 deck gives four purposes: a legal record, a communication tool, reimbursement data, and protection of confidentiality and privacy; Taylor calls communication primary. If it wasn't documented, it wasn't done.

Nine rules that come up:

• Chart the cue, not your inference (Part 2, Validation, cues and clustering).
• Never chart care before giving it, or sign for care you did not give or verify.
• Use military time: 9 PM is 2100.
• For a questionable telephone order, record the exact response, with a second nurse listening and co-signing.
• Log off when you leave the terminal.
• Patients may request an amendment; they never alter the record.
• Incident reports cover near misses and are never mentioned in the chart.
• Medications go on the MAR (drug, dose, route, time, who gave it; for a PRN analgesic, the reason and the effect), not in the narrative note. The flow sheet holds routine care; the graphic record holds vital signs, weight and intake and output.
• Do Not Use (Exam 1): U, IU, QD, QOD, MS, MSO₄, MgSO₄, a trailing zero on a dose (write 1 mg) and a missing leading zero (write 0.5 mg); write the word or the drug's full name. “MSO₄ 2.0 mg q.d.” breaks it three times. PO and BID are allowed.

Correcting a paper entry, in order: one line through it so it stays readable; write “mistaken entry”; initial or sign and date it; write the correct entry. In the EHR, mark it mistaken, add the correction, date and initial it. A late entry is legal if labeled: at 1400 you realize flatus at 0800 was never charted, so chart it now, headed “Late entry,” with both times. Squeezing it into the 0800 slot is backdating, which falsifies the record. A correction leaves the original readable; a late entry says it is late.

ISBARR, to report a change. First assess the patient and have the chart in hand.

NUR 120's deck puts “vital signs stable” under A, as part of the assessment findings. For NUR 110, use Taylor: latest vitals go in B, your opinion in A.

Handoff is at the bedside, with the patient: start by introducing the staff and inviting the patient and family to take part, and report allergies every time. Family members get information only if the patient has authorized it. A verbal order is for urgent situations only: write it down, read it back, prescriber confirms, record it as VO, flag it for signature.

Consultation means another professional assesses the patient and advises you; a referral sends the patient to someone else, and the patient must agree to it.

The oxygen chain: structures, processes, mechanics and transport

Air moves in, gas crosses into the blood, hemoglobin carries it, the heart moves the blood. Learn each link by what is moving and where.

The structures

The lungs run from the base of the diaphragm to an apex above the first rib and are elastic tissue (alveoli, surfactant, pleura). The right lung has three lobes, the left two. The tested skill is sorting a structure into one of four divisions.

The lungs hold more than 300 million alveoli, and the cilia that sweep mucus upward need adequate fluid intake (Part 6, Secretions and inhaled drugs).

Three processes: ventilation, diffusion, perfusion

Respiration is the mechanical and metabolic process moving O₂ from the air into the blood and CO₂ back out, by three processes:

The mechanics of a breath

Inspiration is active. The diaphragm contracts and descends, the intercostals lift the ribs, the chest enlarges, pressure in the lungs falls below atmospheric, and air flows in. Expiration at rest is passive. The muscles relax, the elastic lung recoils, and air flows out. Hard breathing recruits the accessory muscles of the neck, back and abdomen; sucking-in between the ribs is a retraction.

The deck lists “increased intrapleural pressure” under inspiration. That is reversed: intrapleural pressure is always negative and grows more negative as the chest expands.

The deck’s nine factors affecting ventilation:

Volumes and capacities

Seven measurements. Ask of each: one ordinary breath, the biggest breath, the first second, or what is left over?

What makes you breathe

The respiratory center in the medulla and pons sets rate and depth. It listens to chemoreceptors (central in the medulla; peripheral in the aortic arch and carotid bodies) and to proprioceptors in moving joints, which is why exercise raises ventilation before any gas changes. The main stimulus is rising CO₂ and hydrogen ions (a falling pH); a falling O₂ is weaker. Stimulation raises both rate and depth.

One slide gives the stimulus as “increased pH”, which would be alkalosis. The deck’s other slide, Taylor and NUR 120 say rising acidity; answer that.

How fast and deep you breathe sets the CO₂, and the CO₂ sets the pH (Diagnostics, Arterial blood gases). Chronically abnormal O₂ and CO₂ can desensitize the chemoreceptors; what that means for oxygen in COPD is in Part 6, Oxygen therapy.

Transport, and the heart that moves it

97% of oxygen rides on hemoglobin as oxyhemoglobin; a little dissolves in plasma. Taylor gives 98% and 2%; answer 97%. Hemoglobin carries CO₂ back too (the deck and Taylor call this carboxyhemoglobin), so anemia impairs both. Delivery needs three things (lungs to load, hemoglobin to carry, a heart to move); any one failing starves the cell.

Physiology texts keep “carboxyhemoglobin” for carbon monoxide on hemoglobin (CO₂ rides as carbaminohemoglobin). In an item, the deck’s word means CO₂.

The heart, in four lines:

• Refresher (NUR 120 Exam 4): right heart → pulmonary artery → lungs → pulmonary veins → left heart → aorta. CO = stroke volume × heart rate, about 5–6 L/min at rest (Taylor).
• The atria receive blood from the veins; the ventricles pump it out. The coronary arteries fill while the ventricles relax.
• Conduction: SA node → AV node → bundle of His → bundle branches → Purkinje fibers.
• Sympathetic stimulation speeds the heart; the vagus nerve slows it, which is why suctioning can drop the rate.

The deck’s five cardiovascular alterations:

How it fails: which link broke, and who is at risk

The stem names the broken link by the detail it gives. The deck lists eight disease processes, and the table holds all of them: obstructive and restrictive disease, diffusion defects, V/Q mismatching, atherosclerosis, heart failure, anemia and altered oxygen uptake.

The diffusion slide is headed “Four factors influencing diffusion” but lists three; Taylor also gives three. Answer three.

Pneumonia sits in two rows on purpose: consolidation stops filling, and a thick membrane slows diffusion.

Factors across the lifespan

Read every vital sign against its age band; the adult 12–20 matches none of these four columns, and is far off for the two youngest.

What else changes, in three age groups:

• Infants: short airways, so aspiration risk. Surfactant forms at 34–36 weeks (premature infants may need it). A fast heart rate limits how far output can rise.
• Children, 1 to 12: chest-wall fat hides landmarks. Bronchi and eustachian tubes are elongated and less angular. Colds rise with daycare and school: teach hand hygiene.
• Older adults: smaller, rounder lungs; less alveolar surface area; lost chest-wall mobility; lower PaO₂; secretions pool (pneumonia); barrel chest, kyphosis, rigid airways; less elasticity, muscle power and diaphragm efficiency. Avoid opioids and sleeping pills.

Not an age change: more fat over an older adult’s chest (that is the child’s chest), more elastic tissue, a rising PaO₂.

Rates are Taylor’s Ch 40 table. The Ch 26 vital-signs table (your NUR 120 Exam 1 guide) gives newborn 30–60 and infant 30–50.

Environment, lifestyle, health status, and opioids

The deck names four environment-and-lifestyle factors: exposures at home and work, stress, obesity or underweight, and smoking. What to hold, sorted into four areas:

Hypoxia: early signs are compensation, late signs are failure

Hypoxia is inadequate oxygen available to the cells, most often the result of hypoventilation. Four look-alike words sit at different places in the chain:

The three most sensitive tissues each give a sign: the brain (restlessness and confusion first; injury can begin after about five minutes without oxygen), the myocardium (tachycardia, then dysrhythmia and chest pain) and the kidney (a falling urine output). Chronic hypoxia shows in every system: clubbing, an enlarged heart, headaches, altered thinking, chest pain, anorexia, constipation, muscle weakness. Clubbing means months, not minutes; it never answers a question about an acute change.

Breathing terms and patterns, in one table

Each is a rate word, a feeling, or a shape (hyper- and hypoventilation are above).

Respiratory assessment: inspection, percussion and breath sounds

History. Ask what keeps the patient’s air supply adequate, what they already do to breathe well and which aids they use, and ask and look for the six signs of respiratory disorder: cough, sputum, dyspnea, hemoptysis, chest pain, wheezing. In acute distress, act first and take the history later (first-action table: Part 4, Implementing and delegating). Then inspect, palpate, percuss, auscultate.

Percussion: more air than normal, or less?

Five notes, each reporting how much air lies under your finger.

Breath sounds: normal only in their own place

The deck describes vesicular sounds as heard “during expiration”. Taylor and NUR 120 put them mainly on inspiration; answer inspiration.

A normal sound in the wrong place is an abnormal finding: bronchial sounds over the right lower lobe are on the normal list and still abnormal there. For the adventitious sounds, ask first: continuous and musical, or popping?

Diagnostics: pulse oximetry, ABGs, hemoglobin and the other tests

Pulse oximetry: the ranges

The deck defines SpO₂ as the ratio of oxygenated hemoglobin to total hemoglobin: a percentage of whatever hemoglobin is there. Its figures govern:

Other figures you may see: Taylor Ch 40, 90–100% (below 80 less accurate); NUR 120’s deck, 92–100% (85–89% possibly normal in chronic lung disease). Taylor Ch 26 gives 95–100%.

What interferes with the reading, and what does not

Everything that interferes weakens the pulse at the probe or blocks the light. A reading that is accurate and still misleading (anemia, carbon monoxide) is the box above. The troubleshooting order: the patient and vital signs first, then connections and circulation, then the oximeter’s pulse against the heart rate, then the device on someone else. If the patient matches the alarm, treat the patient before the probe.

Arterial blood gases: the two respiratory imbalances

This exam asks for ABGs without compensation: two pictures, both turned by the CO₂ dial. Breathe less and CO₂ accumulates: the blood turns acid. Breathe more and CO₂ is blown off: the blood turns alkaline. The normals are NUR 120’s starred “memorize” slide, and Taylor agrees.

PaO₂ is oxygen pressure in arterial plasma; SaO₂ is hemoglobin saturation measured on the ABG sample; SpO₂ is the oximeter’s noninvasive estimate of it.

Reading one: NUR 120’s four steps, minus compensation. Read the pH (acid, alkaline, normal); the PaCO₂ (high is acid); the HCO₃ (low is acid); then the one that matches the pH names the imbalance. HCO₃ is normal here only because this exam covers uncompensated respiratory imbalances. Outside this exam, don’t assume the other number is normal: once the body compensates, it moves too. Metabolic imbalances and compensation belong to Ch 41.

Drawing one: Allen test first, specimen on ice, oxygen setting on the requisition, pressure 5–10 minutes (longer if anticoagulated).

Hemoglobin, hematocrit and the other tests

A test is invasive when something enters the body, and the nursing care follows from what it enters: a needle in a sterile cavity is why thoracentesis needs consent and surgical asepsis.

First moves and breathing

The deck's goal is keep the airway open, starting with the cheapest tool: orthopneic position for the conscious patient, head tilt for the unconscious one. Refresher: Fowler's 45–60°, high-Fowler's 90°, semi-Fowler's 30° (Exam 2); semi-Fowler's suits IS, suctioning a conscious patient and trach care. Sitting a breathless patient up is free, instant and harmless, so it may come before you assess at all; every “what first” rule is in one table in Part 4, Implementing and delegating.

How to breathe: one table for every technique and device

The deck's four techniques are deep breathing, incentive spirometry, pursed-lip and diaphragmatic; the lab adds huff and cough and deep breathe; the inhalers follow. Two questions sort every row: in or out, slow or fast? Obstructive disease fails on the way out, restrictive disease and atelectasis on the way in (Part 5, How it fails).

Incentive spirometry, eight steps:

1. Set the volume goal.
2. Upright or semi-Fowler's.
3. Assess pain and medicate first; splint the incision.
4. Exhale, then seal the lips on the mouthpiece.
5. Inhale slowly and deeply.
6. Hold 3–5 seconds.
7. Exhale normally; rest if light-headed.
8. 5–10 times every 1–2 hours while awake, then cough.

The deck's “coughing/deep breathing (if not Atelectasis)” is a slip: deep breathing, IS and coughing are how atelectasis is prevented and treated.

The teaching plan has five moves: assess readiness (dyspneic, sedated or in pain is not ready), say why, demonstrate, return demonstration (not “Do you understand?”), which is how a psychomotor skill is evaluated, and anchor the schedule to a habit.

Secretions and inhaled drugs

Fluids and meals. Hydration thins secretions: at least 1.5–2 L a day, more with fever or thick sputum; a cool-mist humidifier for children. Offer small, frequent meals, scheduled 1–2 hours after a breathing treatment, and leave the cannula on during meals.

Chest physiotherapy: percussion with a cupped hand, which should not hurt; vibration; and postural drainage, head down for lower and middle lobes, head up for upper. Never over the spine, sternum, kidneys, lower back or breasts. Taylor does not recommend it after head injury, with uncontrolled hypertension or hypotension, with aspiration risk, for children with pneumonia, for adults with COPD, or for adults after surgery.

Cough medicines: an expectorant (guaifenesin) moves secretions up and is pointless without congestion; a mucolytic loosens them; a suppressant is for a dry cough (codeine sedates and needs a prescription; dextromethorphan is over the counter). Do not suppress a productive cough except for sleep. A cough lasting more than 7 days needs a provider.

Inhaled drugs: bronchodilators open narrowed airways, mucolytics loosen secretions, corticosteroids reduce inflammation. Albuterol causes tremor and palpitations (no extra doses); steroids raise glucose and retain fluid. Refresher from Taylor Ch 30 and your Exam 1 guide: hold about 10 seconds after an MDI puff, a minute between puffs, bronchodilator before steroid, rinse and spit after a steroid. Montelukast prevents attacks and does not stop one.

Oxygen therapy: the drug, the devices, the safety rules

Room air delivers 21% oxygen; oxygen is a drug; it is indicated for hypoxemia. It needs an order naming the device, the flow (or %) and the target; give the least that holds the target. In an emergency, don't wait: falling SpO₂ and visible distress justify oxygen under protocol, provider notified. An assistive person may put a cannula back on, never start oxygen or change the flow. Monitor SpO₂, work of breathing, level of consciousness and the skin under every strap.

Targets. The deck monitors to stay above 90%. On oxygen, Taylor titrates most patients to 94–98% and COPD or CO₂ retainers to 88–92%. Normal ranges: Part 5, Diagnostics.

ATI says COPD oxygen is often limited to 2 L/min: a usual starting point, not a ceiling. The ordered target range decides the flow.

Too much oxygen. “Too much oxygen collapse[s] alveoli”: absorption atelectasis, as high concentrations wash out the nitrogen that holds alveoli open. ATI: alveolar damage can begin within 24 hours of near-100%. CNS signs come first (twitching, nausea, seizures); lung signs with longer use (substernal or pleuritic chest pain, cough, dyspnea). Use the lowest concentration for the shortest time. Humidify by need: not required at 4 L/min or less by cannula or for under 24 hours; add it for dryness or nosebleeds, higher concentrations, and tracheostomies.

The devices

The deck's tent mask (face tent), for a face no mask can touch, has no course figures: watch the SpO₂. Sources vary some mask ranges; the floors (5 and 10) never move.

Applying and weaning. Check the order (device, flow or %, target) → explain the device and why, and post the no-smoking signs → set the flow and confirm it at the device before it touches the face → apply → reassess. Wean by changing device, never by running a mask below its floor. Document the device, flow, assessment before and after, and every flow change.

Wall flowmeter: the green wall outlet, the clear tube with a float ball and the control knob; set the middle of the ball on the ordered line.

No course text describes the flowmeter; these are standard equipment conventions. Check them against the lab's model.

Portable cylinder, six steps:

1. Secure it upright, never between the patient's legs.
2. Read the contents gauge, the one nearer the tank: use it only above 500 psi.
3. Open the valve counterclockwise.
4. Set and confirm the flow.
5. Make sure oxygen is waiting at the destination.
6. Close it clockwise and bleed the gauge.

An oxygen concentrator never runs out, but it needs power.

Fire safety: hazard, then rule

Oxygen does not burn; it supports combustion, so every rule removes an ignition source or a fuel.

Airway procedures: suction, artificial airways, chest tubes, CPR

Suction only when indicated, never on a schedule: visible or audible secretions, a falling SpO₂, coarse crackles over the trachea, or a cough too weak to clear them.

Tracheal suctioning, in order: assess the need → position and hyperoxygenate → insert without suction → suction while withdrawing → reoxygenate and wait before another pass → mouth last, then reassess and document the secretions.

Artificial airways and tracheostomy care

The deck's three airways and two trach types, cuffed and cuffless:

Trach care: sterile; suction first if needed; inner cannula at least every 8 hours (every 4 if secretions are heavy); clean from the stoma outward, one applicator per stroke; a pre-made dressing, never cut gauze; change ties with a second person holding the tube, or put the new ties on before the old come off, snug enough that only a finger or two fits beneath. At the bedside: obturator, a spare tube and one a size smaller, suction, oxygen, a bag.

Chest tubes

The deck's four actions: assist with insertion and removal; monitor respiratory status and vital signs; check the dressing; keep the system patent and intact. The tube drains air (placed high) or fluid (placed low) from the pleural space; the water seal lets air out and not back in.

CPR, choking and the bag

Taylor: check breathing and the carotid pulse together in no more than 10 seconds; compressions at least 2 inches deep, 100–120 a minute, with full recoil.

Choking. If the person can cough forcefully, encourage the cough and do not interfere; if not, ask “Are you choking?” and give abdominal thrusts (never to an infant). If they become unresponsive, start CPR. Bag-valve mask: one breath every 6 seconds, oxygen at 10–12 L.

Oxygenation problem statements

The deck names five labels; the course adds activity intolerance and risk for aspiration. The hook: where does the problem live?

The deck's expected outcomes, made SMART

The deck's four outcomes name a direction but lack a time frame (and three lack a criterion):

The deck's model: the fever case

The Management of Care deck carries one patient through every step: the instructor's own model of a finished plan (rules: Parts 3 and 4).

The heart-failure care plan

The program's model care plan is an oxygenation patient, and an item can enter at any step. A 78-year-old man, second hospital day with heart failure, on room air; you walk him to the bathroom and down the hall.

Step 1 · Recognize cues

Step 2 · Diagnosis: cluster, then choose

The exertional cluster (normal at rest, worse on walking) says supply cannot keep up with demand; the fluid cluster (crackles, edema, orthopnea) is the heart failure itself. The worksheet asks for the main problem the nurse can treat:

Nothing on his list threatens the airway; his circulation problem (decreased cardiac output) is real but treated mostly with drugs; and his breathing cues (the drop to 89% and the short phrases) appear only with exertion and settle at rest. On his list that makes activity intolerance the high-priority problem. It is not a B label in its own right: set beside impaired gas exchange, as in the deck's high-priority question, it ranks second (Part 3, Prioritizing several problems).

Step 3 · Planning: one SMART goal

The model plan's “the patient will exhibit tolerance for increased physical activity by the end of the shift” has a subject and a deadline, but “exhibit tolerance” cannot be measured. Rebuilt:

Step 4 · Take action: interventions, typed (Part 4, Interventions)

Step 5 · Evaluate: a conclusion plus the data

The model plan's “provided 4 L oxygen by cannula while ambulating; sats maintained at 96%” reports what the nurse did: no verdict, no distance, no rest stops (Part 4, Evaluating).

Numbers to know cold

Governing figures only; any variant is in grey in its part.

Counts

Sequences to recite

The tempting error is usually the step that feels like the real work jumping ahead of the check. The what-first orders: Part 4, Implementing and delegating.

Same finding, two answers

Before you call a finding normal or abnormal, find the age, baseline, diagnosis or site it belongs to.

Still open: ask the instructor

Seven open questions, each flagged “Ask the instructor” where it is taught. Until one is answered, use the third column.