NLE Respiratory Nursing — Respiratory Assessment & DiagnosticsRevision Notes

Exam Tips

• If the question mentions a sound heard 'without a stethoscope' → think STRIDOR = upper airway obstruction = emergency.
• Percussion: Dull = fluid or solid tissue (effusion, pneumonia); Hyperresonant = air trapped (emphysema, pneumothorax).
• Fremitus: Increased = consolidation (more solid = more vibration transmission); Decreased = air or fluid separating lung from chest wall.
• The NLE frequently tests the ORDER of physical assessment — remember IPPA (Inspection first, Auscultation last in general assessment but FIRST in abdominal assessment).
• Barrel chest + pursed-lip breathing + use of accessory muscles = classic COPD/emphysema picture.
• Clubbing = CHRONIC hypoxemia. Cyanosis = late sign of ACUTE hypoxemia.

Key Points

• Always follow the order: Inspection → Palpation → Percussion → Auscultation (IPPA). Compare side to side at every step.
• Normal adult respiratory rate: 12–20 breaths/min. Tachypnea >20; bradypnea <12.
• Accessory muscle use, nasal flaring, retractions, pursed-lip breathing, and tripod positioning all indicate INCREASED work of breathing — a priority finding.
• Central cyanosis (blue discoloration of lips and tongue) is a LATE sign of hypoxemia; it requires approximately 5 g/dL of deoxygenated hemoglobin to be visible.
• Clubbing of the fingers indicates CHRONIC hypoxemia (seen in COPD, bronchiectasis, lung cancer).
• Barrel chest (increased anteroposterior diameter) suggests chronic air trapping — classic in emphysema and COPD.
• Tactile fremitus INCREASES over consolidation (pneumonia) and DECREASES over pleural effusion, pneumothorax, or trapped air.
• Normal percussion note over lungs is RESONANT. Dullness = fluid or consolidation. Hyperresonance = trapped air (pneumothorax, emphysema).
• Stridor is heard WITHOUT a stethoscope — it is a high-pitched crowing sound indicating UPPER AIRWAY OBSTRUCTION. This is a medical emergency requiring immediate action.
• Pleural friction rub sounds like grating leather — caused by inflamed pleural surfaces rubbing together (pleuritis).

Definitions

Section Title

Respiratory Physical Assessment: IPPA Order

Common Mistakes

• Confusing crackles (fluid/alveolar problem) with wheezes (airway narrowing) — they have different causes and nursing actions.
• Thinking cyanosis is an EARLY sign — it appears LATE when a large amount of hemoglobin is deoxygenated. SpO2 may be dangerously low before cyanosis is visible.
• Forgetting to compare side to side during IPPA — asymmetry is a key diagnostic clue (e.g., unilateral absent breath sounds in pneumothorax).
• Applying stethoscope over clothing or hair — this creates artifacts and inaccurate findings. Always place on skin.
• Mistaking rhonchi for wheezes — rhonchi clear with coughing; wheezes do not.
• Not recognizing stridor as an emergency — some students wait to auscultate instead of acting immediately.

Formulas

Exam Tips

• The NLE commonly presents a scenario with a clinical picture (e.g., a COPD patient with drowsiness) and gives ABG values — apply ROME in order every time.
• Classic NLE ABG set: pH 7.30, PaCO2 50, HCO3 24 = Respiratory Acidosis, Uncompensated = COPD/hypoventilation.
• Classic NLE ABG set: pH 7.50, PaCO2 30, HCO3 24 = Respiratory Alkalosis = hyperventilation (anxiety, pain, early sepsis).
• Classic NLE ABG set: pH 7.30, PaCO2 40, HCO3 16 = Metabolic Acidosis = DKA, diarrhea, renal failure.
• Classic NLE ABG set: pH 7.50, PaCO2 40, HCO3 30 = Metabolic Alkalosis = vomiting, NGT suction.
• If asked 'what is the priority nursing action after ABG sampling?' → Apply firm pressure for at least 5 minutes.
• If both PaCO2 AND HCO3 are abnormal (both outside normal range), the disorder is PARTIALLY or FULLY compensated.

Key Points

• Normal ABG values (memorize these!): pH 7.35–7.45 | PaCO2 35–45 mmHg | HCO3 22–26 mEq/L | PaO2 80–100 mmHg | SaO2 95–100%.
• Use the ROME method: Respiratory = Opposite (pH and PaCO2 move in OPPOSITE directions); Metabolic = Equal (pH and HCO3 move in the SAME direction).
• Step 1: Check pH → acidosis (<7.35) or alkalosis (>7.45).
• Step 2: Check PaCO2 → if it matches the pH direction (OPPOSITE) = respiratory cause.
• Step 3: Check HCO3 → if it matches the pH direction (SAME) = metabolic cause.
• Step 4: Determine compensation — the system NOT responsible for the primary disorder tries to normalize the pH.
• Respiratory acidosis: caused by hypoventilation, COPD, narcotics, chest wall injury — CO2 builds up.
• Respiratory alkalosis: caused by hyperventilation, anxiety, pain, fever, early sepsis, mechanical over-ventilation.
• Metabolic acidosis: caused by DKA, diarrhea, renal failure, lactic acidosis (shock) — bicarbonate is lost or acid accumulates.
• Metabolic alkalosis: caused by vomiting, NGT suction, excess antacids, diuretics — bicarbonate increases or acid is lost.
• After radial arterial puncture: perform the Allen test FIRST to confirm collateral circulation. Apply firm pressure for AT LEAST 5 minutes (longer if on anticoagulants).
• ABG sampling tip: avoid air bubbles in the syringe; transport on ice if delay >15 minutes; note the patient's temperature and FiO2 on the label.

Definitions

Section Title

Arterial Blood Gas (ABG) Interpretation

Common Mistakes

• Skipping the Allen test before radial arterial puncture — this is a patient safety requirement and an NLE favorite.
• Confusing the ROME directions — remember: Respiratory is OPPOSITE (high CO2 = low pH); Metabolic is EQUAL (low HCO3 = low pH).
• Applying only 2–3 minutes of pressure after arterial puncture — the standard is at least 5 minutes, longer for anticoagulated patients.
• Forgetting that normal SpO2 does NOT rule out CO2 retention — a COPD patient can have SpO2 of 90% but also have a dangerously elevated PaCO2.
• Mixing up the four primary disorders — write out pH, PaCO2, HCO3, and apply ROME systematically every time.

Exam Tips

• If a question mentions carbon monoxide poisoning with 'normal SpO2' → recognize the false reading. Give 100% O2 via NRB and confirm with ABG co-oximetry.
• SpO2 below 90% is a critical value — escalate immediately.
• If asked about the BEST method to assess both oxygenation AND ventilation → ABG (arterial blood gas), not pulse oximetry.

Key Points

• Pulse oximetry (SpO2) is a non-invasive method of estimating oxygen saturation. Normal SpO2 = 95–100%.
• SpO2 reflects SATURATION, not VENTILATION. A patient can have normal SpO2 while retaining dangerous levels of CO2 — only an ABG confirms ventilation status.
• Critical limitation: SpO2 is FALSELY ELEVATED in CARBON MONOXIDE POISONING because the pulse oximeter cannot distinguish oxyhemoglobin from carboxyhemoglobin. A CO poisoning patient may show SpO2 of 99% while actually suffocating.
• Other causes of unreliable SpO2 readings: poor peripheral perfusion, hypothermia, peripheral vascular disease, dark nail polish (especially blue/black/green), artificial nails, motion artifact, severe anemia.
• For COPD patients: target SpO2 of 88–92% (NOT the standard 94–98%) to avoid suppressing the hypoxic drive.
• Place the probe correctly — typically on a finger, earlobe, or toe. Ensure good waveform on the monitor.
• In suspected carbon monoxide poisoning → give 100% oxygen via non-rebreather mask REGARDLESS of SpO2 readings. CO poisoning requires ABG with co-oximetry.

Definitions

Section Title

Pulse Oximetry and Its Limitations

Common Mistakes

• Assuming normal SpO2 means the patient is breathing well — CO2 retention is NOT detected by pulse oximetry.
• Not removing dark nail polish before placing the probe — this causes artifactually low readings.
• Forgetting that CO poisoning gives FALSELY HIGH SpO2 — this is a classic NLE trick question.
• Applying the standard 94–98% SpO2 target to a COPD patient — their target is 88–92%.

Formulas

Exam Tips

• NLE pattern: 'Patient with COPD has an FEV1/FVC ratio of 0.60' → Obstructive pattern. 'Patient with pulmonary fibrosis has reduced FVC but normal ratio' → Restrictive pattern.
• Asthma vs COPD differentiator on PFT: Asthma = reversible obstruction; COPD = irreversible obstruction. Asthma improves significantly after bronchodilator; COPD does not.
• PEFR red zone (<50%) = instruct patient to go to the emergency room immediately.
• For NLE scenarios about spirometry, identify the pattern (obstructive/restrictive), then match it to the clinical disease.

Key Points

• PFTs classify lung disease into OBSTRUCTIVE vs RESTRICTIVE patterns — essential for diagnosis and management.
• Key values: FEV1 (forced expiratory volume in 1 second) and FVC (forced vital capacity).
• The FEV1/FVC RATIO is the most important discriminating value.
• OBSTRUCTIVE pattern (asthma, COPD, bronchiectasis): airflow OUT is limited → FEV1/FVC ratio REDUCED (<70%). FVC may be normal or slightly reduced.
• RESTRICTIVE pattern (pulmonary fibrosis, kyphoscoliosis, obesity, chest wall deformity): lung volumes SHRINK → FVC is REDUCED but FEV1/FVC ratio is NORMAL or INCREASED (because both values shrink proportionally).
• In ASTHMA: obstruction is REVERSIBLE — FEV1/FVC improves significantly after bronchodilator administration (≥12% improvement = reversibility).
• In COPD: obstruction is NOT FULLY REVERSIBLE after bronchodilator — this is a defining characteristic.
• Peak Expiratory Flow Rate (PEFR): measured by a peak flow meter at home by asthmatic patients. Uses a traffic-light zone system.
• PEFR Zones: GREEN = ≥80% of personal best (good control); YELLOW = 50–79% of personal best (caution, use reliever inhaler); RED = <50% of personal best (emergency — go to hospital).
• Teach asthma patients to record their 'personal best' PEFR during a well period and use it as the reference for zone calculations.

Definitions

Section Title

Pulmonary Function Tests (PFTs) / Spirometry

Common Mistakes

• Reversing obstructive and restrictive patterns — remember: Obstructive = low RATIO; Restrictive = low FVC but normal/high ratio.
• Forgetting that asthma is REVERSIBLE and COPD is NOT fully reversible on spirometry.
• Not teaching the personal best concept for PEFR — zones are only meaningful relative to the individual's own best value.
• Confusing PEFR zone colors — RED means EMERGENCY (not just 'caution').

Formulas

Exam Tips

• Memorize the O2 device-FiO2 table as a ranking: NC (lowest FiO2) → Simple Mask → Partial Rebreather → NRB (highest FiO2 without intubation). Venturi = precise/fixed.
• NLE question pattern: 'A patient with COPD is dyspneic. Which O2 device is MOST appropriate?' → Venturi Mask (precise, low FiO2).
• NLE question pattern: 'A patient arrives in the ER with severe hypoxemia. What device delivers the highest FiO2?' → Non-rebreather mask.
• Minimum flow rates to remember: Simple face mask = 5 L/min minimum. NRB = 10–15 L/min. Partial rebreather = 6 L/min.
• Priority nursing action if NRB bag deflates → IMMEDIATELY increase flow rate to re-inflate the bag.
• COPD + oxygen therapy = always target SpO2 88–92%. NLE frequently tests this specific number.

Key Points

• Oxygen is a DRUG — requires a physician's order in most Philippine hospital settings. Under RA 9173 and DOH protocols, nurses administer oxygen per physician's order except in emergency situations.
• Match the delivery device to the required FiO2. Higher FiO2 = more severe hypoxemia.
• NASAL CANNULA: 1–6 L/min → delivers approximately 24–44% FiO2. Most comfortable device. Allows eating, talking, and coughing. Add humidification above 4 L/min to prevent mucosal drying. Flows ABOVE 6 L/min do not meaningfully increase FiO2 and only dry the mucosa.
• SIMPLE FACE MASK: 5–10 L/min → delivers approximately 40–60% FiO2. MINIMUM 5 L/min required to flush exhaled CO2 from the mask (below 5 L/min = CO2 rebreathing = dangerous).
• PARTIAL REBREATHER MASK (with reservoir bag, no one-way valve): 6–11 L/min → delivers approximately 60–80% FiO2. Keep the reservoir bag from FULLY COLLAPSING on inspiration.
• NON-REBREATHER MASK (NRB, reservoir bag + one-way valves on exhalation ports): 10–15 L/min → delivers approximately 80–95% FiO2. Highest concentration possible without intubation. The reservoir bag must REMAIN INFLATED (at least 2/3 full). Used for emergencies and severe hypoxemia.
• VENTURI MASK: delivers PRECISE, FIXED FiO2 regardless of breathing pattern (24%, 28%, 31%, 35%, 40%, 50%). Uses color-coded adapters/entrainment valves. DEVICE OF CHOICE FOR COPD patients needing controlled, low-concentration oxygen.
• COPD OXYGEN TARGET: SpO2 88–92%. Exceeding this can suppress the hypoxic drive in CO2 retainers → hypoventilation → CO2 narcosis. However, NEVER withhold oxygen from a hypoxic patient — titrate carefully.
• Oxygen safety: NO SMOKING and NO OPEN FLAMES near oxygen (fire hazard). Post 'No Smoking/Oxygen in Use' signs. Secure oxygen cylinders upright — falling cylinders are projectile hazards.
• Provide humidification at flows >4 L/min. Inspect skin under mask straps and behind the ears for pressure injury — use foam padding.

Definitions

Section Title

Oxygen Therapy: Delivery Devices and FiO2 Ranges

Common Mistakes

• Setting nasal cannula ABOVE 6 L/min — it does not increase FiO2 but causes painful mucosal drying and nosebleeds.
• Setting simple face mask BELOW 5 L/min — this causes CO2 rebreathing within the mask, worsening the patient's condition.
• Allowing the NRB reservoir bag to DEFLATE completely — this means the patient is not receiving the intended high FiO2 and may be rebreathing exhaled air.
• Giving high-flow oxygen to a COPD patient without monitoring — risk of suppressing hypoxic drive and inducing CO2 narcosis.
• Using a Venturi mask incorrectly — failing to select the correct color-coded adapter for the intended FiO2.
• Not humidifying oxygen at higher flow rates — causes mucosal drying, discomfort, and bloody secretions.

Exam Tips

• Tracheal deviation AWAY from the affected side = TENSION PNEUMOTHORAX (air pushes structures away). Tracheal deviation TOWARD the affected side = ATELECTASIS or fibrosis (collapse pulls structures toward it).
• Flattened diaphragms + hyperinflation = COPD/emphysema on CXR.
• Bilateral 'fluffy' or 'butterfly' infiltrates = pulmonary edema.
• Always verify ETT, NG tube, and central line placement with CXR. This is a standard nursing responsibility after insertion.

Key Points

• The chest X-ray (CXR) is the most common thoracic imaging study — no fasting, no special preparation needed.
• Nursing responsibilities before CXR: REMOVE all metal objects and jewelry (causes artifacts); CONFIRM the patient is not pregnant or shield appropriately; explain the procedure; assist the patient to the correct position (PA view: patient faces the film; AP: film behind the patient — common in ICU with portable machine).
• CXR is used to confirm placement of endotracheal tubes (ETT), central venous catheters, nasogastric tubes, chest tubes, and pacemakers.
• ETT placement on CXR: tip should be 3–5 cm ABOVE the carina. Too deep = right mainstem intubation (left lung collapses). Too high = accidental extubation risk.
• Key CXR findings by condition: Pneumonia = consolidation/infiltrates (white/opaque areas, air bronchograms); Pulmonary edema = bilateral fluffy infiltrates, Kerley B lines, cardiomegaly; COPD/Emphysema = hyperinflation, flattened diaphragms, increased AP diameter; Pneumothorax = visible pleural line, absence of lung markings beyond the line, mediastinal shift AWAY from the affected side in TENSION pneumothorax; Pleural effusion = blunting of costophrenic angles, haziness at the base; Atelectasis = plate-like or lobar opacity with shift of structures TOWARD the affected side.
• In tension pneumothorax, tracheal deviation is AWAY from the affected side — this is the OPPOSITE of atelectasis (toward the affected side). This is a classic NLE differentiator.
• Radiation safety: nurses should minimize exposure, use lead apron if staying in the room, and stand at least 6 feet from the X-ray source.

Definitions

Section Title

Chest X-Ray: Nursing Responsibilities and Key Findings

Common Mistakes

• Forgetting to remove metal objects before CXR — artifacts can obscure important findings.
• Not confirming ETT placement with CXR immediately after intubation — right mainstem intubation is a common post-intubation complication.
• Confusing mediastinal shift direction: TENSION PNEUMOTHORAX pushes mediastinum AWAY from the affected side; ATELECTASIS pulls mediastinum TOWARD the affected side.
• Assuming AP portable CXR is equivalent to PA standing CXR — AP views make the heart appear larger (magnification artifact); always note the view.

Exam Tips

• Three chambers from patient outward: COLLECTION → WATER-SEAL → SUCTION-CONTROL. Know the purpose of each.
• WATER-SEAL chamber: TIDALING = normal; CONTINUOUS BUBBLING = air leak (abnormal).
• SUCTION-CONTROL chamber: GENTLE BUBBLING when suction is active = normal. Vigorous bubbling = increase suction is NOT the answer; adjust to gentle.
• Emergency mnemonics: Tube OUT of chest → THREE-sided dressing. Tube OFF the system → SUBMERGE in sterile water.
• Tension pneumothorax triad: absent breath sounds + tracheal deviation AWAY + hypotension + JVD = medical emergency = needle decompression.
• NLE frequently tests what 'CONTINUOUS bubbling in the water-seal chamber means' → answer = AIR LEAK.
• Keep drainage unit BELOW CHEST at all times — gravity prevents backflow.

Key Points

• A chest tube (intercostal drain) is inserted to remove AIR (pneumothorax), FLUID (pleural effusion, hemothorax, chylothorax), or PUS (empyema) from the pleural space to re-expand the lung and restore negative intrapleural pressure.
• The standard closed drainage system has THREE CHAMBERS: (1) Collection Chamber, (2) Water-Seal Chamber, (3) Suction-Control Chamber.
• COLLECTION CHAMBER: collects drainage. Mark the level with time and date every shift. Normal drainage after thoracotomy is <200 mL/hour. Bright red blood >200 mL/hour = hemorrhage → notify physician IMMEDIATELY.
• WATER-SEAL CHAMBER: contains 2 cm of sterile water. Acts as a ONE-WAY VALVE — air from the pleural space exits but cannot re-enter. TIDALING (rise and fall of the water level with respiration) is NORMAL and expected.
• TIDALING: rises during inspiration (pleural pressure becomes more negative) and falls during expiration in spontaneously breathing patients. ABSENCE of tidaling may indicate: (1) lung is FULLY RE-EXPANDED (good), or (2) tube is KINKED, CLOTTED, or CLAMPED (bad) — assess the patient first.
• SUCTION-CONTROL CHAMBER: regulates the amount of suction applied. In WET systems: fill to the prescribed level (usually 20 cm H2O) — GENTLE BUBBLING in the suction-control chamber is NORMAL when suction is active.
• CONTINUOUS BUBBLING IN THE WATER-SEAL CHAMBER = AIR LEAK. This is abnormal (except during initial pneumothorax evacuation). Troubleshoot: check all connections from the chest wall insertion site to the drainage unit. Clamp momentarily near the chest — if bubbling STOPS, the leak is at the insertion site or in the patient; if bubbling CONTINUES, the leak is in the tubing or system.
• DO NOT routinely clamp the chest tube — clamping with an ongoing air leak can cause TENSION PNEUMOTHORAX.
• DO NOT milk or strip the tubing routinely — this creates excessive negative pressure and can injure the pleural tissue.
• Keep the drainage system BELOW CHEST LEVEL at ALL TIMES to prevent backflow of drainage into the pleural space.
• Encourage DEEP BREATHING, COUGHING, and INCENTIVE SPIROMETRY to promote lung re-expansion.
• Position: affected side UP is commonly used for comfort; HOB elevated 30–45 degrees to promote drainage and respiratory effort.
• EMERGENCY: Chest tube pulled OUT of the chest wall → IMMEDIATELY cover the site with a STERILE OCCLUSIVE DRESSING TAPED ON THREE SIDES (flutter-valve dressing). This allows air to escape but prevents air entry. Taping ALL FOUR SIDES can trap air and cause tension pneumothorax.
• EMERGENCY: Drainage system disconnected from the tube → SUBMERGE the distal end of the chest tube in a container of STERILE WATER or STERILE NORMAL SALINE to re-establish a water seal. Then obtain a new drainage system.

Definitions

Section Title

Chest Tube and Water-Seal Drainage System

Common Mistakes

• Clamping a chest tube when an air leak is present — this traps air in the pleural space and can cause tension pneumothorax.
• Positioning the drainage unit at or ABOVE chest level — allows backflow of drainage and fluid into the pleural space.
• Applying a FOUR-sided occlusive dressing when the chest tube is dislodged — traps air and can cause tension pneumothorax.
• Confusing bubbling in the SUCTION-CONTROL chamber (normal when suction is on) with bubbling in the WATER-SEAL chamber (abnormal = air leak).
• Interpreting absence of tidaling as always a normal finding — it can mean the tube is blocked or kinked, not just that the lung is re-expanded.
• Milking or stripping the tube routinely — this is outdated practice and can cause pleural injury.

Exam Tips

• Post-operative patient + shallow breathing + decreased breath sounds at bases → ATELECTASIS → priority intervention = INCENTIVE SPIROMETRY + deep breathing exercises + early ambulation.
• COPD patient + drowsy + decreased respiratory rate after oxygen started → CO2 NARCOSIS → reduce FiO2 and check ABG.
• Maslow priority: Airway problems ALWAYS come before breathing, circulation, and other needs.
• Under RA 9173, nurses independently implement BREATHING EXERCISES, POSITIONING, and SUCTIONING within their scope of practice. Oxygen therapy initiation in emergencies and chest tube management are collaborative functions.
• NLE may ask about the 'good lung down' rule — it maximizes V/Q matching (perfusion to the better-ventilated lung).

Key Points

• AIRWAY is always the first priority (Maslow's hierarchy: physiological needs first). Establish a patent airway before any other intervention.
• NANDA nursing diagnoses for respiratory patients: Ineffective Airway Clearance; Impaired Gas Exchange; Ineffective Breathing Pattern; Activity Intolerance; Anxiety.
• Position for DYSPNEA: High-Fowler's (90°) or TRIPOD POSITION (leaning forward, hands on knees or table) — maximizes diaphragmatic excursion and lung expansion.
• Position for UNILATERAL LUNG PROBLEMS: 'GOOD LUNG DOWN' (affected lung up) to maximize perfusion to the healthy lung. EXCEPTION: after PNEUMONECTOMY (whole lung removed) → do NOT position on the remaining lung side — place in low-Fowler's or supine.
• PURSED-LIP BREATHING: inhale through the nose for 2 counts, exhale SLOWLY through pursed lips for 4 counts. Keeps airways open by maintaining positive airway pressure during expiration. Prevents air trapping. Teach to COPD/emphysema patients.
• DIAPHRAGMATIC BREATHING: uses the diaphragm as the primary breathing muscle — reduces the work of breathing. Place hand on abdomen — abdomen should rise on inspiration.
• INCENTIVE SPIROMETRY: sustain a slow, deep inspiration and hold for 3–5 seconds. Most effective when performed 10 times hourly while awake. Critical for post-operative patients to prevent ATELECTASIS.
• OXYGEN TOXICITY: caused by prolonged FiO2 >50% for more than 24–48 hours. Signs: substernal chest pain, dry cough, worsening hypoxemia (paradoxical effect). Prevention: use the LOWEST effective FiO2.
• ABSORPTION ATELECTASIS: occurs when high-concentration oxygen washes out nitrogen from alveoli, causing them to collapse when oxygen is absorbed. Another reason to use lowest effective FiO2.
• CO2 NARCOSIS: drowsiness, headache, flushed face, confusion, decreased respiratory rate in a COPD patient given excessive oxygen. Action: reduce FiO2 to achieve SpO2 88–92%, monitor ABG, prepare for non-invasive ventilation if needed.
• HOME OXYGEN SAFETY for Filipino patients: no smoking in the home; keep oxygen away from the gas stove (LPG); secure cylinders; check the flow regularly. Under PhilHealth benefits, home oxygen may be covered for qualifying chronic respiratory conditions — refer to the medical social worker.

Definitions

Section Title

Nursing Management, Patient Teaching, and Complications

Common Mistakes

• Positioning a post-pneumonectomy patient on the REMAINING lung — this compresses the only functional lung.
• Forgetting to teach incentive spirometry BEFORE surgery — preoperative teaching is more effective than postoperative teaching when the patient is in pain.
• Not monitoring for CO2 narcosis in COPD patients receiving oxygen — changes in mentation are early signs.
• Continuing high FiO2 longer than necessary — oxygen toxicity risk increases after 24–48 hours at FiO2 >50%.
• Repositioning dyspneic patients FLAT — this reduces diaphragmatic excursion and worsens breathing difficulty.