Nursing · Adult clinical nursing
Breathing is the first thing to change and the last thing to be counted
In the exams: NCLEX-RN: Physiological Integrity (43–67%); Saudi Nursing Licensure Examination: Adult health nursing (The largest area)
Breathing rate is the most sensitive early sign of deterioration in the whole of nursing and the observation most often estimated rather than counted. A patient whose rate has climbed from sixteen to twenty-eight is in trouble hours before their blood pressure moves, and that fact is written into every early warning system in the world — yet the number is still guessed at the end of a busy round. This subject also carries the largest preventable burdens in global health: pneumonia kills more children than anything else, tuberculosis remains among the largest infectious killers of adults, and the air people breathe indoors and outdoors causes millions of deaths a year. Almost none of that is solved in an intensive care unit.
Breathing responds to low oxygen, to acid in the blood, to fever, to pain and to fear, which makes it the most sensitive single observation available and almost always the first to move. A patient whose rate has climbed steadily across a shift is deteriorating, whatever the other numbers say.
Estimated, usually, and frequently written as sixteen or eighteen because those are the numbers that look normal. Studies of recorded rates show an implausible clustering on round numbers, which is the fingerprint of guessing rather than counting.
Count for a full period, with a watch, without telling the patient you are doing it, because people who know their breathing is being watched change it. Keeping a hand on the wrist as though still taking the pulse is the standard trick and it works.
The body is compensating for something — low oxygen, acid accumulating, a fever, pain, or fear. It does not say which, and that is precisely why it is sensitive. A rate that has risen in a patient nobody is worried about is the most useful minute in a shift.
A patient who has been breathing hard for hours and whose rate now falls, without treatment, may be tiring rather than improving. In respiratory failure that is a late and dangerous sign, and it is the one most often misread as recovery.
Using neck and shoulder muscles, nostrils flaring, drawing in between the ribs, sitting forward with hands on knees, or being unable to finish a sentence are all measurements of work, and none of them require equipment. A patient who cannot complete a sentence is severely unwell regardless of any number.
Blue lips and tongue indicate severe lack of oxygen, and they appear late. On darker skin they are far harder to see, so a system that relies on spotting blueness misses it in exactly the patients who are hardest to assess, which is why effort and rate matter more than colour.
People adopt the position that helps them. Sitting bolt upright, leaning forward, refusing to lie down — each is the patient managing their own mechanics, and forcing somebody flat for a procedure or a bed change can be genuinely dangerous.
Noisy breathing on the way in usually means obstruction high up, in the throat or larynx. Wheeze on the way out usually means narrowed airways lower down. A silent chest in somebody who was wheezing loudly is not improvement — it means too little air is moving to make a sound.
Whether somebody can say a full sentence, a few words, or single words tracks severity better than most equipment and needs nothing at all. It is also the assessment a family can be taught to make at home.
Oxygen is a drug. It has indications, a target range, and harms at both extremes, and it should be prescribed with a target rather than turned up because somebody looks breathless. Treating it as a comfort measure is a recognised source of harm.
Too little starves tissue. Too much, in particular patients with long-standing lung disease, reduces their drive to breathe and lets carbon dioxide accumulate until they become drowsy. Both directions kill, which is why the target range exists and why it differs between patient groups.
Different masks and cannulae deliver very different concentrations, and some require a minimum flow to work at all or to avoid rebreathing. Running a device below its intended flow produces a patient receiving far less than intended while everybody believes otherwise.
It reports the proportion of available haemoglobin carrying oxygen. It does not report how much haemoglobin there is, how much blood is flowing, or whether tissue is receiving what it needs. A severely anaemic or shocked patient can read reassuringly while starving.
Cold hands, poor circulation, movement, nail varnish and certain pigments all produce wrong or absent readings. A number that does not match the patient in front of you is a reason to look at the patient, not to record the number and move on.
Oxygen delivered straight from a cylinder is dry, and the nose and throat that would normally moisten inhaled air are bypassed by a mask or a tube. The result is a dry mouth, thickened secretions that become harder to cough up, cracked lips and a sore throat, which together make a patient less able to clear the chest the oxygen was given to help. Humidification, frequent mouth care and sips of water where swallowing is safe are therefore part of giving oxygen rather than comfort measures alongside it. Patients tolerate masks far better when somebody has attended to this, and a patient who tolerates the mask is a patient who keeps it on.
Airways that are inflamed and over-reactive narrow in response to triggers, and the narrowing is largely reversible. That reversibility is the defining feature and it is why treatment works so well when it is actually taken.
Symptoms that vary — worse at night, worse in the early morning, worse with exercise, cold air, dust, smoke or a particular season — and that come and go rather than progressing steadily. That variability is what separates it from fixed airway disease.
Unable to complete sentences, using accessory muscles, exhausted, a silent chest, confusion or drowsiness. Drowsiness in an acute asthma attack is an emergency, not a patient settling, and it is the sign most often misread.
The preventive inhaler makes nobody feel better on the day and the reliever does, so people use the reliever and quietly abandon the preventer. Explaining that the invisible one is the one keeping them out of hospital, at the start, prevents a great deal of admission.
A very large proportion of people use inhalers incorrectly, which means a treatment recorded as given was never delivered, and the usual response is to escalate the dose. Asking somebody to demonstrate takes a minute and routinely finds the problem.
A written asthma action plan tells somebody what to do when their peak flow falls or their symptoms worsen, in their own words, before they are frightened enough to need a hospital. It names the number or the symptom that means act, what to take, and when to seek help. People given one use fewer emergency services than people given the same information verbally, because a plan on paper survives panic and a conversation does not.
Here the narrowing is largely permanent, the lungs empty poorly, and air is trapped so the chest becomes over-inflated. That is why these patients breathe out slowly through pursed lips, sit forward, and become barrel-chested over years — each is the mechanics visible from the end of the bed.
Tobacco in most of the world, and smoke from cooking and heating fires indoors in much of the rest, which is why it is common in women who have never smoked in households burning solid fuel. Occupational dust adds to both.
Most of the harm, cost and death comes from flare-ups: increased breathlessness, more sputum, or a change in its colour. Each one damages lung function further and raises the chance of the next, so preventing them matters more than anything done between them.
When carbon dioxide rises, people become flushed, tremulous, headachy and progressively drowsy. A patient with long-standing lung disease who becomes settled and sleepy after a period of distress may be accumulating it rather than resting, and this is among the most dangerous misreadings in acute nursing.
Breathlessness is frightening, and fear of it stops people moving, which weakens them and makes them more breathless. Pulmonary rehabilitation breaks that cycle and is under-referred everywhere, and the nurse on the ward is usually the person who decides whether it is mentioned.
Pneumonia kills more children under five than any other infection, overwhelmingly in the poorest countries, and most of those deaths are preventable with recognition, oxygen and treatment that already exists. This is a problem of access rather than of knowledge.
Fast breathing for the child's age, drawing in below the ribs, inability to feed or drink, and abnormal sleepiness. These signs were chosen precisely because they need no equipment, and a health worker with nothing but their eyes and a watch can identify a child who needs referral.
Fever, cough, sputum, breathlessness, chest pain on breathing in, and in older people frequently confusion or a fall instead of any of that. An older person who has become confused with no other explanation deserves a chest examination before anything else.
Food or fluid entering the lungs causes a pneumonia that is among the most common preventable causes of death in stroke, dementia and advanced illness. Some patients aspirate without coughing at all, which is why repeated unexplained chest infections should prompt a swallowing assessment.
What is aspirated is whatever is growing in the mouth at the time, so meticulous mouth care measurably reduces pneumonia in dependent patients. It is treated as comfort work and it is infection prevention.
Tuberculosis remains one of the largest infectious causes of death worldwide, concentrated in the countries most readers of this library will work in. It is airborne, slow, treated for months, and heavy with social consequence.
It travels in particles small enough to stay suspended, so somebody can be exposed without ever going near the patient. That places it in a different precaution category from most infections, requiring fitted respirators and ventilation rather than distance and a surgical mask.
A cough lasting weeks, with weight loss, night sweats, fever or blood in the sputum, in a person from or living in a high-burden setting. It is missed because a cough is ordinary and because the diagnosis carries stigma that makes people delay.
Treatment runs for months and people feel well long before it ends. Stopping early produces relapse and drug resistance, and resistant disease is far harder, longer and more toxic to treat. Supporting completion is social work — cost, travel, side effects, stigma, somebody remembering the person exists.
Fear of being identified stops people testing, collecting treatment and telling their household. A service known to be discreet finds more cases than one known to be thorough, which makes confidentiality a public health measure rather than only an ethical duty.
When somebody is diagnosed with tuberculosis, the people who share their air have been exposed, and finding them is part of treating the case rather than an administrative afterthought. Household members, particularly small children and anyone whose immunity is reduced, are screened. This is uncomfortable work because it requires the patient to name people, and it is done with care precisely because a clumsy approach makes the next patient conceal their household.
The passages for air and food cross at the throat, guarded by a flap that closes during swallowing. That arrangement is the entire reason aspiration exists, and why anything that weakens the swallow — stroke, sedation, reduced consciousness, a very dry mouth — puts material into the lungs.
In a patient with reduced consciousness, position is what protects the airway once the reflexes that normally do it have gone. This is why the recovery position exists, why a drowsy patient is not left flat on their back, and why this is an intervention rather than a courtesy.
A snoring or gurgling noise in an unresponsive patient is the tongue or secretions obstructing the airway, and both are relieved by position and suction rather than by equipment. It is the first thing checked in any collapsed patient for exactly that reason.
Suction removes what a patient cannot clear and also causes low oxygen, trauma and distress if applied too long or too deep. It is done briefly, on the way out rather than continuously, and it is a procedure where more is reliably worse.
An artificial airway bypasses the nose and mouth, which warm, moisten and filter air, so humidification and meticulous suction matter more rather than less. A blocked or displaced tube is an emergency, and the equipment to manage that must be at the bedside rather than down the corridor.
Coughing clears the airways, and a patient who cannot cough effectively cannot protect their own lungs. Pain, weakness, sedation and a recent abdominal or chest wound all reduce it, which is why pain control after surgery is respiratory treatment.
Sitting upright, adequate pain relief, hydration so secretions are not thick, supporting a wound while they cough, and moving them. None of that requires a device, and together it prevents a substantial proportion of post-operative chest infections.
A change in colour, volume or thickness matters more than any single appearance. Blood in sputum always deserves explanation. Rust-coloured, frankly purulent, or suddenly copious sputum in somebody previously stable is a change to report rather than to record.
Sputum means what comes up from the chest, not saliva. A saliva sample is reported as unsuitable or grows mouth organisms and misleads the treatment. Explaining what is needed, and collecting it first thing in the morning, is what makes the result mean anything.
Secretions that are thick cannot be cleared by a cough however strong it is, and the commonest reason they are thick is that the person is dry. A patient who is feverish, breathing fast through an open mouth, and drinking little because they feel too breathless to stop and swallow will produce sputum they cannot shift, and then be described as having a poor cough. Offering fluids frequently and in small amounts, rather than leaving a jug out of reach, changes the consistency of what has to be coughed up. It is one of the least technical interventions in this manual and one of the most reliably effective.
Sudden breathlessness in somebody previously stable has a short list of causes and most are time-critical: a clot in the lung circulation, a collapsed lung, fluid flooding the lungs from a failing heart, a severe asthma attack, or an obstructed airway.
A clot travelling to the lungs causes sudden breathlessness, chest pain worse on breathing in, and sometimes collapse. It frequently follows a period of immobility, and a swollen calf in the days before is the connection people fail to make.
Sudden one-sided chest pain and breathlessness, worse on that side, sometimes in a tall thin young person with no illness at all. Under pressure it can compress the heart and great vessels, which deteriorates rapidly and is relieved mechanically.
Breathlessness that is worse lying flat, that wakes somebody at night, with frothy sputum and crackles, is the left side of the heart failing and flooding the lungs. Sitting them upright is immediate treatment, not positioning.
Anxiety genuinely causes breathlessness, and labelling somebody anxious before excluding the dangerous causes is how clots and collapsed lungs are missed — particularly in young women, in whom this mislabelling is documented.
A child's airway is narrower, so a given amount of swelling narrows it proportionally far more, and children compensate well and then fail suddenly. A child who looks tired after a period of working hard is a child in serious trouble.
Normal breathing rate falls as children grow, so fast is defined against age rather than against an adult number. This is the basis of the simple assessments used worldwide to identify a child who needs referral without any equipment.
Indrawing below the ribs, head bobbing, flaring nostrils and grunting on expiration are signs of serious respiratory distress in an infant. Grunting in particular is often missed by people unfamiliar with children and is a late and ominous sign.
A baby who cannot feed because they cannot breathe and suck at the same time is telling you how severe this is, in a measure the mother can report and repeat. It is frequently more useful than any number.
Distress increases breathing effort and oxygen demand, and a frightened child separated from their parent becomes more distressed. Keeping them together is a respiratory intervention rather than a kindness.
Billions of people cook and heat on solid fuel indoors, and the resulting smoke causes an enormous burden of respiratory disease, falling hardest on women and small children who spend most time near the fire. It is one of the largest environmental health problems in the world and is almost invisible in clinical training.
Air pollution causes millions of deaths a year through respiratory and cardiovascular disease, and it is not distributed evenly — the poorest neighbourhoods have the worst air almost everywhere it has been measured.
Dust, fumes and fibres cause lung disease that appears decades later, in workers who were frequently never told and never monitored. Asking what somebody has worked at, across their whole life, is a respiratory history question and is routinely omitted.
Still the single largest preventable cause of respiratory death. Brief, repeated advice from a clinician measurably increases quit rates, which makes asking about it every time — briefly, without lecturing — one of the highest-value things a nurse does.
Not the fuel, the housing or the regulation. But asking about smoke exposure at home, asking what somebody has worked at, advising on ventilation, and recording the answers so the pattern becomes visible in the data are all within reach.
An occupational or household exposure that is asked about but never written down disappears. Recording that a patient cooks on solid fuel indoors, or has worked twenty years in a quarry, turns an individual history into something that shows up in the data and eventually in a policy. Nurses generate most of that record, and a field left blank is a population that is never counted.
A ventilator does the mechanical work of moving air when a person cannot do enough of it themselves, either because they are too tired, too weak, too sedated, or because their lungs are too stiff or too flooded. It buys time for whatever caused the failure to be treated. It does not treat anything itself, and a patient who is ventilated without the underlying cause being addressed is simply being kept alive while the problem continues.
Pressure delivered through a tight mask can hold airways open and take over part of the work of breathing without anything passing the vocal cords. It works well in specific situations and badly in others, and it depends entirely on a seal, on the patient tolerating it, and on somebody watching whether they are actually improving in the first hour rather than deteriorating quietly inside a mask.
Keeping the head of the bed raised so stomach contents do not travel upwards, meticulous mouth care because what is aspirated is what grows in the mouth, checking the tube position and its security, managing sedation so that it is enough and not more, preventing pressure damage in somebody who cannot move, and watching for the deterioration the machine will not announce.
Muscles that have not worked weaken quickly, including the diaphragm, so a patient ventilated for a week may be unable to breathe unsupported even after the original problem has resolved. Weaning is therefore a planned, gradual process with its own failures, and the daily interruption of sedation to see what somebody can do is one of the interventions with the best evidence behind it.
A ventilated relative cannot speak, may appear to be sleeping peacefully, and may be able to hear. Families need to know what the machine is doing, what the numbers mean, that the person may be aware, and that talking to them is worth doing. Almost none of that is said unless somebody decides to say it.
Fluid can collect between the lung and the chest wall, compressing the lung from outside. It causes breathlessness, reduced movement on that side, and dullness rather than air sounds when the chest is examined. The causes are quite different from fluid inside the lung — infection, heart failure, cancer, liver disease — and the treatment is drainage rather than anything given by mouth.
A drain removes air or fluid from around the lung so it can re-expand. The nursing responsibilities are consistent everywhere: keep the system below the insertion site, never lift the bottle above the chest, watch the fluid level swinging with breathing because that tells you the system is patent, measure and record what comes out, and never clamp a bubbling drain without an explicit instruction.
Air trapped under pressure around a lung compresses not only that lung but the heart and great vessels, and the patient deteriorates rapidly with severe breathlessness, one side not moving, and a falling blood pressure. It is relieved mechanically and urgently, and it is one of the few situations where recognising it and calling loudly is the entire nursing contribution.
Bleeding into the chest after injury or surgery can be substantial and hidden, because a chest holds a great deal of blood before anything is obvious from outside. A drain that suddenly fills, or a patient whose pulse climbs while their drain output rises, is bleeding until proved otherwise.
Some people stop breathing repeatedly while asleep, because the airway collapses when the muscles holding it open relax. They wake briefly hundreds of times without knowing, and arrive complaining of exhaustion, headaches in the morning, poor concentration, or a partner's account of loud snoring and frightening pauses.
Untreated, it is associated with raised blood pressure, heart rhythm problems, stroke and road accidents caused by falling asleep at the wheel. It is also strongly associated with weight, which makes it one of the conditions where the treatment and the cause pull in different directions and where blunt advice does the most damage.
The person affected is asleep and remembers none of it, so the history that makes the diagnosis usually comes from whoever shares the bed. Asking whether anybody has noticed them stop breathing, and how loud the snoring is, is a question people find easier to answer about somebody else than about themselves.
Pressure delivered through a mask overnight holds the airway open and works extremely well when it is used, and a substantial proportion of people stop using it. The reasons are practical — the mask leaks, the straps hurt, it is noisy, a partner objects, it is hot. Asking what specifically is wrong with it finds something fixable far more often than restating why it matters.
Breathlessness at the end of life is what the person reports, and it correlates poorly with oxygen saturation. A patient can be distressingly breathless with normal numbers, and comfortable with poor ones. Treating the number rather than the person is the commonest failure here, and it leaves people frightened while a monitor says everything is fine.
Sitting upright, a fan or moving air on the face, an open window, a calm unhurried presence, explanation, and not crowding the bed. Moving air across the face genuinely reduces the sensation of breathlessness through a nerve pathway rather than through suggestion, and it is one of the cheapest and most reliable interventions in palliative care.
Oxygen helps a breathless person who is short of oxygen. In somebody whose saturation is adequate it frequently adds a mask, a noise, a tether and a dry mouth without reducing the sensation at all. Deciding by whether it helps this person, rather than by reflex, is the professional judgement.
Noisy breathing in the last hours, caused by secretions the person can no longer clear, distresses families far more than it appears to distress the patient. Explaining what it is, repositioning, and stopping unnecessary fluids helps more than suction, which is uncomfortable and usually futile at that stage.
Families watching somebody breathe irregularly, with long pauses, need to be told that this is expected, that it does not mean suffering, and what will happen next. Silence in that room is filled by imagination, and what people imagine is almost always worse than the truth.
Simple breathing tests measure how much air somebody can move and how fast, and they distinguish airways that are narrowed from lungs that are stiff or small. The result depends enormously on effort and technique, so a poorly coached test produces a wrong answer that then follows the patient. Explaining and demonstrating properly is the difference between a measurement and a number.
A simple hand-held meter lets somebody with asthma measure their own airways daily and see a fall before they feel one. It turns a vague sense of being worse into a number that triggers an agreed action, and a written plan built around that number prevents admissions.
A chest film shows fluid, collapse, large masses and much infection, and misses a great deal else, including clots in the lung circulation and early airway disease. Knowing what a test cannot show prevents the dangerous conclusion that a normal film means a normal chest.
A sample measures oxygen, carbon dioxide and acidity within minutes and answers questions that saturation cannot — in particular whether carbon dioxide is accumulating, which is the distinction between a patient who is tired and a patient who is failing. It is painful to obtain from an artery, which is a reason to know why it is being taken.
Almost everything that identifies a seriously unwell chest needs no equipment: rate counted against age, effort, indrawing, ability to speak or feed, colour, position and the trend across a few hours. In a setting with little else these are not second-best; they are the assessment, and being good at them is a skill.
Where oxygen is limited, deciding who receives it and at what concentration becomes a clinical and an ethical question rather than a technical one. Knowing how many cylinders or concentrators exist, whether they work, and who is responsible for refilling them is part of being able to treat anybody at all.
Sitting a patient upright, opening a window, moving a fan, keeping a room from becoming crowded and hot, and clearing an airway by position are available everywhere and are genuinely effective. A great deal of respiratory nursing is mechanical rather than pharmaceutical.
Where treating severe pneumonia is difficult, preventing it matters proportionally more: immunisation, treating a child's illness early, reducing indoor smoke, hand hygiene, and getting people who have been coughing for weeks tested. These need little and prevent the events the system cannot manage.
Some airways respond to things that do the rest of the population no harm at all — pollen, dust mite, animals, mould, cold air, smoke, strong smells. The response is inflammation and narrowing, and it is why two people in the same room can have entirely different experiences of it. The trigger is worth finding because avoiding one trigger is frequently more effective than adding another treatment.
Ask what the person was doing, where they were, and what time of year it happens. A cough that is worse at night, worse in a particular room, worse at work and better on holiday, or worse every spring is telling you something specific. A pattern tied to a workplace is important enough that it changes somebody's livelihood, and it is missed unless the question is asked.
A severe allergic reaction narrows the airway and drops the blood pressure within minutes, and the swelling of the throat is what kills. Difficulty speaking or swallowing, a hoarse voice, swelling of the lips or tongue, or a rash with breathlessness together are an emergency, and lying the person flat when they are breathless makes it worse rather than better.
Second-hand smoke measurably worsens asthma in children, and the exposure happens in homes and vehicles where nobody thinks of it as a clinical matter. Asking who smokes in the house, without accusation, and explaining that smoking outside genuinely changes a child's chest, is a short conversation with a real effect.
Anaesthesia, pain, immobility and a wound that hurts to cough around all reduce the depth of breathing, so small areas of lung collapse and secretions collect. The result is a fever and a deteriorating chest two or three days later, and it is among the most predictable complications in surgical nursing, which is exactly why it is preventable.
A patient who cannot take a deep breath because it hurts will not clear their chest, however willing they are. Adequate pain control, supporting the wound while they cough, sitting them upright and getting them out of bed early do more for the chest after abdominal surgery than anything given for the chest itself.
Rib fractures hurt enormously and stop people breathing deeply, so the danger is not the bone but the pneumonia that follows a chest nobody could clear. In older people a small number of fractured ribs carries a genuinely serious mortality, and that is almost entirely about pain control and clearance rather than about the fracture.
Burns around the face and neck, soot around the nose and mouth, a hoarse voice, singed nasal hair, or a fire in an enclosed space all point to an airway that may swell over the following hours and close. This is anticipated rather than waited for, and it matters before any calculation about surface area or fluid.
A single rate means little and a direction means a great deal. Handing over that a patient is breathing at twenty-four says less than handing over that they were at sixteen this morning, are at twenty-four now, and have needed more oxygen since lunchtime to hold the same saturation.
Numbers do not capture accessory muscle use, inability to finish a sentence, or a patient who has started sitting forward. Those are the observations that change decisions, and they exist only if somebody writes them in words. A chart of perfect numbers beside a patient nobody described is a common and dangerous combination.
A saturation figure without the oxygen alongside it is meaningless. Ninety-four per cent on room air and ninety-four per cent on a high flow are two entirely different patients, and the second is deteriorating while the number stays still. Always hand over both together.
Every early warning system is a floor rather than a ceiling. A nurse who is worried about a patient's breathing should escalate on that alone, and knowing in advance who to call and what the second route is — before the night it is needed — is part of being ready.
Oxygen as a prescribed treatment with a target, recognising the deteriorating patient from observations, severe asthma, pneumonia in a child, and inhaler technique. The scenarios usually give numbers and ask what is happening.
Treating a normal saturation as reassurance in an anaemic or shocked patient; reading a falling breathing rate as improvement; treating a silent chest as settled asthma; treating drowsiness in long-standing lung disease as rest; labelling breathlessness as anxiety before excluding the dangerous causes.
Sit them up, assess airway and breathing first, give oxygen against the prescribed target rather than by feel, get help early, do not leave them, and document. Answers that investigate before acting lose marks everywhere.
Count it, with a watch, for a full period, without telling them. Ask them to demonstrate their inhaler. Sit them up. Do the mouth care. Ask what they have worked at. Each takes a minute and together they are most of what nursing contributes here.
Written in plain sentences on purpose. Nursing is studied in a second language by a large share of the students who will read this, and a sentence that has to be decoded twice is a sentence that teaches less.
These are the twelve questions written with this SUNYRA nursing manual, to check what it teaches. They are not past papers and were not written to any one examination's pattern; an examination tag means only that the examination's published blueprint covers this subject. Difficulty was not graded in the source, so every question is marked medium.
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