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The NUR 325 Module 2 example, in full
Focused Respiratory Assessment: Low-Grade Fever and Falling Oxygen Saturation on the Second Day After Abdominal Surgery
[Student Name]
Southern New Hampshire University
NUR 325: Patient Assessment and Health Literacy
Module Two Focused Assessment
[Instructor Name]
[Date]
The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.
Focused Respiratory Assessment: Low-Grade Fever and Falling Oxygen Saturation on the Second Day After Abdominal Surgery
Subjective Data
Chief complaint: "It hurts to take a big breath, so I just don't."
History of present illness: A 61-year-old woman, a school bus dispatcher, is on postoperative day two after open repair of a large ventral hernia through a midline abdominal incision under general anesthesia. Since yesterday evening she has felt short of breath with activity, such as walking to the bathroom. Onset: gradual over about 12 hours. Character: a sense that she cannot fill her lungs. Aggravating factors: deep breaths and coughing, which pull on the incision. Relieving factors: shallow breathing and lying still. Associated symptoms: a mild, dry cough she suppresses because of pain, and feeling warm. Denies chest pain, calf pain or swelling, productive sputum or chills. Pain at the incision is 6 out of 10 despite scheduled analgesia; she has been reluctant to use the pain button for fear of becoming sleepy.
Relevant history: Body mass index of 36, treated hypertension, former smoker who quit 10 years ago after 25 years of smoking. No asthma or chronic lung disease. Has walked twice since surgery. She has used the incentive spirometer "a few times" and reached about 250 milliliters; the goal written on the device is 1,500 milliliters.
Objective Data
Vital signs: temperature 37.9 degrees Celsius, heart rate 98 beats per minute and regular, respiratory rate 24 breaths per minute and shallow, blood pressure 136/82 mmHg, oxygen saturation 91 percent on room air, down from 96 percent on the day of surgery.
Inspection: Alert and oriented; the bed is almost level, raised only 20 degrees at the head. Rapid, shallow respirations with little lower chest movement. Holds the abdomen when she coughs. No accessory muscle use or cyanosis. Midline abdominal dressing dry and intact.
Palpation: Chest expansion reduced at both bases, more on the right. Tactile fremitus equal at the upper lobes and slightly reduced at the right base. Calves soft, nontender, without swelling.
Percussion: Resonant over the upper lung fields; mildly dull at the right posterior base.
Auscultation: Breath sounds vesicular in the upper fields and diminished at both bases, more on the right. Fine, late inspiratory crackles at the right base. After three coached deep breaths and a splinted cough, the crackles partly cleared and breath sounds at the right base improved. No wheezes, bronchial breath sounds or egophony. Heart sounds regular.
Interpretation
The findings point to atelectasis, collapse of small air spaces in the dependent parts of the lungs, which is one of the most common pulmonary problems after surgery. General anesthesia, an upper abdominal or midline incision, pain that limits deep breathing, obesity and a smoking history all increase the risk (Miskovic & Lumb, 2017). Shallow breathing without periodic deep breaths allows alveoli at the bases to close. The result is reduced expansion, dullness and diminished breath sounds at the bases, fine crackles as collapsed air spaces pop open at the end of inspiration, and lower oxygen saturation as blood passes through unventilated lung (Bickley et al., 2021). The partial clearing of crackles and improvement in breath sounds after deep breaths and coughing is the most useful finding, because it shows that the lung can be reopened.
Other explanations were considered. Pneumonia would be more likely with a productive cough, higher fever, bronchial breath sounds or egophony over a consolidated area, and crackles that do not clear with coughing; none of these were present, though pneumonia can develop if atelectasis persists. Pulmonary embolism remains possible after surgery, but the absence of calf findings and the gradual onset make it less likely; the provider should still consider it if oxygen saturation keeps falling. Fluid overload would usually produce bilateral crackles higher in the lungs and weight gain. Risk models for postoperative pulmonary complications include factors this patient has, such as abdominal surgery and low preoperative oxygen reserve, which is why a small change in saturation deserves attention (Canet et al., 2010).
Communication: SBAR Handoff to the Provider
Situation: 61-year-old woman on postoperative day two after open ventral hernia repair with oxygen saturation 91 percent on room air, down from 96, temperature 37.9, respiratory rate 24 and shallow.
Background: Body mass index 36, former smoker, hypertension. Midline incision. Pain 6 out of 10; avoiding deep breaths and the pain button. Incentive spirometer used rarely, reaching 250 milliliters.
Assessment: Reduced basal expansion, right basal dullness, diminished breath sounds at both bases and fine right basal crackles that partly clear with deep breathing and coughing. No calf findings. I think this is atelectasis related to pain and shallow breathing, but pneumonia and embolism need to be considered if she does not improve.
Recommendation: Please review her pain regimen so she can breathe deeply, and consider a chest radiograph. I have raised the head of the bed, started coached deep breathing and spirometer use every hour while awake, and will recheck saturation and lung sounds in one hour and call if saturation falls below 90 percent or she develops chest pain.
Teaching the Patient
The patient's reluctance to breathe deeply and use her pain medication was the main driver of the problem, so teaching focused on those two points in plain language. The nurse explained: "When you breathe shallowly, the bottom parts of your lungs close up like a deflated balloon. That is why your oxygen is lower. Deep breaths open them again, and I heard that happen when you coughed just now." The nurse showed her how to hug a pillow against the incision before coughing and demonstrated the incentive spirometer, then had her show it back until she reached 750 milliliters. The nurse also explained that taking pain medication as planned is part of recovery, because pain that stops her from breathing deeply is more dangerous than the medication at the prescribed dose.
Using teach-back, the patient described what to do every hour while awake: ten slow breaths on the spirometer, then a splinted cough, and she named the warning signs to report, chest pain, worsening breathlessness or feeling faint.
Summary
A structured focused respiratory assessment found reduced basal expansion, dullness, diminished breath sounds and crackles at the right base that improved with deep breathing, a pattern consistent with postoperative atelectasis in a patient with several risk factors. The nurse considered pneumonia, embolism and fluid overload, communicated the findings and a plan through SBAR, and addressed the root cause, shallow breathing driven by pain, through clear teaching checked with teach-back.
References
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Canet, J., Gallart, L., Gomar, C., Paluzie, G., Vallès, J., Castillo, J., Sabaté, S., Mazo, V., Briones, Z., & Sanchis, J. (2010). Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology, 113(6), 1338-1350. https://doi.org/10.1097/ALN.0b013e3181fc6e0a
Miskovic, A., & Lumb, A. B. (2017). Postoperative pulmonary complications. British Journal of Anaesthesia, 118(3), 317-334. https://doi.org/10.1093/bja/aex002
How this NUR 325 Module 2 example is structured
A focused assessment is graded on whether the data are complete, organized and interpreted, so this one follows the order a nurse collects and reports information. Subjective data come first, including a symptom analysis for the breathlessness and the surgical context. Objective data follow in examination order, inspection, palpation, percussion and auscultation, with the two sides compared at each step and a note on what changed after deep breathing. The interpretation weighs the pattern against pneumonia, embolism and fluid overload. An SBAR handoff shows how the nurse communicated, and a closing section shows teaching delivered at a level the patient could use.
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Upload the NUR 325 Module 2 assessment instructions and rubric and the body system or patient your section assigned. The desk writes a focused assessment sample to that prompt in 24 to 48 hours; the first is free. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.
NUR 325 Module 2 questions, answered
What does NUR 325 Module 2 usually involve?
Early in the course many sections begin system-focused assessments, often through a digital clinical experience, and ask students to document subjective and objective findings and interpret them. Respiratory assessment is a common early system. Your classroom materials specify the platform, patient and documentation format.
How should I document lung sounds in a focused assessment?
Describe the sounds by location and side, name the type of sound using standard terms, and compare the two sides. For example, diminished breath sounds at both bases, fine inspiratory crackles at the right base that partly clear after coughing. Avoid vague terms like clear or normal without saying where you listened.
Why include patient teaching in a NUR 325 assessment paper?
The course pairs patient assessment with health literacy, so many prompts ask how you would explain findings or next steps to the patient. Showing a short, plain-language explanation, checked with teach-back, demonstrates that you can turn clinical data into information the patient can use.