Procedure of Assessing Respirations

Procedure of Assessing Respirations

Equipment
■ A watch or clock with a second hand or digital readout. Assessment
■ Observe for signs of respiratory distress: breathing faster or slower than normal, gasping breaths, confusion, circumoral cyanosis.
■ Determine the baseline respiratory rate and character of respirations.
■ Assess for factors that may affect the respiratory rate (e.g., pain, activity, fever, respiratory disorders).

Key Points
■ Count unobtrusively (e.g., while palpating the radial pulse).
■ Count for 30 seconds if respirations are regular; for 60 seconds if they are irregular. A 60-second count is recommended for increased accuracy, even for regular respirations.
■ Observe the rate, rhythm, and depth of respirations.

Evaluation and Documentation
■ Usually, you will document routine VS (including respirations) on a graphic or flowsheet.
■ When a nursing note is needed, document:
■ Respiratory rate and rhythm.
■ That respirations are either labored or unlabored.
■ If labored, describe in what way (e.g., intercostal retractions, use of accessory muscles, nasal flaring.)
■ Be Smart! Compare to baseline findings. Note other VS, especially temperature. Look for trends. If respirations are not within normal limits, assess oxygenation with a pulse oximeter.

Assess respirations unobtrusively while palpating the pulse