Monitoring respiratory rate

Monitoring respiratory rate - monitoring a client’s respiration rate is essential to facilitate the evaluation of medical treatment and nursing interventions.

Equipment:
A digital watch or watch with a second hand, together with an appropriate chart for recording, is required. The procedures and rationales are given below.

Procedure	Rationale
Explain procedure and ensure adequate understanding	Promote client co-operation and obtain informed consent, though this step is often omitted where there is a danger that the person may voluntarily control their breathing and thus alter the rate
Count respirations as chest rises and falls for a period of one minute	To monitor rate and compare to norm values New-born: 30–80 rpm Early childhood: 20–40 rpm Late childhood: 15–25 rpm Adult male: 14–18 rpm Adult female: 16–20 rpm Pulse-to-respiration ratio = 5:1
Observe depth of respirations	To monitor depth and compare to norm – usually shallow and effortless
Listen for breath sounds, e.g. stridor, wheeze, rub, rattle	To monitor sounds and compare to norm –usually almost inaudible
Observe pattern of breathing and use of accessory muscles	To monitor pattern and compare to norm –usually effortless
Observe colour of skin/mucous membranes, e.g. pallor, cyanosis	To ensure that adequate oxygen is getting to the tissues (i.e. tissue perfusion)
Record rate on appropriate chart and report any abnormalities	Legal requirement to maintain documentation and safeguard client through good communications