Assessing Respirations

This skill is related to: Vital Signs

Assessing respirations is done to:

• Establish baseline data for subsequent evaluation.
• Identify whether the respirations are within the normal range
• Monitor respirations before or after the administration of a general anesthetic or medication that influences respirations.
• Monitor clients at risk for respiratory alterations (fever, pain, acute anxiety, etc.).

Phase	Nursing Activities
Assessment	Assess skin and mucous membrane color (e.g., cyanosis, pallor), position assumed for breathing (e.g., use of orthopneic position), signs of lack of oxygen to the brain (e.g., irritability, restlessness, drowsiness, or loss of consciousness), chest movements (e.g., retractions between the ribs or above or below the sternum), activity tolerance, chest pain, dyspnea, medications affecting respiratory rate, and history of pulmonary conditions, smoking, exposure to toxic fumes, and living with others who smoke.
Planning	Assign: counting and observing respirations may be assigned to APs. The nurse bears the responsibility of follow-up assessments, interprets abnormal respirations, and determines appropriate interventions. Equipment: clock, timer, or watch with a sweep second hand or digital seconds indicator.
Implementation	For a routine assessment of respirations, determine the client’s activity schedule and choose a suitable time to monitor the respirations. Prior to performing the procedure, the nurse must introduce themselves and verify the client’s identity using agency protocol. Explanation of the nurse’s purpose, the procedure, and how the patient will participate. Perform hand hygiene and observe appropriate infection prevention procedures. Provide client privacy. Observe or palpate and count the respiratory rate. The knowledge of the client about their respirations being observed can alter findings. A method to mitigate this effect is to place the client’s arm across the chest while supposedly taking the radial pulse. Stable patients may be observed for 30 seconds rather than the full 60 seconds; any irregularities will warrant a 60-second assessment. Observe the depth, rhythm, and character of respirations. Depth is based on the amount of movement of the chest. Intervals and timing is used to determine rhythm. Character is based on sound and effort. Document the respiratory rate, depth, rhythm, and character on the appropriate record.
Evaluation	Compare the respiratory rate, rhythm, and depth to recent, baseline, or usual range for the age of the client and other vital signs or health status. Appropriate follow-up is conducted for notifying the primary care provider of any abnormalities or expression of dyspnea. Collaboration with other healthcare team members, such as the respiratory therapist, is arranged.