Vital Signs: Respirations
Prerequisite Skills
Concepts of Communication
Critical Element Criteria
Students must meet criteria of Critical Elements to safely perform the skill based on evidence-based practice. Score can be pass/fail, letter grade, or point assignment. Only acceptable score for Critical Elements is 100%
Critical Elements
- Understanding of the importance and variations that can occur with the respiratory rate assessment.
- Create appropriate physical environment.
- Provide privacy.
- Explain procedure.
- Wash hands.
Procedure
Prior to Treatment: (Critical Thinking)
- Gather equipment: Watch with second hand.
- Consider age related variations for exam.
Patient Interaction: (Safety)
- Patient identifiers.
- Create appropriate physical environment.
- Provide privacy.
- Explain procedure.
- Wash hands.
Procedure: (Patient Centered Care)
- Flex patient"s arm and place forearm across the chest or counts unobtrusively.
- Count for 30 seconds if respirations are regular, doubling to determine breaths per minute.
- Count for 60 seconds if breathing is irregular.
- Observe rate, rhythm, and depth.
After Procedure (Patient Centered Care, Safety)
- Provide appropriate nursing management for abnormal findings.
Documentation (Informatics, Communication)
- Outcome of assessment.
- Interventions used for nursing management of care.
- Patient"s response to interventions.