Skill 2-6

Assessing Respiration

Measuring respirations allows for baseline assessment of respiratory function, as well as providing insight into the status of the patient's homeostatic control (the body's internal environment) and presence of physiologic conditions, such as hypoxia (Rolfe, 2019). Respiratory rate abnormalities are important predictors of deteriorating patient conditions and serious events, including cardiac arrest and intensive care admission (Malyca et al., 2019; Tessorolo Souza et al., 2019). Accurate assessment and interpretation of respirations as part of vital sign measurement are important parts of clinical assessment (Rolfe, 2019).

Ventilation (or breathing) is movement of gases in and out of the lungs; inspiration (or inhalation) is the act of breathing in, and expiration (or exhalation) is the act of breathing out. The cycle of inspiration and expiration is counted as one breath. Respiratory rates are measured in breaths per minute. Under normal conditions, healthy adults breathe about 12 to 20 times per minute (respirations per minute); infants and children breathe more rapidly (Hess et al., 2021). Fundamentals Review 2-1 outlines respiratory rate ranges for different age groups. The depth of respirations varies normally from shallow to deep. Respiratory rhythm is the pattern of the breaths and the intervals between them. Respiratory rhythm is normally regular; the breaths and the pauses between occur at evenly spaced intervals. An irregular respiratory rhythm occurs when the breaths and pauses between beats occur at unequal, varied intervals. Table 2-1 outlines various respiratory patterns.

Assess respiratory rate, depth, and rhythm by inspection (observing and listening) or by listening with the stethoscope. Determine the rate by counting the number of breaths per minute.

Move immediately from the pulse assessment to counting the respiratory rate to avoid letting the patient know you are counting respirations. Patients should be unaware of the respiratory assessment because awareness of measurement by observation can alter breathing patterns or rate (Hill et al., 2018).

Delegation Considerations

The measurement of respirations may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Watch with second hand or digital readout
Electronic record or pen and paper or flow sheet
PPE, as indicated

Assessment

Assess the patient for factors that could affect respirations, such as physical activity, medications, body temperature, smoking, anxiety, pain, and presence of disease and/or health conditions. Note baseline or previous respiratory measurements. Assess patient for any signs of respiratory distress, which include retractions, nasal flaring, grunting, dyspnea , orthopnea , or tachypnea.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or needs may require the use of this skill as part of related interventions. An appropriate health problem or need may include:

Altered breathing pattern
Impaired gas exchange
Ineffective airway clearance

Outcome Identification and Planning

The expected outcomes to achieve when assessing respirations are that the patient's respirations are assessed accurately without injury, and the patient experiences minimal discomfort. Other outcomes may be appropriate, depending on the specific diagnosis or patient problem identified for the patient.

Implementation

Action	Rationale
1. While your fingers are still in place for the pulse measurement, after counting the pulse rate, observe the patient's respirations (Figure 1).	The patient may alter the rate of respirations if aware they are being counted (Hill et al., 2018).
2. Note the rise and fall of the patient's chest.	A complete cycle of an inspiration and an expiration composes one respiration.
3. Using a watch with a second hand, count the number of respirations for 30 seconds. Multiply this number by 2 to calculate the respiratory rate per minute. Avoid counting for a 15-second interval.	Sufficient time is necessary to observe the rate, depth, and other characteristics (Hill et al., 2018; Jarvis & Eckhardt, 2020). Use of a 15-second interval and multiplying by 4 can result in a respiratory count that is significantly incorrect (Hill et al., 2018; Jarvis & Eckhardt, 2020). Some literature suggests 60-second counts should be implemented whenever possible to ensure accuracy (Kallioinen et al., 2017).
4. If respirations are abnormal in any way, count the respirations for at least 1 full minute (Jarvis & Eckhardt, 2020).	Increased time allows the detection of unequal timing between respirations.
5. Note the depth and rhythm of the respirations.	This provides additional assessment data regarding the patient's respiratory status (Jarvis & Eckhardt, 2020).
6. When measurement is completed, remove gloves, if worn. Perform hand hygiene. Cover the patient and help them to a position of comfort.	Proper removal of gloves reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. Covering and positioning the patient ensures patient comfort.
7. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene deters the spread of microorganisms.

Evaluation

The expected outcome has been met when the patient's respirations have been assessed accurately without injury, and the patient experienced minimal discomfort.

Documentation

Guidelines

Document respiratory rate, depth, and rhythm on electronic record or flow sheet. Communicate any abnormal findings to the appropriate person.

Sample Documentation

Practice documenting respiration and other vital signs in Lippincott DocuCare.

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

The patient is breathing with such shallow respirations that you cannot count the rate: Sometimes it is easier to count respirations by auscultating the lung sounds. Auscultate lung sounds and count respirations for 30 seconds. Multiply by 2 to calculate the respiratory rate per minute. If the respiratory rate is irregular, count for a full minute. Notify the primary health care provider of the respiratory rate and the shallowness and irregularity of the respirations.

Special Considerations

General Considerations

If respiratory rate or depth is irregular, count respirations for 1 minute.
If respirations are very shallow and difficult to detect, observe the sternal notch, where respiration is more apparent.
If respirations are difficult to detect, such as with patients who are obese or with children, place a hand on the upper chest or abdomen to feel the respiratory rate (Jarvis & Eckhardt, 2020). Alternatively place a hand on the patient's shoulder to feel the respiratory rate (Jensen, 2019).

Infant and Child Considerations

For infants and children, count respirations for 1 full minute to ensure accuracy (Kyle & Carmen, 2021).
Infants' respirations are primarily diaphragmatic; count abdominal movements to assess respiratory rate for infants (Jensen, 2019; Kyle & Carmen, 2021).
Count thoracic movements to assess respiratory rate for infants and children older than 1 year of age (Kyle & Carmen, 2021).
Assess respirations before taking the temperature so that the child is not crying, which would alter the respiratory status.
Assess respirations in infants and children when the child is resting or sitting quietly, because respiratory rate often changes when infants or young children cry, feed, or become more active. The most accurate respiratory rate is obtained when the infant or child is at rest (Jensen, 2019; Kyle & Carmen, 2021).

EVIDENCE FOR PRACTICE

Accurate Respiration Measurement

Measurement of respirations is part of a baseline assessment of respiratory function and provides insight into the status of the patient. Respiratory rate abnormalities are important predictors of deteriorating patient conditions and serious events, including cardiac arrest and intensive care admission (Malyca et al., 2019; Tessorolo Souza et al., 2019). Accurate assessment and interpretation of respirations as part of vital sign measurement are important parts of clinical assessment (Rolfe, 2019).

Related Research

Kallioinen, N., Hill, A., Christofidis, M. J., Horswill, M. S., & Watson, M. O. (2021). Quantitative systematic review: Sources of inaccuracy in manually measured adult respiratory rate data. Journal of Advanced Nursing, 77(1), 98-124. https://doi.org/10.1111/jan.14584

The purpose of this systematic review was to identify potential sources of inaccuracy in manually measured adult respiratory rate data and quantify their effects. A search of Medline, CINAHL, and Cochrane library databases was performed (from databased inception to July 31, 2019). Quantitative studies were included that investigated manual measurement of adult patients' respiratory rate (RR) in clinical settings; identified at least one specific potential source of inaccuracy in the observation or documentation of RR; and, in relation to each source of inaccuracy identified, quantified the prevalence or independent effect on documented RR values. Evidence quality was evaluated by using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields (Kmet et al., 2004, as cited in Kallioinen et al., 2021, p. 100). Studies presenting data on individual sources of inaccuracy in the manual measurement of adult RR were analyzed, assessed for quality, and grouped according to the source of inaccuracy investigated. Quantitative data were extracted and synthesized, and meta-analyses performed where appropriate. Identified studies (n = 49) identified five sources of inaccuracy: (1) the awareness effect creates an artefactual reduction in actual RR; (2) observation methods involving shorter counts cause systematic underscoring of RR; (3) inter- or intraobserver variability causes substantial differences between individual RR measurement observations; (4) value bias in which particular RRs are overrepresented, suggesting estimation; and (5) recording omission, resulting in higher average rates in inpatient versus triage/admission contexts. The researchers concluded manually measured RR data are subject to several potential sources of inaccuracy and a single measurement may be affected by several factors. The researchers suggested health care providers should interpret recorded RR data cautiously unless systems are in place to ensure its accuracy. According to the authors, nurses should count rather than estimate RR, and 60-second counts should be implemented whenever possible to ensure accuracy. Nurses should ensure patients are unaware that their RR is being measured and take care to accurately document the resulting RR value.

Relevance to Nursing Practice

Measurement of respirations provides insight into the status of the patient and is an important predictor of changes and declines in a patient's status. Assessing vital signs as part of a nursing assessment is an important component of care in all health care settings. The usefulness of respiratory rate data depends on the accuracy of the observations and documentation. Nurses have a responsibility to obtain and record accurate measurements of respiratory rate to contribute to accurate and appropriate identification of and changes in patient status.

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Skill 2-6

EVIDENCE FOR PRACTICE