TRINITY VALLEY COMMUNITY COLLEGE

ASSOCIATE DEGREE NURSING

RNSG 1216

PROCEDURE GUIDE AND CHECK-OFF SHEET

ASSESSING RESPIRATIONS

Respiration, the act of breathing, is primarily involuntary but many factors affect the respiratory rate including if the patient is aware of the nurse counting respirations, pain, exercise, fear, anxiety, or temperature. The nurse must assess the rate, rhythm, depth, and effort.

Delegation: This procedure can be delegated to unlicensed assistive personnel with proper training. The nurse retains the responsibility for knowing the patient’s respirations and taking appropriate nursing interventions based on that knowledge. Note: There may

be some times when it is inappropriate to delegate this procedure.

Procedure / Scientific Rationale /
1)  The following equipment is needed for this skill:
a.  watch with a second hand.
2)  Make sure the patient is relaxed, quiet, and does not realize that the nurse is taking the respiratory rate. Wait for at least 15 minutes before counting respiratory rate if patient is not relaxed and quiet. / Fear, pain, or being aware that the nurse is watching may result in an increase rate resulting in a false reading.
3)  Make sure the patient’s chest wall is visible and that nothing is hindering the patient’s respiratory movement. Observation of the movement of the abdomen may also be used to count respirations / Patient can be sitting or lying down but the nurse must make sure the chest movement is easily visible. The abdomen can also be observed since some patients may be diaphragmatic breathers
4)  Continue to hold the patient’s hand after counting the radial pulse and observe the patient’s rise and fall of the chest. Each cycle of inhalation and exhalation is counted as one breath. / Prevents the patient from altering respiratory rate.
5)  The nurse can place a hand on the chest and count respirations if having difficulty in observing the respirations. / By placing a hand on the chest the nurse can feel the rise and fall of the chest.
6)  Count the patient’s respirations noting rate one full inspiration and expiration), rhythm (regular or irregular), depth (deep, normal, or shallow), and effort (labored or unlabored). Count for 30 seconds and multiply by 2 for an adult with a normal rhythm. / Respiratory rate is reported as respirations per minute which is why rate must be multiplied by 2.
With infants and children or adults with an irregular respiratory rate, the nurse must count respirations for 1 full minute.
7)  Document the patient’s respiratory rate in the patient’s record. / Normal respirations are regular rhythm, moderate depth, and no respiratory difficulty.
Newborn 35-40 breaths/minute
Infant up to 1 yr. 30-60 breaths/min
Age 1-3 25-40 breaths/minute

Age 3-6 22-35 breaths/minute

Age 6-12 20-30 breaths/minute

Age 12-18 12-20 breaths/minute
Adult 12-20 breaths/minute
Older Adult 12-20 breaths/minute
8)  Report any abnormal data to the appropriate personnel along with other pertinent respiratory assessment. / Any abnormalities in respirations indicate oxygenation problems which must be addressed immediately. Any
abnormal finding must have a corresponding nursing action.

N:ADN/ADN Syllabus/CBC Curriculum/Level I/1216/Performance Checklist for Basic Skills - Assessing Respirations Reviewed 04/16

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