Nursing & Healthcare Programs

Measuring the Respirations

Written by Amanda R. McDaniel, MS, BSN, RN
Amanda is a BSN/RN with a MS in Physiology and a BA in English. She worked as a medical writer in the pharmaceutical industry for 11 years before pursuing a career in nursing. She now works as a nurse on a NeuroTelemetry unit and continues to write and edit on a freelance basis. Amanda’s LinkedIn

Respiration is a vital sign that is measured frequently in the healthcare setting. Taking this measurement requires no equipment and relatively little time. However, it is a measurement that must be taken accurately, as a change in respiration may indicate the worsening of a patient’s condition.

Measurement of Respirations

  1. Wash hands properly and introduce yourself to the patient. Close the curtain or door to protect patient privacy.
  2. Ensure that the patient is prepared for the assessment:
    • Wait five to ten minutes after patient activity.
    • The head of the bed should be at 45 to 60 degrees if the patient is lying down.
    • Adjust the bedcovers so that you have a clear view of the patient’s chest and abdomen.
    • The patient’s arms should be in a relaxed position across their lower chest or abdomen.
    • The patient should be calm.
  3. Watch a full breath cycle, both inhalation and exhalation.
  4. Look at a clock with a second hand or a digital clock with seconds displayed. Note the second and begin counting the respirations on the next inhale.
    • This can be accomplished by watching the rise (inhalation) and fall (exhalation) of the patient’s hand on their abdomen or gently placing your hand on the patient’s abdomen and watching it rise and fall.
  5. Count the respirations for one full minute. Note if the breath pattern is regular or irregular. Breathing patterns can include:
    • Regular: In adults, the average rate is 12 to 20 breaths per minute. Newborns have an average rate of 30 to 60. The average for infants (six months to one-year-old) is 30; two-year-olds average 25 to 32; and children aged three to 12 years, average 20 breaths per minute. The geriatric population tends to average 16 to 25 breaths per minute.
    • Hyperventilation: More than 20 breaths per minute (in adults) and deeper than normal.
    • Hypoventilation: Fewer than 12 breaths per minute (in adults) and possibly more shallow than normal.
    • Tachypnea: Depth of breathing is normal, but rate is greater than 20 breaths per minute.
    • Apnea: Pauses in respiration that last for several seconds.
    • Cheyne-Stokes respiration: Pattern alternates between hyperventilation and apnea.
    • Kussmaul’s respiration: Pattern is regular, but the breaths are unusually rapid and deep.
  6. Replace the bed covers.
  7. Wash hands properly.
  8. Document the respiratory rate and pattern in the patient’s record, and inform the nurse of any rate or rhythm abnormality or significant change from the previous rate and/or pattern per institutional or unit protocol.

Amanda R. McDaniel, MS, BSN, RN

References

Fetzer, S. J. (2014). Vital signs and physical assessment. In A. G. Perry, P. A. Potter, and W. R. Ostendorf (Eds), Clinical nursing skills & techniques (8th ed., pp. 86-90). St. Louis, MO: Mosby Elsevier.

More Resources

Fowler’s Position

Fowler’s position is used when a patient is eating, is having difficulty breathing, or is ordered by a doctor. This position is easily recognized because the patient will be sitting “straight up.” Semi-Fowler’s is sitting “half-way up,” and is used when patients cannot be laid flat, but wish to be in a more relaxed position than Fowler’s.

Putting on Personal Protective Equipment

Personal protective equipment is worn to protect the mouth, nose, eyes, clothing, and skin from unwanted pathogens. In the health care setting, a patient’s condition often prompts the use of personal protective equipment; however, a health care worker is able to wear personal protective equipment whenever he or she deems it is necessary (e.g., during procedures with the potential for excessive contact with bodily fluids).

Handwashing for CNAs

Handwashing is considered the single most important practice to prevent the spread of infection. Even when hands look clean, they could potentially be crawling with dangerous microorganisms and pathogens. Using soap and friction during handwashing helps loosen the oils on the skin, allowing dirt and pathogens to be rinsed away.

Axillary Temperature with Electronic Thermometer

Compared to other temperature measurement methods, the axillary measurement is considered the least reliable. An axillary temperature measurement typically reads 0.5 to 1 degree Fahrenheit lower than an oral temperature reading [1]. For this reason, it is recommended to use this method only when other methods are contraindicated or when taking an axillary temperature is the safest method for the patient.

Supine Position

Supine position is a natural and comfortable position for most people. For this reason, it is a highly utilized position for nursing procedures. Unfortunately, this position puts pressure on many bony prominences that can lead to discomfort and/or pressure ulcers if the pressure is not relieved every so often (typically every two hours or less).

Sim’s Position

The position a patient is placed in is often ordered by the physician, or recommended by a speech, occupational, or physical therapist. The position dictates whether a patient is sitting, lying, standing; or if they are on their side, back, or prone (face-down). Positioning is also determined by the patient’s current needs, such as: Are they eating? Sleeping? Having surgery on their back? Are they receiving nutrition through a nasogastric tube?