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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

Performing Ostomy Care

Residents who have had a portion of their intestines removed due to illness or trauma may have a temporary or permanent ostomy, which is an opening in the abdomen that is created for the elimination of urine or feces. The portion of the intestine that is connected to the abdominal wall and is visible is called the stoma. A pouch is placed over the stoma to collect feces.

Measuring Blood Pressure

Many factors can interfere with obtaining an accurate blood pressure. The most common mistakes that lead to inaccurate blood pressures are a result of improper technique, including: not supporting the patient’s arm, using the wrong sized cuff, positioning the cuff too low on the patient’s arm, improper positioning of the cuff’s artery marker, and attempting to measure blood pressure through clothing.

person wearing orange and white silicone band

Applying Restraints

Restraints have very strict guidelines for use due to the number of complications that can result. Use of restraints is associated with increased physical and psychosocial health issues. Restraints are only considered necessary when restraint-free alternatives have failed and the patient or others are at risk of harm without the restraints. It is illegal to use restraints for the staff’s convenience or to punish the patient.

Indwelling Catheter Care

Indwelling catheters allow urine to drain from the bladder. They are used when residents are unable to urinate on their own or when the process of cleaning the resident after urination would be difficult for the resident to tolerate (such as during end of life care). Caring for the catheter appropriately is a vital part of preventing infection and skin breakdown.

Caring for a Patient’s Dentures

For patients with dentures, care of the dentures is just as important as brushing natural teeth. Good denture hygiene and fit helps prevent oral irritation and infection.

Assisting the Resident to Transfer from the Bed to a Chair or Wheelchair

It is important to remember on which side to place the chair when assisting a patient in transferring. Putting the chair on the resident’s unaffected side allows the resident to lead with his or her strong extremity. This eases the procedure for the resident and reduces the risk of falling.

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