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

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).

Passive Range of Motion Exercises

Range of motion exercises are used to help prevent or decrease contractures, improve flexibility of joints, and improve strength [1]. Bedridden patients as well as those with reduced mobility may greatly benefit from passive range of motion exercises. However, do not perform these exercises without an order to do so, as it may be contraindicated in certain situations.

Perineal Care of the Female Resident

Perineal care should be performed during a bath, after using the bedpan, and/or after incontinence. Proper technique is important for maintaining hygiene, preventing infection, and avoiding skin breakdown. Because of the close proximity between a woman’s urethra, vagina, and anus, it is essential to only wipe in a front to back motion. Wiping in the opposite direction is associated with a greater risk for developing a urinary tract infection.

Making an Occupied Bed

If a patient is bedridden or on bedrest, the bed linens will need to be changed while the patient is in the bed. For safety reasons, the nurse’s aid should avoid making an occupied bed if the patient is able to get out of bed. Bed linens should be changed according to the facility’s policy or anytime they are wet or soiled.

Applying a Condom Catheter

Condom catheters are used for men who are incontinent. These catheters are external and are meant to be used short-term and changed daily.

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.