Vital Signs
Assessing Respiration: Rate, Rhythm, and Effort
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- » Taking a Temperature
- » Assessing Radial Pulse
- » Assessing Apical Pulse
- » Assessing Apical-Radial Pulse
- » Assessing Respiration: Rate, Rhythm, and Effort
- » Obtaining Blood Pressure by the One-Step Method
- » Obtaining Blood Pressure by the Two-Step Method
- » Measuring Oxygen Saturation with Pulse Oximetry
- » Assessing Pain
- » Measuring Height and Weight
Take the Review Test:
Safety
- Assess the patient with dyspnea, such as one with congestive heart failure, abdominal ascites, or advanced pregnancy, in the position of greatest comfort (the head of the bed is usually elevated to 45 to 60 degrees to promote full ventilatory movement).
- Repositioning may increase the work of breathing, which will increase the respiratory rate.
- Report a respiratory rate of less than 12 or more than 20 breaths per minute or shallow, slow respiration (hypoventilation) to the health care provider or nurse in charge without delay. Immediate intervention may be needed.
- Alert the health care provider or nurse in charge to occasional periods of apnea, which signal an underlying disease in an adult.
Equipment
(Roll cursor over items to see labels)
Wristwatch with second hand or digital display
PrintableDelegation
Do not delegate the skill of assessing respiration if the patient’s condition is unstable. Before delegating this skill to nursing assistive personnel (NAP) for a stable patient, be sure to inform NAP of the following:
- The frequency of measurement and factors related to patient history or risk of increased or decreased respiratory rate or irregular respiration
- The patient’s usual respiratory values and the need to report to you any unusual values
Preparation
- Determine the need to assess the patient’s respiration.
- Note risk factors for respiratory alteration, such as fever, pain or anxiety, diseases of the chest wall or muscles, constrictive chest or abdominal dressings, presence of abdominal incisions, gastric distention, chronic pulmonary diseases, traumatic injury to the chest wall with or without collapse of underlying lung tissue, presence of a chest tube, respiratory infection, pulmonary edema or emboli, head injury with damage to the brain stem, and anemia.
- Assess for signs and symptoms of respiratory alteration, such as bluish or cyanotic appearance of nail beds, lips, mucous membranes, and skin; restlessness, irritability, confusion, or reduced level of consciousness; pain during inspiration; labored or difficult breathing; orthopnea; accessory muscle use; adventitious breath sounds; inability to breathe spontaneously; thick, frothy, blood-tinged, or copious sputum produced on coughing.
- Assess for factors that can affect respiratory rate, such as exercise, anxiety, acute pain, smoking, medications, body position, neurologic injury, and altered hemoglobin levels.
- Assess the results of pertinent tests, including arterial blood gas (ABG) analysis, pulse oximetry, and complete blood count. Compare the patient’s test results with normal values for each test, which may vary among agencies.
- Determine the previous baseline respiratory rate (if available) from the patient’s record.
- If the patient has been active, wait 5 to 10 minutes before assessing respiration.
- Assess respiration after measuring the pulse, so that the patient will not try to voluntarily control his or her breathing.
- Be sure the patient is in a comfortable position, such as sitting or lying with the head of the bed elevated 45 to 60 degrees to promote full ventilatory movement.
Follow-up
- If the patient’s respiration was assessed for the first time, establish this respiratory rate, depth, and rhythm as the baseline. Compare the patient’s respiratory rate to the acceptable range for his or her age.
- If this was not the first respiratory assessment, compare it with the patient’s baseline and usual assessments.
- Correlate the respiratory rate, depth, and rhythm with data obtained from pulse oximetry and arterial blood gas measurements, if available.
- Report abnormal findings to the nurse in charge or to the health care provider.
Documentation
- Document the respiratory rate, depth and rhythm in the electronic medical record (EMR) or nurse's notes.
- Document the measurement of respiratory rate after administration of specific therapies.
- Record the type and amount of oxygen therapy, if used.
- Report abnormal findings to the nurse in charge or to the health care provider.
- Document abnormal respiratory rate, depth and rhythm in the appropriate area of the EMR or nurse's notes.
Review Questions
1. Which action can the nurse take to keep a patient from consciously controlling his or her breathing during an assessment?
Take the patient's temperature while counting the respiratory rate. 
Assess respiration after measuring the pulse. - Assess respiration after taking the blood pressure.
- Assess respiration before measuring the blood pressure.
INCORRECT. This action will not prevent the patient from consciously controlling breathing during an assessment.
CORRECT. Assess respiration after measuring the pulse, so that the patient will not try to voluntarily control his or her breathing.
INCORRECT. This action will not prevent the patient from consciously controlling breathing during an assessment.
INCORRECT. This measure will not prevent the patient from consciously controlling breathing during an assessment.
2. On the last assessment of a patient's respiration, her respiratory rate was 10 breaths per minute. What should the nurse do when conducting the next assessment of this patient’s respiratory rate?
- Count breaths for 10 seconds and multiply by 6.
- Count breaths for 15 seconds and multiply by 4.
- Count breaths for 30 seconds and multiply by 2.
- Count breaths for 60 seconds.
INCORRECT. If the respiratory rate is less than 12 breaths per minute, the nurse should count the patient's breaths for a full 60 seconds.
INCORRECT. If the respiratory rate is less than 12 breaths per minute, the nurse should count the patient's breaths for a full 60 seconds.
INCORRECT. If the respiratory rate is less than 12 breaths per minute, the nurse should count the patient's breaths for a full 60 seconds.
CORRECT. The nurse should count the patient's breaths for a full 60 seconds, because her respiratory rate is less than 12 breaths per minute.
3. When measuring a patient’s respiratory rate, the nurse will count the number of completed respiratory cycles per minute. What is the definition of a respiratory cycle?
- The number of inspirations per minute.
- The number of expirations per minute.
- The number of sighs per minute.
- The number of inspirations and expirations per minute.
INCORRECT. A respiratory cycle consists of one inspiration and expiration, An inspiration is only one half of a respiratory cycle.
INCORRECT. A respiratory cycle consists of one inspiration and expiration. An expiration is only one half of a respiratory cycle.
INCORRECT. The number of sighs per minute is not a respiratory cycle. Sighs are not included in the count of respiratory cycles.
CORRECT. A complete respiratory cycle consists of one inspiration and one expiration.
4. During the assessment of a patient’s respiratory rate, when the second hand reaches the 15-second mark, the respiratory count is 8. What should the nurse do at this time?
- Stop the assessment.
- Stop the assessment, and multiply the number 8 by 2.
- Stop the assessment, and multiply the number 8 by 6.
- Continue to count the patient's breaths for a full 60 seconds.
INCORRECT. The nurse should not stop the assessment. At 8 breaths in the first 15 seconds, the patient has a rapid respiratory rate of more than 20 breaths per minute. The nurse should continue to count the breaths for a full 60 seconds.
INCORRECT. Multiplying the 15-second respiratory rate by 2 would calculate the respiratory rate for only 30 seconds, not the full 60 seconds required when the respiratory rate is rapid.
INCORRECT. Multiplying the 15-second respiratory rate by 6 is not the correct way to calculate a patient’s respiratory rate.
CORRECT. At 8 breaths in the first 15 seconds, the patient has a rapid respiratory rate of more than 20 breaths per minute. The nurse should continue to count the breaths for a full 60 seconds.
5. The nurse plans to assess a patient’s respiratory rate; however, the patient has just returned from ambulating to the bathroom. What should the nurse do to minimize the effect of exercise on the patient’s respiratory rate?
- Assess the pulse for a full 60 seconds before assessing respiration.
- Encourage the patient to rest for 10 minutes before assessing respiration.
- Compare the postexercise respiratory rate with his baseline findings.
- Compare the postexercise findings with the previous at-rest findings.
INCORRECT. The effects of exercise on the respiratory rate will most likely be present after 1 minute.
CORRECT. Waiting 10 minutes before assessing respiration allows the patient's oxygen demand to return to pre-exercise levels.
INCORRECT. Such a comparison will not minimize the effect of exercise on the patient’s respiratory rate.
INCORRECT. Such a comparison will not minimize the effect of exercise on the patient's respiratory rate.
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