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SKILL 5-4

Assessing Respirations
NSO

Basic Skills / Vital Signs / Assessing Respirations

Vital Signs Module / Lesson 4 Chest wall Abdominal cavity

The mechanism of respiration exchanges oxygen (O2) and carbon dioxide (CO2) between cells of the body and the atmosphere. Three processes are involved in respiration: ventilation, mechanical movement of gases into and out of the lungs; diffusion, movement of oxygen and carbon dioxide between the alveoli and the red blood cells; and perfusion, distribution of red blood cells to and from the pulmonary capillaries. You assess ventilation by observing the rate, depth, and rhythm of respiratory movements. Accurate assessment of respiration depends on recognizing normal thoracic and abdominal movements. Normal breathing is both active and passive. On inspiration the diaphragm contracts, causing abdominal organs to move downward and forward, thereby increasing the vertical size of the chest cavity. At the same time, the ribs lift upward and outward and the sternum lifts outward to aid the transverse expansion of the lungs. On expiration the diaphragm relaxes upward, the ribs and sternum return to their relaxed position, and the abdominal organs return to their original position (Fig. 5-9). During quiet breathing, the chest wall gently rises and falls. The body uses more energy during inspiration than during expiration. Expiration is an active process only during exercise, voluntary hyperventilation, and certain disease states.

Inspiration

Diaphragm Expiration Chest wall Abdominal cavity

Diaphragm FIG 5-9 Diaphragmatic and chest wall movement during inspiration and expiration.

Consider specic factors related to patient history or risk for increased or decreased respiratory rate or irregular respirations. Report any abnormalities in respiratory rate or rhythm to the nurse.

Delegation Considerations
The skill of respiration measurement can be delegated to NAP unless the patient is considered unstable (i.e., complaints of dyspnea). The nurse directs the NAP to:

Equipment
Wristwatch with second hand or digital display Pen, pencil, and vital sign ow sheet or record form

STEP
ASSESSMENT 1 Determine need to assess patients respirations: a Assess for risk factors of respiratory alterations: Fever Pain and anxiety Diseases of chest wall or muscles Constrictive chest or abdominal dressings Presence of abdominal incisions Gastric distention Chronic pulm onary disease (emphysema, bronchitis, asthma) Traumatic injury to chest wall with or without collapse of underlying lung tissue Presence of a chest tube Respiratory infection (pneumonia, acute bronchitis) Pulmonary edema and emboli Head injury with damage to brain stem Anemia

RATIONALE

Certain conditions place patient at risk for ventilatory alterations detected by changes in respiratory rate, depth, and rhythm.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

STEP
b

RATIONALE
Physical signs and symptoms indicate alterations in respiratory status.

Assess for signs and symptoms of respiratory alterations, such as the following: Bluish or cyanotic appearance of nail beds, lips, mucous membranes, and skin Restlessness, irritability, confusion, reduced level of consciousness Pain during inspiration Labored or difcult breathing Orthopnea Use of accessory muscles Adventitious breath sounds (see Chapter 6) Inability to breathe spontaneously Thick, frothy, blood-tinged, or copious sputum production c Assess for factors that inuence character of respirations: (1) (2) (3) Exercise Anxiety Acute pain

(4) (5)

Smoking Medications

(6)

Body position

(7) (8)

Neurological injury Hemoglobin function

Allows nurse to anticipate factors that will inuence respirations, ensuring a more accurate interpretation. Respirations increase in rate and depth to meet the need for additional oxygen and rid the body of carbon dioxide. Anxiety causes increase in respiration rate and depth due to sympathetic nervous system stimulation. Pain alters rate and rhythm of respirations; breathing becomes shallow. Patient inhibits or splints chest wall movement when pain is in area of chest or abdomen. Chronic smoking changes pulmonary airways, resulting in an increased respiratory rate at rest when not smoking. Narcotic analgesics, general anesthetics, and sedative hypnotics depress rate and depth; amphetamines and cocaine increase rate and depth, bronchodilators cause dilation of airways that ultimately slows respiratory rate. Standing or sitting erect promotes full ventilatory movement and lung expansion; stooped or slumped posture impairs ventilatory movement; lying at prevents full chest expansion. Damage to the brain stem impairs the respiratory center and inhibits rate and rhythm. Decreased hemoglobin levels lower the amount of oxygen carried in the blood, which results in increased respiratory rate to increase oxygen delivery. An increase in altitude lowers the amount of saturated hemoglobin, which increases respiratory rate and depth. Arterial blood gas values measure arterial blood pH, partial pressure of oxygen and carbon dioxide, and arterial oxygen saturation, which reect patients oxygenation status.

2 Assess pertinent laboratory values: a Arterial blood gases (ABGs): Normal ranges (values vary

slightly among institutions): pH, 7.35 to 7.45 PaCO2, 35 to 45 mm Hg PaO2, 80 to 100 mm Hg SaO2, 95% to 100% b Pulse oximetry (SpO2): Normal SpO2, 90% to 100%; 85% to 89% is acceptable for certain chronic disease conditions; less than 85% is abnormal (see Skill 5-6). c Complete blood count (CBC): Normal CBC for adults (values vary within institutions): Hemoglobin: 14 to 18 g/100 mL, males; 12 to 16 g/100 mL, females Hematocrit: 40% to 54%, males; 38% to 47%, females Red blood cell count: 4.7 to 6.1 million/mm3, males; 4.2 to 5.4 million/mm3, females 3 Determine previous baseline respiratory rate (if available) from patients record.

SpO2 less than 85% is often accompanied by changes in respiratory rate, depth, and rhythm. Complete blood count measures red blood cell count, volume of red blood cells, and concentration of hemoglobin, which reects patients capacity to carry oxygen.

Allows nurse to assess for change in condition. Provides comparison with future respiratory measurements.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

SKILL 5-4

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STEP
NURSING DIAGNOSES

RATIONALE

Activity intolerance Ineffective airway clearance

Ineffective breathing pattern Impaired gas exchange

Impaired spontaneous ventilation

Individualize related factors based on patients condition or needs.

PLANNING 1 Expected outcomes following completion of procedure: Respiratory rate is within acceptable range. Respirations are regular and of normal depth. 2 If patient has been active, wait 5 to 10 minutes before assessing respirations.
3 Assess respirations after pulse measurement in adult.

4 Be sure patient is in comfortable position, preferably sitting or

lying with the head of the bed elevated 45 to 60 degrees.

Adults average 12 to 20 respirations per minute. Respiratory status is stable. Exercise increases respiratory rate and depth. Assessing respirations while patient is at rest allows for objective comparison of values. Inconspicuous assessment of respirations immediately after pulse assessment prevents patient from consciously or unintentionally altering rate and depth of breathing. Sitting erect promotes full ventilatory movement. Position of discomfort will cause patient to breathe more rapidly.

Critical Decision Point Assess patients with difculty breathing (dyspnea), such as those with heart failure, abdominal ascites, or in late stages of pregnancy, in the position of greatest comfort. Repositioning may increase the work of breathing, which will increase respiratory rate. IMPLEMENTATION 1 Draw curtain around bed and/or close door. Perform hand hygiene. 2 Be sure patients chest is visible. If necessary, move bed linen or gown. 3 Place patients arm in relaxed position across the abdomen or lower chest, or place nurses hand directly over patients upper abdomen (see illustration).

Maintains privacy. Prevents transmission of microorganisms. Ensures clear view of chest wall and abdominal movements. A similar position used during pulse assessment allows respiratory rate assessment to be inconspicuous. Patients or nurses hand rises and falls during respiratory cycle.

STEP 3 4 Observe complete respiratory cycle (one inspiration and one

Nurses hand over patients abdomen to check respiration.

expiration). 5 After observing cycle, look at watchs second hand and begin to count rate: when sweep hand hits number on dial, begin time frame, counting one with rst full respiratory cycle.

Rate is accurately determined only after nurse has viewed respiratory cycle. Timing begins with count of one. Respirations occur more slowly than pulse; thus, timing does not begin with zero.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

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STEP
If rhythm is regular, count number of respirations in 30 seconds and multiply by 2. If rhythm is irregular, less than 12, or greater than 20, count for 1 full minute. 7 Note depth of respirations by observing degree of chest wall movement while counting rate. Also, assess depth by palpating chest wall excursion or auscultating the posterior thorax after you have counted rate (see Chapter 6). Describe depth as shallow, normal, or deep. 8 Note rhythm of ventilatory cycle. Normal breathing is regular and uninterrupted. Do not confuse sighing with abnormal rhythm.
6

RATIONALE
Respiratory rate is equivalent to number of respirations per minute. Suspected irregularities require assessment for at least 1 minute (Box 5-4). Character of ventilatory movement reveals specic disease states restricting the volume of air from moving into and out of the lungs.

Character of ventilations reveals specic types of alterations. Periodically people unconsciously take single deep breaths or sighs to expand small airways prone to collapse.

Critical Decision Point Any irregular respiratory pattern or periods of apnea (cessation of respiration for several seconds) are symptoms of underlying disease in
the adult and you need to report this to the health care provider or nurse in charge. Further assessment and immediate intervention is often necessary. 9 Replace bed linen and patients gown. 10 Perform hand hygiene. 11 Discuss ndings with patient as needed.

Restores comfort and promotes sense of well-being. Reduces transmission of microorganisms. Promotes participation in care and understanding of health status.

EVALUATION 1 If assessing respirations for the rst time, establish rate, rhythm, and depth as baseline if within acceptable range. 2 Compare respirations with patients previous baseline and usual rate, rhythm, and depth. 3 Correlate respiratory rate, depth, and rhythm with data obtained from pulse oximetry and arterial blood gas measurements if available.

Used to compare future respiratory assessment. Allows nurse to assess for changes in patients condition and for presence of respiratory alterations. Evaluation of ventilation, perfusion, and diffusion are interrelated.

Unexpected Outcomes
1 Respiratory rate is below 12 breaths per minute (bradypnea) or above 20 breaths per minute (tachypnea). Breathing pattern is sometimes irregular (see Box 5-4). Depth of respirations increased or decreased. Patient complains of feeling short of breath.

Related Interventions
Assess for related factors, including obstructed airway, abnormal breath sounds, productive cough, restlessness, anxiety, and confusion (see Chapter 6). Assist patient to supported sitting position (semi- or high-Fowlers) unless contraindicated. Provide oxygen as ordered (see Chapter 23). Assess for environmental factors that inuence patients respiratory rate, such as secondhand smoke, poor ventilation, or gas fumes. Notify health care provider or nurse in charge if alteration continues. Notify health care provider for additional evaluation and possible medical intervention.

2 Patient demonstrates Kussmauls, Cheyne-Stokes, or Biots respirations (see Box 5-4).

Recording and Reporting

Record respiratory rate on vital sign ow sheet or record (see Fig. 5-6). Record abnormal depth and rhythm in narrative form in nurses notes. Document measurement of respiratory rate after administration of specic therapies in narrative form in the nurses notes. Indicate type and amount of oxygen therapy, if used, in nurses notes. Report abnormal ndings to nurse in charge or health care provider.

Pediatric Considerations
Assess respiratory rates before other vital signs or assessments, if you are able to view movement of chest wall or abdomen. This will allow assessment of rate and rhythm before the child becomes anxious due to stranger anxiety or fear of other assessment procedures. Average respiratory rate (breaths per minute) for newborns is 30 to 60; infant (6 months to 1 year) is 30 to 50; toddler (2 years) is 25 to 32; and child from 3 to 12 years is 20 to 30. Children up to age 7 breathe abdominally so respirations are observed by abdominal movement. An irregular respiratory rate and short apneic spells are normal for newborns. Nurses can simply observe infant or young child while chest and abdomen are exposed. A young child may breathe slowly for a few seconds and then suddenly breathe more rapidly. Use cardiorespiratory monitors for infants or newborns that are at risk for respiratory compromise or sustained apnea.

Teaching Considerations
Patients who demonstrate decreased ventilation often benet from learning deep breathing and coughing exercises (see Chapter 23). Instruct family caregiver to contact home care nurse or health care provider if unusual uctuations in respiratory rate occur.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

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Gerontological Considerations
Aging causes ossication of costal cartilage and downward slant of ribs, resulting in a more rigid rib cage, which reduces chest wall expansion. Kyphosis and scoliosis, frequent in older adults, may also restrict chest expansion. Depth of respirations tends to decrease with aging. The change in lung function with aging results in respiratory rates generally higher in older adults with a range of 16 to 25 breaths per minute. Some older adults depend more on accessory abdominal muscles during respiration than weakened thoracic muscles.

Home Care Considerations

Assess for environmental factors in the home that inuence patients respiratory rate, such as secondhand smoke, poor ventilation, or gas fumes.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.