Respiration - Nursing Pathways
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Transcript Respiration - Nursing Pathways
How to
Measure
Respirations
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Vital Signs in the Ambulatory Setting:
An Evidence-Based Approach
Cecelia L. Crawford, RN, MSN
Respiration Measurement - An Overview
• Equipment for accurate respiratory measurement
Watch or clock with second hand or digital second
counter
Stethoscope
Pen or pencil
Flowsheet, chart, or medical record
Clean hands and fingers!
• Patient in a comfortable & relaxed position
• Waited 5 minutes if patient was active
• Enough time to count the respiratory rate
Respirations – It’s All About The Numbers!
Terminal Digit Preference
• Some people may show a preference for
certain numbers in respiratory rate readings*
Zeros, even numbers, odd numbers
• Be aware you might “like” certain numbers
more than others!
(*Roubsanthisuk, W., Wongsurin, U., Saravich, S., & Buranakitjaroen, P., 2007)
Respiratory Rate Procedure
1. Wash hands & put on gloves, if
appropriate
2. Provide privacy
3. Assist patient to a comfortable & relaxed
position
Respiratory Rate Procedure
4. Position patient for
clear view of chest
movement
5. Place patient’s arm or
your own hand in a
relaxed position
across stomach or
lower chest
6. Observe a complete
respiratory cycle
An inhale and an
exhale
http://www.lane.k12.or.us/CSD/CAM/level1/ASSESS
Respiratory Rate Procedure
7. Count for 60 sec
Full minute count for:
Children
Irregular respirations
Very fast or very slow respirations
8. Count for 30 sec and multiply X2
Shorter time counts = inaccurate data
Normal Respiratory Rates
AGE
Newborn to 6 weeks
Infant (6 weeks to 6 months)
Toddler ( 1 to 3 years)
Young Children ( 3 to 6 years)
Older Children (10 to 14 years)
Adults
BREATHS/MIN
30 - 60
25 - 40
20 - 30
20 - 25
15 - 20
12 - 20
(Mosby’s Critical Care Nursing Reference, 2002; Perry & Potter, 2006)
Respiratory Rate
9. Pediatric patients
If panting, use
stethoscope to count
Agitation can result in
inaccurate RR
Respiratory Rate Procedure
Respiratory rates are NOT a reliable way
to determine low oxygen levels!
RN and MD assessment is needed
Respiratory Rate Procedure
10. Inform the RN or MD for:
Difficult to count
respirations
Very fast or very slow
breathing
Irregular breathing
If patient seems to be
having trouble breathing
Respiratory Rate Procedure
11. Discuss
respiratory rate
with patient or
parent
12. Remove gloves
& wash hands
Respiratory Rate Procedure
13. Document the Results
Flowsheet, clinic record,
or clinic chart
14. Communicate the Results
RN
MD
Respiratory Measurement in the Clinic
• YOU can make the
difference:
Welcoming presence
Decrease any
anxieties & fears
Reassure patients &
family
Accurate vital signs