Respiration - Nursing Pathways

Report
How to
Measure
Respirations
Presentation
title
SUB TITLE HERE
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

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