Respiratory assessment

Gail P. Mooney, MSc, PG Social Research Methods, RGN.

Lecturer, School of Health Science, University of Wales, Swansea.

What it is?

What it is?

The function of the respiratory system is to supply adequate oxygen to the tissues and to remove the waste product carbon dioxide. This is achieved with the inspiration and expiration of air. With each breath there is a pause after expiration.

Normal/ideal values

The rate of respiration will vary with age and gender. A respiratory rate of 12-18 breaths per minute in a healthy adult is considered as normal (Blows, 2001).

Tachypnoea – the rate is regular but over 20 breaths per minute.

Bradypnoea – the rate is regular but less than 12 breaths per minute.

Apnoea – there is an absence of respiration for several seconds – this can lead to respiratory arrest.

Dyspnoea – difficulty in breathing, the patient gasps for air.

Cheyne-Stokes respiration – the breathing is shallow, very slow and laboured with periods of apnoea. This type of breathing is often seen in the dying patient.

Hyperventilation – patients may breathe rapidly due to a physical or psychological cause, for example if they are in pain or panicking. Hyperventilation reduces the carbon dioxide levels in the blood, causing tingling and numbness in the hands; this may cause further distress. In adults, more than 20 breaths a minute is considered moderate, more than 30 breaths is severe (Mallett and Dougherty, 2004).

Recording the respirations

Respirations are recorded for a number of reasons:

• To acquire a baseline.
• To monitor a patient with breathing problems.
• To aid in the diagnosis of disease.
• To evaluate the response to medication that affects the respiratory system.

When measuring and recording respirations the rate, depth and pattern of breathing should be recorded.

The depth (volume) of the breath is known as the tidal volume, this should be around 500ml (Blows, 2001).

The rate should be regular with equal pause between each breath. The rate can be irregular with disease of the respiratory system. Any irregularities should be noted and reported to the medical team.

When observing the respiratory rate, noting the colour of the patient’s lips is important. They may be cyanosed (blue) or discoloured if the patient has respiratory problems. Cyanosis can also be observed in the nail bed, tip of the nose and ear lobes (Woodrow, 2005).

The patient’s oxygen saturation (SaO₂) may be recorded using a pulse oximeter. This will provide an accurate reading of oxygenation in the red blood cells. Using a pulse oximeter may require the patient to have less arterial blood gases performed, by providing the medical team with a guide to the patient’s oxygenation level.

Observe the breathing: is the patient mouth breathing, pursing the lips on expiration, using the abdominal muscles or flaring the nostrils? Nostril flaring in children and babies is indicative of acute respiratory distress (Field, 2000).

The respiratory rate is recorded along with other vital observation: pulse, blood pressure and temperature.

Equipment needed:

Watch with a second hand.

Procedure

• Explain to the patient what you are about to do – even if the patient is unconscious.
• Ensure the patient is comfortable.
• Make sure the patient is as relaxed as possible.
• Observe if the patient is distressed in any way.
• It is best to monitor and record the respirations immediately after taking the pulse – this will aid in a more accurate recording, as the patient will not be aware that you are observing respirations. Awareness that respirations are being recorded can make people alter their breathing.
• Observe the rise and fall of the chest (inspiration and expiration) - this counts as one breath.
• The respirations should be counted for a full minute in order to have an accurate recording.
• Note the pattern of breathing and the depth of the breaths.
• Document your findings on the patient’s observation chart, note any changes and report to the medical team.
• Before leaving ensure the patient is comfortable.

When and how often should the respirations be recorded?

The patient’s condition will dictate the frequency of recording. Respirations should always be recorded when a patient is first admitted into hospital, to acquire a baseline record.

Safety

• Wash hands thoroughly between patients - to eliminate the risk of cross infection.
• Record respirations for a full minute to monitor the respiration pattern and to ensure accuracy of the observation.
• If a patient has been prescribed oxygen, ensure the oxygen mask or nasal cannulae is correctly placed prior to recording respirations, and also check that the oxygen flow rate is set as prescribed and recorded on the observation chart.

References

Blows, W.T. (2001) The Biological Basis of Nursing: Clinical Observations. London: Routledge.

Mallett, J., Dougherty, L. (eds) (2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (6^th ed). Oxford: Blackwell Science.

Field, D. (2000) Respiratory care. In: Sheppard, M., Wright, M. (eds) (2000) Principles and Practice of High Dependency Nursing. Edinburgh: Baillière Tindall.

Woodrow, P. (2002) Assessing respiratory function in older people. Nursing Older People; 14, 3, 27-28.