Assessing Respirations

Purposes:
1. To acquire baseline data against which future measurements can be compared.
2. To monitor abnormal respirations and respiratory patterns and identify changes
3. To monitor respirations before or after the administration of a general anesthetic or any
medication that influence respirations
4. To monitor clients at risk for respiratory alterations
Assessment:
1. Skin and mucous membrane color (cyanosis or pallor)
2. Position assumed for breathing (use of orthopneic position)
3. Signs of lack of oxygen to the brain (irritability, restlessness, drowsiness or loss of consciousness)
4. Chest movements (retractions between the ribs or above or below the sternum)
5. Activity tolerance
6. Chest pain
7. Dyspnea
8. Medications affecting RR
Steps Rationale
Perform hand hygiene and observe appropriate
infection prevention procedures.
Introduce self and verify the client’s identity using
agency protocol.
Inform the client about what you are going to do,
why is it necessary, and how he/she can
participate
Position the patient comfortably
Observe and count respiratory rate
 The client’s awareness that the nurse is
counting the RR could cause the client to
purposefully alter the respiratory pattern.
If you anticipate this, place a hand against
the client chest to feel the chest
movements with breathing, or place the
client’s arm across the chest and observe
the chest movements while supposedly
taking the radial pulse.
 Count the RR for 60 seconds. An inhalation
and exhalation count as one respiration

Observe the depth, rhythm and character of

respirations
 Observe the respirations for depth by
watching the movement of the chest
 Observe the respirations for regular and
irregular rhythm
 Observe the character of respirations, the
sound they produce and the effort they
require
Makes the patient comfortable
Document the RR, depth, rhythm and character
Washes hands