ASSESSING RESPIRATIONS

DEFINITION:
Respiration is the act of breathing. Inhalation or inspiration refers to the intake of air into the lungs.
Exhalation or expiration refers to the breathing out or the movement of gases from the lungs to the
atmosphere. Ventilation is also referring to the movement of air in and out of the lungs. (Berman, 2016)

PURPOSES:
 To acquire baseline data against which future measurements can be compared
 To monitor abnormal respirations and respiratory patterns and identify changes
 To monitor respirations before or after the administration of a general anesthetic or any medication
that influences respirations
 To monitor clients at risk for respiratory alterations (e.g., those with fever, pain, acute anxiety,
chronic obstructive pulmonary disease, asthma, respiratory infection, pulmonary edema or emboli,
chest trauma or constriction, brainstem injury)

PRINCIPLES:
 Wash hands before and after every procedure.
 Provide client privacy
 Before taking the vital signs, be sure that the patient has rested.

EQUIPMENT:
 Clock or watch with a sweep second hand or digital indicator

STEPS:
1. Introduce self, identify the client (ask the
complete name, check the wristband, and bed
tag) and explain the procedure.
RATIONALE:
Checking physician’s order can help the nurse to
know what specific part of the body to be treated.
Introducing oneself helps build trust and rapport
with the patient. And explaining the procedure
helps the patient understand, prepare for the
procedure, and reduces anxiety.

2. Wash hands. To prevent the spread of microorganism.

3. Provide for client's privacy. For the patient to be comfortable and ease anxiety.

4. Observe or palpate and count the respiratory The client’s awareness that the nurse is counting the
rate. respiratory rate could cause alteration of the
 The client's awareness that the nurse is respiratory pattern. (Berman, 2011)
counting the respiratory rate could cause the
client to alter the respiratory pattern. If you
anticipate this, place a hand against the
client's chest to feel the chest movement
with breathing, or place the client's arm
across the chest and observe the chest
movement while supposedly taking the
radial pulse.
 Count the respiratory rate for one full
minute. An inhalation and an exhalation are
counted as one respiration.
5. Observe the depth, rhythm, and character of The client’s awareness that the nurse is counting the
respirations. respiratory rate could cause alteration of the
 Observe the respirations for depth by respiratory pattern. (Berman, 2011)
watching the movement of the chest.
 Observe the respirations for regular or
 Normally,
irregular rhythm.
 Observe the character of respirations- the
sound they produce and the effort they

respirations are
require.

evenly spaced.
(Berman,
2016)
Normally, respirations are evenly spaced.
(Berman,2016)

Normally, respirations are silent and effortless.

(Berman, 2016)
6. Make the client feel comfortable and wash your To have fast recovery of the patient and to prevent
hands. spread of microorganism.

7. Document the respiratory rate on the client’s This is done to evaluate for changes in condition
record. and alterations.

REFERENCE:
Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2017a). Fundamentals of Nursing. Elsevier
Gezondheidszorg.
Berman, A. T., Snyder, S., & Msn Rn, F. G. E. (2020). Kozier & Erb’s Fundamentals of Nursing:
Concepts, Process and Practice (11th ed.). Pearson.