ASSESSING RESPIRATION

ASSESSING RESPIRATION

Respiration is a complex vital function with two complementary processes, the internal and external respirations. Respiration is the act of breathing. One act of respiration consists of one inhalation and on exhalation. Inhalation or inspiration is the act of breathing in, and exhalation, or expiration, is the act of breathing out.

External respiration is a combination of movements delivering air to the body’s circulatory system.

1. Ventilation

2. Conduction of air

3. Diffusion and

4. Perfusion.

Objectives/Purposes:

The respiratory rate is assessed to:

 Determine the per minute rate on admission as a base for comparing future measurements.

 Monitor the effect of injury, disease or stress on the client’s respiratory system.

 Evaluate the client’s response to medications or treatments that affect the respiratory system.

Key Points:

 Assess the client for factors that could indicate respiratory variations.

 Without telling the client what you are doing, watch the chest movements in and out.

 Count in each ventilatory movement as one respiration.

 Count for 30 seconds or one full minute.

Equipment:

 Watch with second hand.

 Paper, pencil

 Vital signs record.

 Abnormal Breathing Patterns

 Recording and Reporting:
 Record respiratory rate and character in nurses’ notes or vital sign flow sheet. Indicate type and amount of oxygen therapy if used by client during assessment. Measurement of respiratory rate after administration of specific therapies should be documented in narrative form in nurses’ notes.
 Report abnormal findings to nurse in charge or physician.

Home care Considerations:
Assess for environmental factors in the home that may influence client’s respiratory rate such as second-hand smoke, poor ventilation, or gas fumes.