Assessment: Respiratory

  1. Assess for factors that influence respirations: exercise, anxiety, acute pain, smoking, medications, body position, neurologic injury, and hemoglobin function.
  2. Assess for deviations from normal values for arterial blood gases, pulse oximetry, and complete blood count.
  3. Ensure patient privacy, perform hand hygiene, and expose patient's chest if necessary.
  4. With patient seated or supine (head of bed elevated), place patient's arm in relaxed position across the abdomen or lower chest. Or place nurse's hand directly over patient's upper abdomen.
  5. Observe one complete respiratory cycle. Then look at watch's second hand and begin to count respiratory rate, beginning with one.
  6. If rhythm is regular, count number of respirations in 30 seconds and multiply by 2. If rhythm is irregular, less than 12, or greater than 20, count for 1 full minute.
  7. Note depth of respirations and rhythm of ventilatory cycle. Normal breathing is regular and uninterrupted, except for occasional sighs (single deep breaths).
  8. Perform hand hygiene.
  9. Compare respirations with patient's previous baseline and usual rate, rhythm, and depth. If respirations are being assessed for the first time, establish rate, rhythm, and depth as baseline if within acceptable range.
  10. Correlate respiratory rate, depth, and rhythm with data obtained from pulse oximetry and arterial blood gas measurements if available.