Assessment of Respiratory Rate (Adult)

The overall function of the respiratory system is to transport air into the lungs and to allow the diffusion of oxygen into the blood. The waste product of carbon dioxide is received from the blood and exhaled via the respiratory system. Breathing is a vital physiological function and is involved in homeostasis, or maintenance of the equilibrium of the body (Marieb 2017).

The four stages in respiration are:

  1. inspiration (breathing in)

  2. gas exchange within the lungs

  3. respiration at cellular level

  4. expiration (breathing out) (Marieb 2017).


The Royal College of Physicians (2017) advises that a raised respiratory rate is a good indicator of serious illness as well as general pain and distress. Accurate reporting of any change in the respiratory function allows for early intervention and treatment, and prevention of further deterioration in the patient’s condition (Duncan 2017; Massey and Merdith 2011; Clarke and Malecki-Ketchell 2016).

PREPARATION AND SAFETY

  • Carry out hand hygiene.

  • Put on personal protective equipment such as apron and gloves if the patient’s condition indicates this.

  • Explain the procedure and gain the patient’s consent and cooperation.

  • The respiratory rate is usually measured at the same time as other vital signs such as temperature and pulse rate.

  • The patient should be relaxed and resting in a quiet, well-lit environment; otherwise, recent activity should be noted.

  • The patient should be positioned in a comfortable position – sitting upright if possible.

  • Ideally the chest should be exposed to allow observation but removal of thick clothing such as a dressing gown will usually suffice.

  • A more accurate observation is obtained if the patient is unaware that their respirations are being counted. Many nurses achieve this by continuing to ‘pretend’ to feel the radial pulse, while actually observing the movement of the chest wall.

PROCEDURE

  1. Observe the movement of the chest wall and count the respirations for a full 60 seconds. One inhalation (breath in) plus 1 exhalation (breath out) = 1 respiration.
    Rationale – The patient may have an irregular respiratory rate and pattern. Counting for one full minute will measure this accurately.

  2. If the breathing is shallow and difficult to observe, lightly rest your hand on the patient’s chest or abdomen to feel movement.
    Rationale – Very shallow or slow breathing can be difficult to see but you should be able to feel movement of the abdomen.

  3. Observe for the following:

    1. the rhythm and depth of respirations.

    2. symmetry of chest movement to see if both sides are moving equally.

    3. use of accessory muscles: accessory muscles include the sternocleidomastoid, scalene, and trapezius muscles in the neck and shoulders. 

    4. excessive use of the abdomen.
      Rationale – Alterations to the rhythm and depth of respirations may indicate a change in the patient’s condition. Use of the accessory muscles suggests that the diaphragm and intercostal muscles are not being used efficiently.

  4. Additionally observe for:

    1. colour – especially cyanosis (blue discoloration) of lips and fingertips. If the patient is dark skinned this can be best observed in the oral mucosa just inside the mouth.

    2. noise – for example, wheeze, stridor. Note if these occur on inspiration, on expiration, or at rest.

    3. cough – observe the characteristics. Is it dry? Productive? What does the sputum look like if present?

    4. equal movement of both sides of the chest.
      Rationale – These additional observations will assist in determining the diagnosis, treatment, and ongoing nursing care of the patient.

ONGOING CARE, MONITORING, AND SUPPORT

  • Thank the patient for their cooperation.

  • Advise them of your findings and any further action you will take, for example, ask the doctor to review.

  • Ensure the patient is comfortable, with the nurse call system to hand if needed.

  • Review the patient as their condition dictates or if there are any changes.

DOCUMENTATION AND REPORTING

  • Document the respiratory observations according to local policy, and report any changes as appropriate to senior nursing or medical staff.

  • Adjust the frequency of observations as necessary or as instructed or as indicated by a change in the NEWS2, if in use.

EQUIPMENT

  • Watch with a second hand.

  • Patient’s documentation, charts, and pen.

  • Apron and non-sterile gloves if needed.

  • Hand-washing or alcohol gel.