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Assessing Respiration

1. The document provides instructions for assessing a patient's respirations using a skills checklist. 2. Key steps include positioning the patient, observing a full respiratory cycle, counting breaths over 30 seconds or 1 minute, and noting the depth and rhythm of respirations. 3. The assessment should be compared to the patient's baseline and age-appropriate parameters, and any abnormal findings should be reported.

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44 views

Assessing Respiration

1. The document provides instructions for assessing a patient's respirations using a skills checklist. 2. Key steps include positioning the patient, observing a full respiratory cycle, counting breaths over 30 seconds or 1 minute, and noting the depth and rhythm of respirations. 3. The assessment should be compared to the patient's baseline and age-appropriate parameters, and any abnormal findings should be reported.

Uploaded by

Jasmine Mankoo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Seneca College Assessing Respirations Skills Checklist

Review Nursing Consideration for Every Skill


1. health care provider (HCP) order 1. Hand Hygiene
2. specific health care facility policy 2. Appropriate PPE
3. if you have the knowledge, skill and 3. Introduce self with designation
judgment to perform the skill 4. Confirmation of patient with 2 indicators
5. Patient privacy
6. Explain procedure & obtain consent
7. Allergies and Sensitivities
8. Check for pain, discomfort or need to use washroom
9. Adjust bed and bedside table to appropriate working height
10. Provide health teaching
Assess
 Risk factors for respiratory alterations
 S&S of respiratory alterations
o cyanotic [blueish] appearance of nail beds, lips, mucous membranes and skin;
o restlessness; irritability; confusion;
o reduced level of consciousness;
o pain during inspirations,
o grunting
o nasal flaring
o labored or difficult breathing;
o adventitious breath;
o inability to breathe spontaneously;
o thick, frothy blood tinged or copious sputum produced on coughing
Assessing 1. Position patient in a comfortable position, preferably sitting or lying.
Respirations 2. Ensure the chest is visible, while leaving gown on
3. OPTION - Place patient’s arm in relaxed position across the abdomen or lower chest, or
place your hand directly over patient’s upper abdomen
4. Observe complete respiratory cycle - one inspiration and one expiration
5. After cycle is observed, look at the watch’s second hand – when second hand reached a
number on watch, begin counting respiratory cycles, starting with “one” for the first full
cycle, then “two” and so on.
 If rhythm is regular - count number of respiration in 30 seconds and multiply by
two
 If rhythm is irregular or less then 12 or greater than 20 - count number of
respiration for a full minute
6. Note depth of respirations
 shallow, normal or deep
7. Note rhythm
 normal breathing is regular and uninterrupted.
 Sighing should not be confused with abnormal rhythm
8. **If assessing pulse rate, please continue with the Pulse Skills Check List**
After Procedure 9. Replace patient’s bed linens.
10. Perform hand hygiene
11. Compare findings to patient’s baseline and to age appropriate parameters.
12. Record rate, rhythm and depth of respirations and use of oxygen.
13. Report abnormal finding

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