Vital Signs – Respirations

Equipment:

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• Wristwatch with second hand
• Pen
• Vital sign flow sheet in chart or electronic health record (EHR)

Steps:

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1. WIIAPA:
   1. Wash hands
   2. Introduce self
   3. Identify patient (use 2 identifiers)
   4. Allergies – don’t forget food allergies
   5. Plan of care
   6. Assess patient

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2. Provide Privacy.
3. Be sure that patient’s chest is visible. If needed, move aside bed linen or gown.
4. Place patient’s arm in relaxed position across abdomen or lower chest or place your hand directly over patient’s upper abdomen.
5. Observe complete respiratory cycle (one inspiration and one expiration).
6. After observing a cycle, look at the second hand of the watch and begin to count rate: when the sweep hand hits the number on the dial, begin the time frame, counting one with the first full respiratory cycle. Timing begins with count of one. Respirations occur more slowly than pulse; thus, timing does not begin with zero.
7. If the rhythm is regular, count the number of respirations in 30 seconds and multiply by 2. If the rhythm is irregular, less than 12, or greater than 20, count for 1 full minute.
8. Note depth of respirations by observing the degree of chest wall movement while counting rate. In addition, assess depth by palpating chest wall excursion or auscultating the posterior thorax after you have counted rate. Describe depth as shallow, normal, or deep.
9. Note rhythm of the ventilatory cycle. Normal breathing is regular and uninterrupted. Do not confuse sighing with abnormal rhythm.
10. Replace bed linen and patient’s gown.
11. Perform hand hygiene.
12. Discuss findings with the patient.
13. Document.