Measuring Respirations
Key Points
- Respirations are counted for a full 60 seconds for accuracy.
- Resident comfort, privacy, and minimal stimulation support more reliable respiratory observations.
- Abnormal respiratory findings require prompt reporting to the nurse.
Equipment
- Watch or clock with second hand
- Hand hygiene supplies
Procedure Steps
- Perform routine pre-procedure actions: knock, identify resident, explain procedure, provide privacy, and perform hand hygiene.
- Position resident comfortably to allow unobstructed observation of chest or abdominal movement.
- Observe respiratory cycles and count respirations for 60 seconds.
- Reassure resident and check comfort after measurement.
- Restore safety setup as appropriate (bed low/locked and call light accessible).
- Perform hand hygiene.
- Document respiratory rate and report abnormal findings to nurse.
Common Errors
- Counting for less than 60 seconds → increased risk of inaccurate rate.
- Distracting resident immediately before count → altered breathing pattern.
- Failing to report abnormal respiratory rate promptly → delayed response to deterioration.
- Omitting documentation time and context → weak trend comparison across shifts.
Related
- measuring-radial-pulse - Pulse and respirations are paired core vital-sign assessments.
- documenting-and-reporting-data - Objective respiratory reporting supports timely nurse intervention.