Skill List > Assessment of Breathing
Clinical Alert
Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:
Based on Nicol: Essential Nursing Skills 4E
Adapted by: Moya Paton BSc MAEd PGCE RNT RN(Adult) RN(Children)
Reviewed by: Katy Elliott BN Hons RN
Last updated: June 2017
Learning Objective
After reading the skill overview, watching the video, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of assessing the patient’s breathing.

Introduction

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 2014).

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 2014).

The assessment of breathing, and counting and recording the respiratory rate, is a crucial part of the overall assessment of the patient’s vital signs (Smith & Rushton 2015). It is important that close and accurate observation of breathing and respiratory rate is not restricted to those patients with conditions known to affect breathing such as asthma or other respiratory or cardiovascular conditions, but that careful observation is carried out for all patients (The Royal College of Physicians (RCP) 2012).

It has been noted that measuring and recording the respiratory rate is frequently overlooked, not carried out accurately, or in up to 50% of cases is not carried out at all. Failure to carry out observation and monitoring of breathing and the respiratory rate represents poor practice which may adversely affect patient safety (NHS National Institute for Health and Care Excellence (NICE) 2017.

The accurate identification of any alteration in the respiratory function is key to early detection of a change in the patient’s condition. The respiratory rate is considered to be a sensitive predictor of clinical deterioration (RCP 2015, Smith & Rushton 2015). Changes may occur in breathing and the respiratory rate long before other changes in the vital signs. Impending adverse clinical events which may be preceded by changes in respiratory function include sepsis, cardiac arrest, metabolic disturbance, and neurological deterioration (Clarke & Malecki-Ketchell 2016). The Royal College of Physicians 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 (Massey & Merdith 2011, Clarke & Malecki-Ketchell 2016).

Recording of the respiratory rate forms an integral part of current evidence-based clinical early warning scoring systems and is the first parameter documented in the National Early Warning Score (NEWS). The respiratory rate is often recorded at the same time as other vital signs such as temperature, pulse, blood pressure, and oxygen saturation levels. According to NICE (2007), the respiratory rate should be recorded a minimum of 12 hourly and more frequently as the patient’s condition dictates or as indicated by the NEWS score (The Royal College of Physicians 2012).

It is imperative that the nurse ensures that measurement and recording of breathing and the respiratory rate is carried out carefully and accurately, and that any change is reported immediately to the nurse or clinician in charge (RCP 2012, Rushton 2015).

No special equipment is required to measure and record the respiratory rate; however, good clinical observation skills and a sound underpinning knowledge of the importance of measuring this vital sign are crucial.

Respiratory rate must not be taken in isolation but forms a part of the whole assessment (RCP 2012).  If the patient looks unwell the nurse or clinician in charge must be informed as certain medications such as opiate (i.e. morphine or codeine) and sedatives may affect the respiratory rate (Clarke & Malecki-Ketchell 2016).  In patients who are in pain and or anxious, their respiratory rate may be higher than their normal and again, this needs to be reported to the nurse or clinician in charge.

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 NEWS if in use.
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