Skill List > Respiration Assessment (Child)
Clinical Alert
A child’s inability to breathe spontaneously needs immediate attention. As much as possible, always keep family members present during the assessment because a child’s fear affects respirations (Hockenberry & Wilson 2014). For infants and children with difficulty breathing (dyspnoea) resulting from factors such as airway obstruction, asthma, congestive heart failure, or abdominal distension, assess them in their most comfortable position. Repositioning may increase the work of breathing, which will increase the respiratory rate and/or cause airway obstruction.

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 Mosby Nursing Skills    
Adapted by: Matthew Carey RN Child BSc Dip HE
Updated by: Janet Kelsey BSc(Hons) MSc PGCEA AdvDipEd RSCN RN RNT
Last updated: August 2017
Tripod position.
Location of recessions. (From Hockenberry M J, Wilson D 2007 Wong's Nursing Care of Infants and Children, 8th edn. Mosby, St Louis.)
Imaginary landmarks of the chest. A Anterior. B Right lateral. C Posterior. (From Hockenberry M J, Wilson D 2007 Wong's Nursing Care of Infants and Children, 8th edn. Mosby, St Louis.)
Location of lobes within thoracic cavity. A Anterior view. B Left lateral view. C Right lateral view. D Posterior view. (From Hockenberry M J, Wilson D 2007 Wong's Nursing Care of Infants and Children, 8th edn. Mosby, St Louis.)
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 respiratory assessment in children and infants.

Introduction

Respiratory failure leading to respiratory arrest is the most common pathway to cardiac arrest in infants and young children with respiratory illness (advanced Life Support Group 2016). Children are subject to lower and upper obstruction as a direct result of their anatomy and physiology (Aylott 2008, Hammer 2013). Therefore, a thorough assessment of respiratory status is essential essential and respiratory rate, pattern and effort should form part of the assessment and measurement of vital signs of every child or young person (Royal College of Nursing 2017).

The function of the respiratory system is to supply oxygen (O2) to the tissues and eliminate carbon dioxide (CO2) from the body (Tortora 2016). The respiratory control centre is located in the brainstem where the rate of ventilation is managed through changes in arterial carbon dioxide and hydrogen ion concentrations. Three processes are involved in respiration:

  • Ventilation: the mechanical movement of gases into and out of the lungs.
  • Diffusion: the movement of O2 and CO2 between the alveoli and the red blood cells.
  • Perfusion: the delivery of arterial blood to the tissues (cells) of the body.

In children, respiratory function affects all body systems, and, conversely, all body systems greatly affect respiratory effort. For instance, children have faster metabolic rates than adults; the younger the child is, the higher the oxygen requirement (Hammer 2013). A child’s anatomical and physiological characteristics include the following:

  • Trachea is short (length is proportional to age, e.g., an infant’s trachea is around 7 mm long).
  • Airway diameter is small.
  • Cricoid cartilage is the narrowest part of the airway.
  • Alveoli are fewer in number but increase with age.
  • Larynx is high and anterior.
  • Epiglottis is high, large, and floppy.
  • Ribs are horizontal (chest diameter at maximum so cannot increase tidal volume) and cartilaginous.
  • Chest wall is thin.
  • Intercostal muscles are poorly developed so the diaphragm is the muscle of respiration.
  • Infants up to the age of 4 months are obligate nose breathers, have a large head in proportion to their total body size, and a decreased ability to maintain their airway in a neutral (open) position (Aylott 2008, Hammer 2013, Tortora 2016).

Breathing consists of inspiration and expiration. Inspiration occurs when the external intercostal muscles and the diaphragm contract, increasing the volume of the thoracic cavity. In the paediatric patient, the diaphragm is the stronger of the muscles and is the major organ of respiration (Hammer 2013). During expiration, the same muscles relax and there is an accompanying decrease in the size of the thoracic cavity. During normal breathing the chest and abdomen gently rise and fall. Inspiration is an active process and expiration is passive when at rest; therefore, more energy is required during inspiration than during expiration. Expiration becomes an active process only during exercise, purposeful hyperventilation, and certain disease states.

Because of the immature intercostal muscles and cartilaginous ribs, chest wall collapse on inspiration occurs during respiratory distress and recession is seen. Restriction of air flow in the upper or lower airways causes reduced pressure in the thoracic cavity during inspiration, and the muscles are pulled inwards (recession). Recession can be supraclavicular, suprasternal (tracheal tug), sternal, substernal, subcostal, or intercostal. In addition, children with respiratory distress may also exhibit nasal flaring or, in infants, head bobbing. Severe respiratory distress can result in a breathing pattern known as ‘see-saw’ breathing, which is the paradoxical movement of the abdomen during inspiration. Another sign of severe respiratory distress is grunting, a forced expiration against a partially closed glottis, which helps keep alveoli open (Aylott 2006).

Normal respiratory rates for paediatric patients vary with age and, like adults, increase with stress or activity (Advanced Life Support Group 2016).  When assessing the respiratory rate of a child, the nurse must consider the age-specific norm (Table 1); the presence of any chronic respiratory problem; the child’s temperature (Nijman et al. (2012) reported that temperature has a 'modest yet clinically significant effect on the respiratory rate of children'; the presence of stress, fear, or pain; and any activity occurring just prior to the assessment.

Table 1 Normal respiratory rate relating to age. (Advanced Paediatric Life Support 2016.)

Age (years)

 Respiratory rate (breaths/min)

Neonate

< 1

1–5

5–12

> 12

25–50

25–40

20–35

18–25

12–24

Assessment should incorporate observation of the general appearance and position of the child (to maintain own airway), respiratory rate, work of breathing, and quantity and quality of breath sounds hence incorporating the look, listen and feel approach (Aylott 2008, Advanced Life Support Group 2016).The nurse directly assesses breathing by observing rate, depth, rhythm, symmetry, effort, and pattern of breathing, including looking for any signs of increased work of breathing.

Begin by looking. Are they struggling to breathe? Do they look drowsy or lethargic or irritable and restless? Are the responsive? What is their skin colour – is it pale mottled or cyanosed? Is their trachea central or is it deviated to the side? All of these can be assessed with a hands-off approach. The presence of oral or nasal secretions should be noted, and the colour and amount of the secretions. The presence of a cough should be noted and, if productive, the characteristics of the sputum. The child’s chest and abdomen are assessed, noting their shape and the movements during breathing. Is the child breathing regularly? Are they breathing rapidly then slowing or halting? Remember this may be a normal pattern of breathing for small infants. What is the rate of breathing measured over 60 seconds? Observe for signs of respiratory distress such as recession or head bobbing as described above. 

Listen for any audible upper (stridor or grunting) or lower (wheezing) airway sounds; these may be heard without a stethoscope. Ask the parents what sounds they have heard and how the child’s breathing has changed from normal. Listen with a stethoscope for the child’s lung sounds: what sounds can be heard? Are there clear breath sounds or coarse noises caused by secretions? Are the sounds localised or spread across the chest? Identify where you can hear them and document this. If no sound at all is heard this is potentially life threatening, as it may indicate no air entry and emergency assistance should be sought. Assess all of the chest listening to the anterior, posterior, under the axilla, and to the length of the inspiratory and expiratory phases. The expiratory phase should be about twice as long as the inspiratory phase. Alterations in this timing may indicate where the obstruction is: an upper airway obstruction may cause increased inspiratory time and a lower airway obstruction an increased expiratory phase.  

Feel by placing your hands on the chest – you should feel vibration as the child speaks or cries and this should be equal on both sides.

Infants should be approached with care because loud noises or rapid movements may startle them, causing an increase in their respiratory rate. Younger children may also be frightened by strangers and should be approached gradually, after first speaking with the child. Many observations can be easily made when a child is sleeping or when being held by a family member. When possible, assess respirations for baseline rate, rhythm, depth, symmetry, and audible respiratory sounds from a reasonable distance before approaching the child. At the same time, note level of consciousness including muscle tone and position, developmentally appropriate behaviour, interaction with the environment and family, skin colour, and quality of speech or cry (Advanced Life Support Group 2016).

If respiratory dysfunction is suspected during assessment, additional procedures may be carried out, including pulse oximetry (SpO2), blood gas, full blood count, chest X-ray, peak expiratory flow rate (PEFR), or end-tidal CO2 monitoring in the seriously unwell infant or child. Pulse oximetry is a non-invasive measurement of oxygen levels, and for infants and children without cardiac disease should be 94% or above (Advanced Life Support Group 2016)  A full blood count assesses the level of haemoglobin (needed to carry oxygen). Blood gases provide essential information regarding levels of oxygen, CO2 retention, and acid–base balance. A chest X-ray will provide an image of the heart, lungs, airways, and blood vessels and can assist in the diagnosis of many conditions. A peak flow meter measures the air flow on expiration. End-tidal CO2 monitoring provides an assessment of how effectively CO2 is being exhaled from the lungs (children experiencing respiratory depression will have elevated levels of CO2) (Advanced Life Support Group 2016).

Patient and family education

  • Teach or reinforce the child’s and family’s understanding about the purpose of respiratory assessment, the nurse’s role, and how family can help the infant or child in the process.
  • Answer the child’s and family’s questions about respiratory assessment.
  • Consider simple ways to assess the child’s respiratory status, recognise problems, and intervene, such as assessing for nasal congestion in the infant and providing basic airway clearance procedures (e.g., suctioning) before feeding.
  • Educate the child and family on the child’s condition, assessment, and any immediate interventions required, as appropriate.
  • Educate and refer the child and family to appropriate resources for long-term assessment needs when required.
  • Discuss the assessment in relation to any medications or interventions that may be required with the child and family.
  • Provide discharge instructions related to recognition of respiratory problems, including appropriate contact information.

Preparation and safety

  • Determine the need to assess the child’s respirations:
    • Assess the child’s age and developmental level and family’s understanding of the need for assessment.
    • Note the risk factors for respiratory changes: fever, pain, anxiety, fear, respiratory infection, upper or lower airway dysfunctions, diseases of chest wall or muscles, constrictive chest or abdominal dressings, abdominal incisions, gastric distension, chronic pulmonary disease, traumatic injury to chest wall with or without collapse of underlying lung tissue, presence of a chest tube (chest drain), pulmonary oedema and emboli, head injury with damage to brain stem, and anaemia.
    • Assess for signs and symptoms of respiratory distress:
      • Child’s appearance: pallor, cyanosis, restlessness, irritability, confusion, or reduced level of consciousness, decreased muscle tone.
        Any significant changes in respiratory status or rate associated with decreased level of consciousness, irritability, listlessness, or any abnormal neurological sign or symptom requires immediate intervention (Advanced Life Support Group 2016).
      • Assess the child’s breathing for any of the following: pain during inspiration; laboured or difficulty breathing; apnoea, bradypnoea, or tachypnoea; use of accessory muscles (recession); abnormal breath sounds; nasal discharge, nasal flaring, congestion, sputum; head bobbing, tracheal tug, type and quality of cry, cough, audible upper or lower airway noises; position of comfort; dysphagia; or drooling.
        Caution: any respiratory signs or symptoms, if abnormal for the child’s age, need further assessment and intervention.
  • Assess for factors that influence the character of respirations:
    • Infants are unique.
      Young infants often have periodic breathing. The infant may take slow breaths for a few seconds and then suddenly breathe more rapidly. There should not be any accompanying abnormal signs or symptoms, and the respiratory rate should be within the expected range for age. Any persistent resting respiratory rate greater than 60 breaths/min without reasonable explanation (e.g., fever) is a sign of respiratory distress.
    • Anxiety and fear increase respiratory rate and may increase effort.
    • Exercise increases respiratory rate and depth.
    • Acute pain alters respiratory rate and rhythm, makes breathing shallow, and may inhibit or cause splinting of chest or abdominal wall movement in painful areas.
    • Passive smoke exposure or smoking increases respiratory rate at rest even when not smoking.
    • Certain medication can affect respiration. Narcotics, sedation, and general anaesthetics cause depression of respiratory rate and depth. Amphetamines, cocaine, and many illegal street drugs can increase the respiratory rate and depth. Bronchodilators can improve breathing and slow the respiratory rate (to normal), although some cause tachycardia and nervousness, which may result in an increased respiratory rate.
    • Body position can support breathing and lung expansion through standing or sitting erect or being held upright; however, a stooped or slumped posture can impair ventilatory movement and chest expansion. Laying an infant flat on their abdomen when asleep will splint and support their breathing.
      Children and older infants generally assume a position of comfort that enables their airway to be open as much as possible and facilitates breathing. Young infants, unable to support their head, may need to be positioned with the head slightly elevated in an infant car seat or propped up in a cot while being closely observed.
    • Neurological injury or illness can inhibit respiratory rate and rhythm. Children with a congenital or acquired neurological condition must be assessed as related to their baseline.
    • Haemoglobin function can affect the respiratory status, for example, decreased levels of haemoglobin (anaemia) or decreased functioning of haemoglobin (high altitude sickness or sickle cell anaemia). Decreased oxygen delivery to the tissues causes an increase in respiratory rate.
    • Associated tachypnoea is caused by fever, metabolic acidosis, shock, and cardiac problems.
  • Determine the infant or child’s normal previous baseline observations (if available) from their notes.
  • Assess the child and obtain the respiratory history of the child:
    • Ask the child or their family about the child’s breathing:
      • Discuss the child’s feeding and level of activity making note of any difficulties related to fatigue, breathing, or colour change.
        Rationale – Infants and children in respiratory distress will often exhibit a change in behaviour from their norm. In addition, older children and infants may show little interest in wanting to eat or drink. Young infants may have a weak suck and decreased intake related to fatigue and inability to nurse or bottle feed (Hockenberry & Wilson 2014).
      • Assess for presence and duration of signs and symptoms such as upper airway congestion, nasal discharge or nasal flaring, cough (dry or productive), sputum (colour, odour, and amount), or sudden onset of drooling relating to upper airway obstruction (in children who would not be expected to be teething).
        Rationale – The history as given by either the child or family can provide valuable diagnostic information when combined with the physical assessment and adjunctive tests.
      • Obtain a history related to the presence of congenital or acquired, acute or chronic airway and breathing abnormalities.
    • Obtain information regarding the child’s developmental milestones and assess for any chronic neurological or developmental problems.
  • Assess the child’s and family’s readiness or need to learn about respiratory assessment.
  • Provide developmentally appropriate toys or a child’s normal comfort item for distraction. If the child appears stable and is being held by a family member, allow the child to remain with that person.
  • Obtain an appropriately sized, latex-free stethoscope.

Procedure

  1. Perform hand hygiene. Wear personal protective equipment where necessary.
  2. Identify the correct child, confirming full name.
  3. Draw the curtain around the cot or bed and/or close the door.
    Rationale – Maintains privacy.
  4. Before approaching the child, quickly assess level of consciousness, general appearance, work of breathing, and perfusion to the skin (Advanced Life Support Group 2016).
  5. If the child’s level of understanding is appropriate, if they are not in distress, and appear active, attempt to quiet the child before taking vital signs.
  6. Without disturbing the infant or child, assess respiratory rate, counting over 60 s. If possible, ask the family to move bedlinen or loosen clothing to allow assessment of the chest and abdomen. The healthcare professional may pretend to take a pulse or listen to the heartbeat while observing the respiratory rate.
    Rationale – Children may alter their respiratory pattern if they are disturbed or made aware that you are counting their respirations (Aylott 2008). Infants and young children may have periodic breathing or slightly irregular breathing and therefore require the full 1 min count. Loosening clothing or bedlinen ensures a clear view of chest wall and abdominal movements. The normal respirations of an infant are primarily diaphragmatic; simultaneous abdominal and chest movement will be noted (Advanced Life Support Group 2016).
  7. Depending on the child’s status, rate can be counted by observing, palpating, or auscultation. It is important for the healthcare professional to be aware of normal respiratory rates depending on age (Advanced Life Support Group 2016) (Table 1).
    Rates are higher the younger the child is. The most accurate rate is obtained when the child is quiet or calm.
  8. Assess the pattern of breathing. Note the rhythm of the ventilatory cycle. Normal breathing in the older child and adolescent is regular and uninterrupted. Normal breathing in the younger child is frequently irregular (periodic breathing). Observe for breathing pattern, such as periods of bradypnoea, tachypnoea, or apnoea.
    Rationale – Suspected alterations in breathing pattern require assessment for at least 60 s. View rhythm, rate, and pattern in the context of other data such as fever, pain, fear or anxiety, or need for more oxygen. Infants are unable to increase tidal volume and compensate by increasing their respiratory rate. Tachypnoea, therefore, is important to note because it is often the first sign of respiratory distress (Aylott 2008).
    Infant apnoea is defined as pause in breathing for 20 s or longer, or a pause of shorter duration associated with bradycardia or cyanosis
    (Aylott 2008).
  9. Note the depth of respirations, subjectively assessed by observing the degree of chest wall and abdominal movement while counting the rate. The nurse can also objectively assess depth by palpating chest wall and abdominal excursion. Depth is described as shallow, normal, or deep.
    Rationale – Deep, rapid respirations (hyperpnoea) are commonly seen with metabolic acidosis while shallow respirations occur with neurological problems or with prolonged and worsening respiratory distress (Hockenberry & Wilson 2014).
  10. Observe the child’s position (allowing the child to remain in a position of comfort) to determine if the child is attempting to protect the airway and improve respiration.
    Rationale – It is essential to monitor and support the child’s own attempts to protect the airway and improve respiration. A child who assumes the tripod position may be attempting to protect their airway (Figure 1).
  11. Assess the child for signs of increased work of breathing:
    1. Observe for nasal flaring. If it is present, note whether the flaring is bilateral or unilateral.
      Rationale – Nasal flaring is abnormal and can be mild to severe (Aylott 2008).
    2. If recession is present, assess severity and depth, and note location: subcostal, substernal, intercostal, supraclavicular, suprasternal, and sternal  (Figure 2). Note the presence of see-saw respirations, head bobbing, or grunting.
      Rationale – Recession is always abnormal and indicates respiratory distress. The infant or child’s age and severity of condition influence the location and depth of the recession (Advanced Life Support Group 2016)Grunting, head bobbing, and/or see-saw respirations are signs of impending respiratory failure and need immediate intervention (Hockenberry & Wilson 2014, Advanced Life Support Group 2016).
  12. Examine the child’s chest size and shape.
    Rationale – Infant’s chest size is generally smaller than head size. Congenital deformities of the chest can affect respirations. Pectus excavatum (depressed sternum) and pectus carinatum (convex protruding sternum) ​(Hockenberry & Wilson 2014) as well as other thoracic deformities may affect respiratory effort and tidal volume.

    Box 1 Effective auscultation. (From Hockenberry M J, Wilson D 2014 Wong's Nursing Care of Infants and Children, 10th edn. Mosby, St Louis.)

    • Make certain child is relaxed and not crying, talking, or laughing. Record if child is crying.
    • Check that room is comfortable and quiet.
    • Warm stethoscope before placing it against skin.
    • Apply firm pressure on chest piece but not enough to prevent vibrations and transmission of sound.
    • Avoid placing stethoscope over hair or clothing, moving it against skin, breathing on tubing, or sliding fingers over chest piece, which may cause sounds that falsely resemble pathologic findings.
    • Use a symmetric and orderly approach to compare sounds.


  13. Auscultate lung sounds with a stethoscope using a sequential order (Box 1). Although auscultation may be performed if the child is crying, document the child’s behaviour at the time of the assessment.
    Rationale – Crying can change breath sounds (Hockenberry & Wilson 2014).
    1. Locate the child’s chest landmarks (Figure 3):
      1. Find the posterior thorax and anterior axillary lower chest landmarks (Hockenberry & Wilson 2014, (Advanced Life Support Group 2016). For the older child, frontal chest landmarks may be used.
        Rationale – For the infant or child, the chest is so small that referred sounds complicate auscultation. The recommendation for the younger child is to listen to lower lung lobe bases on the anterior axillary line and to all lobes on the posterior chest.
      2. Identify the anatomical placement of lobes of lungs in relation to the child’s ribs (Hockenberry & Wilson 2014) (Figure 4).
        Rationale – Listening to a child’s lungs requires knowledge of skeletal and anatomical positions of lung lobes (Hockenberry & Wilson 2014).
    2. Use a warmed stethoscope on the chest for good skin contact. Use a stethoscope diaphragm sized to the child’s chest or bell side. Place the stethoscope on the anterior axillary lower chest and posterior thorax landmarks.
      If the stethoscope’s diaphragm side is too large, it might not contact the skin enough on a young infant’s chest wall and could affect your ability to hear lung sounds clearly.
    3. For the older child, ask the child to breathe deeply. For younger child, use age-appropriate games (e.g., blowing bubbles (Hockenberry & Wilson 2014)) or ask the child to imitate deep breathing, to facilitate deep breathing.
      Rationale – Lung sounds are heard best when the child breathes deeply.
    4. Listen for normal lung sounds and adventitious or abnormal sounds (Box 2). For children, abnormal sounds may include stridor or grunting in the upper airway or wheezing or crackles in the lower airway (Hockenberry & Wilson 2014, Advanced Life Support Group 2016). 

      Box 2 Classification of normal breath sounds. (From Hockenberry M J, Wilson D 2014 Wong's Nursing Care of Infants and Children, 10th edn. Mosby, St Louis.)

      Vesicular breath sounds
      • Heard over entire surface of lungs, with exception of upper intrascapular area and area beneath manubrium.
      • Inspiration is louder, longer, and higher pitched than expiration.
      • Sound is soft, swishing noise.

      Bronchovesicular breath sounds
      • Heard over manubrium and in upper intrascapular regions where trachea and bronchi bifurcate.
      • Inspiration is louder and higher pitched than in vesicular breathing.

      Bronchial breath sounds
      • Heard only over trachea near suprasternal notch.
      • Inspiratory phase is short, and expiratory phase is long.


      1. Listen for several full respiratory cycles (one cycle = one inspiration and one expiration).
        Rationale – Allows the opportunity to identify the length of inspiratory/expiratory phases and sounds.
      2. Use a zigzag pattern of moving the stethoscope on the child’s chest to listen to and compare lung sounds.
      3. Note lung lobe site, strength, equal or unilateral sounds, and if inspiratory or expiratory or both.
      4. Note whether sounds are heard with the stethoscope or audibly.
        Rationale – Asymmetric breath sounds may indicate pathology. Sounds audible to the ear may indicate more distress (Advanced Life Support Group 2016).
        Stridor is a high-pitched sound indicative of upper airway narrowing. Stridor may be inspiratory, expiratory, or both inspiratory and expiratory (Jevon 2012, Advanced Life Support Group 2016). New onset stridor requires immediate investigation. Secretions in the upper airway may cause gurgling, indicating the need for suctioning. Grunting is a forced expiration against a partially closed glottis and is a compensatory mechanism to keep the alveoli open. Grunting is typically a life-threatening sign (Aylott 2008, Jevon 2012). Wheezing – or no wheezing where wheezing was previously present – if coupled with a clinical deterioration might mean impending respiratory failure.
  14. Depending on the status of the child, assessment tools can be used. These include measurement of oxygen saturation via pulse oximetry, blood gases, chest X-ray, or peak expiratory flow meter (PEFR) or end-tidal CO2 monitoring.
    No test results are considered in isolation. They are an adjunctive assessment and the appearance and behaviour of the child must always be considered.
  15. Replace clothing and bedlinen if necessary.
    Rationale – Restores comfort and promotes a sense of well-being.
    As soon as possible after assessment, cover the child – particularly an infant. Small children and infants may easily become cold if left uncovered, even at normal room temperature.
  16. Perform hand hygiene.
    Rationale – Reduces transmission of micro-organisms.
  17. Discuss findings with the child and family and other healthcare professionals as needed.
    Rationale – Promotes participation in care and understanding of health status.
  18. Document assessment findings in the child’s notes.

Ongoing care, monitoring and support

  • If respirations are being assessed for the first time, establish all parameters of rate, rhythm, depth, symmetry, effort and pattern, lung sounds, colour, oximetry, level of consciousness, behaviour, tone, activity, and any signs or symptoms as baseline for this child.
    Rationale – Even if the results of the assessment are not textbook normal, they will still be used to compare future respiratory assessments for this child.
  • If this was not the first respiration assessment for the child, compare the current assessment with the child’s previous assessment and baseline.
    Rationale – Allows the nurse to assess for changes (improvements or deterioration) in the child’s condition.
  • Correlate all respiratory assessments with other adjunctive data and assessments and collaborate with other healthcare professionals. Any abnormal findings must be reported.
    Rationale – Evaluation of one system is not done independently of the other systems.
  • Re-evaluate according to the child’s respiratory status, as advised by the physician or local policy dictates, in order to determine the frequency of respiratory reassessment.
    Rationale – Reassessment shows trends and can indicate improvement or deterioration in the infant or child’s condition, or indicate the requirement for further intervention.
  • Develop an individualised care plan according to the respiratory assessment findings.

Documentation and reporting

Record in the child's notes the following:
  • Record respiratory assessment on the vital sign observations chart and in the infant or child’s health record.
  • Education given to the child and family, making a note of their response and understanding.
  • Assessments made in conjunction with any specific therapies.
  • Record and report any abnormalities in respiratory parameters, such as abnormal depth, rhythm, pattern, symmetry, effort or lung sounds, and adjuncts.
  • Improvements noted and expected outcomes.
  • Any nursing interventions and outcomes related to respiratory assessment.
  • Time, type, and amount of oxygen therapy, if used.
  • Pulse oximetry readings and whether the infant or child is in air or requiring oxygen.
  • Details of unexpected outcomes.
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