Health Assessment, part 6: Assessing Respirations

Hi, I'm Meris, and in this video, I'm going to be talking to you about how to assess your patient's respirations. I'll be talking to you about the different assessment components along with some expected findings and unexpected findings when assessing respirations. I'm going to be following along using our health assessment flashcards. These are available on our website, leveluprn.com, if you want to grab a set for yourself. And if you already had your own deck, go ahead and pull it out, and we can follow along together. All right. Let's go ahead and get started. So first up, we're going to be talking about the assessment components and the technique for obtaining your patient's respirations. So some of the components, what are the things we're going to assess when we are looking at the respiratory rate, and just overall respiratory status of our patient. We're going to look at the rate, so how fast or slow it is; the depth, meaning how much is my patient expanding their rib cage, right? Are we taking shallow little breaths, or are we breathing really deeply? Or we sort of just breathing at a normal depth? The rhythms. Were we breathing regularly or irregularly? And then the effort. Am I having nice, quiet work of breathing like I am right now, or am I putting a lot of work into breathing? And we'll talk about that in the future.

Now, the assessment technique. You don't want to alert your patient to the fact that you are counting their respirations because as soon as I become aware of my respirations, I now am no longer breathing involuntarily. I'm breathing by thinking about it. So if I say to my patient, "Please remain still. I am now going to assess your respiratory rate," they're going to kind of, "Oop," and then, "How do I breathe normally? Is this right?" We don't want them to know that we are counting. So what we're going to do is after we take our patient's pulse, we're then going to just leave our hand there for the next 30 seconds while, instead of counting the pulse, we are going to watch the rise and fall of our patient's chest. Now, again, remember that this is the same idea for the pulse. If their respiratory regularity, if it's regular, then we can count for 30 seconds and multiply by two. However, if our patient's breathing irregularly, then we do need to count for a full minute, 60 seconds. And very important to understand because we could end up getting a falsely high or low number if we only count for 30 seconds.

Now, let's talk about expected findings. Again, and I've given you this disclaimer before when we talked about pulse, every facility, every textbook, every school has slightly different numbers that they want you to know. If the numbers your school wants you to know are different than the ones that I provide you, just take a pen, mark it out, and write the numbers you need to know. It's okay. Everything on here is sourced using the most up-to-date peer-reviewed information, but again, facilities and schools vary. So in bold red text here, we have the respiratory rate for adults, which is 12 to 20 breaths per minute. For children, it's going to be 20 to 30, and for infants, it will be 30 to 60. So important to remember that, and remember that children and infants breathe significantly more often than adults, and that makes sense on a physiological level, right? So first of all, they're just smaller. Their lungs are smaller. But also, they have a much higher metabolic demand because they need to be growing those muscles and bones and all their tissues. That's why these kids are just on the go, go, go, right? They have a higher metabolic demand, so they're going to need to breathe more frequently to get enough oxygen and get rid of the carbon dioxide. The depth, we just expect it to be not too deep, not too shallow, and consistent. The rhythm, we expect it to be regular. And then the effort, we expect easy, unlabored work of breathing. Okay, so that's that's kind of how I would chart that patient resting comfortably in bed, with easy, quiet work of breathing or no obvious labored breathing.

Now let's talk about unexpected findings. Tachypnea, tachy meaning fast, and pnea meaning related to air, so we're breathing too fast. That's going to be for adults a respiratory rate greater than 20 breaths per minute. And bradypnea, so brady meaning slow, so slow breathing, bradypnea is going to be less than 12 breaths per minute for an adult. Hyperventilation and hypoventilation actually has more to do with the depth. So a patient who is hypoventilating, typically that means that we're having shallow respirations, but you will also hear people use hyper and hypoventilation to refer to the rate of breathing as well. Just make sure to clarify with your instructor or your facility so that you know which term to use. Irregular respirations like Cheyne-Stokes or Biot's respirations, irregular respirations are not normal. They're an unexpected finding. Apnea, A meaning the absence of or without and pnea meaning breathing air, so no breathing. And this is technically a period of 15 seconds or more. So your patients who are sleeping, they might not be breathing quite as often as when they're awake, but if they stop breathing for 15 seconds or greater, then we would consider that an apneic period. That's also considered abnormal. And then dyspnea, dys meaning bad, and so bad breathing, or they're having a hard time breathing. This is going to be what we would typically call difficulty breathing.

So things that you need to know, you've got to memorize this, you must know the signs of dyspnea now and forevermore. So accessory muscle use. If I am looking at this patient and I can see their intercostal muscles, I can see their neck muscles, I can see what we call substernal retractions beneath their sternum, all of that is wildly abnormal, especially in children. If I see a child who I can see all of these muscles every time they're breathing, ooh, it gives me the heebie-jeebies. I don't like it because that's not a well child, but same for an adult. You can see across the room whether somebody is having increased work of breathing that is causing them distress. Their whole body moves. Every breath is like they're fighting for their lives. Other things we might see would be nasal flaring. Again, especially with children, but if my patient's nose is flaring with breaths, that means they're trying to get more air in, and that's not good either, okay? Also in children and infants especially, but this can happen in adults as well. Any kind of grunting can signify to us that that patient is having a hard time breathing. So all of those things would be considered unexpected findings.

All right. Let's go ahead and test your knowledge of some key facts I provided in this video using my quiz questions. For how long should the nurse assess the respirations of a patient who is breathing irregularly? For 60 full seconds or one minute. What is the expected respiratory range for an adult patient? The expected respiratory range for an adult patient is 12 to 20 breaths per minute. How should the nurse describe the respirations of an adult patient who is breathing 28 times per minute? The nurse should describe this as tachypnea. All right. I hope that review was helpful for you. I would love to hear any comments, and especially if you have a way to remember something that is funny or unique, I want to hear that and I know other students do too. You're doing a really good job. I know this is hard stuff, but I'm super proud of you. Thanks for studying with me.

When it comes to your patient's work of breathing-- and again, I'm an adult ER trauma nurse. I try to stay away from kids, so I'm talking specifically about adults. Your patient's work of breathing tells you a lot about them and the interventions that they will require. If they're just working a little bit more than usual, I'm not super concerned. Maybe we need to put them on some oxygen or something like that. But I have had patients where they come in from EMS, and they are on CPAP, so they're already receiving positive airway pressure, and they are still working so hard to breathe. And I vividly remember one such patient who was working so hard to breathe. He was working harder to breathe than any human being I had ever seen who was already being ventilated with positive pressure. And he was diaphoretic, sweaty. He was pouring sweat. And before we even got him over onto our hospital cart, I'm calling the doctor and saying, "I need you to come. We got to intubate this guy," right? Your patients who are working so hard to breathe, they will not be able to keep that work of breathing up for very long, so you need to be thinking about what's the worst-case scenario? If we don't intervene, what's going to happen when they go downhill? Just a little tip, but work of breathing, if I see a really increased work of breathing, I am thinking, oh, big red flags. Something is scary, and we better get our contingency plans in place.