VITAL SIGNS TAKING

ASSESSING RESPIRATION

Jenny Rose Leynes-Ignacio, EdD, MAN, RN, LPT

OVERVIEW OF THE RESPIRATORY SYSTEM
RESPIRATION
It is the act of breathing and it involves the
exchange of gases between the individual and
the environment
2 KINDS OF RESPIRATION
1. External/Pulmonary respiration
Exchange of oxygen and carbon
dioxide between the alveoli of the
lungs and the pulmonary blood
2. Internal/cellular
respiration
Exchange of gases
between the
circulating blood
and cells of the
body
VENTILATION/BREATHING
• also used to refer to the
movement of air in and out of the
lungs.
• Two process of Breathing
1. Inspiration/inhalation
• Refers to the intake of air into
the lungs
2. Expiration/exhalation
• Refers to the breathing out or
movement of gases from the lungs
to the atmosphere
VENTILATION/BREATHING
• Medulla Oblongata
• is the primary respiratory
control center.
• Its main function is to send
signals to the muscles that
control respiration to cause
breathing to occur.
• Pons
• Its main function is to control
the rate or speed of involuntary
respiration.
Mechanics of Breathing
 Overview of Breathing

Breathing - Health Video: MedlinePlus Medical Encyclopedia. Retrieved from https://medlineplus.gov/ency/anatomyvideos/000018.htm

MECHANICS OF BREATHING
 ASSESSING RESPIRATION
• Rate
• described in breaths per minute (bpm)
• Depth
• Can be established by watching the movement of the chest
• Normal, deep, or shallow
• Rhythm
• Regularity of the inspiration and exhalation
• Regular or irregular
• Quality and Character
• the amount of effort a client must exert to breathe
• Normal or effortless
• labored breathing
• the sound of breathing – silent (n), adventitious sounds (abn)
 RESPIRATORY RATE

Age Normal Respiratory Rate

Newborns 35 (30-80) bpm
1 year 30 (20-40) bpm
5-8 years 20 (15-25) bpm
10 years 19 (15-20) bpm
Teen 18 (15-20) bpm
Adult 16 (12-20) bpm
Older Adult (>70) 16 (15-20) bpm
TERMS USED TO DESCRIBE THE
CHARACTER OF RESPIRATION:
TERMS USED TO DESCRIBE THE
CHARACTER OF RESPIRATION:
 TERMS USED TO DESCRIBE THE
CHARACTER OF RESPIRATION:
• Hyperventilation - overexpansion of the lungs characterized by
rapid and deep breaths

• Hypoventilation - underexpansion of the lungs, characterized by

decreased rate and depth

• Dyspnea - Difficult and labored breathing

• Orthopnea - Ability to breathe only in an upright sitting or

standing position
TERMS USED TO DESCRIBE THE
CHARACTER OF RESPIRATION:
 ADVENTITIOUS BREATH SOUNDS
• Stridor—a shrill, harsh sound heard
during inspiration with laryngeal
obstruction
• Stertor—snoring or sonorous
respiration, usually due to a partial
obstruction of the upper airway
• Wheeze (ronchi)—continuous, high-
pitched musical squeak or whistling sound
occurring on expiration and sometimes
on inspiration when air moves through a
narrowed or partially obstructed airway
• Bubbling—gurgling sounds heard as air
passes through moist secretions in the
respiratory tract (Crackles and plueral
rub)
 CHEST MOVEMENTS

Intercostal retraction—
indrawing between the ribs

Substernal retraction—
indrawing beneath the
breastbone

Suprasternal retraction—
indrawing above the clavicles
 SECRETIONS AND
COUGHING
• Hemoptysis—the presence of
blood in the sputum
• Productive cough—a cough
accompanied by expectorated
secretions
• Nonproductive cough—a dry,
harsh cough without secretions
ASSESSING RESPIRATIONS
PURPOSES
• To acquire baseline data against which future measurements can
be compared

• To monitor abnormal respirations and respiratory patterns and

identify changes

• To monitor respirations before or after the administration of a

general anesthetic or any medication that influences respirations

• To monitor clients at risk for respiratory alterations (e.g., those

with fever, pain, acute anxiety, chronic obstructive pulmonary
disease, asthma, respiratory infection, pulmonary edema or emboli,
chest trauma or constriction, brainstem injury)
ASSESSING RESPIRATIONS
ASSESSMENT
• Skin and mucous membrane color (e.g., cyanosis or pallor)
• Position assumed for breathing (e.g., use of orthopneic
position)
• Signs of lack of oxygen to the brain (e.g., irritability,
restlessness, drowsiness, or loss of consciousness)
• Chest movements (e.g., retractions between the ribs or above
or below the sternum)
• Activity tolerance, Chest pain, Dyspnea
• Medications affecting respiratory rate
ASSESSING RESPIRATIONS

Performance
1. Assemble equipment: Watch with a second hand or
indicator

2. Perform hand hygiene.

3. Introduce yourself.

4. Verify the client’s identity.

5. Explain the procedure.

6. Provide for client privacy.

ASSESSING RESPIRATIONS

Performance
7. Place the client’s arm across the chest and observe the chest
movements while supposedly taking the radial pulse.

8. Count for 60 seconds.

9. Observe the depth, rhythm, and character of respirations.
10. Inform the client of the RR (cycles/min = cpm),
(breaths/min = bpm).

11. Document the respiratory rate, depth, rhythm, and character on

the appropriate record.
 ASSESSING RESPIRATIONS
EVALUATION
• Relate respiratory rate to other vital signs; relate respiratory
rhythm and depth to baseline data and health status.
• Report to the primary care provider a respiratory rate
• significantly above or below the normal range
• any notable change in respirations from previous
assessments;
• irregular respiratory rhythm; inadequate respiratory depth;
abnormal character of breathing—orthopnea, wheezing,
stridor, or bubbling; and any complaints of dyspnea.
Assessing the Respiratory Rate
 BLOOD
PRESSURE
ASSESSMENT