7.4 Respirations Measurement

Counting Respirations Discreetly

Respirations are the act of breathing: drawing air in (inhalation) and pushing it out (exhalation). One respiration equals one full inhalation plus one exhalation, the complete rise and fall of the chest. The normal adult rate is 12-20 breaths per minute.

What to Assess

Normal Rates Change With Age

The Key Technique

Do not tell the patient you are counting respirations. Breathing is under conscious control, so awareness makes a person speed up or slow down. The standard trick: finish counting the pulse, then keep your fingers on the wrist and count the chest rise and fall while the patient still believes you are timing the pulse. Count the full 60 seconds when breathing is irregular, and watch for use of the accessory muscles of the neck and shoulders, which signals extra effort.

Abnormal Patterns, Distress, and Oxygen Saturation

Naming Breathing Patterns

Signs of Respiratory Distress to Report at Once

• Visual: flared nostrils, pursed-lip breathing, retractions (skin pulling between the ribs), use of neck and shoulder muscles, cyanosis (bluish lips or nailbeds), or sitting upright leaning forward (tripod position)
• Sounds: wheezing, stridor (harsh high-pitched sound on inhaling), gurgling, or gasping
• Words: "I can't breathe," "I can't catch my breath"

Oxygen Saturation (SpO2)

Pulse oximetry clips a sensor on a finger or earlobe to read the percent of hemoglobin carrying oxygen. Normal is 95-100%.

Accuracy drops with cold or poorly perfused hands, dark or artificial nails, movement, and low blood pressure. Remove dark polish or move the sensor to a warmer finger before trusting a low number.

Documentation examples: Normal: "Respirations 16, regular, unlabored." Abnormal: "Respirations 28, shallow, labored with accessory muscle use, SpO2 92%, nurse notified." Emergency: "Respirations 32, labored, lips dusky, nurse called STAT."

Positioning, Oxygen, and Reporting Respirations

Position Affects Breathing

How a patient is positioned changes how easily they breathe, which is testable knowledge. A patient who is short of breath is helped into a Fowler's or high-Fowler's position (head of bed raised 45 to 90 degrees) because sitting upright lets the diaphragm drop and the lungs expand. A patient with orthopnea literally cannot breathe lying flat and may sleep propped on several pillows. Forcing a breathless resident to lie supine is the wrong action; raise the head of the bed and report.

Counting With Oxygen and Equipment

Many residents wear a nasal cannula delivering oxygen, often 2 to 4 liters per minute. The CNA does not start, stop, or change the oxygen flow rate; that is a licensed task. You may, however, observe that the cannula prongs are seated, the tubing is not kinked, and note the oxygen status while you count respirations. Always record whether the patient is on room air or oxygen when you chart a respiratory rate or SpO2, because the same SpO2 means something very different on 4 liters than on room air.

A Worked Scenario

A CNA finishes counting a pulse of 82, then keeps fingers on the wrist and counts the chest rising and falling 9 times in 60 seconds. Nine breaths is bradypnea (below 10). The resident also seems very drowsy and recently received pain medication. The CNA does not assume it is harmless sleep; slow breathing plus heavy sedation can signal an opioid effect, so this is reported to the nurse at once, with the rate, the sedation level, and the recent medication noted.

Counting Tips That Protect Accuracy

Watch a clearly visible chest or place a hand lightly on the abdomen if breathing is shallow. Count one complete rise-and-fall as a single breath, not two. If you lose count, restart the full minute rather than guessing. And never coach the patient to "breathe normally," which defeats the purpose. Discreet, accurate counting plus precise reporting is the whole skill. On the NNAAP exam, respirations are frequently bundled with the pulse skill, so a tested candidate counts the pulse, holds the wrist, counts respirations for a full minute, and records both numbers separately on the worksheet before reporting either one.