Respiration: Counting Technique, Tachypnea, and Bradypnea

What Counts as One Breath

One respiration equals one full cycle of inspiration (breathing in) and expiration (breathing out). You count the cycle, not the direction. A resident who breathes in, then out, has completed one respiration. Count each complete in-and-out cycle as one breath.

The normal adult range is 12-20 breaths per minute. This range is for adults at rest. Children breathe faster; infants can be 30-40 per minute. In an Indiana LTC facility, your residents are adults, so 12-20 is the range you use.

The Stealth Counting Technique

Respiration is the only vital sign that the resident can consciously change. If you tell a resident, "I am going to count your breathing now," the resident becomes aware of their breathing and the rate changes - usually it speeds up because people tend to breathe faster when they think about it. Some residents breathe slower or hold their breath. Either way, the reading is no longer a true resting rate.

The standard technique avoids this problem:

1. Finish counting the radial pulse for 60 seconds.
2. Keep your fingers on the wrist. Do not announce that you are switching to respiration.
3. Shift your eyes to the resident's chest or abdomen without moving your head obviously. Watch the rise and fall of the chest or abdomen.
4. Count each rise-and-fall cycle as one breath for a full 60 seconds.
5. The resident thinks you are still counting the pulse. The breathing rate stays at its true resting level.

If the resident asks what you are doing, you can say you are finishing the pulse check or rechecking the pulse. Do not say you are counting breaths until after the count is done.

Normal Range and Thresholds

Some sources use 24 as the tachypnea threshold; Indiana LTC practice uses 20 as the upper end of normal. A resident breathing 22 per minute is outside the normal range and should be reported, even if 22 is not a dramatic emergency. The nurse decides whether 22 is concerning based on the resident's baseline and condition; the CNA reports it.

Depth and Ease: Beyond the Number

The rate is only half the assessment. The CNA also observes the depth and ease of each breath and reports abnormalities even when the rate is within 12-20:

• Shallow breathing - small chest movements, barely visible. Can indicate muscle weakness, neurological depression, or lung consolidation. Report.
• Labored breathing - visible use of accessory muscles in the neck or abdomen, flaring nostrils, retractions between ribs. Report immediately, even if rate is 18.
• Noisy breathing - wheezing (high-pitched musical sound on exhalation), rhonchi (low-pitched rattling), stridor (harsh inspiratory sound). Report; the nurse may need to auscultate.
• Cheyne-Stokes - progressively deeper, then progressively shallower, then a period of apnea (no breathing), then the cycle repeats. Common in end-of-life care and certain brain injuries. Report immediately.
• Dyspnea - the resident says they feel short of breath, or appears air hungry. This is a subjective report combined with objective signs; report immediately.

Document both the rate and the observed characteristics. For example: "20 bpm, shallow, slight wheeze noted" or "16 bpm, regular, easy, unlabored." The nurse needs both pieces to interpret the finding.

Factors That Change the Rate

If a resident has been active - transferred, walked, or agitated - wait a few minutes before counting respirations so the rate returns to resting baseline. The same applies to pulse. Document if the reading was taken after activity.

When to Report

Report immediately to the licensed nurse if:

• Rate is below 12 or above 20.
• Breathing is irregular, with pauses or periods of no breathing.
• Breathing is labored, shallow, or noisy regardless of the rate.
• The resident reports shortness of breath (dyspnea).
• The resident's color changes - cyanosis (bluish tint to lips, nail beds, or skin) is an emergency.
• The rate has changed significantly from the resident's documented baseline, even if still within 12-20.

Cyanosis is not a vital sign number, but a CNA who observes bluish lips or nail beds must report it immediately - it signals hypoxia, a low oxygen level in the blood. Do not wait to finish charting. Call the nurse.

Common Errors on the Skills Evaluation

• Announcing that you are counting respirations - the critical error. The resident becomes aware and the rate changes. Always keep your fingers on the wrist and transition silently.
• Counting for less than 60 seconds. Like pulse, the skills evaluation requires a full 60-second count.
• Counting inspiration and expiration as two separate breaths. One in-and-out cycle is one breath.
• Watching the resident's face instead of the chest. The chest or abdomen is where you see the movement; the face does not move enough to count reliably.
• Failing to report an abnormal rate or abnormal breathing characteristics. Reporting is a critical step.

The Resident on Oxygen

A resident on supplemental oxygen (nasal cannula, simple mask) still has their respiration counted and observed the same way. The oxygen does not change the counting technique. Report if the rate is outside 12-20 or if the breathing is labored, shallow, or noisy. Also report if the oxygen equipment appears to have a problem - tubing disconnected, cannula displaced from the nose, water in the tubing, or the concentrator alarming. The CNA does not adjust the oxygen flow rate (that is outside scope), but the CNA is responsible for observing and reporting equipment problems.

Respiration and the Care Plan

Some residents have a chronic respiratory condition (COPD, asthma, heart failure) and a baseline rate that sits at or above the upper end of normal. A resident with severe COPD may run 22 breaths per minute at rest as their baseline. The care plan documents the baseline and the report threshold. As always, compare to the care plan and report any sudden change from baseline even if the absolute number is within 12-20.

Counting Without Being Seen

The transition from pulse to respiration must look natural. If you lift your fingers off the wrist, put your pen down, and stare at the resident's chest, the resident knows something changed. The smoother the transition, the more accurate the reading. Practice the sequence: finish the pulse count, keep your fingers in place, shift only your eyes to the chest, start counting on the next chest rise. Your posture does not change. Your hand does not move. Only your gaze shifts.

The Resident Who Notices

Some residents are very alert and will ask, "Are you still checking my pulse?" or "What are you looking at?" Answer calmly: "Just finishing up the pulse check" or "Making sure the reading is steady." Do not say you are counting breaths until the count is complete and recorded. If the resident has already altered their breathing by the time you start, wait a minute for them to forget about it, then recount.

Apnea and What It Means

Apnea is a period of no breathing. If you are counting and the resident stops breathing for more than a few seconds, this is an emergency - call the nurse immediately and stay with the resident. Do not wait for the 60-second count to finish. Brief pauses of 2-3 seconds can be normal in some older adults during sleep, but longer pauses or pauses while awake must be reported. Cheyne-Stokes breathing, described earlier, includes apnea periods and is a specific pattern the nurse needs to know about.

Documenting Respiration

Document the rate, rhythm, depth, and ease. The minimum documentation is the number, but good charting includes the qualitative observations. Examples:

• "16 bpm, regular, easy, unlabored."
• "20 bpm, irregular with 5-second pause, shallow, reported to LPN Smith."
• "24 bpm, labored, wheezing noted on exhalation, reported to RN Jones, oxygen saturation per pulse oximeter 88 percent (nurse reading)."

Note that pulse oximetry is typically read by the licensed nurse or by the CNA if facility policy allows; if you read it, document it. If the nurse read it, note that the nurse obtained the reading. Do not document a number you did not personally observe.